Egypt - Demographic and Health Survey - 2009

Publication date: 2009

Egypt Demographic and Health Survey 2008Dem ographic and H ealth S urvey E gypt 2008 Egypt Demographic and Health Survey 2008 Fatma El-Zanaty Ann Way March 2009 El-Zanaty and Associates Ministry of Health The 2008 Egypt Demographic and Health Survey (2008 EDHS) was conducted on behalf of the Ministry of Health by El- Zanaty and Associates. The Central Laboratory at the Ministry of Health was responsible for the hepatitis C testing component of the survey. The 2008 EDHS is part of the worldwide MEASURE DHS project which is funded by the United States Agency for International Development (USAID). USAID/Cairo was the main contributor of funding for the survey. Support for the survey was also provided by UNICEF. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID and UNICEF. Additional information about the 2008 EDHS may be obtained from the Ministry of Health, 3 Magles El Shaab Street, Cairo, Egypt; Telephone: 20-2-27948555 and Fax: 20-2-27924156. Information about DHS surveys may be obtained from the MEASURE DHS Project, Macro International, 11785 Beltsville Drive, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@macrointernational.com, Internet: http://www.measuredhs.com. Recommended citation: El-Zanaty, Fatma and Ann Way. 2009. Egypt Demographic and Health Survey 2008. Cairo, Egypt: Ministry of Health, El-Zanaty and Associates, and Macro International. Contents | iii CONTENTS Page TABLES AND FIGURES .ix PREFACE. xix ACKNOWLEDGMENTS . xxi SUMMARY OF FINDINGS . xxiii MAP OF EGYPT . xxx CHAPTER 1 INTRODUCTION 1.1 Geography .1 1.2 Population Size and Structure .1 1.3 Recent Rate of Natural Increase .1 1.4 2008 Egypt Demographic and Health Survey .3 1.4.1 Organization and Objectives .3 1.4.2 Timetable .3 1.4.3 Sample Design.4 1.4.4 Questionnaire Development.6 1.4.5 Biomarker Data Collection.7 1.4.6 Pretest .7 1.4.7 Data Collection Activities .8 1.4.8 Fieldwork .9 1.4.9 Data Processing Activities.10 1.5 Survey Coverage .10 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS 2.1 Characteristics of the Household Population .13 2.1.1 Age and Sex Composition.13 2.1.2 Household Composition .15 2.2 Education of the Household Population .16 2.3 Housing Characteristics .18 2.3.1 Drinking Water Access and Treatment .18 2.3.2 Drinking Water Storage Practices .20 2.3.3 Sanitation Facilities and Waste Disposal.21 2.3.4 Other Housing Characteristics.22 2.4 Household Possessions.23 2.5 Household Wealth.25 CHAPTER 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3.1 Background Characteristics of the Ever-married Women Sample.27 3.1.1 Demographic and Socio-economic Characteristics.27 iv │ Contents 3.1.2 Educational Attainment.29 3.1.3 Literacy.30 3.1.4 Exposure to Mass Media .31 3.1.5 Employment Status .33 3.2 Women’s Participation in Household Decision-making .37 3.2.1 Disposal of Earnings .37 3.2.2 Women’s Roles in Household Decision-Making.41 3.3 Women’s Attitude toward Wife Beating .42 3.4 Background Characteristics of Respondents Eligible for Health Issues Interview.44 CHAPTER 4 FERTILITY 4.1 Current Fertility Levels by Residence .47 4.2 Fertility Differentials by Background Characteristics.49 4.3 Fertility Trends .50 4.3.1 Retrospective Data .50 4.3.2 Comparison with Previous Surveys.51 4.4 Children Ever Born and Living.52 4.5 Birth Intervals.54 4.5.1 Intervals between Births.54 4.5.2 Attitudes about the Ideal Birth Interval.56 4.6 Age at First Birth.56 4.7 Teenage Pregnancy and Motherhood.57 CHAPTER 5 KNOWLEDGE, ATTITUDES, AND EVER USE OF FAMILY PLANNING 5.1 Knowledge of Family Planning Methods .59 5.2 Exposure to Family Planning Messages .60 5.3 Knowledge of Fertile Period .62 5.4 Knowledge of Breastfeeding as a Family Planning Method.63 5.5 Ever Use of Family Planning .65 5.5.1 Levels of Ever Use.65 5.5.2 Trends in Ever Use.66 5.5.3 Differentials in Ever Use.67 5.6 First Use of Family Planning .68 5.7 Attitude about Timing of Adoption of Contraception.68 CHAPTER 6 CURRENT USE OF FAMILY PLANNING 6.1 Current Use of Family Planning .71 6.2 Differentials In Current Use Of Family Planning .71 6.2.1 Differentials by Residence.71 6.2.2 Differentials by Selected Background Characteristics.72 6.2.3 Differentials by Governorate .74 6.3 Trends in Current Use of Family Planning.75 6.3.1 Trends by Method .75 6.3.2 Trends by Urban-Rural Residence and Place of Residence.77 Contents | v 6.3.3 Trends by Governorate .78 6.4 Sources for Modern Family Planning Methods.79 6.4.1 Sources by Method.79 6.4.2 Sources by Method and Residence .80 6.4.3 Trends in Sources of Modern Methods .81 6.5 Pill Brands.82 6.6 Cost of Methods.83 6.6.1 Pill Users .83 6.6.2 Injectable Users .83 6.6.3 IUD Users.84 6.7 Participation in Family Planning Decisions.85 6.8 Informed Choice.86 CHAPTER 7 NONUSE OF FAMILY PLANNING AND INTENTION TO USE 7.1 Discontinuation Rates .89 7.2 Reasons for Discontinuation of Contraceptive Use .91 7.3 Intention to Use Contraception in the Future .92 7.4 Reasons for Nonuse .92 7.5 Preferred Method .93 7.6 Contact of Nonusers with Outreach Workers/Health Care Providers .93 CHAPTER 8 PROXIMATE DETERMINANTS OF FERTILITY 8.1 Marital Status .97 8.2 Consanguinity .98 8.3 Age at First Marriage .99 8.4 Postpartum Amenorrhea, Abstinence, and Insusceptibility. 101 8.5 Termination of Exposure to Pregnancy . 103 CHAPTER 9 FERTILITY PREFERENCES 9.1 Desire for More Children . 105 9.2 Need for Family Planning. 108 9.3 Ideal Number of Children . 110 9.4 Unplanned and Unwanted Fertility . 113 CHAPTER 10 INFANT AND CHILD MORTALITY 10.1 Assessment of Data Quality . 115 10.2 Levels and Trends in Early Childhood Mortality . 116 10.2.1 Levels of Mortality . 116 10.2.2 Trends in Mortality Based on Retrospective Data . 116 10.2.3 Trends in Mortality Based on Data from Multiple Surveys . 117 10.3 Differentials in Mortality. 118 10.3.1 Socioeconomic Differentials . 118 10.3.2 Demographic Differentials . 120 10.4 Perinatal Mortality. 121 vi │ Contents 10.5 High-Risk Fertility Behavior . 123 CHAPTER 11 MATERNAL HEALTH CARE AND OTHER WOMEN’S HEALTH ISSUES 11.1 Pregnancy Care. 125 11.1.1 Antenatal Care Coverage . 125 11.1.2 Tetanus Toxoid Vaccinations . 126 11.1.3 Any Medical Care During Pregnancy . 127 11.1.4 Differentials in Pregnancy Care Indicators . 127 11.2 Content of Pregnancy Care . 129 11.3 Delivery Care. 131 11.3.1 Place of Delivery . 131 11.3.2 Assistance at Delivery . 133 11.3.3 Caesarean Deliveries . 135 11.3.4 Birth Weight . 135 11.4 Trends in Antenatal and Delivery Care Indicators . 136 11.5 Postnatal Care. 138 11.5.1 Postnatal Checkup for the Mother . 138 11.5.2 Postnatal Checkup for the Baby . 140 11.6 Family Planning and Breastfeeding Advice. 143 11.7 Exposure to Safe Pregnancy Messages . 143 11.8 Sexually Transmitted Infections . 145 11.9 Women’s Access to Health Care . 147 CHAPTER 12 CHILD HEALTH 12.1 Immunization of Children . 149 12.1.1 Collection of Data . 149 12.1.2 Routine Immunization against Common Childhood Illnesses . 149 12.1.3 Trends and Differentials in Vaccination Coverage . 151 12.1.4 Participation in National Immunization Days . 153 12.2 Acute Respiratory Infection . 153 12.2.1 Prevalence of ARI . 153 12.2.2 Consultation, Treatment, and Feeding Practices. 154 12.2.3 Differentials in ARI Prevalence and Responses to the Illness . 155 12.3 Diarrhea . 157 12.3.1 Prevalence of Diarrhea . 157 12.3.2 Consultation, Treatment and Feeding Practices. 158 12.3.3 Differentials in Feeding and Treatment Practices. 159 12.4 Disposal of Children’s Stools . 162 CHAPTER 13 FEEDING PRACTICES AND MICRONUTRIENT SUPPLEMENTATION 13.1 Breastfeeding and Supplementation . 165 13.1.1 Initiation of Breastfeeding . 165 13.1.2 Introduction of Complementary Feeding . 167 13.1.3 Median Durations and Frequency of Breastfeeding and Prevalence of Bottle-feeding . 169 Contents | vii 13.2 Dietary Diversity among Children and Women . 171 13.2.1 Foods and Liquids Consumed by Infants and Young Children . 171 13.2.2 Appropriate Infant and Young Child Feeding . 172 13.2.3 Foods and Liquids Consumed by Women. 175 13.3 Micronutrient Supplementation . 176 13.3.1 Use of Iodized Salt. 177 13.3.2 Micronutrient Intake among Young Children . 178 13.3.3 Micronutrient Intake among Mothers. 180 CHAPTER 14 NUTRITIONAL STATUS 14.1 Nutritional Status of Children . 183 14.1.1 Measurement of Nutritional Status among Young Children . 183 14.1.2 Results of Data Collection . 184 14.1.3 Levels of Child Malnutrition . 184 14.1.4 Trends in Child Nutrition . 188 14.2 Nutritional Status of Never-married Youth and Young Adults. 188 14.2.1 Measurement of Nutritional Status among Youth and Young Adults . 189 14.2.2 Results of Data Collection . 189 14.2.3 Levels of Malnutrition among Never-married Youth and Young Adults . 189 14.3 Nutritional Status of Women and Men . 192 CHAPTER 15 FEMALE CIRCUMCISION 15.1 Prevalence of Female Circumcision among Women Age 15-49. 197 15.2 Women’s Circumcision Experience . 198 15.3 Prevalence of Female Circumcision among Young Girls. 199 15.4 Circumcision Experience of Young Girls . 201 15.5 Support for Female Circumcision among Women and Men . 202 15.6 Reasons for Support of Female Circumcision. 204 15.7 Exposure to Information about Circumcision . 207 CHAPTER 16 AVIAN INFLUENZA 16.1 Household Ownership of Poultry and Other Birds . 209 16.2 Locations Where Poultry Kept . 211 16.3 Awareness of Avian Influenza. 213 16.4 Awareness of Avian Influenza Symptoms in Poultry/Birds . 215 16.5 Awareness of Avian Influenza Risks and Symptoms Among Humans. 217 16.6 Awareness of Modes of Transmission and Prevention . 218 16.7 Attitudes towards Avian Influenza Risks . 221 CHAPTER 17 ADULT HEALTH ISSUES 17.1 Use of Tobacco. 223 17.2 History of Diabetes and Cardiovascular Disease . 227 17.3 High Blood Pressure. 228 viii │ Contents 17.4 Lifetime History of Medical Procedures and Injections . 235 17.5 Recent History of Injections . 237 17.6 Awareness of Safe Injection Practices . 239 CHAPTER 18 KNOWLEDGE AND PREVALENCE OF HEPATITIS C 18.1 Hepatitis C Knowledge. 241 18.2 Self-reported Prevalence of Hepatitis C and Liver Disease . 246 18.3 Hepatitis C Testing in the 2008 EDHS. 247 18.3.1 Heptatitis C Testing Protocol. 247 18.3.2 Coverage of the HCV Testing. 248 18.3.3 Return of the Results of the HCV Testing . 251 18.4 Prevalence of Hepatitis C . 251 CHAPTER 19 KNOWLEDGE AND ATTITUDES ABOUT HIV/AIDS 19.1 Knowledge of HIV/AIDS. 259 19.2 Knowledge of Mother-to-Child Transmission . 263 19.3 Accepting Attitudes towards People Living with AIDS. 265 19.4 Knowledge of a Source for HIV Testing . 268 19.5 Sources of Information about AIDS . 269 CHAPTER 20 HEALTH CARE EXPENSES AND HEALTH CARE COVERAGE 20.1 Expenses Associated with Health Provider Visits . 271 20.2 Expenses Associated with Hospital Stays. 274 20.3 Expenses Associated with Maternal Health Services. 276 20.4 Health Insurance Coverage . 278 REFERENCES . 281 APPENDIX A PERSONS INVOLVED IN THE 2008 EGYPT DEMOGRAPHIC AND HEALTH SURVEY . 285 APPENDIX B SAMPLE DESIGN . 291 APPENDIX C ESTIMATES OF SAMPLING ERRORS . 297 APPENDIX D DATA QUALITY TABLES .311 APPENDIX E NUTRITIONAL STATUS OF CHILDREN: 2008 EDHS DATA ACCORDING TO THE NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION . 317 APPENDIX F QUESTIONNAIRES. 321 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Population of Egypt, 1990-2007 .1 Table 1.2 Life expectancy, Egypt .2 Table 1.3 Survey timetable, 2008 EDHS .4 Table 1.4 Sample results.11 Figure 1.1 Trend in Natural Increase Rates. Egypt 1991-2007.2 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS Table 2.1 Household population by age, sex, and residence.13 Table 2.2 Trends in population distribution by age, 1988-2008.15 Table 2.3 Household composition by residence .15 Table 2.4.1 Educational attainment of male household population by age and residence .17 Table 2.4.2 Educational attainment of female household population by age and residence .18 Table 2.5 Household drinking water access and treatment by residence.19 Table 2.6 Household drinking water storage practices by residence.20 Table 2.7 Sanitation facilities by residence.21 Table 2.8 Dwelling characteristics by residence .23 Table 2.9 Household possessions by residence .24 Table 2.10 Wealth quintiles by residence .26 Figure 2.1 Population Pyramid of Egypt .14 CHAPTER 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of ever-married respondents .28 Table 3.2 Educational attainment by background characteristics .29 Table 3.3 Literacy by background characteristics .31 Table 3.4 Exposure to mass media by background characteristics .33 Table 3.5 Employment status by background characteristics .34 Table 3.6 Occupation by background characteristics .36 Table 3.7 Type of employment.37 Table 3.8 Relative magnitude of woman's earnings by background characteristics.38 Table 3.9 Control over woman's earnings .39 Table 3.10 Control over husband's earnings by background characteristics .40 Table 3.11 Relative magnitude of earnings and control over woman's and husband's earnings .41 Table 3.12 Women's participation in decision-making .41 Table 3.13 Women's participation in decision-making by background characteristics.42 Table 3.14 Attitudes towards wife beating by background characteristics .43 x | Tables and Figures Table 3.15 Selected background characteristics of respondents eligible for health issues interview.44 Table 3.16 Literacy status and recent exposure to mass media of respondents eligible for health issues interview .45 Table 3.17 Employment status, occupation, and type of earnings of respondents eligible for health issues interview .45 Figure 3.1 Percentage of Ever-Married Women Exposed to Media at Least Once Per Week.32 Figure 3.2 Occupation among Working Women .35 CHAPTER 4 FERTILITY Table 4.1 Current fertility by residence.47 Table 4.2 Fertility by background characteristics .49 Table 4.3 Trends in age-specific fertility rates.50 Table 4.4 Trends in fertility.51 Table 4.5 Trends in fertility by residence .52 Table 4.6 Children ever born and living.53 Table 4.7 Birth intervals by background characteristics .55 Table 4.8 Ideal birth interval by residence .56 Table 4.9 Age at first birth .57 Table 4.10 Median age at first birth by background characteristics.57 Table 4.11 Teenage pregnancy and motherhood by background characteristics .58 Figure 4.1 Total Fertility Rates by Place of Residence.49 CHAPTER 5 KNOWLEDGE, ATTITUDES, AND EVER USE OF FAMILY PLANNING Table 5.1 Family planning knowledge.59 Table 5.2 Exposure to family planning messages by background characteristics.61 Table 5.3 Knowledge of fertile period.63 Table 5.4 Belief breastfeeding reduces chances of pregnancy .63 Table 5.5 Beliefs concerning breastfeeding and a woman's protection from pregnancy .64 Table 5.6 Ever use of family planning methods by age .65 Table 5.7 Trends in ever use of family planning method .66 Table 5.8 Ever use of family planning methods by background characteristics.67 Table 5.9 Number of living children at time of first use of family planning .68 Table 5.10 Timing of use of family planning among newly married couples by background characteristics .69 Figure 5.1 Trends in Family Planning Knowledge, Egypt 2005-2008 .60 Figure 5.2 Trends in Exposure to Family Planning Messages Egypt 2005-2008 .62 Figure 5.3 Trends in Ever Use of Familly Planning, Egypt 1980-2008 .66 CHAPTER 6 CURRENT USE OF FAMILY PLANNING Table 6.1 Current use of family planning methods by residence .72 Tables and Figures | xi Table 6.2 Current use of family planning methods by selected demographic and social characteristics .73 Table 6.3 Current use of family planning by governorate .74 Table 6.4 Trends in current use of family planning.75 Table 6.5 Trends in family planning method mix .76 Table 6.6 Trends in family planning use by residence .77 Table 6.7 Trends in current use of family planning methods by governorate .78 Table 6.8 Source for modern family planning methods .80 Table 6.9 Sources of family planning methods by residence .81 Table 6.10 Trends in reliance on public sector source for contraceptive method by residence .82 Table 6.11 Brand of pill .82 Table 6.12 Knowledge of pill brand suitable for breastfeeding women.83 Table 6.13 Cost of method for pill users .84 Table 6.14 Cost of method for injectable users .84 Table 6.15 Cost of method for IUD users .85 Table 6.16 Family planning decision-making .86 Table 6.17 Informed choice .88 Figure 6.1 Current Use by Method .71 Figure 6.2 Trends in Current Use, Egypt 1980-2008 .76 CHAPTER 7 NONUSE OF FAMILY PLANNING AND INTENTION TO USE Table 7.1 Contraceptive discontinuation rates .90 Table 7.2 Reasons for discontinuation .91 Table 7.3 Future use of family planning .92 Table 7.4 Reason for not intending to use contraception .93 Table 7.5 Preferred family planning method.93 Table 7.6 Discussion of family planning in contacts with fieldworkers or health providers by background characteristics .94 CHAPTER 8 PROXIMATE DETERMINANTS OF FERTILITY Table 8.1 Current marital status .97 Table 8.2 Consanguinity by background characteristics.98 Table 8.3 Age at first marriage .99 Table 8.4 Median age at first marriage by background characteristics. 100 Table 8.5 Postpartum amenorrhea, abstinence and insusceptibility. 101 Table 8.6 Median duration of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics. 103 Table 8.7 Menopause. 103 Figure 8.1 Percentage of Births Whose Mothers are Amenorrheic, Abstaining, or Insusceptible. 102 CHAPTER 9 FERTILITY PREFERENCES Table 9.1 Fertility preferences by number of living children . 105 xii | Tables and Figures Table 9.2 Fertility preferences by age . 106 Table 9.3 Desire to limit childbearing by background characteristics. 107 Table 9.4 Need for family planning by background characteristics . 109 Table 9.5 Reason for not using contraception . 110 Table 9.6 Ideal number of children . 111 Table 9.7 Mean ideal number of children by background characteristics . 112 Table 9.8 Husband's fertility preference by wife's ideal number of children. 112 Table 9.9 Fertility planning status. 113 Table 9.10 Wanted fertility rates by background characteristics . 114 Figure 9.1 Desire for More Children among Currently Married Women. 106 CHAPTER 10 INFANT AND CHILD MORTALITY Table 10.1 Early childhood mortality rates . 117 Table 10.2 Trends in early childhood mortality. 117 Table 10.3 Early childhood mortality rates by socioeconomic characteristics. 119 Table 10.4 Early childhood mortality rates by demographic characteristics. 121 Table 10.5 Perinatal mortality by background characteristics . 122 Table 10.6 High-risk fertility behavior . 124 Figure 10.1 Trends in Under-five Mortality, Egypt 1967-2006 . 118 Figure 10.2 Under-Five Mortality by Place of Residence . 120 CHAPTER 11 MATERNAL HEALTH CARE AND OTHER WOMEN’S HEALTH ISSUES Table 11.1 Antenatal care. 125 Table 11.2 Tetanus toxoid coverage during pregnancy . 126 Table 11.3 Last birth protected against neonatal tetanus . 127 Table 11.4 Medical care other antenatal care or tetanus toxoid injection during pregnancy. 127 Table 11.5 Care during pregnancy by background characteristics . 128 Table 11.6 Content of pregnancy care. 130 Table 11.7 Place of delivery and time spent in health facility following delivery by background characteristics . 132 Table 11.8 Reason for not delivering last birth in health facility. 133 Table 11.9 Assistance during delivery by background characteristics . 134 Table 11.10 Caesarean deliveries by background characteristics . 135 Table 11.11 Child's size at birth by background characteristics. 136 Table 11.12 Trends in maternal health indicators by residence. 137 Table 11.13 Postnatal care for mother . 139 Table 11.14 Postnatal care for mother by background characteristics. 140 Table 11.15 Postnatal care for child. 141 Table 11.16 Postnatal care for child by background characteristics . 142 Table 11.17 Exposure to family planning and breastfeeding information. 143 Table 11.18 Coverage of safe pregnancy messages by background characteristics . 144 Table 11.19 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms by background characteristics . 146 Table 11.20 Problems in accessing health care . 148 Tables and Figures | xiii Figure 11.1 Trends in Maternal Health Indicators, Egypt 1995-2008. 138 CHAPTER 12 CHILD HEALTH Table 12.1 Vaccinations by source of information. 150 Table 12.2 Vaccinations by background characteristics . 152 Table 12.3 Number of times vaccinated in national immunization day campaigns by residence . 153 Table 12.4 Prevalence of cough. 153 Table 12.5 Consultation about ARI episode . 154 Table 12.6 Treatment and feeding practices for children ill with ARI symptoms . 155 Table 12.7 Prevalence and treatment of ARI symptoms by background characteristics . 156 Table 12.8 Prevalence of diarrhea by background characteristics. 157 Table 12.9 Consultation about diarrheal episode. 158 Table 12.10 Treatment and feeding practices during diarrhea. 159 Table 12.11 Feeding practices during diarrhea . 160 Table 12.12 Consultation with provider and treatment of diarrhea by background characteristics . 162 Table 12.13 Disposal of children's stools. 163 CHAPTER 13 FEEDING PRACTICES AND MICRONUTRIENT SUPPLEMENTATION Table 13.1 Initial breastfeeding by background characteristics . 166 Table 13.2 Breastfeeding status by age . 168 Table 13.3 Median duration and frequency of breastfeeding and prevalence of bottlefeeding by background characteristics . 170 Table 13.4 Foods and liquids consumed by children in the day or night preceding the interview. 172 Table 13.5 Infant and young child feeding (IYCF) practices in Egypt. 174 Table 13.6 Foods and liquids consumed by mothers in the day or night preceding the interview by background characteristics . 176 Table 13.7 Presence of iodized salt in household by background characteristics . 177 Table 13.8 Micronutrient intake among children by background characteristics. 179 Table 13.9 Micronutrient intake among mothers by background characteristics . 181 Figure 13.1 Among Last Children Born in the Five Years Preceding the Survey Who Ever Received Prelacteal Feeds, Percentage Receiving Various Types of Liquids. 167 Figure 13.2 Infant Feeding Practices by Age. 168 Figure 13.3 Infant and Young Child Feeding (IYCF) Practices . 175 CHAPTER 14 NUTRITIONAL STATUS Table 14.1 Nutritional status of children by children's characteristics. 185 Table 14.2 Nutritional status of children by mother's characteristics . 187 Table 14.3.1 Nutritional status of never-married female youth and young adults by background characteristics . 190 Table 14.3.2 Nutritional status of never-married male youth and young adults by background characteristics . 191 xiv | Tables and Figures Table 14.4 Anthropometric indicators of nutritional status of adult women. 192 Table 14.5 Nutritional status of defacto adult women age 15-59 by background characteristics . 193 Table 14.6 Anthropometric indicators of nutritional status of defacto men 15-59 . 194 Table 14.7 Nutritional status of defacto adult men age 15-59 by background characteristics . 195 Figure 14.1 Nutritional Status of Children by Age . 186 Figure 14.2 Trend in Nutritional Status of Young Children (WHO Child Growth Standards), Egypt 2000-2008 . 188 CHAPTER 15 FEMALE CIRCUMCISION Table 15.1 Prevalence of female circumcision among all women 15-49 by background characteristics . 197 Table 15.2 Age at circumcision among all women age 15-49 by residence . 198 Table 15.3 Person performing circumcisions among all women by residence. 198 Table 15.4 Current and expected prevalence of female circumcision among young girls . 199 Table 15.5 Current and expected prevalence of female circumcision among girls by background characteristics . 200 Table 15.6 Age at circumcision among girls by residence. 201 Table 15.7 Person performing circumcisions among girls by residence. 201 Table 15.8.1 Attitude about continuation of female circumcision by background characteristics: All women age 15-49. 202 Table 15.8.2 Attitude about continuation of female circumcision by background characteristics: All men age 15-49. 203 Table 15.9.1 Beliefs about female circumcision by background characteristics: All women age 15-49. 205 Table 15.9.2 Beliefs about female circumcision by background characteristics: All men age 15-49 . 206 Table 15.10.1 Exposure to information regarding female circumcision by background characteristics: All women age 15-49. 207 Table 15.10.2 Exposure to information regarding female circumcision by background characteristics: All men age 15-49. 208 Figure 15.1 Trends in Attitudes toward Female Circumcision among Ever-married Women Age 15-49, Egypt 1995-2008. 204 CHAPTER 16 AVIAN INFLUENZA Table 16.1 Household possession of poultry/birds . 209 Table 16.2 Type of poultry/birds owned . 211 Table 16.3 Locations where poultry/birds kept . 212 Table 16.4 Use of cages or enclosures for poultry/birds. 213 Table 16.5 Awareness of avian influenza and recent sources of information about AI by background characteristics . 214 Table 16.6 Knowledge of avian influenza symptoms in poultry or birds by background characteristics . 215 Tables and Figures | xv Table 16.7 Awareness of risks and symptoms of avian influenza infection in humans by background characteristics . 217 Table 16.8 Knowledge of modes of transmission and prevention for avian influenza. 219 Table 16.9 Awareness of modes of transmission and prevention for avian influenza infection in humans by background characteristics. 220 Table 16.10 Attitudes about avian influenza . 221 Figure 16.1 Trend in Percentage of Households Owning Poultry by Place of Residence, 1988-2008. 210 Figure 16.2 Awareness of Symptoms of Avian Influenza in Poultry or Birds . 216 Figure 16.3 Awareness of Actions to Take When Birds Are Ill or Die Suddenly . 216 Figure 16.4 Awareness of Avian Influenza Symptoms in Humans. 218 CHAPTER 17 ADULT HEALTH ISSUES Table 17.1 Use of tobacco. 224 Table 17.2.1 Prevalence of smoking and exposure to information about health effects of second-hand smoke by background characteristics: Women. 225 Table 17.2.2 Prevalence of smoking and exposure to information about health effects of second-hand smoke by background characteristics: Men . 226 Table 17.3 History of diabetes, heart attack and stroke. 227 Table 17.4 History of hypertension and actions taken to lower blood pressure . 228 Table 17.5 Availability of final blood pressure measurement. 229 Table 17.6.1 Levels of hypertension by socioeconomic characteristics: Women . 231 Table 17.6.2 Levels of hypertension by socioeconomic characteristics: Men. 232 Table 17.7.1 Levels of hypertension by health status measures: Women. 233 Table 17.7.2 Levels of hypertension by health status measures: Men . 234 Table 17.8 Lifetime prevalence of medical procedures by background characteristics. 236 Table 17.9 Prevalence of injections during the six-month period prior to the survey . 237 Table 17.10 Injection prevalence by background characteristics . 238 Table 17.11.1 Exposure to information regarding injection safety by background characteristics: Women. 239 Table 17.11.2 Exposure to information regarding injection safety by background characteristics: Men . 240 Figure 17.1 Awareness of Hypertension and Treatment Status among Hypertensive Women and Men Age 15-59 . 235 CHAPTER 18 KNOWLEDGE AND PREVALENCE OF HEPATITIS C Table 18.1.1 Knowledge of hepatitis C by background characteristics: Women . 242 Table 18.1.2 Knowledge of hepatitis C by background characteristics: Men. 243 Table 18.2.1 Knowledge of the ways a person can contract hepatitis C by background characteristics: Women . 244 Table 18.2.2 Knowledge of the ways a person can contract hepatitis C by background characteristics: Men. 245 Table 18.3 Self-reported prevalence of hepatitis infection, symptoms of liver disease, and liver disease . 246 xvi | Tables and Figures Table 18.4 Coverage of hepatitis C testing among the de facto population age 15-59 years by age . 249 Table 18.5 Coverage of hepatitis C testing among the de facto population age 15-59 years by selected background characteristics . 250 Table 18.6 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by age . 252 Table 18.7 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by socioeconomic characteristics . 254 Table 18.8 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by lifetime history of medical procedures and injections . 256 Figure 18.1 Percentage of Women and Men Positive on the RNA Test for the Hepatitis C Virus by Age . 253 Figure 18.2 Percentage of Women and Men Age 15-59 Positive on HVC-RNA Test by Receipt of Injection to Treat Schistomiasis . 258 CHAPTER 19 KNOWLEDGE AND ATTITUDES ABOUT HIV/AIDS Table 19.1.1 Knowledge of AIDS by background characteristics: Women. 260 Table 19.1.2 Knowledge of AIDS by background characteristics: Men . 261 Table 19.2 Comprehensive knowledge of AIDS among youth by background characteristics . 262 Table 19.3.1 Knowledge of prevention of mother-to-child transmission (PMTCT) of HIV by background characteristics: Women. 264 Table 19.3.2 Knowledge of prevention of mother-to-child transmission (PMTCT) of HIV by background characteristics: Men . 265 Table 19.4.1 Accepting attitudes toward those living with HIV by background characteristics: Women. 266 Table 19.4.2 Accepting attitudes toward those living with HIV by background characteristics: Men . 267 Table 19.5 Knowledge of a place where HIV testing available by background characteristics . 268 Table 19.6.1 Sources of information about AIDS by background characteristics: Women . 269 Table 19.6.2 Sources of information about AIDS by background characteristics: Men. 270 Figure 19.1 Percentage of Youth and Young Adults with Comprehensive AIDS Knowledge by Sex and Urban-Rural Residence . 263 CHAPTER 20 HEALTH CARE EXPENSES AND HEALTH CARE COVERAGE Table 20.1 Visit to health provider recently . 272 Table 20.2 Expenses for last health care consultation. 273 Table 20.3 Total expenses incurred for last health care consultation by type of provider consulted. 274 Table 20.4 Hospital stays in past 12 months . 275 Table 20.5 Total expenses incurred relating to last hospitalization . 276 Table 20.6 Total expenses incurred relating to antenatal care services . 276 Table 20.7 Total expenses incurred relating to delivery services. 277 Table 20.8 Total expenses incurred relating to postnatal care services. 277 Tables and Figures | xvii Table 20.9 Health insurance coverage. 278 Figure 20.1 Percentage of Women and Men Age 15-59 Covered by Health Insurance, According to Place of Residence . 279 APPENDIX B SAMPLE DESIGN Table B.1 Sample allocation for the 2008 EDHS .293 Table B.2.1 Sample implementation for ever-married women component of the 2008 EDHS . 294 Table B.2.2 Sample implementation for health issues component of the 2008 EDHS. 295 APPENDIX C ESTIMATES OF SAMPLING ERRORS Table C.1 List of selected variables for sampling errors, Egypt 2008. 298 Table C.2 Sampling errors for National sample, Egypt 2008 . 299 Table C.3 Sampling errors for Urban sample, Egypt 2008. 300 Table C.4 Sampling errors for Rural sample, Egypt 2008 . 301 Table C.5 Sampling errors for Urban Governorates sample, Egypt 2008 . 302 Table C.6 Sampling errors for Lower Egypt sample, Egypt 2008. 303 Table C.7 Sampling errors for Lower Egypt, Urban sample, Egypt 2008. 304 Table C.8 Sampling errors for Lower Egypt, Rural sample, Egypt 2008 . 305 Table C.9 Sampling errors for Upper Egypt sample, Egypt 2008 . 306 Table C.10 Sampling errors for Upper Egypt, Urban sample, Egypt 2008 . 307 Table C.11 Sampling errors for Upper Egypt, Rural sample, Egypt 2008 . 308 Table C.12 Sampling errors for Frontier Governorates sample, Egypt 2008. 309 APPENDIX D DATA QUALITY TABLES Table D.1 Household age distribution . 311 Table D.2 Age distribution of eligible and interviewed women . 312 Table D.3 Completeness of reporting . 312 Table D.4 Reporting of age at death in days . 313 Table D.5 Reporting of age at death in months. 314 Table D.6 Births by calendar years . 315 APPENDIX E NUTRITIONAL STATUS OF CHILDREN: 2008 EDHS DATA ACCORDING TO THE NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION Table E.1 Nutritional status of children by children's characteristics according to the NCHS/CDC/WHO International Reference Population . 317 Table E.2 Nutritional status of children by mother's characteristics according to the NCHS/CDC/WHO International Reference Population . 318 xviii | Tables and Figures Table E.3 Trends in nutritional status of children according to the NCHS/CDC/WHO International Reference Population . 319 Figure E.1 Trend in Nutritional Status of Young Children, Egypt 1992-2008 (NCHS/CDC/WHO Reference Population). 319 Preface | xix PREFACE Health for all is the main health objective of the Egyptian government. To monitor and evaluate progress toward the achievement of this goal, reliable data are needed. These data come from two primary sources: the health service delivery system (service-based data) and the community (household-based data). The two types of data complement each other in enhancing the information available to monitor progress in the health sector. Beginning in 1980, a number of household surveys have been carried out in Egypt to obtain data from the community on the current health situation, including a series of Demographic and Health Sur- veys of which the 2008 EDHS is the most recent. The results of the 2008 EDHS show that several key maternal and child health indicators including antenatal care coverage, medical assistance at delivery, and infant and child mortality have improved. The survey also found that family planning use is rising and fertility is continuing to decline although at a slow pace. In addition, the 2008 Egypt DHS collected information relating to other health issues that Egypt is facing including knowledge and practices relating to avian influenza and the prevalence of high blood pressure among the adult population. By collecting and testing blood samples for the hepatitis C virus from respondents, the survey also provides the first nation-wide data on the prevalence of infection with the hepatitis C virus among the Egyptian population age 15-59 years. The findings of the 2008 EDHS together with service-based data are very important for measur- ing the achievements of the health program to date as well as for planning future interventions to address Egypt’s health challenges. Based on the above-mentioned considerations, it is very important that the re- sults of the 2008 EDHS should be widely disseminated at different levels of health management, in the central offices as well as local governments, and to the community at large. Prof. Dr. Hatem El-Gabaly Minister of Health Acknowledgments | xxi ACKNOWLEDGMENTS The 2008 Egypt Demographic and Health Survey continues the long-standing commitment and efforts in Egypt to obtain data on fertility, contraceptive practice and maternal and child health. The focus on avian influenza, hepatitis C and adult health issues including hypertension reflects the need to obtain data to better address these challenges. Overall, the wealth of demographic and health data that the survey provides will help in charting future directions for the population and health programs. This important survey could not have been implemented without the active support and dedicated efforts of a large number of institutions and individuals. The support and approval of H.E. Prof. Dr. Hatem El-Gabaly was instrumental in securing the implementation of the EDHS. USAID/Cairo through its bilateral health and population projects was the main contributor of funding for the survey. UNICEF also provided financial support. Technical assistance came from the USAID-sponsored MEASURE DHS project. I am deeply grateful to the Ministry of Health (MOH) staff who contributed to the successful completion of this project, especially Dr.Nasr EL-Sayed, Minister Assistant of Primary Health Care, Pre- vention, and Family Planning, who provided strong continuing support to the project and has shown great interest in the survey results. Special thanks also go to Dr. Amr Kandil, Under Secretary of Preventive Affairs, for his continuous support during the survey implementation. I also gratefully acknowledge the Population and Health Office staff at USAID/Cairo, especially Ms. Holly Fluty Dempsey, Director of the Population and Health Office, and Ms. Shadia Attia, Research and Monitoring Advisor, Population and Health Office, for their support and valuable comments through- out the survey activities. I would like to thank the administrative staff at USAID and the American Em- bassy who helped to ensure that the equipment and supplies used for the hepatitis C component were available on time to start the fieldwork. I also acknowledge with gratitude Mr. Dennis Arends, Chief of Social Policy Monitoring and Evaluation, and Ms. Manar Soliman, Senior Program Assistant, UNICEF, for their support. The Hepatitis C testing was carried out at the Central Health Laboratory (MOH). I would like to thank Dr. Aly Abdelstar, Dr. Amal Naguib, and Dr. Ahmed Safwat at the Central Laboratory for their dedication in completing the testing in a very timely fashion. I would also like to thank Dr. Mohamed Aly Saber and Dr. Effat El-Sherbiny at the Theodor Bil- harz Research Institute (TBRI) for the support that TBRI provided during the quality assurance testing. Dr. Ann Way of Macro International, who worked closely with us on all phases of EDHS, de- serves special thanks for all her efforts throughout the survey. My thanks also are extended to Dr. Alfredo Aliaga for his advice and guidance in designing the sample. Ms. Jeanne Cushing deserves my deepest thanks for her assistance in data processing and tabulation required for this report. Ms. Jasbir Sangha pro- vided invaluable assistance with the hepatitis C testing component of the survey. Special thanks extend to the staff at the family planning sector/MOH for their financial and ad- ministrative support. xxii | Acknowledgments I would like to express my appreciation for all the senior, office, and field staff at El-Zanaty and Associates for the dedication and skill with which they performed their tasks. Finally, I would like to express my appreciation to all households and participants who responded in the survey; without their participation this survey would have been impossible. Fatma El-Zanaty Technical Director Summary of Findings | xxiii SUMMARY OF FINDINGS The 2008 Egypt Demographic and Health (2008 EDHS) Survey is the ninth in a series of Demographic and Health Surveys conducted in Egypt. The 2008 EDHS was undertaken to pro- vide estimates for key population indicators in- cluding fertility, contraceptive use, infant and child mortality, immunization levels, maternal and child health, and nutrition. To obtain this information, a nationally representative sample of 16,527 ever-married women age 15-49 was interviewed. The 2008 EDHS also collected information on a number of other health topics from 6,578 women and 5,430 men age 15-59 living in a subsample of one in four of the households sur- veyed. Among the key topics covered in these interviews were knowledge and awareness of avian influenza, HIV/AIDS and hepatitis C; pre- vious history of hypertension, cardiovascular illness diabetes and liver disease; attitudes and behavior with respect to female circumcision; health care costs; and health insurance coverage. In addition to the interview results, blood pressure measurements and blood samples for hepatitis C testing were obtained from women and men age 15-59 interviewed in the special health issues component of the survey. Height and weight measures were collected for children under age six and never-married youths and young adults age 10-19 years in all households in the survey. In the subsample of households selected for the health issues survey, these measurements were also obtained for all women and men age 20-59 while in the remaining households in the sample, measurements were recorded only for ever-married women age 20-49. FERTILITY BEHAVIOR Levels, Trends and Differentials. The fer- tility rate in the 2008 EDHS was 3.0 births per woman, only very slightly lower than the rate observed in the 2005 EDHS (3.1 births per woman). In rural areas, the fertility rate is 3.2 births, around 20 percent higher than the rate in urban areas (2.7 births). Fertility levels are highest in Upper Egypt (3.4 births) and in the Frontier Governorates (3.3 births) and lowest in the Urban Governorates (2.6 births). Education is strongly associated with lower fertility as is wealth. The fertility rate decreases from a level of 3.4 births among women in the lowest wealth quintile to 2.7 births among women in the highest quintile. Age at Marriage. One of the factors influencing the on-going fertility decline in Egypt has been the steady increase in the age at which women marry. Currently, the median age at first marriage among women age 25-29 is 21.2 years. One of the most important effects of the increase in the age at first marriage has been a reduction in adolescent fertility. Adolescent childbearing carries higher risks of morbidity and mortality for the mother and child, particularly when the mother is under age 18. At the time of the 2008 EDHS, 10 per- cent of women age 15-19 had given birth or were pregnant with their first child. FAMILY PLANNING USE Family Planning Knowledge and Attitudes. Widespread awareness of family planning methods has been a crucial element in the successful expan- sion of family planning use in Egypt. The 2008 EDHS found that all currently married women age 15-49 knew about at least one family planning method, and the average woman was aware of at least 6 methods. Coverage of family planning IEC efforts is widespread. However, only 67 percent of married women had heard or seen a family planning message during the six months prior to the 2008 EDHS, which is substantially lower than the level of exposure to family planning messages reported in 2005 EDHS (91 percent). xxiv | Summary of Findings Family planning has broad support among Egyptian couples. Most ever-married women age 15-49 (93 percent) consider it appropriate for a couple to begin family planning use after they have their first child. However, very few women who approve of family planning use (2 percent) think that it is appropriate for a newly married couple to use contraception to delay the first pregnancy. Levels and Trends. The Egyptian govern- ment’s commitment to providing widely acces- sible family planning services has been a very important factor in the on-going fertility decline. Contraceptive use levels more than doubled in Egypt between 1980 and 2003, from 24 percent to 60 percent. The 2008 EDHS results indicate that the contraceptive use remains stable at 60 percent. The IUD continues to be by far the most widely used method; 36 percent of married women were relying on the IUD, 12 percent on the pill, and 7 percent on injectables. Differentials in Use. As expected, given the nearly universal disapproval of family planning use before the first birth, less than 1 percent of currently married women who had not yet had a child were using at the time of 2008 EDHS. Use rates increased rapidly with family size; 46 per- cent of women with one child were using and use rates peaked at 76 percent among women with 3 children. Use rates exceeded 60 percent in the Urban Governorates, in both urban and rural areas in Lower Egypt, and in urban areas in Upper Egypt. In contrast, 48 percent of currently mar- ried women were using in rural Upper Egypt and 52 percent in the Frontier Governorates. Use rates rose from 55 percent of women in the low- est wealth quintile to 65 percent among women in the highest quintile. Discontinuation of Use. A key concern for the family planning program is the rate at which users discontinue use of contraception and their reasons for stopping. Overall, 26 percent of us- ers during the five-year prior to the 2008 EDHS discontinued using a method within 12 months of starting use. The rate of discontinuation during the first year of use was much higher among pill us- ers (40 percent) and injectable users (37 percent) than among IUD users (12 percent). With regard to the reasons for stopping use, users were more likely to discontinue during the first year of use because they experienced side effects or had health concerns. This pattern is similar to that observed in 2005. Overall, 8 percent of users who discontinued during the first 12 months of use switched to another method within two months of the time they discon- tinued. Provision of Services. Both government health facilities and private sector providers play an impor- tant role in the delivery of family planning services. The 2008 EDHS showed that 60 percent all users of modern methods went to Ministry of Health or other governmental providers for their method. This repre- sents a slight increase from the situation in 2005, when 57 percent of users relied on public sector fa- cilities for their methods. Public sector providers were the principal source for the IUD and injectables at the time of the 2008 EDHS while seven in ten pill users obtained their method from a pharmacy. The 2008 EDHS results suggest that family planning providers are not always offering women the information necessary to make an informed choice about the method best suited to their contra- ceptive needs. In particular, around one in three us- ers of modern methods were not provided informa- tion about methods other than the one they adopt. Although side effects caused many users to discon- tinue, providers also were counselling only slightly more than half (56 percent) of the users about poten- tial side effects. NEED FOR FAMILY PLANNING Fertility Preferences. Many Egyptian women are having more births than they consider ideal. Overall, 5 percent of births in the five years prior to the survey were reported to be mistimed, that is, wanted later, and 9 percent were unwanted. If Egyp- tian women were to have the number of children they consider ideal, the total fertility rate would fall from 3.0 births to 2.4 births per woman. Unmet Need for Family Planning. Taking into account both their fertility desire at the time of the Summary of Findings | xxv survey and their exposure to the risk of preg- nancy, 9 percent of currently married women were considered to have an immediate need for family planning. Unmet need is greatest among women in rural Upper Egypt, where 15 percent of women are in need of family planning to achieve their childbearing goals. INFANT AND CHILD MORTALITY Levels and Trends. At the mortality level prevailing in the five-year period before the 2008 EDHS, one in 36 Egyptian children will die before their fifth birthday, with more than 80 percent of deaths occurring during a child’s first birthday. The level of early childhood mortality has fallen substantially since the mid-1960s, when around one in four children died before reaching age five. Socioeconomic Differentials. Mortality is higher in rural than urban areas. The highest level is found in Upper Egypt and the lowest in Lower Egypt. Differentials are especially large across wealth quintiles; children born to women in the lowest wealth quintile are around two and one half times more likely to die by their fifth birthday than children born to mothers in the highest quintile. Demographic Differentials. Mortality risks are especially high for births that occur within too short a period after a prior birth. The under- five mortality rate among children born less than two years after a previous birth was 70 deaths per 1,000 births, more than three times the level among children born four or more years after a previous birth. During the five years prior to the 2008 EDHS, 18 percent of non-first births occurred within 24 months of a previous birth. Breast- feeding practices, especially the early introduc- tion of supplemental foods, reduce the time a woman is amenorrheic following a birth and, thus, contribute to short birth intervals. Half of Egyptian mothers become exposed to the risk of another pregnancy within four months of giving birth. MATERNAL HEALTH Care during Pregnancy. The care that a woman receives during pregnancy reduces the risks of illness and death for both the mother and the child. Overall, women saw a medical provider for at least some type of care during pregnancy in the case of 94 percent of all last births that occurred during the five-year period prior to the 2008 EDHS. Women reported that they had antenatal care, i.e., care sought specifically to monitor the pregnancy, in the case of 74 percent of births. They saw a provider for the recommended minimum number of antenatal care visits (four) in the case of 66 percent of births. Tetanus toxoid injections are given during preg- nancy for the prevention of neonatal tetanus, an im- portant cause of death among newborns. Around 76 percent of last-born children during the five-year period prior to the 2008 EDHS were fully protected against neonatal tetanus. Content of Pregnancy Care. Women reported that they had been weighed and their blood pressure monitored during pregnancy in the case of more than eight in ten births in which a medical provider was seen for pregnancy care. Urine and blood samples were taken from the mother during antenatal care visits for almost seven in ten births. Mothers were less likely to have been given advice about potential pregnancy complications; they reported being told about the signs of pregnancy complications in about one-third of the births and about where to seek assis- tance if they experienced problems in the case of 31 percent of the births. Delivery Care. Trained medical personnel as- sisted at 79 percent of births during the five-year period prior to the 2008 EDHS. Dayas (traditional birth attendants) assisted with most of the remaining deliveries. 72 percent of deliveries took place in a health facility, with delivery care provided some- what more often at private than governmental facili- ties. Almost three in ten deliveries were by Caesar- ean section. Postnatal Care. Care following delivery is very important for both the mother and her child, espe- cially if the birth occurs in the home without medical assistance. In Egypt, mothers reported they were seen for postnatal care following 67 percent of all xxvi | Summary of Findings deliveries but in only 7 percent of deliveries that were not assisted by a medical provider. Thirty percent of infants born during the five-year pe- riod prior to the EDHS were seen for postnatal care. However, a recent campaign to encourage mothers to have a blood sample taken from the child’s heel for screening within two weeks fol- lowing delivery has been effective; 90 percent of last-born children had a blood sample taken from the heel within two weeks following deliv- ery. Differentials in Coverage. A woman’s resi- dence and education status are strongly associ- ated with the receipt of maternity care. For ex- ample, the percentage of births in which the mother received regular antenatal care was 57 percent among rural births compared to 80 per- cent among urban births. Coverage of maternity care services is especially low in rural Upper Egypt, where regular antenatal care was received for 49 percent of births and 59 percent of deliv- eries were medically assisted. Regular antenatal care was received for just over 40 percent of births to women in the lowest wealth quintile compared to nearly 90 percent of births to women in the highest quintile. The proportion of births assisted by a medical provider rose stead- ily with the wealth quintile from 55 percent in the lowest quintile to 97 percent in the highest quintile. Trends in Coverage. Coverage of mater- nity care services has improved markedly in Egypt. Coverage of antenatal care services grew from 39 percent in 1995 to 74 percent in 2008. Medically assisted deliveries also increased over the period, from a level of 46 percent in 1995 to 79 percent in 2008. Of some concern is the four- fold increase in Caesarean deliveries, from 7 percent in 1995 to 28 in 2008. CHILD HEALTH Childhood Vaccination Coverage. One of the primary means for improving survival during childhood is increasing the proportion of chil- dren vaccinated against the major preventable diseases. The 2008 EDHS found that that 92 percent of children 12-23 months were fully immunized against the six major preventable childhood illnesses (tuberculosis, diphtheria, whoop- ing cough, tetanus, polio and measles). In addition, 96 percent of young children also had the recom- mended three doses of the hepatitis vaccine. Prevalence and Treatment of Childhood Ill- nesses. The 2008 EDHS provided data on the preva- lence and treatment of two common childhood ill- nesses, diarrhea and acute respiratory illness. Nine percent of children under five were reported to have had diarrhea in the two weeks preceding the survey. Medical advice was sought in treating somewhat more than half (56 percent) of these cases. Use of ORS packets (28 percent) or a homemade solution of sugar, salt and water (3 percent) to combat the dehy- dration was common. Altogether 38 percent of chil- dren ill with diarrhea were treated with some form of ORT or increased fluids. A child was considered to have symptoms of an acute respiratory infection if he/she had a cough ac- companied by short, rapid breathing that the mother described as related to a chest problem. During the two weeks preceding the survey, 8 percent of chil- dren had ARI symptoms. A provider was consulted about the illness in the case of 79 percent of children with these symptoms, and mothers reported that an- tibiotics were given to 58 percent of the children. NUTRITION INDICATORS FOR CHILDREN AND WOMEN Infant Feeding Practices. Breastfeeding is nearly universal in Egypt, and the average length of time that a child is breastfed is relatively long (17.9 months). However, breastfeeding practices for very young children are not optimal. According to the 2008 EDHS results, 47 percent of infants received prelacteal feeds (i.e., they are given some type of liquid until the mother’s breast milk flows freely). Exclusive breastfeeding (i.e., without any food or liquid) is recommended during the first six months of life because it provides all the necessary nutrients and avoids exposure to disease agents. However, in Egypt, only a minority of babies are exclusively breastfed throughout the first 6 months of life. By age 4-5 months, around seven in ten ba- bies born during the five-year period before the EDHS were receiving some form of supplementa- Summary of Findings | xxvii tion, with somewhat more than three in ten given complementary foods. Appropriate infant and young child feeding (IYCF) practices include timely initiation of feeding solid/semi-solid foods from age six months and increasing the amount of foods and frequency of feeding as the child gets older while maintaining frequent breastfeeding. Feed- ing practices for only around 40 percent of chil- dren age 6-23 months met the minimum stan- dard with respect to all three of these feeding practices. Nutritional Status of Children. Using growth standards generated by WHO from data collected in a Multicentre Growth Reference Study, the 2008 EDHS found that 29 percent of Egyptian children age 0-4 years showed evi- dence of chronic malnutrition or stunting, and 7 percent are acutely malnourished. A comparison of the results with the 2005 EDHS suggested that children’s nutritional status deteriorated dur- ing the period between the two surveys. For ex- ample, the stunting level increased by 26 percent between the surveys. Nutritional Status of Youth and Young Adults. Five percent of never-married males age 10-19 and six percent of never-married females age 10-19 in Egypt were classified as over- weight, i.e., their BMI values at or above the 95th percentile on age and sex-specific BMI growth charts. The BMI values for an additional 15 percent of males and 19 percent of females fell between the 85th and 95th percentiles, indi- cating that they were at risk of becoming over- weight. At the other end of the scale, 5 percent of males and 3 percent of females were consid- ered to be underweight, i.e., their BMI values fall below the 5th percentile on the growth charts. Nutritional Status of Women and Men Age 15-59. One indicator of the nutritional status of adults is the body mass index. Exclud- ing those who were pregnant or less than two months postpartum, the mean BMI of all women age 15-59 was 28.9. The majority of women had a BMI of 25.0 or higher and are considered overweight (28 percent) or obese (40 percent). Two percent of women had a BMI below 18.5, the level indicating chronic energy deficiency. The mean BMI among men age 15-59 was 25.8, which was below that observed for nonpregnant women. The majority of men had a BMI of 25.0 or higher and were considered overweight (34 percent) or obese (18 percent). Three percent of men had a BMI below 18.5. Vitamin A Supplementation. Vitamin A is a micronutrient found in very small quantities in some foods. It is considered essential for normal sight, growth, and development. Information collected in the survey on the diet of young children and their mothers indicates that 36 percent of children under age 3 and slightly more than half of their mothers are consuming foods rich in vitamin A on a daily basis. Egypt has a program of vitamin A supplementa- tion for new mothers and for babies. Mothers re- ported receiving a vitamin A capsule postpartum in the case of nearly 57 percent of all births in the five- year period before the survey. Around 12 percent of children age 6-59 months had received a vitamin A capsule. Iodization of Salt. Iodine is another important micronutrient. Egypt has adopted a program of forti- fying salt with iodine to prevent iodine deficiency. Overall, 79 percent of households were found to be using salt containing some iodine. FEMALE CIRCUMCISION Level and Trends. Female circumcision (also referred to as female genital cutting) has been a tra- dition in Egypt since the Pharonic period. The 2008 EDHS obtained information from all women inter- viewed in the survey on their circumcision status and from ever-married women on the circumcision status of their daughters age 17 and younger. Overall, 91 percent of all women age 15-49 have been circum- cised. However, there is evidence that the practice may be declining. For example, while exceeding 80 percent, female circumcision rates among women under age 25 are lower than rates in the 25-49 age groups, where 94-96 percent of women have been circumcised. The likelihood that a woman is circum- cised also declines with the woman’s education level and is markedly lower among women in the highest xxviii | Summary of Findings wealth quintile than in other quintiles (78 per- cent versus 92 percent or higher). The data collected on daughter’s circumci- sion status also indicates that the practice will continue to decline over the next 15-20 years, from the current level of around 80 percent among girls approaching their 18th birthday to around 45 percent. Attitudes and Beliefs. Attitudes about cir- cumcision also appear to be changing. The pro- portion of ever-married women age 15-49 women who believe that circumcision should continue has dropped from 82 percent in 1995 to 63 percent at the time of the 2008 EDHS. KNOWLEDGE AND PREVALENCE OF HEPATITIS C Awareness of hepatitis C and modes of transmission. Eighty percent of women and 85 percent of men age 15-59 were aware of hepati- tis C. Men were somewhat more knowledgeable than women about modes in which hepatitis C virus can be transmitted. Seventy-nine percent of men knowing about hepatitis C were able to name at least one way in which the virus can be transmitted compared to 70 percent of women. Prevalence of hepatitis C infection. In ad- dition to responding to questions about hepatitis C, women and men age 15-59 years living in the subsample of households selected for the health issues survey were asked to provide blood sam- ples for testing for the hepatitis C virus. Overall, 15 percent of women and men age 15-59 had antibodies to the HCV virus in their blood, indi- cating that they had been exposed to the virus at some point. Ten percent were found to have an active infection. Men (12 percent) were more likely to be in- fected than women (8 percent) and, the levels of infection increased sharply with age among both women and men. In the 55-59 year age group, 30 percent of men and 24 percent of women showed evidence of active infection. HCV infec- tion was higher among rural than urban residents (12 percent compared with 7 percent). Active infection rates were particularly high among individuals who reported receipt of at least one injection to treat schistosomiasis (20 percent) compared to those who had not received such an injection (9 percent). These results support the as- sumption that improper infection control procedures during schistosomiasis treatment campaigns played an important role in the spread of hepatitis C infec- tion in Egypt. HIGH BLOOD PRESSURE Blood pressure measurements were taken at three points during the special health issues inter- views with women and men age 15-59. The results of these measurements were combined with informa- tion obtained from respondents on whether they were taking medication to lower blood pressure to assess the level of hypertension among the EDHS respondents. Overall, 13 percent of women and 11 percent of men were considered to be hypertensive. Hypertension levels for both women and men in- creased steadily with age. For example, women age 55-59 were more than three times as likely as women age 35-39 to be hypertensive (46 percent and 13 percent, respectively). As expected, nutritional status also was strongly related to the rate of hypertension for both women and men. Women classified as obese were around four times as likely (21 percent) as women with BMI within the normal range (5 percent) to be hyperten- sive, while women classified as overweight were twice as likely (11 percent and 5 percent, respec- tively). Among men, 18 percent of those who were obese and 13 percent of those who were overweight were hypertensive compared to only 6 percent of men whose BMI fell within the normal range. AVIAN INFLUENZA Household ownership of poultry and birds. The 2008 EDHS found that around one in six house- holds owned or kept poultry. This is about half the level reported in the 1988 Egypt DHS (33 percent). To reduce the potential for transmission of the avian influenza virus from birds to humans, it is recom- mended that poultry or birds be located away from the household living area; however, around one in Summary of Findings | xxix five households were keeping poultry or birds within the family living area. Awareness of modes of transmission and prevention of avian influenza. Virtually all women and men age 15-59 (99 percent) had heard about avian influenza. Seven in 10 re- spondents who had heard of avian influenza were knowledgeable about the symptoms of the disease to watch for in poultry or birds. With regard to symptoms of avian influenza in hu- mans, around six in ten respondents who had heard of avian influenza were able to name at least one symptom of avian influenza in humans. Most respondents who were aware that humans could contract the avian influenza virus were able to name at least one way in which a person might contract the virus and at least one way in which the risk of infection might be reduced. However, only 8 percent were able to name at least four ways in which the virus might be transmitted to a person and only 21 percent were able to name four ways to limit the chance of infection. OTHER HEALTH ISSUES Awareness of HIV/AIDS. Seventy-three percent of women and 87 percent of men age 15-59 have heard about HIV/AIDS. Although many women and men had a basic knowledge of AIDS, the proportions aware of ways in which the risk of infection can be reduced were gener- ally low. Overall, only 7 percent of women and 18 percent of men were classified as having comprehensive correct knowledge about AIDS. Injection safety. Failure to follow safe injection practices increases the risk of transmission of blood- borne pathogens. The EDHS collected information from all respondents to assess the coverage of recent IEC efforts designed to increase population aware- ness about safe injection practices. Twenty-seven percent of women and 19 percent of men age 15-59 reported that they had received information about what people should do to be sure that injections are given safely in the six months prior to the survey. The EDHS also collected information on the prevalence of injections and on the degree of com- pliance with injection safety procedures. Sixteen percent of respondents had had at least one injection during the six-month period prior to the survey. Among those who had had an injection, 70 percent had received at least one medical injection, i.e., an injection administered by a doctor, nurse, pharmacist or other health care provider. Eighty-four percent of those respondents who had had a medical injection said that the medical provider had taken the syringe and needle from a new unopened package. Smoking. Less than 1 percent of women age 15-59 themselves currently smoke or use any form of tobacco compared to 44 percent of men in the same age group. Thirty-nine percent of women and 37 percent of men had received information about the adverse health effects of second-hand smoke in the six-month period prior to the 2008 EDHS. Health insurance coverage. Slightly more than one in four respondents age 15-59 years (28 percent) had health insurance. Around six in ten respondents who were insured had coverage from the General Health Insurance Authority, 27 percent had coverage through their own or another family member’s em- ployer, 10 percent (primarily among those under age 25) had insurance through a university, and 4 per- cent through a syndicate. xxx | Map of Egypt Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY Egypt is located in the northeast corner of the African continent. It is bordered by Libya to the west, Sudan to the south, the Red Sea to the east, and the Mediterranean Sea to the north. Egypt has the largest, most densely settled population among the Arab countries. The total area of the country covers approximately one million square kilometres. However, much of the land is desert, and only 6 percent of Egypt’s area is inhabited. Recently, the Egyptian government adopted a policy of land reclamation and fostering of new settlements in the desert. Despite these efforts, the majority of Egyptians live either in the Nile Delta located in the north of the country or in the narrow Nile Valley south of Cairo. At the time the fieldwork for the 2008 Egypt Demographic and Health Survey began (EDHS), Egypt was administratively divided into 26 governorates (see map) and Luxor City.1 The four Urban Governorates (Cairo, Alexandria, Port Said, and Suez) have no rural population. Each of the other 22 governorates is subdivided into urban and rural areas. Nine of these governorates are located in the Nile Delta (Lower Egypt), eight are located in the Nile Valley (Upper Egypt), and the remaining five Frontier Governorates are located on the eastern and western boundaries of Egypt. 1.2 POPULATION SIZE AND STRUCTURE The latest population census in Egypt was carried out in November 2006. According to the results, Egypt has a de facto population of 72.2 million. This number excludes the roughly 3.9 million Egyptians who are living abroad. By the beginning of 2008, it is estimated that population had increased by around one and half million to reach 74.3 million (CAPMAS 2008). Table 1.1 presents the trend between 1990 and 2007 in the size of Egypt’s population and in the distribution of the population by urban-rural residence. The table shows that the total Egypt’s population increased during this period by more than 40 percent. Despite the sizeable population expansion, the percentage of the Egyptian population living in areas classified as urban remained virtually unchanged during the period. 1.3 RECENT RATE OF NATURAL INCREASE The rate of natural increase represents the differ- ence between the level of births and deaths in a population. It indicates how fast a population will grow, taking into 1In May 2008, two new governorates were created: 6th of October and Helwan. These governorates were created from Cairo and Giza governorates. Table 1.1 Population of Egypt, 1990-2007 Total population in Egypt and the percentage living in urban and rural areas, 1990-2007 Place of residence Years Total population (millions)1 Urban Rural 1990 51,911 43.4 56.6 1991 52,985 43.2 56.8 1992 54,082 43.2 56.8 1993 55,201 43.1 56.9 1994 56,344 43.1 56.9 1995 57,642 42.9 57.1 1996 58,835 42.6 57.4 1997 60,053 42.6 57.4 1998 61,296 42.6 57.4 1999 62,565 42.5 57.5 2000 63.860 42.5 57.5 2001 65,182 43.1 56.9 2002 66,531 42.9 57.1 2003 67,908 42.9 57.1 2004 69,313 42.8 57.2 2005 70,748 42.7 57.3 2006 72,212 42.5 57.5 2007 73,608 43.1 56.9 1 Figures exclude Egyptians living abroad Source: CAPMAS 2008, Table 2.2 2 | Introduction account these two natural events. Figure 1.1 shows that the rate of natural increase has been declining in Egypt since 1991.2 Most of the decline in the rate of natural increase has been the result of changes in fertility behaviour. The crude birth rate (CBR) dropped from a level of 39 per thousand population in 1986 (not shown) to 28 per thousand by 1994. As Figure 1.1 shows, the decline levelled off in the mid-1990s, with the CBR fluctuating around a level of 27 births per thousand until the end of the decade. At that point, the CBR resumed declining although slowly reaching a level of 25.7 in 2006 and then rising slightly to 26.6 in 2007. The crude death rate (CDR), already at a comparably low level in 1990, also declined further in the period although the pace of decline was slow and erratic with a level of 6.1 in 2007. The declines in mortality Egypt has experienced have had a demonstrable effect on increasing the life expectancy at birth of the Egyptian population. Life expectancy at birth represents the average number of years a child born in a specific year may be expected to live during his/her lifetime. As Table 1.2 shows, life expectancy increased by 20.2 years for females and 17.9 years for males between 1960 and 2007. 2 A third factor influencing population growth is migration, which is not taken into account in Figure 1.1. Table 1.2 Life expectancy, Egypt Life expectancy at birth by sex, Egypt 1960-2007 Year Male Female 1960 51.6 53.8 1976 52.7 57.7 1986 60.5 63.5 1991 62.8 66.4 1996 65.1 69.0 1999 66.3 70.5 2001 67.1 71.5 2002 67.5 71.9 2003 67.9 72.3 2004 68.4 72.8 2005 68.8 73.5 2006 69.2 73.6 2007 69.5 74.0 Source: CAPMAS, 2008, Table 3.7 Figure 1.1 Trend in Natural Increase Rates Egypt 1991-2007 ) )) ) ) ) ) ) ) ) ) ) ) ) ) ) ) 7.2 6.9 6.7 6.6 6.7 6.5 6.5 6.5 6.4 6.3 6.2 6.4 6.1 6.4 6.4 6.3 6.1 + ++ + + + + + + + + + + + + + + 30 26.9 28.1 27.7 27.9 28.3 27.5 27.5 27 27.4 26.7 26.5 26.2 25.7 25.5 25.7 26.6 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year 0 5 10 15 20 25 30 35 Percentage Crude birth rate Crude death rate+ ) Source: CAPMAS 2008 Note: Rates are per thousand population. Introduction | 3 1.4 2008 EGYPT DEMOGRAPHIC AND HEALTH SURVEY 1.4.1 Organization and Objectives The Egypt Demographic and Health Survey (2008 EDHS) is the latest in a series of a nationally representative population and health surveys conducted in Egypt.3 The 2008 EDHS was conducted under the auspices of the Ministry of Health (MOH) and implemented by El-Zanaty & Associates. Technical support for the 2008 EDHS was provided by Macro International through the MEASURE DHS project. MEASURE DHS is sponsored by the U.S. Agency for International Development (USAID) to assist countries worldwide in conducting surveys to obtain information on key population and health indicators. USAID/Cairo was the main financial contributor to the survey. The United Nations Children’s Fund (UNICEF) also supported the survey financially. The 2008 EDHS was undertaken to provide estimates for key population indicators including fertility, contraceptive use, infant and child mortality, immunization levels, coverage of antenatal and delivery care, maternal and child health, and nutrition. In addition, the survey was designed to provide information on a number of health topics and on the prevalence of hepatitis C and high blood pressure among the population age 15-59 years. The survey results are intended to assist policymakers and planners in assessing the current health and population programs and in designing new strategies for improving reproductive health and health services in Egypt. 1.4.2 Timetable The 2008 EDHS was executed in four stages. The first stage involved preparatory activities, including designing the sample and updating the frame. At the same time, the survey questionnaires were developed, pretested, and finalized. The preparatory stage was initiated in August 2007, and all of the activities were completed by end of January 2008. The second stage, which took place from February through June 2008, involved training of field staff and interviewing eligible households and individual respondents. The third stage encompassed all of the data processing activities necessary to produce a clean data file, including editing, coding, entering and verifying the data as well as checking it for consistency. This stage started soon after the beginning of the fieldwork and lasted until early August 2008. The focus of the final stage of the survey was analyzing the data and preparing the report. This phase began in October 2008 with the publication of the preliminary report, which presented the main findings from the survey. The activities involved in each of the stages are described in more detail below. The survey timetable is presented in Table 1.3. 3 The 2008 EDHS is the sixth full-scale Demographic and Health Survey to be implemented in Egypt; the earlier surveys were conducted in 1988, 1992, 1995, 2000, and 2005. Three additional interim DHS surveys were carried out in 1997 and 1998 and 2003. Other national-level surveys for which results are shown in this report include the 1980 Egyptian Fertility Survey (EFS), the 1984 Egypt Contraceptive Prevalence Survey (ECPS), and the 1991 Egypt Maternal and Child Health Survey (EMCHS). 4 | Introduction Table 1.3 Survey timetable, 2008 Egypt DHS Activity Starting date Duration Updating the sample frame August 2007 1 month Mapping September 2007 7 weeks Quick-count operation October 2007 3 months Recruitment and training of listing staff January 2008 1 week Listing and re-listing January 2008 5 weeks Sample selection February 2008 4 weeks Questionnaire design November 2007 2 months Preparation of training materials January 2008 6 weeks Pretest January 2008 3 weeks Finalization of questionnaires January 2008 2 month Training of data collection staff February 2008 5 weeks Printing survey materials March 2008 2 weeks Fieldwork March 2008 10 weeks Reinterviews May 2008 1 month Office editing and coding March 2008 3 months Data entry April 2008 3 months Computer editing April 2008 3 months Preliminary report September 2008 1 month Detailed tabulations October 2008 2 months Final report preparation October 2008 6 months 1.4.3 Sample Design The primary objective of the sample design for the 2008 EDHS was to provide estimates of key population and health indicators including fertility and child mortality rates for the country as a whole and for six major administrative regions ( Urban Governorates, urban Lower Egypt, rural Lower Egypt, urban Upper Egypt, rural Upper Egypt, and the Frontier Governorates). In the Urban Governorates, Lower Egypt, and Upper Egypt, the 2008 EDHS design allowed for governorate-level estimates of most of the key variables, with the exception of the fertility and mortality rates. In the Frontier Governorates, the sample size was not sufficiently large to provide separate estimates for the individual governorates. To meet the survey objectives, the number of households selected in the 2008 EDHS sample from each governorate was not proportional to the size of the population in the governorate. As a result, the 2008 EDHS sample is not self-weighting at the national level, and weights have to be applied to the data to obtain the national-level estimates presented in this report. A more detailed description of the 2008 EDHS sample design is included in Appendix B. Sampling errors for selected variables are presented in Appendix C. The sample for the 2008 EDHS was selected in three stages. The first stage included selecting the primary sampling units. The units of selection were shiakhas/towns in urban areas and villages in rural areas. A list of these units which was based on the 2006 census was obtained from CAPMAS, and this list was used in selecting the primary sampling units (PSUs). Prior to the selection of the PSUs, the frame Introduction | 5 was further reviewed to identify any administrative changes that had occurred after the 2006 Census. The updating process included both office work and field visits for a period of around 2 months. After it was completed, urban and rural units were separately stratified by geographical location in a serpentine order from the northwest corner to the southeast corner within each governorate. During this process, shiakhas or villages with a population less than 2,500 were grouped with contiguous shiakhas or villages (usually within the same kism or marquez) to form units with a population of at least 5,000. After the frame was ordered, a total of 610 primary sampling units (275 shiakhas/towns and 335 villages) were selected. The second stage of selection involved several steps. First, detailed maps of the PSUs chosen during the first stage were obtained and divided into parts of roughly equal population size (about 5,000). In shiakhas/towns or villages with a population of 100,000 or more, three parts were selected, two parts were selected from PSU’s with population 20,000 or more (and less than 100,000). In the remaining smaller shiakhas/towns or villages, only one part was selected. Overall, a total of 998 parts were selected from the shiakhas/towns and villages in the 2008 EDHS sample. A quick count was then carried out to provide an estimate of the number of households in each part. This information was needed to divide each part into standard segments of about 200 households. A group of 48 experienced field workers participated in the quick count operation. They were organized into 15 teams, each consisting of 1 supervisor, 1 cartographer and 1 counter. A one-week training course conducted prior to the quick count included both classroom sessions and two field practices in a shiakha/town and a village not covered in the survey. The quick-count operation took place between the end of October 2007 and end of December 2007. As a quality control measure, the quick count was repeated in 10 percent of the parts. If the difference between the results of the first and second quick count was less than 2 percent, then the first count was accepted. No major discrepancies were found between the two counts in most of the areas for which the count was repeated. After the quick count, a total of 1,267 segments were chosen from the parts in each shiakha/ town and village in the 2008 EDHS sample (i.e., two segments were selected from 561 PSUs and three segments from 48 PSUs and one segment from one PSU). A household listing operation was then implemented in each of the selected segments. To conduct this operation, 14 supervisors and 28 listers were organized into 14 teams. Generally, each listing team consisted of a supervisor and two listers. A one-week training course for the listing staff was held at the beginning of January 2008. The training involved classroom lectures and two days of field practice in three urban and rural locations not covered in the survey. The listing operation took place during a six-week period, beginning immediately after the training. About 10 percent of the segments were relisted. Two criteria were used to select segments for relisting. First, segments were relisted when the number of households in the listing differed markedly from that expected according to the quick count information. Second, a number of segments were randomly selected to be relisted as an additional quality control test. Overall, the discrepancies found in comparisons of the listings were not major. The third stage involved selecting the household sample. Using the household listing for each segment, a systematic random sample of households was selected for the 2008 EDHS sample. All ever- married women 15-49 who were present in the sampled households on the night before the survey team visited were eligible for the main DHS interview. In addition, in a subsample of one-quarter of the households in each segment, all women and men age 15-59 who were present in the household on the night before the interview were eligible for the health issues interviews and the hepatitis C testing. 6 | Introduction 1.4.4 Questionnaire Development Three questionnaires were used in the 2008 EDHS: a household questionnaire, an ever-married woman questionnaire, and a health issues questionnaire. The household and ever-married woman’s questionnaires were based on the questionnaires that had been used in earlier EDHS surveys and on model survey instruments developed in the MEASURE DHS program. The majority of the content of the health issues questionnaire was developed especially for the 2008 EDHS although some sections (e.g., the questions on female circumcision and HIV/AIDS knowledge and attitudes) were also based on questionnaires used in earlier EDHS surveys or were drawn from the model instruments from the MEASURE DHS program. The questionnaires were developed in English and translated into Arabic. The first part of the household questionnaire was used to enumerate all usual members and visitors to the selected households and to collect information on the age, sex, marital status, educational attainment, and relationship to the household head of each household member or visitor. This information provided basic demographic data for Egyptian households. It was also used to identify the women who were eligible for the individual interview (i.e., ever-married women 15-49) as well as individuals eligible for the special health issues interviews and the hepatitis testing subsample. In the second part of the household questionnaire, there were questions relating to the socioeconomic status of the household including questions on housing characteristics (e.g., the number of rooms, the flooring material, the source of water and the type of toilet facilities) and on ownership of a variety of consumer goods. A special module was included in the household questionnaire on ownership of poultry and birds. In addition, height and weight measurements of respondents, youth, and children under age six were taken during the survey and recorded in the household questionnaire. The informed consent for the hepatitis C testing obtained from eligible respondents age 15-59 was also recorded in the household questionnaire. The woman’s questionnaire was administered to all ever-married women age 15-49 who were usual residents or who were present in the household during the night before the interviewer’s visit. It obtained information on the following topics: • Respondent’s background • Reproduction • Contraceptive knowledge and use • Fertility preferences and attitudes about family planning • Pregnancy and breastfeeding • Immunization and child health • Husband’s background and women’s work • Female circumcision • Health care access and other health concerns • Mother and child nutrition. The woman’s questionnaire included a monthly calendar, which was used to record the history of the respondent’s marriage status, fertility, contraceptive use including the source where the method was obtained, and the reason for discontinuation for each segment of use status during each month of an approximately five-year period starting from January 2003. The health issues questionnaire collected information on the following topics: Introduction | 7 • Background characteristics of men age 15-59, never-married women age 15-59, and ever- married women age 50-59 • Female circumcision • Health insurance coverage and health care cost • Knowledge and attitudes about HIV/AIDS • Medical procedures and safe injections • Hepatitis C • Hypertension, heart disease and diabetes • Avian influenza • Smoking Blood pressure readings were also obtained for respondents at three points during the health issues interview. 1.4.5 Biomarker Data Collection As noted earlier, the 2008 EDHS included the collection of three types of biomarkers: (1) anthropometric (height and weight) measurements; (2) venous blood samples for hepatitis C testing; and (3) blood pressure measurements. Specially trained teams of three individuals including at least one physician and one laboratory technician were responsible for obtaining the anthropometric measurements for all eligible respondents and the venous blood samples. The EDHS survey interviewers were trained to collect the blood pressure measurements. Anthropometric measurements. Height and weight measures were collected in all households included in the EDHS survey for children under age six and never-married youth and young adults age 10-19 years. In the subsample of households selected for the health issues survey, the measurements were also obtained for all women and men age 20-59 while in the remaining households in the sample, measurements were recorded only for ever-married women age 20-49. Additional information on the procedures used and the results of the anthropometric measurement is provided in Chapter 14 of this report. Hepatitis C testing. The hepatitis C testing component of the EDHS involved the collection of venous blood samples for testing in the Central Laboratory from all individuals age 15-59 years living in the subsample of households selected for the health issues survey. A full description of the protocol for the hepatitis C testing component of the 2008 EDHS and the results of the testing is included in Chapter 18. Blood pressure measurements. In the 2008 EDHS, blood pressure measurements were taken for all of the women and men age 15-59 with whom the the special health issues interviews were conducted. Chapter 17 includes a detailed description of the equipment and procedures used in obtaining the blood pressure measurements from respondents. 1.4.6 Pretest A pretest was conducted during the preparation for the 2008 EDHS. After a two-week training course, the household and individual questionnaires were pretested in January 2008 in a small number of households. Three supervisors, three field editors, and 12 interviewers participated in the first pretest. The pretest was conducted in three governorates: Cairo, Gharbia ( Lower Egypt), and Fayoum (Upper Egypt). A sample of 275 households was selected: 92 households in each governorate. The data collection took 8 | Introduction about four days and a total of 268 household and 261 individual interviews were completed during the pretest. Hepatitis C blood testing was also carried during the pretest. The questionnaires for the 2008 EDHS were finalized after the pretest. Both comments from interviewers and tabulations of the pretest results were reviewed during the process of finalizing the ques- tionnaires. English versions of the final Arabic language questionnaires are included in Appendix F. 1.4.7 Data Collection Activities Staff recruitment. To recruit interviewers and field editors, a list was obtained from the Ministry of Social Solidarity (MOSS) of female personnel who were working to fulfill the one-year period of governmental public service that is mandatory for university graduates. All candidates nominated by MOSS for the field staff positions were interviewed, and only those who were qualified were accepted into the training program. All candidates for the interviewer and field editor positions were recent university graduates. Another basic qualification was a willingness to work in any of the governorates covered in the survey. With a few exceptions, interviewers who had previous experience in surveys were not accepted into the training program. This decision was made to reduce any bias that might result from previous survey experience and to ensure that all trainees had a similar background. However, previous survey experience was a basic qualification for the candidates for the positions of supervisor. The Hepatitis C testing teams were composed of physicians, laboratory technician, and nurses. Some candidates for the hepatitis C testing teams were assigned by the MOH, and others were recruited from among newly graduated physicians and private laboratories. Training materials. A variety of materials were developed for use in training personnel involved in the fieldwork. A lengthy interviewer’s manual, including general guidelines for conducting an interview as well as specific instructions for asking each of the questions in the EDHS questionnaires, was prepared and given to all field staff. In addition, a chart for converting months from the Islamic calendar to the Gregorian calendar was designed for the 60 months before the 2008 EDHS and distributed to all field staff along with a calendar of well-known worldwide or local events. Other training materials, including special manuals describing the duties of the team supervisor and the rules for field editing, were prepared. Instructions for anthropometric data collection were included in a manual for the staff trained to collect height and weight data. Special manuals covering the procedures to be followed in the hepatitis C blood testing and the blood pressure measurement were also prepared. Training for supervisors and interviewers. A special training program for supervisors was conducted during a one-day period prior to the main fieldwork training. This training focused specifically on the supervisor’s duties, but it also covered the 2008 EDHS questionnaires in order to give supervisors a basic understanding of the content of the survey prior to the main training program. Training for interviewers for the 2008 EDHS data collection began on the 9th of February 2008. Fourteen supervisors, 87 interviewers, and 52 Health Personnel for Hepatitis C-testing and the staff responsible for the anthropometric data collection staff (14 doctors, 28 technicians, and 10 nurses ) participated in the training program. The five-week training program, which was held in Cairo, included the following: Introduction | 9 • Lectures related to basic interview techniques and to specific survey topics (e.g., fertility and family planning, maternal and child health, and female circumcision) • Sessions on how to fill out the questionnaire, using visual aids • Training on blood pressure measurement • Role playing and mock interviews • Five days of field practice in areas not covered in the survey • Four quizzes. Trainees who failed to show interest in the survey, who did not attend the training program on a regular basis, or who failed the first two quizzes were terminated immediately. Before the fourth field practice, a list was prepared of the 20 trainees who had performed best during both the classroom and field practices. Following the fourth field practice, 14 of these trainees were chosen to be field editors. A special training session was held for the field editors after their selection. By the end of the training course, 69 of the 87 candidates originally recruited for interviewer training had been selected to work as interviewers or field editors in the EDHS fieldwork. Training for staff responsible for the anthropometric measurements and hepatitis C testing. All health personnel (total 52) attended the training for anthropometric data collection and hepatitis C testing. The training was held in parallel to the main training for around four weeks. The supervisors attended most of the morning sessions to be aware of all procedures of Hepatitis C testing. The training included both classroom lectures and practice measurement and venues blood drawn procedure, and practice in households. At the end of the program, the 42 most-qualified trainees (27 males and 15 females) were selected for the anthropometric data collection and Hepatitis C testing. 1.4.8 Fieldwork Fieldwork for the 2008 EDHS began on March 15th , 2008 and was completed in late May 2008. The field staff was divided into 14 teams; each team had 1 supervisor, 1 field editor, 4 interviewers (one male), and 3 health staff members assigned to height and weight measurement and Hepatitis C testing (one at least has to be female). During the fieldwork, the 14 field teams worked in separate governorates; the number of governorates assigned to an individual team varied from two to three, according to the sample size in the governorates. The teams were closely supervised throughout the fieldwork by a fieldwork coordinator, two assistant fieldwork coordinators, and other senior staff. Due to the fact that the blood samples had to be drawn and transferred to the central lab in Cairo, thirteen teams were assigned to work first in Upper Egypt governorates in order to complete the data collection before the weather became excessively hot. As soon as the main data collection was completed in the first group of governorates, a random sample of up to 10 percent of the households was selected for reinterview as a quality control measure. Shorter versions of the 2008 EDHS questionnaires were prepared and used for the reinterviews. The visits to PSUs to conduct reinterviews also afforded an opportunity to make callbacks to complete interviews with households or individuals who were not available at the time of the original visit by the 2008 EDHS interviewers. Household or individual questionnaires in which there were significant errors that could not be corrected in the office were also assigned for callbacks. Special teams were organized to handle callbacks and reinterviews. During this phase of the survey, interviewers were not allowed to work in the governorate in which they had worked in the initial fieldwork. Callbacks and reinterviews began in late May 2008 and took about one months to complete. 10 | Introduction 1.4.9 Data Processing Activities Office editing. Staff from the central office were responsible for collecting questionnaires from the teams as soon as interviewing in a cluster was completed. Office editors reviewed questionnaires for consistency and completeness, and a few questions (e.g., occupation) were coded in the office prior to data entry. To provide feedback for the field teams, the office editors were instructed to report any problems detected while editing the questionnaires, which were reviewed by the senior staff. If serious errors were found in one or more questionnaires from a cluster, the supervisor of the team working in that cluster was notified and advised of the steps to be taken to avoid these problems in the future. Machine entry and editing. Machine entry and editing began while interviewing teams were still in the field. The data from the questionnaires were entered and edited on microcomputers using the Census and Survey Processing System (CSPro), a software package for entering, editing, tabulating, and disseminating data from censuses and surveys. In addition the transmittal forms for Hepatitis C individuals as well as the blood sample sheet including the bar code were entered by one person. Special computer programs were also set up to facilitate the tracking of the results of the testing of the blood samples collected during the survey at the Central Health Laboratory. The bar codes attached to the samples in the field were used for logging in and identifying the samples throughout the processing, which took place at three separate locations within the Central Laboratory. The bar code also served as the means to link the laboratory test results and the survey data file. Twelve data entry personnel used twelve microcomputers to process the 2008 EDHS survey data. During the machine entry, 100 percent of each segment was re-entered for verification. The data processing staff completed the entry and editing of data by mid July 2008. 1.5 SURVEY COVERAGE Table 1.4 summarizes the outcome of the fieldwork for the 2008 EDHS by place of residence. The table shows that, during the main fieldwork and callback phases of the survey, out of 19,739 households selected for the 2008 EDHS 19,147 households were found, and 18,968 households were successfully interviewed which represents a response rate of 99.1 percent. As noted above, for the ever-married woman interviews, an eligible respondent was defined as an ever-married woman age 15-49 who was present in the household on the night before the interview. A total of 16,571 eligible ever-married women were identified in the households in the 2008 EDHS sample. Of these women, 16,527 were successfully interviewed. The ever-married women response rate was 99.7 percent. A total of 4,953 households were selected for the health issues subsample. Of these, 4,757 were found and 4,662 interviewed. The household response rate in the health issues subsample was only slightly lower than the response rate in the entire EDHS sample (98 percent). Women and men were eligible for the health issues interview if they were age 15-59 years (regardless of marital status) and were present in the household on the night before the interview. A total of 12,780 individuals (6,702 women and 6,078 men) who met these criteria were identified in the subsample of households selected for the special health issues interviews, of which 12,008 were successfully interviewed. Taking into account both eligible women and men, the response rate for the health issues was 94 percent. As expected, the response rate among women (98 percent) was higher than the rate among men (89 percent), with the principal reason being the fact that men were more likely to be working and, thus, not as easy to contact for interview as women. Introduction | 11 Table 1.4 Sample results Percent distribution of households and individuals by the result of the main DHS survey and the special health issues survey interviews and response rates, according to residence, Egypt 2008 Lower Egypt Upper Egypt Result Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Main Survey Households (HH) Sampled 9,395 10,344 3,627 7,578 2,401 5,177 7,500 2,614 4,886 1,034 19,739 Found 9,002 10,145 3,484 7,352 2,287 5,065 7,340 2,524 4,816 971 19,147 Interviewed 8,852 10,116 3,391 7,303 2,256 5,047 7,310 2,504 4,806 964 18,968 HH response rate 98.3 99.7 97.3 99.3 98.6 99.6 99.6 99.2 99.8 99.3 99.1 Ever-married women age 15-49 (EMW) Identified 6,699 9,872 2,421 6,522 1,742 4,780 6,703 1,927 4,776 925 16,571 Interviewed 6,677 9,850 2,419 6,515 1,738 4,777 6,682 1,920 4,762 911 16,527 EMW response rate 99.7 99.8 99.9 99.9 99.8 99.9 99.7 99.6 99.7 98.5 99.7 Health Issues (HI) Subsample Households (HI-HH) Sampled 2,357 2,596 916 1,897 597 1,300 1,880 655 1,225 260 4,953 Found 2,224 2,533 864 1,812 554 1,258 1,832 625 1,207 249 4,757 Interviewed 2,141 2,521 813 1,787 538 1,249 1,819 615 1,204 243 4,662 HI-HH response rate 96.3 99.5 94.1 98.6 97.1 99.3 99.3 98.4 99.8 97.6 98.0 All women age 15-59 (HI-W) Identified 2,827 3,875 1,079 2,486 668 1,818 2,749 829 1,920 388 6,702 Interviewed 2,747 3,831 1,043 2,460 657 1,803 2,705 809 1,896 370 6,578 HI-W response rate 97.2 98.9 96.7 99.0 98.4 99.2 98.4 97.6 98.8 95.4 98.1 All men age 15-59 (HI-M) Identified 2,660 3,418 979 2,259 608 1,651 2,433 795 1,638 407 6,078 Interviewed 2,319 3,111 826 2,072 546 1,526 2,186 709 1,477 346 5,430 HI-M response rate 87.2 91.0 84.4 91.7 89.8 92.4 89.8 89.2 90.2 85.0 89.3 Total age 15-59 (HI-T) Identified 5,487 7,293 2,058 4,745 1,276 3,469 5,182 1,624 3,558 795 12,780 Interviewed 5,066 6,942 1,869 4,532 1,203 3,329 4,891 1,518 3,373 716 12,008 HI-T response rate 92.3 95.2 90.8 95.5 94.3 96.0 94.4 93.5 94.8 90.1 94.0 Characteristics of Households | 13 CHARACTERISTICS OF HOUSEHOLDS 2 The objective of this chapter is to provide a demographic and socioeconomic profile of the 2008 EDHS household sample. Information is presented on the age, sex, and education of the household population, as well as on housing facilities and household possessions. The profile of the households provided in this chapter will help in understanding the results of the 2008 EDHS in the following chapters. In addition, it may provide useful input for social and economic development planning. 2.1 CHARACTERISTICS OF THE HOUSEHOLD POPULATION The questionnaire for the 2008 EDHS included two questions distinguishing between the de jure population (persons who usually live in selected household) and the de facto population (persons who spent the night before the interview in the household). The differences between these populations are small. Therefore, since past surveys and censuses have generally been based on de facto populations, the tabulations of the EDHS household data presented in this chapter are based on the de facto definition, unless otherwise stated. 2.1.1 Age and Sex Composition Table 2.1 presents the percent distribution of the de facto population by age, according to urban- rural residence and sex. The table describes the demographic context in which behaviors examined later in the report occur. Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and urban-rural residence, Egypt 2008 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 10.3 9.9 10.1 13.5 12.5 13.0 12.1 11.4 11.7 5-9 10.9 9.8 10.4 13.0 12.0 12.5 12.1 11.1 11.6 10-14 9.7 9.7 9.7 11.9 10.9 11.4 10.9 10.4 10.7 15-19 10.2 9.7 10.0 11.1 10.8 11.0 10.7 10.3 10.5 20-24 10.4 10.6 10.5 9.5 10.9 10.2 9.9 10.8 10.4 25-29 8.4 9.0 8.7 7.6 9.0 8.3 8.0 9.0 8.5 30-34 6.1 6.7 6.4 6.1 6.2 6.1 6.1 6.4 6.3 35-39 5.7 6.4 6.0 5.3 5.7 5.5 5.5 6.0 5.7 40-44 5.7 6.1 5.9 5.1 5.2 5.2 5.4 5.6 5.5 45-49 5.8 5.5 5.7 4.4 4.7 4.5 5.0 5.0 5.0 50-54 5.0 5.2 5.1 3.5 3.2 3.3 4.2 4.1 4.1 55-59 4.0 3.7 3.9 3.1 3.0 3.1 3.5 3.3 3.4 60-64 3.1 3.1 3.1 2.0 2.1 2.0 2.4 2.5 2.5 65-69 2.1 2.1 2.1 1.6 1.4 1.5 1.8 1.7 1.7 70-74 1.2 1.2 1.2 1.1 1.1 1.1 1.2 1.2 1.2 75-79 0.6 0.6 0.6 0.7 0.6 0.6 0.7 0.6 0.6 80 + 0.5 0.6 0.6 0.6 0.6 0.6 0.5 0.6 0.6 Don't know/missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 18,618 18,935 37,553 24,245 25,070 49,314 42,863 44,005 86,868 14 | Characteristics of Households The population spending the night before the interview in the households selected for the survey included 86,868 individuals, of which 49 percent were males and 51 percent females. The age structure of the de facto household population reflects the effects of past demographic trends in Egypt, particularly high fertility. The majority of the household population (55 percent) was less than 25 years old, and 34 percent were less than 15 years old. The proportion under age 15 was greater in the rural population (37 percent) than in the urban population (30 percent). This difference is an outcome of lower fertility over the past several decades in urban areas compared with rural areas. The population pyramid shown in Figure 2.1 was constructed using the sex and age distribution of the 2008 EDHS household population. The pyramid has a wide base. This pattern is typical of countries that have experienced relatively high fertility in the recent past. Table 2.2 presents a comparison of the distribution of the household population by broad age groups for the six EDHS surveys carried out between 1988 and 2008. The dependency ratio, defined as the ratio of the non-productive population (persons under age 15 and age 65 and over) to the population age 15-64, is calculated based on these figures. The ratio was 62 at the time of the 2008 EDHS, a level around 20 points lower than that observed in 1988. This decline in the dependency ratio represents a substantial lessening in the burden placed on persons in the productive ages to support older and younger household members. Figure 2.1 Population Pyramid of Egypt 80 + 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 0123456 0 1 2 3 4 5 6 Male Female Percent EDHS 2008 FemaleMale Characteristics of Households | 15 2.1.2 Household Composition Table 2.3 presents the distribution of households in the 2008 EDHS sample by sex of the head of the household and by the number of de jure household members. These characteristics are important because they are often associated with socioeconomic differences between households. For example, female-headed households frequently are poorer than households headed by males. In addition, the size and composition of the household affects the allocation of financial and other resources among household members, which in turn influences the overall well-being of these individuals. Household size is also associated with crowding in the dwelling, which can lead to unfavorable health conditions. Table 2.3 Household composition by residence Percent distribution of households by sex of head of household and by household size, according to residence, Egypt 2008 Lower Egypt Upper Egypt Characteristic Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Household headship Male 84.9 88.0 84.0 87.4 85.7 88.2 86.9 85.5 87.7 93.0 86.6 Female 15.1 12.0 16.0 12.6 14.3 11.8 13.1 14.5 12.3 7.0 13.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of usual members 0 0.1 0.0 0.0 0.1 0.1 0.0 0.0 0.1 0.0 0.1 0.0 1 7.4 3.7 8.7 4.5 6.5 3.7 4.6 6.0 3.8 6.0 5.5 2 13.5 10.2 14.2 11.7 13.4 11.0 10.3 12.5 9.0 12.3 11.8 3 16.4 12.3 17.2 14.7 15.7 14.2 11.9 16.2 9.4 11.1 14.3 4 23.2 18.4 23.7 22.6 25.2 21.5 16.3 20.6 13.6 16.1 20.7 5 21.0 18.9 20.5 21.9 23.0 21.4 17.0 19.9 15.2 17.9 19.9 6 10.3 14.6 8.8 13.0 10.5 14.0 14.3 12.5 15.4 14.7 12.5 7 4.8 8.7 4.4 6.0 4.0 6.9 9.6 6.4 11.5 8.1 6.9 8 1.7 4.7 1.5 2.1 1.1 2.5 6.1 2.7 8.2 3.7 3.3 9+ 1.5 8.5 1.0 3.5 0.5 4.8 9.9 3.2 13.9 10.0 5.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 9,159 9,809 4,182 8,348 2,466 5,881 6,204 2,338 3,865 235 18,968 Mean size 4.1 5.1 3.9 4.5 4.0 4.7 5.3 4.4 5.8 5.1 4.6 Note: Table is based on de jure members, i.e., usual residents. Table 2.2 Trends in population distribution by age, 1988-2008 Percent distribution of the de facto population by age and dependency ratio, Egypt 1988-2008 Age group 1988 EDHS 1992 EDHS 1995 EDHS 2000 EDHS 2005 EDHS 2008 EDHS Less than 15 41.2 41.7 40.0 37.3 34.2 34.0 15-64 55.0 54.6 56.3 59.1 61.7 61.9 65+ 3.8 3.7 3.7 3.6 4.1 4.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Median age na 18.8 19.3 20.3 21.7 22.5 Dependency ratio 81.8 83.2 77.6 69.2 62.1 61.5 na = not available Source: El-Zanaty and Way, 2006, Table 2.2 16 | Characteristics of Households Most EDHS households were headed by males; the head was female in only 13 percent of the households surveyed. There were differences in the proportions of households headed by females across residential categories. Sixteen percent of households in the Urban Governorates had a female head compared with 12 percent of the households in rural areas of Lower and Upper Egypt. The Frontier Governorates had the lowest proportion of female-headed households (7 percent). The average EDHS household had 4.6 persons per household. Slightly less than one-third of the households (32 percent) had three or fewer members, while 15 percent of the households had seven or more members. In general, rural households were larger than urban households. For example, only 8 percent of urban households had seven or more members, compared with 22 percent of rural households. Household size varied from an average of 3.9 persons in the Urban Governorates to 5.8 persons in rural Upper Egypt. 2.2 EDUCATION OF THE HOUSEHOLD POPULATION The educational level of household members is among the most important characteristics of the household because it is associated with many phenomena including reproductive behavior, use of contraception, and the health of children. Primary education in Egypt starts at age 6 and consisted of six years of schooling.1 A further three-year period, known as the preparatory stage, is considered basic education and is compulsory. The secondary stage, which includes another three years of schooling, is not compulsory. During the household interviews, questions were included on the highest level of schooling completed for all household members age six and older and on recent school attendance for household members age 6-24 years. The information collected on the educational attainment of all household members is presented in Tables 2.4.1 and 2.4.2. A comparison of Tables 2.4.1 and 2.4.2 highlights the gap in educational attainment between males and females. Overall, 85 percent of males in the 2008 EDHS households had ever attended school, compared with 72 percent of females. The median number of years of schooling for men was 6.7, which is almost 2 years higher than the median for women (4.9 years). 1Between 1989 and 2004, primary education was five years. Characteristics of Households | 17 Table 2.4.1 Educational attainment of male household population by age and residence Percent distribution of the de facto male household population age six and over by highest level of education attended or completed and median number of years of schooling, according to background characteristics, Egypt 2008 Background characteristic No education Some primary Completed primary Some secondary Completed secondary More than secondary Don't know/ missing Total Number Median number of years Age 6-9 12.2 87.3 0.0 0.0 0.0 0.0 0.5 100.0 4,057 0.4 10-14 2.4 56.0 1.1 40.5 0.0 0.0 0.0 100.0 4,684 4.6 15-19 3.9 5.1 3.9 59.1 15.7 12.3 0.0 100.0 4,587 8.7 20-24 6.5 5.5 3.7 12.6 41.8 29.7 0.1 100.0 4,256 10.6 25-29 8.0 7.5 6.6 11.4 42.9 23.5 0.2 100.0 3,411 10.4 30-34 8.9 8.5 5.2 15.3 41.5 20.5 0.0 100.0 2,617 11.1 35-39 13.8 11.4 3.6 12.9 41.5 16.7 0.0 100.0 2,351 11.2 40-44 20.2 12.5 5.6 10.1 33.9 17.7 0.0 100.0 2,309 11.1 45-49 23.4 13.8 6.4 9.7 26.7 20.0 0.0 100.0 2,154 8.5 50-54 30.0 14.5 7.6 7.1 23.2 17.6 0.0 100.0 1,781 5.7 55-59 37.2 11.3 7.8 7.6 19.5 16.5 0.0 100.0 1,504 5.2 60-64 39.8 11.1 9.1 5.7 17.6 16.7 0.0 100.0 1,046 4.8 65+ 59.7 11.1 6.3 4.4 9.0 9.3 0.3 100.0 1,798 0.0 Residence Urban 9.6 21.2 4.2 18.4 24.5 22.0 0.0 100.0 16,290 8.9 Rural 19.1 25.9 4.3 20.1 21.9 8.5 0.2 100.0 20,267 5.4 Place of residence Urban Governorates 9.2 21.1 5.1 19.5 23.4 21.7 0.0 100.0 7,241 8.6 Lower Egypt 14.9 23.9 4.6 19.3 23.8 13.4 0.1 100.0 15,814 6.6 Urban 8.9 21.7 3.9 18.1 25.3 22.1 0.0 100.0 4,334 9.2 Rural 17.1 24.7 4.9 19.7 23.3 10.1 0.1 100.0 11,480 5.9 Upper Egypt 18.1 25.3 3.3 19.3 21.8 12.0 0.2 100.0 12,980 5.8 Urban 10.9 20.8 3.1 16.8 25.1 23.2 0.1 100.0 4,357 9.5 Rural 21.7 27.6 3.4 20.5 20.1 6.3 0.2 100.0 8,622 4.8 Frontier Governorates 14.4 21.8 5.2 18.7 29.2 10.5 0.2 100.0 521 7.2 Total 14.9 23.8 4.3 19.3 23.1 14.5 0.1 100.0 36,556 6.7 An examination of the education distributions for successive cohorts indicates that there have been changes over time in the educational attainment of both men and women. For example, the median number of years of schooling is 10.6 for males age 20-24 years, nearly double the median for males in the 50-54 age group (5.7 years). The improvement in educational attainment has been even more striking for women; the median number of years of schooling is 10.5 for females age 20-24 years, around three times the median for females in the age group 40-44 (3.6 years). As a result of the gains in female education, the gap in the educational attainment between males and females has almost disappeared among younger cohorts. For example, the differential in the median number of years of schooling is 0.1 years between men and women age 20-24. Urban residents were more likely to have attended school and to have remained in school for a longer period than rural residents. The results in Tables 2.4.1 and 2.4.2 also show that gender differences in educational attainment are less evident in urban than in rural areas. For example, the median number of years of schooling is 5.4 years among rural men, 2.5 years greater than the median among rural women (2.9 years). The difference is much smaller in urban areas, where the median number of years of schooling is 8.9 years for men, compared with 7.6 years for women. By place of residence, gender differences in the likelihood of attending school are most evident in rural Upper Egypt where 78 percent of men had ever attended school, compared with 57 percent of women. The gender gap is least apparent in urban Lower Egypt where 85 percent of women had some education, compared with 91 percent of men. 18 | Characteristics of Households Table 2.4.2 Educational attainment of female household population by age and residence Percent distribution of the de facto female household population age six and over by highest level of education attended or completed and median number of years of schooling, according to background characteristics, Egypt 2008 Background characteristic No education Some primary Completed primary Some secondary Completed secondary More than secondary Don't know/ missing Total Number Median number of years Age 6-9 16.4 83.0 0.0 0.0 0.0 0.0 0.5 100.0 3,770 0.4 10-14 4.6 53.2 1.0 41.2 0.0 0.0 0.1 100.0 4,582 4.6 15-19 9.2 2.8 2.7 53.1 18.6 13.6 0.0 100.0 4,554 8.8 20-24 15.4 3.7 2.8 10.4 40.2 27.4 0.1 100.0 4,758 10.5 25-29 20.6 6.8 3.6 9.4 39.5 20.1 0.0 100.0 3,949 10.3 30-34 26.8 7.3 3.8 13.0 33.8 15.1 0.1 100.0 2,822 8.9 35-39 36.2 9.1 2.7 9.6 31.0 11.4 0.0 100.0 2,640 7.3 40-44 42.8 12.5 4.4 6.4 24.5 9.4 0.0 100.0 2,471 3.6 45-49 50.5 12.9 5.8 4.3 17.0 9.4 0.1 100.0 2,220 0.0 50-54 51.5 13.8 6.5 3.7 13.2 11.1 0.1 100.0 1,786 0.0 55-59 62.4 12.4 7.2 3.3 8.6 6.0 0.1 100.0 1,450 0.0 60-64 66.7 10.4 4.8 3.5 7.9 5.7 1.0 100.0 1,108 0.0 65+ 80.3 7.6 3.2 1.1 3.6 2.6 1.6 100.0 1,781 0.0 Residence Urban 18.2 18.9 3.9 16.7 23.2 19.1 0.1 100.0 16,648 7.6 Rural 36.0 22.2 2.6 16.2 17.5 5.2 0.3 100.0 21,244 2.9 Place of residence Urban Governorates 18.5 19.0 4.4 16.8 21.8 19.5 0.1 100.0 7,443 7.3 Lower Egypt 26.5 20.7 2.9 16.2 23.1 10.5 0.1 100.0 16,268 5.3 Urban 15.3 18.7 3.5 16.1 26.5 19.8 0.2 100.0 4,415 8.7 Rural 30.6 21.4 2.6 16.2 21.9 7.1 0.1 100.0 11,853 4.3 Upper Egypt 35.4 21.8 2.7 16.4 15.4 7.8 0.3 100.0 13,690 3.2 Urban 20.0 18.9 3.3 17.1 22.5 18.2 0.1 100.0 4,462 7.2 Rural 42.9 23.3 2.4 16.1 12.0 2.8 0.5 100.0 9,228 1.0 Frontier Governorates 30.2 18.7 5.0 18.8 17.9 9.0 0.4 100.0 492 4.7 Total 28.2 20.7 3.1 16.4 20.0 11.3 0.2 100.0 37,892 4.9 2.3 HOUSING CHARACTERISTICS The 2008 EDHS survey collected information on a range of housing characteristics. These data are presented in Tables 2.5 through 2.8 for households and for the total de jure household population. 2.3.1 Drinking Water Access and Treatment Increasing access to improved drinking water is one of the Millennium Development Goals that Egypt along with other nations worldwide has adopted (United Nations General Assembly 2001). Improved sources are defined as those sources which are likely to provide safe drinking water (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2004). Improved sources include water obtained a piped source within the dwelling, a public tap, a tubehole or borehole, or a protected well or spring.2 The results in Table 2.5 show that 98 percent of EDHS households had access to drinking water from an improved source. In most cases, the source was a piped connection in the dwelling itself or the plot (92 percent). Almost all households obtained the water from a source on premises (97 percent). The majority of households fetching drinking water from a source outside the dwelling or plot were within 30 minutes of this source. For households in which the water source was not on the premises, women age 15 and older were responsible for fetching the water. 2 A well or spring which is covered or otherwise ‘protected’ from contamination from surface water or animals. Characteristics of Households | 19 Table 2.5 Household drinking water access and treatment by residence Percent distribution of households by source of drinking water, time to collect water (if not within residence or plot), person fetching the water and interruption of water supply during two week period prior to the survey and percentage of households using various modes for treating drinking water, according to urban-rural residence and place of residence and percent distribution of the de jure population by household drinking water arrangements and percentage of the de jure population living in households using various modes to treat drinking water, Egypt 2008 Lower Egypt Upper Egypt Drinking water Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total house- holds Total de jure population Source of drinking water1 Improved source 99.8 96.7 99.9 98.6 99.8 98.1 96.9 100.0 95.1 88.4 98.2 98.0 Piped into residence/plot 98.5 86.7 99.6 92.2 97.4 90.0 88.2 98.2 82.2 81.2 92.4 91.4 Public tap 0.6 4.3 0.3 2.0 0.4 2.7 4.7 1.4 6.7 1.4 2.5 2.6 Tubewell/borehole 0.2 3.3 0.0 2.8 0.7 3.8 1.7 0.1 2.6 0.1 1.8 2.3 Protected well/spring 0.5 2.4 0.0 1.5 1.4 1.5 2.3 0.2 3.6 5.6 1.5 1.7 Unimproved source 0.2 3.2 0.1 1.3 0.1 1.8 3.0 0.0 4.8 11.5 1.7 2.0 Unprotected well/spring 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.2 0.0 0.0 Tanker truck/cart 0.2 3.1 0.1 1.3 0.1 1.8 3.0 0.0 4.7 11.3 1.7 1.9 Surface water 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Other/missing 0.0 0.1 0.0 0.1 0.1 0.1 0.0 0.0 0.1 0.1 0.0 0.0 Time to water source On premises 99.5 94.8 99.8 97.5 99.6 96.6 95.0 98.9 92.6 89.2 97.1 96.7 Within 15 minutes 0.1 1.7 0.1 0.8 0.1 1.0 1.8 0.2 2.8 1.0 1.0 1.1 15-29 minutes 0.1 1.4 0.1 0.7 0.1 0.9 1.4 0.3 2.1 0.7 0.8 0.9 30+ minutes 0.2 1.1 0.0 0.8 0.2 1.0 0.8 0.2 1.1 5.4 0.7 0.7 Don’t know/missing 0.1 0.9 0.0 0.3 0.0 0.5 1.0 0.2 1.4 3.7 0.5 0.6 Person obtaining water for household Adult man 0.2 0.7 0.0 0.4 0.1 0.5 0.5 0.2 0.7 9.1 0.5 0.5 Adult woman 0.3 3.5 0.1 1.8 0.3 2.4 3.5 0.6 5.2 1.1 2.0 2.2 Male child under 15 years old 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 Female child under 15 years old 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.1 0.2 0.0 0.0 Water on premises/other/ missing 99.5 95.7 99.8 97.8 99.6 97.0 96.0 99.1 94.1 89.7 97.5 97.3 Water supply interrupted Not interrupted 74.3 67.8 77.9 71.9 74.1 70.9 65.9 70.5 63.2 45.9 70.9 69.3 Daily/almost daily 7.9 9.1 8.1 8.5 7.8 8.8 7.9 5.5 9.3 34.3 8.5 8.8 Few times per week 10.9 15.0 9.9 12.7 11.3 13.2 15.4 11.8 17.6 15.9 13.0 13.9 Less frequently 6.5 7.7 3.7 6.6 6.4 6.6 10.3 11.9 9.4 3.4 7.1 7.7 Don’t know/missing 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.3 0.5 0.5 0.4 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 9,159 9,809 4,182 8,348 2,466 5,881 6,204 2,338 3,865 235 18,968 87,480 Water treated prior to drinking Not treated 93.8 96.3 95.1 94.8 92.8 95.6 95.6 92.9 97.2 92.2 95.1 95.5 Boiled 0.6 0.3 0.5 0.4 0.7 0.3 0.5 0.6 0.4 0.4 0.4 0.4 Bleach/chlorine added 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 Strained through cloth/cotton 0.4 0.1 0.5 0.2 0.4 0.1 0.2 0.2 0.1 0.4 0.3 0.2 Water filter used 4.6 1.3 3.5 2.9 5.9 1.7 2.3 5.1 0.7 4.9 2.9 2.5 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Stand and settle/other 0.8 2.2 0.4 1.9 0.7 2.5 1.6 1.4 1.6 2.3 1.5 1.6 Total 9,159 9,809 4,182 8,348 2,466 5,881 6,204 2,338 3,865 235 18,968 87,480 1 Because the quality of bottled water is not known, households using bottled water are classified according to the source of water used for cooking and washing. The majority of EDHS households experienced no interruptions in their water supply during the two-week period before the survey. However, 9 percent said the supply had been interrupted on a daily or almost daily basis, 13 percent reported interruptions at least a few times per week while 7 percent experienced less frequent interruptions. 20 | Characteristics of Households EDHS households generally did not treat the water they drink. Among households reporting that the water was treated (5 percent), the most common practices were to filter the water (3 percent) or to let it stand and settle (2 percent). Looking at the variation in drinking water indicators by residence, households in the Frontier Governorates were the least likely to obtain water from an improved source (88 percent). Interruptions in the water supply were more common in Frontier Governorates (54 percent) and rural Upper Egypt (37 percent) than in other areas within Egypt. 2.3.2 Drinking Water Storage Practices The 2008 EDHS also obtained information on water storage practices. The results are presented in Table 2.6. Around 17 percent of households reported they stored drinking water. In those households, the EDHS interviewers asked to see the containers in which the water was stored. More than nine in ten households that stored drinking water used covered containers. The households storing water were about evenly divided between those who used containers with wide mouths and those using containers with narrow mouths. Considering the manner in which water was dispensed from the container, about half of the households ladled the water out of the container and the other half employed a tapped container or poured the water directly from the container. Differentials by residence were generally minor. However, households in the Frontier Governorates were more likely to store their drinking water than other households. Table 2.6 Household drinking water storage practices by residence Percent distribution of households by storage of drinking water and, among households in which water is stored, percent distribution by presence of covers on the containers in which water is stored, type of container in which water is stored, manner in which water is dispensed from containers, according to urban-rural residence and place of residence and percent distribution of the de jure population by household drinking water storage and percent of de jure population living in households in which water is stored by various storage practices, Egypt 2008 Lower Egypt Upper Egypt Drinking water Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total house- holds Total de jure population Storage of drinking water Stored 12.3 20.9 11.8 15.0 9.4 17.3 21.2 13.7 25.7 50.3 16.7 17.9 Not stored 87.7 79.1 88.2 85.0 90.5 82.7 78.8 86.3 74.2 49.7 83.2 82.1 Don't know/missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 9,159 9,809 4,182 8,348 2,466 5,881 6,204 2,338 3,865 235 18,968 87,480 Storage containers covered All covered 94.9 93.1 94.5 95.4 96.6 95.1 92.6 96.2 91.4 85.9 93.8 93.5 Some covered 4.4 5.1 5.1 3.5 2.6 3.7 5.4 2.8 6.2 11.7 4.8 5.1 None covered 0.7 1.7 0.3 1.1 0.8 1.1 2.0 1.0 2.3 2.4 1.4 1.4 Not able to observe/missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Type of storage container Wide mouths 36.8 56.8 29.5 46.8 31.6 50.3 60.1 49.9 63.4 48.8 49.7 52.5 Narrow mouths 59.8 39.5 65.9 49.5 66.8 45.5 36.9 47.5 33.5 46.8 46.7 43.8 Both types 3.4 3.7 4.6 3.7 1.6 4.2 2.9 2.6 3.0 4.4 3.6 3.7 Not able to observe/missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Water dispensed from container Ladled 34.9 57.6 30.8 46.2 27.6 50.5 61.0 49.1 64.9 35.6 49.6 52.3 Tap/ poured directly 64.8 42.0 68.5 53.4 72.4 49.0 38.8 50.9 34.9 64.4 50.1 47.3 Other 0.3 0.2 0.7 0.3 0.0 0.4 0.1 0.0 0.1 0.0 0.3 0.3 Not able to observe/missing 0.0 0.1 0.0 0.1 0.0 0.1 0.1 0.0 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households storing water 1,128 2,046 494 1,248 233 1,015 1,314 320 994 118 3,174 15,661 Characteristics of Households | 21 2.3.3 Sanitation Facilities and Waste Disposal Ensuring adequate sanitation facilities is another Millennium Development Goal. Table 2.7 shows that most EDHS households had access to a toilet. Forty-nine percent had modern flush toilets, and an identical percentage had traditional flush toilets. Less than 1 percent of households had no toilet facility. Most households (97 percent) reported that the toilet was connected to a public sewer, bayara (vault), or a septic system. Three percent shared the toilet facility with at least one other household. Table 2.7 Sanitation facilities by residence Percent distribution of households by type of toilet facility, drainage system, number of households using the toilet facility, type of sanitation facilities, and method of disposal of kitchen waste and trash, according to urban-rural residence and place of residence and percent distribution of de jure population by sanitation facilities, Egypt 2008 Lower Egypt Upper Egypt Sanitation facility Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total house- holds Total de jure population Sanitation facility Modern flush toilet 77.1 21.8 83.8 43.9 76.7 30.1 30.6 66.2 9.1 53.4 48.5 42.2 Traditional with tank flush 1.3 2.7 1.0 1.5 0.8 1.8 3.3 2.2 4.0 4.7 2.0 2.3 Traditional with bucket flush 21.4 74.1 15.1 54.2 22.4 67.6 64.1 31.2 84.1 39.7 48.7 54.7 Pit latrine/bucket toilet 0.1 0.6 0.1 0.1 0.1 0.1 0.9 0.1 1.3 1.3 0.4 0.3 Other/missing 0.0 0.1 0.0 0.1 0.0 0.2 0.1 0.0 0.1 0.0 0.1 0.1 No facility 0.1 0.7 0.0 0.1 0.0 0.1 1.0 0.3 1.5 0.9 0.4 0.4 Drainage system Public sewer 89.8 37.0 96.8 64.6 93.1 52.6 37.2 76.5 13.5 42.8 62.5 56.5 Vault (Bayara) 5.4 28.5 1.5 9.4 0.8 13.0 37.6 14.4 51.7 46.0 17.3 21.4 Septic system 4.3 28.4 1.2 21.9 6.1 28.5 20.7 8.0 28.4 9.0 16.8 18.4 Pipe connected to canal 0.1 4.2 0.3 3.8 0.0 5.3 1.5 0.0 2.4 0.1 2.2 2.4 Pipe connected to groundwater 0.0 0.2 0.0 0.0 0.0 0.0 0.4 0.1 0.5 0.3 0.1 0.1 Emptied (no connection) 0.2 0.9 0.0 0.2 0.0 0.3 1.3 0.5 1.8 0.7 0.5 0.6 Other/don’t know 0.1 0.2 0.1 0.1 0.0 0.2 0.2 0.2 0.2 0.1 0.2 0.2 No toilet facility 0.1 0.7 0.0 0.1 0.0 0.1 1.0 0.3 1.5 0.9 0.4 0.4 Number of households using toilet No facility 0.1 0.7 0.0 0.1 0.0 0.1 1.0 0.3 1.5 0.9 0.4 0.4 One 98.2 94.0 98.2 98.0 98.9 97.6 92.0 97.5 88.6 96.5 96.1 95.2 Two 0.8 2.7 0.9 1.0 0.4 1.3 3.4 1.0 4.9 0.7 1.8 2.2 3+ households 0.7 2.2 0.7 0.7 0.5 0.8 3.1 0.9 4.4 1.0 1.5 1.9 Not sure/missing 0.2 0.4 0.2 0.2 0.2 0.2 0.5 0.3 0.6 0.9 0.3 0.3 Sanitation facilities Improved1 97.7 88.5 97.7 93.8 98.8 91.7 88.5 96.6 83.6 94.7 92.9 91.9 Not improved 2.3 11.5 2.3 6.2 1.2 8.3 11.5 3.4 16.4 5.3 7.1 8.1 Disposal of kitchen waste and trash Collected from home 46.5 28.2 41.0 43.0 55.9 37.7 26.9 48.3 14.0 21.2 37.0 33.5 Collected from container in street 34.4 3.5 48.3 7.5 17.1 3.4 12.5 27.5 3.5 31.7 18.4 16.6 Dumped into street/empty plot 16.4 31.2 9.9 30.0 25.0 32.0 25.2 17.8 29.7 37.5 24.1 25.1 Dumped into canal/ drainage 0.8 16.4 0.5 10.2 1.2 13.9 13.1 0.9 20.4 1.4 8.9 10.2 Burned 1.4 15.5 0.1 5.4 0.2 7.5 19.0 5.1 27.4 7.9 8.7 11.2 Fed to animals 0.2 4.6 0.0 3.7 0.5 5.1 2.5 0.3 3.8 0.2 2.5 3.0 Other 0.1 0.6 0.1 0.2 0.1 0.2 0.7 0.1 1.1 0.0 0.3 0.4 Don’t know/missing 0.1 0.1 0.1 0.1 0.0 0.1 0.1 0.0 0.2 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 9,159 9,809 4,182 8,348 2,466 5,881 6,204 2,338 3,865 235 18,968 87,480 1 The household is considered to have improved sanitation facilities if the household has sole use of a modern or traditional flush toilet that empties into a public sewer, Bayara (vault) or septic system. 22 | Characteristics of Households A household is classified as having an improved toilet if the toilet is used only by members of one household (i.e., it is not shared) and if the facility used by the household separates the waste from human contact (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2004). Table 2.7 shows that 93 percent of EDHS households had access to an improved toilet facility, i.e., the households had sole use of a toilet that flushed or pour flushed into a sewer, bayara, or a septic system. The proportion of households using an improved facility was lowest in rural Upper Egypt (84 percent). Table 2.7 also presents information on waste disposal practices. The majority of households (55 percent) reported that kitchen waste or trash was collected, either at the dwelling or from a container in the street (i.e., a container shared with others). Around one-third of households dumped waste or trash into the street, an empty plot or a canal or drainage ditch, 9 percent burned waste or trash, and 3 percent fed it to animals. Dumping or burning waste or trash was much more common in rural than in urban areas (63 percent and 19 percent, respectively). More than 7 in 10 households in rural Upper Egypt dispose of trash by dumping (50 percent) or burning (27 percent). 2.3.4 Other Housing Characteristics Table 2.8 shows the distribution of households according to other dwelling characteristics for which information was obtained in the 2008 EDHS. The majority of households (84 percent) lived in apartments in urban areas, whereas the majority of rural households (62 percent) occupied free-standing houses. Eighty-seven percent of rural households owned their dwelling. Ownership was less common in urban areas, particularly in the Urban Governorates, where only slightly more than half of households owned their dwelling. Virtually all of the households in the EDHS sample had electricity, with only 1 percent of households in the Frontier Governorates and Upper Egypt reporting that they did not have electricity in their households. With regard to flooring, around nine in ten households (89 percent) in the EDHS sample lived in dwellings with a tile (ceramic, marble or cement) or cement floor. About 10 percent had a dirt (earth/sand) floor in their dwelling. Rural households were more likely than urban households to live in dwellings with a dirt floor (17 percent and 1 percent, respectively). Dirt floors were around five times more common in rural Upper Egypt than in rural Lower Egypt (33 percent and 7 percent, respectively). Table 2.8 also shows that 11 percent of EDHS households lived in dwellings with one or two rooms, 75 percent had three or four rooms, and 13 percent had five rooms or more. The mean number of rooms per household was 3.6, and there was an average of 1.4 persons per room. Rural households were more crowded than urban households. The mean number of persons per room was 1.3 in urban areas, compared with 1.5 persons in rural areas. Characteristics of Households | 23 Table 2.8 Dwelling characteristics by residence Percent distribution of households by type and tenure of dwelling, availability of electricity, type of flooring, and number of rooms and mean number of rooms and persons per room according to urban-rural residence and place of residence and percentage of de jure population by dwelling characteristics, Egypt 2008 Lower Egypt Upper Egypt Dwelling characteristic Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total house- holds Total de jure population Type of dwelling Apartment 84.2 36.9 92.0 57.5 82.8 46.8 41.5 73.7 22.0 49.0 59.7 52.4 Free standing house 13.5 61.8 4.6 42.0 16.8 52.6 56.2 24.4 75.4 48.9 38.5 46.2 Other 2.2 1.3 3.5 0.5 0.4 0.5 2.3 1.9 2.5 2.1 1.7 1.3 Missing 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 0.0 Tenure Owned/owned jointly 57.5 87.4 51.6 80.9 66.0 87.1 76.8 58.9 87.7 69.0 72.9 76.5 Rented 37.3 4.8 44.0 12.0 28.4 5.1 15.7 34.7 4.2 27.4 20.5 17.7 Other 5.2 7.7 4.4 7.0 5.5 7.6 7.4 6.3 8.0 3.5 6.5 5.7 Missing 0.0 0.1 0.0 0.1 0.1 0.1 0.1 0.1 0.1 0.0 0.1 0.1 Electricity Yes 99.9 99.3 99.9 99.8 99.9 99.8 99.0 99.8 98.5 98.6 99.6 99.6 No 0.1 0.7 0.1 0.2 0.1 0.2 1.0 0.2 1.5 1.4 0.4 0.4 Flooring material Ceramic/marble tiles 25.0 6.0 29.1 11.8 20.5 8.1 9.9 22.1 2.6 23.4 15.1 12.9 Cement tiles 66.2 44.9 64.7 59.9 72.5 54.7 42.6 63.0 30.2 52.6 55.2 52.2 Cement 5.8 31.3 4.0 22.4 5.6 29.5 24.5 8.8 33.9 19.3 19.0 22.0 Carpet/vinyl/polished wood 1.5 0.6 1.6 0.9 1.0 0.9 0.9 2.0 0.2 0.9 1.0 0.9 Wood Planks 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Earth/sand 1.4 17.1 0.5 4.9 0.4 6.8 22.1 4.2 32.9 3.8 9.6 11.9 Other/missing 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.0 0.1 0.0 0.0 0.1 Number of rooms1 1-2 10.8 11.8 13.6 6.3 6.0 6.4 16.7 11.2 20.1 9.2 11.3 9.7 3-4 80.1 70.0 79.1 78.5 83.3 76.5 67.3 78.7 60.4 71.0 74.9 72.1 5+ 8.8 17.7 7.2 14.9 10.5 16.7 15.4 9.7 18.9 19.3 13.4 17.8 Missing/DK 0.2 0.5 0.2 0.4 0.2 0.4 0.5 0.4 0.6 0.5 0.4 0.4 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 9,159 9,809 4,182 8,348 2,466 5,881 6,204 2,338 3,865 235 18,968 87,480 Mean rooms per household 3.4 3.7 3.3 3.7 3.6 3.8 3.5 3.5 3.6 3.8 3.6 3.8 Mean persons per room 1.3 1.5 1.3 1.3 1.2 1.3 1.6 1.4 1.8 1.4 1.4 1.7 1 Number of rooms does not include kitchen, hallways and bathrooms. 2.4 HOUSEHOLD POSSESSIONS Table 2.9 provides information on household ownership of durable goods and other possessions. Ninety-five percent of EDHS households owned a television (color or black and white), and more than seven in ten households owned a radio. Seventy percent of households were connected to a satellite dish; 47 percent owned the dish and 24 percent were connected to but did not own a dish. Eight percent of households had a video or DVD player. Around two-thirds of households had a telephone, with 41 percent having a mobile phone. Fourteen percent of households owned a computer. A majority of the households in the EDHS sample owned most basic appliances. More than nine in ten households had washing machine (automatic/other), an electric fan and a refrigerator, and four in ten had a water heater. Relatively small proportions of households possessed the other appliances and electric goods in Table 2.9; less than 5 percent had a sewing machine, a freezer, an air conditioner, or a dishwasher. 24 | Characteristics of Households Considering household furnishings, almost all EDHs households owned a bed, over 90 percent owned sofa, and 85 percent or more had hanging lamp, a chair and table. Six in ten household owned a tablia, and around one-quarter had a kolla/zeer. At least one household member owned a watch in around 90 percent of the households. Table 2.9 Household possessions by residence Percentage of households possessing various household effects, means of transportation, farm animals/poultry/birds, agricultural land, and bank/savings account according to urban-rural residence and place of residence, and percentage of de jure population by household possessions, Egypt 2008 Lower Egypt Upper Egypt Household possessions Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total house- holds Total de jure population Household effects Radio 80.0 67.8 81.7 78.1 81.3 76.8 62.4 76.0 54.1 70.8 73.7 72.6 Television 96.8 92.8 96.7 96.7 97.7 96.3 90.8 96.1 87.5 92.1 94.7 95.4 Black and white television 4.7 11.3 4.3 5.9 3.5 6.9 13.7 6.6 18.0 5.5 8.1 9.0 Color television 93.7 83.1 94.3 91.9 95.5 90.4 79.2 91.1 72.0 87.0 88.2 88.4 Video/DVD 13.2 2.5 16.4 4.8 10.0 2.7 5.6 11.1 2.2 7.8 7.7 6.9 Telephone 76.3 50.9 77.2 58.4 72.8 52.4 60.0 78.9 48.6 66.1 63.2 63.4 Landline telephone 61.6 38.2 62.0 46.2 60.1 40.3 45.8 63.6 35.1 40.3 49.5 49.6 Mobile telephone 54.1 27.8 55.1 31.7 43.8 26.6 42.1 63.0 29.4 50.3 40.5 40.8 Satellite dish 79.4 61.8 78.4 75.2 84.4 71.3 58.1 76.0 47.3 72.7 70.3 70.0 Owns satellite dish 55.4 38.8 50.4 46.0 58.3 40.9 44.6 60.0 35.4 67.0 46.8 46.8 Connected from elsewhere 24.0 23.0 28.0 29.2 26.1 30.5 13.5 16.0 11.9 5.7 23.5 23.3 Computer 23.0 5.0 25.1 10.0 20.0 5.9 11.0 23.3 3.6 9.2 13.7 12.9 Sewing machine 4.9 2.9 5.1 2.7 2.8 2.7 4.4 6.6 3.1 6.8 3.9 4.0 Electric fan 93.3 89.8 93.0 96.1 97.5 95.5 84.7 90.1 81.4 78.1 91.5 91.4 Air conditioner 8.1 0.6 9.7 1.6 4.4 0.4 4.1 9.5 0.8 4.6 4.2 3.6 Refrigerator 96.2 86.4 97.1 95.9 97.9 95.0 81.1 93.4 73.6 87.3 91.2 90.8 Freezer 6.9 0.8 8.3 2.1 5.0 0.9 2.8 6.5 0.5 3.6 3.7 3.3 Water heater 61.1 20.6 62.6 39.0 66.0 27.7 26.7 54.4 10.0 36.3 40.2 36.1 Dishwasher 3.4 0.1 4.8 0.5 1.2 0.2 1.3 3.4 0.1 1.3 1.7 1.3 Washing machine 96.8 90.8 97.0 97.0 98.1 96.5 87.1 95.3 82.1 88.6 93.7 94.1 Automatic washing machine 39.0 5.9 44.9 13.8 30.0 7.0 17.4 38.9 4.3 20.0 21.9 19.0 Other washing machine 67.8 88.1 59.6 89.7 81.1 93.3 75.5 67.7 80.3 78.2 78.3 81.2 Bed 99.2 97.1 99.5 99.3 99.7 99.2 95.6 98.4 94.0 97.3 98.1 98.1 Sofa 94.1 92.1 94.9 93.4 93.8 93.2 91.8 93.5 90.7 82.6 93.1 93.0 Hanging lamp 76.4 92.0 69.4 90.6 86.0 92.5 86.4 78.4 91.2 85.9 84.5 86.1 Table 91.2 86.3 87.6 93.1 96.2 91.9 83.5 92.6 78.0 83.1 88.7 88.7 Tablia 45.7 72.6 41.1 62.2 48.8 67.8 68.6 50.2 79.8 60.0 59.6 64.1 Chair 92.3 78.2 92.5 88.0 95.0 85.1 76.0 89.3 68.0 82.5 85.0 83.6 Kolla/zeer 8.3 40.2 4.2 26.0 8.4 33.4 37.4 15.4 50.7 14.0 24.8 28.9 Watch 95.7 82.6 97.5 92.0 96.6 90.0 78.9 91.4 71.3 90.9 88.9 88.6 Means of transportation Animal drawn cart 0.7 6.9 0.5 5.6 0.8 7.7 3.7 0.9 5.4 5.8 3.9 5.2 Bicycle 5.8 13.5 2.4 10.5 7.1 12.0 13.9 10.4 16.0 5.6 9.8 11.9 Motorcycle/scooter 1.9 3.1 0.9 2.7 2.3 2.9 3.2 3.0 3.2 5.5 2.5 2.9 Car/van/truck 12.7 3.0 14.6 5.0 9.0 3.3 6.4 13.0 2.4 12.8 7.7 7.3 Farm animals/poultry/ birds 4.6 37.6 1.9 22.2 4.7 29.6 34.2 9.1 49.5 21.5 21.6 27.6 Agricultural land 3.0 24.1 2.0 17.4 3.6 23.1 17.3 4.2 25.3 13.4 13.9 17.6 Bank/saving account 15.1 3.3 20.3 5.4 10.7 3.2 6.2 10.8 3.5 9.0 9.0 8.2 None of the above 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.1 0.2 0.3 0.0 0.0 Number of households 9,159 9,809 4,182 8,348 2,466 5,881 6,204 2,338 3,865 235 18,968 87,480 Characteristics of Households | 25 Urban households were more likely to have most items than rural households. For example, 79 percent of households in urban areas were connected to a satellite dish compared with 62 percent of households in rural areas. Rates of ownership of various household possessions also differed by place of residence, with higher rates of ownership for most items reported among households in the Urban Governorates, Lower Egypt, and the Frontier Governorates than in Upper Egypt. For most items, households in rural Upper Egypt had the lowest rates of ownership. Table 2.9 also includes information on household ownership of a means of transportation. Overall, 8 percent of households owned a car, van, or truck, with the highest rate of ownership in the Urban Governorates (15 percent) and the lowest rate in rural Upper Egypt (2 percent). Animal carts were owned more often by rural than urban households (7 percent and 1 percent). Relatively few households had a motorcycle, and rates of ownership of bicycles varied from 2 percent in the Urban Governorates to 16 percent in rural Upper Egypt. As expected, households in rural areas were significantly more likely than urban households to own a farm or other land. Twenty-four percent of rural households owned a farm or other land, compared with only 3 percent of urban households. There was also considerable variation in the proportion of EDHS households reporting that they owned farm animals, from 50 percent of households in rural Upper Egypt to 2 percent of households in the Urban Governorates. Table 2.9 also shows that comparatively few EDHS households had at least one member with a bank/savings account (9 percent). Urban households, especially households living in the Urban Governorates, were more than five times as likely as rural households to have an account. 2.5 HOUSEHOLD WEALTH Information on household assets was used to create an index representing the wealth of the households interviewed in the EDHS. The wealth index is a proxy for long-term standard of living of the household (Rutstein and Johnson, 2004). To construct the wealth index, each household asset for which information was collected in the survey was assigned a weight or factor score generated through principal components analysis, and the resulting asset scores were standardized. The EDHS households were then assigned a standardized score for each asset, where the score differed depending on whether or not the household owned that asset. The scores were summed by household. Individuals were ranked according to the total score of the household in which they resided and divided into population quintiles, i.e., five groups with the same number of individuals in each. The wealth index has been compared against both poverty rates and gross domestic product per capita for India, and against expenditure data from household surveys in Nepal, Pakistan and Indonesia (Filmer and Pritchett, 1998) and Guatemala (Rutstein 1999). The evidence from those studies suggests that the assets index is highly comparable to conventionally measured consumption expenditures. Table 2.10 shows the distribution of the de jure EDHS household population by wealth quintile and residence. A much larger proportion of the population in urban areas than in rural areas was found in the highest wealth index group (41 percent and 5 percent, respectively). In turn, more of the rural than urban population fell in the lowest wealth index group (31 percent and 5 percent, respectively). Considering place of residence, slightly less than half of the population in the Urban Governorates was in the highest wealth quintile (47 percent) compared with 13 percent of the population in Upper Egypt and 14 percent in Lower Egypt. The population in rural Upper Egypt was especially concentrated at the lower end of the wealth index, with 50 percent falling into the lowest wealth quintile. 26 | Characteristics of Households Table 2.10 Wealth quintiles by residence Percent distribution of the de jure household population by wealth quintiles according to urban-rural residence and place of residence, Egypt 2008 Lower Egypt Upper Egypt Quintile Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Lowest 4.8 31.3 2.5 12.4 2.0 16.1 37.5 10.7 49.8 22.0 20.0 Second 7.2 29.5 4.6 23.6 6.2 29.9 23.6 11.9 29.0 17.9 20.0 Middle 16.5 22.6 15.3 26.8 18.8 29.7 14.5 15.8 14.0 21.3 20.0 Fourth 30.6 12.1 30.7 23.1 38.5 17.6 11.0 23.0 5.5 20.6 20.0 Highest 40.9 4.5 47.0 14.0 34.5 6.7 13.3 38.5 1.8 18.1 20.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 37,311 50,169 16,379 37,319 9,893 27,426 32,578 10,230 22,348 1,204 87,480 Background Characteristics of Respondents | 27 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3 This chapter first provides a profile of the ever-married women who were interviewed in the 2008 Egypt DHS. Information is presented on a number of basic characteristics of these women including age, residence, education, and work status. Then the chapter explores in more depth the women’s educational and employment status, their participation in household decision-making, and control over earnings. Finally, the chapter also presents information on the background characteristics of the women and men with whom interviews were conducted in the special health issues component of the survey. The information presented on the two groups of EDHS respondents will help in understanding the findings in the following chapters. 3.1 BACKGROUND CHARACTERISTICS OF THE EVER-MARRIED WOMEN SAMPLE As discussed in Chapter 1, all ever-married women age 15-49 who were usual residents or present in the households selected for the 2008 EDHS sample on the night before the interviewer’s visit were eligible for a detailed interview that was designed to obtain information on basic demographic and health indicators. Information on selected background characteristics of the ever-married women interviewed in the EDHS is presented below. 3.1.1 Demographic and Socio-economic Characteristics Table 3.1 presents the distribution of the ever-married women who were interviewed in the 2008 EDHS by marital status, age, urban-rural residence, place of residence, educational level, work status and wealth quintile. Among the ever-married women in the sample, 93 percent were currently married, 4 percent widowed, and 3 percent divorced or separated. Looking at the age distribution in Table 3.1, around two- fifths of these women were under age 30, and about three-tenths were age 40 and over. There were fewer women in the 15-19 and 20-24 age groups than in the 25-29 cohort. This somewhat older age pattern is the result of the inclusion of only ever-married women in the sample and the increasing tendency to delay marriage until older ages in Egypt. The changes in marriage patterns are described in more detail in Chapter 8. The majority of the EDHS respondents (59 percent) were living in rural areas. Considering place of residence, 18 percent of the women were from the Urban Governorates, 46 percent from Lower Egypt, 35 percent from Upper Egypt, and 1 percent from the Frontier Governorates. Fifteen percent of ever- married women were working for cash at the time of the survey. The educational level of the 2008 EDHS respondents varied considerably. Around one-third of the women never attended school, while 45 percent completed at least the secondary level. The women were fairly evenly distributed across the wealth quintiles, with the smallest percentage found in the lowest wealth quintile (18 percent). 28 | Background Characteristics of Respondents Table 3.1 Background characteristics of ever-married respondents Percent distribution of ever-married women age 15-49 by background characteristics, Egypt 2008 Background characteristic Weighted percent Weighted number Unweighted number Marital status Married 93.2 15,396 15,406 Widowed 4.1 670 660 Divorced 2.1 353 351 Separated 0.7 107 110 Age 15-19 3.8 620 636 20-24 15.6 2,584 2,621 25-29 20.4 3,367 3,318 30-34 16.1 2,664 2,703 35-39 15.6 2,586 2,553 40-44 15.0 2,473 2,440 45-49 13.5 2,234 2,256 Urban-rural residence Urban 41.2 6,809 6,677 Rural 58.8 9,718 9,850 Place of residence Urban Governorates 17.7 2,931 2,419 Lower Egypt 46.1 7,618 6,515 Urban 11.7 1,936 1,738 Rural 34.4 5,682 4,777 Upper Egypt 34.8 5,751 6,682 Urban 10.8 1,792 1,920 Rural 24.0 3,959 4,762 Frontier Governorates 1.4 227 911 Education No education 32.1 5,302 5,542 Some primary 8.4 1,394 1,427 Primary complete/some secondary 14.6 2,413 2,382 Secondary complete/higher 44.9 7,418 7,176 Work status Working for cash 14.9 2,459 2,456 Not working for cash 85.1 14,068 14,071 Wealth quintile Lowest 18.4 3,033 3,415 Second 19.7 3,252 3,368 Middle 20.5 3,394 3,382 Fourth 21.2 3,505 3,211 Highest 20.2 3,343 3,151 Total 100.0 16,527 16,527 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Background Characteristics of Respondents | 29 3.1.2 Educational Attainment The relationship between the educational level of EDHS respondents in the ever-married sample and other background characteristics is explored in Table 3.2. As expected, the level of education decreases with increasing age among respondents age 25 and over. However, the table also shows that respondents age 20-29 had a higher level of education than respondents in the 15-19 age group. This pattern is somewhat unexpected because, as described in Chapter 2, participation in schooling has been steadily rising among Egyptian women. The explanation lies in the fact that women who marry early typically leave school at a younger age than women who marry later. Thus, EDHS respondents in the 15- 19 age group include a disproportionate number of less-educated women in comparison with older cohorts. Table 3.2 Educational attainment by background characteristics Percent distribution of ever-married women age 15-49 by highest level of schooling attended or completed, and median number of years of schooling, according to background characteristics, Egypt 2008 Highest level of schooling attended or completed Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Number of ever- married women Median years of schooling Age 15-19 25.4 4.8 4.8 30.3 32.6 2.2 100.0 620 7.3 20-24 21.2 4.8 3.5 13.2 46.0 11.3 100.0 2,584 10.2 25-29 22.3 6.9 3.7 10.8 40.8 15.4 100.0 3,367 10.2 30-34 26.9 7.5 3.4 13.6 34.8 13.9 100.0 2,664 8.9 35-39 36.1 9.0 2.8 9.7 31.2 11.3 100.0 2,586 7.4 40-44 42.9 12.3 4.3 6.4 24.4 9.7 100.0 2,473 3.6 45-49 50.9 12.2 6.2 4.3 16.8 9.6 100.0 2,234 0.0 Urban-rural residence Urban 17.1 7.3 4.9 11.6 38.5 20.6 100.0 6,809 10.6 Rural 42.6 9.2 3.3 10.0 29.4 5.5 100.0 9,718 4.0 Place of residence Urban Governorates 17.0 8.0 6.0 13.1 34.9 21.1 100.0 2,931 10.5 Lower Egypt 28.9 8.0 3.7 9.7 38.9 10.8 100.0 7,618 9.9 Urban 13.1 6.2 4.6 10.4 45.1 20.6 100.0 1,936 10.9 Rural 34.2 8.7 3.4 9.5 36.8 7.4 100.0 5,682 7.1 Upper Egypt 44.0 9.3 3.2 10.5 24.7 8.3 100.0 5,751 3.5 Urban 21.0 7.6 3.5 10.5 37.2 20.3 100.0 1,792 10.5 Rural 54.4 10.1 3.1 10.6 19.0 2.8 100.0 3,959 0.0 Frontier Governorates 34.4 5.4 5.7 12.6 30.0 12.0 100.0 227 7.5 Work status Working for cash 16.2 4.3 1.8 2.9 39.5 35.2 100.0 2,459 11.8 Not working for cash 34.9 9.1 4.3 12.0 32.0 7.6 100.0 14,068 6.1 Wealth quintile Lowest 68.2 10.8 3.1 7.5 10.1 0.3 100.0 3,033 0.0 Second 50.0 10.6 3.2 11.3 22.7 2.1 100.0 3,252 - Middle 28.2 10.6 5.3 12.7 38.3 4.8 100.0 3,394 7.4 Fourth 14.6 7.6 4.9 13.4 47.3 12.1 100.0 3,505 10.4 Highest 4.1 2.8 3.0 7.9 44.1 38.1 100.0 3,343 11.8 Total women ever-married 15-49 32.1 8.4 4.0 10.6 33.1 11.7 100.0 16,527 7.6 1 Completed 5 grades at the primary level 2 Completed 3 grades at the secondary level 30 | Background Characteristics of Respondents Urban respondents were more highly educated than those from rural areas. Among urban women, 59 percent had completed secondary school or higher, compared with 35 percent of rural women. Educational levels were lowest in rural Upper Egypt, where 54 percent of the women had never attended school. The highest educational levels were found in Urban Lower Egypt and the Urban Governorates, where only 13 percent and 17 percent, respectively, of women had never attended school. Educational attainment rises with the wealth quintile. More than eight in ten women in the highest wealth quintile had completed secondary school or higher, while around seven in ten women in the lowest quintile had never attended school. 3.1.3 Literacy The 2008 EDHS assessed literacy among respondents who had never been to school or who had attended only the primary level by asking if they could read a newspaper or letter easily, with difficulty, or if they could not read at all.1 As Table 3.3 shows, around two-thirds of ever-married women in the EDHS sample were considered to be literate. Most of these women who were classified as literate had completed at least the primary level at school and were not asked directly about their ability to read. Only a small minority of women who never attended school or had less than a primary education reported that they could read a newspaper or letter. The proportion literate was somewhat lower among women age 15-19 than among those in the 20-24 and 25-29 age groups. This pattern is again related to the fact that the EDHS sample included only ever-married women. Women in their teens who are already married are more likely to have never attended school or to have left school early than other women. The strong association between residence and literacy observed in Table 3.3 is clearly a reflection of residential differences in educational levels. Rural women were more than twice as likely as urban women to be unable to read at all. Illiteracy levels were markedly higher among ever-married women from Upper Egypt, especially those living in rural areas, than among other women. Table 3.3 also shows that the level of illiteracy decreased with increasing wealth. Five percent of ever-married women in the highest wealth quintile were illiterate compared to 73 percent of women in the lowest quintile. 1 This procedure for assessing literacy status in the 2008 EDHS differed from the procedure employed in a number of earlier EDHS surveys including the 2000 and 2005 surveys. In the latter surveys, the literacy status of women who had never been to school or who had attended only the primary level was assessed by asking women to read several simple sentences. Thus, the literacy results presented in Table 3.3, which rely on women’s self-reported literacy status, are not directly comparable to the results of earlier EDHS surveys in which there was a direct assessment of women’s ability to read. Background Characteristics of Respondents | 31 Table 3.3 Literacy by background characteristics Percent distribution of ever-married women age 15-49 by level of schooling and self-reported ability to read newspaper or letter and percentage literate, according to background characteristics, Egypt 2008 No education or attended only primary Self-reported ability to read a newspaper or letter Background characteristic Attended preparatory school or higher Easily With difficulty Not at all Missing Total Number of ever- married women Percentage literate1 Age 15-19 65.0 1.7 6.5 26.6 0.2 100.0 620 73.2 20-24 70.5 0.8 6.0 22.6 0.1 100.0 2,584 77.3 25-29 67.0 1.4 7.0 24.5 0.1 100.0 3,367 75.4 30-34 62.2 1.3 6.8 29.6 0.1 100.0 2,664 70.3 35-39 52.2 2.1 6.6 39.0 0.0 100.0 2,586 60.9 40-44 40.5 3.1 8.1 48.4 0.0 100.0 2,473 51.6 45-49 30.7 4.1 8.7 56.3 0.1 100.0 2,234 43.6 Urban-rural residence Urban 70.7 2.7 7.0 19.5 0.0 100.0 6,809 80.4 Rural 44.9 1.6 7.2 46.2 0.1 100.0 9,718 53.6 Place of residence Urban Governorates 69.1 3.4 8.7 18.8 0.0 100.0 2,931 81.2 Lower Egypt 59.4 1.4 6.2 32.9 0.1 100.0 7,618 67.0 Urban 76.2 1.7 5.4 16.8 0.0 100.0 1,936 83.2 Rural 53.7 1.3 6.4 38.4 0.1 100.0 5,682 61.5 Upper Egypt 43.5 2.1 7.5 46.9 0.1 100.0 5,751 53.1 Urban 67.9 2.8 6.0 23.3 0.0 100.0 1,792 76.7 Rural 32.5 1.8 8.1 57.5 0.1 100.0 3,959 42.4 Frontier Governorates 54.6 3.0 9.0 33.3 0.2 100.0 227 66.6 Wealth quintile Lowest 17.9 1.5 7.5 73.0 0.1 100.0 3,033 26.9 Second 36.2 1.4 8.4 53.9 0.1 100.0 3,252 46.0 Middle 55.8 2.4 9.2 32.5 0.1 100.0 3,394 67.4 Fourth 72.8 2.7 7.6 16.9 0.1 100.0 3,505 83.0 Highest 90.1 2.2 2.9 4.9 0.0 100.0 3,343 95.1 Total 55.5 2.0 7.1 35.2 0.1 100.0 16,527 64.7 1Includes women who attended preparatory school or higher and women who had no education or attended only the primary level but report they can read a newspaper or letter easily or with difficulty 3.1.4 Exposure to Mass Media The 2008 EDHS collected information on the extent to which ever-married women are regularly exposed to both broadcast and print media. These data are important because mass media are extensively used in Egypt to convey family planning and health messages to the population. Figure 3.1 shows that 96 percent of the ever-married women interviewed in the EDHS watched television at least once a week, about half listened to radio at least once a week, and slightly more than one in ten women read a newspaper or magazine on a weekly basis. Only 8 percent of women reported regular exposure to all three media, and 3 percent had no exposure to print or broadcast media. 32 | Background Characteristics of Respondents According to the results presented in Table 3.4, ever-married women living in urban areas were somewhat more likely to be exposed to the mass media channels, particularly newspapers or magazines, than rural women. This is may be due to the fact that the literacy rate is much higher among women in urban areas than among those in rural areas. Overall, 14 percent of urban women were exposed to all three media at least once a week, compared with only 3 percent of rural women. Considering place of residence, the majority of ever-married women in every residential category watched television and listened to the radio at least once a week. The percentage that read a newspaper or magazine at least once a week varied considerably, from 4 percent in rural Upper Egypt to 25 percent in the urban Upper Egypt. The percentage who reported that they had not been exposed to any media ranged from 1 percent of women in the Urban Governorates and urban Lower Egypt to 8 percent of women in rural Upper Egypt. The percentages reporting exposure to each of the three mass media increased with the woman’s education level, with the increase being especially marked for printed media. There was also a strong association between wealth and exposure to mass media. Considering exposure to all three media, around one-quarter of women in the highest wealth quintile watched television, listened to the radio and read a newspaper or magazine at least once per week compared to 1 percent of women in the lowest quintile. 96 49 11 8 3 Television Radio Print All three media No media 0 20 40 60 80 100 Figure 3.1 Percentage of Ever-Married Women Exposed to Media at Least Once Per Week EDHS 2008 Percent Background Characteristics of Respondents | 33 Table 3.4 Exposure to mass media by background characteristics Percentage of ever-married women age 15-49 who are exposed to specific media weekly, by selected background characteristics, Egypt 2008 Background characteristic Watches television at least once a week Listens to the radio at least once a week Reads a magazine/ newspaper at least once a week All three media at least once a week No media at least once a week Number of ever-married women Age 15-19 95.6 43.8 2.9 2.0 3.0 620 20-24 96.7 45.8 7.3 5.3 2.6 2,584 25-29 96.4 49.7 11.3 8.0 2.8 3,367 30-34 96.4 50.0 11.0 7.7 2.7 2,664 35-39 96.9 50.1 11.3 7.7 2.6 2,586 40-44 95.5 50.6 12.6 9.6 3.3 2,473 45-49 95.8 49.6 13.0 9.6 3.0 2,234 Urban-rural residence Urban 98.1 55.7 19.6 14.1 1.2 6,809 Rural 95.0 44.5 4.5 3.2 4.0 9,718 Place of residence Urban Governorates 98.3 61.3 19.7 15.4 0.9 2,931 Lower Egypt 98.4 52.8 7.2 5.3 1.1 7,618 Urban 99.1 55.4 14.6 10.5 0.6 1,936 Rural 98.2 51.9 4.7 3.5 1.2 5,682 Upper Egypt 92.5 38.3 10.6 7.0 6.0 5,751 Urban 97.0 48.1 24.9 16.2 2.2 1,792 Rural 90.6 33.9 4.2 2.8 7.7 3,959 Frontier Governorates 91.1 41.6 14.8 7.7 7.2 227 Education No education 92.5 33.4 0.2 0.2 6.2 5,302 Some primary 95.9 45.7 1.5 1.1 2.8 1,394 Primary complete/ some secondary 97.6 53.5 6.7 5.2 1.5 2,413 Secondary complete/higher 98.6 59.6 21.3 15.2 0.9 7,418 Wealth quintile Lowest 85.5 27.9 1.1 0.7 12.1 3,033 Second 97.6 41.4 2.3 1.4 1.7 3,252 Middle 98.6 50.4 5.1 3.4 0.6 3,394 Fourth 99.1 59.3 11.0 8.1 0.4 3,505 Highest 99.4 63.8 33.2 24.2 0.3 3,343 Total 96.3 49.1 10.7 7.7 2.8 16,527 3.1.5 Employment Status Ever-married women were asked a number of questions in the 2008 EDHS to identify women who were working at the time of the survey as well as women who were not working at the time of the survey but who had been employed in the 12 months prior to the survey. Women who were working at the time they were interviewed were asked additional questions about the kind of work they were doing and about whether or not they were being paid in cash for their work. Table 3.5 presents the percent distribution of ever-married women age 15-49 according to current and recent employment. Overall, 16 percent of these women were currently engaged in some economic activity. Most of the women who were not working did not report recent work experience; less than 1 percent of the respondents who were not working at the time of EDHS interview had had a job during the 12-month period before the survey. 34 | Background Characteristics of Respondents Table 3.5 Employment status by background characteristics Percent distribution of ever-married women age 15-49 by employment status, according to background characteristics, Egypt 2008 Employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Not employed in the 12 months preceding the survey Missing/ don't know Total Number of ever- married women Age 15-19 2.7 0.0 97.3 0.0 100.0 620 20-24 5.0 0.2 94.8 0.0 100.0 2,584 25-29 13.3 0.4 86.3 0.0 100.0 3,367 30-34 16.6 0.4 83.0 0.0 100.0 2,664 35-39 20.2 0.2 79.6 0.0 100.0 2,586 40-44 24.0 0.3 75.6 0.0 100.0 2,473 45-49 24.8 0.1 75.1 0.0 100.0 2,234 Marital status Currently married 15.7 0.3 84.0 0.0 100.0 15,396 Divorced/separated/widowed 25.5 0.2 74.3 0.0 100.0 1,131 Number of living children 0 10.5 0.7 88.7 0.0 100.0 1,752 1-2 15.8 0.3 83.9 0.0 100.0 6,377 3-4 20.4 0.2 79.4 0.0 100.0 6,010 5+ 12.0 0.2 87.8 0.0 100.0 2,389 Urban-rural residence Urban 21.1 0.5 78.5 0.0 100.0 6,809 Rural 13.1 0.1 86.8 0.0 100.0 9,718 Place of residence Urban Governorates 19.4 0.5 80.1 0.0 100.0 2,931 Lower Egypt 17.4 0.2 82.4 0.0 100.0 7,618 Urban 22.5 0.4 77.1 0.0 100.0 1,936 Rural 15.6 0.1 84.2 0.0 100.0 5,682 Upper Egypt 13.3 0.3 86.4 0.0 100.0 5,751 Urban 21.9 0.5 77.6 0.0 100.0 1,792 Rural 9.4 0.2 90.4 0.0 100.0 3,959 Frontier Governorates 20.7 0.0 79.3 0.0 100.0 227 Education No education 10.5 0.1 89.4 0.0 100.0 5,302 Some primary 10.0 0.1 89.9 0.0 100.0 1,394 Primary complete/ some secondary 5.7 0.2 94.0 0.1 100.0 2,413 Secondary complete/higher 25.2 0.5 74.3 0.0 100.0 7,418 Wealth quintile Lowest 11.0 0.1 88.9 0.0 100.0 3,033 Second 10.0 0.2 89.7 0.0 100.0 3,252 Middle 13.9 0.1 86.0 0.0 100.0 3,394 Fourth 17.3 0.5 82.2 0.0 100.0 3,505 Highest 28.9 0.4 70.6 0.0 100.0 3,343 Total 16.4 0.3 83.4 0.0 100.0 16,527 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Background Characteristics of Respondents | 35 Table 3.5 shows that women in the 45-49 age group were more likely to be currently employed than younger women. The comparatively small proportions of ever-married women under age 30 and especially of ever-married women under age 25 who worked may be related to the greater childcare responsibilities. With regard to the other employment differentials presented in Table 3.5, women living in urban Lower Egypt, women who completed secondary school or higher, and women in the highest wealth quintile were much more likely to be employed at the time of the survey than other women. In the EDHS 2008, ever-married women who indicated that they were working or had worked within the year before the survey were asked about the kind of work that they did. Their response was recorded exactly as they gave it and was the basis for the coding of occupation that occurred after the survey in the central office. As Figure 3.2 shows, the majority of women who were currently working were employed in non- agricultural occupations. Slightly less than half of working women (46 percent) were in professional, technical, and managerial positions or in clerical occupations. An additional 19 percent were working in sales and services, and 5 percent work in jobs categorized as unskilled manual labour. Fifteen percent of working women were involved in some type of agricultural activity. Table 3.6 looks at the differences in the occupational profile of working women according to selected background characteristics. As expected, the proportions involved in professional, technical and managerial occupations and in clerical positions were much greater among urban women than rural women. These proportions also increased rapidly with both education and wealth. Overall, more than six in ten working women who have attained a secondary or higher education or fall in the highest wealth quintile were employed in professional, technical, managerial or clerical occupations. EDHS 2008 Figure 3.2 Occupation among Working Women Technical/ Professional/ Managerial 46% Sales and services 19% Unskilled manual 5% Agricultural 14% Skilled manual 4% Clerical 11% 36 | Background Characteristics of Respondents Table 3.6 Occupation by background characteristics Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Egypt 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of employed ever- married women Age 15-19 * * * * * * * * 17 20-24 45.1 4.0 18.9 6.5 6.5 19.1 0.0 100.0 135 25-29 49.4 7.8 15.1 6.2 3.8 16.8 0.9 100.0 460 30-34 48.1 10.2 20.8 1.4 4.3 15.1 0.1 100.0 453 35-39 52.1 7.2 16.1 3.1 7.7 13.9 0.0 100.0 526 40-44 40.5 15.1 19.5 5.2 5.6 13.9 0.2 100.0 603 45-49 42.7 17.6 21.8 3.5 2.8 11.0 0.6 100.0 556 Marital status Currently married 47.8 11.5 17.7 3.5 4.5 14.7 0.4 100.0 2,459 Divorced/separated/ widowed 30.0 10.5 26.9 8.6 10.3 13.3 0.3 100.0 290 Number of living children 0 51.4 11.2 21.1 3.2 3.1 10.0 0.0 100.0 197 1-2 52.9 11.5 16.2 4.1 3.7 10.7 0.8 100.0 1,026 3-4 45.3 13.1 19.3 3.7 4.8 13.6 0.1 100.0 1,235 5+ 20.4 3.9 22.9 5.5 12.4 35.0 0.0 100.0 291 Urban-rural residence Urban 56.5 14.6 20.3 3.8 3.7 0.7 0.4 100.0 1,466 Rural 33.9 7.8 16.8 4.2 6.6 30.4 0.3 100.0 1,284 Place of residence Urban Governorates 53.0 14.2 22.9 6.2 3.4 0.2 0.2 100.0 584 Lower Egypt 43.6 11.8 15.7 3.6 4.8 20.1 0.4 100.0 1,336 Urban 60.1 18.3 15.1 2.3 3.1 0.6 0.6 100.0 443 Rural 35.4 8.6 16.1 4.2 5.6 29.7 0.3 100.0 894 Upper Egypt 44.2 8.5 20.6 3.2 7.1 16.1 0.4 100.0 783 Urban 57.4 10.8 22.5 2.2 5.2 1.4 0.5 100.0 402 Rural 30.2 6.0 18.5 4.2 9.1 31.7 0.3 100.0 380 Frontier Governorates 55.1 14.2 16.6 3.3 1.3 9.0 0.6 100.0 47 Education No education 2.9 0.0 24.3 7.5 16.1 48.8 0.4 100.0 563 Some primary 6.4 0.9 21.2 11.1 16.7 43.7 0.0 100.0 141 Primary complete/ some secondary 9.1 5.1 39.5 15.4 12.0 18.9 0.0 100.0 142 Secondary complete/ higher 64.3 16.0 15.2 1.6 0.5 1.9 0.4 100.0 1,904 Wealth quintile Lowest 4.7 0.2 15.1 3.4 15.7 60.2 0.7 100.0 336 Second 19.1 6.0 18.9 7.6 11.2 37.3 0.0 100.0 334 Middle 38.3 10.9 23.9 5.4 7.9 13.3 0.3 100.0 475 Fourth 49.5 18.1 24.0 4.4 1.9 1.5 0.6 100.0 623 Highest 70.6 13.1 13.8 2.1 0.0 0.1 0.3 100.0 982 Total 45.9 11.4 18.6 4.0 5.1 14.5 0.4 100.0 2,750 Note: An asterisk indicates a figure is based on less than 25 cases and has been suppressed. Table 3.7 shows that, among women who worked, more than 90 percent earned cash for the work they did. Among working women, the majority (70 percent) worked for someone other than a relative, 8 percent worked for a family member while 22 percent were self-employed. The majority of women who worked were employed on a full-year basis (91 percent), 7 percent worked seasonally, and 2 percent worked occasionally. Background Characteristics of Respondents | 37 Table 3.7 Type of employment Percent distribution of ever-married women employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Egypt 2008 Employment characteristics Agricultural work Non- agricultural work Missing Total Type of earnings Cash only 24.4 95.5 72.2 85.1 Cash and in-kind 25.9 2.5 10.0 6.0 In-kind only 5.2 0.3 0.0 1.0 Not paid 44.4 1.4 13.0 7.7 Missing 0.0 0.3 4.9 0.2 Total 100.0 100.0 100.0 100.0 Type of employer Employed by family member 38.9 3.0 13.0 8.2 Employed by nonfamily member 36.1 75.3 72.2 69.6 Self-employed 25.0 21.5 10.0 22.0 Missing 0.0 0.2 4.9 0.2 Total 100.0 100.0 100.0 100.0 Continuity of employment All year 68.8 95.0 95.1 91.1 Seasonal 26.5 3.2 0.0 6.6 Occasional 4.7 1.6 0.0 2.1 Missing 0.0 0.2 4.9 0.2 Total 100.0 100.0 100.0 100.0 Number of employed ever-married women 400 2,340 10 2,750 Women working in agricultural occupations were much less likely than other working women to be paid for the work they do (56 percent and 98 percent, respectively). This can be explained by the fact that most women who work in an agricultural occupation were assisting their husbands or another family member; around two-fifths of ever-married women who were employed in agricultural occupations were working for a family member compared with only 3 percent of working women who were involved in non-agricultural occupations. Finally, the results in Table 3.7 show that the majority of working women reported that they worked year-round. However, as expected, seasonal work was more common among women working in agricultural occupations than among women employed in non-agricultural occupations (27 percent and 3 percent, respectively). 3.2 WOMEN’S PARTICIPATION IN HOUSEHOLD DECISION-MAKING   The 2008 EDHS obtained information from ever-married women on their participation in several areas of household decision-making. These data relate to women’s status and empowerment, which have been shown to influence demographic and health outcomes for women and children. 3.2.1 Disposal of Earnings   The EDHS included a number of questions to assess the magnitude of women’s earnings relative to those of their husbands, women’s control over the use of their earnings, and women’s participation in decisions on how their husband’s earnings were used. This information has implications for the 38 | Background Characteristics of Respondents empowerment of women. Employment and earnings were more likely to empower women if their earnings were perceived as significant relative to those of their husband and if women themselves control their own earnings. Women also were clearly empowered if they have a voice in how their husbands’ earnings were spent. Tables 3.8 and 3.9 present information on the measures related to women’s earnings for currently married women who worked and received cash earnings during the 12-month period prior to the survey. With regard to magnitude of women’s earnings, Table 3.8 shows that more than half of women earned less than their husbands regardless of the subgroup to which they belong. Only 7 percent of women earned more than their husbands. Table 3.8 Relative magnitude of woman's earnings by background characteristics Percent distribution of currently married women employed in the 12 months preceding the survey and receiving cash earnings by women's earnings relative to husband's earnings, according to background characteristics, Egypt 2008 Background characteristic Woman earns less Woman earns same Woman earns more/ husband no earnings Don't know/ missing Total Number of employed, currently married women Age 15-19 * * * * * 9 20-24 60.3 15.9 6.3 17.5 100.0 118 25-29 58.0 21.0 4.7 16.2 100.0 386 30-34 51.9 26.7 6.4 15.0 100.0 384 35-39 50.9 28.9 9.2 11.1 100.0 426 40-44 54.0 25.0 7.8 13.2 100.0 471 45-49 55.7 24.8 6.6 12.9 100.0 430 Number of living children 0 56.3 21.2 5.7 16.7 100.0 153 1-2 53.2 26.4 5.3 15.1 100.0 867 3-4 55.0 24.9 7.9 12.2 100.0 1,017 5+ 54.9 19.0 10.4 15.8 100.0 187 Urban-rural residence Urban 54.7 26.0 6.3 13.0 100.0 1,282 Rural 53.9 23.0 7.8 15.3 100.0 942 Place of residence Urban Governorates 52.6 24.0 6.5 16.9 100.0 507 Lower Egypt 52.9 26.6 5.4 15.2 100.0 1,062 Urban 56.1 29.1 3.3 11.5 100.0 394 Rural 51.0 25.1 6.6 17.4 100.0 667 Upper Egypt 58.1 22.3 9.9 9.8 100.0 614 Urban 55.8 25.5 9.0 9.7 100.0 346 Rural 60.9 18.1 11.0 9.9 100.0 268 Frontier Governorates 59.2 23.6 10.2 7.0 100.0 42 Education No education 46.3 21.6 14.7 17.4 100.0 304 Some primary 46.7 22.1 8.9 22.2 100.0 90 Primary complete/some secondary 52.9 21.8 6.6 18.6 100.0 102 Secondary complete/higher 56.3 25.6 5.5 12.6 100.0 1,728 Wealth quintile Lowest 54.1 18.3 13.0 14.6 100.0 177 Second 47.6 23.0 9.8 19.6 100.0 224 Middle 52.6 23.0 8.8 15.5 100.0 379 Fourth 48.6 25.5 8.1 17.8 100.0 540 Highest 60.3 26.7 3.6 9.4 100.0 904 Total 54.4 24.7 6.9 13.9 100.0 2,224 Note: An asterisk indicates a figure is based on less than 25 cases and has been suppressed. Background Characteristics of Respondents | 39 With regard to decisions about how a woman’s earnings are used, Table 3.9 shows that most currently married women who had cash earnings either made decisions about how their earnings were used by themselves (20 percent) or jointly with the husband (73 percent). Only a small minority of women reported that these decisions were made mainly by the husband. Women were most likely to say that the husband or someone else mainly made the decisions about how the woman’s earnings were used if they had less than a primary education or fell within the lowest wealth quintile; however, even among women in these groups, more than eight in ten women were involved in decisions on how their earnings were spent. Table 3.9 Control over woman's earnings Percent distribution of currently married women employed in the 12 months preceding the survey and receiving cash earnings by person mainly deciding how the woman's earnings are used, according to background characteristics, Egypt 2008 Background characteristic Woman Jointly with husband Husband Other/ missing Total Number of employed, currently married women Age 15-19 * * * * * 9 20-24 21.6 67.3 2.8 8.3 100.0 118 25-29 17.2 73.2 2.0 7.6 100.0 386 30-34 20.0 73.6 1.9 4.6 100.0 384 35-39 17.9 74.9 3.2 4.0 100.0 426 40-44 18.3 76.5 1.6 3.7 100.0 471 45-49 25.7 68.0 1.8 4.5 100.0 430 Number of living children 0 20.3 72.3 3.0 4.3 100.0 153 1-2 21.1 70.5 2.0 6.4 100.0 867 3-4 18.2 76.2 1.4 4.3 100.0 1,017 5+ 23.1 66.9 6.9 3.1 100.0 187 Urban-rural residence Urban 20.4 73.4 1.6 4.6 100.0 1,282 Rural 19.2 72.2 3.0 5.5 100.0 942 Place of residence Urban Governorates 21.3 71.2 2.1 5.4 100.0 507 Lower Egypt 17.7 74.7 1.5 6.0 100.0 1,062 Urban 18.1 75.6 1.1 5.1 100.0 394 Rural 17.4 74.2 1.8 6.6 100.0 667 Upper Egypt 23.2 70.5 3.2 3.0 100.0 614 Urban 22.7 72.7 1.2 3.4 100.0 346 Rural 23.8 67.6 5.9 2.6 100.0 268 Frontier Governorates 9.6 83.1 4.4 2.9 100.0 42 Education No education 18.3 71.1 6.7 3.9 100.0 304 Some primary 20.5 72.4 2.5 4.5 100.0 90 Primary complete/some secondary 16.5 76.3 2.8 4.4 100.0 102 Secondary complete/ higher 20.3 73.1 1.4 5.3 100.0 1,728 Wealth quintile Lowest 28.0 61.6 6.9 3.4 100.0 177 Second 15.9 74.0 3.8 6.3 100.0 224 Middle 16.6 75.7 2.8 4.9 100.0 379 Fourth 17.1 75.2 1.9 5.8 100.0 540 Highest 22.3 72.3 0.8 4.6 100.0 904 Total 19.9 72.9 2.2 5.0 100.0 2,224 Note: An asterisk indicates a figure is based on less than 25 cases and has been suppressed. 40 | Background Characteristics of Respondents Table 3.10 focuses on decisions about how the husband’s earnings were used. The results indicate that, as was true with regard to the woman’s earnings, the majority of women (71 percent) say that these decisions were made jointly by the couple. Twenty-two percent of the women say the husband decides by himself how to spend his earnings. The table shows that women from urban areas, educated women, women working for cash, and women in the highest wealth quintile were more likely to report that decisions about how the husband’s earning were used were made jointly than other women. Women living in rural areas, particularly in Upper Egypt and women from the Frontier Governorates were the most likely to report that the husband made these decisions alone. Even among these groups, however, joint decision-making was the norm. Table 3.10 Control over husband's earnings by background characteristics Percent distribution of currently married women by person mainly deciding how the husband's earnings are used, according to background characteristics, Egypt 2008 Background characteristic Woman Jointly Husband Husband no earnings Other/ missing Total Number of currently married women Age 15-19 0.6 60.6 25.4 2.9 10.5 100.0 605 20-24 1.9 67.7 22.2 1.3 6.9 100.0 2,527 25-29 2.7 71.1 21.6 0.7 4.0 100.0 3,264 30-34 2.9 73.6 20.9 0.5 2.1 100.0 2,551 35-39 3.3 72.5 21.6 0.4 2.2 100.0 2,406 40-44 3.0 72.1 22.1 1.2 1.7 100.0 2,188 45-49 3.1 70.9 22.7 2.1 1.1 100.0 1,855 Number of living children 0 1.6 65.7 25.2 1.5 6.0 100.0 1,612 1-2 2.4 72.6 20.0 1.0 4.0 100.0 5,961 3-4 3.0 73.0 20.5 0.7 2.8 100.0 5,627 5+ 3.6 64.6 28.3 1.6 1.8 100.0 2,196 Urban-rural residence Urban 2.2 75.3 20.4 0.9 1.2 100.0 6,316 Rural 3.0 67.8 23.0 1.2 5.0 100.0 9,080 Place of residence Urban Governorates 2.6 70.5 24.9 1.0 1.1 100.0 2,727 Lower Egypt 1.8 79.9 14.7 0.7 3.0 100.0 7,128 Urban 1.4 87.3 9.6 0.7 1.0 100.0 1,801 Rural 1.9 77.4 16.4 0.7 3.6 100.0 5,326 Upper Egypt 4.0 59.8 29.3 1.5 5.4 100.0 5,326 Urban 2.6 71.3 23.7 0.8 1.6 100.0 1,646 Rural 4.7 54.7 31.8 1.8 7.1 100.0 3,680 Frontier Governorates 0.9 52.8 41.6 1.6 3.1 100.0 216 Education No education 3.3 59.2 31.4 1.7 4.6 100.0 4,758 Some primary 3.5 67.4 24.4 0.9 3.8 100.0 1,259 Primary complete/some secondary 2.6 67.7 24.5 1.1 4.1 100.0 2,273 Secondary complete/ higher 2.2 80.4 14.3 0.6 2.5 100.0 7,106 Work status Working for cash 3.1 82.0 11.7 0.2 3.0 100.0 2,182 Not working for cash 2.6 69.0 23.6 1.2 3.6 100.0 13,215 Wealth quintile Lowest 3.4 58.5 29.3 1.8 7.0 100.0 2,764 Second 3.1 64.0 26.1 1.1 5.7 100.0 3,014 Middle 2.6 73.5 19.9 1.0 3.0 100.0 3,172 Fourth 2.2 77.9 17.5 0.9 1.5 100.0 3,268 Highest 2.2 78.4 18.1 0.4 0.9 100.0 3,178 Total 2.7 70.9 21.9 1.0 3.5 100.0 15,396 Background Characteristics of Respondents | 41 Table 3.11 looks at how a woman’s control over decisions about how her and her husband’s earnings were spent relative to the magnitude of the woman’s earnings relative to that of her husband. As expected, women earning more than the husband have the highest level of autonomy in making decisions about spending. Somewhat surprisingly, women who earned less than the husband had a greater degree of personal autonomy in making decisions about how their own earnings were spent than women earning about the same amount as the husband. Table 3.11 Relative magnitude of earnings and control over woman's and husband's earnings Percent distribution of currently married women by person who decides how a woman's cash earnings are used, and the percent distribution by who decides how a woman's husband's earnings are used, according to the relation between woman's and husband's earnings in last 12 months, Egypt 2008 Control over earnings Woman earns less Woman earns same Woman earns more/ husband no earnings Woman does not know what husband earns Woman has no cash earnings/ not working Currently married women Control over woman's earnings Woman 21.9 16.0 34.7 11.6 na 19.9 Jointly with husband 75.2 82.0 61.6 53.5 na 72.9 Husband 2.5 1.2 2.2 2.8 na 2.2 Other/missing 0.4 0.8 1.5 32.2 na 5.0 Total 100.0 100.0 100.0 100.0 na 100.0 Number of women 1,210 550 155 310 0 2,224 Control over husband's earnings Woman 2.7 3.1 12.8 1.7 2.7 2.7 Jointly with husband 83.2 90.1 70.8 79.0 69.9 71.8 Husband 13.5 6.2 15.8 16.3 23.9 22.2 Other/missing 0.7 0.6 0.6 3.0 3.6 3.2 Total1 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,208 550 109 309 13,017 15,192 na = Not applicable 1 Excludes cases where the woman or her husband had no earnings and includes cases where the woman does not know whether or not she earns more or less than the husband.   3.2.2 Women’s Roles in Household Decision-Making   To further assess women’s roles in household decision-making, respondents were asked questions in the ever-married women’s survey about who in the household (respondent, husband, both, other) had the final say in making decisions relating to: the woman’s own health care, large household purchases, daily household purchases, and visits to friends or relatives. Table 3.12 shows that, with respect to all four types of decisions, the majority of currently married women reported that the decisions were either made jointly or by the husband or someone else. Women were most likely to say they alone made decisions in the area of daily household purchases. Table 3.12 Women's participation in decision-making Percent distribution of currently married women by person who has the final say in making specific decisions, according to type of decision, Egypt 2008 Decision Woman Jointly with husband Husband Someone else Other/ missing Total Number of women Own health care 25.6 61.2 11.8 1.3 0.2 100.0 15,396 Large household purchases 4.7 49.8 40.0 5.2 0.3 100.0 15,396 Daily household purchases 43.9 34.0 15.5 6.5 0.2 100.0 15,396 Visits to family or relatives 9.4 72.6 16.5 1.3 0.3 100.0 15,396 42 | Background Characteristics of Respondents Table 3.13 presents differentials in the proportions of currently married women who reported that they alone or jointly have the final say with respect to various decisions. The table shows that 6 percent of women said they had no involvement in making any of the four types of decisions. The likelihood of a woman being involved in household decision-making generally increased with the age of the woman and with parity up to four children. Rural women, especially those living in Upper Egypt, and women from the Frontier Governorates were generally less likely than other women to report that they make decisions alone or jointly. Education and wealth were directly related to involvement in making the various household decisions. Women working for cash were also more likely than other women to report having a say in the various decisions. Table 3.13 Women's participation in decision-making by background characteristics Percentage of currently married women who say that they alone or jointly have the final say in specific decisions, by background characteristics, Egypt 2008 Percentage who alone or jointly have final say in: Background characteristic Own health care Making large purchases Making daily purchases Visits to family or relatives None of the specified decisions Number of currently married women Age 15-19 76.1 42.7 60.3 71.4 11.9 605 20-24 83.5 48.3 69.2 80.0 7.8 2,527 25-29 86.4 54.6 76.4 82.3 6.6 3,264 30-34 88.0 56.5 80.4 83.0 5.3 2,551 35-39 88.6 57.2 82.6 82.0 4.6 2,406 40-44 89.0 56.1 82.9 83.6 4.5 2,188 45-49 88.7 58.9 82.2 83.7 4.8 1,855 Number of living children 0 81.9 49.5 65.4 78.5 9.4 1,612 1-2 88.0 56.3 77.7 83.5 5.4 5,961 3-4 88.5 56.2 81.5 83.5 4.8 5,627 5+ 82.4 49.1 77.7 76.1 7.7 2,196 Urban-rural residence Urban 91.9 61.9 83.7 87.6 3.0 6,316 Rural 83.2 49.4 73.7 78.0 8.0 9,080 Place of residence Urban Governorates 93.3 61.9 87.4 89.4 1.9 2,727 Lower Egypt 90.5 61.5 81.6 85.8 4.0 7,128 Urban 95.2 71.4 85.9 88.9 1.9 1,801 Rural 88.9 58.2 80.1 84.7 4.8 5,326 Upper Egypt 78.9 42.1 68.6 73.4 10.1 5,326 Urban 87.1 52.7 76.8 84.2 5.0 1,646 Rural 75.3 37.3 65.0 68.6 12.3 3,680 Frontier Governorates 73.6 39.4 59.3 70.0 18.4 216 Education No education 79.4 41.9 72.9 72.0 9.8 4,758 Some primary 84.1 56.1 78.8 81.8 6.6 1,259 Primary complete/some secondary 85.6 52.9 77.2 81.9 6.1 2,273 Secondary complete/ higher 92.5 63.3 81.2 88.7 3.2 7,106 Work status Working for cash 94.4 69.5 88.7 91.9 1.6 2,182 Not working for cash 85.5 52.1 76.0 80.3 6.7 13,215 Wealth quintile Lowest 77.2 38.8 68.6 70.1 11.4 2,764 Second 82.1 45.1 71.9 76.8 8.3 3,014 Middle 87.1 57.0 78.3 81.8 5.8 3,172 Fourth 91.7 64.7 84.0 86.9 3.5 3,268 Highest 94.1 64.4 84.7 92.1 1.7 3,178 Total 86.8 54.6 77.8 81.9 6.0 15,396 3.3 WOMEN’S ATTITUDE TOWARD WIFE BEATING An important measure of women’s welfare status is the extent to which they are subject to domestic violence. The 2008 EDHS assessed women’s attitudes toward wife beating but did not collect information on women’s experience of domestic violence. Respondents in the ever-married women Background Characteristics of Respondents | 43 sample were asked if a husband is justified in hitting or beating his wife if she: goes out without telling him, neglects the children, argues with him, refuses to have sex with him, and burns the food. The results presented in Table 3.14 show that 39 percent of women agreed that wife beating would be justified in at least one of the specified circumstances. The reasons women most often agreed justified wife beating were going out without telling the husband and neglecting children (reported by 32 and 29 percent of women, respectively). Table 3.14 Attitudes towards wife beating by background characteristics Percentage of ever-married women who agree that a husband is justified in beating his wife, by selected background characteristics, Egypt 2008 Percentage agreeing husband is justified in hitting or beating his wife if she: Background characteristic Goes out without telling him Neglects the children Argues with him Refuses to have sex with him Burns the food Percentage agreeing that husband justified in beating for at least one reason Percentage agreeing that husband justified in beating for all five reasons Number of ever- married women Age 15-19 40.5 38.3 19.5 26.0 11.4 50.4 8.2 620 20-24 33.0 30.7 14.2 20.4 8.1 40.2 6.0 2,584 25-29 28.2 25.8 12.2 17.9 6.1 35.3 4.3 3,367 30-34 28.8 28.0 13.3 20.5 7.4 38.1 5.3 2,664 35-39 29.9 27.9 14.0 21.3 6.9 38.1 5.1 2,586 40-44 34.4 30.9 17.2 23.9 8.9 41.0 7.0 2,473 45-49 34.4 32.4 18.5 26.9 9.9 42.5 7.9 2,234 Marital status Currently married 31.8 29.6 14.8 21.8 7.9 39.7 5.9 15,396 Divorced/separated/widowed 28.6 26.2 15.5 20.5 8.1 35.0 5.8 1,131 Number of living children 0 31.4 28.8 13.9 20.7 8.7 38.5 6.2 1,752 1-2 26.2 24.7 11.1 17.2 5.7 34.1 4.0 6,377 3-4 30.3 28.2 13.6 20.8 7.0 38.1 5.2 6,010 5+ 49.1 45.2 28.8 36.4 15.3 57.2 12.5 2,389 Urban-rural residence Urban 20.2 17.8 8.0 14.0 3.2 27.7 2.2 6,809 Rural 39.5 37.5 19.6 27.1 11.2 47.5 8.5 9,718 Place of residence Urban Governorates 18.0 11.1 5.8 12.4 2.0 24.0 1.3 2,931 Lower Egypt 28.4 27.3 11.0 18.0 4.9 35.7 3.8 7,618 Urban 18.6 21.0 6.6 12.7 2.4 27.5 1.4 1,936 Rural 31.8 29.5 12.5 19.9 5.8 38.4 4.7 5,682 Upper Egypt 42.0 41.3 24.4 30.8 14.8 51.5 10.9 5,751 Urban 24.1 24.2 12.5 16.7 5.8 32.6 4.1 1,792 Rural 50.2 49.0 29.8 37.2 18.8 60.1 14.0 3,959 Frontier Governorates 45.7 33.1 17.5 32.1 9.4 52.6 6.5 227 Education No education 51.3 46.6 28.2 37.6 16.0 59.3 12.7 5,302 Some primary 41.6 39.0 20.5 28.7 10.5 50.4 8.0 1,394 Primary complete/some secondary 32.6 29.4 12.0 19.5 5.5 41.3 3.4 2,413 Secondary complete/ higher 15.2 15.2 5.1 9.6 2.4 22.4 1.4 7,418 Number of decisions in which woman has final say 0 42.0 36.7 23.4 31.1 12.6 47.9 9.9 2,047 1-2 48.1 44.6 26.3 35.8 14.5 56.5 11.4 3,435 3-4 24.4 23.3 9.7 15.5 5.0 32.4 3.4 11,045 Wealth quintile Lowest 54.6 51.8 33.2 40.1 20.0 62.9 15.8 3,033 Second 42.0 39.3 20.6 29.2 11.5 50.7 8.7 3,252 Middle 32.4 30.1 13.3 21.6 6.2 40.9 4.6 3,394 Fourth 21.1 19.7 6.7 13.2 2.2 28.9 1.3 3,505 Highest 10.5 8.8 2.6 6.5 1.0 16.3 0.3 3,343 Total 31.5 29.4 14.8 21.7 7.9 39.3 5.9 16,527 44 | Background Characteristics of Respondents Younger women age 15-19, women with 5 or more children, those residing in rural areas, women with no education, and those in the lowest wealth quintile were more likely to agree that a husband is justified in hitting or beating wife for at least one of the specified reasons. 3.4 BACKGROUND CHARACTERISTICS OF RESPONDENTS ELIGIBLE FOR HEALTH ISSUES INTERVIEW As described in the first chapter of the report, the 2008 EDHS included interviews with women and men age 15-59 living in the subsample of one-quarter of the households selected for the special health issues component of the survey. Table 3.15 presents the percent distribution of the respondents inter- viewed in the special health issues component of the survey by selected background characteristics. The results show that 34 percent of the women and men interviewed in this component of the EDHS were less than 25 years old. Around one-third of the respondents had never married, while 63 percent were cur- rently married. Forty-four percent lived in urban areas and 56 percent in rural areas. Table 3.15 Selected background characteristics of respondents eligible for health issues interview Percent distribution of the population age 15-59 by selected background characteristics, Egypt 2008 Women Men Total Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 16.9 1,064 1,126 19.0 1,087 1,078 17.9 2,151 2,204 20-24 17.3 1,091 1,189 15.2 869 906 16.3 1,960 2,095 25-29 14.4 906 948 12.7 729 733 13.6 1,635 1,681 30-34 10.9 688 748 11.1 634 618 11.0 1,322 1,366 35-39 10.7 673 708 9.4 535 546 10.1 1,209 1,254 40-44 9.0 568 600 10.2 581 586 9.6 1,148 1,186 45-49 8.7 550 570 8.6 494 473 8.7 1,044 1,043 50-59 11.9 751 762 13.8 788 758 12.8 1,539 1,520 Marital status Never married 25.0 1,570 1,686 40.1 2,293 2,323 32.2 3,864 4,009 Married 67.2 4,225 4,460 58.8 3,363 3,321 63.2 7,588 7,781 Widowed 6.1 381 384 0.3 19 20 3.3 400 404 Divorced 1.4 87 94 0.5 30 25 1.0 118 119 Separated 0.4 27 27 0.2 13 9 0.3 39 36 Urban-rural residence Urban 43.5 2,736 2,777 44.6 2,552 2,377 44.0 5,288 5,154 Rural 56.5 3,555 3,874 55.4 3,165 3,321 56.0 6,720 7,195 Place of residence Urban Governorates 20.3 1,276 1,055 20.5 1,169 837 20.4 2,445 1,892 Lower Egypt 43.4 2,731 2,470 43.4 2,481 2,112 43.4 5,212 4,582 Urban 11.0 689 660 10.9 622 548 10.9 1,311 1,208 Rural 32.5 2,041 1,810 32.5 1,860 1,564 32.5 3,901 3,374 Upper Egypt 34.9 2,195 2,753 34.5 1,973 2,399 34.7 4,168 5,152 Urban 11.3 713 821 12.2 696 752 11.7 1,409 1,573 Rural 23.6 1,482 1,932 22.3 1,277 1,647 23.0 2,759 3,579 Frontier Governorates 1.4 89 373 1.6 93 350 1.5 182 723 Education No education 29.8 1,873 2,066 12.5 715 716 21.6 2,588 2,782 Some primary 8.2 517 543 9.9 568 561 9.0 1,084 1,104 Primary complete/ some secondary 21.3 1,342 1,390 27.6 1,577 1,512 24.3 2,919 2,902 Secondary complete/ higher 40.7 2,559 2,652 50.0 2,857 2,909 45.1 5,417 5,561 Wealth quintile Lowest 17.4 1,095 1,330 16.6 947 1,101 17.0 2,042 2,431 Second 20.4 1,281 1,434 20.3 1,161 1,238 20.3 2,442 2,672 Middle 19.6 1,236 1,320 20.8 1,190 1,191 20.2 2,425 2,511 Fourth 20.3 1,279 1,202 20.3 1,161 1,033 20.3 2,440 2,235 Highest 22.2 1,399 1,365 22.0 1,260 1,135 22.1 2,659 2,500 Total 100.0 6,290 6,651 100.0 5,718 5,698 100.0 12,008 12,349 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Background Characteristics of Respondents | 45 Twenty percent of women and men inter- viewed in the health issues component of the EDHS were from the Urban Governorates, 43 percent from Lower Egypt, 35 percent from Upper Egypt, and just 2 percent from the Frontier Governorates. Twenty-two percent of these respondents had never attended school, while 45 percent had a secondary or higher education. Differentials in the distributions of men and women by the background characteristics were minimal except for marital status and education, with women being more likely to be currently married and to have lower education attainment than men. Table 3.16 presents information on the self- reported literacy status and on the level of media ex- posure among respondents interviewed in the health issues survey. The results show that around three- quarters of the respondents were literate. As expected, the proportion literate was higher among men than among women (84 percent and 66 percent, re- spectively). Most of the respondents were exposed to media on a regular basis. Over 95 percent of respondents reported watching TV at least once a week, 51 percent listened to the radio, and 16 percent read a magazine or newspaper at least once a week. Just over one-tenth of respondents were exposed to all three media on a weekly basis. Men were more likely to be exposed to mass media than women, especially to print media. Table 3.17 presents the distribution of the respondents interviewed in the health issues com- ponent of the EDHS by employment status, occu- pation and type of earnings. Seventy-eight percent of men were currently employed compared with only 16 percent of women. The majority of work- ing women were employed in professional/techni- cal/managerial occupations (44 percent), followed by sales and services (20 percent). Men were most likely to be working in skilled manual labor (30 percent) and professional/technical/managerial (23 percent) occupations. More than nine in ten of the women and men who were working were paid at least some cash for the work they did. Table 3.16 Literacy status and recent exposure to mass media of respondents eligible for health issues interview Percent distribution of the population age 15-59 by literacy status and percentage who are exposed to specific media weekly, Egypt 2008 Literacy and media exposure Women 15-59 Men 15-59 Total Literacy status Literate1 66.2 83.5 74.5 Not literate2 33.6 15.9 25.2 Missing 0.1 0.6 0.3 Total 100.0 100.0 100.0 Number 6,290 5,718 12,008 Media exposure3 Television 95.6 96.1 95.8 Radio 48.9 53.7 51.2 Magazine/ newspaper 11.3 21.0 15.9 All three media 8.0 14.5 11.1 No media 3.4 2.4 2.9 Number 6,290 5,718 12,008 1Refers to respondents who attended preparatory school or higher and respondents with no or primary education who can read a newspaper or letter easily or with difficulty. 2Refers to respondents with no or primary education who cannot read a newspaper or letter at all. 3At least once per week Table 3.17 Employment status, occupation, and type of earnings of respondents eligible for health issues interview Percent distribution of the population age 15-59 by employment status, and percent distribution of employed persons by occupa- tion and type of earnings, Egypt 2008 Employment, occupation and type of earnings Women 15-59 Men 15-59 Total Employment status Currently employed1 16.4 78.4 45.9 Not employed 83.5 21.5 54.0 Missing 0.1 0.1 0.1 Total percent 100.0 100.0 100.0 Number 6,290 5,718 12,008 Occupation Professional/ technical/ managerial 44.0 23.0 26.9 Clerical 9.1 4.2 5.1 Sales and services 19.6 18.3 18.6 Skilled manual 7.9 29.5 25.4 Unskilled manual 5.2 4.4 4.6 Agriculture 14.1 19.1 18.2 Missing 0.2 1.5 1.2 Type of earnings Cash only 86.8 88.1 87.8 Cash and in-kind 6.0 9.5 8.9 In-kind only 0.8 0.5 0.6 Not paid 6.0 1.5 2.3 Missing 0.3 0.5 0.4 Total percent 100.0 100.0 100.0 Number employed 1,031 4,484 5,515 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Fertility | 47 FERTILITY 4 This chapter examines levels, patterns, and trends in both current and cumulative fertility in Egypt. The chapter also considers information on the length of the interval between births and the age at which the average Egyptian woman bears her first child. The data on birth intervals are important since short intervals are strongly associated with childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the child and the mother. Fertility data were collected in EDHS 2008 in several ways. First, each woman 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 may have died. Next, 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. For living children, a question was asked about whether the child was living in the household or away. For dead children, the age at death was recorded. Finally, information was collected on whether currently married women were pregnant at the time of the survey. 4.1 CURRENT FERTILITY LEVELS BY RESIDENCE The level of current fertility is one of the most important topics in this report because of its direct relevance to population policies and programs. Table 4.1 presents several measures of current fertility including age-specific fertility rates, the total fertility rate, the general fertility rate, and the crude birth rate. These rates are presented for the three-year period preceding the survey, a period covering portions of the calendar years 2005-2008. The three-year period was chosen for calculating these rates (rather than a longer or a shorter period) to provide the most current information, reduce sampling error, and avoid problems of the displacement of births. Table 4.1 Current fertility by residence Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by urban-rural residence and place of residence, Egypt 2008 Lower Egypt Upper Egypt Age group Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total 15-19 32 64 24 52 25 60 60 41 68 55 50 20-24 132 196 127 180 142 191 179 130 204 160 169 25-29 175 193 166 183 173 188 197 191 201 201 185 30-34 127 117 119 105 114 101 145 154 140 147 122 35-39 61 58 61 49 58 46 71 65 74 73 59 40-44 15 19 23 8 5 10 24 10 32 23 17 45-49 2 2 2 0 0 0 5 4 6 6 2 TFR 15-49 2.7 3.2 2.6 2.9 2.6 3.0 3.4 3.0 3.6 3.3 3.0 TFR 15-44 2.7 3.2 2.6 2.9 2.6 3.0 3.4 3.0 3.6 3.3 3.0 GFR 93 117 87 104 88 110 118 100 127 116 106 CBR 23.3 29.1 22.3 26.7 22.5 28.1 28.7 25.2 30.5 27.8 26.6 Note: Age-specific rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate for ages 15-49, expressed per woman GFR: General fertility rate (births divided by the number of women age 15-44),expressed per 1,000 women CBR: Crude birth rate expressed per 1,000 population 48 | Fertility The age-specific fertility rates shown in Table 4.1 are useful in understanding the age pattern of fertility. Numerators of age-specific fertility rates are calculated by identifying live births that occurred in the period 1-36 months prior to the survey (determined from the date of interview and date of birth of the child), and classifying them by the age (in five-year age groups) of the mother at the time of the child’s birth. The denominators of these rates are the number of woman-years lived in each of the specified five- year age groups in the period 1-36 months prior to the survey. Although information on fertility was obtained only for ever-married women, data from the household interviews on the age structure of the population of never-married women was used to calculate the all-women rates. This procedure assumes that women who have never been married have had no children. The total fertility rate (TFR) is a useful measure for examining the overall level of fertility. It is interpreted as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed rates. The TFR is calculated by summing the age-specific fertility rates. The TFR is presented in Table 4.1 for women age 15-44 and women 15-49 to facilitate comparisons with other surveys in which the age range of interviewed women may differ from that in the 2008 EDHS. The TFR in Table 4.1 shows that, if fertility rates were to remain constant at the level prevailing during the three-year period before the 2008 EDHS (approximately March 2005 to February 2008), an Egyptian woman would bear 3 children between her 15th and 50th birthdays. The rural TFR is 3.2 births per woman, around 20 percent higher than the rate in urban areas (2.7 births). Considering the variation by place of residence, women in rural Lower Egypt are bearing children at the same rate as women in urban Upper Egypt (3 births per woman each). The highest TFR is observed for rural Upper Egypt (3.6 births per woman), followed by the rate for the Frontier Governorates (3.3 births per woman). The lowest TFR is 2.6 births per woman in the Urban Governorates and urban Lower Egypt; one child lower than the rate in rural Upper Egypt. Egyptian women tend to have children early in the reproductive period. At the current age- specific fertility rates shown in Table 4.1, an Egyptian woman will give birth to 1.1 children—more than one-third of her lifetime births—by age 25 and 2.0 children—two-thirds of her lifetime births—by age 30. The age pattern of fertility is similar in urban and rural areas. Fertility peaks in the age group 25-29 at 193 births per thousand among rural women and at 175 births per thousand among urban women. Looking at the variation in age-specific fertility by place of residence, rates are generally higher in rural Upper Egypt than in the other areas except in the 30-34 age group, where the highest rates are observed in the urban Upper Egypt. Finally, Table 4.1 presents estimates of the crude birth rate and general fertility rate for the three- year period before the 2008 EDHS. The general fertility rate (GFR) represents the annual number of births in a population per 1,000 women age 15-44. The crude birth rate (CBR) is the annual number of births in a population per 1,000 persons. Both measures are based on the birth history data for the three- year period before the survey and the age-sex distribution of the household population. For the period 2005-2008, the crude birth rate was 27 births per thousand populations, and the general fertility rate was 106 births per thousand women. As was the case with the TFR, there are substantial differences by residence in the CBR and the GFR. The lowest rates are found in the Urban Governorates, where the CBR was 22 births per thousand populations and the GFR was 87 births per thousand women. In contrast, in rural Upper Egypt where the rates are highest, the CBR was 31 births per thousand populations, and the GFR was 127 births per thousand women. Fertility | 49 4.2 FERTILITY DIFFERENTIALS BY BACKGROUND CHARACTERISTICS Table 4.2 highlights differences in the TFR and two additional fertility measures—the percentage currently pregnant and the mean number of children ever born to women age 40- 49—by residence, education and wealth. Like the TFR, the percentage pregnant provides a measure of current fertility, although it is subject to some degree of error as women may not recognize or report all first trimester pregnancies. The mean number of children ever born (CEB) among women 40-49 serves as a measure of cumulative fertility, taking into account the past fertility behaviour of women who are nearing the end of the reproductive period. If fertility is stable over time in a popu- lation, the TFR and the mean CEB for women 40-49 will be similar. If fertility levels are falling, the TFR will be lower than the mean CEB among older women. The differentials in the fertility meas- ures in Table 4.2 further document the strong influence of residence on fertility in Egypt. The mean CEB among older women varies from 3.3 births in the Urban Governorates and urban Lower Egypt to 5.5 births in rural Upper Egypt. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Egypt 2008 Background characteristic Total fertility rate Percentage currently pregnant1 Mean number of children ever born to women age 40-49 Urban-rural residence Urban 2.7 5.7 3.5 Rural 3.2 7.3 4.7 Place of residence Urban Governorates 2.6 6.1 3.3 Lower Egypt 2.9 6.4 3.9 Urban 2.6 5.0 3.3 Rural 3.0 6.9 4.2 Upper Egypt 3.4 6.9 4.9 Urban 3.0 5.1 3.9 Rural 3.6 7.8 5.5 Frontier Governorates 3.3 8.4 4.7 Education No education 3.4 5.8 4.8 Some primary 3.2 5.3 4.6 Primary complete/ some secondary 3.0 4.9 3.9 Secondary complete/higher 3.0 7.8 3.1 Wealth quintile Lowest 3.4 5.7 5.2 Second 3.1 6.9 4.9 Middle 3.0 7.2 4.2 Fourth 2.9 7.1 3.6 Highest 2.7 5.7 3.1 Total 3.0 6.5 4.2 1Women age 15-49 years 3 2.6 2.9 2.6 3 3.4 3 3.6 3.3 Total Egypt Urban Governorates Total Urban Rural Total Urban Rural Frontier Governorates 0 1 2 3 4 Figure 4.1 Total Fertility Rates by Place of Residence 3.0 3.03.0 Percent EDHS 2008 Lower Egypt Upper Egypt 50 | Fertility The results in Table 4.2 show the strong influence woman’s education has on fertility behaviour. The TFR decreases with increasing educational level, from 3.4 births among women with no education to 3 births among women who had completed primary or higher education. The differentials in completed fertility across educational groups are especially striking. The mean number of children ever born is 4.8 among women age 40-49 with no education, compared with 3.1 among women who have completed secondary school. The fertility measures in Table 4.2 also vary markedly by wealth quintile. The TFR deceases from a level of 3.4 births among women in the lowest wealth quintile to 2.7 births among women in the highest wealth quintile. Similarly, the mean number of children ever born among women 40-49 is 5.2 in the lowest wealth quintile compared with 3.1 births among women in the highest wealth quintile. A comparison of TFR and the mean CEB among women age 40-49 provides an indication of the magnitude and direction of fertility change over the past several decades in Egypt. Overall, the comparison shows that fertility has declined substantially; women age 40-49 had an average of 4.2 births over their lifetime, 1.2 births more than the current TFR. Considering the patterns for subgroups, the largest difference between current and cumulative fertility is observed in rural Upper Egypt, where the TFR is around 2 births lower than the mean number of children ever born to women 40-49. Interestingly, the TFR for women with a secondary or higher education is nearly the same as the mean CEB. This pattern suggests that fertility has remained stable among highly educated women for several decades. Finally, Table 4.2 shows that 7 percent of the 2008 EDHS respondents were pregnant at the time of the survey. Looking at residential differentials, women in the Frontier Governorates have the highest percentage currently pregnant (8 percent), while the percentage is lowest in urban Lower Egypt and urban Upper Egypt (5 percent, each). Surprisingly, the percentage of women who were pregnant is higher for women with a secondary or higher education than for other women. This is due at least in part to the fact that, on average, highly-educated women married at older ages than women in the other education categories and, thus, they were more likely to be in the family-building stage at the time of the survey than other women. 4.3 FERTILITY TRENDS 4.3.1 Retrospective Data Table 4.3 uses information from the retrospective birth histories obtained from EDHS respondents to exam- ine trends in age-specific fertility rates for successive five-year periods before the survey. To calculate these rates, births were classified according to the period of time in which the birth occurred and the mother’s age at the time of birth. Because women 50 years and over were not interviewed in the 2008 EDHS, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years and more prior to the survey, because women in that age group would have been 50 years or older at the time of the survey. The results in Table 4.3 confirm that fertility has fallen substantially among all age groups, with the most rapid relative decline occurring in the 15-19 age group. Overall, the cumulative fertility rate for Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Egypt 2008 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 50 60 66 80 20-24 168 199 211 229 25-29 181 210 218 238 30-34 117 140 151 [177] 35-39 58 75 [97] - 40-44 16 [30] - - 45-49 [3] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Fertility | 51 women age 15-29 decreased from 2.7 births per woman during the period 15-19 years before the survey to 2 births per woman in the five-year period preceding the survey. 4.3.2 Comparison with Previous Surveys Table 4.4 shows the TFR estimates from a series of surveys conducted in Egypt during the period 1979 through 2008. The surveys vary in the timeframes for which the TFR estimates are available. For example, the rates from the EFS, ECPS and the EMCHS are based on births in a one-year period before the survey, while the rates for the EDHS surveys are based on births in the three-year period before the interview date. In general, three-year rates are subject to less sampling variability than one-year rates. The size of the sample covered in a specific survey is another factor related to sampling variability. In general, rates from surveys with comparatively large samples are subject to less sampling variability than rates from surveys with smaller samples. Thus, the rates for the 1997, 1998, and 2003 Interim DHS surveys have somewhat greater margins of error than full-scale DHS surveys (i.e., the surveys conducted in 1988, 1992, 1995, 2000, 2005, and 2008). Sampling errors for the TFRs derived from the 2008 EDHS are presented in Appendix C. Table 4.4 Trends in fertility Age-specific fertility rates (per 1,000 women) and total fertility rates, Egypt 1979-2008 EFS ECPS 1988 EDHS 1991 EMCHS 1992 EDHS 1995 EDHS 1997 Interim EDHS 1998 Interim EDHS 2000 EDHS 2003 Interim EDHS 2005 EDHS 2008 EDHS Age 1979- 19801 1983- 19841 1986- 19882 1990- 19911 1990- 19922 1993- 19952 1995- 19972 1996- 19982 1997- 20002 2000- 20032 2002- 20052 2005- 20082 15-19 78 73 72 73 63 61 52 64 51 47 48 50 20-24 256 205 220 207 208 200 186 192 196 185 175 169 25-29 280 265 243 235 222 210 189 194 208 190 194 185 30-34 239 223 182 158 155 140 135 135 147 128 125 122 35-39 139 151 118 97 89 81 65 73 75 62 63 59 40-44 53 42 41 41 43 27 18 22 24 19 19 17 45-49 12 13 6 14 6 7 5 1 4 6 2 2 TFR 5.3 4.9 4.4 4.1 3.9 3.6 3.3 3.4 3.5 3.2 3.1 3.0 Note: Rates for the age group 45-49 may be slightly biased due to truncation. 1 Rates are for the 12-month period preceding the survey. 2 Rates are for the 36-month period preceding the survey. Source: El-Zanaty and Way, 2006, Table 4.4 The results in Table 4.4 show that fertility has declined almost continuously in Egypt over the past two decades, from 5.3 births per woman at the time of the 1980 EFS to 3 births per woman at the time of the 2008 EDHS. The decline in fertility was especially rapid during the period between the mid- 1980s and the mid-1990s. In contrast, during the period between the 2005 and 2008 EDHS surveys, the TFR dropped by only 0.1 births. The results in Table 4.4 indicate that all age groups have shared in the decline in fertility rates. However, the decline has been more rapid among older women than among younger women. Age- specific fertility rates among women age 30 and over fell by around 50 percent or more between the 1980 EFS and the 2008 EDHS. In contrast, fertility rates among women under age 30 declined by around one- third during this period. As a result of the differences in the pace of fertility change across various age groups, childbearing has become somewhat more concentrated among women under age 30. Currently, a woman will have an average of 2 births by her 30th birthday, roughly two-thirds of her lifetime births. This pattern is typical of countries like Egypt in which fertility levels are declining. 52 | Fertility The trend in fertility by residence is presented in Table 4.5 for the period between the 1988 EDHS and the 2008 EDHS.1 Urban fertility declined between the 1988 and 1992 surveys, from 3.5 to 2.9 births. The decline levelled off early in the 1990s, with the urban TFR fluctuating around three births throughout the rest of the 1990s, before falling to a level of 2.6 births in 2003. Urban fertility has remained essentially stable since 2003. In rural areas, fertility levels has declined continuously over the past two decades, from 5.4 births per woman at the time of the 1988 EDHS to 3.2 births per woman at the time of the 2008 EDHS. Table 4.5 Trends in fertility by residence Total fertility rates by urban-rural residence and place of residence, Egypt 1986-2008 1988 EDHS 1991 EMCHS 1992 EDHS 1995 EDHS 1997 Interim EDHS 1998 Interim EDHS 2000 EDHS 2003 Interim EDHS 2005 EDHS 2008 EDHS Residence 1986- 19882 1990- 19911 1990- 19922 1993- 19952 1995- 19972 1996- 19982 1997- 20002 2000- 20032 2002- 20052 2005- 20082 Urban-rural residence Urban 3.5 3.3 2.9 3.0 2.7 2.8 3.1 2.6 2.7 2.7 Rural 5.4 5.6 4.9 4.2 3.7 3.9 3.9 3.6 3.4 3.2 Place of residence Urban Governorates 3.0 2.9 2.7 2.8 2.5 2.7 2.9 2.3 2.5 2.6 Lower Egypt 4.5 na 3.7 3.2 3.0 3.1 3.2 3.1 2.9 2.9 Urban 3.8 3.5 2.8 2.7 2.6 2.4 3.1 2.8 2.7 2.6 Rural 4.7 4.9 4.1 3.5 3.2 3.2 3.3 3.2 3.0 3.0 Upper Egypt 5.4 na 5.2 4.7 4.2 4.3 4.2 3.8 3.7 3.4 Urban 4.2 3.9 3.6 3.8 3.3 3.3 3.4 2.9 3.1 3.0 Rural 6.2 6.7 6.0 5.2 4.6 4.5 4.7 4.2 3.9 3.6 Frontier Governorates na na na 4.0 na na 3.8 na 3.3 3.3 TFR 4.4 4.1 3.9 3.6 3.3 3.4 3.5 3.2 3.1 3.0 Note: Rates for the age group 45-49 may be slightly biased due to truncation. 1 Rates are for the 12-month period preceding the survey. 2 Rates are for the 36-month period preceding the survey. na = Not available Source: El-Zanaty and Way, 2006, Table 4.5 Considering the place of residence, declines in fertility were observed in all areas between the 1988 and 2008 surveys. Women in rural Upper Egypt experienced the greatest absolute change in fertility levels, with the TFR dropping from 6.2 births at the time of the 1988 survey to 3.6 births per woman at the 2008 EDHS. The TFR in rural Lower Egypt, which was 4.7 births at the time of the 1988 survey (the level reached in 2000 in rural Upper Egypt), dropped to 3 births at the time of the 2008 EDHS. Overall, fertility also declined in the Urban Governorates and in urban areas within Lower Egypt and Upper Egypt over the past several decades; however, the decline in urban areas has been slower and more erratic than the change observed in rural Egypt. 4.4 CHILDREN EVER BORN AND LIVING Table 4.6 presents the distributions of all women and currently married women by the total number of children ever born. These distributions reflect the accumulation of births among EDHS respondents over the past 30 years and, therefore, their relevance to the current situation is limited. 1 Residential differentials in the TFR are not available for the 1980 EFS and the 1984 ECPS surveys. Fertility | 53 However, the information is useful in looking at how average family size varies across age groups and for looking at the level of primary infertility. Since only ever-married women were interviewed in the 2008 EDHS, information on the reproductive histories of never-married women is not available. However, virtually all births in Egypt occur within marriage; thus, in calculating these fertility measures for all women, never-married women were assumed to have had no births. The marked differences between the results for currently married women and for all women at the younger ages are due to the comparatively large numbers of never- married women in those age groups who, as noted, are assumed to have had no births. Table 4.6 shows that the average Egyptian woman has given birth to 2 children. Out of that number, 1.9 children are still alive, indicating that around 5 percent of the children ever born to EDHS respondents have died. Reflecting the natural family-building process, the number of children that women have born increases directly with age from an average of less than one child among women age 20-24 to an average of 4.4 births among women 45-49. As expected, the likelihood that at least one of a woman’s children will have died also increases with the woman’s age. Out of the average of 4.4 children born to women 45- 49, an average of 0.4 children or 9 percent are no longer alive. Table 4.6 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, and mean number of children ever born and mean number of living children, according to age group, Egypt 2008 Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number of women Mean number of children ever born Mean number of living children ALL WOMEN 15-19 94.0 5.1 0.7 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 4,618 0.07 0.07 20-24 59.2 22.3 14.4 3.4 0.6 0.1 0.0 0.0 0.0 0.0 0.0 100.0 4,806 0.64 0.62 25-29 25.0 17.5 30.3 18.4 6.6 1.7 0.3 0.1 0.1 0.0 0.0 100.0 4,090 1.71 1.66 30-34 11.7 8.2 23.5 29.3 15.0 7.2 3.6 1.1 0.3 0.0 0.0 100.0 2,862 2.71 2.60 35-39 7.1 5.1 15.1 28.7 21.3 11.9 5.8 2.8 1.3 0.3 0.5 100.0 2,683 3.39 3.22 40-44 6.4 3.1 12.1 24.2 20.9 13.8 7.9 5.7 3.1 1.5 1.4 100.0 2,527 3.92 3.66 45-49 5.8 3.2 10.3 19.3 17.7 12.7 12.2 8.1 5.4 2.4 2.8 100.0 2,277 4.42 3.99 Total 37.8 10.7 15.0 15.0 9.3 5.2 3.1 1.8 1.0 0.4 0.5 100.0 23,863 1.98 1.86 CURRENTLY MARRIED WOMEN 15-19 55.1 38.3 5.6 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 605 0.52 0.50 20-24 23.8 41.2 27.2 6.5 1.1 0.1 0.0 0.0 0.0 0.0 0.0 100.0 2,527 1.20 1.16 25-29 8.4 20.8 37.4 22.6 8.1 2.1 0.4 0.1 0.1 0.0 0.0 100.0 3,264 2.10 2.04 30-34 4.7 7.9 25.4 32.1 16.4 8.0 4.0 1.2 0.4 0.0 0.0 100.0 2,551 2.96 2.84 35-39 3.3 4.2 15.3 30.3 22.5 12.9 6.3 3.1 1.4 0.4 0.5 100.0 2,406 3.58 3.41 40-44 4.0 2.4 11.3 25.2 22.0 14.2 8.5 6.1 3.2 1.6 1.5 100.0 2,188 4.10 3.83 45-49 3.5 2.4 10.1 19.6 18.5 13.4 12.4 8.5 5.6 2.7 3.1 100.0 1,855 4.60 4.16 Total 10.1 15.3 22.0 21.9 13.5 7.4 4.4 2.6 1.4 0.6 0.7 100.0 15,396 2.85 2.69 54 | Fertility 4.5 BIRTH INTERVALS 4.5.1 Intervals between Births A child’s health status is closely related to the length of preceding birth interval. Research has shown that children born too soon after a previous birth (i.e., within 24 months) are at greater risk of illness and death than those born after a longer interval. In addition, short birth intervals may have 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 her children. The duration of breastfeeding for the older child may also be shortened if the mother becomes pregnant. Table 4.7 shows the percent distribution of second order and higher (non-first) births in the five years preceding the survey by length of the previous birth interval. Birth intervals during the period were relatively long, with more than eighty percent of non-first births occurring at least two years after the previous birth. More than half of births took place at least three years after a prior birth. The median interval was 37.5 months, which is about two months longer than the median interval at the 2005 EDHS (35.4 months). Although the majority of non-first births were appropriately spaced, 18 percent were born too soon after a prior birth, i.e., within 24 months of a previous birth. Table 4.7 shows that younger women have shorter birth intervals than older women. The median interval varied from 20 months among the small number of births to women age 15-19 to 64.6 months among births to women age 40-49. The median birth interval was only around three months longer when the prior birth was a boy than the child was a girl. It was 12 months longer in cases where the prior birth was alive than when that child has died (37.9 months and 25.7 months, respectively). The median birth interval in urban areas was 39.9 months, compared with 36.3 months in rural areas. Birth intervals were longer in urban Lower Egypt and Urban Governorates (43.5 and 39.8 months, respectively) than in urban Upper Egypt (37.8 months). In rural areas, the median birth interval was longer in Lower Egypt (38.7 months) than in Upper Egypt (34.1 months). No clear association was observed between the woman’s educational level and the average birth interval. However, intervals were substantially longer for births to women who are working for cash than for births to other women (40.8 months and 37.1 months, respectively). The median birth interval among women in the highest quintile wealth was around 6 months longer than that observed among women in the lowest quintile. Fertility | 55 Table 4.7 Birth intervals by background characteristics Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, according to background characteristics, Egypt 2008 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48+ Total Number of non-first births Median number of months since preceding birth Sex of preceding birth Male 6.8 9.6 27.0 21.3 35.3 100.0 3,560 39.2 Female 8.8 11.3 29.7 21.0 29.2 100.0 3,487 36.1 Survival of preceding birth Living 6.9 10.3 28.5 21.6 32.7 100.0 6,791 37.9 Dead 32.0 12.2 25.5 8.4 21.8 100.0 256 25.7 Birth order 2-3 9.0 11.4 31.3 22.4 25.9 100.0 4,847 35.3 4-5 5.2 8.0 21.1 18.1 47.6 100.0 1,608 46.7 6+ 4.8 8.6 24.4 19.6 42.6 100.0 593 43.5 Age 15-19 38.7 26.9 32.5 1.9 0.0 100.0 44 19.5 20-29 10.4 13.3 35.5 23.4 17.5 100.0 3,564 32.7 30-39 5.1 7.5 22.3 20.2 44.8 100.0 2,933 45.0 40-49 2.9 5.2 12.9 12.7 66.3 100.0 506 64.6 Urban-rural residence Urban 7.6 10.2 24.3 20.1 37.8 100.0 2,529 39.9 Rural 7.9 10.5 30.6 21.8 29.2 100.0 4,518 36.3 Place of residence Urban Governorates 7.9 9.2 26.0 18.0 38.8 100.0 1,060 39.8 Lower Egypt 6.4 9.6 26.1 23.4 34.5 100.0 2,901 39.6 Urban 5.6 9.8 21.1 23.8 39.7 100.0 641 43.5 Rural 6.7 9.5 27.5 23.3 32.9 100.0 2,260 38.7 Upper Egypt 9.0 11.7 31.4 20.1 27.7 100.0 2,980 34.9 Urban 8.8 12.1 24.4 19.9 34.8 100.0 763 37.8 Rural 9.1 11.6 33.8 20.2 25.3 100.0 2,217 34.1 Frontier Governorates 9.7 8.7 27.5 19.3 34.7 100.0 106 37.9 Education No education 8.1 10.9 29.6 18.3 33.1 100.0 2,099 36.6 Some primary 6.7 8.6 28.6 20.7 35.5 100.0 560 38.6 Primary complete/some secondary 7.9 8.2 24.9 23.0 35.9 100.0 1,116 40.1 Secondary complete/higher 7.8 11.2 28.7 22.4 30.0 100.0 3,271 36.9 Work status Working for cash 7.1 6.6 27.6 21.7 37.0 100.0 831 40.8 Not working for cash 7.9 10.9 28.5 21.1 31.6 100.0 6,216 37.1 Wealth quintile Lowest 9.0 12.4 32.6 19.3 26.7 100.0 1,615 34.1 Second 8.9 10.0 30.4 20.4 30.3 100.0 1,412 36.3 Middle 6.6 10.0 27.1 24.0 32.2 100.0 1,489 38.8 Fourth 6.8 9.0 26.7 21.2 36.2 100.0 1,352 39.5 Highest 7.5 10.3 23.5 20.8 37.8 100.0 1,180 40.2 Total 7.8 10.4 28.4 21.2 32.3 100.0 7,047 37.5 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 56 | Fertility 4.5.2 Attitudes about the Ideal Birth Interval Ever-married women were asked in the 2008 EDHS about the ideal length of time that a woman should ideally wait between births. The responses for this question are presented in Table 4.8. Overall, 46 percent of the women felt births ideally should be spaced two years apart and 35 percent favoured a three- year interval between births. Only 16 percent of the women believed births should be spaced at least four years apart. Women in urban areas, particularly in the Urban Governorates, were somewhat less likely than rural women to think births should be spaced less than three years apart. Table 4.8 Ideal birth interval by residence Percent distribution of ever-married women 15-49 by the length of time that a woman should wait between births, Egypt 2008 Lower Egypt Upper Egypt Ideal interval between births Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total 1 year 1.9 4.0 1.5 2.8 2.1 3.1 4.3 2.2 5.2 3.3 3.1 2 years 41.6 48.7 40.0 45.8 41.5 47.2 48.4 43.4 50.7 52.8 45.8 3 years 36.5 33.9 35.5 36.8 37.8 36.4 32.5 37.2 30.3 30.8 35.0 4 years 12.4 9.8 11.6 11.5 14.7 10.4 9.7 11.5 8.9 7.7 10.8 5 or more years 7.2 3.2 11.2 2.6 3.1 2.3 4.6 5.5 4.2 4.7 4.8 Don't know 0.2 0.4 0.1 0.3 0.4 0.3 0.5 0.2 0.6 0.6 0.3 Missing 0.1 0.1 0.1 0.2 0.3 0.2 0.0 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 6,809 9,718 2,931 7,618 1,936 5,682 5,751 1,792 3,959 227 16,527 4.6 AGE AT FIRST BIRTH The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. In many countries, postponement of first births has contributed greatly to overall fertility decline. Table 4.9 presents the distribution of women by age at first birth, according to their current age. For women under age 25, the median age at first birth is not shown because less than 50 percent of women in those ages had given birth at the time of the survey. The results in Table 4.9 indicate that the age at which the average Egyptian women have their first birth has increased over time. Women in younger cohorts are much less likely than older women to have given birth to their first child while they were in their teens. For example, among women age 45-49, 31 percent had become a mother before age 20, while only 25 percent of women age 25-29 had given birth to their first child before age 20. Overall, Table 4.9 shows that the median age at first birth ranged from a low of 22.2 years among women age 45-49 to 22.9 years among women age 25-29. These cohort changes parallel increases in the median age at first marriage that took place during the same period (see Chapter 8). Fertility | 57 Table 4.9 Age at first birth Percentage of all women who gave birth by exact ages, and median age at first birth, by current age, Egypt 2008 Percentage who gave birth by exact age Current age 15 18 20 22 25 Percentage who have never given birth Number of women Median age at first birth 15-19 0.1 na na na na 94.0 4,618 a 20-24 0.6 6.5 21.5 na na 59.2 4,806 a 25-29 1.1 9.6 25.1 43.5 64.3 25.0 4,090 22.9 30-34 1.6 12.2 27.0 45.2 67.2 11.7 2,862 22.6 35-39 2.0 14.2 29.2 46.3 69.4 7.1 2,683 22.4 40-44 1.9 14.9 30.0 48.7 70.5 6.4 2,527 22.2 45-49 3.2 15.5 30.7 48.1 69.3 5.8 2,277 22.2 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.10 presents trends in the median age at first birth across age cohorts for key subgroups. The measures are presented for women age 25-49 years to ensure that half of the women have already had a birth. Overall, the median age at first birth is 22.5 years for women 25-49. However, there are wide differ- ences in the age at which women first gave birth among the various subgroups. Urban women started childbearing two and half years later than their rural counterparts. On average, women in rural Upper Egypt had their first birth more than one year earlier than women in rural Lower Egypt and about four years earlier than women in the Urban Governorates. Women who had a sec- ondary or higher education had their first birth on average four years later than women with no education. There is a 4 year difference in the median age at first birth between women in the lowest and highest wealth quintiles. 4.7 TEENAGE PREGNANCY AND MOTHERHOOD Teenage fertility is a major health concern because teenage mothers and their children are at high risk of ill- ness and death. Childbearing during the teenage years also frequently has adverse Table 4.10 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 2008 Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 Women age 25-49 Urban-rural residence Urban 24.5 24.1 23.6 23.5 23.9 23.9 Rural 21.7 21.6 21.4 21.0 21.0 21.4 Place of residence Urban Governorates 25.0 24.4 23.7 23.9 24.7 24.3 Lower Egypt 22.5 22.7 22.5 22.0 22.0 22.3 Urban 24.0 24.0 23.5 23.2 23.7 23.7 Rural 22.0 22.1 22.1 21.5 21.3 21.8 Upper Egypt 22.2 21.5 21.4 21.0 21.3 21.6 Urban 24.3 23.5 24.1 23.0 22.9 23.6 Rural 21.3 20.7 20.1 20.0 20.5 20.6 Frontier Governorates 23.4 22.9 21.9 22.6 22.3 22.7 Education No education 20.5 20.6 20.3 20.5 20.6 20.5 Some primary 20.8 20.7 20.6 21.1 21.0 20.9 Primary complete/ some secondary 20.8 20.8 20.9 21.4 22.1 21.0 Secondary complete/ higher 24.1 24.4 24.4 24.5 25.8 24.5 Wealth quintile Lowest 21.0 20.6 20.6 20.7 21.0 20.8 Second 21.9 21.3 20.6 20.6 20.3 21.0 Middle 22.3 22.3 21.8 21.6 21.3 21.9 Fourth 23.3 23.3 23.4 22.9 22.9 23.2 Highest a 24.9 24.7 24.5 25.1 24.8 Total 22.9 22.6 22.4 22.2 22.2 22.5 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 58 | Fertility social consequences, particularly on female educational attainment since women who become mothers in their teens are more likely to curtail education. Table 4.11 shows the percentage of women age 15-19 who were mothers or who were pregnant with their first child at the time of the 2008 EDHS. The overall level of teenage childbearing was 10 percent, almost the same as that recorded in the 2005 EDHS (9 percent). The proportion of women who had begun childbearing rises rapidly throughout the teenage years, from less than one percent among 15-year-olds to 7 percent among 17-year-olds, 13 percent among 18- year-olds, and 24 percent among 19-year-olds. There were significant residential differences in the level of teenage childbearing. In rural areas, the level of teenage fertility (12 percent) was almost twice the level in urban areas (7 percent). Upper Egypt had the highest level of teenage childbearing, especially in the rural areas (14 percent), while the level was lowest in Urban Governorates and urban Lower Egypt (5 percent, each). The level of teenage fertility was strongly associated with a woman’s educational level. The proportion of women age 15-19 who were pregnant or who had already had a birth was highest among women with no education (26 percent). Teenagers in the three lowest wealth quintiles were more than twice as likely as women in the highest wealth quintile to have begun bearing children. Table 4.11 Teenage pregnancy and motherhood by background characteristics Percentage of women age 15-19 who are mothers or pregnant with their first child, by background characteristics, Egypt 2008 Percentage who are: Background characteristic Mothers Pregnant with first child Percentage who have begun childbearing Number of women Age 15 0.1 0.6 0.8 853 16 1.1 1.1 2.2 924 17 3.6 3.8 7.4 931 18 8.4 4.1 12.5 936 19 15.6 8.3 23.9 973 Urban-rural residence Urban 4.4 2.2 6.5 1,635 Rural 7.4 4.9 12.3 2,754 Place of residence Urban Governorates 3.2 2.1 5.4 791 Lower Egypt 5.8 3.4 9.2 1,980 Urban 3.8 1.0 4.8 504 Rural 6.5 4.2 10.7 1,477 Upper Egypt 7.4 4.7 12.1 1,782 Urban 4.8 2.4 7.2 530 Rural 8.5 5.6 14.1 1,252 Frontier Governorates 3.5 4.0 7.5 67 Education No education 16.6 9.5 26.2 428 Some primary 10.7 3.2 13.9 131 Primary complete/some secondary 4.1 1.8 5.8 2,592 Secondary complete/ higher 5.8 5.4 11.2 1,460 Wealth quintile Lowest 8.1 3.6 11.7 975 Second 7.3 4.6 11.9 1,006 Middle 6.2 3.9 10.1 900 Fourth 4.7 4.4 9.1 876 Highest 2.9 1.9 4.8 865 Total 6.0 3.7 9.6 4,618 Knowledge, Attitudes, and Ever Use of Family Planning | 59 KNOWLEDGE, ATTITUDES, AND EVER USE OF FAMILY PLANNING 5 This chapter first presents 2008 EDHS results relating to knowledge of family planning methods and the channels through which Egyptian women receive information about family planning methods. The chapter next considers data from the survey on women’s awareness of the timing of the fertile period and of the circumstances under which breastfeeding may play in delaying pregnancy. The chapter then looks at information on the level of ever use of family planning and the timing of the first adoption of family planning methods. 5.1 KNOWLEDGE OF FAMILY PLANNING METHODS Awareness of family planning methods is crucial in decisions on whether to use a contraceptive method and which method to use. One of the main objectives of the 2008 EDHS was to determine the level of knowledge of contraceptive methods. To assess contraceptive knowledge, respondents were first asked an open-ended question about the contraceptive methods about which they had heard. All methods named in response to this question were recorded as recognized. If a respondent failed to mention any of the methods listed in the questionnaire, the interviewer would describe the method and ask whether the respondent had heard about it. Methods recognized by the respondent after the description was read were also recorded as known. Information on knowledge of specific methods was collected in the 2008 EDHS for nine modern methods (pill, IUD, injectable, implant, vaginal methods (diaphragm and contraceptive foam or jelly), condom, female sterilization, male sterilization, and emergency contraception) 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. 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 analysis that follows, knowledge of a family planning method is defined simply as having heard of a method. The results in Table 5.1 show that knowledge of family planning methods is universal among currently married women in Egypt. Almost all currently married women age 15-49 interviewed in the EDHS knew about the pill, IUD, and injectable, and 94 percent knew about implant. Fifty-eight percent knew about female sterilization, and nearly 50 percent knew about the condom. Other methods were less widely recognized. Only 13 percent knew about vaginal methods, 9 percent knew about male sterilization, and emergency contraception was recognized by around 6 percent. Prolonged breastfeeding was the most Table 5.1 Family planning knowledge Percentage of currently married women 15- 49 knowing about specific family planning methods by method and the mean number of family planning methods known, Egypt 2008 Method Knows method Any method 100.0 Any modern method 100.0 Pill 99.7 IUD 99.8 Injectables 99.4 Implant 93.7 Diaphragm /foam/jelly 12.6 Condom 48.7 Female sterilization 57.6 Male sterilization 8.5 Emergency contraception 5.6 Any traditional method 75.9 Periodic abstinence 28.1 Withdrawal 21.4 Prolonged breastfeeding 70.1 Folk method 0.5 Mean number of methods known 6.5 Number of women 15,396 60 | Knowledge, Attitudes, and Ever Use of Family Planning commonly recognized traditional method (70 percent). The mean number of methods known by women was 6.5. Figure 5.1 compares the levels of knowledge of specific methods found in the 2008 EDHS with levels observed in the 2005 EDHS survey. Almost all women in both surveys knew about the pill, IUD and injectable, and 94 percent knew about the implant. In the case of all of the other methods except prolonged breastfeeding, however, knowledge levels decreased over the period. The declines were greatest in the case of vaginal methods (from 21 percent to 13 percent) and female sterilization (from 66 percent to 58 percent). 5.2 EXPOSURE TO FAMILY PLANNING MESSAGES The 2008 EDHS obtained information on the types of media through which women received family planning information. The 2008 EDHS collected these data by asking respondents whether they had heard a family planning message through broadcast media (television or radio) and through printed materials, community meetings and religious leaders during the 6 months prior to the interview ( i.e., the period from around October 2007 up to March 2008). The information on the media channels on which women are currently relying may be useful in guiding future information and education efforts in Egypt's family planning program. As expected, Table 5.2 confirms that television is the primary source of family planning information. Around 60 percent of currently married women age 15-49 interviewed in the EDHS had seen a recent family planning message on television, compared with 19 percent who had listened to a message on the radio. Twenty-six percent of EDHS respondents had seen a family planning poster, billboard, or signboard. Other communication channels reached far fewer women. Only 7 percent had read about family planning in a newspaper or magazine, while community meetings and religious leaders were named by 2 percent and 1 percent of women, respectively, as a source from which they had received information about family planning. One third of women were not exposed to any family planning messages during the 6 months prior to the survey. 100 100 99 94 21 53 66 8 7 35 28 65 100 100 99 94 13 49 58 9 6 28 21 70 Pill IUD Injectable Implant Vaginal methods Condom Female sterili- zation Male sterili- zation Emer- gency contra- ception Periodic abstinence With- drawal Prolonged breast- feeding 2005 2008 Figure 5.1 Trends in Family Planning Knowledge, Egypt 2005-2008 Percentage of currently married women Knowledge, Attitudes, and Ever Use of Family Planning | 61 Table 5.2 Exposure to family planning messages by background characteristics Percentage of currently married women by whether they heard or saw a family planning message on various media in the 6 months prior to the interview according to background characteristics, Egypt 2008 Background characteristic Radio Television News- paper/ magazine Poster/ billboard/ sign Com- munity meeting Religious leader No exposure to family planning messages Number of women Age 15-19 18.0 56.9 3.3 29.3 1.2 0.9 31.8 605 20-24 18.0 61.3 5.2 30.3 1.5 0.9 29.2 2,527 25-29 19.8 60.7 7.0 31.1 1.9 1.2 29.5 3,264 30-34 21.5 59.7 8.2 29.8 2.0 1.1 30.8 2,551 35-39 19.5 57.9 6.9 23.4 2.2 1.1 33.5 2,406 40-44 19.6 56.1 7.4 20.2 1.8 1.1 37.2 2,188 45-49 17.1 49.5 6.7 17.5 1.7 1.6 43.7 1,855 Urban-rural residence Urban 22.8 56.3 10.5 29.3 1.6 1.4 32.3 6,316 Rural 16.9 59.3 4.2 24.2 1.9 1.0 33.8 9,080 Place of residence Urban Governorates 26.8 51.6 8.6 24.2 1.5 1.8 36.2 2,727 Lower Egypt 17.8 64.3 6.2 24.9 1.5 0.2 31.6 7,128 Urban 19.3 64.7 11.5 30.5 1.7 0.4 29.9 1,801 Rural 17.3 64.2 4.5 23.0 1.5 0.1 32.2 5,326 Upper Egypt 17.4 53.2 6.5 29.3 2.4 2.1 33.5 5,326 Urban 20.5 54.8 12.4 36.3 1.8 1.8 28.1 1,646 Rural 16.1 52.5 3.9 26.2 2.7 2.3 35.9 3,680 Frontier Governorates 19.8 52.6 8.4 25.9 1.8 0.5 40.4 216 Education No education 14.0 50.2 0.5 15.8 1.2 0.8 42.6 4,758 Some primary 15.3 52.6 1.5 24.6 1.2 1.3 36.9 1,259 Primary complete/some secondary 21.4 57.4 3.1 26.3 1.1 1.0 32.5 2,273 Secondary complete/ higher 22.9 64.5 13.1 33.6 2.6 1.4 26.5 7,106 Work status Working for cash 23.4 61.3 17.4 33.1 5.1 2.0 29.6 2,182 Not working for cash 18.6 57.5 5.0 25.2 1.3 1.0 33.8 13,215 Wealth quintile Lowest 12.5 49.1 1.2 19.8 1.5 1.3 41.8 2,764 Second 16.7 58.8 2.5 21.5 1.8 1.0 35.0 3,014 Middle 20.3 63.5 4.6 25.9 1.7 0.9 29.5 3,172 Fourth 19.5 59.2 7.2 31.4 1.6 0.8 31.2 3,268 Highest 26.6 58.6 17.5 31.5 2.4 1.9 29.7 3,178 Total 19.3 58.1 6.8 26.3 1.8 1.2 33.2 15,396 62 | Knowledge, Attitudes, and Ever Use of Family Planning The proportions of currently-married women who had heard a family planning message on either television or radio varied by residence, with women in the Urban Governorates being the least likely to have been reached by television and women in Upper Egypt being the least likely to have been reached by radio. As expected, exposure to family planning information through print media increased with educational level. Differences in the proportions who had heard about family planning at a community meeting or from a religious leader were not very pronounced across the subgroups for which results are shown in Table 5.2. Comparing the level of exposure found in 2008 with the level observed in 2005, Figure 5.2 shows a clear decline in exposure to family planning messages, regardless of the source. One reason may be the fact that most of households now have a satellite dish and, therefore, women are less likely to watch the public television channels through which family planning messages are broadcast. It is also possible that fewer family planning messages are being aired, particularly on television, as the media reduce the overall time allotted for free public service messages. 5.3 KNOWLEDGE OF FERTILE PERIOD An elementary understanding of reproductive physiology, particularly knowledge of when in the ovulatory cycle a woman is most likely to become pregnant, may be useful in ensuring success in the use of coitus-related methods such as the condom, vaginal methods and withdrawal. Such knowledge is especially critical for the practice of periodic abstinence. To investigate women’s knowledge about their fertile period, 2008 EDHS respondents were asked whether there are certain days a woman is more likely to become pregnant if she has sexual intercourse. Those who responded affirmatively to that question were asked whether this time is just before the period begins, during the period, right after the period ends, or halfway between two periods. 63 89 21 28 4 3 9 19 58 7 26 2 1 33 Radio Television Newspaper/ magazine Poster/ billboard/ sign Community meeting Religious leader No exposure 0 20 40 60 80 100 2005 2008 Figure 5.2 Trends in Exposure to Family Planning Messages Egypt 2005-2008 Percentage of currently married women who heard or saw a family planning method on various media Knowledge, Attitudes, and Ever Use of Family Planning | 63 Table 5.3 shows that understanding of the ovulatory cycle is limited among Egyptian women. Around one-fifth of the ever- married women age 15-49 interviewed in the EDHS knew that a woman has a greater probability of becoming pregnant if she has sexual intercourse halfway between two periods. More than four in ten respondents either were unable to say when a woman is most at risk of pregnancy or believed that a woman’s risk is the same throughout the ovulatory cycle. 5.4 KNOWLEDGE OF BREASTFEEDING AS A FAMILY PLANNING METHOD Prolonged breastfeeding is the most widely known tradi- tional family planning method among Egyptian women; as shown in Table 5.4, around 7 in 10 currently married respondents in the EDHS believed that a mother is protected from pregnancy during the time she is breastfeeding. Although the belief that women who prolong breastfeeding are protected from pregnancy is widespread, it is not clear that Egyptian women fully understand the conditions under which breastfeeding may be effective as a family planning method. Research on which the lactational amenorrhea method is based indicates that a breastfeeding mother has a high degree of protection from pregnancy if three conditions are met: (1) the child is less than 6 months old; (2) the mother is still amenorrheic, i.e., her menstrual period has not returned; and (3) the baby is exclusively or nearly exclusively breastfed and fed frequently both during the day and at night. To explore women’s awareness of these conditions, the 2008 EDHS included questions about the number of months a woman is protected from pregnancy if she breastfeeds, whether a breastfeeding mother is protected from pregnancy if her menstrual period returns, and whether the mother is still protected if the child is given other liquids or solids besides breast milk or if the baby sleeps through the night without feeding and feeds only a few times during the day. The questions were directed toward women who reported during the administration of the contraceptive knowledge and use table that they had heard of prolonged breastfeeding and an additional 2 percent of women who did not know about prolonged breastfeeding but indicated in response to a separate screening question that they believed breastfeeding can help a woman to avoid pregnancy (Table 5.4). Table 5.5 shows that few women were aware of the comparatively short period after birth during which breastfeeding may afford a woman protection from pregnancy. Only 4 percent of the women reported correctly that a woman is only protected from a pregnancy during the first 6 months that she breastfeeds her child. More than one-third of women thought that a breastfeeding mother is protected from pregnancy until her period is back, and more than quarter believed that a mother is protected until the child is weaned. Women were more knowledgeable about some of the situations in which breastfeeding does not protect a mother from pregnancy. More than nine in ten currently married women knew a breastfeeding mother is not protected from pregnancy after her menstrual period returns. Seven in ten women agreed Table 5.3 Knowledge of fertile period Percent distribution of ever-married women 15-49 by knowledge of the fertile period during the ovulatory cycle, Egypt 2008 Perceived fertile period Percent Just before her period begins 1.4 During her period 0.3 Right after her period has ended 32.9 Halfway between two periods 20.7 Other 0.2 No specific time 20.7 Don't know 23.6 Missing 0.3 Total 100.0 Number of women 16,527 Table 5.4 Belief breastfeeding reduces chances of pregnancy Percent distribution of currently married women 15- 49 who know about prolonged breastfeeding or who do not know about prolonged breastfeeding but believe breastfeeding can be a family planning method, Egypt 2008 Belief breastfeeding reduces chances of pregnancy Percent Knows prolonged breastfeeding 70.1 Does not know prolonged breastfeeding 29.9 Believes breastfeeding can help woman avoid pregnancy 2.2 Does not believe breastfeeding can help woman avoid pregnancy 27.6 Missing 0.0 Total 100.0 Number of currently married women 15,396 64 | Knowledge, Attitudes, and Ever Use of Family Planning that a breastfeeding mother was not protected from pregnancy if the child was given other liquids or solids and two-thirds of women agreed that a breastfeeding mother was not protected from pregnancy if she was breastfeeding the child only a few times during the day and not at all at night. Table 5.5 shows that knowledge of the conditions under which a breastfeeding mother may be protected from pregnancy varied by background characteristics, although the differentials were not substantial in most cases. In general, women age 15-19 were least likely and women in the Frontier Governorates were most likely to recognize the conditions under which a breastfeeding mother would not be protected from pregnancy. Table 5.5 Beliefs concerning breastfeeding and a woman's protection from pregnancy Percent distribution of currently married women knowing about prolonged breastfeeding or agreeing that breastfeeding can help a woman avoid pregnancy by the number of months a woman is protected from pregnancy if she breastfeeds and percentage who believe that a breastfeeding mother is not protected from pregnancy if her menstrual period returns, if the child is given other liquids or solids besides breast milk, or if the baby sleeps through the night without feeding and feeds only a few times during the day, by background characteristics, Egypt 2008 Percentage saying mother is not protected from pregnancy if: Number of months mother protected from pregnancy if breastfeeding Background characteristic 0-5 6-11 12 or more Until period back Until she stops/ child weaned Other/ don’t know/ missing Total percent Men- strual period returns Child given other liquids/ solids Child not breast- fed at night and fed only few times during day Number of women Age 15-19 4.0 7.0 19.2 30.6 23.8 15.5 100.0 85.5 55.3 51.9 334 20-24 3.8 5.7 19.5 35.6 25.2 10.2 100.0 92.2 67.6 62.5 1,684 25-29 4.3 6.8 18.3 37.7 26.7 6.2 100.0 94.5 72.2 67.8 2,372 30-34 3.9 6.6 18.8 36.2 28.5 6.1 100.0 95.6 72.8 68.6 1,882 35-39 3.4 6.5 20.4 36.3 27.8 5.6 100.0 95.4 71.7 69.4 1,787 40-44 3.1 4.2 22.2 36.3 28.0 6.1 100.0 94.7 72.5 68.9 1,660 45-49 3.1 4.2 21.1 39.0 28.1 4.4 100.0 95.2 67.6 64.2 1,423 Urban-rural residence Urban 3.4 6.4 17.3 43.4 23.7 5.9 100.0 95.4 74.1 70.2 4,854 Rural 3.9 5.4 21.9 31.4 30.0 7.4 100.0 93.5 67.6 63.8 6,287 Place of residence Urban Governorates 3.3 5.7 13.7 55.0 18.4 3.9 100.0 96.3 74.1 68.0 2,265 Lower Egypt 4.7 5.6 16.6 30.8 34.1 8.1 100.0 95.5 69.7 66.0 4,737 Urban 3.6 5.3 15.0 34.5 33.4 8.2 100.0 95.6 72.5 70.6 1,228 Rural 5.1 5.8 17.2 29.5 34.4 8.0 100.0 95.4 68.7 64.3 3,509 Upper Egypt 2.6 6.0 27.3 32.9 24.2 7.0 100.0 91.8 68.7 66.0 3,973 Urban 3.5 8.3 25.5 31.5 23.5 7.7 100.0 93.5 74.7 72.8 1,252 Rural 2.3 4.9 28.1 33.5 24.5 6.7 100.0 91.0 65.9 62.9 2,721 Frontier Governorates 3.4 8.6 21.4 41.7 22.8 2.0 100.0 96.8 84.8 79.3 166 Education No education 3.6 4.0 22.7 32.7 32.0 5.0 100.0 94.1 64.5 59.4 3,326 Some primary 4.2 5.8 22.9 35.2 25.0 6.9 100.0 94.6 65.1 61.5 925 Primary complete/some secondary 3.2 6.3 21.4 37.9 25.8 5.4 100.0 94.3 72.2 67.2 1,660 Secondary complete/ higher 3.8 6.8 17.1 39.0 25.0 8.2 100.0 94.5 74.7 71.9 5,231 Work status Working for cash 3.2 7.5 19.0 39.9 23.5 6.8 100.0 95.0 74.1 73.9 1,740 Not working for cash 3.8 5.5 20.0 36.0 27.9 6.7 100.0 94.2 69.8 65.2 9,401 Wealth quintile Lowest 3.2 3.8 27.7 30.5 28.2 6.7 100.0 92.1 63.6 58.8 1,930 Second 3.9 5.2 22.5 30.4 31.4 6.5 100.0 93.8 66.1 61.4 2,036 Middle 3.4 6.4 20.4 34.3 29.0 6.5 100.0 95.1 68.7 65.2 2,245 Fourth 4.6 6.3 14.5 41.5 27.0 6.1 100.0 95.6 75.3 71.8 2,455 Highest 3.1 7.0 16.5 43.9 21.6 7.8 100.0 94.7 76.2 73.2 2,475 Total 3.7 5.8 19.9 36.6 27.2 6.7 100.0 94.3 70.5 66.6 11,141 Knowledge, Attitudes, and Ever Use of Family Planning | 65 5.5 EVER USE OF FAMILY PLANNING The 2008 EDHS collected data on the level of ever use of family planning methods. These data were obtained by asking respondents separately about whether they had ever used each of the family planning methods that they knew. The following sections explore the level of ever use of family planning methods among Egyptian women. 5.5.1 Levels of Ever Use Table 5.6 shows the percentages of ever-married women and currently married women who had ever used family planning according to a woman’s age and the method used. Overall, the results indicate that 82 percent of married women had used a family planning method at some time. Across age groups, the highest level of ever use of any family planning method among currently-married women was observed in the 35-39 age group (92 percent), while the lowest level is found among women age 15-19 (31 percent). Virtually all of the women who had ever used a method had experience with modern methods. The most commonly used modern method was the IUD, followed by the pill and then injectable. Around 14 percent of women had ever used a traditional method. The most widely used traditional method was prolonged breastfeeding (12 percent), followed by periodic abstinence (1 percent). Table 5.6 Ever use of family planning methods by age Percentage of ever-married women and currently married women who have ever used a family planning method, by specific method and age, Egypt 2008 Modern method Traditional method Age Any meth- od Any mo- dern meth- od Pill IUD Injec- tables Im- plant Dia- phragm/ foam/ jelly Con- dom Fe- male sterile- zation Male sterile- zation Emer- gency contra- ception Any tradi- tional me- thod Peri- odic absti- nence With- drawal Pro- longed breast- feeding Folk meth- od Never used any Number of women EVER-MARRIED WOMEN 15-19 30.5 27.1 9.4 18.5 2.9 0.3 0.0 0.0 0.0 0.0 0.0 5.5 0.0 0.2 5.3 0.0 69.5 620 20-24 63.7 59.9 25.8 39.4 10.7 0.5 0.0 0.4 0.0 0.0 0.1 7.8 0.3 0.2 7.3 0.0 36.3 2,584 25-29 81.7 78.2 33.5 57.4 19.4 1.7 0.1 1.9 0.1 0.0 0.1 12.2 0.7 0.6 11.2 0.0 18.3 3,367 30-34 87.6 85.8 39.6 66.7 26.2 2.8 0.3 3.1 0.5 0.0 0.1 14.5 1.3 1.2 12.5 0.1 12.4 2,664 35-39 89.3 87.8 41.9 69.3 27.2 2.5 0.3 3.2 1.3 0.0 0.1 14.9 1.4 1.0 13.3 0.1 10.7 2,586 40-44 88.2 86.3 42.1 68.6 25.9 2.2 0.5 3.4 2.3 0.0 0.1 16.0 2.2 1.7 13.3 0.1 11.8 2,473 45-49 85.2 83.0 42.3 65.6 22.0 1.6 0.7 3.4 2.5 0.0 0.2 19.2 1.9 1.4 17.3 0.0 14.8 2,234 Total 80.6 78.0 36.2 59.3 21.1 1.8 0.3 2.4 1.0 0.0 0.1 13.6 1.2 1.0 12.1 0.1 19.4 16,527 CURRENTLY MARRIED WOMEN 15-19 30.8 27.4 9.6 18.6 2.9 0.3 0.0 0.0 0.0 0.0 0.0 5.6 0.0 0.2 5.4 0.0 69.2 605 20-24 64.6 60.8 26.3 40.0 10.8 0.5 0.0 0.4 0.0 0.0 0.1 7.9 0.3 0.2 7.4 0.0 35.4 2,527 25-29 82.6 79.1 33.9 58.2 19.6 1.8 0.1 1.9 0.1 0.0 0.1 12.3 0.8 0.6 11.3 0.0 17.4 3,264 30-34 88.9 87.1 40.5 67.8 26.6 2.8 0.3 3.1 0.6 0.0 0.1 14.7 1.4 1.3 12.6 0.1 11.1 2,551 35-39 91.5 90.3 43.3 71.3 28.3 2.7 0.3 3.3 1.4 0.0 0.1 15.0 1.5 1.1 13.3 0.1 8.5 2,406 40-44 90.9 89.1 43.8 71.0 27.3 2.3 0.6 3.8 2.4 0.0 0.2 16.8 2.5 1.9 13.8 0.1 9.1 2,188 45-49 88.1 86.4 43.9 68.9 23.8 1.9 0.9 3.8 2.7 0.0 0.3 20.0 2.2 1.6 17.9 0.0 11.9 1,855 Total 81.9 79.4 36.9 60.4 21.6 1.9 0.3 2.5 1.0 0.0 0.1 13.7 1.3 1.0 12.1 0.1 18.1 15,396 66 | Knowledge, Attitudes, and Ever Use of Family Planning 5.5.2 Trends in Ever Use Table 5.7 presents trends in the level of ever use of family planning among ever-married women during the period 1980-2008. The level of ever-use of any method increased from 40 percent in 1980 to 81 percent in 2008, an average of 1.5 percentage points per year (Figure 5.3) With regard to the trends in use of specific methods, the most significant change has been the rise in IUD use. The level of ever use of the IUD was about 60 percent at the time of the 2008 EDHS, four times the level reported in 1984 (15 percent). In the case of the pill, the level of ever use peaked at 46 percent in 1988, before dropping steadily thereafter to a level of 36 percent in 2008. Ever use of the injectable was rare before the mid 1990s when use of this method began to steadily increase, reaching a level of 21 percent in 2005. Table 5.7 Trends in ever use of family planning method Percentage of ever-married women ever using any family planning method, Egypt 1980-2008 Method 1980 EFS 1984 ECPS 1988 EDHS 1991 EMCHS 1992 EDHS 1995 EDHS 2000 EDHS 2005 EDHS 2008 EDHS Any method 39.8 48.2 57.4 63.2 64.6 68.4 75.1 79.6 80.6 Any modern method 38.9 46.7 55.9 59.8 62.9 66.7 73.4 77.7 78.0 Pill 35.8 41.0 46.0 44.7 44.0 44.2 39.8 38.9 36.2 IUD 8.7 14.8 24.6 32.3 39.7 46.1 55.9 60.7 59.3 Injectables 0.5 1.1 2.3 na 2.9 6.2 14.1 20.7 21.1 Implants na na na na na na 0.3 1.4 1.8 Vaginal methods 1.2 3.9 5.3 na 3.6 2.2 1.5 0.5 0.3 Condom 5.0 3.4 8.6 na 7.5 7.7 3.7 3.8 2.4 Female sterilization 0.7 1.4 1.5 na 1.1 1.1 1.4 1.2 1.0 Male sterilization 0.1 0.0 0.0 na 0.0 0.0 0.0 0.0 0.0 Emergency contraception na na na na na na na 0.1 0.1 Any traditional method na 5.3 11.4 na 9.5 10.8 8. 3 12.9 13.6 Periodic abstinence 2.7 1.4 3.7 na 3.4 3.3 1. 5 2.0 1.2 Withdrawal 2.3 1.0 2.4 na 2.6 2.5 0. 8 1.5 1.0 Prolonged breastfeeding na 3.1 6.5 na 4.9 6.6 6. 3 10.5 12.1 Other methods na 0.5 0.8 na 0.4 0.4 0. 3 0.1 0.1 Number of women 8,788 10,013 8,911 9,073 9,864 14,779 15,573 19,474 16,527 na = Information on the method was not collected or was not reported. Source: El-Zanaty and Way, 2006, Table 5.6 40 48 57 65 68 75 80 81 1980 1984 1988 1992 1995 2000 2005 2008 0 20 40 60 80 100 Figure 5.3 Trends in Ever Use of Familly Planning Egypt 1980-2008 Percentage of ever-married women ever using any family planning method Knowledge, Attitudes, and Ever Use of Family Planning | 67 5.5.3 Differentials in Ever Use Table 5.8 presents differences in the overall proportions of ever-married women who have ever used family planning and in the number of methods with which ever users had experience. More than half (52 percent) of the ever users had experience with only one method, while 31 percent had used two methods, and 17 percent had tried three or more methods. Older women were not only more likely to have ever used family planning but also, if they have used it, to have experience with a greater number of methods than younger women. For example, only about 5 percent of women age 15-24 had used three or more methods, compared with more than 20 percent of women age 35-39. Table 5.8 Ever use of family planning methods by background characteristics Percentage of ever-married women who have ever used a family planning method, and, among ever users, percent distribution by number of methods ever used, according to background characteristics, Egypt 2008 Number of methods ever used Background characteristic Percent- age ever used any method Number of ever married women 1 2 3+ Total Mean number of methods ever used Number ever using family planning methods Age 15-19 30.5 620 80.7 18.4 0.8 100.0 1.2 189 20-24 63.7 2,584 72.0 23.6 4.4 100.0 1.3 1,645 25-29 81.7 3,367 59.6 28.1 12.3 100.0 1.6 2,751 30-34 87.6 2,664 48.4 33.3 18.3 100.0 1.8 2,335 35-39 89.3 2,586 45.2 34.8 20.0 100.0 1.8 2,310 40-44 88.2 2,473 44.8 32.9 22.3 100.0 1.8 2,180 45-49 85.2 2,234 42.5 36.1 21.5 100.0 1.9 1,904 Urban-rural residence Urban 83.2 6,809 53.0 31.0 16.0 100.0 1.7 5,662 Rural 78.7 9,718 51.5 31.7 16.8 100.0 1.7 7,653 Place of residence Urban Governorates 83.4 2,931 53.2 30.7 16.1 100.0 1.7 2,444 Lower Egypt 83.4 7,618 54.1 31.9 14.1 100.0 1.6 6,354 Urban 85.0 1,936 54.4 32.3 13.3 100.0 1.6 1,645 Rural 82.9 5,682 54.0 31.7 14.3 100.0 1.6 4,709 Upper Egypt 75.7 5,751 48.8 31.0 20.2 100.0 1.8 4,351 Urban 81.6 1,792 51.3 29.7 18.9 100.0 1.8 1,461 Rural 73.0 3,959 47.5 31.7 20.8 100.0 1.8 2,890 Frontier Governorates 72.6 227 46.6 34.8 18.6 100.0 1.8 165 Education No education 80.0 5,302 47.7 33.3 18.9 100.0 1.8 4,242 Some primary 85.1 1,394 41.8 35.6 22.6 100.0 1.9 1,185 Primary complete/ some secondary 79.9 2,413 48.0 33.1 18.8 100.0 1.8 1,927 Secondary complete/higher 80.3 7,418 58.6 28.7 12.8 100.0 1.6 5,959 Work status Working for cash 86.1 2,459 50.9 30.7 18.3 100.0 1.7 2,119 Not working for cash 79.6 14,068 52.3 31.5 16.1 100.0 1.7 11,196 Wealth quintile Lowest 76.2 3,033 48.1 32.5 19.4 100.0 1.8 2,312 Second 78.1 3,252 50.3 32.4 17.2 100.0 1.7 2,540 Middle 82.5 3,394 50.8 32.7 16.5 100.0 1.7 2,799 Fourth 82.3 3,505 54.4 29.8 15.8 100.0 1.7 2,886 Highest 83.1 3,343 55.9 30.0 14.1 100.0 1.6 2,777 Total 80.6 16,527 52.1 31.4 16.5 100.0 1.7 13,314 68 | Knowledge, Attitudes, and Ever Use of Family Planning Looking at the other subgroups for which information is presented in Table 5.8, women from urban areas, women with some primary education, women who are working for cash, and women in the highest wealth quintile were more likely than other women to have ever used a family planning method. Women from rural Upper Egypt and Frontier Governorates had the least experience with family planning (73 percent, each), while women from urban Lower Egypt had the most experience with family planning (85 percent). There is comparatively little variation by residence among ever users in the number of methods that ever users have tried. 5.6 FIRST USE OF FAMILY PLANNING Women who reported that they had used family planning methods at some time were asked about the number of children they had when they first used family planning. These data are useful in identifying the stage in the family-building process when women begin using family planning as well as their motivation for adopting family planning. Table 5.9 presents the percent distribution of ever-married women by the number of living children at the time of the first use of family planning. Almost none of the women started using family planning immediately after marriage while they were still childless. Overall, around six in ten women began use of family planning after they had had their first child (58 percent), 12 percent started after they had had two children, and 11 percent had three or more children before using family planning. Looking at the age patterns, there has been a shift in the timing of the adoption of the first contraceptive method, with younger women initiating use of family planning methods at lower parities than older women. For example, 68 percent of women age 25-29 started family planning use after their first child compared with 48 percent of women 45-49. Table 5.9 Number of living children at time of first use of family planning Percent distribution of ever-married women by number of living children at the time of first use of family planning and age, Egypt 2008 Number of living children at time of first use of contraception Age Never used 0 1 2 3 4+ Missing Total Number of women 15-19 69.5 0.1 28.4 1.9 0.1 0.0 0.0 100.0 620 20-24 36.3 0.3 55.8 6.8 0.7 0.1 0.0 100.0 2,584 25-29 18.3 0.4 67.9 10.1 2.3 1.0 0.0 100.0 3,367 30-34 12.4 0.1 65.9 13.0 4.4 4.1 0.1 100.0 2,664 35-39 10.7 0.1 59.9 15.2 6.6 7.3 0.1 100.0 2,586 40-44 11.8 0.2 50.0 15.8 8.8 13.2 0.0 100.0 2,473 45-49 14.8 0.1 47.7 14.3 8.8 14.2 0.1 100.0 2,234 Total 19.4 0.2 57.5 12.0 4.8 5.9 0.0 100.0 16,527 5.7 ATTITUDE ABOUT TIMING OF ADOPTION OF CONTRACEPTION The 2008 EDHS included questions about the appropriateness of a couple’s use of family plan- ning before the first pregnancy and after the first birth. Most ever-married women age 15-49 (93 percent) considered it appropriate for a couple to begin using family planning after the first birth. In contrast, only 2 percent regarded use before the first pregnancy as appropriate. Knowledge, Attitudes, and Ever Use of Family Planning | 69 Although few women in any subgroup considered it appropriate to adopt family planning before the first birth, the results in Table 5.10 indicate there is some variability across subgroups in the attitude toward family planning use after the first birth. The groups with the highest proportions considering use after the first birth as appropriate include women from the Urban Governorates (98 percent) and women in the highest wealth quintile (97 percent). The groups with the lowest proportions considering use after the first birth as appropriate are women from rural Upper Egypt and women with no education (84 percent, and 88 percent respectively). Table 5.10 Timing of use of family planning among newly married couples by background characteristics Percentage of ever-married women by attitude about appropriateness of a couple's using family planning before the first pregnancy and after the first birth, according to background characteristics, Egypt 2008 Family planning use appropriate: Background characteristic Before first pregnancy After first birth Number of women Age 15-19 1.7 90.7 620 20-24 1.3 94.2 2,584 25-29 1.8 93.8 3,367 30-34 1.3 94.8 2,664 35-39 1.3 93.3 2,586 40-44 1.6 90.9 2,473 45-49 1.4 89.9 2,234 Urban-rural residence Urban 1.6 95.6 6,809 Rural 1.4 91.0 9,718 Place of residence Urban Governorates 1.1 98.2 2,931 Lower Egypt 1.0 95.7 7,618 Urban 0.9 96.0 1,936 Rural 1.0 95.6 5,682 Upper Egypt 2.3 86.5 5,751 Urban 3.1 91.3 1,792 Rural 1.9 84.4 3,959 Frontier Governorates 1.8 89.0 227 Education No education 1.5 87.9 5,302 Some primary 1.1 91.6 1,394 Primary complete/some secondary 1.5 93.9 2,413 Secondary complete/higher 1.5 96.3 7,418 Work status Working for cash 1.5 95.0 2,459 Not working for cash 1.5 92.5 14,068 Wealth quintile Lowest 2.0 86.6 3,033 Second 1.5 91.2 3,252 Middle 1.1 93.4 3,394 Fourth 1.1 95.7 3,505 Highest 1.7 96.6 3,343 Total 2008 EDHS 1.5 92.9 16,527 Total 2005 EDHS 2.4 93.3 19,474 Total 2003 EDHS 4.9 90.1 8,958 Total 2000 EDHS 4.7 84.7 15,024 Current Use of Family Planning | 71 CURRENT USE OF FAMILY PLANNING 6 The data on the current use of family planning collected in the 2008 EDHS is among the most important information obtained in the survey since it provides insight into one of the principal determi- nants of fertility and also serves as a key measure for assessing the success of the national family planning program. 6.1 CURRENT USE OF FAMILY PLANNING Overall, the EDHS results indicate that 60 percent of currently married women in Egypt are using contraception (Figure 6.1). The IUD, pill, and injectables are the most widely used methods: 36 percent of currently married women interviewed in the EDHS were currently using the IUD, 12 percent were relying on the pill, and 7 percent were employing injectables. Relatively small proportions of women were using other modern methods; e.g., 1 percent was using the condom. Three percent of women reported use of traditional methods. 6.2 DIFFERENTIALS IN CURRENT USE OF FAMILY PLANNING 6.2.1 Differentials by Residence The 2008 EDHS found that there were marked differences in the level of current use of family planning methods by residence (Table 6.1). Urban women were more likely to be using than rural women (64 percent and 58 percent, respectively). Use rates were higher in the Urban Governorates (65 percent) Figure 6.1 Current Use by Method EDHS 2008 Traditional method 3% Other modern 2%Pill 12% IUD 36% Injectables 7% Not currently using 40% 72 | Current Use of Family Planning and Lower Egypt (64 percent) than in Upper Egypt (53 percent) and the Frontier Governorates (52 percent). Within Upper Egypt, the use rate among urban women (62 percent) was markedly higher than the rate among rural women (48 percent). The urban-rural differential was much narrower within Lower Egypt; 66 percent of married women living in urban areas in Lower Egypt were using a family planning method compared with 64 percent of rural women. The IUD was the most frequently used method in every residential category, followed by the pill and injectables. The extent to which the IUD dominated the method mix, however, varied across residential subgroups. For example, women in the Urban Governorates and in rural Lower Egypt were around four times as likely to be using the IUD as the pill. In all other residential areas except rural Upper Egypt, there were two to three times as many IUD users as pill users. The pill was the second most widely used method in all areas except rural Upper Egypt, where the proportion of women using injectables is the same as the proportion relying on the pill. Table 6.1 Current use of family planning methods by residence Percent distribution of currently married women 15-49, by family planning method currently used, according to urban-rural residence and place of residence, Egypt 2008 Lower Egypt Upper Egypt Method Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Any method 64.3 57.5 65.2 64.3 65.5 63.9 52.7 62.4 48.4 52.3 60.3 Any modern method 61.6 54.8 62.6 62.4 63.8 62.0 48.9 58.4 44.7 48.6 57.6 Pill 12.9 11.2 11.5 11.7 14.0 11.0 12.2 14.1 11.4 13.3 11.9 IUD 41.2 32.6 43.4 41.6 43.3 41.1 25.3 36.3 20.4 26.6 36.1 Injectables 4.8 9.2 4.7 6.9 4.4 7.7 9.5 5.5 11.4 5.5 7.4 Implant 0.4 0.5 0.5 0.3 0.0 0.4 0.6 0.7 0.6 1.1 0.5 Diaphragm /foam/jelly 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.0 Condom 1.4 0.3 1.8 0.4 0.9 0.3 0.5 1.2 0.2 1.1 0.7 Female sterilization 0.8 1.2 0.7 1.4 1.1 1.5 0.7 0.7 0.7 1.0 1.0 Any traditional method 2.7 2.7 2.6 1.9 1.7 2.0 3.7 4.0 3.7 3.7 2.7 Periodic abstinence 0.9 0.1 0.9 0.4 0.9 0.2 0.3 0.9 0.0 0.2 0.4 Withdrawal 0.3 0.2 0.4 0.2 0.1 0.2 0.2 0.4 0.1 0.1 0.2 Prolonged breastfeeding 1.5 2.3 1.1 1.3 0.7 1.5 3.3 2.7 3.5 3.3 2.0 Other 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 Not currently using 35.7 42.5 34.8 35.7 34.5 36.1 47.3 37.6 51.6 47.7 39.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 6,316 9,080 2,727 7,128 1,801 5,326 5,326 1,646 3,680 216 15,396 6.2.2 Differentials by Selected Background Characteristics Table 6.2 presents differentials in the levels of current use among the currently married women age 15-49 interviewed in the EDHS by background characteristics other than residence. Current use rose rapidly with age, from a level of 23 percent among currently married women 15-19 to a peak of 74 percent among women 35-39. The IUD was the most popular method among women in all age groups, with the highest levels of IUD use found among women age 35-39 (46 percent). Current Use of Family Planning | 73 Table 6.2 Current use of family planning methods by selected demographic and social characteristics Percent distribution of currently married women 15-49 by family planning method currently used according to selected demographic and social characteristics, Egypt 2008 Modern method Traditional method Background characteristic Any method Any mod- ern method Pill IUD Inject- able Im- plant Dia- phragm/ foam/ jelly Con- dom Female sterili- zation Any tradi- tional method Periodic absti- nence With- drawal Pro- longed breast- feeding Other Not currently using Total Number of women Age 15-19 23.4 19.8 4.9 14.1 0.7 0.0 0.0 0.0 0.0 3.7 0.0 0.2 3.5 0.0 76.6 100.0 605 20-24 44.6 40.9 11.1 24.5 4.7 0.2 0.0 0.3 0.0 3.8 0.2 0.0 3.6 0.0 55.4 100.0 2,527 25-29 59.8 56.3 13.3 34.7 7.6 0.4 0.0 0.3 0.1 3.5 0.3 0.1 3.1 0.0 40.2 100.0 3,264 30-34 67.6 64.8 13.9 39.7 9.1 0.7 0.0 0.9 0.6 2.7 0.3 0.3 2.1 0.0 32.4 100.0 2,551 35-39 74.3 72.4 13.4 46.4 9.9 0.5 0.0 0.9 1.4 1.9 0.5 0.3 1.1 0.1 25.7 100.0 2,406 40-44 72.5 70.7 12.7 44.6 9.1 0.7 0.0 1.1 2.4 1.9 0.8 0.5 0.5 0.1 27.5 100.0 2,188 45-49 51.9 50.5 7.2 33.3 5.3 0.4 0.1 1.5 2.7 1.4 1.0 0.3 0.0 0.0 48.1 100.0 1,855 Number of living children 0 0.4 0.4 0.1 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 99.6 100.0 1,612 1 46.0 42.2 12.1 27.5 1.8 0.2 0.0 0.5 0.1 3.8 0.5 0.1 3.3 0.0 54.0 100.0 2,393 2 68.1 64.8 14.7 42.5 6.2 0.4 0.0 0.8 0.3 3.2 0.7 0.4 2.1 0.0 31.9 100.0 3,568 3 76.4 73.6 12.5 49.9 8.8 0.4 0.0 1.0 0.9 2.8 0.6 0.3 1.9 0.0 23.6 100.0 3,508 4+ 71.0 68.6 13.4 37.7 13.2 0.8 0.0 0.8 2.7 2.5 0.2 0.3 1.9 0.1 29.0 100.0 4,316 Education No education 57.7 55.5 10.2 30.8 11.9 0.5 0.0 0.4 1.6 2.2 0.1 0.1 2.0 0.0 42.3 100.0 4,758 Some primary 62.4 59.6 11.3 35.0 9.9 0.4 0.0 0.7 2.3 2.8 0.1 0.0 2.6 0.0 37.6 100.0 1,259 Primary comp./ some sec. 59.5 56.4 13.0 33.8 7.7 0.6 0.0 0.6 0.8 3.1 0.3 0.3 2.5 0.1 40.5 100.0 2,273 Sec. comp./ higher 61.9 59.0 12.8 40.5 3.8 0.4 0.0 1.0 0.5 2.9 0.8 0.3 1.7 0.0 38.1 100.0 7,106 Work status Working for cash 68.0 64.7 11.8 43.7 5.5 0.3 0.0 1.9 1.5 3.3 1.6 0.6 1.1 0.1 32.0 100.0 2,182 Not working for cash 59.0 56.4 11.9 34.8 7.7 0.5 0.0 0.5 0.9 2.6 0.3 0.2 2.1 0.0 41.0 100.0 13,215 Wealth quintile Lowest 55.4 51.9 9.9 25.9 14.1 0.6 0.0 0.3 1.0 3.6 0.0 0.0 3.5 0.0 44.6 100.0 2,764 Second 57.1 54.8 11.1 31.6 10.0 0.5 0.0 0.4 1.2 2.3 0.0 0.1 2.2 0.0 42.9 100.0 3,014 Middle 61.2 58.8 13.3 35.7 7.6 0.5 0.0 0.4 1.2 2.4 0.2 0.1 2.0 0.0 38.8 100.0 3,172 Fourth 61.4 59.3 12.1 41.2 4.1 0.4 0.0 0.7 0.9 2.1 0.5 0.4 1.2 0.1 38.6 100.0 3,268 Highest 65.4 62.3 12.8 44.5 2.2 0.3 0.1 1.7 0.8 3.1 1.4 0.5 1.2 0.0 34.6 100.0 3,178 Total 60.3 57.6 11.9 36.1 7.4 0.5 0.0 0.7 1.0 2.7 0.4 0.2 2.0 0.0 39.7 100.0 15,396 Note: If more than one method is used, only the most effective method is considered in this tabulation. The EDHS results indicate that few Egyptian women use contraception before having the first birth; less than 1 percent of childless women were using a method at the time of the survey. Among women with more than one child, contraceptive use increased sharply with the number of living children, peaking at 76 percent among women with 3 children. Considering education status, the main differential was between women who never attended school and those who had at least some schooling. Among the latter group, there were only minor variations in use rates by the level of schooling. Injectable use declined directly with a woman’s educational level. 74 | Current Use of Family Planning Women employed in a job for which they were paid in cash were more likely to be currently using family planning methods than women not working for cash (68 percent and 59 percent, respectively). This was largely due to a higher rate of IUD use among women working for cash than among other women. As expected, contraceptive use increased with the wealth quintile. Current use was 10 percentage points higher among women in the highest wealth quintile than among women in the lowest quintile (65 percent and 55 percent, respectively). There was strong direct relationship between wealth and the level of IUD use. Among women in the highest quintile, the level of IUD use was 45 percent compared with 26 percent among women in the lowest quintile. Pill use did not vary much by wealth quintile, peaking at 13 percent among women in the middle quintile. On the other hand, injectable use decreased with the wealth quintile, from 14 percent among women in the lowest quintile to 2 percent among women in the highest quintile. 6.2.3 Differentials by Governorate Current use levels are presented in Table 6.3 for the four Urban Governorates and the 18 governorates in Lower Egypt and Upper Egypt. Data are not shown separately for the Frontier Governorates because the samples from the individual governorates in this region were not sufficiently large to allow separate estimation of the use rates. Table 6.3 Current use of family planning by governorate Percentage of currently married women 15-49 currently using any method, any modern method, the pill, the IUD or injectables by governorate, Egypt 2008 Governorate Any method Any modern method Pill IUD Injectables Number of women Urban Governorates 65.2 62.6 11.5 43.4 4.7 2,727 Cairo 66.8 64.4 12.2 44.6 4.7 1,588 Alexandria 63.7 61.0 9.8 43.3 4.6 891 Port Said 54.7 51.8 11.4 32.8 4.6 130 Suez 65.8 63.6 16.0 39.9 5.8 118 Lower Egypt 64.3 62.4 11.7 41.6 6.9 7,128 Damietta 64.2 63.5 14.4 40.2 6.6 231 Dakahlia 64.4 61.9 9.1 43.7 6.0 1,054 Sharkia 65.7 63.4 15.4 37.8 7.6 1,206 Kalyubia 59.9 58.3 10.6 40.7 5.4 1,007 Kafr El-Sheikh 62.1 60.0 9.6 36.8 10.7 658 Gharbia 67.1 65.1 10.8 47.2 5.5 892 Menoufia 66.3 66.1 13.6 44.2 6.4 801 Behera 66.1 64.1 11.2 43.9 7.4 1,068 Ismailia 56.5 51.7 12.7 29.5 7.9 212 Upper Egypt 52.7 48.9 12.2 25.3 9.5 5,326 Giza 62.4 59.0 11.4 39.5 5.8 1,287 Beni Suef 56.9 50.6 9.1 27.7 10.7 485 Fayoum 55.7 52.6 8.2 28.4 14.9 475 Menya 54.1 50.6 11.7 19.4 17.3 864 Assuit 47.4 43.2 11.1 21.2 9.6 678 Souhag 36.3 32.8 10.4 16.3 5.1 683 Luxor 54.5 50.9 23.0 20.7 5.7 72 Qena 48.0 44.2 20.0 15.7 6.8 567 Aswan 53.4 51.4 20.5 20.5 8.9 214 Total1 60.3 57.6 11.9 36.1 7.4 15,396 Note: If more than one method is used, only the most effective method is shown in this tabulation. 1 Total includes women from the Frontier Governorates Current Use of Family Planning | 75 There is considerable variability in the levels of current use in the governorates for which results are presented in Table 6.3. At the time of the 2008 EDHS, use rates were 60 percent or higher in all of the Urban Governorates except for Port Said and in all of the governorates in Lower Egypt except for Ismailia. Within the Urban Governorates, Cairo had the highest use rate (67 percent) and Port Said (55 percent) the lowest rate. Within Lower Egypt, use rates varied from 57 percent in Ismailia to 67 percent in Gharbia. In Upper Egypt, only Giza governorate, of which a large part is included in the Cairo Metropolitan area, had a use rate over 60 percent. Among the other governorates in Upper Egypt, use rates ranged from 36 percent in Souhag to 57 percent in Beni Suef. Table 6.3 also shows the rates of current use of the pill, the IUD, and injectables for each governorate at the time of the 2008 EDHS. The IUD was the most popular method among users in all governorates except Luxor, Qena, and Aswan. In Luxor and Qena, women were more likely to be using the pill than the IUD, while in Aswan, the pill and the IUD were equally popular among women. The highest level of IUD use was observed in Gharbia (47 percent) and the lowest level is in Qena and Souhag (16 percent each). Luxor had the highest level of pill use (23 percent), while the lowest level was found in Fayoum (8 percent). Use of injectables was highest in Menya (17 percent) and Fayoum (15 percent). 6.3 TRENDS IN CURRENT USE OF FAMILY PLANNING 6.3.1 Trends by Method The results from the 2008 EDHS and earlier surveys can be used to examine the changes that have taken place in the level and pattern of contraceptive use in Egypt since 1980 (Table 6.4 and Figure 6.2). Contraceptive use in Egypt doubled during the 11-year period between 1980 and 1991, from 24 percent to 48 percent. The use rate continued to rise over the next 12 years although at slower pace, reaching a level of 60 percent in 2003, where it has remained virtually unchanged. Table 6.4 Trends in current use of family planning Percent distribution of currently married women 15-49 by the family planning method currently used, Egypt 1980-2008 Method 1980 EFS 1984 ECPS 1988 EDHS 1991 EMCHS 1992 EDHS 1995 EDHS 1997 EIDHS 1998 EIDHS 2000 EDHS 2003 EIDHS 2005 EDHS 2008 EDHS Any method 24.2 30.3 37.8 47.6 47.1 47.9 54.5 51.8 56.1 60.0 59.2 60.3 Any modern method 22.8 28.7 35.4 44.3 44.8 45.5 51.8 49.5 53.9 56.6 56.5 57.6 Pill 16.6 16.5 15.3 15.9 12.9 10.4 10.2 8.7 9.5 9.3 9.9 11.9 IUD 4.1 8.4 15.7 24.2 27.9 30.0 34.6 34.3 35.5 36.7 36.5 36.1 Injectables na 0.3 0.1 na 0.5 2.4 3.9 3.9 6.1 7.9 7.0 7.4 Implants na na na na 0.0 0.0 0.1 0.0 0.2 0.9 0.8 0.5 Diaphragm/foam/jelly 0.3 0.7 0.4 na 0.4 0.1 0.2 0.1 0.2 0.1 0.0 0.0 Condom 1.1 1.3 2.4 na 2.0 1.4 1.5 1.1 1.0 0.9 1.0 0.7 Female sterilization 0.7 1.5 1.5 na 1.1 1.1 1.4 1.3 1.4 0.9 1.3 1.0 Any traditional method 1.4 1.6 2.4 3.3 2.3 2.4 2.7 2.3 2.2 3.4 2.7 2.7 Periodic abstinence 0.5 0.6 0.6 na 0.7 0.8 0.6 0.8 0.6 0.8 0.7 0.4 Withdrawal 0.4 0.3 0.5 na 0.7 0.5 0.4 0.3 0.2 0.4 0.3 0.2 Prolonged breastfeeding na 0.6 1.1 na 0.9 1.0 1.5 1.1 1.2 2.1 1.6 2.0 Other 0.3 0.1 0.2 na 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.0 Not using 75.8 69.7 62.2 62.2 52.9 52.1 45.5 48.2 43.9 40.0 40.8 39.7 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 8,012 9,158 8,221 8,406 9,153 13,710 5,157 5,971 14,382 8,445 18,187 15,396 na = Information on the method was not collected or was not reported. Source: El-Zanaty and Way, 2006, Table 6.4 Table 6.4 also documents the changes that have occurred in the use of specific methods over the past several decades. The IUD use rate rose from 4 percent in 1980 to 36 percent in 2000, where it has remained essentially stable. There was a significant increase in the use of the injectable after the method became available in the early 1990s, with the rate rising from less than 1 percent in 1992 to nearly 8 76 | Current Use of Family Planning percent in 2003. During the five-year period between 2003 and the 2008 EDHS, however, the use rate did not increase further. In contrast to the IUD and the injectable, pill use declined from a rate of 17 percent in 1980 to 9 percent in 1998, where it remained essentially stable until 2005. Between 2005 and 2008, pill use increased modestly to 12 percent. Trends over time in the method mix among users, that is, the distribution of users according to the method used are presented in Table 6.5. The dramatic shift from pill to IUD use that occurred during the past two decades is clear in the table. In 1980, almost 70 percent of current users relied on the pill, more than four times the percentage of users who relied on the IUD. By 2008, 60 percent of current users relied on the IUD compared to 20 percent who employed the pill. The relatively rapid expansion of the use of injectables is also evident. Twelve percent of current users relied on injectables in 2008, compared with 5 percent in 1995 and only 1 percent in 1992. Table 6.5 Trends in family planning method mix Percent distribution of currently married women 15-49 who are currently using any family planning method by the method used, Egypt 1980-2008 Method 1980 EFS 1984 ECPS 1988 EDHS 1992 EDHS 1995 EDHS 2000 EDHS 2005 EDHS 2008 EDHS Pill 68.6 54.4 40.5 27.4 21.7 16.9 16.7 19.7 IUD 15.9 27.7 41.6 59.2 62.6 63.4 61.5 59.8 Injectables 0.0 1.0 0.3 1.1 5.0 10.9 11.9 12.3 Condom 4.5 4.3 6.3 4.2 2.9 1.7 1.7 1.2 Female sterilization 2.9 5.0 4.0 2.3 2.3 2.5 2.2 1.8 Other modern methods 1.3 2.3 1.0 0.9 0.5 0.7 1.5 0.8 Traditional methods 5.8 5.3 6.3 4.9 5.0 3.9 4.6 4.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,939 2,775 3,108 4,311 6,567 8,063 10,779 9,290 Source: El- Zanaty and Way, 2006, Table 6.5 24 38 47 48 56 59 60 1980 1988 1992 1995 2000 2005 2008 0 20 40 60 80 100 Percent Figure 6.2 Trends in Current Use Egypt 1980-2008 Note: Data are for currently married women currently using any family planning method. Current Use of Family Planning | 77 6.3.2 Trends by Urban-Rural Residence and Place of Residence Table 6.6 shows trends in the rate of current use of family planning methods between 1984 and 2008 by residence. Overall, both the absolute and relative increase in current use between 1984 and 2008 was much greater among rural women than urban women. In both urban and rural areas, contraceptive use increased at a faster rate in the 1980s than in the 1990s. In urban areas, change was most rapid between 1984 and 1992, when the current use rate rose by 12 percentage points, from 45 percent in 1984 to 57 percent in 1992. The urban use rate continued to rise after 1992, and six in ten married women in urban areas were currently using family planning in 2000. 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 19 percent to 38 percent). The upward trend in the rural use rate continued during the remainder of the 1990s, reaching a level of 52 percent in 2000. During the 2000-2008 period, use rates continued to rise steadily among rural women although at a much slower rate than earlier. Among urban women, on the other hand, the trend in the use rate during the 2000-2008 was more erratic although the rate in 2008 (64 percent) was three percentage points higher than the rate in 2000. Looking at the overall changes by place of residence, Table 6.6 shows that the greatest absolute increase in use rates between 1984 and 2008 occurred in rural Upper Egypt (40 percentage points), followed by rural Lower Egypt (36 percentage points). Within urban areas, the absolute gain in current use over the period was greatest in urban Upper Egypt (26 percentage points). The increases in contraceptive use during the period were more modest but still substantial in the Urban Governorates and in urban Lower Egypt (16 and 18 percentage points, respectively). Table 6.6 Trends in family planning use by residence Percentage of currently married women 15-49 currently using any family planning method by urban-rural residence and place of residence, Egypt 1984-2008 Residence 1984 ECPS 1988 EDHS 1992 EDHS 1995 EDHS 1997 EIDHS 1998 EIDHS 2000 EDHS 2003 EIDHS 2005 EDHS 2008 EDHS Urban-rural residence Urban 45.1 51.8 57.0 56.4 63.1 59.3 61.2 65.5 62.6 64.3 Rural 19.2 24.5 38.4 40.5 47.1 45.6 52.0 55.9 56.8 57.5 Place of residence Urban Governorates 49.6 56.0 59.1 58.1 67.0 62.1 62.7 68.5 63.9 65.2 Lower Egypt 34.1 41.2 53.5 55.4 61.6 59.2 62.4 65.2 65.9 64.3 Urban 47.6 54.5 60.5 59.1 65.9 62.2 64.9 66.3 64.1 65.5 Rural 28.5 35.6 50.5 53.8 59.9 58.1 61.4 64.8 66.5 63.9 Upper Egypt 17.3 22.1 31.4 32.1 37.4 36.5 45.1 49.4 49.9 52.7 Urban 36.8 41.5 48.1 49.9 52.1 50.8 55.4 59.8 60.0 62.4 Rural 7.9 11.5 24.3 24.0 30.3 29.9 40.2 44.7 45.2 48.4 Frontier Governorates na na na 44.0 na na 43.0 na 49.3 52.3 Total 30.3 37.8 47.1 47.9 54.5 51.8 56.1 60.0 59.2 60.3 na = Information on the method was not collected or was not reported Source: El-Zanaty and Way, 2006, Table 6.6 Table 6.6 also shows that the timing of major changes in the levels of contraceptive use varied by residence. Much of the expansion in contraceptive use in Urban Governorates and urban Lower Egypt took place in the first 10 years of the period, while in urban Upper Egypt, the absolute increase was more pronounced after 1995. In rural Lower Egypt, contraceptive use more than doubled between 1984 and 1997 and then slowed considerably. On the other hand, in rural Upper Egypt, there were striking increases throughout the period; the level of use tripled from 8 percent to 24 percent between 1984 and 1995 and then doubled again to reach 48 percent in 2008. 78 | Current Use of Family Planning 6.3.3 Trends by Governorate Table 6.7 presents the trend in current use rates at the governorate level between 1988 and 2008. Some caution should be used in interpreting changes in use levels for individual governorates, especially if the changes are minor. The comparatively small sample sizes on which the governorate-level estimates are based increases the sampling variability and, thus, reduces the likelihood that small changes are significant. All governorates experienced increases in use levels over the roughly 20-year period between the 1988 and 2008 EDHS surveys. In absolute terms, the governorates in Upper Egypt, where use levels were lowest in 1988 (i.e., rates of 20 percent or less), had the largest increases during the period. Within Upper Egypt, the greatest absolute increase took place in Beni Suef, where use more than tripled, from 15 percent in 1988 to 57 percent in 2008. Giza Governorate, where use levels were moderately high in 1988 (46 percent), had the lowest absolute gain in use during the entire period (17 percentage points). Souhag, where the prevalence level is currently the lowest among all Upper Egypt governorates (36 percent), also experienced a comparatively modest growth in use levels between 1988 and 2008 (20 percentage points). Table 6.7 Trends in current use of family planning methods by governorate Percentage of currently married women 15-49 who are currently using any family planning method by governorate, Egypt 1988-2008 Governorate 1988 EDHS 1992 EDHS 1995 EDHS 2000 EDHS 2005 EDHS 2008 EDHS Urban Governorates 56.0 59.1 58.1 62.7 63.9 65.2 Cairo 58.9 58.1 56.9 62.3 63.8 66.8 Alexandria 51.6 62.1 59.8 64.7 64.5 63.7 Port Said 48.2 60.5 59.7 57.7 61.6 54.7 Suez 50.3 57.3 62.4 58.0 64.0 65.8 Lower Egypt 41.2 53.5 55.4 62.4 65.9 64.3 Damietta 54.1 53.4 57.4 58.8 63.9 64.2 Dakhalia 41.3 52.8 54.9 62.8 64.4 64.4 Sharkia 35.2 49.2 53.1 61.4 61.2 65.7 Kalyubia 42.3 57.9 55.6 64.0 69.4 59.9 Kafr-El-Sheikh 41.7 47.2 54.4 64.2 65.8 62.1 Gharbia 50.1 55.9 55.9 65.7 69.7 67.1 Menoufia 43.9 55.7 54.3 61.3 64.2 66.3 Behera 32.5 54.7 58.7 59.8 68.7 66.1 Ismailia 41.0 50.2 58.5 58.9 59.6 56.5 Upper Egypt 22.1 31.4 32.1 45.1 49.9 52.7 Giza 45.7 49.9 50.9 60.5 62.1 62.4 Beni Suef 15.3 29.2 30.4 53.0 56.0 56.9 Fayoum 20.2 33.3 34.0 50.4 55.9 55.7 Menya 16.6 21.9 24.3 46.7 51.4 54.1 Assuit 12.7 28.2 22.1 32.9 37.9 47.4 Souhag 16.2 19.8 21.7 27.5 32.7 36.3 Luxor na na na na na 54.5 Qena 12.2 24.7 26.3 34.6 47.2 48.0 Aswan 18.6 31.9 36.0 44.9 49.0 53.4 Total 37.8 47.1 47.9 56.1 59.2 60.3 na = Information not available Source: El-Zanaty and Way, 2006, Table 6.8 Current Use of Family Planning | 79 Looking at the pattern of change within Lower Egypt governorates, Behera, where the use rate was lowest in 1988 (33 percent), experienced the greatest absolute growth in use levels between the 1988 and 2008 surveys (34 percentage points). Damietta, which had the highest level of use in 1988 (54 percent), registered the lowest absolute change in use levels (10 percentage points). Considering the Urban Governorates, Suez had a somewhat larger overall increase in its use rate (16 percentage points) between 1988 and 2008 than was observed in Alexandria (12 percentage points each). The overall increase in use levels in Suez and Alexandria was much greater than that experienced in Cairo and Port Said over the 20-year period (8 and 7 percentage points, respectively). Looking at the trends in current use by governorate between the 2005 and 2008 EDHS surveys, use levels increased in 12 governorates, remained at the same level in Dakhalia, and declined in the remaining governorates. In Lower Egypt, the largest gain in use during this period (around 4 percentage points) was observed in Sharkia. In Upper Egypt, the absolute change in use rates was largest in Assuit (10 percentage points). Port Said and Kalyubia experienced the largest declines in use (7 percentage points and 10 percentage points, respectively). 6.4 SOURCES FOR MODERN FAMILY PLANNING METHODS 6.4.1 Sources by Method In the 2008 EDHS detailed information was collected on 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 had gotten their method at the beginning of the current segment of use. A code identifying the type of source was then recorded in the questionnaire and in the calendar in the month at the beginning of the period of use. Users relying on supply methods like the pill and the injectable were also asked about the source where they had most recently obtained the method. Table 6.8 shows the distribution of current users by source. Overall, current family planning users were more likely to obtain their method from a governmental source than from a private sector source (60 percent and 40 percent, respectively). However, the source for family planning method varied markedly by method. The majority of current users of the IUD (67 percent) had the method inserted at a public sector source. In general, those users relying on a government source for the IUD got the device inserted at a static facility; however, 3 percent obtained the method from mobile clinics. Thirty-two percent of IUD users went to private physicians, hospitals, or clinics for the method, while 2 percent obtained the method at clinics operated by private voluntary organizations, including those of the Egyptian Family Planning Association and the Clinical Services Improvement Project. The public sector was the main source for injectables, with about nine in ten users obtaining the method from a governmental source. As was the case with the IUD, most injectable users obtained their method at a static facility, especially rural health units (47 percent). Three percent got injectables from a mobile clinic. Regarding the sources for other methods, pill users mainly got their method from a pharmacy (70 percent), as did couples using the condom (74 percent). Sterilizations were more frequently performed at private hospitals/clinics or doctors than at governmental facilities. 80 | Current Use of Family Planning Table 6.8 Source for modern family planning methods Percent distribution of current users of modern family planning methods by most recent source, according to specific method, Egypt 2008 Source Pill IUD Injectables Male condom Female sterilization Total1 Public sector 24.5 66.6 89.0 19.2 26.2 59.6 Urban hospital (general/district) 1.5 6.3 5.4 0.2 15.4 5.6 Urban health unit 3.6 15.2 15.0 9.7 0.0 12.4 Health office 0.9 4.0 2.4 2.9 0.0 3.0 Rural hospital (complementary) 2.1 5.4 9.2 0.3 0.2 5.0 Rural health unit 12.3 18.9 46.5 1.6 0.0 20.4 MCH center 2.7 11.9 7.1 3.8 0.0 9.0 Mobile unit 0.9 3.2 2.8 0.7 0.0 2.6 University/teaching hospital 0.2 1.0 0.5 0.0 8.9 0.9 Health Insurance Organization 0.1 0.6 0.1 0.0 0.8 0.4 Curative Care Organization 0.0 0.0 0.0 0.0 0.0 0.0 Other governmental 0.1 0.1 0.0 0.0 0.8 0.1 Private sector 75.4 33.4 10.5 79.5 73.8 40.3 Nongovernmental/private voluntary organization (NGO/PVO) 0.3 1.8 0.2 0.0 0.5 1.3 Egypt Family Planning Association 0.1 0.3 0.0 0.0 0.0 0.2 Clinical Services Improvement Project 0.1 1.1 0.1 0.0 0.0 0.7 Other NGO 0.1 0.4 0.1 0.0 0.5 0.3 Private medical 75.1 31.6 10.3 79.5 73.3 39.1 Private hospital/clinic 0.3 2.7 0.9 1.3 14.4 2.2 Private doctor 4.8 27.3 3.3 4.0 58.2 19.7 Nurse 0.0 0.0 0.5 0.0 0.0 0.1 Pharmacy 69.6 0.0 5.3 74.3 0.0 16.0 Mosque health unit 0.3 1.4 0.3 0.0 0.7 1.0 Church health unit 0.0 0.1 0.1 0.0 0.0 0.1 Other non-medical 0.1 0.0 0.4 0.0 0.0 0.1 Friend/relative 0.1 0.0 0.4 0.0 0.0 0.1 Don't know/no one 0.0 0.0 0.0 1.3 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of users 1,831 5,557 1,140 112 165 8,877 1 Includes users of the implant and vaginal method users for whom the source distribution is not shown separately 6.4.2 Sources by Method and Residence Residential variations in the type of source are presented in Table 6.9 for all modern methods and for the pill and the IUD. In general, rural women were more likely to go to a public sector source to obtain their method than urban women (67 percent and 51 percent, respectively). The proportion of users obtaining their method from a public health facility ranged from 46 percent of users in urban Lower Egypt to 68 percent of users in rural Upper Egypt. In all areas, the pharmacy was the principal source for pill users, with only a minority getting their method from public sector facilities. However, the size of this minority varied by residence; only 13 percent of pill users in urban Lower Egypt get their method from a public sector facility compared with 32 percent in the Frontier Governorates. The majority of IUD users rely on public sector sources for the method. Reliance on public sector sources for the IUD is most frequent in rural areas; around three-quarters of IUD users in rural Upper Egypt and rural Lower Egypt obtained the method from a public health facility. Current Use of Family Planning | 81 Table 6.9 Sources of family planning methods by residence Percent distribution of current users of modern family planning methods by method and most recent source, according to residence, Egypt 2008 Lower Egypt Upper Egypt Method and source Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total1 PILL Public sector 17.9 29.9 18.7 24.8 13.2 29.7 26.6 21.2 29.7 (32.1) 24.5 Private sector 81.9 70.1 81.3 75.2 86.8 70.3 73.1 78.1 70.3 (67.9) 75.4 NGO/PVOs 0.2 0.5 0.0 0.7 0.6 0.8 0.0 0.0 0.0 (0.0) 0.3 Private hospital/ clinic/ doctor/nurse 6.3 4.2 7.9 5.2 7.0 4.5 3.7 3.5 3.8 (4.4) 5.1 Mosque/church clinic 0.5 0.2 0.1 0.2 0.7 0.0 0.5 0.7 0.4 (0.0) 0.3 Pharmacy 75.0 65.3 73.3 69.0 78.6 65.0 68.9 73.9 66.2 (63.5) 69.6 Other/don’t know/missing 0.2 0.0 0.0 0.0 0.0 0.0 0.3 0.7 0.0 (0.0) 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of users 817 1,014 314 837 251 586 651 232 420 29 1,831 IUD Public sector 58.8 73.4 63.2 67.9 55.8 72.2 66.8 53.6 77.4 61.0 66.6 Private sector 41.2 26.6 36.8 32.1 44.2 27.8 33.2 46.4 22.6 39.0 33.4 NGO/PVOs 1.9 1.8 0.7 2.1 3.3 1.7 2.2 2.5 2.0 0.0 1.8 Private hospital/clinic/ doctor/nurse 36.3 24.5 32.1 29.4 39.1 25.9 29.4 41.3 19.9 37.9 30.0 Mosque/church clinic 3.0 0.3 4.0 0.6 1.8 0.2 1.6 2.6 0.7 1.1 1.6 Pharmacy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other/don’t know/missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of users 2,601 2,956 1,183 2,968 781 2,188 1,349 598 751 58 5,557 ALL MODERN METHODS Public sector 50.7 66.5 55.3 60.8 46.4 65.8 60.3 47.4 67.9 56.1 59.6 Private sector 49.1 33.5 44.6 39.2 53.5 34.2 39.5 52.3 31.9 43.9 40.3 NGO/PVOs 1.3 1.2 0.5 1.6 2.3 1.4 1.2 1.7 0.9 0.0 1.3 Private hospital/clinic/ doctor/nurse 27.3 17.8 25.0 22.9 30.3 20.3 18.4 28.3 12.6 23.9 22.0 Mosque/church clinic 2.2 0.3 2.9 0.5 1.3 0.2 1.0 1.9 0.5 0.6 1.1 Pharmacy 18.3 14.2 16.2 14.1 19.5 12.3 18.9 20.5 18.0 19.4 16.0 Other/don’t know/missing 0.1 0.1 0.1 0.0 0.1 0.0 0.2 0.3 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of users 3,893 4,984 1,709 4,452 1,150 3,303 2,610 964 1,646 105 8,877 Note:Figures in parentheses are based on 25-49 unweighted cases. NGO = Nongovernmental organization PVO = Private voluntary organization 1 Includes users of the implant and vaginal methods for whom the source distribution is not shown separately. 6.4.3 Trends in Sources of Modern Methods Trends in the source of family planning methods during the period between the 1995 EDHS and the 2008 EDHS are presented in Table 6.10 for IUD users and for users of all modern methods. Overall, the data show that the percentage of users who obtained the modern method at a public sector provider increased from 36 percent in 1995 to 60 percent in 2008. Much of that increase is due to increased reliance on the public sector for IUD. Table 6.10 indicates that the percentage of IUD users relying on the public sector for services rose from 45 percent in 1995 to 67 percent in 2008. 82 | Current Use of Family Planning Considering the variation by residence, the trend toward an increased reliance on public sector providers for modern methods was observed among users in all areas. However, the absolute increase was much greater for rural users than urban users. The greatest increase was for rural users from Upper Egypt (33 percentage points). Table 6.10 Trends in reliance on public sector source for contraceptive method by residence Percentage of current users of the IUD and of all modern methods obtaining the method at a public sector source by urban-rural residence and place of residence, Egypt 1995-2008 IUD Modern methods Residence 1995 EDHS 2000 EDHS 2005 EDHS 2008 EDHS 1995 EDHS 2000 EDHS 2005 EDHS 2008 EDHS Urban-rural residence Urban 42.8 48.7 54.8 58.8 34.0 42.0 48.0 50.7 Rural 46.7 59.4 67.7 73.4 37.7 54.8 63.2 66.5 Place of residence Urban Governorates 46.5 48.8 60.5 63.2 39.7 43.5 54.2 55.3 Lower Egypt 44.4 54.9 62.8 67.9 35.2 50.2 57.2 60.8 Urban 37.4 47.5 48.8 55.8 27.5 40.9 41.5 46.4 Rural 47.3 58.0 67.5 72.2 38.6 54.1 62.6 65.8 Upper Egypt 42.1 57.3 60.9 66.8 32.3 50.0 56.8 60.3 Urban 39.9 50.1 51.8 53.6 29.6 40.8 44.9 47.4 Rural 44.5 63.5 68.1 77.4 34.8 56.3 64.3 67.9 Frontier Governorates 31.3 44.9 61.4 61.0 25.2 41.0 59.6 56.1 Total 44.5 54.0 61.8 66.6 35.7 48.6 56.6 59.6 Source: El-Zanaty and Way, 2006, Table 6.11 6.5 PILL BRANDS A number of questions were included in the 2008 EDHS relating to the brand of pills women were using and that they had heard about. Information about the brands pill users had adopted was collected by asking pill users to show the packet of pills. If the packet was available, interviewers recorded the name of the brand. If a user was unable to show the EDHS interviewer the packet, she was asked to name the brand she was using. Table 6.11 shows that about one-fifth of pill users were not able to show a packet or identify the brand they were using. Combined pills or pills containing both estrogen and progestin may interfere with the production of milk among breast- feeding mothers and also may affect breast milk composition (Blackburn et al. 2000). Breastfeeding mothers are advised to take progestin-only pills in order to avoid these adverse effects. In order to look at the extent to which breastfeeding mothers are following Table 6.11 Brand of pill Percent distribution of current pill users by the brand of pill used and breastfeeding status, Egypt 2008 Pill brand Currently breastfeeding users Non- breastfeeding users Total Suitable for breastfeeding users 44.2 4.8 16.6 Microlut 18.9 2.4 7.3 Exluton 5.5 0.8 2.2 Levo-nor 19.8 1.6 7.1 Other brands 37.4 76.2 64.5 Norminest 0.5 0.1 0.2 Nordette 0.9 3.9 3.0 Microvlar 0.0 0.1 0.1 Anovlar 0.0 0.1 0.1 Trivolar 0.2 0.1 0.1 Marvelon 1.8 2.5 2.3 Microcept 24.3 51.4 43.3 Microgynon 0.6 0.2 0.3 Stero 0.0 0.1 0.1 Triocept 3.3 7.8 6.5 Gynera 3.5 7.3 6.2 Trinordiol 0.0 0.0 0.0 Cilest 1.9 2.4 2.3 Microvior30 0.3 0.0 0.1 Don't know/missing 18.4 19.1 18.9 Total 100.0 100.0 100.0 Number of pill users 549 1,283 1,831 Current Use of Family Planning | 83 this recommendation, Table 6.11 identifies pill brands according to their hormonal composition and classifies pill users according to their breastfeeding status. Among the breastfeeding mothers for whom information on pill brands was obtained, 44 percent were using progestin-pills. An additional question was included in the 2008 EDHS to ascertain the extent to which women in Egypt are aware of the availability of pill brands that are suitable for use by breastfeeding mothers. Overall, Table 6.12 shows that around three in five ever-married women reported they had heard about a contraceptive pill which was suitable for breastfeeding women. However, most of these women were not able to identify a brand of pills that is appropriate for use by breastfeeding mothers. Table 6.12 Knowledge of pill brand suitable for breastfeeding women Percent distribution of ever-married women by level of knowledge of pill brand suitable for breastfeeding women, Egypt 2008 Pill brand Total Knows about pill suitable for breastfeeding women 64.9 Names correct brand 2.7 Names incorrect brand 0.1 Cannot name brand 62.2 Doesn't know about pill suitable for breastfeeding women 34.9 Missing 0.2 Total 100.0 Number of women 16,527 6.6 COST OF METHODS In the 2008 EDHS, users of the pill, the IUD and injectables were asked about the actual amounts they had paid for their method. 6.6.1 Pill Users According to the results in Table 6.13, virtually all pill users are paying more than 50 piastres for a cycle of pills, and 45 percent pay more than one pound (100 piastres). The median cost of a cycle is just over one pound (101 piastres), which is the same as the median cost reported at the time of the 2005 EDHS. The mean cost is over four pounds (440 piastres). 6.6.2 Injectable Users Table 6.14 presents information on the cost of injectables at the time of the 2008 EDHS. Sixty- one percent of injectable users paid two pounds or less. The median cost was 1.8 pounds, which is slightly higher than the median cost reported for injectables at the time of 2005 EDHS (1.7 pounds). The slight increase in the median cost between 2005 and 2008 could be due to the fact that in 2008 only 3 percent of injectables users the method for free compared with 8 percent in 2005. 84 | Current Use of Family Planning 6.6.3 IUD Users Table 6.15 presents the actual amount that IUD users paid for services. The table shows that, while relatively few IUD users (5 percent) got the method for free, 30 percent of users paid less than 3 pounds for IUD. At the other extreme, 26 percent of IUD users paid more than 20 pounds to obtain the method. The amount that a user paid to obtain an IUD varied with the type of provider. The lowest median cost was observed among those users who obtained the method from a public sector source (3.0 pounds). The median cost at a NGO/PVO clinic was 10.5 pounds, almost three and a half times the cost that an average user paid at a public sector facility, but roughly one-third the amount users who have the IUD inserted by a private doctor or at a private hospital or clinic paid (35.4 pounds). A comparison of the median cost for an IUD at the time of the 2008 EDHS with the median cost paid by all IUD users at the time of the 2005 EDHS (4.7 pounds) indicates that the cost of an IUD decreased modestly for the average user during the period between the two surveys. Looking at the trend in costs by the provider, the median cost of an IUD at public health facilities and mosque/church clinics in 2008 was the same or virtually the same as the median amount that users paid in 2005 for an IUD from these sources while the median amount paid by users obtaining the method from NGO/PVO clinics decreased between 2005 and 2008. In contrast, the median amount paid by users who obtained the method from a private doctor or clinic increased by 5 pounds during the period between the survey. The increasing cost of the IUD at private sector facilities may be one factor explaining the rise in the proportion of users obtaining the IUD at governmental facilities since the 2005 survey. Table 6.13 Cost of method for pill users Percent distribution of current users of the pill by cost of a cycle of pills (in piastres) and the median and mean amounts paid for the pill, Egypt 2008 Total Free 0.6 1-50 piastres 0.2 51-75 piastres 40.1 76-100 piastres 11.9 101-200 piastres 7.1 201-300 piastres 12.9 301-999 piastres 2.8 1000-1300 piastres 10.4 More than 1300 piastres 11.9 Don't know/missing 1.9 Total 100.0 Number of pill users 1,831 2008 EDHS Median 100.7 Mean 439.7 2005 EDHS Median 101.0 Mean 426.8 Table 6.14 Cost of method for injectable users Percent distribution of current users of injectables by the cost of the method (in pounds), Egypt 2008 Total Free 3.3 < 1 pounds 0.0 1-1.9 pounds 61.0 2-2.9 pounds 15.3 3-4.9 pounds 5.5 5-6.9 pounds 6.3 7-8.9 pounds 2.5 9-9.9 pounds 0.8 10+ pounds 5.0 Don't know/missing 0.2 Total 100.0 Number of injectable users 1,140 2008 EDHS Median 1.8 Mean 2.6 2005 EDHS Median 1.7 Mean 3.7 Current Use of Family Planning | 85 Table 6.15 Cost of method for IUD users Percent distribution of current users of IUD by cost of the method (in pounds), according to the type of provider, and the median and mean amounts paid for the IUD, Egypt 2008 Public health facility Private doctor/ clinic NGO/ PVO clinic Mosque/ church clinic Total Free 5.5 2.5 4.4 1.7 4.5 < 3 pounds 44.6 1.1 13.0 6.2 30.3 3-4.9 pounds 22.3 0.6 9.7 5.1 15.3 5-9.9 pounds 18.4 2.2 18.7 10.9 13.4 10-14.9 pounds 3.2 5.0 12.0 20.5 4.1 15-19.9 pounds 1.8 4.9 15.7 6.3 3.0 20-29.9 pounds 1.2 19.6 3.9 22.4 7.1 30-49.9 pounds 0.7 24.1 9.3 12.7 8.1 50 pounds or more 0.4 34.7 12.9 10.3 11.1 Don't know/missing 1.9 5.5 0.5 4.0 3.0 Total 100.0 100.0 100.0 100.0 100.0 Number of IUD users 3,699 1,670 101 88 5,557 2008 EDHS Median 3.0 35.4 10.5 15.8 4.2 Mean 4.0 44.8 17.7 20.5 16.5 2005 EDHS Median 2.9 30.4 15.2 15.8 4.7 Mean 4.1 39.7 19.0 17.9 14.1 NGO = Nongovernmental organization PVO = Private voluntary organization 6.7 PARTICIPATION IN FAMILY PLANNING DECISIONS Women who were using a family planning method at the time of the 2008 EDHS were asked questions about who was mainly responsible for the decision to use family planning. Table 6.16 shows that virtually all women participated in the decision to use a family planning method. The majority of users made the decision to use jointly with their husband (86 percent) while 10 percent said that they themselves are mainly responsible for use of family planning. Only 2 percent of current users indicated that the husband is mainly responsible for the decision to use a method. Differentials by background characteristics are generally not significant. However, women age 15-19 years, rural women, those from rural Upper Egypt, uneducated women and women with some primary education, and women in the lowest wealth quintiles were somewhat more likely than other women to be the main person responsible for the decision to use family planning. 86 | Current Use of Family Planning Table 6.16 Family planning decision-making Percent distribution of current users by person mainly responsible for decision to use family planning, according to background characteristics, Egypt 2008 Person mainly responsible for decision to use contraception Background characteristics Mainly respondent Joint decision Mainly husband Other/ missing Total Number of women Age 15-19 15.4 79.4 3.3 1.8 100.0 142 20-24 9.4 86.9 2.2 1.5 100.0 1,128 25-29 9.4 87.7 1.9 1.1 100.0 1,952 30-34 10.0 84.9 2.7 2.4 100.0 1,723 35-39 10.5 85.1 2.3 2.0 100.0 1,788 40-44 10.0 84.9 2.3 2.9 100.0 1,587 45-49 11.0 83.6 1.4 4.0 100.0 962 Number of living children 0 * * * * 100.0 7 1 10.0 85.6 2.7 1.7 100.0 1,101 2 9.2 86.4 2.2 2.2 100.0 2,429 3 8.3 87.5 1.9 2.3 100.0 2,680 4+ 12.4 83.1 2.3 2.2 100.0 3,066 Place of residence Urban Governorates 9.7 84.5 1.9 3.9 100.0 1,777 Lower Egypt 9.1 87.4 1.9 1.7 100.0 4,586 Urban 6.9 89.3 1.6 2.2 100.0 1,180 Rural 9.8 86.8 2.0 1.5 100.0 3,405 Upper Egypt 12.0 83.3 2.9 1.8 100.0 2,806 Urban 7.4 87.1 2.8 2.7 100.0 1,026 Rural 14.6 81.1 3.0 1.3 100.0 1,780 Frontier Governorates 10.1 83.7 2.8 3.3 100.0 113 Urban-rural residence Urban 8.3 86.5 2.1 3.1 100.0 4,059 Rural 11.4 84.8 2.3 1.4 100.0 5,223 Education No education 12.6 83.3 2.6 1.4 100.0 2,745 Some primary 13.1 82.4 3.2 1.3 100.0 785 Primary complete/some secondary 11.2 83.8 2.6 2.3 100.0 1,353 Secondary complete/ higher 7.6 88.0 1.7 2.7 100.0 4,399 Work status Working for cash 7.9 85.7 1.8 4.6 100.0 1,484 Not working for cash 10.5 85.5 2.3 1.7 100.0 7,799 Wealth quintile Lowest 13.1 82.8 2.8 1.3 100.0 1,533 Second 12.2 83.5 2.7 1.6 100.0 1,723 Middle 9.9 86.5 2.2 1.4 100.0 1,941 Fourth 8.2 87.7 1.8 2.3 100.0 2,006 Highest 8.1 86.3 1.8 3.9 100.0 2,079 Total 10.1 85.5 2.2 2.2 100.0 9,282 Note: An asterisk indicates that a figures is based on less than 25 unweighted cases and has been suppressed. 6.8 INFORMED CHOICE Ensuring that potential users have the information they need to make informed choices is a vital component of family planning programs. Users should be informed of the range of methods that are available so they can make decisions about the contraceptive method that is most appropriate for their situations. Family planning providers should also inform potential users of the side effects that they may experience when using specific methods and what they should do if they encounter any of the effects. This information both assists the user in coping with side effects and decreases unnecessary discontinua- tion of temporary methods. Current Use of Family Planning | 87 The 2008 EDHS included a number of questions designed to assess whether women who were currently using family planning at the time of the survey had received sufficient information to make informed choices. Current users were asked whether they had been told about other methods, told about side effects, or given advice about what to do about side effects by the provider from whom they obtained their method. If they were not told about other methods or about side effects during that consultation, they were asked if they had ever received information from a provider about these topics. Caution must be exercised in interpreting the responses to these questions since they are subjective. In addition, they also suffer from an unknown degree of recall error, i.e., many users had gone to the provider months or even years before the EDHS interview and may not have remembered accurately everything that took place during the encounter. Nevertheless, the results of these questions provide at least some insight into the nature of the counselling that family planning users are receiving from their providers. Table 6.17 presents information on the informed choice indicators for current users who adopted the method in January 2003 or later. In general, the information exchange between many current users and their provider is fairly limited. Two-thirds of users reported that the provider discussed methods other than the one the user received. Fifty-six percent of users were told about side effects and 46 percent were told what to do if they experienced side effects. In cases where the users received information needed to make an informed choice, they generally reported that they received the information from the provider whom they consulted at the beginning of the current segment of use. Table 6.17 also shows that the proportion of users receiving the information needed to make an informed choice did not vary markedly with the type of clinical providers. The largest differentials were observed in the percentages receiving information about method side effects. However, users obtaining the method from a pharmacy were much less likely than other users to have received information, especially about side effects, necessary to make an informed choice. 88 | Current Use of Family Planning Table 6.17 Informed choice Percentage of current users who began the current segment of use since January 2003 who reported they were advised about various aspects of the method they obtained according to type of source and method, Egypt 2008 Information provided Public sector Private clinical1 Pharmacy Total2 PILL Told about other methods 71.5 76.5 46.3 64.3 At start of current segment 64.9 70.4 33.3 55.6 Ever but not during current segment 6.5 6.1 13.0 8.7 Told about side effects 47.6 64.3 33.3 47.6 At start of current segment 44.4 61.0 27.8 43.5 Ever but not during current segment 3.2 3.3 5.5 4.1 Told what to do about side effects 38.7 54.0 21.7 37.3 Number of users 502 401 496 1,413 IUD Told about other methods 66.9 74.7 na 69.5 At start of current segment 61.0 69.5 na 63.8 Ever but not during current segment 6.0 5.2 na 5.8 Told about side effects 56.0 67.2 na 59.8 At start of current segment 52.4 63.5 na 56.1 Ever but not during current segment 3.6 3.7 na 3.6 Told what to do about side effects 47.2 59.3 na 51.2 Number of users 2,256 1,090 na 3,389 INJECTABLES Told about other methods 64.0 63.4 (40.6) 63.0 At start of current segment 56.6 57.0 (31.1) 55.6 Ever but not during current segment 7.4 6.4 (9.4) 7.4 Told about side effects 54.9 46.7 (40.8) 53.8 At start of current segment 51.7 39.6 (33.0) 50.2 Ever but not during current segment 3.2 7.1 (7.8) 3.6 Told what to do about side effects 43.1 41.4 (27.6) 42.5 Number of users 735 61 32 831 ALL MODERN METHODS3 Told about other methods 66.8 74.7 45.9 67.0 At start of current segment 60.4 69.1 33.2 60.2 Ever but not during current segment 6.5 5.6 12.8 6.8 Told about side effects 54.6 66.2 32.8 55.8 At start of current segment 51.2 62.6 27.4 52.1 Ever but not during current segment 3.4 3.6 5.4 3.7 Told what to do about side effects 45.2 57.1 21.6 46.3 Number of users 3,576 1,631 580 5,851 Note: Table excludes users who obtained method from friends/relatives. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable NGO = Nongovernmental organization PVO = Private voluntary organization 1 Includes private hospital/clinic, private doctor/nurse, mosque/church clinic 2 Includes users reporting they obtained method from NGO/PVO source who are not shown separately in table 3 Includes only current users who began segment of use since January 2003 Nonuse of Family Planning and Intention to Use | 89 NONUSE OF FAMILY PLANNING AND INTENTION TO USE 7 One of the primary objectives of the 2008 EDHS is to provide information on reasons for nonuse and on the intention to use family planning in the future. Such information is of particular interest to policymakers and program managers as they seek to address the contraceptive needs of nonusers who are concerned about spacing or limiting their fertility. Thus, this chapter focuses on women who are not using family planning. It presents information on: levels of family planning discontinuation, reasons for discontinuation, reasons for nonuse, intention to use in the future, timing of future use, and the methods preferred among women who are not currently using a family planning method. 7.1 DISCONTINUATION RATES A key concern for the family planning program in Egypt is the rate at which users discontinue use of contraception and the reasons for such discontinuations. Although users may discontinue because they want another child, they often stop for other reasons including contraceptive failure, dissatisfaction with the method, and health concerns, leaving them exposed to the risk of an unintended pregnancy. The 2008 EDHs obtained information that can be used to look both at the extent of discontinuation among users and at the reasons users have for stopping use. The data used to analyze discontinuation were collected by asking respondents for information on all episodes of contraceptive use between January 2003 and the date of the interview. For each interval of use, the woman was asked the contraceptive method used and the date of use (year and month) and, if applicable, the date she stopped using and the reason for discontinuation. If a woman reported that she was using a method in January 2003, she was also asked for the date when that segment of use began. Using the 2008 EDHS calendar data, life-table techniques were used to calculate the discontinua- tion rates presented in Table 7.1. The rates shown in the table are based on episodes of use that began during the period 3 to 59 months prior to the 2008 EDHS. They are one-year discontinuation rates; i.e., they represent the proportion of users discontinuing within the first 12 months after beginning to use the method. In calculating the rates, the month of interview and the two preceding months were dropped to avoid any bias that might be introduced by unrecognized pregnancy. The rates are cumulative, i.e., they are obtained by dividing the number of discontinuations at each duration of use (in single months) by the number of months of exposure at that duration. The single-month rates were then cumulated to produce a one-year rate. The rates are presented separately for the following five methods: pills, injectables, IUDs, condoms, and prolonged breastfeeding. To ensure a sufficient number of segments of use to allow calculation of the rates, the reasons for discontinuation are grouped into four specific categories: method failure, desire for pregnancy, side effects/health concerns, and other reasons including husband’s disapproval, need for a more effective method, marital dissolution, etc. In deriving these rates, the reasons for discontinuation are treated as competing risks; thus, the rates are additive across the reasons for discontinuation. Overall, Table 7.1 shows that women stopped using a method within 12 months of starting use in the case of one-quarter of all episodes of contraceptive use during the five-year period prior to the EDHS. Side effects or health concerns were the motivating factors for 9 percent of the discontinuations. Eight percent were due to the user’s desire to become pregnant (4 percent) or to other fertility-related reasons including marital dissolution, infrequent sex, and the onset of menopause (4 percent). Three percent of 90 | Nonuse of Family Planning and Intention to Use discontinuations were due to method failure (i.e., the user became pregnant while using the method) and 2 percent were a result of the user’s desire for a more effective method. Other method-related reasons including lack of access, cost, and inconvenience were responsible for 2 percent of discontinuations. Regarding individual methods, the highest discontinuation rates were observed for the pill and prolonged breastfeeding (40 percent each), followed by the injectable (37 percent). The IUD had the lowest discontinuation rate; users discontinued within 12 months of adopting in the case of only 12 per- cent of all of the episodes of use during the five-year period prior to the survey. Table 7.1 also provides information on the reasons women gave for discontinuing use. Although the reasons for discontinuation varied somewhat by method, side effects or health concerns were the most frequent reasons for discontinuation among users of injectables (21 percent), the pill (12 percent), and the IUD (6 percent). Method failure was most often cause of discontinuation among condom users (8 percent) and least often mentioned as a reason for discontinuation of the IUD and injectables (about 1 percent). Pill and injectable users are more likely than users of other methods to discontinue use because they wanted to become pregnant or for other fertility-related reasons including infrequent sex. Wanting an effective method was a more frequent motivation for discontinuation among users of the condom (7 percent) and prolonged breastfeeding (5 percent) than users of other methods. Finally, Table 7.1 shows the proportion of episodes of use in which the user switched to another method after they discontinued. The results indicate that users were most likely to adopt a new method after discontinuing the condom and prolonged breastfeeding and least likely to switch to another method if they were using the IUD. Table 7.1 Contraceptive discontinuation rates Among women who started an episode of contraceptive use in the five year-period before the survey, percentage of episodes discontinued within 12 months after beginning use, by reason for discontinuation and percentage who switched to another method, Egypt 2008 Reason for discontinuation Method Method failure Desire to become pregnant Other fertility related reasons2 Side effects/ health reasons Wanted more effective method Other method related reasons3 Other reasons Any reason Switched to another method4 Pill 6.2 7.2 8.5 12.4 3.1 1.0 1.7 40.0 10.3 IUD 0.9 3.2 0.9 6.0 0.0 0.3 0.4 11.8 3.3 Injectables 0.9 5.2 5.7 21.1 0.9 0.4 2.5 36.8 11.9 Male condom 8.2 2.8 1.3 0.0 6.8 2.6 10.2 31.9 18.0 Prolonged breastfeeding 6.2 1.0 0.4 0.3 4.7 20.4 7.4 40.3 19.5 All methods1 2.9 4.4 3.6 9.4 1.5 2.2 1.8 25.9 8.1 Number of episodes of use 281 410 368 941 156 211 175 2,542 810 Note: Figures are based on lifetable calculations using information on episodes of use that began 3-59 months prior to the survey. 1 Includes methods for which rates are not shown separately in table 2 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation 3 Includes lack of access/too far, costs too much, and inconvenient to use 4 Used a different method in the month following discontinuation or said they wanted a more effective method and started another method within two months of discontinuation Nonuse of Family Planning and Intention to Use | 91 7.2 REASONS FOR DISCONTINUATION OF CONTRACEPTIVE USE Table 7.2 looks in greater detail at the reasons the 2008 EDHS respondents gave for discontinuing use. The table shows the percent distribution of all discontinuations in the five-year period prior to the survey by the main reason for discontinuing according to the specific method. More than one-third of all discontinuations during the five-year period before the 2008 EDHS occurred because the user wanted to have a child. Wanting another child was most often cited reason for discontinuations among IUD users (49 percent) and pill users (33 percent). Table 7.2 Reasons for discontinuation Percent distribution of discontinuations of methods in the five years preceding the survey by main reason for discontinuation, according to method, Egypt 2008. Reason Pill IUD Injection Condom Prolonged breast- feeding All methods1 Became pregnant while using 14.8 5.0 3.1 30.2 15.4 8.6 Wanted to become pregnant 32.7 48.6 24.6 17.6 6.4 36.0 Husband disapproved 0.5 0.2 0.4 15.5 0.2 0.5 Side effects 23.3 30.4 48.2 0.0 0.9 28.5 Health concerns 2.6 1.6 4.1 0.4 0.2 2.1 Access/availability 0.2 0.0 0.3 0.0 0.0 0.1 Wanted a more effective method 5.0 0.3 1.4 13.6 7.8 2.7 Inconvenient to use 1.5 0.9 0.8 4.6 51.0 5.4 Infrequent sex/husband away 13.2 3.1 8.5 9.7 0.3 6.6 Cost too much 0.1 0.0 0.0 0.0 0.0 0.0 Fatalistic 0.1 0.0 0.2 0.0 0.0 0.1 Difficult to get pregnant/menopausal 1.3 2.2 1.5 1.6 0.0 1.6 Marital dissolution/separation 1.6 3.3 1.8 0.0 0.3 2.3 Doctor's opinion 0.1 1.2 0.0 0.0 0.2 0.7 IUD fell out 1.3 1.2 2.5 2.2 10.5 2.3 Other 1.8 2.1 2.6 4.6 6.8 2.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 2,525 4,251 1,503 80 788 9,358 1Includes methods for which the distributions are not shown separately in the table. Side effects and health concerns accounted for around three in ten of all discontinuations. They were cited as the reason for more than half of all discontinuations of the injectable (52 percent) during the five-year period before the survey, and they were the second most common cause of discontinuation among IUD and pill users (32 percent and 26 percent, respectively). Nine percent of all discontinuations were the result of method failure; i.e., the woman became pregnant while using a method. Method failure was most often mentioned as the reason for discontinu- ation of the condom (30 percent) and also was frequently a factor in discontinuation of the pill and prolonged breastfeeding (15 percent each). Dissatisfaction with the method was a major factor in discontinuations for some methods. In the case of prolonged breastfeeding, for example, 51 percent of discontinuations were because the woman found the method inconvenient to use. Concern about method effectiveness was a factor in more than one in ten (14 percent) discontinuations of the condom. 92 | Nonuse of Family Planning and Intention to Use Table 7.2 also shows that program-related factors such as cost or access were almost never cited as reasons for discontinuation. Except for the condom, the husband’s disapproval was also rarely cited as a main factor affecting the decision to discontinue use. Sixteen percent of discontinuations of the condom were due to the husband’s unwillingness to use the method. Factors that reduced or eliminated the risk of pregnancy (e.g., infrequent sex/husband away, difficulty in getting pregnant/menopause, and marital dissolution) accounted for more than 11 percent of discontinuations. 7.3 INTENTION TO USE CONTRACEPTION IN THE FUTURE To obtain 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 about their intention to adopt family planning methods in the future. Table 7.3 shows the percent distribution of nonusers by their intention to use in the future, according to number of living children. Table 7.3 Future use of family planning Percent distribution of currently married women who are not using a contraceptive method by intention to use in the future, according to number of living children, Egypt 2008 Number of living children1 Intention 0 1 2 3 4+ Total Intends to use 60.4 79.7 72.2 64.1 41.0 63.7 Unsure 12.7 6.1 6.2 4.4 4.2 6.5 Does not intend to use 26.9 13.9 21.2 31.1 53.5 29.2 Missing 0.0 0.4 0.4 0.4 1.2 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 986 1,487 1,280 972 1,389 6,114 1Includes current pregnancy Among all currently married nonusers, 64 percent intended to use family planning at some time in the future, 29 percent did not plan to use in the future, and the remaining nonusers were unsure about their intentions. The intention to use varies with the number of living children the nonuser has. Overall, the proportion saying they planned to use in the future decreased from a high of 80 percent among women with one child to 41 percent of women with four or more children. Among childless women, six in ten intended to use in the future. 7. 4 REASONS FOR NONUSE Table 7.4 presents the distribution of currently married non-users who did not intend to use in the future by the main reason they gave for not using. The reasons for nonuse are of interest to the family planning program since they help to identify areas for potential interventions to support the adoption of contraception by nonusers. Around three-quarters of nonusers had various fertility-related reasons for not planning to adopt contraception. These reasons included a perceived lack of need for contraception because the woman was subfecund or infecund (37 percent), menopausal or had had a hysterectomy (13 percent), or was not sexually active or had sex infrequently (10 percent). In addition, 14 percent of the nonusers wanted more children. Method-related reasons were cited by a significant proportion of nonusers; 10 percent had health concerns and 7 percent mentioned fear of side effects. Opposition to use—either the woman’s own attitude or that of her husband—was a factor for 6 percent of the nonusers. Nonuse of Family Planning and Intention to Use | 93 Table 7.4 classifies women into two age groups (under age 30 and age 30 and over) in order to consider how the reasons for nonuse were related to a woman’s age. Nonusers under age 30 were more likely than nonusers age 30 or over to mention the desire to have as many children as possible (44 percent and 9 percent, respectively). As might be expected, lack of need for contraception because of menopause or hysterectomy was a reason given almost exclusively by older nonusers. Opposition to use was cited more often by younger than older nonusers (11 percent and 5 percent, respectively). Older women mentioned health concerns as a reason for nonuse around twice as often as younger women (10 percent and 5 percent, respectively). Table 7.4 Reason for not intending to use contraception Percent distribution of currently married women who are not using a contraceptive method and who do not intend to use in the future by main reason for not intending to use, according to age, Egypt 2008 Reason 15-29 30-49 Total Fertility-related reasons 69.8 74.4 73.8 Not having sex 0.5 2.9 2.6 Infrequent sex/no sex 5.1 7.6 7.3 Menopausal/had hysterectomy 0.0 15.4 13.3 Subfecund/infecund 20.3 39.4 36.9 Wants as many children as possible 43.9 9.2 13.8 Opposition to use 11.2 5.3 6.0 Respondent opposed 2.5 2.1 2.1 Husband/partner opposed 6.4 1.8 2.4 Religious prohibition 2.3 1.4 1.5 Lack of knowledge 1.0 0.0 0.2 Knows no method 0.4 0.0 0.1 Knows no source 0.6 0.0 0.1 Method-related reasons 15.9 18.2 17.9 Health concerns 4.8 10.4 9.7 Fear of side effects 9.2 6.8 7.1 Costs too much 0.0 0.1 0.1 Inconvenient to use 1.2 0.3 0.4 Interfere with body's normal processes 0.7 0.6 0.6 Other 0.3 0.9 0.8 Don’t know 0.8 0.1 0.2 Missing 1.0 1.1 1.1 Total 100.0 100.0 100.0 Number of women 236 1,552 1,788 7.5 PREFERRED METHOD Nonusers who planned to use family planning in the future were asked about the method they would prefer to use. Table 7.5 shows that 33 percent of all nonusers who planned to use preferred the IUD. The remaining nonusers who expressed a preference were more likely to prefer the pill (19 percent) than injectables (7 percent). More than one- third of the nonusers intending to use a method in the future were unsure which method they prefer (23 percent) or said they would rely on the doctor’s advice (13 percent). 7.6 CONTACT OF NONUSERS WITH OUTREACH WORKERS/ HEALTH CARE PROVIDERS The 2008 EDHS collected information on whether nonusers had any recent contact with community workers or health care providers. Such contacts provide an opportunity to counsel the nonuser about the need for family planning. To obtain this information, nonusers were Table 7.5 Preferred family planning method Percent distribution of currently mar- ried women who are not using a family planning method but who intend to use in the future by preferred method, Egypt 2008 Method Total Pill 19.1 IUD 33.4 Injectables 7.1 Condom 0.1 Female sterilization 0.3 Male sterilization 0.0 Implants (Norplant) 1.0 Periodic abstinence 0.1 Withdrawal 0.0 Prolonged breastfeeding 0.6 Other 1.6 As doctor recommends 13.3 Unsure 23.3 Total 100.0 Number of women 3,898 94 | Nonuse of Family Planning and Intention to Use asked whether they had been visited at home at anytime during the 6 months preceding the survey by an outreach worker (e.g., a raiyda refia) or anyone else who had talked with them about family planning. They were also asked 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 7.6 presents the data on both the proportion of currently married nonusers who had any contact with an outreach worker or health facility and the proportion who discussed family planning with an outreach worker or other health care provider during the 6 months prior to the EDHS interview. Relatively few women had been reached through community outreach efforts, with only 4 percent of nonusers reporting that they had been visited at home by a fieldworker. The proportion reporting outreach visits was similar to the level at the time of the 2005 EDHS and 2000 EDHS (4 percent). The highest level of contacts was observed in rural Upper Egypt, where 8 percent of nonusers reported being contacted at home in the 2008 EDHS, a level slightly above that reported in 2005 (6 percent). Table 7.6 Discussion of family planning in contacts with fieldworkers or health providers by background characteristics Percentage of currently married 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 2008 Background characteristic Visited at home by family planning worker Visited public health facility (PHF) Visited PHF, discussed family planning Visited private health facility (PrHF) Visited PrHF, discussed family planning Had some contact with family planning worker or health facility Discussed family planning with family planning worker or staff at health facility Number of women Age 15-19 4.3 40.2 10.1 46.6 8.0 62.0 18.3 463 20-24 5.1 42.0 12.5 46.5 10.3 64.1 20.3 1,400 25-29 5.4 40.7 9.7 43.2 8.6 63.7 18.3 1,312 30-34 6.0 34.4 10.7 40.1 7.8 55.2 18.2 828 35-39 3.4 28.0 8.2 30.8 7.6 45.7 15.0 618 40-44 2.4 17.5 4.0 20.6 3.7 32.9 8.4 601 45-49 2.7 14.1 3.4 18.3 1.7 26.8 6.9 892 Urban-rural residence Urban 1.4 32.9 8.4 42.0 8.1 55.1 13.8 2,257 Rural 6.2 32.6 9.1 33.6 6.8 50.6 16.9 3,857 Place of residence Urban Governorates 1.5 37.4 7.7 46.4 7.9 61.3 13.6 950 Lower Egypt 4.0 31.8 9.2 36.2 8.1 49.6 15.9 2,542 Urban 0.7 28.0 9.2 37.6 8.2 48.1 14.4 621 Rural 5.1 33.0 9.2 35.8 8.1 50.0 16.3 1,921 Upper Egypt 6.1 31.8 9.0 33.8 6.2 51.8 16.6 2,519 Urban 1.8 30.6 8.7 40.8 8.4 53.3 13.3 619 Rural 7.5 32.2 9.1 31.5 5.5 51.3 17.7 1,900 Frontier Governorates 2.5 32.9 8.8 29.7 4.9 47.3 12.8 103 Education No education 4.6 26.9 6.9 24.3 3.8 41.0 12.5 2,013 Some primary 4.5 32.5 4.4 28.1 3.0 49.2 9.4 474 Primary complete/some secondary 4.6 35.8 10.3 39.2 6.7 56.2 17.0 920 Secondary complete/higher 4.2 36.0 10.6 46.5 10.7 59.9 18.9 2,707 Work status Working for cash 4.4 29.7 7.4 36.1 9.4 49.6 16.8 698 Not working for cash 4.5 33.1 9.1 36.8 7.0 52.6 15.6 5,416 Wealth quintile Lowest 6.0 30.5 7.2 25.7 4.7 46.0 14.6 1,232 Second 5.2 32.9 9.7 31.8 5.7 49.1 15.6 1,292 Middle 5.8 38.1 11.6 37.5 7.6 54.9 18.7 1,231 Fourth 3.0 34.1 9.2 41.0 8.3 56.1 15.2 1,261 Highest 1.9 27.1 6.3 49.0 10.3 55.7 14.7 1,099 Total 4.4 32.7 8.9 36.7 7.3 52.3 15.8 6,114 Nonuse of Family Planning and Intention to Use | 95 Table 7.6 also looks at the extent to which nonusers had an opportunity to discuss family planning during the visits they made to health facilities. Around one-third of nonusers made at least one visit to a government health facility during the six-month period before the survey, and a slightly higher proportion (37 percent) went to a private doctor or private health facility at least once. Looking at whether family planning was discussed during those contacts, women who visited private sector health facilities were somewhat less likely than those visiting public facilities to report that family planning was discussed during a visit (7 percent and 9 percent, respectively). Taking into account both contacts with fieldworkers and contacts with health facilities, 16 percent of nonusers reported a contact in which family planning was discussed during the six months prior to the survey. This proportion is higher than the level reported in 2005 EDHS (11 percent). Although the results in Table 7.6 suggest that there are many “missed” opportunities for informing and motivating nonusers about family planning, some caution must be exercised in drawing such conclusions. Not all visits to health providers present appropriate opportunities for offering family planning information or services, and not all nonusers are interested in/or in need of family planning when they visit a facility. Nevertheless, the results in Table 7.6 suggest that there is potential for taking more advantage of other visits that women make to facilities to offer family planning information. Proximate Determinants of Fertility | 97 PROXIMATE DETERMINANTS OF FERTILITY 8 This chapter considers a number of factors other than contraception that influence fertility including marriage, postpartum amenorrhea and abstinence and menopause. Marriage is among the most important of these proximate determinants since it is a primary indicator of women’s exposure to the risk of pregnancy. Early age at first marriage in a population is usually associated with a longer period of exposure to the risk of pregnancy and thus higher fertility levels. The early initiation of childbearing associated with early marriage may also adversely affect women’s and children’s health. Postpartum amenorrhea and postpartum abstinence, which determine the length of time a woman is insusceptible to pregnancy after childbirth, affect the length of birth intervals and thus fertility levels. Menopause is important since it marks the end of a woman’s period of exposure to the risk of pregnancy. In the 2008 EDHS, questions about the proximate determinants of fertility were included in the questionnaire which was administered only to ever-married women. However, a number of the tables, which examine the proximate determinants in this chapter, are based on all women, i.e., on ever-married women and never-married women. In constructing these tables, the denominators have been expanded to represent all women by multiplying the number of ever-married women by an inflation factor equal to the ratio of all women to ever-married women reported in the household questionnaire. The inflation factors are calculated by single years of age, either for the population as a whole or, in cases where the results are presented by background characteristics, separately for each category of the characteristic in question. 8.1 MARITAL STATUS Table 8.1 shows the distribution of all women age 15-49 by current marital status. Overall, 65 percent of women are currently married, 3 percent are widowed, 2 percent are divorced or separated (not living together), and 31 percent have never married. The proportion never married decreases rapidly with age, from 87 percent among women age 15-19 to 46 percent among women age 20-24 to only 2 percent among women 40 years and older. The virtual universality of marriage among women is further evidenced from the fact that among women age 30 and over, 93 percent or more are or have been married. Table 8.1 Current marital status Percent distribution of women by current marital status, according to age, Egypt 2008 Marital status Age Never married Married Divorced Separated Widowed Total Number of women 15-19 86.6 13.1 0.2 0.1 0.1 100.0 4,618 20-24 46.2 52.6 0.7 0.3 0.1 100.0 4,806 25-29 17.7 79.8 1.4 0.5 0.6 100.0 4,090 30-34 6.9 89.1 2.0 0.6 1.4 100.0 2,862 35-39 3.6 89.7 2.4 0.4 3.8 100.0 2,683 40-44 2.1 86.6 2.7 1.0 7.5 100.0 2,527 45-49 1.9 81.5 2.7 0.6 13.3 100.0 2,277 Total 30.7 64.5 1.5 0.5 2.8 100.0 23,863 98 | Proximate Determinants of Fertility Most disruption of marital unions appears to be due to the death of the husband. As expected, the proportion widowed increases steadily with age, from less than 1 percent among women under age 30 to 13 percent among women age 45-49. The proportion divorced and separated does not exceed 4 percent of women in any age group. 8.2 CONSANGUINITY Marriages between relatives (consanguineous marriages) are common in Egypt. According to the 2008 EDHS data presented in Table 8.2, around three in ten ever-married women reported that their current or, in the case of widowed or divorced women, their most recent husband was a relative. Most of consanguineous marriages involved first or second cousins. In such marriages, the husband was somewhat more likely to be a relative from the father’s side than the mother’s side (14 percent and 8 percent, respectively). Table 8.2 Consanguinity by background characteristics Percent distribution of ever-married women by relationship to their (last) husband, according to background characteristics, Egypt 2008 First cousin Second cousin Background characteristic Father's side Mother's side Father's side Mother's side Other blood relative Relative by marriage/ not related Missing Total Number of women Age 15-19 13.3 6.0 7.6 2.5 7.5 63.0 0.1 100.0 620 20-24 10.1 6.8 6.1 2.5 7.9 66.7 0.1 100.0 2,584 25-29 8.5 6.0 4.3 2.3 7.3 71.7 0.0 100.0 3,367 30-34 9.6 5.3 4.7 2.4 7.2 70.8 0.1 100.0 2,664 35-39 9.3 5.0 4.2 2.5 7.2 71.9 0.0 100.0 2,586 40-44 10.5 6.3 3.6 2.8 6.9 69.8 0.1 100.0 2,473 45-49 10.8 5.4 4.3 2.2 5.5 72.0 0.0 100.0 2,234 Urban-rural residence Urban 7.5 4.9 2.9 2.4 5.5 76.8 0.0 100.0 6,809 Rural 11.5 6.4 5.8 2.5 8.1 65.6 0.0 100.0 9,718 Place of residence Urban Governorates 7.4 5.1 2.5 2.3 5.9 76.6 0.1 100.0 2,931 Lower Egypt 8.0 5.0 3.3 1.9 5.2 76.6 0.0 100.0 7,618 Urban 6.0 3.7 2.3 2.3 3.7 82.2 0.0 100.0 1,936 Rural 8.6 5.5 3.7 1.7 5.8 74.7 0.0 100.0 5,682 Upper Egypt 13.3 7.2 7.4 3.3 10.0 58.7 0.0 100.0 5,751 Urban 8.8 5.9 4.1 2.5 6.9 71.8 0.0 100.0 1,792 Rural 15.4 7.8 8.9 3.6 11.5 52.8 0.1 100.0 3,959 Frontier Governorates 13.6 5.1 6.3 2.5 6.7 65.8 0.0 100.0 227 Education No education 12.6 6.8 5.1 2.8 8.0 64.6 0.0 100.0 5,302 Some primary 11.0 7.1 6.7 3.1 9.3 62.7 0.0 100.0 1,394 Primary complete/some secondary 11.3 5.9 6.1 2.6 7.6 66.5 0.1 100.0 2,413 Secondary complete/higher 7.1 4.8 3.4 2.0 5.8 76.8 0.1 100.0 7,418 Work status Working for cash 6.2 4.0 3.0 2.0 5.4 79.3 0.1 100.0 2,459 Not working for cash 10.4 6.1 4.9 2.5 7.3 68.6 0.0 100.0 14,068 Wealth quintile Lowest 14.6 6.8 6.8 3.3 9.1 59.4 0.0 100.0 3,033 Second 11.3 7.5 6.2 2.3 8.0 64.6 0.1 100.0 3,252 Middle 10.6 6.1 4.9 2.9 6.8 68.7 0.0 100.0 3,394 Fourth 7.8 4.8 3.7 2.1 6.6 75.0 0.0 100.0 3,505 Highest 5.4 4.0 1.9 1.7 5.0 81.9 0.1 100.0 3,343 Total 9.8 5.8 4.6 2.4 7.1 70.2 0.0 100.0 16,527 Proximate Determinants of Fertility | 99 As expected, consanguineous marriages were more common among rural than urban women; one-third of the marriages in rural areas involved relatives compared to less than one-quarter of the marriages in urban areas. Considering place of residence, the highest rate of consanguineous marriages was found in rural Upper Egypt, where nearly half of marriages were between relatives. The rate of consanguineous marriage was lowest in urban Lower Egypt (18 percent) and the Urban Governorates (23 percent). A woman’s chance of marrying a relative decreased from 35 percent among women who had never attended school to 23 percent among women with a secondary education or higher. The likelihood of consanguineous marriage was greater among women who were not working for cash than among women who were working for cash (31 percent and 21 percent, respectively). It decreased by wealth quintile, from a level of 41 percent among women in the lowest wealth quintile to 18 percent of women in the highest quintile. 8.3 AGE AT FIRST MARRIAGE The duration of exposure to the risk of pregnancy in a society is closely associated with the age at which women first marry. Thus, trends in age at first marriage can help explain changes in fertility levels in Egypt. Table 8.3 shows both the percentage of women who had ever married by selected exact ages and the median age at first marriage, according to current age. The results document a substantial increase in the age at first marriage among younger cohorts. Accompanying the overall trend to later marriage is a marked decline in the proportion of women marrying at very young ages. The percentage of women married by exact age 15 dropped from 12 percent among women age 45-49 to 2 percent among women age 20-24. The percentage of women married by exact age 18 fell from 39 percent among women 45-49 to 17 percent among women 20-24. Table 8.3 Age at first marriage Percentage of women who were first married by specific exact age 15, 18, 20, 22 and 25, and median age at first marriage, according to current age, Egypt 2008 Percentage first married by exact age: Current age 15 18 20 22 25 Percentage never married Number Median age at first marriage 15-19 1.1 na na na na 86.6 4,618 a 20-24 2.2 16.6 33.7 na na 46.2 4,806 a 25-29 3.9 20.6 39.3 56.1 73.8 17.7 4,090 21.2 30-34 6.4 24.5 41.9 58.0 78.0 6.9 2,862 20.9 35-39 8.2 28.6 46.1 63.6 79.5 3.6 2,683 20.4 40-44 9.5 32.8 49.9 66.3 82.3 2.1 2,527 20.0 45-49 11.8 38.7 52.5 67.2 81.9 1.9 2,277 19.6 Women age 25-49 7.4 27.8 45.0 61.4 78.5 7.7 14,439 20.6 na = Not applicable a Omitted because less than 50 percent of women married for the first time by the beginning of the age group Differentials in the median age at first marriage by selected background characteristics are presented in Table 8.4. The table shows early marriage is much more common in rural than in urban areas. The median age at first marriage among urban women age 25-49 was 22.2 years, around three years higher than the median age at first marriage among rural women (19.4 years). There are marked differentials in the age of first marriage among women 25-49 by place of residence. On average, Table 8.4 shows that women married about two years earlier on average in rural 100 | Proximate Determinants of Fertility Upper Egypt (18.3 years) than in rural Lower Egypt (20.0 years). In turn, the median age at first marriage in the Urban Governorates (22.6 years) was higher than in either urban Lower Egypt (22.0 years) or urban Upper Egypt (21.7 years). An examination of the trend across age cohorts suggests that there have been substantial increases over time in the median age at marriage within all areas, with the changes in rural Upper Egypt being especially marked. Table 8.4 also shows large differences in age at first marriage by educational level. The median age at first marriage among women with a secondary education or higher was 22.9 years, more than three years higher than the median age among women who have completed the primary but not the secondary level (19.3 years) and about five years higher than among women who never attended school (18.0 years). The magnitude of the educational differential in the age at marriage does not vary greatly across age cohorts, which suggests that much of the upward trend in the age at marriage over the past several decades in Egypt has been due to increases in educational attainment among women. The median age at first marriage also rises with the wealth quintile. The median age at first marriage among women in the lowest wealth quintile is 18.3 years, which is almost five years lower than women in the highest quintile (23.2 years). Table 8.4 Median age at first marriage by background characteristics Median age at first marriage among women age 25-49, by current age and background characteristics, Egypt 2008 Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 Women age 25-49 Urban-rural residence Urban 22.9 22.4 21.9 21.6 21.6 22.2 Rural 20.1 19.9 19.3 18.6 17.9 19.4 Place of residence Urban Governorates 23.5 22.8 22.1 22.0 22.3 22.6 Lower Egypt 20.9 21.1 20.5 20.0 19.6 20.5 Urban 22.6 22.5 21.7 21.5 21.6 22.0 Rural 20.4 20.7 20.1 19.5 18.8 20.0 Upper Egypt 20.5 19.6 19.2 18.6 18.2 19.4 Urban 22.6 21.8 21.9 20.9 20.4 21.7 Rural 19.5 18.6 17.8 17.2 17.1 18.3 Frontier Governorates 21.4 20.6 20.1 19.4 20.0 20.6 Education No education 18.7 18.4 18.1 17.7 17.4 18.0 Some primary 19.1 18.7 18.2 18.6 18.5 18.6 Primary complete/some secondary 19.3 19.2 19.2 19.6 19.8 19.3 Secondary complete/higher 22.7 22.9 22.7 22.9 24.0 22.9 Wealth quintile Lowest 19.2 18.4 18.2 18.2 17.3 18.3 Second 20.1 19.5 18.6 18.2 17.7 18.9 Middle 20.7 20.8 19.8 19.6 18.7 20.1 Fourth 21.8 21.6 21.7 20.8 20.7 21.4 Highest 23.5 23.4 23.1 22.7 23.2 23.2 Total 21.2 20.9 20.4 20.0 19.6 20.6 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. Proximate Determinants of Fertility | 101 8.4 POSTPARTUM AMENORRHEA, ABSTINENCE, AND INSUSCEPTIBILITY Among women who are not using contraception, exposure to the risk of pregnancy in the period after a birth is influenced primarily by two factors: breastfeeding and sexual abstinence. Breastfeeding prolongs postpartum protection from conception through its effect on the length of the period of amenorrhea (the period prior to the return of menses) after a birth. More frequent breastfeeding for longer durations as well as delays in the age at which supplementary foods are introduced are associated with longer periods of postpartum amenorrhea. Delaying the resumption of sexual relations after a birth also prolongs the period of postpartum protection. For the purposes of the following discussion, women are considered insusceptible to pregnancy if they are not at risk of conception, either because they are amenorrheic or abstaining after a birth. The percentage of births during the three years preceding the survey for which mothers are postpartum amenorrheic, postpartum abstaining, and postpartum insusceptible is shown in Table 8.5, according to the number of months since the birth. These distributions are based on current status information, i.e., on the proportion of births occurring x months before the survey for which mothers were still amenorrheic, abstaining, or insusceptible at the time of the survey. Thus, the results presented in the table are based on cross-sectional data, representing the experience of mothers of all births at a single point in time rather than showing the experience of a cohort of mothers over time. The data are grouped in two-month intervals to minimize the fluctuations in the estimates. The median- and mean-duration estimates shown at the bottom of Table 8.5 are calculated from the current status distributions presented in the table. The prevalence/incidence mean which also is shown in Table 8.5 is obtained by dividing the number of mothers who are amenorrheic, abstaining, or insusceptible by the average number of births per month over the 36-month period. Table 8.5 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Egypt 2008 Percentage of births for which the mother is: Months since birth Amenorrheic Abstaining Insusceptible Number of births < 2 89.7 74.5 93.2 303 2-3 45.0 8.8 48.3 413 4-5 36.7 6.6 41.1 397 6-7 29.5 5.2 33.4 483 8-9 25.6 3.5 28.0 421 10-11 16.6 3.6 18.9 378 12-13 18.7 3.7 21.5 354 14-15 16.3 1.2 16.5 357 16-17 7.7 0.7 8.2 374 18-19 6.2 1.1 7.4 354 20-21 6.2 0.8 6.8 400 22-23 1.8 2.2 3.9 336 24-25 1.8 0.4 2.2 336 26-27 3.7 1.2 4.7 376 28-29 2.4 0.7 3.1 332 30-31 2.0 0.7 2.7 315 32-33 1.4 0.4 1.8 352 34-35 1.3 0.4 1.7 307 Total 17.7 5.9 19.5 6,588 Median 3.0 1.6 3.4 - Mean 6.6 2.7 7.2 - Prevalence/incidence mean 6.4 2.1 7.0 - 102 | Proximate Determinants of Fertility Overall, the period of amenorrhea after birth is not long for the average of Egyptian woman. As Figure 8.1 shows, the percentage of babies whose mothers are amenorrheic declines from around 90 percent in the two months immediately after a birth to 45 percent during the period two to three months after birth. By the period 4 to 5 months after a birth, mothers of 37 percent of births are still amenorrheic, and by 12 to 13 months after a birth, mothers have not resumed menstruation in the case of only 19 percent of births. The median duration of postpartum amenorrhea is 3.0 months, and the mean duration is 6.6 months. The relatively short average duration of postpartum amenorrhea is related to breastfeeding patterns, especially the early introduction of supplemental foods (see Chapter 13). As in other Islamic countries, many couples in Egypt observe the traditional practice of abstain- ing from sexual relations for a period of 40 days after a birth. Reflecting this tradition, the percentage of births for which the mother is still abstaining decreases rapidly, from 75 percent in the 2-month period immediately after a birth to only 9 percent at 2 to 3 months after a birth. The combined effects of postpartum amenorrhea and postpartum abstinence are reflected in the period of postpartum insusceptibility after a birth. Overall, about half (48 percent) of all Egyptian women are susceptible to the risk of pregnancy by 4 months after a birth. The mean duration of the period of postpartum insusceptibility is 7.2 months, and the median duration is 3.4 months The median durations of postpartum amenorrhea, postpartum abstinence, and postpartum insus- ceptibility are presented in Table 8.6, according to selected background characteristics. In general, the periods of insusceptibility to the risk of conception are longer for older women, rural women, women in Upper Egypt, women with no or some primary education, women not working for cash and women in the lowest wealth quintile than for women in other groups. Differentials in the durations of insusceptibility are owed primarily to differences in the length of the periods of postpartum amenorrhea, since the average duration of postpartum abstinence does not vary greatly among the population subgroups. + + + + + + + + + + + + + + + + + + ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 Months 0 20 40 60 80 100 Percent Amenorrheic Abstaining Insusceptible) ! + EDHS 2008 Figure 8.1 Percentage of Births Whose Mothers are Amenorrheic, Abstaining, or Insusceptible Proximate Determinants of Fertility | 103 Table 8.6 Median duration of postpartum amenorrhea, abstinence, and insusceptibility by back- ground characteristics Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Egypt 2008 Background characteristic Amenorrhea Abstinence Insusceptability Number of births Age 15-29 2.9 1.6 3.3 4,532 30-49 3.3 1.7 3.6 2,056 Urban-rural residence Urban 2.5 1.8 3.0 2,483 Rural 3.2 1.5 3.6 4,105 Place of residence Urban Governorates 2.3 1.8 2.5 1,062 Lower Egypt 2.8 1.6 3.1 2,866 Urban 2.5 1.8 2.7 641 Rural 2.9 1.5 3.2 2,225 Upper Egypt 3.6 1.6 4.3 2,563 Urban 3.3 1.8 4.3 719 Rural 3.7 1.6 4.3 1,844 Frontier Governorates 3.3 1.1 3.9 96 Education No education 3.6 1.5 4.1 1,614 Some primary 4.0 1.9 4.3 418 Primary complete/some secondary 2.8 1.8 3.5 1,009 Secondary complete/higher 2.7 1.6 3.0 3,547 Work status Working for cash 2.7 1.3 2.9 680 Not working for cash 3.0 1.7 3.5 5,908 Wealth quintile Lowest 4.0 1.5 4.9 1,306 Second 3.2 1.5 3.8 1,320 Middle 2.6 1.5 3.0 1,372 Fourth 2.5 1.9 2.9 1,356 Highest 2.9 1.7 3.1 1,234 Total 3.0 1.6 3.4 6,588 Note: Medians are based on current status. 8. 5 TERMINATION OF EXPOSURE TO PREGNANCY Another factor influencing the risk of pregnancy among women is menopause among older women. Table 8.7 presents data on the proportion menopausal among women age 30 and over who were currently married, non-pregnant and non-amenorrheic at the time of the survey. For the purposes of the table, a woman was considered to be menopausal if she met one of the two following conditions: 1) she declared herself menopausal at the time of the interview, or 2) she had not had a period for six months or more before the survey and was neither pregnant nor amenorrheic. Based on this definition, Table 8.7 shows that few respondents under age 40 are menopausal. However, the proportion menopausal rises rapidly with age among older women, from 6 percent of women age 40-41 to 40 percent of women in the oldest age group (48-49 years). Table 8.7 Menopause Percentage of women age 30-49 who are menopausal, by age, Egypt 2008 Age Percentage menopausal1 Number of women 30-34 2.5 2,664 35-39 3.9 2,586 40-41 5.8 1,050 42-43 7.7 1,029 44-45 13.9 968 46-47 24.1 792 48-49 39.8 868 Total 9.8 9,957 1 Includes women who are not preg- nant, who are not postpartum amenor- rheic, and whose last menstrual period occurred six or more months preceding the survey and women who declared themselves to be menopausal Fertility Preferences | 105 FERTILITY PREFERENCES 9 Insight into the fertility desires in a population is important, both for estimating the potential unmet need for family planning and for predicting future fertility. This chapter presents data from the 2008 EDHS on the fertility intentions, need for family planning services, and desired family size among Egyptian women. It also considers the potential effect on fertility if unwanted pregnancies were prevented. 9.1 DESIRE FOR MORE CHILDREN The 2008 EDHS obtained information on fertility preference by asking non-sterilized currently married women the question: “Would you like to have (a/another) child or would you prefer not to have any (more) children?” For pregnant women, the question was prefaced by the wording, “After the child you are expecting. . . .” Women who wanted more children were then asked how long they would like to wait before the birth of their next child. Sterilized women were considered to want no more children for the purposes of the fertility preference tabulations presented in this chapter. Table 9.1 and Figure 9.1 show the reproductive intentions of currently married women interviewed in the 2008 EDHS. The majority of married women did not want any more children (62 percent) or were sterilized (1 percent). Almost all of the remaining women (32 percent) wanted another child. Among those wanting another child, the majority—17 percent of all currently married women— either wanted to wait two years or more to have the next birth or were unsure of when they wanted another child. Less than half of the women who wanted another child—14 percent of all currently married women—wanted a child soon (within two years). Table 9.1 Fertility preferences by number of living children Percent distribution of currently married women by desire for children, according to number of living children, Egypt 2008 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total Have another soon2 93.3 26.1 10.7 3.1 1.6 0.9 0.8 14.1 Have another later3 0.2 62.8 22.0 4.5 1.7 1.3 0.2 17.3 Have another, undecided when 0.0 1.3 0.8 0.4 0.3 0.4 0.1 0.6 Undecided 0.4 2.0 6.1 2.3 1.5 0.5 1.3 2.7 Want no more 0.4 6.4 59.1 87.1 90.2 90.4 87.3 61.9 Sterilized 0.0 0.0 0.2 0.8 1.8 3.0 3.7 1.0 Declared infecund 5.7 1.2 1.0 1.8 2.9 3.4 6.6 2.4 Missing 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 992 2,589 3,708 3,652 2,206 1,142 1,106 15,396 Note: Women who have been sterilized are considered to want no more children. 1 Includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 106 | Fertility Preferences The desire for a child was strongly related to the number of living children the woman already had. There was very little interest in spacing the first birth. More than nine in ten women who had not yet begun childbearing at the time of the survey wanted a birth soon. More than nine in ten women who had one child also expressed a desire to have another; however, the majority (63 percent) of these women wanted to wait two years or more to have the next birth. Among women with more than one child, the desire to cease childbearing increased rapidly with the number of children, from 59 percent among women with two children to 90 percent among women with four or five children. Table 9.2 shows the distribution of currently married women by the desire for children, according to age. As expected, older women were much more likely to want no more children than younger women. The proportion of women who wanted no more children or who were sterilized was only 5 percent in the youngest age group, increased to 23 percent among those age 20-24, and peaked at 90 percent among women age 40-44. Table 9.2 Fertility preferences by age Percent distribution of currently married women by desire for children, according to age, Egypt 2008 Desire for children 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Wants another soon1 36.2 25.1 17.8 12.8 9.3 5.6 3.2 14.1 Wants another later2 56.0 47.6 25.0 9.4 2.0 0.8 0.0 17.3 Wants another, unsure timing 0.3 0.9 1.1 0.7 0.3 0.1 0.1 0.6 Undecided 2.1 3.9 5.4 2.8 1.8 0.6 0.2 2.7 Wants no more 5.2 22.5 50.5 73.2 84.3 87.2 79.8 61.9 Sterilized 0.0 0.0 0.1 0.6 1.4 2.4 2.7 1.0 Declared infecund 0.0 0.0 0.1 0.5 0.8 3.3 13.9 2.4 Missing 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 605 2,527 3,264 2,551 2,406 2,188 1,855 15,396 Note: Women who have been sterilized are considered to want no more children. 1 Wants next birth within 2 years 2 Wants to delay next birth for 2 or more years Figure 9.1 Desire for More Children among Currently Married Women EDHS 2008 Want another, unsure timing 1%Want another soon 14% Undecided 3% Want another later 17% Declared infecund 2% Want no more/ sterilized 63% Fertility Preferences | 107 The desire to space children was concentrated among younger women. Fifty-six percent of women age 15-19 and 48 percent of the women age 20-24 wanted to delay having a child for at least two years, compared with 9 percent of those age 30-34. Table 9.3 shows the variation in the percentage of currently married women who wanted no more children or who were sterilized with the number of living children (including any current pregnancy) for various subgroups. The results indicate that urban women expressed a desire to limit family size at lower parities than rural women. For example, 66 percent of urban women with two children wanted to stop childbearing, compared with 53 percent of rural women with two children. The urban-rural differential in the desire for children narrowed among women with four or more children. Table 9.3 Desire to limit childbearing by background characteristics Percentage of currently married women who want no more children, by number of living children and background characteristics, Egypt 2008 Number of living children1 Background characteristic 0 1 2 3 4 5 6+ Total Urban-rural residence Urban 0.6 8.9 66.1 90.3 92.1 94.8 91.1 64.5 Rural 0.3 4.6 53.3 86.0 91.9 92.7 90.9 61.8 Place of residence Urban Governorates 1.5 11.1 72.5 91.8 94.1 97.6 87.2 66.5 Lower Egypt 0.1 5.8 62.5 91.6 94.1 94.3 88.0 64.3 Urban 0.0 9.3 64.6 90.8 93.3 97.0 84.9 65.4 Rural 0.2 4.7 61.7 91.9 94.4 93.7 88.4 63.9 Upper Egypt 0.3 4.5 43.6 79.2 88.6 91.8 92.8 59.5 Urban 0.0 5.2 55.6 87.9 88.9 90.8 96.5 61.0 Rural 0.5 4.2 36.5 73.8 88.5 92.1 92.2 58.9 Frontier Governorates 0.0 4.4 50.2 77.4 83.3 89.1 88.2 55.2 Education No education 0.5 14.2 55.2 86.6 90.9 93.2 90.2 72.0 Some primary 0.8 8.4 64.7 83.1 95.9 92.9 95.0 75.1 Primary complete/some secondary 1.3 5.8 56.1 85.9 91.5 92.9 93.6 60.5 Secondary complete/higher 0.0 4.3 60.9 90.1 92.3 94.8 87.2 55.5 Work status Working for cash 0.6 10.7 71.4 91.2 93.6 97.3 93.0 72.9 Not working for cash 0.4 6.0 57.0 87.2 91.7 93.0 90.8 61.3 Wealth quintile Lowest 0.3 8.3 48.0 80.8 90.3 93.3 93.3 65.5 Second 0.2 5.8 50.4 85.0 93.1 93.3 88.9 61.8 Middle 1.4 5.4 59.1 89.0 92.0 93.0 89.0 63.6 Fourth 0.0 6.8 62.1 90.2 91.7 92.1 93.5 61.6 Highest 0.2 6.4 68.6 91.0 93.1 97.2 85.5 62.3 Total 0.4 6.4 59.4 87.9 92.0 93.4 91.0 62.9 Note: Women who have been sterilized are considered to want no more children. 1 Includes current pregnancy Looking at the differentials by place of residence, married women living in the Frontier Governorates and rural Upper Egypt were generally the least likely to want to limit childbearing. For example, 92 percent of married women with three children in the Urban Governorates and in both urban and total areas in Lower Egypt wanted no more children (or were sterilized). In contrast, 74 percent of married women with three children in rural Upper Egypt and 77 percent in the Frontier Governorates wanted to limit childbearing. 108 | Fertility Preferences Table 9.3 also shows that overall the proportion wanting no more children generally declined as the woman’s educational level increased. To some extent, this pattern reflects the interrelationships between a woman’s age, education level and her fertility preferences; educational levels are higher among younger women than older women and younger women are more likely to want another child than older women. Interestingly, the relationship between the woman’s educational status and the desire for children was not uniformly positive within parity groups. Women who were working for cash were consistently slightly more likely to want to limit childbearing than other women, regardless of the number of children the woman has. On the other hand, the desire to limit childbearing was not consistently related to wealth. 9.2 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 who are the most in need of contraceptive services. Table 9.4 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 9.4) include the following: (1) 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 two or more years, are unsure whether they want another child, or want another child but are unsure when to have the birth. (2) 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 contraceptive method. These women are considered to be in need of better contraception. Women with a met need for family planning (shown in columns 4-6 of Table 9.4) include women who are currently using contraception. The total demand for family planning (shown in columns 10-12 of Table 9.4) represents the sum of unmet need and met need. The total demand also includes pregnant and amenorrheic women who became pregnant while using a family planning method. The percentage of the total demand that is satisfied is shown in the column 13 in Table 9.4. According to Table 9.4, the total unmet need in Egypt at the time of the 2008 EDHS was 9 percent; about a third of this need represented a desire to space the next birth, and the remainder represented an interest in limiting births. The total met need for family planning (i.e., the proportion of women currently using contraception) was 60 percent. Most users were limiters, with only about one in five users reporting a desire to delay the next birth for two or more years. Fertility Preferences | 109 Table 9.4 Need for family planning by background characteristics Percentage of currently married women with unmet need for family planning,,met need for family planning, need for better contraception, and the total demand for family planning, by background characteristics, Egypt 2008 Unmet need for family planning1 Met need for family planning (currently using)2 Need for better contraception (contraceptive failure)3 Total demand for family planning4 Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Percent- age of demand satisfied Number of women Age 15-19 6.9 1.0 7.9 21.3 2.1 23.4 0.5 0.0 0.5 28.7 3.1 31.9 75.2 605 20-24 6.9 2.1 9.0 31.7 12.9 44.6 0.8 0.1 0.9 39.4 15.1 54.5 83.5 2,527 25-29 5.3 4.6 9.8 22.9 36.9 59.8 1.0 0.4 1.3 29.2 41.8 71.0 86.1 3,264 30-34 3.2 7.0 10.2 9.9 57.6 67.6 0.7 0.6 1.3 13.8 65.2 79.0 87.1 2,551 35-39 1.5 7.9 9.4 3.4 70.9 74.3 0.3 0.4 0.7 5.2 79.2 84.4 88.8 2,406 40-44 0.6 8.3 8.9 0.7 71.9 72.5 0.1 0.2 0.3 1.4 80.4 81.7 89.1 2,188 45-49 0.1 7.1 7.2 0.1 51.7 51.9 0.0 0.0 0.0 0.2 58.9 59.1 87.8 1,855 Urban-rural residence Urban 2.5 4.2 6.7 13.8 50.4 64.3 0.6 0.2 0.8 16.9 54.9 71.8 90.7 6,316 Rural 4.0 6.9 10.9 12.7 44.8 57.5 0.5 0.3 0.8 17.3 52.0 69.2 84.3 9,080 Place of residence Urban Governorates 2.5 3.5 5.9 13.3 51.9 65.2 0.6 0.2 0.8 16.3 55.6 71.9 91.7 2,727 Lower Egypt 2.5 4.9 7.4 13.7 50.6 64.3 0.5 0.3 0.8 16.7 55.8 72.5 89.8 7,128 Urban 2.0 4.5 6.4 13.3 52.2 65.5 0.6 0.1 0.6 15.8 56.7 72.6 91.1 1,801 Rural 2.7 5.0 7.7 13.9 50.1 63.9 0.4 0.4 0.8 17.0 55.5 72.5 89.3 5,326 Upper Egypt 5.0 8.2 13.1 12.4 40.3 52.7 0.6 0.3 0.9 18.0 48.8 66.7 80.3 5,326 Urban 2.9 5.1 8.0 15.3 47.1 62.4 0.6 0.4 1.0 18.8 52.5 71.3 88.8 1,646 Rural 5.9 9.5 15.4 11.1 37.2 48.4 0.6 0.3 0.9 17.6 47.1 64.6 76.1 3,680 Frontier Governorates 4.2 5.8 10.0 13.8 38.5 52.3 0.5 0.1 0.6 18.4 44.5 62.9 84.1 216 Education No education 3.0 7.9 10.8 7.2 50.4 57.7 0.4 0.3 0.7 10.6 58.6 69.2 84.3 4,758 Some primary 2.2 7.6 9.8 8.0 54.3 62.4 0.3 0.4 0.7 10.5 62.3 72.8 86.6 1,259 Primary complete/some secondary 3.4 6.1 9.4 13.8 45.8 59.5 0.6 0.3 0.9 17.8 52.1 69.9 86.5 2,273 Secondary complete/ higher 3.9 3.9 7.8 17.9 44.0 61.9 0.6 0.3 0.9 22.4 48.2 70.6 88.9 7,106 Work status Working for cash 2.0 5.3 7.3 9.6 58.4 68.0 0.8 0.2 0.9 12.4 63.8 76.2 90.4 2,182 Not working for cash 3.6 5.9 9.5 13.8 45.2 59.0 0.5 0.3 0.8 17.9 51.4 69.3 86.3 13,215 Wealth quintile Lowest 4.2 8.5 12.8 10.8 44.6 55.4 0.5 0.3 0.8 15.6 53.5 69.1 81.5 2,764 Second 3.8 6.6 10.4 11.9 45.2 57.1 0.4 0.3 0.7 16.1 52.1 68.2 84.8 3,014 Middle 3.8 5.4 9.3 13.4 47.8 61.2 0.5 0.4 0.9 17.6 53.7 71.3 87.0 3,172 Fourth 3.1 4.8 7.8 14.1 47.3 61.4 0.8 0.3 1.1 18.0 52.4 70.3 88.8 3,268 Highest 2.2 4.0 6.1 15.3 50.1 65.4 0.5 0.1 0.6 17.9 54.2 72.1 91.5 3,178 Total 3.4 5.8 9.2 13.2 47.1 60.3 0.5 0.3 0.8 17.1 53.2 70.3 87.0 15,396 1 Unmet need for spacing 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 a better method of contraception). Also excluded are menopausal or infecund women. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child 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 for better contraception. 4 Total demand includes pregnant or amenorrheic women who became pregnant while using a method (contraceptive failure) in addition to the unmet and met need for family planning. 110 | Fertility Preferences Overall, the total demand for family planning comprised 70 percent of the married women inter- viewed in the EDHS. Eighty-seven percent of that demand was satisfied. Looking at variations in the proportion of the total demand for family planning that was satisfied, the most striking finding in Table 9.4 is the fact that 80 percent or more of the demand for services was satisfied in almost all subgroups. The level of satisfied demand was highest among women living in Urban Governorates (92 percent) and lowest among women living in rural Upper Egypt (76 per- cent). Table 9.5 considers the reasons women who wanted to delay or avoid another method gave in response to the question of why they were not using contraception. Almost two-thirds of these women gave fertility-related reasons in response to this question; 31 percent mentioned that they were not exposed to preg- nancy because they were menopausal or had had a hysterectomy, had difficulty becoming pregnant or were still amenorrheic following their last birth. More than one in four (28 percent) said they were not having sexual intercourse or had sex infrequently. Health con- cerns and side effects were cited by 12 and 13 percent of women, respectively. 9.3 IDEAL NUMBER OF CHILDREN The discussion of fertility preferences earlier in this chapter focused on the respondent’s wishes for the future. A woman’s preferences obviously are influenced by the number of children she already has. The 2008 EDHS attempted to obtain a measure of fertility preferences that was less dependent on the woman’s current family size by asking about the respondent’s ideal number of children. The question about ideal family size required a woman to perform the difficult task of considering the number of children she would choose to have in her whole life regardless of the number (if any) that she had already borne. Seven percent of women gave a nonnumeric response to the question about ideal family size, reflecting the difficulty that these respondents had with the abstract nature of the question. Table 9.6 shows the distribution of ever-married women by their ideal number of children, according to number of living children. In considering the results in Table 9.6, it is important to remember that for several reasons, the ideal number of children tends to be fairly closely associated with the actual number of children a woman has. First, women who want a large family tend to have more children than other women. Second, women may rationalize their ideal family size so that as the actual number of children increases, their preferred family size also increases. Furthermore, women with a larger family— being on average older than women with small families—may prefer a larger ideal family size because of attitudes that they acquired 20 to 30 years ago. Table 9.5 Reason for not using contraception Percentage of currently married women who are not using a contraceptive method and who want to delay or avoid having a birth by the reasons they are not using a method, according to the fertility intention, Egypt 2008 Reason Wants later Does not want Total Fertility-related Not having sex 2.5 3.8 3.5 Infrequent sex/no sex 26.9 23.6 24.3 Menopausal/had hysterectomy 0.4 13.7 10.8 Subfecund/infecund 4.8 9.9 8.8 Postpartum/amenorrheic 24.0 8.1 11.5 Breastfeeding 11.6 2.4 4.4 Opposition to use Respondent opposed 2.8 2.9 2.9 Husband/partner opposed 6.4 2.8 3.6 Others opposed 0.8 0.1 0.2 Religious prohibition 0.2 1.1 0.9 Lack of knowledge Knows no method 0.2 0.0 0.1 Knows no source 0.1 0.1 0.1 Method-related Health concerns 3.7 14.6 12.3 Fear of side effects 11.2 13.8 13.2 Lack of access/too far 0.3 0.0 0.1 Costs too much 0.2 0.7 0.6 Inconvenient to use 0.7 0.8 0.8 Interferes with body's normal processes 0.9 1.9 1.7 Other Fatalistic 3.1 6.3 5.6 Waiting for period to return 2.2 1.1 1.4 Other 3.3 2.3 2.5 Don’t know 0.5 0.3 0.3 Number of women 498 1,811 2,310 Fertility Preferences | 111 Overall, Table 9.6 shows that ever-married women who expressed a numeric preference wanted an average of 2.9 children. Thirty-nine percent of ever-married women who expressed a numeric preference wanted a two-child family, while 27 percent considered a three-child family ideal. Relatively few wanted five or more children. As expected, higher parity women showed a preference for more children; the mean ideal number of children ranged from 2.4 children among women with one child to 4.3 children among women with six or more children. Table 9.6 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 for currently married women, according to number of living children, Egypt 2008 Number of living children1 Ideal number of children 0 1 2 3 4 5 6+ Total 0 0.4 0.2 0.1 0.2 0.2 0.4 0.4 0.2 1 11.8 3.1 1.5 1.1 1.3 0.6 0.5 2.2 2 51.9 59.7 56.3 30.4 21.2 18.0 9.8 39.2 3 16.2 24.7 26.0 42.2 20.0 20.8 15.0 26.9 4 8.7 7.2 10.5 15.6 39.8 28.2 24.8 17.6 5 3.4 1.1 1.5 3.2 4.9 13.0 13.1 4.1 6+ 1.7 0.8 0.9 1.5 2.9 6.3 14.9 2.8 Non-numeric responses 5.9 3.2 3.2 5.8 9.5 12.6 21.5 6.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,130 2,793 3,922 3,878 2,363 1,234 1,207 16,527 Mean ideal number children for: Ever-married women 2.4 2.4 2.6 3.0 3.4 3.7 4.3 2.9 Number of women 1,063 2,705 3,797 3,652 2,137 1,079 947 15,380 Currently married women 2.5 2.5 2.6 2.9 3.4 3.7 4.3 2.9 Number of women 936 2,510 3,604 3,446 2,004 996 872 14,368 Note: The mean excludes women giving non-numeric answers. 1Includes current pregnancy The results in Table 9.6 also clearly show that many women in Egypt have had more children than they would now prefer. For example, 43 percent of EDHS respondents with four children said that they would have preferred to have three or fewer children. More than two-thirds of the women with five children considered a smaller family ideal. Table 9.7 presents the mean ideal number of children for ever-married women by age and background characteristics. On average, women who lived in the Urban Governorates, in Lower Egypt (either in urban or rural areas), and in urban Upper Egypt, women who had completed at least a primary education, women working for cash and women in the middle through highest wealth quintiles wanted fewer than three children. The mean ideal family size was highest in the Frontier Governorates (3.4 children) and in rural Upper Egypt (3.3 children). Across all subgroups, younger women generally desired fewer children than older women. 112 | Fertility Preferences Table 9.7 Mean ideal number of children by background characteristics Mean ideal number of children for ever-married women, by age and background characteristics, Egypt 2008 Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Urban-rural residence Urban 2.6 2.5 2.5 2.7 2.9 3.0 3.1 2.8 Rural 2.7 2.7 2.8 3.0 3.2 3.4 3.7 3.0 Place of residence Urban Governorates 2.3 2.4 2.4 2.5 2.8 2.8 3.0 2.7 Lower Egypt 2.5 2.5 2.6 2.8 2.9 3.1 3.3 2.8 Urban 2.8 2.5 2.6 2.7 2.8 3.0 3.0 2.8 Rural 2.5 2.5 2.6 2.9 3.0 3.2 3.5 2.9 Upper Egypt 2.8 2.8 3.0 3.1 3.4 3.6 3.8 3.2 Urban 2.7 2.7 2.6 2.9 3.0 3.2 3.3 2.9 Rural 2.8 2.9 3.1 3.2 3.6 3.9 4.1 3.3 Frontier Governorates 2.9 2.9 3.2 3.3 3.6 3.7 3.7 3.4 Education No education 2.8 2.8 2.9 3.1 3.3 3.5 3.8 3.3 Some primary 2.5 2.6 2.8 3.0 3.1 3.3 3.6 3.1 Primary complete/some secondary 2.7 2.6 2.8 2.9 3.0 3.1 3.1 2.9 Secondary complete/higher 2.6 2.6 2.6 2.7 2.9 2.9 2.8 2.7 Work status Working for cash 3.0 2.6 2.6 2.6 3.0 2.9 2.9 2.8 Not working for cash 2.6 2.6 2.7 2.9 3.1 3.3 3.6 3.0 Wealth quintile Lowest 2.7 2.8 3.0 3.2 3.4 3.7 3.9 3.3 Second 2.8 2.7 2.8 3.0 3.3 3.6 3.8 3.1 Middle 2.7 2.6 2.7 2.9 3.0 3.0 3.6 2.9 Fourth 2.5 2.5 2.6 2.7 3.0 3.1 3.1 2.8 Highest 2.5 2.5 2.5 2.6 2.8 2.8 2.9 2.7 Total 2.7 2.6 2.7 2.9 3.1 3.2 3.4 2.9 The results in Table 9.8 show that 63 percent of currently married women believed that they and their husband agree about the number of children they want. Among the remaining women, the majority (23 percent) believed that their husband would like to have more children than they themselves wanted. Women whose ideal family size was between two and four children were more likely to say that their husband shared the same family size goal than women who wanted smaller or larger families. Table 9.8 Husband's fertility preference by wife's ideal number of children Percent distribution of currently married women by husband's fertility preference, according to the woman's ideal number of children, Egypt 2008 Wife’s ideal number of children Husband's fertility preference 0 1 2 3 4 5 6+ Non- numeric responses Total Wants same * 59.3 67.9 68.1 61.7 52.9 46.6 25.0 62.6 Wants more * 31.1 23.6 21.8 23.2 26.9 26.9 12.2 22.7 Wants fewer * 2.8 2.6 3.9 5.4 8.8 15.8 2.3 4.0 Sterilized * 0.2 0.7 0.8 1.6 1.3 2.2 1.6 1.0 Don't know/missing * 6.7 5.3 5.4 8.1 10.0 8.5 58.8 9.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 21 324 6,035 4,217 2,726 623 422 1,028 15,396 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Fertility Preferences | 113 9.4 UNPLANNED AND UNWANTED FERTILITY Several indicators of the level of unwanted fertility can be derived from the 2008 EDHS data. First, responses to a question about the planning status of prior births, i.e., whether a birth was planned (wanted then), unplanned (wanted later), or not wanted at all, provide some indication of the extent of unwanted childbearing. In interpreting these data, however, it is important to remember that women may rationalize mistimed or unwanted pregnancies, declaring them as wanted after the children are born. Table 9.9 shows the percent distribution of births in the five years preceding the 2008 EDHS by planning status of the birth. Overall, 14 percent of births in the five-year period were not wanted at the time of conception, with 5 percent wanted but at a later time and 9 percent not wanted at all. The proportion of births that were not wanted at the time of conception increased directly with birth order. Somewhat more than one-third of all fourth and higher order births were unplanned, compared with only about one-tenth of second order births. The planning status of births was also affected by the age of the mother. In general, the older the mother, the larger the percentage of children that were unwanted at conception; for example, slightly less than half of the births to women age 40-45 were unwanted. Table 9.9 Fertility planning status Percent distribution of births in the five years preceding the survey (including current preg- nancies), by fertility planning status, according to birth order and mother's age at birth, Egypt 2008 Planning status of birth Birth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 98.2 1.2 0.1 0.5 100.0 4,073 2 89.8 8.9 0.9 0.4 100.0 3,306 3 83.4 6.5 9.3 0.8 100.0 2,316 4+ 61.8 4.9 32.7 0.6 100.0 2,450 Age at birth <20 95.7 3.2 0.6 0.4 100.0 1,398 20-24 91.9 5.8 1.8 0.5 100.0 4,268 25-29 86.6 6.0 7.0 0.5 100.0 3,574 30-34 77.0 4.7 17.7 0.6 100.0 1,826 35-39 63.9 2.3 33.1 0.7 100.0 848 40-44 51.0 1.2 46.7 1.1 100.0 217 45-49 * * * * 100.0 14 Total 85.7 5.1 8.7 0.5 100.0 12,145 Note: An asterisk indicates a figure is based on fewer than 25 cases and has been suppressed. A second approach to measuring unwanted fertility is to calculate what the fertility rate would be if all unwanted births were avoided. This wanted fertility rate is calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. Women who did not report a numeric ideal family size are assumed to have wanted all their births. To the extent that women are unwilling to report an ideal family size that is lower than their actual family size, the wanted fertility rate may be overestimated. 114 | Fertility Preferences Table 9.10 presents total wanted fertility rates and total fertility rates for the three-year period before the survey for various subgroups. Overall, the wanted fertility rate was 2.4 births per women. Thus, if unwanted births could be eliminated, the total fertility rate in Egypt would decline by around 20 percent. The gap between the wanted and actual fertility rates was greatest among rural women (especially those living in Upper Egypt), women in the Frontier Governorates, women who never attended school or had less than a primary education, and women in the lowest wealth quintile. Table 9.10 Wanted fertility rates by background characteristics Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Egypt 2008 Background characteristic Total wanted fertility rate Total fertility rate Urban-rural residence Urban 2.2 2.7 Rural 2.5 3.2 Place of residence Urban Governorates 2.2 2.6 Lower Egypt 2.4 2.9 Urban 2.1 2.6 Rural 2.5 3.0 Upper Egypt 2.5 3.4 Urban 2.3 3.0 Rural 2.6 3.6 Frontier Governorates 2.6 3.3 Education No education 2.6 3.4 Some primary 2.4 3.2 Primary complete/some secondary 2.3 3.0 Secondary complete/higher 2.5 3.0 Wealth quintile Lowest 2.5 3.4 Second 2.3 3.1 Middle 2.4 3.0 Fourth 2.4 2.9 Highest 2.3 2.7 Total 2.4 3.0 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Infant and Child Mortality | 115 INFANT AND CHILD MORTALITY 10 This chapter presents information on the levels and trends in mortality among children under five years of age in Egypt and looks at the variation in mortality levels according to demographic and socioeconomic characteristics that have been shown to influence infant and childhood mortality (e.g., residence, young maternal age at birth, and short birth intervals). The mortality levels from the 2008 EDHS are central to the assessment of the current demographic situation in Egypt. Mortality levels are also one of the main indicators of the standard of living or development of a population. Thus, identifying segments of the child population that are at greater risk of dying contributes to efforts to improve child survival and lower the exposure of young children to risk. 10.1 ASSESSMENT OF DATA QUALITY The 2008 EDHS mortality estimates are calculated from information that was collected in the birth history section of the woman’s questionnaire. The birth history section includes a set of initial questions about the number of sons and daughters living with the mother, the number who live elsewhere, and the number who have died. These questions are followed by a retrospective birth history in which a listing of all of the respondent’s births is obtained, starting with the first birth. For each birth, information is collected on the sex, month and year of birth, survivorship status, and current age, or age at death, of each of the respondent’s live births. This information is used to directly estimate the mortality rates. In this chapter, the following rates are used to assess and measure infant and child mortality: Neonatal mortality: the probability of dying within the first month of life; Postneonatal mortality: the difference between infant and neonatal mortality; Infant mortality: the probability of dying during the first year of life; Child mortality: the probability of dying between the first and fifth birthday; Under-five mortality: the probability of dying before the fifth birthday. The reliability of mortality estimates derived from birth history data is affected by a number of factors. These factors include the completeness with which deaths of children are reported, and the extent to which birth dates and ages at death are accurately reported. Omissions of either births or deaths are a more serious problem since they affect the level of the mortality estimates. Errors in reporting of birth dates may cause a distortion of trends over time, while errors in reporting of age at death can distort the age pattern of mortality. Omissions can be detected by examining the proportion of neonatal deaths that occur during the first week of life and the proportion of infant deaths that take place during the first month of life. Thus, if there is substantial underreporting of deaths, the results would be an abnormally low ratio of deaths under seven days to all neonatal deaths. Since underreporting of deaths is likely to be more common for births that occurred a long time before the survey, it is important to explore whether these ratios change markedly over time. Inspection of the ratio of deaths in the first six days of life to all neonatal deaths (shown in Appendix Table D.4) shows that the proportion of neonatal deaths that took place in the first week of life ranges from 70 percent for deaths during the period 0-4 years before the survey to 59 percent for deaths during the period 15-19 years before the survey. There is some variation over time in the proportion of neonatal to all infant deaths (shown in Appendix Table D.5), which ranges from 69 percent in the period 116 | Infant and Child Mortality 0-4 years before the survey to 54 percent during the period 10-19 years before the survey. These ratios are within acceptable limits for the levels of mortality observed during these time periods. Errors in the reporting of birth dates also affect the accuracy of period mortality estimates. An examination of the distribution of dead children according to their birth date indicates that there is an excess of deaths in calendar year 2002 (shown in Appendix Table D.6). The transference occurred in the case of both living and dead children. A similar pattern is evident in the data from Demographic and Health Surveys in other countries as well as Egypt; it is thought to result, at least partially, from interviewer transference of births out of the period for which health data were collected (January 2003 through the date of the survey) in order to reduce the workload. The effect of the transference is a slight underestimate of mortality in the period 0-4 years prior to the survey and an overestimate of mortality in the period 5-9 years prior to the survey. Results from a simulation study conducted with a number of DHS countries suggests the error introduced in the mortality estimates is typically less than 5 percent (Macro International Inc., 1993). Another problem common to the collection of birth history data is heaping of age at death, especially at age 12 months. Errors in the reporting of the age at death will bias estimates of the age pattern of mortality if the errors result in transference of deaths between the age segments for which the rates are calculated. For example, an overestimate of child mortality relative to infant mortality may result if children who died during the first year of life are reported to have died at age one year (12 months) or older. In an effort to avoid this problem, EDHS interviewers were instructed to record the age at death in months for deaths under age two years. In addition, they were asked to probe whenever the mother reported an age at death of “1 year” or “12 months.” Despite these procedures, the data on age at death from the 2008 EDHS exhibits considerable heaping at age 12 months (shown in Appendix Table D.5). However, the heaping is much less evident for deaths occurring in the period 0-4 years before the survey than for deaths taking place further in the past. As a result, the effect of heaping on the 2008 EDHS mortality estimates is not large. 10.2 LEVELS AND TRENDS IN EARLY CHILDHOOD MORTALITY Table 10.1 presents neonatal, postneonatal, infant, child, and under-five mortality rates for a fifteen-year period preceding the 2008 EDHS. These results describe the current level of mortality in Egypt and allow an assessment of recent trends in mortality among young children. 10.2.1 Levels of Mortality Under-five mortality for the period 0-4 years before the survey was 28 deaths per 1,000 births. At this level, about one in thirty-six Egyptian children will die before the fifth birthday. The infant mortality rate was 25 deaths per 1,000 births, and the neonatal mortality rate was 16 deaths per 1,000 births. This indicates that around 87 percent of early childhood deaths in Egypt are taking place before a child’s first birthday, with more than half (58 percent) occurring during the first month of life. 10.2.2 Trends in Mortality Based on Retrospective Data Mortality estimates derived from the retrospective birth history data collected in the 2008 EDHS are used in Table 10.1 to examine the trends in early childhood mortality in Egypt over the past 15 years. Although subject to some degree of recall bias, the results suggest that early childhood mortality levels have declined steadily over the past 15 years. Infant mortality decreased by around 40 percent, from a level of 41 deaths per 1,000 births during the period 10-14 years before the survey (circa 1994-1998) to a level of 25 deaths per 1,000 in the five-year period preceding the EDHS (circa 2004-2008). Under-five mortality declined from 54 deaths per 1,000 births during the period 10-14 years before the survey to 28 deaths in the five-year period before the survey. Infant and Child Mortality | 117 Table 10.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Egypt 2008 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 16.3 8.2 24.5 3.9 28.3 5-9 18.6 14.1 32.7 6.0 38.5 10-14 21.4 19.2 40.6 14.0 54.0 1 Computed as the difference between the infant and neonatal mortality rates 10.2.3 Trends in Mortality Based on Data from Multiple Surveys Another approach to looking at trends in mortality levels involves the comparison of estimates from surveys conducted at different points in time. Table 10.2 and Figure 10.1 present the trend in early childhood mortality rates for successive five-year periods before the five rounds of the Egypt DHS surveys and the 1980 Egypt Fertility Survey. Together, the estimates span the 40-year period between the 1980 EFS and the 2008 EDHS. Table 10.2 Trends in early childhood mortality Trends in neonatal, infant, and under-five mortality from various selected surveys, Egypt 1965-2008 Preference period Approximate midpoint Survey Neonatal mortality Infant mortality Under-five mortality 2004-2008 2006 2008 EDHS 16 25 28 2001-2005 2003 EDHS-05 20 33 41 1999-2003 2001 2008 EDHS 19 33 39 1996-2000 1998 EDHS-05 26 48 59 1996-2000 1998 EDHS-00 24 44 54 1994-1998 1996 2008 EDHS 21 41 54 1991-1995 1993 EDHS-05 32 60 81 1991-1995 1993 EDHS-00 34 66 84 1991-1995 1993 EDHS-95 30 63 81 1988-1992 1990 EDHS-92 33 62 85 1986-1990 1988 EDHS-00 37 74 103 1986-1990 1988 EDHS-95 44 82 110 1984-1988 1986 EDHS-88 39 73 102 1983-1987 1985 EDHS-92 51 97 130 1981-1985 1983 EDHS-95 45 97 139 1979-1983 1981 EDHS-88 58 120 167 1978-1982 1980 EDHS-92 48 108 157 1975-1979 1977 EFS-80 59 132 191 1974-1978 1976 EDHS-88 53 124 203 1970-1974 1972 EFS-80 67 146 238 1965-1969 1967 EFS-80 63 141 243 Source: EFS-80: Abdel-Azeem et al., 1993, Table 10.4 EDHS-88: Sayed et al., 1989, Table 8.3 and 8.4 EDHS-92: El-Zanaty et al., 1993, Table 10.1 EDHS-95: El-Zanaty et al., 1995, Table 9.1 EDHS-00: El-Zanaty and Way., 2001, Table 10.1 EDHS-05: El-Zanaty and Way., 2006, Table 10.1 118 | Infant and Child Mortality In examining the estimates, it is important to remember that the reporting of mortality events is generally better for the five-year period immediately before a survey since mothers are more likely to forget or fail to mention deaths further back in time. Thus, the estimate for the five-year period immedi- ately prior to each of the surveys shown in Table 10.2 is likely to be the most accurate. Sampling error also must be taken into account in interpreting the trends in the table. Sampling errors are typically fairly large for mortality rates. For these reasons, the differences or fluctuations between mortality estimates for roughly the same time periods from different surveys in Table 10.2 should be interpreted with caution, particularly where they are small. The estimates presented in Table 10.2 confirm that early childhood mortality has fallen significantly in Egypt during the past three decades. An Egyptian child was almost six times as likely to die before the fifth birthday in the mid-1960s as in the early 2000s (Figure 10.1). The trends in Table 10.2 also document the changing age pattern of deaths among young children. As the overall rates decreased, mortality is increasingly concentrated in the earliest months of life. In the mid-1960s, around 40 percent of deaths occurred after the child’s first birthday; by the time of the 2008 EDHS, only 14 percent of all deaths under age five took place after the first 12 months of life. 10.3 DIFFERENTIALS IN MORTALITY Selected demographic and socio-economic differentials in early childhood mortality are presented in Tables 10.3 and 10.4, respectively. For most variables, the mortality estimates are calculated for a ten- year period before the survey so that the rates are based on a sufficient number of cases in each category to ensure statistical significance. However, because the information on birth-size was collected only for births occurring between January 2003 and the date of the survey interview, the mortality rates for this variable relate to only the five-year period before the EDHS. 10.3.1 Socioeconomic Differentials Table 10.3 shows that urban-rural differences in early childhood mortality favor urban children, i.e., urban children have a lower probability of dying at any stage of early childhood than rural children. Figure 10.1 Trends in Under-five Mortality Egypt 1967-2006 EDHS 2008 + ++ ( ( ( # # # $ $ $ ' ' ' ) ) ) , , , 67 72 76 77 80 81 83 85 86 88 90 93 98 2003 2006 Mid-point of calendar reference period 0 50 100 150 200 250 300 Deaths per 1,000 births 1980 EFS 1988 EDHS 1992 EDHS 1995 EDHS 2000 EDHS 2005 EDHS 2008 EDHS , ) ' $ # ( + Infant and Child Mortality | 119 For example, under-five mortality in urban areas is 29 per 1,000 births, 19 percent lower than under-five mortality in rural areas (36 per 1,000). Considering place of residence, the lowest mortality rates are found in urban Lower Egypt while the highest rates are found in rural Upper Egypt (see Figure 10.2). Under-five mortality in rural Upper Egypt is 46 deaths per 1,000 births, around 65 percent higher than under-five mortality in rural Lower Egypt (28 deaths per 1,000 births). Although mortality in rural Upper Egypt is higher at all ages than mortality in rural Lower Egypt, the large differential in postneonatal mortality is particularly noteworthy. The postneonatal mortality rate in rural Upper Egypt is 19 deaths per 1,000 births, more than double the rate in rural Lower Egypt (8 deaths per 1,000 births). The child mortality rate in rural Upper Egypt (7 deaths per 1,000) is almost twice as high as the rate in rural Lower Egypt (4 deaths per 1,000). Table 10.3 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by socioeconomic characteristic, Egypt 2008 Socioeconomic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Urban-rural residence Urban 17.6 7.9 25.4 3.4 28.7 Rural 17.4 13.1 30.5 5.9 36.2 Place of residence Urban Governorates 20.8 8.9 29.7 2.5 32.2 Lower Egypt 14.1 7.3 21.3 4.1 25.3 Urban 11.2 3.7 14.9 3.1 18.0 Rural 15.0 8.4 23.4 4.4 27.6 Upper Egypt 19.9 16.4 36.3 6.6 42.7 Urban 19.6 10.4 30.0 4.5 34.4 Rural 20.0 18.6 38.6 7.4 45.7 Frontier Governorates 15.9 8.2 24.1 9.6 33.5 Education No education 20.5 17.1 37.6 6.7 44.0 Some primary 17.0 12.2 29.3 6.8 35.8 Primary complete/some secondary 17.9 11.4 29.3 6.1 35.2 Secondary complete/higher 15.4 6.8 22.2 2.6 24.7 Wealth quintile Lowest 20.9 21.2 42.1 7.2 49.0 Second 18.0 12.6 30.5 5.7 36.1 Middle 18.8 7.4 26.2 6.1 32.2 Fourth 16.1 8.5 24.6 2.6 27.2 Highest 12.5 4.3 16.8 2.1 18.9 Total 17.5 11.1 28.6 4.9 33.4 1 Computed as the difference between the infant and neonatal mortality rates 120 | Infant and Child Mortality Mortality levels among urban children are also higher in Upper Egypt than in Lower Egypt, primarily because of higher infant mortality. The infant mortality rate is 30 deaths per 1,000 births in the Urban Governorates and urban Upper Egypt compared with 15 deaths per 1,000 in urban Lower Egypt. Mortality levels among children age 1-4 years range from a low of 3 deaths per 1,000 in the Urban Governorates and urban Lower Egypt to 5 deaths per 1,000 in urban Upper Egypt. Overall, mortality is generally inversely related to mother's education, with children born to women who never attended school being almost twice as likely to die by the fifth birthday as children born to mothers with a secondary or higher education (44 deaths per 1,000 births versus 25 deaths per 1,000 births, respectively). Births to mothers in the highest wealth quintile are two and a half times as likely to survive to the fifth birthday as children born to mothers in the lowest quintile. 10.3.2 Demographic Differentials Table 10.4 shows the relationship between early childhood mortality and selected demographic variables including the sex of the child, mother's age at birth, birth order, length of the previous birth intervals, and mother's perception concerning the size of the child at birth. As expected, neonatal mortality is higher among boys than girls (23 deaths per 1,000 and 12 deaths per 1,000, respectively). Sex differentials in postneonatal and child mortality rates are quite small. Under-five mortality is higher among boys (38 deaths per 1,000 births) than among girls (28 deaths per 1,000 births). The effect of young maternal age at birth on mortality is evident in Table 10.4. Children born to mothers who were under age 20 at the time of the birth or over age 40 are significantly more likely to die at all ages than children born to other mothers. Mortality levels are generally lowest for births to mothers age 20-29. Considering birth order, seventh order and higher births have the highest mortality. For example, the infant mortality rate observed among births of order seven or higher is 46 deaths compared with 41 deaths per 1,000 or lower among other births. Figure 10.2 Under-Five Mortality by Place of Residence 32 25 18 28 43 34 46 34 Urban Governorates Total Urban Rural Total Urban Rural Frontier Governorates 0 10 20 30 40 50 Percent Lower Egypt Upper Egypt EDHS 2008 Infant and Child Mortality | 121 Table 10.4 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Egypt 2008 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 22.9 10.6 33.5 5.1 38.4 Female 11.7 11.7 23.4 4.7 28.0 Mother's age at birth <20 21.3 16.5 37.9 4.3 42.0 20-29 15.6 10.1 25.6 5.0 30.5 30-39 18.8 10.7 29.5 4.7 34.0 40-49 40.1 16.3 56.4 13.6 69.2 Birth order 1 17.6 9.9 27.5 3.3 30.7 2-3 13.7 8.7 22.4 4.9 27.2 4-6 24.5 16.4 40.9 5.5 46.2 7+ 24.4 21.3 45.7 13.1 58.2 Previous birth interval <2 years 32.9 26.5 59.4 10.9 69.6 2 years 13.1 9.1 22.1 4.2 26.2 3 years 9.2 9.4 18.6 5.8 24.3 4+ years 15.2 4.5 19.7 2.8 22.5 Birth size2 Small/very small 39.4 14.4 53.8 - - Average or larger 12.5 7.2 19.7 - - 1 Computed as the difference between the infant and neonatal mortality rates 2 Rates for the five-year period before the survey The length of the previous birth interval is also associated with mortality levels. Overall, the under-five mortality rate among children born less than two years after a previous birth is 70 deaths per 1,000 births, more than three times the level among children born four or more years after a previous birth. Coupled with the finding in Chapter 4 that about 18 percent of all non-first births occur within 24 months of the previous birth, these results indicate the importance of continuing efforts to promote the use of family planning for birth spacing. Research has shown that a child's size at birth is an important predictor of the risk of dying during early infancy. For all births in the five-year period before the 2008 EDHS, mothers were asked if the child was small or very small, average or large. Table 10.4 shows that the children who were considered by their mothers to be small or very small at birth were at greater risk of dying than children who were described as average or larger. For example, infant mortality for children who were considered by their mothers to be small or very small is 54 deaths per 1,000 compared with 20 deaths per 1,000 for children regarded as average or larger. 10.4 PERINATAL MORTALITY Perinatal deaths include deaths to live births within the first seven days of life (early neonatal deaths) and pregnancy losses occurring after seven months of gestation (stillbirths). In the 2008 EDHS, information on stillbirths was obtained for the five years preceding the survey and recorded in the calendar. The distinction between a stillbirth and an early neonatal death is often a fine one, depending on 122 | Infant and Child Mortality observing and then recalling sometimes-faint signs of life following delivery. The causes of stillbirths and early neonatal deaths are closely linked, and just examining one or the other can understate the true level of mortality around delivery. Table 10.5 presents the number of still births and early neonatal deaths and the perinatal mortality rate for the five-year period prior to the 2008 EDHS by selected background characteristics. Overall, the perinatal mortality rate is 19 per 1,000 pregnancies, which shows a decline that the level observed in 2005 (23 per 1,000 pregnancies). Table 10.5 Perinatal mortality by background characteristics Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five- year period preceding the survey, by background characteristics, Egypt 2008 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 9 11 16.5 1,245 20-29 42 72 16.7 6,841 30-39 26 29 23.2 2,381 40-49 10 5 69.6 211 Previous pregnancy interval in months First pregnancy 25 40 19.6 3,301 <15 7 24 39.7 794 15-26 9 21 17.7 1,672 27-38 11 7 9.7 1,865 39+ 35 26 20.0 3,046 Urban-rural residence Urban 33 56 22.4 3,957 Rural 54 62 17.3 6,721 Place of residence Urban Governorates 12 30 24.9 1,690 Lower Egypt 38 32 15.0 4,625 Urban 12 4 15.1 1,022 Rural 26 28 15.0 3,602 Upper Egypt 36 54 21.2 4,209 Urban 8 21 25.1 1,149 Rural 28 33 19.8 3,060 Frontier Governorates 2 2 25.9 153 Education No education 24 28 18.7 2,759 Some primary 8 8 22.2 729 Primary complete/some secondary 9 22 19.3 1,633 Secondary complete/higher 46 60 19.0 5,556 Wealth quintile Lowest 24 24 22.4 2,169 Second 18 29 21.7 2,143 Middle 17 25 18.7 2,269 Fourth 17 23 18.6 2,130 Highest 12 16 14.0 1,967 Total 87 118 19.2 10,677 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more month's duration. Infant and Child Mortality | 123 10.5 HIGH-RISK FERTILITY BEHAVIOR Research has indicated that there is a strong relationship between maternal fertility patterns and children's survival risks. Typically, the risk of early childhood death increases among children born to mothers who are too young or too old, children born after too short birth intervals, and children of high birth order. For the purpose of this analysis, a mother is classified as “too young” if she is less than 18 years of age, and “too old” if she is over 34 years at the time of the birth. A “short birth interval” is defined by the birth occurring less than 24 months after a previous birth; and a child is of “high birth order,” if the mother had previously given birth to three or more children (i.e., the child is of birth order four or higher). Table 10.6 shows the percent distributions of births in the five-year period of currently married women according to these elevated risk factors. The table also examines the relative risk of dying for children by comparing the proportion dead in each specified high-risk category with the proportion dead among children not in any high-risk category. First births, although often at increased risk, are included in the not in any high-risk category in this analysis because they are not considered an avoidable risk. Thirty-five percent of births in the five-year period before the survey were in at least one of the specified high-risk categories, and 9 percent were associated with two or more high-risk factors. A short birth interval and high birth order were the most common high-risk factors. As the second column of Table 10.6 shows, the risk of dying for a child who falls into any of the high-risk categories is 2.17 times that for a child not in any high-risk category. Considering the risk categories separately, children are at highest risk of dying if the mother is 18 years and younger at the time of the birth or if the child is born within two years of a previous birth. Generally, risk ratios were higher for children in multiple high-risk categories than for children in any single high-risk category. The final column in Table 10.6 examines the potential for high-risk births among currently married women. A woman's current age, time elapsed since the last birth, and parity are used to determine the risk categories in which any birth she conceived at the time of the survey would fall. For example, if a respondent who is age 40, has had four births and had her last birth 12 months ago were to become pregnant, she would fall in the multiple high-risk category of being too old, too high parity (four or more births), and giving birth too soon (less than 24 months) after a previous birth. Overall, the majority of currently married women (72 percent) have the potential of giving birth to a child at elevated risk of mortality. About one in three women has the potential for having a birth in a single high-risk category (mainly high birth order), while about 41 percent have the potential for having a birth in a multiple high-risk category (mainly older maternal age and high birth order). 124 | Infant and Child Mortality Table 10.6 High-risk fertility behavior Among children born in the five years preceding the survey, percent distribution by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Egypt 2008 Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women1 Not in any high risk category2 35.0 1.00 20.3a Unavoidable risk category First-order births between ages 18 and 34 years 30.0 1.32 8.1 Single high-risk category Mother’s age <18 2.5 2.93 0.5 Mother’s age >34 2.4 0.97 8.3 Birth interval <24 months 9.0 2.34 10.9 Birth order >3 12.1 1.49 11.5 Subtotal 25.9 1.88 31.1 Multiple high-risk category Age <18 and birth interval <24 months2 0.2 0.00 0.1 Age >34 and birth interval <24 months 0.1 7.54 0.3 Age >34 and birth order >3 6.0 2.68 32.8 Age >34 and birth interval <24 months and birth order >3 0.6 0.00 1.9 Birth interval <24 months and birth order >3 2.1 4.93 5.3 Subtotal 9.1 3.03 40.5 In any avoidable high-risk category 35.0 2.17 71.6 Total 100.0 na 100.0 Number of births 10,590 na 15,396 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women Maternal Health Care and Other Women’s Health Issues | 125 MATERNAL HEALTH CARE AND OTHER WOMEN’S HEALTH ISSUES 11 Using data from the 2008 EDHS, this chapter looks first at the extent to which women are obtaining medical care during pregnancy and at the time of delivery and the care that women and newborns received in the postpartum period. The chapter then presents trends across time in the key maternal care indicators using the results from the 2008 EDHS and earlier surveys. The chapter also considers the advice that women are receiving about breastfeeding and family planning during pregnancy and women’s exposure to media messages intended to promote safe pregnancy practices. Finally, the chapter assesses women’s knowledge of and recent experience with sexually transmitted infections. 11.1 PREGNANCY CARE The 2008 EDHS collected a range of information on the type of care that Egyptian women received during pregnancy, in- cluding information on antenatal care and tetanus toxoid vaccina- tions. The survey also obtained information on whether women had sought medical care during pregnancy for reasons not directly related to the pregnancy. Finally, women were also asked a number of questions about the nature of the care they received. 11.1.1 Antenatal Care Coverage Early and regular checkups by trained medical providers are very important in monitoring women’s health status during pregnancy. Table 11.1 presents data on the coverage of antenatal care services for births during the five-year period before the 2008 EDHS. A birth is considered to have received regular care if the mother said that she had made at least four antenatal care visits, i.e., a visit to a trained medical provider for care for the pregnancy. The results in Table 11.1 indicate that Egyptian women received antenatal care from a medical provider for 74 percent of the births that took place during the five-year period before the survey. Most women saw a doctor for care, with less than 1 per- cent reporting that they had received care only from a trained nurse or midwife. Antenatal care was obtained more than twice as often from a private sector provider as from a public sector pro- vider (55 percent and 19 percent, respectively). Table 11.1 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 antenatal (ANC) care was sought, the number of antenatal care visits, and the percent distribution of last births in the five- year period prior to the survey by the stage of pregnancy at the time of the first and last visits, Egypt 2008 Total ANC provider Doctor 73.3 Trained nurse/midwife 0.3 Birth attendant 0.0 Missing 0.0 No care 26.4 Source for ANC Public sector 19.1 Urban hospital 1.2 Urban health unit 5.0 Health office 0.7 Rural hospital 1.6 Rural health unit 7.4 MCH center 2.3 Other government 1.0 Private sector 54.5 Nongovernmental 0.3 Private medical 54.1 Other nonmedical 0.1 Don’t know/missing 0.0 No care 26.4 Number of ANC visits None 26.4 1 0.5 2 2.7 3 3.6 4+ 66.0 Don't know/missing 0.8 Total 100.0 Number of births 10,590 Median number of ANC visits 7.9 Number of months pregnant at time of first ANC visit No antenatal care 25.8 <4 61.1 4-5 10.1 6-7 2.4 8+ 0.5 Don't know/missing 0.1 Months pregnant at last ANC visit No antenatal care 25.8 < 6 months 1.2 6-7 months 3.0 8+ months 69.9 Don't know/missing 0.0 Total 100.0 Number of last births 7,896 126 | Maternal Health Care and Other Women’s Health Issues Women received regular antenatal care (i.e., they made four or more visits to a provider) for nearly two-thirds of births during the five years before the survey. Considering only those births for which care was received, the median number of antenatal visits was 7.9. Table 11.1 shows that most Egyptian mothers who received antenatal care began seeing a provider within the first six months of pregnancy. Mothers saw a provider for care for the first time before the sixth month of pregnancy for 96 percent of births for which antenatal care was reported (i.e., for 71 percent of all births). To detect problems that might affect the delivery, women should also see a provider during the last stages of pregnancy. Table 11.1 shows that, among women who received antenatal care, the majority (i.e., for 70 percent of all births) saw a provider in the eighth month of pregnancy or later. 11.1.2 Tetanus Toxoid Vaccinations Tetanus toxoid injections are given to women during pregnancy to prevent deaths from neonatal tetanus. Neonatal tetanus can result when sterile procedures are not followed in cutting the umbilical cord after delivery. To assess the tetanus toxoid coverage, information was collected for all births during the five-year period prior to the 2008 EDHS on the number of doses of tetanus toxoid vaccine the mother received during pregnancy and on the source(s) for the vaccinations. Table 11.2 shows that women received one dose of tetanus toxoid vaccine in the case of 40 percent of births during the five-year period before the 2008 EDHS, and two or more doses in the case of 41 percent of births. Mothers reported obtaining the injection from a public sector provider for 77 percent of all births, i.e., for more than nine in ten births in which a tetanus toxoid vaccina- tion was received. Table 11.2 also shows that a substantial minority (20 percent) of women had received at least one tetanus toxoid injection for the last birth although they had not gone to a provider for antenatal care. According to MOH guidelines, these women should have been encouraged by the provider from which they received the tetanus toxoid injection to go for ante- natal care; however, the majority—15 percent of women— indicated that they were not advised to obtain antenatal care. Finally, questions were included in the 2008 EDHS on a woman’s lifetime receipt of tetanus toxoid injections in order to ascertain if her last birth was fully protected from neonatal tetanus. An infant is considered to be fully protected if any of the following criteria are met: (1) the mother had two tetanus toxoid injections during the pregnancy; (2) the mother had a tetanus toxoid injection during the pregnancy plus an additional injection in the 10 years prior to the pregnancy; or (3) the mother did not have a tetanus toxoid injection during pregnancy but had at least five injections prior to the pregnancy. According to the EDHS results presented in Table 11.3, slightly more than three-quarters of last-born children during the five-year period before the survey were fully protected against neonatal tetanus. Table 11.2 Tetanus toxoid coverage during pregnancy 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 percent distribution of last births in the five-year period by whether mothers receiving a TT injection but no antenatal care (ANC) were advised during a TT visit to go for antenatal care, Egypt 2008 Total Number of doses None 18.8 One injection 39.5 Two or more injections 41.3 Don't know/missing 0.3 Source for TT injection Public sector 76.8 Urban hospital 2.2 Urban health unit 16.2 Health office 3.1 Rural hospital 7.9 Rural health unit 38.9 MCH center 7.9 Other government 0.6 Private sector 3.9 Nongovernmental 0.3 Private medical 3.6 Other nonmedical 0.0 Don’t know/missing 0.5 No injection 18.8 Total 100.0 Number of births 10,590 Advised to get antenatal care Had antenatal care 74.2 Had TT 60.1 No TT 14.1 Had TT but no ANC 19.6 Advised to seek ANC at TT visit 4.0 Not advised about ANC at TT visit 15.0 Missing/don’t know about ANC at TT visit 0.7 No ANC and no TT 6.1 Missing 0.1 Total 100.0 Number of last births 7,896 Maternal Health Care and Other Women’s Health Issues | 127 Table 11.3 Last birth protected against neonatal tetanus Percent distribution of last births during the five-year period before the survey by protection against neonatal tetanus, Egypt 2008 Total Protected 76.4 Two doses during pregnancy 37.7 One dose during pregnancy and one dose in 10-years before pregnancy 37.5 None but 5 or more lifetime doses 1.2 Unprotected 22.2 One dose during pregnancy but no other dose in 10 years before pregnancy 3.4 None and less than five lifetime doses 18.7 Don't know/missing 1.5 Total 100.0 Number of last births 7,896 11.1.3 Any Medical Care During Pregnancy The 2008 EDHS collected information about other medical consultations women may have had in addition to visits they made to a provider for pregnancy-related care for the last birth. Table 11.4 shows that only a small minority of women (7 percent) reported seeing a medical provider for care unrelated to their pregnancy. Most of these women had also seen a provider for antenatal care and/or a tetanus toxoid injection. The information on antenatal visits, tetanus toxoid immunizations, and medical consultations unrelated to the woman’s pregnancy is combined in Table 11.4 in order to assess the extent of the contacts women have with medical providers during pregnancy. The table shows that a large majority of women saw a medical provider for some type of care when they were pregnant with their last born child; only 6 percent neither had an antenatal care visit, received a tetanus toxoid injection nor saw a provider for other medical care. Table 11.4 Medical care other antenatal care or tetanus toxoid injection during pregnancy Percent distribution of last births during the five-year period before the survey by mother's report of seeing doctor or other health worker at any time during the pregnancy for care other than antenatal care (ANC) checkup or tetanus toxoid (TT) injection, according to mother's ANC and TT status, Egypt 2008 Other medical care during pregnancy ANC only ANC and TT injection TT injection only Neither ANC nor TT injection Total Had other care 0.9 3.2 1.9 0.5 6.5 No other care 13.2 56.9 17.7 5.6 93.5 Total 14.1 60.1 19.6 6.1 100.0 11.1.4 Differentials in Pregnancy Care Indicators Table 11.5 presents the differentials in pregnancy care indicators by selected background charac- teristics. Three of the indicators are presented for all births during the five-year period prior to the survey: the percentage for receiving any antenatal care, the percentage receiving regular antenatal care, and the percentage whose mother was given at least one tetanus toxoid injection. The table also presents 128 | Maternal Health Care and Other Women’s Health Issues differentials for three indicators for which information was collected only for the last birth: the percentage having a medical consultation unrelated to the pregnancy, the percentage consulting a medical provider for any reason (i.e., for ANC, for a TT injection, and/or for care unrelated to the pregnancy), and the percentage considered to be fully protected against neonatal tetanus. In general, mothers age 35 and over were slightly less likely to report receiving care than younger mothers. Although not uniform, the child’s birth order was negatively related to most of the pregnancy care indicators except medical care unrelated to pregnancy which increased with increasing birth order. Birth order differentials were especially large in the case of regular antenatal care, with mothers of first- order births being nearly twice as likely as mothers of sixth-order or higher births to have regular care. Table 11.5 Care during pregnancy by background characteristics Percentage of all births in the five-year period before the survey whose mother received any antenatal care (ANC) from a trained medical provider, regular antenatal care from a trained medical provider, and one or more tetanus toxoid (TT) injections, and percentage of last births during the five-year period before the survey whose mothers received other medical care unrelated to the pregnancy, whose mothers received any medical care during pregnancy and who were protected against neonatal tetanus, by selected background characteristics, Egypt 2008 Background characteristics Any ANC Regular ANC1 One or more TT injection(s) Number of births during five-year period before survey Medical care unrelated to the pregnancy Any medical care Protected against neonatal tetanus Number of last births Age at birth <20 72.9 64.4 89.8 1,235 7.3 96.1 83.9 727 20-34 74.3 66.8 81.3 8,392 6.2 95.1 77.9 6,294 35-49 68.4 60.3 64.9 963 7.5 87.2 59.3 874 Birth order 1 82.8 76.5 87.1 3,468 5.8 98.2 78.9 2,097 2-3 73.2 65.0 81.5 4,922 6.0 95.8 79.2 3,924 4-5 63.0 55.7 72.1 1,608 8.4 89.4 69.4 1,380 6+ 52.0 39.8 62.2 593 7.8 80.3 62.7 495 Urban-rural residence Urban 85.0 80.5 71.4 3,924 7.1 95.4 66.2 3,012 Rural 66.9 57.4 86.4 6,666 6.1 93.7 82.6 4,883 Place of residence Urban Governorates 89.2 85.1 68.0 1,679 8.7 96.0 62.8 1,294 Lower Egypt 75.0 67.7 84.8 4,587 3.3 95.2 81.3 3,500 Urban 82.8 79.9 73.2 1,011 3.6 94.3 69.3 794 Rural 72.8 64.2 88.0 3,576 3.2 95.4 84.8 2,706 Upper Egypt 65.9 56.4 82.0 4,173 9.2 92.9 76.7 2,990 Urban 81.8 75.4 74.4 1,141 8.0 96.0 68.1 854 Rural 59.9 49.2 84.8 3,032 9.7 91.7 80.2 2,136 Frontier Governorates 71.0 64.7 73.5 151 5.6 88.1 68.7 111 Education No education 54.6 45.0 81.5 2,735 6.9 89.4 77.6 1,997 Some primary 68.2 58.3 81.2 721 8.7 91.1 76.9 528 Primary complete/some secondary 74.1 64.6 81.4 1,624 7.0 94.8 78.0 1,239 Secondary complete/higher 83.6 77.7 80.3 5,510 5.8 97.1 75.2 4,132 Work status Working for cash 83.4 77.6 75.8 1,168 7.7 95.5 68.4 903 Not working for cash 72.4 64.5 81.5 9,422 6.3 94.2 77.4 6,993 Wealth quintile Lowest 53.5 41.4 83.1 2,145 8.1 89.6 79.0 1,525 Second 64.4 55.8 88.0 2,125 6.3 93.2 84.4 1,557 Middle 73.7 64.2 85.4 2,251 5.7 95.1 82.2 1,659 Fourth 85.7 80.8 81.5 2,113 5.4 96.3 77.4 1,626 Highest 92.4 89.8 64.6 1,956 7.0 97.4 58.1 1,528 Total 73.6 66.0 80.8 10,590 6.5 94.4 76.4 7,896 1 A woman is considered to have had regular antenatal care if she had four or more visits during the pregnancy. Maternal Health Care and Other Women’s Health Issues | 129 Urban mothers see medical providers for antenatal care during pregnancy more often than rural mothers. For example, mothers received regular antenatal care for 81 percent of urban births compared to 57 percent of rural births. On the other hand, rural mothers are more likely than urban mothers to receive tetanus toxoid injections during pregnancy. Births in rural Upper Egypt rank lowest on all of the pregnancy care indicators, except the measures of tetanus toxoid coverage. There is a generally positive association between the women’s education and wealth status and the various pregnancy care indicators. The relationships are particularly marked in the case of regular antenatal care. Among women who have a secondary or higher education, 78 percent have received regular antenatal care compared to 45 percent of women who have never attended school. Mothers in the highest wealth quintile are more than twice as likely as mothers in the lowest wealth quintile to have received regular care. 11.2 CONTENT OF PREGNANCY CARE In the 2008 EDHS, women who reported that they received antenatal care, tetanus toxoid injections, or other medical care unrelated to the pregnancy were asked whether they were weighed, had their blood pressure measured, and urine and blood samples taken during any of the visits they made to a medical provider during their pregnancy. These women were also asked whether 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 whether they were given or had bought iron tablets or syrup. Iron supplementation during pregnancy is recommended to prevent iron deficiency anemia, which is a common problem among pregnant women. Some caution must be exercised in considering the information in Table 11.6 since it depends on the mother’s understanding of the questions, e.g., her understanding of what blood pressure measurement involves. It also depends on the mother’s recall of events during visits to the provider that may have taken place a number of years before the 2008 EDHS interview. Nonetheless, the results are useful in providing insight into the content of the care Egyptian women receive during pregnancy. Table 11.6 shows that, for more than eight in ten last births for which mothers saw a medical provider during pregnancy, the women reported that they had been weighed or their blood pressure had been monitored during the visit to the provider. Mothers reported that urine and blood samples were taken in the case of around seven in ten births and 44 percent received or bought iron tablets or syrup. Mothers were advised about the complications that they might experience in 34 percent of the births and were told to seek assistance if they had problems in 31 percent of the births. The quality of the medical care that a woman received was better for mothers who saw a medical provider for antenatal care than for other mothers. Mothers who saw a provider for regular antenatal were the most likely to report that routine screening procedures were performed; for example, more than nine in ten mothers who had regular antenatal care were weighed and had their blood pressure monitored and around eight in ten had urine or blood samples taken. The proportions who reported receiving or being given iron supplement and who were advised about pregnancy complications were also higher for mothers who saw a provider for regular antenatal care than for other mothers. 130 | Maternal Health Care and Other Women’s Health Issues Table 11.6 Content of pregnancy care Percentage of last births in the five-year period before the survey whose mothers received any medical care during the pregnancy, by content of the care and selected background characteristics, Egypt 2008 Background characteristics Weighed Blood pressure measured Urine sample Blood sample taken Received/ bought iron tablets/ syrup Told about signs of compli- cations Told where to go if had any compli- cations Number of last births Medical care during pregnancy Had ANC 92.2 93.2 76.8 78.7 49.5 39.8 36.8 5,860 4 or more visits 92.8 94.3 77.8 79.4 50.1 41.5 38.5 5,252 1-3 visits 86.4 84.3 68.5 73.0 43.7 25.4 22.5 608 No ANC 70.3 63.5 39.6 40.7 22.3 13.3 11.2 1,589 TT or other care 71.3 64.1 40.0 41.3 22.2 13.5 11.5 1,550 No medical care/don’t know/ missing (30.3) (37.1) (25.3) (20.8) (24.4) (6.2) (2.2) 39 Type of ANC provider Public sector 96.3 94.9 84.8 85.3 52.9 38.3 34.4 1,498 Private sector 90.9 92.8 74.3 76.7 48.7 40.3 37.7 4,487 Both 94.4 96.6 82.1 86.5 63.6 42.2 38.7 124 No care/missing 70.3 63.5 39.7 40.8 22.3 13.4 11.3 1,589 Age at birth <20 90.1 88.2 72.4 76.2 40.5 34.4 31.4 699 20-34 87.6 87.1 68.8 70.2 43.9 34.0 31.2 5,989 35-49 84.3 84.5 66.6 68.9 44.2 35.1 32.7 762 Birth order 1 92.6 92.3 78.1 80.6 49.3 39.5 36.7 2,060 2-3 87.2 86.5 66.8 67.9 42.7 33.9 31.2 3,759 4-5 83.9 83.1 64.5 66.3 40.2 30.1 26.9 1,234 6+ 75.1 74.1 54.5 58.5 33.8 21.4 18.8 397 Urban-rural residence Urban 91.5 91.2 77.7 77.7 52.5 45.8 43.3 2,874 Rural 85.0 84.2 63.4 66.2 38.1 26.8 23.9 4,575 Place of residence Urban Governorates 94.3 92.4 84.8 85.4 62.9 52.8 50.3 1,242 Lower Egypt 87.9 88.9 64.0 65.0 35.4 25.7 23.7 3,331 Urban 90.3 92.2 67.1 66.3 35.7 29.6 27.7 748 Rural 87.2 88.0 63.1 64.6 35.3 24.6 22.6 2,582 Upper Egypt 84.0 82.1 67.5 70.8 45.0 35.7 31.8 2,779 Urban 88.6 88.9 76.9 77.1 52.6 50.3 47.3 820 Rural 82.0 79.2 63.6 68.1 41.8 29.6 25.3 1,959 Frontier Governorates 88.5 84.6 73.1 71.1 42.3 39.8 39.3 98 Education No education 81.5 78.7 60.9 64.3 35.6 26.1 23.1 1,784 Some primary 84.7 84.4 65.1 68.7 37.6 27.8 24.9 481 Primary comp./some secondary 87.9 87.1 67.7 69.5 43.1 31.4 28.6 1,175 Secondary complete/higher 90.4 90.8 73.2 74.0 48.1 39.3 36.6 4,010 Work status Working for cash 89.3 89.5 73.1 75.5 49.5 41.0 38.8 863 Not working for cash 87.3 86.5 68.3 70.0 42.9 33.2 30.4 6,587 Wealth quintile Lowest 81.7 76.7 60.3 64.2 35.3 23.2 20.2 1,366 Second 83.6 83.1 63.6 66.4 37.2 26.4 23.7 1,451 Middle 86.2 86.4 66.4 69.2 38.1 28.9 25.9 1,578 Fourth 92.3 92.7 74.6 73.9 46.8 38.5 35.3 1,566 Highest 93.1 94.4 78.6 78.8 60.1 52.6 50.7 1,489 Total 87.5 86.9 68.9 70.6 43.7 34.1 31.4 7,450 Note: Figures in parentheses are based on 25-49 unweighted cases. Maternal Health Care and Other Women’s Health Issues | 131 The content of the care women received varies according to the other demographic and socioeconomic characteristics shown in Table 11.6. For example, there is a negative association between the proportions reporting routine antenatal care procedures and the child’s birth order. In general, the procedures were more likely to have been performed for urban than for rural births, with particularly low levels found for births in rural Upper Egypt. The likelihood that the routine antenatal care procedures shown in Table 11.6 were carried out increases with both education and wealth. The procedures are also more common among births to women who worked for cash than for births to other women. 11.3 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 child. For all births in the five-year period before the survey, the 2008 EDHS collected information on where the birth occurred and on whether the mother was assisted at delivery by trained medical personnel. For births occurring in health facilities, a question was also asked about the time that the mother spent in the facility following the delivery. For mothers who did not give birth in a health facility, information was obtained on the reasons these women did not deliver in a facility. All mothers were also asked about whether or not the birth was by caesarean section and several questions about the child’s weight at birth. 11.3.1 Place of Delivery Slightly more than seven in ten births in the five-year period before the survey occurred in a health facility (Table 11.7). The majority of women delivering in a facility (55 percent) spent less than 24 hours in the facility after giving birth, and 40 percent reported they spent less than 6 hours at the facility after the birth. Table 11.7 shows that, as expected, births to women who had antenatal care were much more likely to take place in a health facility than other births. Moreover, among births in which the mother had received antenatal care, deliveries were less likely to occur in a health facility if the mother had three or fewer antenatal visits prior to the birth than if she had had more regular care (62 percent and 82 percent, respectively). Table 11.7 also shows that the likelihood of the delivery outside a facility was greatest for births of order six or higher, rural births, especially births in rural Upper Egypt, and births to women with no education. Women in the lowest wealth quintile were most likely to have had a home delivery; fewer than half of the births to women in the quintile took place in a health facility. Regarding the type of health facility, the majority of facility deliveries (45 percent of all births) occurred in private health facilities. Births to mothers in the highest wealth quintile were most likely to have been delivered in a private facility (70 percent). 132 | Maternal Health Care and Other Women’s Health Issues Table 11.7 Place of delivery and time spent in health facility following delivery by background characteristics Percent distribution of births in the five-year period before the survey by place where the mother gave birth and, among births delivered in health facilities, the percent distribution by time mothers spent in the facility after the delivery, according to selected background characteristics, Egypt 2008 Less than one day Health facility Background characteristics Any Public Private At own/ other home Other/ missing Total Number of births 0-5 hours 6-23 hours 1-2 days 3 or more days Don't know/ missing Total Number of births delivered in health facility Antenatal care during pregnancy Had ANC 80.2 27.6 52.6 19.8 0.0 100.0 7,813 38.2 15.2 35.3 10.8 0.4 100.0 6,265 1-3 visits 61.9 25.9 36.1 37.9 0.2 100.0 852 50.4 13.2 27.3 8.6 0.5 100.0 528 4 or more visits 82.4 27.9 54.6 17.6 0.0 100.0 6,960 37.1 15.4 36.1 11.0 0.3 100.0 5,737 No ANC/don’t know/ missing 47.9 24.9 23.0 52.0 0.1 100.0 2,777 47.9 14.3 27.5 9.9 0.4 100.0 1,331 Age at birth <20 69.8 26.1 43.7 30.2 0.0 100.0 1,235 43.9 15.2 29.6 10.7 0.6 100.0 863 20-34 71.8 26.7 45.2 28.1 0.0 100.0 8,392 40.1 15.0 34.4 10.1 0.4 100.0 6,027 35-49 73.4 30.1 43.3 26.4 0.2 100.0 963 33.3 16.0 35.3 15.3 0.1 100.0 707 Birth order 1 81.5 28.9 52.5 18.5 0.0 100.0 3,468 36.3 15.8 37.2 10.0 0.6 100.0 2,825 2-3 71.2 26.7 44.5 28.8 0.0 100.0 4,922 40.8 14.6 33.5 10.9 0.2 100.0 3,505 4-5 59.1 24.8 34.3 40.8 0.1 100.0 1,608 45.2 14.4 29.2 11.1 0.1 100.0 951 6+ 53.3 22.4 30.9 46.6 0.1 100.0 593 47.4 15.8 24.1 12.3 0.4 100.0 316 Urban-rural residence Urban 85.5 33.5 52.0 14.5 0.0 100.0 3,924 34.7 16.3 38.3 10.5 0.2 100.0 3,356 Rural 63.6 23.0 40.6 36.3 0.1 100.0 6,666 44.1 14.1 30.5 10.8 0.5 100.0 4,241 Place of residence Urban Governorates 89.4 40.0 49.4 10.6 0.0 100.0 1,679 31.5 18.8 40.4 9.0 0.2 100.0 1,501 Lower Egypt 78.1 23.1 55.1 21.8 0.1 100.0 4,587 40.1 13.5 35.0 10.8 0.5 100.0 3,584 Urban 87.5 24.6 62.8 12.5 0.0 100.0 1,011 32.6 13.8 40.9 12.5 0.1 100.0 884 Rural 75.5 22.6 52.9 24.4 0.1 100.0 3,576 42.6 13.4 33.1 10.3 0.6 100.0 2,700 Upper Egypt 57.5 25.3 32.2 42.4 0.0 100.0 4,173 44.3 15.2 28.7 11.5 0.3 100.0 2,401 Urban 78.5 30.9 47.6 21.5 0.0 100.0 1,141 40.5 14.8 33.1 11.2 0.4 100.0 896 Rural 49.7 23.2 26.4 50.3 0.0 100.0 3,032 46.6 15.4 26.1 11.7 0.3 100.0 1,506 Frontier Governorates 72.9 43.3 29.6 27.1 0.0 100.0 151 51.9 12.9 26.4 8.1 0.8 100.0 110 Education No education 51.5 24.0 27.5 48.4 0.1 100.0 2,735 43.7 15.7 27.5 12.6 0.5 100.0 1,409 Some primary 62.8 35.7 27.0 37.2 0.0 100.0 721 39.2 20.5 29.0 10.5 0.8 100.0 452 Primary complete/ some secondary 72.3 32.8 39.5 27.7 0.0 100.0 1,624 43.6 16.3 29.0 10.7 0.4 100.0 1,174 Secondary complete/ higher 82.8 25.5 57.3 17.2 0.0 100.0 5,510 37.9 14.0 37.7 10.0 0.3 100.0 4,561 Work status Working for cash 83.9 29.4 54.4 16.0 0.1 100.0 1,168 30.1 13.2 40.4 16.3 0.1 100.0 979 Not working for cash 70.2 26.6 43.6 29.7 0.0 100.0 9,422 41.4 15.4 33.0 9.8 0.4 100.0 6,617 Wealth quintile Lowest 45.4 22.4 23.0 54.6 0.0 100.0 2,145 44.9 18.0 23.4 13.2 0.4 100.0 973 Second 61.7 27.0 34.7 38.2 0.1 100.0 2,125 45.2 12.8 29.2 12.1 0.8 100.0 1,311 Middle 74.0 29.7 44.4 25.9 0.1 100.0 2,251 43.0 14.7 31.9 10.0 0.4 100.0 1,667 Fourth 85.0 30.9 54.1 15.0 0.0 100.0 2,113 39.2 14.4 36.4 9.9 0.2 100.0 1,795 Highest 94.6 24.4 70.2 5.4 0.0 100.0 1,956 31.6 16.2 42.4 9.6 0.2 100.0 1,850 Total 71.7 26.9 44.8 28.2 0.0 100.0 10,590 39.9 15.1 34.0 10.7 0.4 100.0 7,597 Maternal Health Care and Other Women’s Health Issues | 133 Women who did not deliver the last birth in a health facility were asked about the reason(s) for not going to a facility for the delivery. Table 11.8 shows that the majority (63 percent) reported that they had not considered it ‘necessary’ to deliver in a facility. An additional 11 percent gave as a reason that facility deliveries were not the custom, 23 percent cited the cost of a facility delivery, and 7 percent mentioned poor quality of services at facilities. Table 11.8 Reason for not delivering last birth in health facility Percentage of last births in the five-year period before the survey whose mothers did not deliver in a health facility according to the reason for not giving birth in a facility, Egypt 2008 Reason Number of births Costs too much 23.4 Facility not open 2.5 Too far/no transport 2.1 Poor quality service 6.5 No female provider 0.5 Husband/family did not allow 1.5 Not necessary 62.9 Not customary 11.3 Sudden delivery 6.1 Other 1.3 Total 2,182 11.3.2 Assistance at Delivery Table 11.9 presents information on the person assisting with the delivery for all births during the five years before the survey. If the mother was assisted at delivery by more than one individual, only the most qualified is shown in the table. Doctors (74 percent) or trained nurses or midwives (5 percent) assisted at delivery of the majority of births in the five-year period before the survey. Most of the remaining births were assisted by dayas (traditional birth attendants). Twenty-six percent of births which took place outside of a health facility were assisted by trained medical personnel. Antenatal care, particularly regular antenatal care, is strongly associated with the likelihood that births will be medically assisted. Considering other characteristics, medically-assisted deliveries were most common for urban births, particularly those in the Urban Governorates and in urban Lower Egypt, births to highly educated mothers, and births to mothers in the highest wealth quintile. Dayas were most likely to assist at delivery when the birth was of order six or higher, the mother lived in rural Upper Egypt, the mother never attended school or the mother was in the lowest wealth quintile. 134 | Maternal Health Care and Other Women’s Health Issues Table 11.9 Assistance during delivery by background characteristics Percent distribution of live births in the five years preceding the survey by type of assistance during delivery, according to selected background characteristics, Egypt 2008 Assisted by medical provider Background characteristics Any Doctor Trained nurse/ midwife Daya Relative/ other No one Total Number of births Antenatal care during pregnancy Had ANC 86.3 82.0 4.3 12.5 0.7 0.4 100.0 7,813 1-3 visits 72.5 64.8 7.7 25.2 1.3 1.0 100.0 852 4 or more visits 88.0 84.1 3.9 11.0 0.7 0.4 100.0 6,960 No ANC/don’t know/missing 57.9 53.0 4.9 39.9 1.2 1.0 100.0 2,777 Place of delivery Health facility 99.6 99.3 0.3 0.1 0.2 0.1 100.0 7,597 Not in health facility 26.2 11.2 15.1 69.5 2.6 1.7 100.0 2,994 Age at birth <20 76.2 72.2 4.0 22.6 0.6 0.6 100.0 1,235 20-34 79.1 74.5 4.6 19.6 0.8 0.5 100.0 8,392 35-49 80.0 76.1 3.9 17.0 1.5 1.5 100.0 963 Birth order 1 87.1 83.6 3.4 12.2 0.5 0.2 100.0 3,468 2-3 78.4 73.6 4.8 20.2 0.8 0.5 100.0 4,922 4-5 68.9 63.0 5.9 28.5 1.5 1.2 100.0 1,608 6+ 61.3 57.5 3.8 35.1 1.7 1.8 100.0 593 Urban-rural residence Urban 90.2 86.8 3.3 9.1 0.4 0.4 100.0 3,924 Rural 72.2 67.1 5.1 25.9 1.2 0.7 100.0 6,666 Place of residence Urban Governorates 92.3 90.3 2.0 7.2 0.2 0.3 100.0 1,679 Lower Egypt 85.3 80.9 4.4 13.9 0.5 0.4 100.0 4,587 Urban 92.0 89.9 2.1 7.1 0.4 0.5 100.0 1,011 Rural 83.4 78.4 5.0 15.7 0.5 0.4 100.0 3,576 Upper Egypt 66.4 60.8 5.6 31.3 1.4 0.8 100.0 4,173 Urban 85.6 79.3 6.3 13.5 0.4 0.5 100.0 1,141 Rural 59.2 53.8 5.3 38.0 1.8 1.0 100.0 3,032 Frontier Governorates 79.1 75.0 4.1 14.0 4.0 2.9 100.0 151 Education No education 59.7 55.0 4.7 37.7 1.5 1.0 100.0 2,735 Some primary 73.1 67.0 6.2 24.2 1.7 1.0 100.0 721 Primary complete/ some secondary 79.3 74.4 4.9 19.1 0.8 0.8 100.0 1,624 Secondary complete/higher 89.0 85.0 4.0 10.3 0.5 0.2 100.0 5,510 Work status Working for cash 89.8 85.5 4.3 9.1 0.7 0.4 100.0 1,168 Not working for cash 77.5 73.0 4.5 21.0 0.9 0.6 100.0 9,422 Wealth index Lowest 55.2 49.2 5.9 41.4 2.1 1.4 100.0 2,145 Second 70.1 65.0 5.1 28.1 1.1 0.6 100.0 2,125 Middle 82.8 77.2 5.7 16.5 0.3 0.4 100.0 2,251 Fourth 90.7 86.8 3.9 8.3 0.6 0.3 100.0 2,113 Highest 96.9 95.6 1.3 2.7 0.1 0.2 100.0 1,956 Total 78.9 74.4 4.5 19.7 0.9 0.6 100.0 10,590 Maternal Health Care and Other Women’s Health Issues | 135 11.3.3 Caesarean Deliveries The 2008 EDHS obtained information on the frequency of caesarean sections. This information can be compared with findings from earlier rounds of the DHS survey in Egypt to assess trends over time in Caesarean deliveries. Table 11.10 shows that more than one-quarter of deliveries in the five-year period before the 2008 EDHS survey were by caesarean section. Women delivering in a private health facility were slightly more likely than women delivering in a government facility to have a Caesarean delivery. The likelihood of a Caesarean delivery increased with the age of the mother and decreased with the child’s birth order. Thirty-seven percent of urban births were Caesarean deliveries compared to 22 percent of rural births. Considering place of residence, urban Lower Egypt had the highest proportion of Caesarean deliveries (43 percent) followed by the Urban Governorates (39 percent). The likelihood of a Caesarean delivery increased with both the mother’s educa- tional status and was greater among women working for cash than among other women. The rate of Caesarean deliveries peaked at 45 percent among women in the highest wealth quintile compared to 14 percent among women in the lowest quintile. 11.3.4 Birth Weight Mothers were able to provide a birth weight for only 42 percent of babies. Among those births, Table 11.11 shows that 11 percent were classified as low birth weight; i.e., they weighed less than 2.5 kilograms at birth. Table 11.11 also includes information on the mother’s assessment of the baby’s size at birth. It is impor- tant to remember that this assessment is based on the mother’s own perception of what is a small, average, or large baby and not on a uniform definition. Only 3 percent of mothers considered their babies as very small while an additional 10 percent reported that their babies were smaller than average. Looking at the variation by background characteristics, there are only relatively minor differences in both the proportion of babies weighing less than 2.5 kilograms and the proportion of births regarded as small or as smaller than average. Table 11.10 Caesarean deliveries by background characteristics Percentage of births in the five-year period before the survey that were delivered by caesarean section, according to selected back- ground characteristics, Egypt 2008 Background characteristics Caesarean delivery Place of delivery Public health facility 33.2 Private health facility 41.7 At home/don’t know/missing na Age at birth <20 23.0 20-34 27.8 35-49 32.0 Birth order 1 33.4 2-3 27.8 4-5 19.6 6+ 14.0 Urban-rural residence Urban 37.1 Rural 22.0 Place of residence Urban Governorates 38.5 Lower Egypt 30.9 Urban 43.2 Rural 27.4 Upper Egypt 19.9 Urban 30.9 Rural 15.8 Frontier Governorates 20.0 Education No education 17.8 Some primary 18.4 Primary complete/some secondary 24.9 Secondary complete/higher 34.5 Work status Working for cash 42.3 Not working for cash 25.8 Wealth index Lowest 13.6 Second 19.2 Middle 26.2 Fourth 35.8 Highest 44.9 Total 27.6 na = Not applicable 136 | Maternal Health Care and Other Women’s Health Issues Table 11.11 Child's size at birth by background characteristics Among births in the five years preceding the survey, percentage with a reported birth weight, the percent distribution of births with a reported birth weight by the birth weight and, among births in the five years preceding the survey, the percent distribution by the mother's estimate of the baby's size at birth, according to background characteristics, Egypt 2008 Birth weight among births with reported weight Child's size among all live births Background characteristics Percentage of births with reported birth weight Less than 2.5 kg 2.5 kg/ more Total percent Number of births Very small Smaller than average Average or larger Don't know/ missing Total percent Number of births Age at birth <20 37.6 11.6 88.4 100.0 465 4.4 10.6 84.8 0.2 100.0 1,235 20-34 41.9 11.2 88.8 100.0 3,519 3.0 9.5 87.0 0.5 100.0 8,392 35-49 45.0 9.6 90.4 100.0 433 4.3 8.9 86.5 0.3 100.0 963 Birth order 1 46.6 11.1 88.9 100.0 1,616 3.7 10.4 85.3 0.7 100.0 3,468 2-3 41.5 10.7 89.3 100.0 2,044 2.7 9.2 87.8 0.3 100.0 4,922 4-5 35.3 12.1 87.9 100.0 567 3.7 8.4 87.6 0.3 100.0 1,608 6+ 32.0 12.9 87.1 100.0 189 4.8 11.0 83.7 0.4 100.0 593 Urban-rural residence Urban 56.2 12.0 88.0 100.0 2,207 3.3 10.7 85.7 0.3 100.0 3,924 Rural 33.1 10.2 89.8 100.0 2,210 3.3 8.9 87.3 0.5 100.0 6,666 Place of residence Urban Governorates 68.4 12.4 87.6 100.0 1,148 3.1 10.3 86.4 0.3 100.0 1,679 Lower Egypt 36.7 9.1 90.9 100.0 1,684 2.6 7.1 89.8 0.5 100.0 4,587 Urban 44.3 7.9 92.1 100.0 448 2.9 7.8 89.1 0.3 100.0 1,011 Rural 34.6 9.5 90.5 100.0 1,236 2.6 6.9 90.0 0.6 100.0 3,576 Upper Egypt 36.3 12.5 87.5 100.0 1,516 4.1 12.1 83.5 0.3 100.0 4,173 Urban 49.1 14.9 85.1 100.0 560 3.8 13.9 82.0 0.2 100.0 1,141 Rural 31.5 11.1 88.9 100.0 955 4.2 11.4 84.1 0.4 100.0 3,032 Frontier Governorates 45.5 7.7 92.3 100.0 69 4.0 9.0 85.9 1.1 100.0 151 Education No education 27.9 10.2 89.8 100.0 763 3.5 9.4 86.4 0.8 100.0 2,735 Some primary 30.7 15.3 84.7 100.0 222 4.9 12.0 82.9 0.3 100.0 721 Primary complete/ some secondary 38.8 11.3 88.7 100.0 630 3.8 11.1 85.0 0.0 100.0 1,624 Secondary complete/ higher 50.8 11.0 89.0 100.0 2,801 2.8 8.9 87.9 0.4 100.0 5,510 Work status Working for cash 53.1 11.5 88.5 100.0 621 2.9 9.9 86.9 0.3 100.0 1,168 Not working for cash 40.3 11.0 89.0 100.0 3,796 3.3 9.5 86.7 0.4 100.0 9,422 Wealth index Lowest 26.4 10.7 89.3 100.0 566 3.8 11.1 84.4 0.7 100.0 2,145 Second 28.7 13.8 86.2 100.0 609 3.1 9.3 87.2 0.4 100.0 2,125 Middle 38.7 13.2 86.8 100.0 871 3.7 9.1 86.9 0.3 100.0 2,251 Fourth 50.2 11.2 88.8 100.0 1,060 3.4 8.5 87.6 0.5 100.0 2,113 Highest 67.0 8.5 91.5 100.0 1,311 2.3 9.9 87.6 0.2 100.0 1,956 Total 41.7 11.1 88.9 100.0 4,417 3.3 9.6 86.7 0.4 100.0 10,590 11.4 TRENDS IN ANTENATAL AND DELIVERY CARE INDICATORS Table 11.12 and Figure 11.1 present trends in antenatal and delivery care indicators by residence for the 20-year period between the 1988 and 2008 EDHS surveys. The table documents upward trends in all of the indicators, with the trend in tetanus toxoid coverage being particularly notable. Overall, there was a more than sevenfold increase in the percentage of births for which the mother received at least one tetanus toxoid injection, from 11 percent at the time of the 1988 EDHS to the current level of 81 percent. Maternal Health Care and Other Women’s Health Issues | 137 During the period between the 1988 and 2008 surveys, there were also substantial gains in antenatal care coverage and in the proportion of medically assisted deliveries. Regarding the latter indicator, Table 11.12 shows that only slightly more than one-third of births were medically assisted at the time of the 1988 survey. By the time of the 2008 survey, this proportion had climbed to just under 80 percent. All residential categories shared in the improvements in maternal health indicators. Rural areas, however, continue to lag behind urban areas in both antenatal care coverage and in medically assisted deliveries. Table 11.12 Trends in maternal health indicators by residence Percentage of births in the five years preceding the survey whose mothers had antenatal care from a doctor or trained nurse/midwife, four or more antenatal care visits, at least one tetanus toxoid injection, were assisted at delivery by a medical provider, and were delivered by caesarean section by urban-rural residence and place of residence, Egypt 1988-2008 Lower Egypt Upper Egypt Maternal health indicator Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Any antenatal care 1988 na na na na na na na na na na na 1992 na na na na na na na na na na na 1995 58.3 27.2 59.2 41.9 65.2 34.5 28.6 51.2 20.8 41.4 39.1 2000 70.4 41.9 74.1 53.5 71.2 47.2 44.3 65.1 36.9 44.6 52.9 2005 82.2 62.1 84.0 78.0 88.4 74.7 57.5 75.8 50.6 68.1 69.6 2008 85.0 66.9 89.2 75.0 82.8 72.8 65.9 81.8 59.9 71.0 73.6 Regular antenatal care1 1988 na na na na na na na na na na na 1992 na na na na na na na na na na na 1995 50.0 14.9 55.1 27.9 52.0 20.2 17.9 40.6 10.1 na 28.3 2000 53.9 25.9 56.0 38.9 56.2 32.8 27.2 49.8 19.2 28.5 36.7 2005 74.8 49.2 78.9 66.7 80.8 62.2 45.0 65.8 37.3 59.1 58.5 2008 80.5 57.4 85.1 67.7 79.9 64.2 56.4 75.4 49.2 64.7 66.0 Tetanus toxoid injection 1988 12.6 10.6 8.8 13.1 14.8 12.5 11.1 17.3 8.6 na 11.4 1992 56.9 57.5 52.0 64.0 67.8 62.7 53.3 55.3 52.8 na 57.8 1995 66.7 71.2 64.2 75.6 70.2 77.4 66.3 67.6 65.9 59.8 69.5 2000 70.1 73.9 62.4 79.1 75.3 80.4 70.0 75.4 68.1 64.2 72.4 2005 70.3 83.2 65.2 81.9 73.4 84.5 79.9 73.4 82.3 69.6 78.5 2008 71.4 86.4 68.0 84.8 73.2 88.0 82.0 74.4 84.8 73.5 80.8 Medically assisted delivery 1988 57.0 19.1 64.9 31.1 54.4 23.3 23.9 46.9 14.4 na 34.6 1992 62.5 27.5 68.3 39.7 62.9 32.5 29.7 51.8 23.0 na 40.7 1995 67.9 32.8 69.2 51.4 75.1 43.9 32.2 59.6 22.9 59.3 46.3 2000 81.4 48.0 83.7 65.1 84.7 58.1 47.8 74.7 38.2 60.4 60.9 2005 88.7 65.8 90.7 81.6 92.9 78.0 62.6 83.8 54.8 71.8 74.2 2008 90.2 72.2 92.3 85.3 92.0 83.4 66.4 85.6 59.2 79.1 78.9 Caesarean deliveries 1988 na na na na na na na na na na na 1992 na na na na na na na na na na na 1995 10.7 4.2 12.3 7.3 11.3 6.1 3.8 7.9 2.4 3.4 6.6 2000 16.7 6.3 19.3 11.2 17.7 8.9 6.1 12.6 3.8 5.3 10.3 2005 29.2 14.6 33.8 24.5 34.9 21.2 11.8 20.4 8.6 14.3 19.9 2008 37.1 22.0 38.5 30.9 43.2 27.4 19.9 30.9 15.8 20.0 27.6 na = Not available 1 A woman is considered to have had regular antenatal care if she had 4 or more visits during the pregnancy. Source: El-Zanaty and Way, 2006, Table 11.12 138 | Maternal Health Care and Other Women’s Health Issues As the proportion of medically-assisted deliveries increased, Table 11.12 also shows that there has been a substantial rise in the proportions of births reported by the mother to have been delivered by Caesarean section.1 Caesarean deliveries were more than four times as common in 2008 as in 1995. Although increases in the proportions of Caesarean deliveries were observed in all residential categories between 1995 and 2008, Caesarean deliveries continued to be much more common in urban than in rural areas. 11.5 POSTNATAL CARE Care after delivery is very important for both the mother and her child. Proper care after delivery is especially important for births occurring in the home. The Ministry of Health recommends several visits for postnatal care. The first visit should occur within two days of delivery, and the last at 40 days. In addition there should be at least two other visits, one at seven days after delivery and another at 15 days. 11.5.1 Postnatal Checkup for the Mother Both women delivering in health facilities and those delivering outside of facilities were asked questions about the receipt of postnatal care. Women giving birth in a health facility were asked if a provider checked on their health after they delivered before they were discharged and, if not, whether they had seen someone for a postnatal checkup after they were discharged from the facility. It is possible that women delivering in a facility may not have remembered or recognized that a postnatal checkup was conducted during their stay in the facility. However, it is felt that most women could accurately report on whether they were seen by a provider for a checkup before discharge and that this approach to collecting 1The same question was used in all of the EDHS surveys to collect information on the prevalence of Caesarean deliveries. However, it is possible that as the proportion of all births occurring in health facilities increased over the period covered by the surveys, a somewhat greater number of women may have misunderstood the reference to Caesarean birth. 39 28 70 46 7 53 37 72 61 10 70 59 79 74 20 74 66 81 79 28 Any antenatal care Regular antenatal care Tetanus toxoid injection Medically assisted delivery Caesarean delivery 0 20 40 60 80 100 Percent 1995 2000 2005 2008 Figure 11.1 Trends in Maternal Health Indicators Egypt 1995-2008 Percentage of births in the five years before the survey Maternal Health Care and Other Women’s Health Issues | 139 the information is preferable to an assumption that all women delivering in a health facility had a postnatal checkup.2 Table 11.13 presents the percent distribution of all births during the five-year period before the survey by whether or not the mother received postnatal care and, if so, the type of provider. The table also shows the source of postnatal care and tim- ing of the first postnatal checkup. Overall, women reported they had a postnatal check- up in the case of 66 percent of all births during the five-year period before the sur- vey. Postpartum care is largely confined to births assisted by a medical provider; post- natal checkups were reported by mothers of 82 percent of the births assisted at delivery by a health provider (largely a doctor) during the five-year period prior to the survey. Mothers rarely reported receiving postnatal care when the birth was assisted by a daya or other person (8 percent). Table 11.13 also shows that most mothers who had a postnatal checkup saw a medical provider for the care. Among last births during the five-year period prior to the survey, postnatal checkups took place more often in private facilities than in facilities operated by the government. With regard to the timing of postnatal checkups, mothers saw a provider for the checkup within two days of the delivery for almost all last births for which any postnatal care was reported. Table 11.14 presents differentials in postnatal care indicators for the last birth during the five-year period before the survey. The table shows that the likelihood of receiving postnatal care did not vary markedly with age, but declined with the child’s birth order. Postnatal care was more common for urban than rural mothers, with mothers living in rural Upper Egypt were least likely to report receiving postnatal care. The percentages of mothers who had postnatal care increased with both education level and the wealth quintile. 2 The latter assumption was made in the 2000 EDHS and 2003 EIDHS surveys and, thus, the results of the current survey are not comparable to the findings published in the reports for those surveys. Table 11.13 Postnatal care for mother Percent distribution of births during the five-year period before the survey by type of provider and percentage distribution of last births by source of the first medical postnatal checkup for mother and timing of first postnatal care checkup, according to the type of assistance at delivery, Egypt 2008 Postnatal care Medically assisted births Births assisted by daya/ other/ no one All births Provider of postnatal care Doctor 81.2 6.7 65.5 Trained nursemidwife 0.7 0.3 0.6 Daya 0.0 0.5 0.1 Don't know/missing 0.0 0.3 0.1 No postnatal care 18.0 92.2 33.7 Total 100.0 100.0 100.0 Number of births 8,352 2,238 10,590 Source for first postnatal checkup Health facility 82.2 6.1 66.9 Public sector 30.2 2.9 24.7 Private sector 52.0 3.3 42.2 At own/other home 0.2 1.0 0.4 Don’t know/missing 0.0 0.5 0.1 No postnatal care 17.5 92.3 32.6 Total 100.0 100.0 100.0 Number of last births 6,304 1,592 7,896 Timing of first postnatal checkup Within 2 days of delivery 80.5 1.5 64.6 Less than 4 hours 65.3 0.8 52.3 4-23 hours 11.8 0.2 9.5 24-48 hours 3.3 0.5 2.8 3-7 days after delivery 0.8 2.2 1.1 8-27 days after delivery 0.2 0.5 0.3 28-41 days after delivery 0.3 2.1 0.7 42 days or more after delivery 0.2 0.9 0.3 Don't know/missing 0.5 0.4 0.5 No care 17.5 92.3 32.6 Total 100.0 100.0 100.0 Number of last births 6,304 1,592 7,896 140 | Maternal Health Care and Other Women’s Health Issues Table 11.14 Postnatal care for mother by background characteristics Percentage of last births during the five-year period before the survey whose mother had any postnatal care and whose mother had a postnatal checkup within two days of the delivery, according to the type of assistance at delivery, and selected background characteristics, Egypt 2008 Medically assisted births Births assisted by daya/other/no one All births Background characteristics Had any postnatal care1 Had postnatal checkup within 2 days after delivery Number of last births assisted by health providers Had any postnatal care1 Had postnatal checkup within 2 days after delivery Number of last births assisted by daya/ other/ no one Had any postnatal care1 Had postnatal checkup within 2 days after delivery Number of last births Age at birth <20 81.6 79.3 577 7.0 0.8 150 66.2 63.1 727 20-34 82.2 80.2 5,024 7.1 1.5 1,270 67.0 64.3 6,294 35-49 84.9 83.3 703 6.4 2.2 171 69.6 67.4 874 Birth order 1 86.1 83.7 1,870 5.7 1.1 227 77.4 74.7 2,097 2-3 82.5 80.6 3,157 7.7 1.2 767 67.9 65.1 3,924 4-5 77.7 76.6 971 6.4 2.1 408 56.6 54.5 1,380 6+ 74.6 72.3 305 7.3 1.8 190 48.8 45.3 495 Urban-rural residence Urban 88.9 87.0 2,731 8.8 2.2 281 81.4 79.1 3,012 Rural 77.5 75.5 3,573 6.6 1.4 1,310 58.5 55.6 4,883 Place of residence Urban Governorates 91.3 89.6 1,197 9.7 0.0 97 85.2 83.0 1,294 Lower Egypt 82.5 81.1 2,981 7.5 2.2 519 71.4 69.4 3,500 Urban 88.6 87.4 728 11.2 5.6 66 82.2 80.7 794 Rural 80.5 79.1 2,253 6.9 1.6 454 68.2 66.1 2,706 Upper Egypt 77.1 74.1 2,036 6.5 1.3 955 54.6 50.9 2,990 Urban 85.9 82.9 744 6.8 1.8 111 75.7 72.4 854 Rural 72.1 69.0 1,292 6.5 1.2 844 46.2 42.2 2,136 Frontier Governorates 81.8 80.5 90 6.9 2.4 21 67.6 65.7 111 Education No education 73.7 72.1 1,225 5.6 1.1 772 47.4 44.7 1,997 Some primary 76.0 73.2 389 9.7 2.3 138 58.6 54.6 528 Primary complete/ some secondary 82.8 80.3 993 7.8 1.8 247 67.8 64.7 1,239 Secondary complete/ higher 85.9 84.1 3,697 8.3 1.8 435 77.7 75.4 4,132 Work status Working for cash 85.9 83.9 814 10.9 3.6 89 78.6 76.0 903 Not working for cash 81.9 80.0 5,490 6.8 1.4 1,503 65.8 63.1 6,993 Wealth quintile Lowest 70.4 67.7 865 5.9 1.1 660 42.5 38.9 1,525 Second 77.5 75.5 1,096 7.2 1.5 461 56.7 53.6 1,557 Middle 79.2 77.4 1,388 6.1 1.1 271 67.2 64.9 1,659 Fourth 85.5 83.8 1,475 11.0 2.9 151 78.6 76.3 1,626 Highest 93.1 91.2 1,480 (13.8) (5.2) 48 90.6 88.5 1,528 Total 82.4 80.5 6,304 7.0 1.5 1,592 67.2 64.6 7,896 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes postnatal checkup occurring at any time following the child's birth including checkups taking place 42 or more days after the birth. 11.5.2 Postnatal Checkup for the Baby Women giving birth during the five-year period before the survey were asked whether or not the child had had a postnatal checkup for each birth they had during the period. In addition, information was collected for the last birth the woman had during the five-year period on the source where the postnatal checkup occurred and the timing of the first checkup following delivery. A question was also included for all last-born children about whether or not a blood sample had been taken from the child’s heel. The MOH has established a program to promote the collection of blood samples in the two-week period following a child’s birth to screen for genetic problems. Maternal Health Care and Other Women’s Health Issues | 141 Table 11.15 presents the percent distri- bution of all births during the five-year period before the survey by whether or not the child received postnatal care and, if so, the type of provider. The table also shows the source of postnatal care and timing of the first postnatal checkup. Overall, women reported that their infant had had postnatal checkup in the case of 30 percent of all births during the five-year period before the survey. Postnatal checkups were re- ported by mothers of 32 percent of the births assisted at delivery by a health provider (largely a doctor) during the five-year period prior to the survey compared to 19 percent of births assisted by a daya or other person. Table 11.15 also shows that mothers reported that a blood sample was taken from the child’s heel within two weeks of delivery in the case of 89 percent of last-born children during the five-year period before the survey. Table 11.15 shows that almost all infants who had a postnatal checkup were seen by a doctor. Infants were more than twice as likely to have been taken to a private provider for the postnatal checkup as to a public health facility (22 percent and 8 percent, respectively). Since many of the children who die in infancy die in the early neonatal period, it is important for the postnatal checkup to take place soon after delivery in order to screen for conditions that may threaten an in- fant’s survival. The results in Table 11.15 indicate that about one-fifth of newborns are seen for the first checkup within a week following delivery but that only 8 percent of all last births were seen for the first checkup within two days of their birth. Table 11.16 shows that postnatal check- ups were somewhat more prevalent among urban infants than rural infants. Looking at place of residence, the likelihood that an infant would have a checkup was lowest in the Frontier Governorates (22 percent), and it increased with both the mother’s education and the wealth quintile. However, even among infants born to mothers with a secondary or higher education and among infants in the highest wealth quintile, less than half were seen for a checkup. Differences in this proportion of babies from whom a heel sample was taken were generally minor across the subgroups shown in Table 11.16. The largest differential observed was for the child’s birth order, with 79 percent of sixth-order birth or higher having a heel sample taken compared to 92 percent of first order births. Table 11.15 Postnatal care for child Percent distribution of births during the five-year period before the survey by provider for first postnatal checkup for child and percent distribution of last birth during the five-year period before the survey by the source for first medical postnatal care checkup, timing of first checkup, and mother's report as to whether sample of blood was taken from baby's heel during the first 2 weeks following delivery, according to the type of assistance at delivery, Egypt 2008 Postnatal care for child Medically assisted births Births assisted by daya/ other/ no one All births Provider of postnatal care Doctor 32.3 18.7 29.4 Trained nursemidwife 0.1 0.1 0.1 Daya 0.0 0.3 0.1 Don't know/missing 1.4 2.1 1.6 No postnatal care 66.2 78.6 68.8 Total 100.0 100.0 100.0 Number of births 8,352 2,238 10,590 Source for first postnatal checkup Health facility 32.7 18.9 30.0 Public sector 8.1 6.7 7.8 Private sector 24.7 12.2 22.2 At own/other home 0.4 0.0 0.3 Don’t know/missing 0.0 0.0 0.0 No postnatal care 66.8 81.0 69.7 Timing of first postnatal checkup Within 2 days of delivery 9.1 2.8 7.8 Less than 4 hours 4.3 0.4 3.5 4-23 hours 0.9 0.4 0.8 24-48 hours 3.9 2.0 3.5 3-7 days after delivery 13.6 8.3 12.5 8-27 days after delivery 4.0 2.9 3.8 28-41 days after delivery 5.7 4.6 5.5 42 days or more after delivery 0.8 0.3 0.7 No care 66.8 81.0 69.7 Blood sample from child's foot Sample taken within: 90.1 90.1 90.1 0-7 days 87.2 86.5 87.1 8-14 days 1.5 2.1 1.7 More than 14 days 0.5 1.1 0.7 Don't know time/missing 0.8 0.4 0.7 Sample not taken 8.9 8.8 8.9 Don't know/missing 1.0 1.1 1.0 Total 100.0 100.0 100.0 Number of last births 6,304 1,592 7,896 142 | Maternal Health Care and Other Women’s Health Issues Table 11.16 Postnatal care for child by background characteristics Percentage of last births in the five-year period before the survey for which the child received any postnatal care, percentage receiving a postnatal checkup within two days of the delivery and percentage of babies from whom a blood sample was taken from the heel by type of delivery assistance, according to selected background characteristics, Egypt 2008 Medically assisted delivery Births assisted by daya/other/no one All births Background characteristics Had any post- natal care1 Had post- natal check- up within 2 days after delivery Had heel sample taken within 2 weeks of delivery Number of last births assisted by health providers Had any post- natal care1 Had post- natal check-up within 2 days after delivery Had heel sample taken within 2 weeks of delivery Number of last births assisted by daya/ other/ no one Had any post- natal care1 Had post- natal checkup within 2 days after delivery Had heel sample taken within 2 weeks of delivery Number of last births Age at birth <20 37.3 9.9 90.2 577 19.2 2.4 92.5 150 33.6 8.3 90.7 727 20-34 32.6 8.8 89.0 5,024 19.5 2.9 89.8 1,270 30.0 7.6 89.2 6,294 35-49 33.6 10.4 85.7 703 14.5 2.9 77.2 171 29.9 8.9 84.0 874 Birth order 1 36.8 10.0 91.7 1,870 21.4 3.1 91.9 227 35.2 9.3 91.7 2,097 2-3 31.1 8.5 89.2 3,157 18.9 2.9 92.3 767 28.7 7.4 89.8 3,924 4-5 35.0 9.5 84.7 971 18.6 2.8 85.6 408 30.2 7.5 84.9 1,380 6+ 26.9 7.5 80.0 305 17.0 2.5 76.6 190 23.1 5.6 78.7 495 Urban-rural residence Urban 38.0 11.9 88.5 2,731 18.3 4.3 86.0 281 36.2 11.2 88.3 3,012 Rural 29.5 6.9 89.0 3,573 19.1 2.5 89.2 1,310 26.7 5.7 89.0 4,883 Place of residence Urban Governorates 40.5 10.1 91.6 1,197 20.7 4.8 80.1 97 39.0 9.7 90.8 1,294 Lower Egypt 26.9 6.2 91.8 2,981 11.0 1.4 94.6 519 24.5 5.5 92.3 3,500 Urban 30.0 8.5 89.5 728 6.7 1.8 92.1 66 28.1 7.9 89.8 794 Rural 25.8 5.4 92.6 2,253 11.6 1.4 95.0 454 23.4 4.7 93.0 2,706 Upper Egypt 38.6 12.8 82.6 2,036 23.3 3.4 86.3 955 33.7 9.8 83.8 2,990 Urban 43.3 18.5 82.5 744 23.5 5.2 87.3 111 40.7 16.8 83.1 854 Rural 36.0 9.6 82.7 1,292 23.2 3.1 86.2 844 30.9 7.0 84.1 2,136 Frontier Governorates 22.2 6.0 89.1 90 12.4 4.0 86.3 21 20.3 5.6 88.6 111 Education No education 28.8 6.0 88.1 1,225 17.2 2.6 84.9 772 24.3 4.7 86.9 1,997 Some primary 30.1 9.4 85.9 389 22.4 2.9 93.2 138 28.1 7.7 87.8 528 Primary complete/ some secondary 33.5 7.4 85.3 993 20.7 3.4 89.1 247 31.0 6.6 86.1 1,239 Secondary complete/ higher 34.9 10.5 90.2 3,697 19.9 2.9 93.6 435 33.3 9.7 90.6 4,132 Work status Working for cash 35.5 10.9 87.3 814 14.0 0.9 86.4 89 33.4 10.0 87.2 903 Not working for cash 32.8 8.8 89.0 5,490 19.3 3.0 88.8 1,503 29.9 7.5 88.9 6,993 Wealth quintile Lowest 31.4 6.7 85.8 865 20.0 2.6 87.3 660 26.5 5.0 86.4 1,525 Second 30.0 7.1 88.1 1,096 18.1 3.1 89.3 461 26.5 5.9 88.5 1,557 Middle 29.5 6.1 89.5 1,388 19.7 2.5 89.0 271 27.9 5.5 89.4 1,659 Fourth 33.9 9.4 89.6 1,475 11.8 2.3 92.6 151 31.9 8.7 89.9 1,626 Highest 39.3 14.4 89.5 1,480 (31.3) (7.2) (86.8) 48 39.0 14.2 89.4 1,528 Total 33.2 9.1 88.8 6,304 19.0 2.8 88.7 1,592 30.3 7.8 88.7 7,896 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes postnatal checkup occurring at any time following the child's birth including checkups taking place 42 or more days after the birth Maternal Health Care and Other Women’s Health Issues | 143 11.6 FAMILY PLANNING AND BREASTFEEDING ADVICE The 2008 EDHS collected information from women who delivered their last birth within the five- year period before the EDHS on whether or not they had received any advice about family planning and breastfeeding during the time they were pregnant, at the time they delivered or during the two months following delivery. Table 11.17 shows that 30 percent of mothers said that they were given advice about family planning and 23 percent about breastfeeding. With regard to the source of the advice, health providers were the most frequently mentioned source for both family planning and breastfeeding advice. Table 11.17 Exposure to family planning and breastfeeding information Percentage of last births in the five- year period before the survey whose mothers received information about family planning and breastfeeding from various sources, Egypt 2008 Source of information Percent Family planning Health provider 26.6 Social worker 0.5 Daya 0.2 Religious leader 0.0 Neighbors/friends 0.5 Household member 1.4 Other relative 3.0 Other 0.0 Any source 30.3 Breastfeeding Health provider 14.2 Social worker 0.3 Daya 0.2 Religious leader 0.0 Neighbors/friends 0.6 Household member 2.9 Other relative 6.8 Other 0.3 Any source 23.2 Total 7,896 11.7 EXPOSURE TO SAFE PREGNANCY MESSAGES Media messages designed to make women more aware of the danger signs during pregnancy are part of an information, education and communication campaign to promote safe pregnancy in Egypt. The 2008 EDHS included questions to assess the coverage of these messages and to identify the media through which women had heard or seen the messages most recently. Table 11.18 shows that 21 percent of the ever-married women who were asked these questions had heard about the danger signs to watch for during pregnancy. Women age 15-19 (35 percent) were the most likely and women age 45-49 (13 percent) were least likely to have heard or seen a message. 144 | Maternal Health Care and Other Women’s Health Issues With regard to the most recent information source, 56 percent had last received the information through television while 33 percent cited medical providers as the most recent source of information. Five percent or less of women mentioned other information sources (e.g., radio or print media). The largest proportions mentioning medical providers were found among women under age 25, especially women 15- 19, and women from the Urban Governorates. Table 11.18 Coverage of safe pregnancy messages by background characteristics Percentage of ever-married women 15-49 reporting they had received information about danger signs women must be aware of to have a safe 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 2008 Source for information about pregnancy danger signs Background characteristics Percentage receiving information about danger signs Number of women TV Radio Print media1 Service provider Husband/ other relative Friends/ neighbors/ other Total percent Number of women knowing danger signs Antenatal care Had birth 22.6 7,896 55.2 1.1 2.5 35.8 3.7 1.8 100.0 1,786 Antenatal care 25.0 5,860 56.1 1.0 2.7 35.6 3.0 1.6 100.0 1,467 No antenatal care 15.7 2,035 50.8 1.2 1.8 36.6 7.0 2.5 100.0 319 No birth 18.8 8,631 55.9 0.9 4.7 30.0 5.7 2.7 100.0 1,624 Age 5-year groups 15-19 34.6 620 39.5 0.8 0.2 50.1 7.1 2.3 100.0 215 20-24 28.5 2,584 43.4 0.4 1.7 46.7 6.0 1.8 100.0 736 25-29 24.5 3,367 55.5 1.0 2.9 36.7 2.9 1.1 100.0 824 30-34 21.0 2,664 61.5 0.8 4.1 28.3 3.0 2.3 100.0 560 35-39 16.4 2,586 59.6 2.4 5.9 25.7 3.2 3.2 100.0 425 40-44 14.4 2,473 66.0 0.9 5.7 17.4 6.2 3.9 100.0 356 45-49 13.1 2,234 67.8 1.1 6.0 14.3 7.8 3.1 100.0 293 Urban-rural residence Urban 20.4 6,809 53.1 1.1 6.3 34.4 4.0 1.1 100.0 1,387 Rural 20.8 9,718 57.2 0.9 1.7 32.1 5.1 3.0 100.0 2,023 Place of residence Urban Governorates 17.0 2,931 38.3 1.3 10.2 47.9 2.2 0.1 100.0 498 Lower Egypt 20.7 7,618 61.9 1.0 1.8 28.5 5.0 1.9 100.0 1,580 Urban 22.7 1,936 63.3 1.1 3.3 26.8 4.6 0.9 100.0 439 Rural 20.1 5,682 61.3 0.9 1.3 29.1 5.1 2.3 100.0 1,142 Upper Egypt 22.3 5,751 54.9 0.9 2.6 32.9 5.2 3.5 100.0 1,281 Urban 23.0 1,792 60.3 0.8 4.2 26.5 5.5 2.6 100.0 412 Rural 22.0 3,959 52.4 0.9 1.8 35.9 5.1 3.9 100.0 869 Frontier Governorates 22.2 227 42.8 0.7 17.9 32.4 4.7 1.5 100.0 50 Education No education 14.7 5,302 57.6 1.1 0.8 31.1 5.6 3.8 100.0 781 Some primary 13.2 1,394 52.4 1.4 0.7 32.5 9.1 3.9 100.0 184 Primary complete/ some secondary 20.8 2,413 52.1 1.0 2.3 37.6 5.1 1.8 100.0 503 Secondary complete/ higher 26.2 7,418 55.9 0.9 5.3 32.7 3.7 1.5 100.0 1,942 Work status Working for cash 23.3 2,459 52.9 1.2 10.2 29.6 2.8 3.2 100.0 572 Not working for cash 20.2 14,068 56.1 1.0 2.2 33.7 5.0 2.0 100.0 2,838 Wealth quintile Lowest 15.0 3,033 58.3 1.1 1.0 29.9 5.3 4.6 100.0 456 Second 20.1 3,252 57.2 0.9 1.1 32.4 5.6 2.8 100.0 652 Middle 20.7 3,394 57.9 1.3 2.7 31.8 4.3 2.0 100.0 704 Fourth 20.8 3,505 54.6 1.2 2.7 34.8 4.7 2.0 100.0 730 Highest 25.9 3,343 51.7 0.7 8.2 34.7 3.8 1.0 100.0 867 Total 20.6 16,527 55.5 1.0 3.6 33.0 4.6 2.2 100.0 3,410 1 Includes newspaper, magazine, pamphlet, brochure, or poster Maternal Health Care and Other Women’s Health Issues | 145 11.8 SEXUALLY TRANSMITTED INFECTIONS In the 2008 EDHS, several questions were asked during the ever-married women’s interviews to assess awareness and recent experience with sexually transmitted infections (STI). First women were asked if they had heard about any infections that could be transmitted by sexual contact. They were also asked if they had had an STI in the past 12 months. In addition, they were asked if, in the past year, they had experienced a genital sore or ulcer and if they had had any genital discharge. Women who had had an infection or experienced symptoms were asked additional questions relating to any treatment that they may have sought for the infection or symptoms. In interpreting the results of these questions, it must be cautioned that the reporting of an abnormal discharge or genital sore or ulcer does not definitively identify STI in women. However, the results provide some insight into the extent to which women are aware of and are seeking medical assistance for abnormal reproductive tract symptoms. The results in Table 11.19 indicate that around six in ten currently married women had heard about sexually transmitted infections.3 Knowledge of other STIs varied considerably by background characteristic. For example, urban women were more likely than rural women to know about STIs (69 percent and 52 percent, respectively) and women in the highest wealth quintile were more than twice as likely as those in the lowest quintile to be aware of STIs. According to the results in Table 11.19, only two percent of women reported having had an infection which they had gotten through sexual contact during the 12 months prior to the survey. However, 11 percent of women had had a bad-smelling abnormal genital discharge and 10 percent a genital sore or ulcer. The proportion of women reporting recent experience with STIs or STI symptoms decreased with age and was higher in Upper Egypt than in other areas. Sixty-four percent of women experiencing an STI or STI symptoms sought medical treatment. Women who sought treatment were more than twice as likely to consult a private medical provider as a public health facility. Women from urban Upper Egypt were most likely to have sought treatment and women age 45-49 years the least likely (73 percent and 51 percent, respectively). 3The results in Table 11.19 are not comparable to levels of STI awareness reported in earlier DHS surveys because of differences in the question wording. 146 | Maternal Health Care and Other Women’s Health Issues Table 11.19 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms by background characteristics Among currently married women, percentage who have heard of infections other than AIDS that can be transmitted through sexual contact and percentage with self-reported STI and/or symptoms of an STI in the past 12 months, and, among women with self-reported STI or STI symptoms, the percentage seeking treatment by the type of provider, according to selected background characteristics, Egypt 2008 Percentage of currently married women with self-reported STI/STI symptoms in past 12 months Percentage with self-reported STI/STI symptoms who sought treatment from Background characteristics Percentage of currently married women who have heard of infections that can be transmitted through sexual contact STI Abnormal genital discharge Genital sore or ulcer STI, genital discharge, sore, or ulcer Number of currently married women Any medical provider Any public medical provider Any private/non- governmental medical provider Number of women with STI/STI symptoms Current age 15-19 45.8 1.5 11.7 11.2 19.1 605 70.4 10.0 60.3 116 20-24 58.6 1.4 12.2 11.1 18.0 2,527 69.7 16.6 53.3 454 25-29 63.0 1.8 12.6 10.4 18.4 3,264 64.4 15.9 49.1 600 30-34 62.2 1.6 12.6 9.9 17.5 2,551 66.2 22.4 44.1 446 35-39 59.9 1.8 11.7 10.1 16.5 2,406 61.9 19.5 43.6 398 40-44 55.1 1.4 8.7 7.8 13.5 2,188 58.0 17.7 40.8 295 45-49 53.1 0.7 7.2 7.2 11.1 1,855 50.7 18.2 32.9 205 Urban-rural residence Urban 68.6 2.2 12.7 10.0 17.3 6,316 64.8 17.8 47.5 1,091 Rural 51.7 1.1 10.1 9.5 15.7 9,080 62.8 17.9 45.4 1,423 Place of residence Urban Governorates 70.9 2.5 14.2 9.9 18.0 2,727 60.0 19.7 40.8 490 Lower Egypt 62.6 1.1 7.7 5.7 10.9 7,128 64.2 15.7 48.9 775 Urban 73.3 1.5 8.4 5.6 11.3 1,801 62.1 10.9 51.2 204 Rural 59.0 0.9 7.4 5.7 10.7 5,326 64.9 17.5 48.1 571 Upper Egypt 47.5 1.5 14.1 14.7 22.5 5,326 64.7 18.0 47.3 1,199 Urban 60.6 2.1 14.6 14.7 22.2 1,646 72.7 18.1 55.3 366 Rural 41.6 1.2 13.9 14.7 22.7 3,680 61.2 17.9 43.8 834 Frontier Governorates 51.0 4.9 15.7 12.9 22.3 216 67.7 31.3 36.5 48 Education No education 34.9 1.0 9.6 9.7 15.6 4,758 55.7 21.2 34.9 740 Some primary 48.1 1.1 11.4 10.2 17.7 1,259 54.1 16.9 37.9 223 Primary complete/ some secondary 55.0 2.3 13.3 10.6 18.3 2,273 66.0 20.7 46.5 417 Secondary complete/ higher 77.6 1.7 11.5 9.3 16.0 7,106 70.0 14.8 55.3 1,133 Work status Working for cash 76.2 1.7 10.0 8.9 14.8 2,182 66.8 15.4 51.4 322 Not working for cash 55.8 1.5 11.4 9.8 16.6 13,215 63.2 18.2 45.6 2,191 Wealth quintile Lowest 34.8 0.8 11.8 12.7 19.3 2,764 56.4 19.9 37.6 535 Second 47.4 1.4 10.5 10.4 16.8 3,014 61.1 19.6 41.7 508 Middle 59.8 1.6 10.2 8.5 14.8 3,172 65.4 19.6 45.8 469 Fourth 67.8 1.2 10.8 8.4 14.8 3,268 64.4 17.8 47.5 484 Highest 79.6 2.6 12.6 9.0 16.3 3,178 71.5 12.6 59.3 519 Total 58.7 1.5 11.2 9.7 16.3 15,396 63.7 17.9 46.3 2,513 Maternal Health Care and Other Women’s Health Issues | 147 11.9 WOMEN’S ACCESS TO HEALTH CARE Another important topic explored in the 2008 EDHS was the type of barriers women may face in accessing health care for themselves. To obtain this information, EDHS respondents were asked whether each of the following factors would be a big problem for them in obtaining medical advice or treatment if they were sick: getting permission to go, getting money for treatment, the distance to the health facility, having to take transportation, concern about going alone to the facility, lack of a female health care provider, lack of any health care provider, and concern about the availability of drugs. Table 11.20 shows that eight in ten women identified at least one of these obstacles to getting health care as potentially a major problem in accessing health care for themselves. Women most frequently cited the lack of a health care provider (63 percent) and lack of drugs (64 percent) as potentially big problems followed by difficulties in getting the money to pay for treatment (44 percent), concern that no female health care provider would be available (40 percent), and not wanting to go alone (26 percent). Twenty percent or less of women mentioned as potential barriers the need to arrange for transport, the distance to the provider, or the need to get permission from the husband or someone else before they could go for care. Urban women were somewhat less likely than rural women to report at least one potential obstacle. Women from urban Lower Egypt were the least likely and women from rural Upper Egypt the most likely to mention at least one potential obstacle. As expected, highly educated women and women who work for cash were less likely than other women to perceive any big problems in accessing health care. The percentage of women who identified at least one potential problem in accessing health care also decreased with increasing wealth. There also are differences in the types of obstacles that women regard as big problems across the population subgroups for which results are presented in Table 11.20. For example, women in the Frontier Governorates were much more likely than women from other areas to mention lack of a female provider, not wanting to go alone, having to take transport, distance to health facility, and getting permission to go for treatment as potential barriers to accessing care. As expected, the percentage saying that getting the money to pay for care would be a big problem declined with the wealth quintile, from 70 percent of women in the lowest wealth quintile to 16 percent of women in the highest quintile. More than half of women living in rural areas cited getting money as a barrier compared to around a third of urban women. 148 | Maternal Health Care and Other Women’s Health Issues Table 11.20 Problems in accessing health care Percentage of ever-married women who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Egypt 2008 Background characteristics Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern no female provider available Concern no provider available Concern no drugs available At least one problem accessing health care Number of women Current age 15-19 10.1 46.2 20.5 23.2 36.8 50.2 66.4 68.5 88.4 620 20-24 7.6 44.8 17.5 19.3 29.6 43.9 64.3 64.9 82.0 2,584 25-29 7.7 42.5 16.0 18.3 25.8 40.9 61.5 62.1 79.0 3,367 30-34 7.3 42.8 17.1 19.4 25.9 40.8 62.9 64.3 79.7 2,664 35-39 6.4 43.7 17.7 21.0 24.0 38.8 61.7 63.4 78.9 2,586 40-44 6.9 46.4 16.5 18.2 23.9 38.8 64.3 65.1 80.4 2,473 45-49 6.7 46.1 17.6 20.2 25.3 36.1 63.7 65.6 79.4 2,234 Number of living children 0 8.0 38.2 16.5 19.7 32.0 42.2 61.5 61.9 79.8 1,752 1-2 7.0 40.7 15.6 17.5 25.5 39.0 62.3 62.8 78.4 6,377 3-4 6.3 44.4 17.2 19.6 24.3 39.8 62.5 63.9 79.7 6,010 5+ 9.7 58.1 21.5 24.4 28.6 44.7 67.9 70.6 86.6 2,389 Urban-rural residence Urban 5.7 34.5 12.4 13.2 23.3 34.4 57.1 59.8 74.4 6,809 Rural 8.3 51.2 20.4 23.8 28.2 44.6 67.3 67.4 84.2 9,718 Place of residence Urban Governorates 6.7 37.0 13.7 13.8 25.0 30.0 56.8 59.2 72.9 2,931 Lower Egypt 5.8 41.6 16.5 20.5 23.8 36.2 65.8 61.8 77.5 7,618 Urban 4.0 28.5 10.1 11.3 20.9 29.4 59.6 57.9 71.4 1,936 Rural 6.5 46.1 18.6 23.7 24.7 38.5 67.9 63.2 79.6 5,682 Upper Egypt 8.8 51.7 19.0 20.2 29.1 50.4 62.8 69.8 87.2 5,751 Urban 4.6 36.8 11.3 12.6 21.0 44.7 54.5 61.8 79.1 1,792 Rural 10.7 58.4 22.5 23.7 32.8 53.0 66.6 73.5 90.8 3,959 Frontier Governorates 21.9 40.4 37.3 36.8 48.1 63.9 62.1 70.4 86.6 227 Education No education 10.6 63.3 24.3 27.7 30.7 48.5 69.6 72.2 88.4 5,302 Some primary 9.8 56.4 22.2 25.3 28.6 40.8 68.0 70.6 87.4 1,394 Primary complete/some secondary 7.9 46.0 17.8 20.0 29.6 42.6 64.7 66.3 83.1 2,413 Secondary complete/higher 4.1 27.9 10.8 12.3 21.4 33.9 57.0 56.7 72.0 7,418 Work status Working for cash 3.9 30.6 12.3 13.1 16.8 29.5 55.7 57.1 70.0 2,459 Not working for cash 7.8 46.7 18.0 20.6 27.8 42.3 64.4 65.5 82.0 14,068 Wealth quintile Lowest 12.6 70.4 29.2 31.0 32.9 51.0 71.5 76.9 92.0 3,033 Second 8.3 55.9 21.6 25.2 28.2 45.3 69.2 68.5 85.7 3,252 Middle 6.9 46.8 17.5 21.0 26.6 40.2 66.8 66.7 83.1 3,394 Fourth 5.1 35.5 11.9 13.9 24.3 37.3 61.9 62.8 79.0 3,505 Highest 4.0 16.1 7.1 7.8 19.7 29.5 47.1 47.7 62.4 3,343 Total 7.2 44.3 17.1 19.5 26.2 40.4 63.1 64.3 80.2 16,527 Child Health | 149 CHILD HEALTH 12 Many deaths in early childhood can be prevented by immunizing children against preventable diseases and by ensuring that children receive prompt and appropriate treatment when they become ill. This chapter presents information from the 2008 EDHS on the level of immunization among young children. The chapter also considers information from the EDHS on the prevalence and treatment of a number of common childhood illnesses including diarrhea, acute respiratory infections, and fever. 12.1 IMMUNIZATION OF CHILDREN World Health Organization guidelines for childhood immunizations call for all children to receive a BCG vaccination against tuberculosis; three doses of the DPT vaccine to prevent diphtheria, pertussis, and tetanus; three doses of polio vaccine; and a measles vaccination during the first year of life. In addition to these standard immunizations, Egypt’s childhood immunization program recommends that children receive three doses of the hepatitis vaccine. 12.1.1 Collection of Data In Egypt, routine immunizations are recorded on a child’s birth record (certificate) or on a special child health card. In collecting data on immunization coverage in the 2008 EDHS, mothers were asked to show the interviewer the birth record and/or health card for each child born since January 2003. When the mother was able to show the birth record and/or health card, the dates of vaccinations were copied from the document(s) to the questionnaire. If neither a birth record nor a health card was available (or a vaccination was not recorded), mothers were asked a series of questions to determine whether the child had ever received specific vaccines and, if so, the number of doses. In addition to the program of routine immunizations, Egypt has recently conducted a number of special national immunization days (NID) in the effort to eradicate polio. Therefore, the EDHS asked several questions on whether the child had participated in any of the NID campaigns and, if so, during how many of the campaigns the child had received a polio immunization. 12.1.2 Routine Immunization against Common Childhood Illnesses Table 12.1 shows information on vaccination coverage according to the source of the informa- tion, i.e., the child’s birth record and/or health card or the mother’s report. The table is restricted to children 12-23 months of age in order to focus on recent coverage levels. The first three columns of the table provide information on the proportions of children who were immunized at any age up to the time of the survey. The fourth column presents the proportion of children who were vaccinated by age 12 months, the age at which children should have received all of the recom- mended vaccinations. For children with vaccination records, the percentage of children immunized by age 12 months was calculated based on the child’s birth date and the dates on which specific vaccines were given as reported on the vaccination record. For children whose information was based on mother’s recall, the proportion of vaccinations given during the first year of life was assumed to be the same as that for children with a written vaccination record. 150 | Child Health Table 12.1 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Egypt 2008 Vaccinated at any time before survey Vaccination Vaccination card Mother's report Either source Vaccinated by 12 months of age3 Valid dates BCG 67.7 31.2 99.0 98.6 89.1 DPT 1 68.5 31.3 99.8 99.8 90.6 DPT 2 68.4 31.3 99.7 99.6 87.3 DPT 3+ 68.0 29.7 97.6 97.3 80.6 DPT activated 34.5 7.7 42.1 1.7 33.4 Polio 01 59.3 27.5 86.7 86.7 33.6 Polio 1 68.5 31.3 99.8 99.8 97.9 Polio 2 68.4 30.9 99.3 99.3 95.1 Polio 3 68.1 26.4 94.5 94.2 88.8 Polio 4 61.0 18.7 79.7 78.1 69.3 Polio activated 35.3 8.0 43.2 3.2 37.3 Hepatitis 1 68.3 31.0 99.3 99.3 79.5 Hepatitis 2 68.0 30.9 98.9 98.7 75.0 Hepatitis 3 67.4 28.7 96.1 95.7 68.1 Measles 67.2 31.1 98.3 96.6 82.6 MMR 30.2 15.4 45.6 2.4 18.5 Fully immunized2 66.2 25.5 91.7 89.8 64.2 Fully immunized and 3 doses of hepatitis vaccine 65.7 24.8 90.4 88.6 53.9 No vaccinations 0.0 0.2 0.2 0.4 0.3 Number of children 1,479 681 2,160 2,160 1,479 1 Polio 0 is the polio vaccination given at birth. 2 A child is considered to be fully immunized if the child has received BCG, a measles or MMR vaccination, three DPT vaccinations, and three polio vaccinations 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. Table 12.1 shows that birth records and/or health cards were available in the case of 1,479 out of 2,160 of the children age 12-23 months (68 percent). For the remaining children, the information on vaccinations was based on the mother’s report. The results in Table 12.1 indicate that the childhood immunization program in Egypt has wide coverage. Among children 12-23 months, less than 1 percent had never been immunized against any of the vaccine preventable diseases. Coverage levels for BCG were virtually universal, and 98 percent of children 12-23 months had received a measles vaccination. The proportions receiving three doses of the DPT and polio vaccines were 98 percent and 95 percent, respectively. Overall, 92 percent of children were considered immunized against all of these preventable diseases, i.e., they had received a BCG and measles vaccination and three doses of the DPT and polio vaccines. Child Health | 151 Hepatitis vaccinations were introduced into Egypt’s childhood immunization program in the mid- 1990s. Table 12.1 shows that coverage levels were high for the hepatitis vaccine, with 96 percent of children reported as having received the third dose of this vaccine. Overall, 90 percent of children 12-23 months were fully immunized against hepatitis as well as the other six preventable illnesses. Finally, the percentages in the third column of Table 12.1 can be compared with those in the fourth column to assess the proportion of vaccinated children who, as recommended, had received the vaccinations before the child’s first birthday. Overall, 90 percent of the children 12-23 months had received all of the required vaccinations (excluding hepatitis) by their first birthday. 12.1.3 Trends and Differentials in Vaccination Coverage As Table 12.2 shows, the levels of vaccination coverage increased substantially during the period between the 1992 and 2008 EDHS surveys. Overall, the proportion fully immunized at the time of the 2008 survey, i.e., the proportion who had received BCG and measles vaccinations and three doses of DPT and polio, was 25 percentage points higher than the level recorded at the time of the 1992 EDHS (67 percent). Table 12.2 also presents differentials in vaccination coverage among children 12-23 months according to selected background characteristics. Given the widespread coverage of the immunization program in Egypt, the differences are small. Girls were slightly more likely than boys to be fully immunized. By residence, the percentages fully immunized varied from 86 percent in the Frontier Governorates to 94 percent in the Urban Governorates and Lower Egypt. T ab le 1 2. 2 V ac ci na tio ns b y ba ck gr ou nd c ha ra ct er ist ic s A m on g ch ild re n 12 -2 3 m on th s, th e pe rc en ta ge w ho h ad v ac ci na tio n re co rd s se en a nd w ho re ce iv ed e ac h va cc in e (a cc or di ng to th e va cc in at io n ca rd s or th e m ot he r's re po rt) , b y se le ct ed b ac kg ro un d ch ar ac te ris tic s, E gy pt 2 00 8, a nd tr en ds in p er ce nt ag es re ce iv in g va rio us v ac ci ne s, E gy pt 1 99 2- 20 08 D PT Po lio H ep at iti s Re co rd se en BC G 1 2 3 AD PT 0 1 2 3 4 AP 1 2 3 M ea sle s M M R Fu lly im m u- ni ze d Fu lly im m u- nI ze d pl us 3 do se s he pa tit is N on e N um be r of ch ild re n S ex M al e 69 .6 99 .2 99 .8 99 .6 97 .0 41 .2 87 .0 99 .8 99 .1 93 .4 80 .1 41 .3 99 .3 99 .0 96 .1 98 .0 44 .6 90 .9 90 .0 0. 2 1, 10 6 Fe m al e 67 .3 98 .7 99 .8 99 .7 98 .3 43 .1 86 .4 99 .8 99 .5 95 .6 79 .3 45 .2 99 .3 98 .8 96 .1 98 .7 46 .6 92 .5 90 .9 0. 2 1, 05 4 B ir th o rd er 1 68 .2 99 .1 99 .9 99 .8 98 .5 46 .4 89 .8 99 .9 99 .5 93 .7 80 .8 47 .3 99 .7 99 .5 96 .5 99 .6 49 .8 92 .5 90 .9 0. 1 71 6 2- 3 67 .8 98 .9 99 .8 99 .5 96 .8 38 .7 85 .2 99 .8 99 .2 94 .9 79 .4 40 .4 99 .2 98 .6 95 .8 97 .7 42 .6 91 .4 90 .3 0. 2 1, 03 5 4- 5 71 .2 99 .2 99 .9 99 .9 98 .7 42 .6 86 .0 99 .9 99 .2 95 .1 77 .3 43 .0 99 .1 98 .9 96 .8 97 .5 44 .0 92 .0 90 .7 0. 1 29 1 6+ 69 .5 98 .0 10 0. 0 10 0. 0 96 .9 45 .5 83 .8 10 0. 0 99 .3 94 .0 82 .3 44 .2 98 .5 98 .3 95 .5 98 .1 49 .6 88 .6 88 .4 0. 0 11 8 U rb an -r ur al U rb an 68 .4 99 .5 99 .8 99 .5 98 .5 44 .6 88 .3 99 .8 99 .5 95 .3 80 .9 45 .6 99 .8 99 .4 97 .3 98 .3 46 .0 93 .7 92 .5 0. 2 83 0 Ru ra l 68 .5 98 .6 99 .8 99 .7 97 .1 40 .6 85 .7 99 .8 99 .2 94 .0 79 .0 41 .8 99 .0 98 .6 95 .4 98 .3 45 .3 90 .5 89 .1 0. 2 1, 33 0 P la ce o f r es id en ce U rb an G ov er no ra te s 65 .2 99 .6 99 .6 99 .6 98 .7 49 .7 90 .0 99 .6 99 .5 96 .5 86 .9 46 .1 99 .6 99 .6 97 .3 97 .9 48 .3 94 .3 93 .0 0. 4 37 1 Lo w er E gy pt 66 .5 98 .9 10 0. 0 99 .9 98 .2 40 .9 87 .4 10 0. 0 99 .2 95 .8 79 .8 46 .6 99 .7 99 .3 98 .0 99 .2 46 .9 93 .7 93 .1 0. 0 93 7 U rb an 69 .9 99 .4 10 0. 0 99 .4 98 .8 45 .4 89 .4 10 0. 0 99 .4 96 .6 79 .8 54 .5 1 00 .0 99 .4 98 .2 99 .4 50 .0 95 .9 95 .3 0. 0 21 5 R ur al 65 .4 98 .8 10 0. 0 10 0. 0 98 .1 39 .6 86 .9 10 0. 0 99 .1 95 .5 79 .8 44 .2 99 .6 99 .3 97 .9 99 .1 46 .0 93 .1 92 .4 0. 0 72 2 U pp er E gy pt 72 .6 98 .8 99 .8 99 .6 96 .6 40 .2 84 .6 99 .8 99 .4 92 .4 76 .9 38 .5 98 .7 98 .4 93 .9 97 .6 43 .0 88 .4 86 .7 0. 2 81 8 U rb an 72 .8 99 .6 10 0. 0 99 .6 98 .2 36 .4 85 .2 10 0. 0 99 .6 92 .6 73 .2 37 .3 1 00 .0 99 .6 97 .0 98 .3 39 .2 90 .9 89 .8 0. 0 22 2 R ur al 72 .5 98 .5 99 .7 99 .6 96 .0 41 .7 84 .3 99 .7 99 .3 92 .3 78 .3 38 .9 98 .3 98 .0 92 .8 97 .4 44 .4 87 .5 85 .5 0. 3 59 5 Fr on tie r G ov er no ra te s 62 .1 98 .2 98 .2 96 .1 93 .3 36 .8 81 .7 98 .8 97 .9 88 .7 66 .6 35 .7 98 .2 91 .6 85 .5 96 .7 39 .5 86 .2 81 .5 1. 2 34 E du ca tio n N o ed uc at io n 66 .0 99 .5 99 .7 99 .6 97 .0 40 .9 84 .8 99 .8 98 .9 94 .6 77 .1 38 .9 99 .3 98 .9 94 .9 97 .7 45 .9 91 .4 89 .6 0. 2 53 6 So m e pr im ar y 71 .9 97 .5 98 .4 98 .1 93 .9 34 .9 86 .7 98 .4 96 .9 90 .3 75 .1 31 .8 95 .9 95 .5 91 .9 95 .3 38 .9 86 .9 86 .9 1. 6 14 1 Pr im ar y co m p. /s om e se c. 69 .1 98 .0 10 0. 0 99 .9 96 .4 43 .8 85 .0 10 0. 0 99 .9 93 .8 80 .8 46 .5 99 .1 98 .4 94 .0 99 .3 44 .5 90 .4 88 .1 0. 0 32 5 Se co nd ar y co m p. /h ig he r 69 .1 99 .2 10 0. 0 99 .8 98 .7 43 .1 88 .1 10 0. 0 99 .6 95 .1 81 .2 45 .8 99 .8 99 .5 97 .8 98 .7 46 .5 92 .8 91 .9 0. 0 1, 15 8 W or k st at us W or ki ng fo r c as h 65 .6 98 .9 10 0. 0 1 00 .0 97 .2 41 .8 92 .0 10 0. 0 98 .9 95 .6 83 .7 45 .3 1 00 .0 99 .8 95 .2 99 .6 47 .2 93 .7 91 .7 0. 0 19 4 N ot w or ki ng fo r c as h 68 .8 99 .0 99 .8 99 .6 97 .7 42 .2 86 .2 99 .8 99 .3 94 .4 79 .3 43 .0 99 .2 98 .8 96 .2 98 .2 45 .4 91 .5 90 .3 0. 2 1, 96 6 W ea lth q ui nt ile Lo w es t 68 .4 97 .8 99 .7 99 .4 96 .6 40 .0 83 .2 99 .7 99 .4 93 .9 78 .1 36 .9 98 .4 97 .8 93 .5 97 .5 40 .8 89 .4 86 .8 0. 3 44 6 Se co nd 64 .9 99 .1 10 0. 0 99 .8 96 .2 35 .7 85 .1 10 0. 0 98 .7 93 .4 73 .2 36 .4 99 .0 98 .5 93 .9 98 .0 47 .4 89 .5 87 .3 0. 0 41 2 M id dl e 71 .1 99 .1 99 .5 99 .5 97 .8 42 .1 85 .1 99 .5 99 .2 95 .4 83 .4 45 .5 99 .2 99 .1 98 .1 98 .0 44 .2 92 .8 92 .7 0. 5 42 8 Fo ur th 68 .7 99 .8 10 0. 0 99 .7 98 .6 43 .5 87 .4 10 0. 0 99 .6 93 .7 78 .7 46 .2 1 00 .0 99 .3 97 .4 99 .0 46 .3 92 .5 91 .9 0. 0 45 4 H ig he st 69 .2 99 .1 10 0. 0 1 00 .0 98 .9 49 .2 92 .9 10 0. 0 99 .7 96 .1 85 .1 51 .2 1 00 .0 99 .9 97 .7 99 .2 49 .5 94 .4 93 .4 0. 0 41 9 T ot al E D H S 20 08 68 .5 99 .0 99 .8 99 .7 97 .6 42 .1 86 .7 99 .8 99 .3 94 .5 79 .7 43 .2 99 .3 98 .9 96 .1 98 .3 45 .6 91 .7 90 .4 0. 2 2, 16 0 T ot al E D H S 20 05 73 .3 98 .0 99 .1 97 .5 93 .5 32 .3 27 .7 99 .6 98 .8 96 .6 67 .0 35 .3 91 .2 86 .4 79 .8 96 .6 22 .6 88 .7 75 .9 0. 2 2, 68 0 T ot al E D H S 20 00 72 .5 99 .3 99 .2 97 .1 94 .0 na na 99 .6 97 .7 94 .9 na na 98 .7 96 .3 93 .0 96 .9 na 92 .2 91 .1 0. 2 2, 17 0 T ot al E D H S 19 95 50 .1 94 .7 96 .2 92 .8 83 .0 na na 97 .0 93 .9 84 .2 na na 75 .4 71 .0 56 .9 89 .2 na 79 .1 na 2. 5 2, 08 5 T ot al E D H S 19 92 55 .2 89 .5 92 .8 87 .8 76 .4 na na 94 .5 90 .1 78 .9 na na 81 .5 na na na na 67 .4 na 3. 8 1, 59 4 N ot e: A c hi ld is c on sid er ed to b e fu lly im m un iz ed if th e ch ild h as re ce iv ed B C G , a m ea sle s or M M R va cc in at io n, th re e D PT v ac ci na tio ns , a nd th re e po lio v ac ci na tio ns . na = n ot a va ila bl e Po lio 0 is th e po lio v ac ci na tio n gi ve n at b irt h; A D PT - Ac tiv at ed D PT ; A P - A ct iv at ed P ol io ; a nd M M R - M ea sle s, m um ps , a nd ru be lla 152 | Child Health Child Health | 153 12.1.4 Participation in National Immunization Days During the two-year period before the 2008 EDHS, a series of national immunization day cam- paigns were held in an effort to ensure that all young children in Egypt are fully immunized against polio. The survey collected information on children’s participation in the NID campaigns. Table 12.3 shows that the NID campaigns have achieved wide coverage; nine in ten children under age five were reported to have received an immunization during one of the NIDs. Children in the Urban Governorates were most likely to have participated in a NIDs campaign while children from rural Upper Egypt were least likely to have participated (93 percent and 88 percent, respectively). Table 12.3 Number of times vaccinated in national immunization day campaigns by residence Percent distribution of children under five years by the number of times the child received a polio immunization during a national immunization day (NID) campaign within a two-year period before the survey, Egypt 2008 Lower Egypt Upper Egypt Number of NIDs days Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total None 7.6 9.8 5.9 7.9 7.7 8.0 11.4 10.0 12.0 9.3 9.0 1-4 60.8 57.7 59.4 57.4 58.0 57.2 59.9 64.4 58.3 67.0 58.8 5-9 28.2 29.5 29.6 31.9 32.1 31.9 25.9 23.5 26.7 21.7 29.0 10 + 2.9 2.5 4.2 2.5 2.1 2.6 2.2 1.9 2.4 1.2 2.6 Don’t know/missing 0.5 0.5 0.8 0.3 0.1 0.4 0.5 0.2 0.7 0.7 0.5 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of children 3,820 6,508 1,622 4,507 1,000 3,508 4,050 1,107 2,943 148 10,327 If NIDs participation is taken into account, it is estimated that 97 percent of all children age 12-23 months were fully immunized against polio, i.e., they received at least three doses of polio vaccine. 12.2 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI), particularly pneu- monia, is a common cause of death among infants and young children. Early diagnosis and treatment with antibiotics can prevent a large proportion of the deaths due to pneumonia. 12.2.1 Prevalence of ARI Information on the prevalence of ARI was collected in the 2008 EDHS by asking mothers of children under five years of age three questions. The first question identified children who had been ill with a cough in the two weeks before the survey. Thirteen percent of children under age five had had a cough during the two-week period before the survey (Table 12.4). For the children who had had a cough, a second question was asked to determine if the child had breathed faster than usual with short rapid breaths or had had difficulty breathing. If the mother indicated that the child had experienced fast or difficult breathing, they were asked whether it was the result of a problem in the chest or a blocked or runny nose. Mothers reported that 9 percent of the children with a cough experi- Table 12.4 Prevalence of cough Percent distribution of children under five years by cough and related symptoms during the two- week period before the survey, Egypt 2008 Cough and cough symptoms Percent Cough 13.4 Cough with short, rapid, or difficult breathing 9.3 Blocked/runny nose only 1.4 Chest-related only 3.2 Both blocked/runny nose and chest-related 4.6 Don’t know/missing 0.1 Cough without short, rapid, or difficult breathing 4.1 No cough 86.6 Total percent 100.0 Number of children 10,327 Note: Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related) is considered proxy for pneumonia. 154 | Child Health enced fast or difficult breathing. Table 12.4 shows that mothers attributed the breathing problems in most of these children—8 percent of all children under age five—to a problem in the chest. In considering the ARI findings, several points should be noted. First, the prevalence of ARI varies seasonally, and the EDHS results represent the situation at the time of the interview (circa March- May 2008) and not the situation at other times of the year in Egypt. The data also are subject to reporting error although the short reference period (two weeks) reduces the likelihood of such error. The symptoms for which information is collected in the EDHS—cough with fast or difficult breathing involving a chest problem—are signs of pneumonia but are less appropriate for assessing the presence of other ARI-related conditions (coughs and colds, wheezing, ear infection, and streptococcal sore throat). Thus, the EDHS results do not provide information on the prevalence and treatment of the full range of ARI problems children experience. Finally, the 2008 EDHS findings are not strictly comparable to earlier DHS surveys since those surveys did not ask if the mother considered the child’s cough and rapid or difficult breathing to be chest-related. 12.2.2 Consultation, Treatment, and Feeding Practices Women whose children had chest-related ARI symp- toms were asked whether they had sought advice or treatment for the illness. Table 12.5 indicates that, according to the mother’s report, advice or treatment was sought from a health provider for 79 percent of the children who were ill. Most of the families sought advice from only one provider when a child was ill with ARI symptoms. Private health care pro- viders were the first source consulted in 64 percent of the cases. For slightly more than 60 percent of the children ill with ARI symptoms, the first consultation took place the day they became ill. Table 12.6 considers the actions taken to treat the illness. Ninety percent of children with chest-related ARI symptoms were given some type of medicine. Antipyretics and cough medicine were the most frequently given medi- cines. Fifty-eight percent of the children received an anti- biotic, with most receiving the drug orally. Questions were also asked about feeding practices during the illness. It is recommended that children receive in- creased liquids when they are ill and that food not be reduced. The results in Table 12.6 indicate the actions taken when the child had ARI symptoms were often counter to this advice. Children ill with chest-related ARI symptoms were most often given either less fluids than normal (56 percent) or nothing to drink (11 percent). There also was a clear tendency for children to receive less food than normal; only 17 percent the children ill with ARI symptoms were given the same or more food than normal. Table 12.5 Consultation about ARI episode Among children with ARI symptoms, percent distribution by number of sources from which advice or treatment was sought during illness, and among ill children for whom a source was con- sulted, the first source consulted during the illness and the timing of the first consultation, Egypt 2008 Consultation Percent Number of sources consulted None 20.9 1 76.9 2 or more 2.2 Total percent 100.0 Number of ill children 805 Source consulted first about illness Public sector 28.7 Urban Hospital 10.0 Urban health unit 5.2 Health office 0.5 Rural hospital 1.5 Rural health unit 7.1 MCH center 1.5 Other government 2.9 Private sector 63.6 Nongovernmental 0.7 Private medical 62.9 Private hospital/clinic 3.0 Private doctor 58.7 Other private medical 1.1 Pharmacy 7.7 Other nonmedical 0.0 Timing of first consultation First day child ill 62.4 2-3 days after child ill 32.7 4-5 days after child ill 2.6 6 or more days after child ill 2.2 Don’t know/missing 0.1 Total percent 100.0 Number of children having consultation(s) 637 Child Health | 155 Table 12.6 Treatment and feeding practices for children ill with ARI symptoms Among children under five ill with ARI symptoms, percentage given various drugs to treat the illness and percent distribution by feeding practices during illness, Egypt 2008 Treatment practices Percent Drugs given Given any drug(s) 89.6 Any antibiotic 57.9 Pill/syrup 43.0 Had antibiotic at home 4.0 Got antibiotic elsewhere 39.0 Injection 22.6 Antipyretic 52.9 Cough medicine 62.8 Other/unknown drug 11.1 No drug given 10.4 Number of ill children 805 Amount of liquids offered Same as usual 24.0 More 8.6 Somewhat less 33.9 Much less 22.5 Nothing to drink 11.0 Missing 0.0 Amount of food offered Same as usual 15.7 More 1.4 Somewhat less 33.1 Much less 21.5 Stopped food 12.5 Never gave food 15.6 Missing 0.2 Total percent 100.0 Number of ill children 805 Note: Percentages given various drugs will not add to the total percentage given any drug(s) because more than one response regarding the drugs given was possible. 12.2.3 Differentials in ARI Prevalence and Responses to the Illness Table 12.7 presents differences in the prevalence of chest-related ARI symptoms and in consultation and treatment practices by background characteristics. The proportion of children ill with chest-related ARI symptoms does not vary greatly with the background characteristics shown in the table. It peaks at 12 percent among children age 6-11 months and children living in urban areas in Upper Egypt. Children in Lower Egypt and children older than 24 months were the least likely to have symptoms (5 percent and 6 percent, respectively). Table 12.7 shows that, regardless of the background characteristic, the majority of families take some action when a child is ill with chest-related ARI symptoms. Mothers report that there was no consultation or treatment given in the case of only 8 percent of children ill with chest-related ARI symptoms. Families were least likely to have taken any action if a child was 48-59 months. 156 | Child Health With regard to feeding practices during ARI episodes, younger children, especially those under 6 months of age, were less likely to have been offered increased liquids or given increased or the same amount of food than older children. Rural children ill with ARI symptoms were somewhat less likely than urban children to be offered increased fluids. On the other hand, rural children were nearly twice as likely as urban children to have been offered the same or an increased amount of food during ARI episodes. Table 12.7 Prevalence and treatment of ARI symptoms by background characteristics Percentage of children under five ill with ARI symptoms in the two weeks before the survey and, among ill children, percentage receiving medical care, given antibiotic, receiving no treatment/consultation, offered increased fluids and offered increased or same amount of food, by selected background characteristics, Egypt 2008 Among children with ARI symptoms, percentage: Health provider consulted1 Background characteristic Percentage ill with ARI symptoms Number of children Any2 Public Private2 Given antibiotic No consul- tation/ treatment Offered increased fluids Offered increased/ same amount of food Number of children ill with ARI symptoms Child’s age <6 8.6 1,110 84.7 20.5 64.2 63.0 10.0 0.0 7.3 95 6-11 12.1 1,284 75.4 20.1 55.3 57.4 7.4 5.4 9.0 155 12-23 9.9 2,160 73.6 24.8 48.8 59.7 4.4 12.3 18.7 215 24-35 6.4 2,002 68.9 23.7 45.1 53.6 9.4 7.2 21.5 129 36-47 5.6 1,928 68.1 23.3 44.8 61.8 5.0 11.6 19.4 108 48-59 5.5 1,843 67.8 22.6 45.2 51.3 13.9 12.2 27.2 102 Sex Male 8.3 5,236 77.1 23.6 53.5 60.0 6.2 6.6 14.6 433 Female 7.3 5,091 68.3 21.7 46.6 55.4 9.5 10.9 20.0 372 Urban-rural residence Urban 9.1 3,820 78.1 25.2 52.9 63.1 5.1 10.6 11.8 347 Rural 7.0 6,508 69.2 20.8 48.4 53.9 9.7 7.1 21.1 458 Place of residence Urban Governorates 9.4 1,622 83.9 24.8 59.1 63.7 4.9 10.5 10.2 152 Lower Egypt 4.8 4,507 73.4 19.9 53.6 62.7 6.1 6.8 17.7 218 Urban 5.4 1,000 74.0 22.6 51.4 56.6 1.0 6.9 6.6 54 Rural 4.7 3,508 73.2 19.0 54.3 64.7 7.8 6.8 21.3 164 Upper Egypt 10.5 4,050 68.7 22.9 45.8 53.1 9.8 8.7 19.4 424 Urban 12.1 1,107 73.1 26.0 47.1 65.2 7.2 11.7 15.9 134 Rural 9.9 2,943 66.6 21.5 45.2 47.5 10.9 7.2 21.1 290 Frontier Governorates 7.2 148 (84.2) (45.1) (39.1) (67.6) (0.0) (13.7) (11.0) 11 Education No education 8.5 2,669 70.8 26.8 44.0 50.4 12.5 7.2 18.1 227 Some primary 9.6 696 70.8 33.3 37.5 50.0 5.2 10.5 21.7 67 Primary complete/ some secondary 7.7 1,577 74.6 22.7 51.9 57.1 7.5 4.3 20.9 121 Secondary complete/ higher 7.2 5,385 74.3 18.6 55.7 63.8 5.4 10.4 14.5 390 Work status Working for cash 8.5 1,133 76.1 21.7 54.4 62.7 9.7 3.3 21.1 96 Not working for cash 7.7 9,194 72.6 22.9 49.8 57.2 7.5 9.3 16.6 709 Wealth quintile Lowest 9.8 2,080 69.6 27.4 42.2 52.4 12.3 4.7 22.4 204 Second 6.8 2,060 70.8 23.8 47.0 51.4 10.0 10.4 21.3 140 Middle 6.9 2,198 66.4 23.3 43.1 63.9 6.1 11.8 13.5 152 Fourth 8.0 2,065 78.5 24.8 53.7 62.8 3.3 5.3 15.4 164 Highest 7.5 1,924 80.9 12.1 68.8 60.0 5.8 12.7 11.3 144 Total 7.8 10,327 73.0 22.7 50.3 57.9 7.7 8.6 17.1 805 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Refers to first source consulted 2 Excludes pharmacy Child Health | 157 12.3 DIARRHEA Dehydration caused by severe diarrhea is a major cause of death among young children. A simple and effective response to dehydration is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy (ORT). ORT may include the use of a solution prepared from commercially produced packets of oral re- hydration salts (ORS) or a homemade mixture usually prepared from sugar, salt, and water. Increasing the amount of any other liquids given to a child during a diarrheal episode is another means of preventing dehydration. In the 2008 EDHS, mothers were asked whether any of their children under five years of age had had diarrhea during the two-week period preceding the survey. If the child had had diar- rhea, the mother was asked about what actions were taken to treat the diarrhea and about feeding practices during the diarrheal episode. 12.3.1 Prevalence of Diarrhea Table 12.8 shows the percentages of chil- dren under age five who had any diarrhea and who had diarrhea with blood in the feces, at some time during the two-week period before the survey. Blood in the stools is a symptom of dys- entery. In considering the information in Table 12.8, it is important to note that the prevalence figures may involve some reporting error since they are based on the mothers’ subjective assess- ment of the child’s illness. Since there are seasonal variations in the pattern of diarrheal ill- nesses, it also should be remembered that the percentages in Table 12.8 represent the preva- lence of diarrhea at the time of the 2008 EDHS (circa March-May 2008) and not the situation at other times of the year in Egypt. Among children under age five, 9 percent were reported by their mothers to have been ill with diarrhea during the two-week period before the EDHS interview. Less than 1 percent had diarrhea with bloody stools. Children under age 24 months, particularly those age 6-11 months, were more likely to have suffered from diarrhea than older children. Looking at the residential Table 12.8 Prevalence of diarrhea by background characteristics Percentage of children under five years with diarrhea in the two weeks preceding the survey, by background characteristics, Egypt 2008 Background characteristic All diarrhea Diarrhea with blood Number of children Age in months <6 12.6 0.6 1,110 6-11 18.6 1.1 1,284 12-23 11.3 0.6 2,160 24-35 6.5 0.2 2,002 36-47 3.3 0.2 1,928 48-59 3.1 0.0 1,843 Sex Male 8.9 0.4 5,236 Female 8.0 0.4 5,091 Source of drinking water Improved1 8.4 0.4 9,535 Not improved 6.8 0.1 244 Not de jure resident/missing 9.8 0.9 548 Toilet facility Improved2 8.3 0.4 8,823 Not improved 9.1 0.5 957 Not de jure resident/missing 9.8 0.9 548 Urban-rural residence Urban 9.2 0.5 3,820 Rural 8.0 0.4 6,508 Place of residence Urban Governorates 9.5 0.5 1,622 Lower Egypt 5.8 0.4 4,507 Urban 5.3 0.3 1,000 Rural 6.0 0.4 3,508 Upper Egypt 11.1 0.4 4,050 Urban 12.6 0.7 1,107 Rural 10.5 0.3 2,943 Frontier Governorates 6.1 0.1 148 Education No education 7.5 0.4 2,669 Some primary 13.1 0.8 696 Primary complete/some secondary 9.3 0.4 1,577 Secondary complete/higher 8.1 0.3 5,385 Work status Working for cash 6.8 0.2 1,133 Not working for cash 8.7 0.4 9,194 Wealth quintile Lowest 9.8 0.3 2,080 Second 8.6 0.5 2,060 Middle 8.7 0.6 2,198 Fourth 7.8 0.4 2,065 Highest 7.3 0.3 1,924 Total 8.5 0.4 10,327 1Improved sources are defined as those sources which are likely to provide safe drinking water and include water obtained from a piped source within the dwelling, a public tap, a borehole, or a protected well or spring. 2 The household is considered to have improved sanitation facilities if the household has sole use of a modern or traditional flush toilet that empties into a public sewer, Bayara (vault) or septic system. 158 | Child Health differentials, diarrheal episodes were more common among children living in Upper Egypt and the Urban Governorates than in Lower Egypt and the Frontier Governorates. Diarrheal prevalence decreased somewhat with the wealth quintile. Surprisingly, diarrheal prevalence was slightly lower among the small number of children living in households where the drinking water source is unimproved than among children living in households with an improved drinking water source. The relationship between diarrheal prevalence and toilet facilities conforms to the expectation that children living in households where the toilet facility is unimproved would have a higher rate of diarrheal illness than children living in households with an improved toilet facility; however the differential is not large. 12.3.2 Consultation, Treatment and Feeding Practices Information is available from the 2008 EDHS on the actions that were taken when a child had diarrhea during the two-week period before the survey. Table 12.9 shows that advice or treatment was sought at a health facility in 63 per- cent of all recent diarrheal episodes. Among those seeking medical advice, almost all consulted only one provider. Private health care providers were consulted nearly twice as often as providers at public sector facilities. Around six in ten of the consultations were reported to have occurred on the first day the child was ill, and parents waited 4 or more days to seek advice in a small minority of cases (6 percent). Table 12.10 presents information on the drugs or other treatments employed when a child was ill with diarrhea. Nearly one-quarter of children were not given anything to treat the diarrhea. Virtually all ever-married women age 15-49 (96 percent) were aware of the availability of packets of oral rehydration salts that can be used to prevent dehydration (not shown in table). However, only 28 percent of children suf- fering from diarrhea were given a solution prepared using a packet of oral rehydration salts. In 3 percent of the cases, the child was given a solution of sugar and salt (i.e., a recom- mended home fluid (RHF)). Antibiotics and anti-diarrheal medications are genera- lly not recommended to treat diarrhea in young children. However, Table 12.10 shows that antibiotics were given to one-third of the children with diarrhea, 15 percent received antimotility drugs, and 34 percent were given other drugs, e.g., antipyretics to treat the fever accompanying the diarrhea. The results in Table 12.10 also show that feeding practices during diarrheal episodes are not optimal. Fluids were increased for only 11 percent of the children ill with diarrhea. In 31 percent of the cases, the mother said that the child was either given nothing to drink (12 percent) or much less fluid than normal (19 percent), while 29 percent of the children received somewhat less than the normal amount of liquids. Table 12.9 Consultation about diarrheal episode Among children with diarrhea, percent distribution by number of sources from which advice or treatment was sought during illness and, among ill children for whom a source was consulted, the first source consulted during the illness and the timing of the first consultation, Egypt 2008 Consultation All diarrhea Number of sources consulted None 37.3 1 59.9 2 or more 2.7 Total percent 100.0 Number of ill children 874 Source consulted first about illness Public sector 29.1 Urban Hospital 8.4 Urban health unit 3.1 Health office 0.6 Rural hospital 1.9 Rural health unit 9.5 MCH center 1.8 Other government 3.8 Private sector 59.5 Nongovernmental 0.4 Private medical 59.1 Private hospital/clinic 3.9 Private doctor 53.2 Other private medical 1.9 Pharmacy 11.3 Other nonmedical 0.1 Timing of first consultation First day child ill 62.6 2-3 days after child ill 30.8 4-5 days after child ill 4.3 6 or more days after child ill 1.9 Don’t know/missing 0.4 Total percent 100.0 Number of children having consultation(s) 547 Child Health | 159 Table 12.10 Treatment and feeding practices during diarrhea Percent distribution of children under five years who had diarrhea in the two weeks preceding the survey by ORS packet and drugs or other remedies used to treat diarrhea and by amount of liquids and food offered compared to normal practice, Egypt 2008 Treatment and feeding practices Percent Drugs/other treatment Any drug/ other treatment 76.7 ORT 28.4 ORS packet 28.4 Homemade SS solution 2.9 Antibiotic pill/syrup/injection 33.1 Antimotility 14.8 IV 0.4 Zinc 0.3 Other/unknown pill/syrup/injection 33.8 Home remedy 2.3 No drug/other treatment given/ missing 23.3 Number of ill children 100.0 Amount of liquids offered Same as usual 29.1 More 11.0 Somewhat less 28.8 Much less 18.6 None 12.3 Don't know/missing 0.1 Amount of food offered Same as usual 18.6 More 1.2 Somewhat less 28.4 Much less 18.1 None 10.3 Never gave food 23.3 Total percent 100.0 Number of ill children 874 Note: Percentages given various drugs will not add to the total percentage given drug(s) because more than one response regarding the drugs given was possible. It is important that children who have diarrhea receive adequate nutrients; thus, it is recom- mended that that a child with diarrhea should be offered more food than normal or at least continue to be fed the same amounts as usual. Table 12.10 shows that only one-fifth of children suffering from diarrhea were fed normally (19 percent) or given an increased amount of food (1 percent). Many children with diarrhea were fed much less than normal (18 percent) or given nothing to eat (10 percent). 12.3.3 Differentials in Feeding and Treatment Practices Table 12.11 presents information on how feeding practices during diarrheal episodes vary by background characteristics. The results show that, regardless of the subgroup, only a small minority of children—averaging 6 percent—were fed optimally when they were ill with diarrhea, i.e., the child was offered increased fluids and continued feeding. As noted earlier, use of ORT is important because it increases fluid intake during diarrhea. Table 12.11 shows that, overall, around one in five children with diarrhea received both continued feeding and some form of increased fluid intake (ORT and/or increased fluids). 160 | Child Health Table 12.11 Feeding practices during diarrhea Percent distribution of children under age five who had diarrhea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, the percentage of children given increased fluids and continued feeding during the diarrhea episode, and the percentage of children who continued feeding and were given ORT and/or increased fluids during the episode of diarrhea, by background characteristics, Egypt 2008 Amount of liquids offered Amount of food offered Background characteristic Same as usual More Some- what less Much less None Don't know/ missing Total Same as usual More Some- what less Much less None Never gave food Total Per- centage given increased fluids and continued feeding 1,2 Percentage who con- tinued feed- ing and were given ORT and/or increased fluids3 Number of children with diarrhea Age in months <6 32.0 2.5 21.6 11.7 32.2 0.0 100.0 4.5 0.0 3.2 5.0 3.2 84.1 100.0 0.2 3.4 140 6-11 27.6 11.5 28.7 18.8 13.1 0.3 100.0 10.9 1.4 26.1 16.9 17.7 26.9 100.0 3.4 15.5 239 12-23 25.3 12.8 33.3 21.6 7.0 0.0 100.0 24.8 0.6 36.6 19.5 10.4 8.0 100.0 8.2 26.8 244 24-35 33.9 16.7 19.7 22.2 7.5 0.0 100.0 25.8 3.1 31.4 27.5 11.2 1.0 100.0 10.0 24.1 129 36-47 33.0 12.0 37.4 14.0 3.5 0.0 100.0 36.2 1.2 35.9 22.1 3.5 1.2 100.0 6.6 15.7 64 48-59 29.8 8.5 38.7 19.5 3.6 0.0 100.0 23.1 1.7 50.0 23.2 2.1 0.0 100.0 7.1 29.6 57 Sex Male 28.0 12.4 28.0 17.3 14.1 0.2 100.0 19.7 0.9 28.8 18.2 9.2 23.3 100.0 7.3 21.8 467 Female 30.5 9.5 29.7 20.1 10.3 0.0 100.0 17.4 1.6 28.0 18.0 11.6 23.4 100.0 3.9 15.7 407 Type of diarrhea Non-bloody 30.0 10.9 28.8 17.9 12.4 0.0 100.0 18.9 1.2 28.3 17.7 10.3 23.7 100.0 5.7 19.2 831 Bloody (11.5) (14.4) (28.6) (32.4) (11.2) (1.8) 100.0 (13.6) (1.7) (32.1) (24.5) (10.8) (17.2) 100.0 (5.8) (13.5) 43 Any other illness Had other illness 24.5 10.2 28.3 22.1 14.7 0.2 100.0 13.5 0.7 26.0 20.2 15.2 24.3 100.0 4.2 14.9 401 Fever only 22.0 11.8 28.1 20.4 17.6 0.0 100.0 15.1 1.0 27.0 19.1 13.9 23.9 100.0 5.8 14.4 178 ARI only (39.7) (4.9) (28.5) (11.7) (12.1) (3.0) 100.0 (7.6) (4.7) (21.5) (8.4) (9.5) (48.2) 100.0 (4.9) (20.0) 26 Fever and ARI 24.8 9.6 28.3 24.9 12.4 0.0 100.0 12.9 0.0 25.7 22.7 17.1 21.5 100.0 2.7 14.7 198 No other illness 33.0 11.7 29.2 15.7 10.3 0.0 100.0 22.9 1.6 30.5 16.3 6.2 22.5 100.0 7.0 22.3 472 Urban-rural residence Urban 25.2 13.7 25.7 22.9 12.2 0.2 100.0 11.5 0.5 30.1 23.3 10.2 24.4 100.0 7.0 16.9 351 Rural 31.7 9.3 30.8 15.8 12.4 0.0 100.0 23.4 1.7 27.3 14.5 10.4 22.6 100.0 4.8 20.3 523 Place of residence Urban Governorates 28.4 17.4 20.6 26.8 6.7 0.0 100.0 9.1 0.0 31.1 24.2 10.4 25.2 100.0 7.8 19.0 154 Lower Egypt 26.4 7.5 28.8 21.3 16.0 0.0 100.0 22.8 0.9 26.6 19.6 13.1 16.9 100.0 2.5 15.0 262 Urban 19.1 8.1 21.6 30.2 21.0 0.0 100.0 18.5 0.0 21.7 28.8 13.5 17.5 100.0 2.3 5.8 53 Rural 28.3 7.4 30.6 19.1 14.7 0.0 100.0 23.9 1.2 27.9 17.3 13.0 16.8 100.0 2.6 17.4 210 Upper Egypt 30.9 10.9 31.7 14.2 12.1 0.2 100.0 19.4 1.7 28.7 15.0 8.7 26.5 100.0 6.7 21.0 449 Urban 24.0 11.7 33.3 15.4 15.0 0.6 100.0 11.4 1.1 32.6 20.3 8.7 25.9 100.0 8.0 18.1 139 Rural 34.0 10.5 31.0 13.6 10.9 0.0 100.0 23.1 2.0 26.9 12.6 8.7 26.7 100.0 6.1 22.3 310 Frontier Governorates (30.0) (13.0) (23.6) (25.1) (8.3) (0.0) 100.0 (17.2) (4.6) (23.6) (21.1) (9.2) (24.2) 100.0 (10.7) (29.3) 9 Mother's education No education 34.0 8.3 33.3 14.5 9.5 0.4 100.0 24.8 2.4 28.7 12.4 7.9 23.8 100.0 5.0 22.4 200 Some primary 24.8 14.1 28.8 17.7 14.7 0.0 100.0 11.3 0.9 35.3 18.6 17.5 16.3 100.0 5.8 17.0 91 Primary complete/ some secondary 25.6 12.6 24.9 25.0 11.8 0.0 100.0 17.8 0.6 24.8 23.4 6.4 26.9 100.0 5.9 20.2 146 Secondary complete/ higher 29.0 11.1 28.0 18.6 13.3 0.0 100.0 17.6 0.9 28.1 18.7 11.3 23.4 100.0 5.9 17.3 437 Wealth quintile Lowest 29.7 8.4 34.7 14.7 12.5 0.0 100.0 23.9 1.6 26.0 12.4 10.5 25.6 100.0 5.5 20.6 204 Second 33.2 14.4 27.0 15.0 10.4 0.0 100.0 21.0 2.8 27.4 15.4 10.6 22.8 100.0 5.8 24.0 178 Middle 26.3 10.2 30.8 17.8 14.5 0.4 100.0 16.2 0.4 32.2 18.9 7.0 25.2 100.0 5.7 22.3 191 Fourth 25.1 9.7 20.9 29.9 14.4 0.0 100.0 15.1 0.5 27.5 26.1 9.9 20.9 100.0 5.3 11.9 161 Highest 31.6 13.3 28.9 17.3 8.9 0.0 100.0 15.1 0.5 29.2 19.4 14.6 21.1 100.0 6.4 13.7 140 Total 29.1 11.0 28.8 18.6 12.3 0.1 100.0 18.6 1.2 28.4 18.1 10.3 23.3 100.0 5.7 18.9 874 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Equivalent to the UNICEF/WHO indicator "Home management of diarrhea." MICS Indicator 34 2 Continued feeding includes children who were given more, same as usual, or somewhat less food during the diarrhea episode 3 Equivalent to UNICEF MICS Indicator 35. Child Health | 161 Although the pattern was not uniform, children age 12 months and older were more likely than younger children to have received continued feeding and some form of increased fluids. Optimal feeding practices or a combination of continued feeding and ORT usage and/or increased fluids was somewhat more common among boys than girls, among urban children than children living in rural areas, and among children from the Frontier Governorates than children from other areas. The variation in these practices by education level and the wealth quintile are not uniform; however, children in the three lowest wealth quintiles were markedly more likely than children in the two highest quintiles to have received continued feeding and ORT and/or increased fluids. Table 12.12 provides additional detail on the variation in the approaches used in treating diarrhea across subgroups. The majority of children in all of the subgroups received some form of care or treatment for the diarrhea. In general, the differences across subgroups in specific treatment approaches are greater with respect to the proportions adopting various feeding practices than in the proportions seeking medical care or using antibiotics or other medications. With regard to the proportions seeking medical care, the highest rates were observed for children living in rural Lower Egypt and in urban Upper Egypt and among children in the highest wealth quintile. Use of antibiotics for treating diarrheal episodes was most often reported in rural Lower Egypt and urban Upper Egypt. 162 | Child Health Table 12.12 Consultation with provider and treatment of diarrhea by background characteristics Among children ill with diarrhea in the two weeks preceding the survey, percentage receiving medical care, oral rehydration therapy (ORT), other treatment and no treatment, according to background characteristics, Egypt 2008 Oral rehydration therapy ORT Health provider consulted1 Background characteristic Any2 Public Private2 ORS packets Home salt/ sugar solution (HSS) Either ORS or HSS Increased fluids Given ORT/ increased fluids Increased/ same amount of food Antibiotic injection/ pill/syrup Other injection/ pill/syrup/ zinc/IV/ antimotility Home remedy/ other No care/ treat- ment Number of ill children Age in months <6 60.0 16.9 43.1 24.4 1.7 24.4 2.5 26.4 4.5 32.0 32.1 15.7 19.7 140 6-11 65.1 18.0 47.0 30.7 2.5 32.2 11.5 40.3 12.3 35.7 32.9 22.8 19.4 239 12-23 56.0 19.2 36.8 34.1 3.3 36.3 12.8 44.8 25.5 35.5 34.3 22.2 16.2 244 24-35 43.6 14.9 28.8 22.7 3.1 25.8 16.7 39.3 28.9 26.6 25.4 18.9 24.6 129 36-47 40.9 24.0 16.9 19.0 4.1 23.1 12.0 29.0 37.4 27.1 25.2 18.5 25.0 64 48-59 45.3 18.9 26.4 27.3 4.1 30.5 8.5 37.8 24.7 35.3 32.8 15.5 19.2 57 Sex Male 57.2 20.4 36.8 30.5 3.0 32.2 12.4 40.6 20.6 34.0 28.8 20.0 20.9 467 Female 53.5 15.7 37.8 26.0 2.8 28.2 9.5 35.4 19.0 32.0 34.5 20.3 18.4 407 Urban-rural residence Urban 57.3 18.4 38.9 27.6 3.6 30.0 13.7 38.7 11.9 31.3 31.9 24.2 18.7 351 Rural 54.3 18.1 36.2 28.9 2.4 30.6 9.3 37.9 25.1 34.3 31.1 17.4 20.3 523 Place of residence Urban Governorates 53.7 18.9 34.8 31.5 4.8 35.1 17.4 47.2 9.1 25.5 27.9 26.1 21.9 154 Lower Egypt 59.7 16.9 42.8 22.2 1.4 23.1 7.5 29.5 23.7 36.1 32.8 26.1 15.9 262 Urban 54.7 11.2 43.4 9.2 0.0 9.2 8.1 16.2 18.5 26.8 31.0 33.5 17.9 53 Rural 61.0 18.4 42.6 25.5 1.8 26.6 7.4 32.8 25.0 38.4 33.2 24.3 15.4 210 Upper Egypt 53.9 18.5 35.4 30.9 3.1 32.9 10.9 40.0 21.2 34.1 31.9 14.6 21.0 449 Urban 62.6 20.1 42.5 29.7 3.5 31.6 11.7 37.0 12.5 39.4 36.8 18.8 15.8 139 Rural 49.9 17.8 32.2 31.5 2.9 33.5 10.5 41.4 25.1 31.7 29.8 12.8 23.4 310 Frontier Governorates (44.0) (28.7) (15.3) (31.1) (2.3) (33.4) (13.0) (46.4) (21.8) (23.2) (29.2) (17.2) (28.6) 9 Education No education 54.2 20.3 34.0 34.0 1.6 34.6 8.3 39.9 27.2 33.5 28.4 10.3 21.1 200 Some primary 53.6 21.2 32.4 21.5 3.8 25.3 14.1 36.5 12.2 33.0 34.9 22.7 18.3 91 Primary complete/ some secondary 52.5 18.6 33.9 29.7 5.9 33.1 12.6 42.9 18.4 29.8 27.6 19.3 24.0 146 Secondary complete/higher 57.5 16.5 41.0 26.9 2.2 28.6 11.1 36.2 18.5 34.0 33.4 24.3 17.9 437 Work status Working for cash 52.8 21.3 31.5 23.8 3.6 27.4 8.3 32.3 20.0 29.8 34.3 35.2 19.9 77 Not working for cash 55.8 17.9 37.9 28.9 2.8 30.7 11.3 38.8 19.8 33.4 31.2 18.6 19.7 796 Wealth quintile Lowest 50.6 20.9 29.7 34.0 3.2 35.8 8.4 41.1 25.5 31.3 25.7 12.8 22.3 204 Second 56.5 16.6 40.0 32.7 2.4 34.3 14.4 45.1 23.9 31.4 25.1 20.5 18.7 178 Middle 59.8 23.0 36.8 26.7 3.9 29.7 10.2 37.9 16.7 35.8 34.3 23.4 15.8 191 Fourth 50.4 14.7 35.8 23.5 1.1 24.6 9.7 30.3 15.5 35.2 36.6 21.1 21.9 161 Highest 61.3 13.8 47.4 22.8 3.8 25.1 13.3 34.7 15.6 31.6 38.1 24.6 20.1 140 Total 55.5 18.2 37.3 28.4 2.9 30.4 11.0 38.2 19.8 33.1 31.5 20.1 19.7 874 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Refers to first source consulted 2 Excludes pharmacy 12.4 DISPOSAL OF CHILDREN’S STOOLS If feces are left uncontained, disease may be spread by direct contact or through animal contact. Children’s feces are often a cause of fecal contamination in the household environment since they are frequently not disposed of properly. To obtain information on this issue, mothers who had at least one child born in January 2003 or later were asked about what was done to dispose of the stools the last time their youngest child had passed stools. Almost all mothers reported that the child either used a toilet or Child Health | 163 latrine when defecating (42 percent) or the child’s stools were thrown into the toilet or latrine (43 percent). Mothers reporting other means of stool disposal generally said the stools were thrown in the garbage (12 percent). Overall, Table 12.13 shows that stools were disposed of safely in the case of 85 percent of all children. The proportion reporting safe stool disposal practices generally increased with the age of the child. Somewhat surprisingly, the proportion was lower in urban areas than in rural areas and in the Urban Governorates than in other areas. The proportion reporting safe stool disposal practices also generally decreased with the wealth quintile. These patterns may be related to the greater use of disposable diapers among the urban and wealthier households. Table 12.13 Disposal of children's stools Percent distribution of youngest children under age five living with the mother by the manner of disposal of the child's last fecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Egypt 2008 Manner of disposal of child’s stools Background characteristic Child used toilet/ latrine Put/ rinsed into toilet/ latrine Buried Put/ rinsed into drain/ ditch Thrown into garbage Left in the open Other Don't know/ missing Total Percentage of children whose stools are disposed of safely Number of children Age in months <6 1.2 56.6 0.2 2.5 39.1 0.0 0.5 0.0 100.0 58.0 529 6-11 3.4 66.7 0.0 2.1 27.2 0.2 0.4 0.0 100.0 70.1 748 12-23 19.6 60.8 0.1 2.6 15.4 1.2 0.0 0.3 100.0 80.5 1,355 24-35 54.6 36.2 0.2 1.5 6.6 0.8 0.0 0.1 100.0 91.0 1,562 36-47 58.6 31.9 0.3 1.0 6.8 1.2 0.0 0.2 100.0 90.8 1,799 48-59 59.6 30.9 0.2 1.5 6.9 0.7 0.2 0.2 100.0 90.6 1,800 Toilet facility Improved1 42.7 42.0 0.1 1.5 12.7 0.6 0.1 0.2 100.0 84.8 6,680 Not improved 41.2 46.3 1.0 3.1 5.1 2.9 0.4 0.0 100.0 88.5 696 Not de jure resident/ missing 32.9 44.6 0.2 2.1 19.6 0.4 0.0 0.2 100.0 77.7 417 Urban-rural residence Urban 43.2 33.4 0.0 1.7 21.3 0.2 0.1 0.1 100.0 76.6 2,973 Rural 41.3 48.2 0.3 1.7 7.0 1.2 0.2 0.2 100.0 89.8 4,820 Place of residence Urban Governorates 42.6 26.1 0.0 2.2 28.8 0.1 0.0 0.1 100.0 68.7 1,271 Lower Egypt 43.4 45.7 0.0 1.2 9.3 0.2 0.1 0.1 100.0 89.2 3,459 Urban 45.7 40.2 0.0 1.5 12.7 0.0 0.0 0.0 100.0 85.8 788 Rural 42.8 47.4 0.0 1.0 8.4 0.2 0.2 0.1 100.0 90.1 2,670 Upper Egypt 40.4 45.9 0.4 2.1 8.9 1.8 0.2 0.3 100.0 86.7 2,954 Urban 42.4 37.5 0.0 1.2 18.0 0.4 0.3 0.1 100.0 79.9 845 Rural 39.5 49.3 0.6 2.5 5.2 2.4 0.1 0.4 100.0 89.4 2,109 Frontier Governorates 36.6 42.3 2.1 1.6 14.8 2.1 0.0 0.5 100.0 81.0 110 Education No education 43.1 45.5 0.4 2.2 5.9 2.5 0.1 0.3 100.0 89.0 1,967 Some primary 44.2 44.6 0.3 2.1 7.5 1.2 0.0 0.2 100.0 89.1 521 Primary complete/some secondary 42.1 43.3 0.2 1.8 11.5 0.6 0.3 0.1 100.0 85.7 1,222 Secondary complete/ higher 41.2 40.6 0.0 1.4 16.5 0.0 0.1 0.1 100.0 81.9 4,083 Work status Working for cash 49.1 34.7 0.0 1.0 14.6 0.5 0.0 0.2 100.0 83.7 891 Not working for cash 41.1 43.6 0.2 1.8 12.1 0.9 0.1 0.2 100.0 84.9 6,902 Wealth quintile Lowest 38.7 50.6 0.7 2.2 3.8 3.4 0.2 0.3 100.0 90.1 1,508 Second 40.8 49.9 0.3 1.6 6.6 0.6 0.2 0.1 100.0 91.0 1,531 Middle 42.8 46.6 0.0 1.1 8.8 0.2 0.2 0.2 100.0 89.4 1,635 Fourth 42.4 39.0 0.0 2.2 16.3 0.0 0.0 0.1 100.0 81.4 1,602 Highest 45.4 26.5 0.0 1.4 26.6 0.0 0.0 0.2 100.0 71.8 1,516 Total 42.0 42.6 0.2 1.7 12.4 0.8 0.1 0.2 100.0 84.8 7,793 1 The household is considered to have improved sanitation facilities if the household has sole use of a modern or traditional flush toilet that empties into a public sewer, Bayara (vault) or septic system. Feeding Practices and Micronutrient Supplementation | 165 FEEDING PRACTICES AND MICRONUTRIENT SUPPLEMENTATION 13 Adequate nutrition is critical to child development. This chapter assesses a number of aspects of feeding practices that are important in ensuring adequate nutrition for infants and young children including early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding for up to two years of age and beyond, timely introduction of complementary feeding at six months of age, frequency of feeding solid/semi-solid foods, and diet diversity. The chapter also discusses the diversity of food groups consumed by mothers who gave birth in the last three years, providing important information on maternal eating patterns (for example, vitamin A-rich foods). Finally, the chapter considers consumption of vitamin A-rich and iron-rich foods, micronutrient supplementation for iron and vitamin A, and micronutrient fortification (iodized or iodated household cooking salt) for both women and children. 13.1 BREASTFEEDING AND SUPPLEMENTATION The pattern of infant feeding has an important influence on the health of children. Feeding practices are the principal determinant of a young child’s nutritional status, and poor nutritional status has been shown to increase the risk of illness and death among children. Breastfeeding practices also have an effect on the mother’s fertility. Frequent breastfeeding for long durations is associated with longer periods of postpartum amenorrhea and thus longer birth intervals and lower fertility. 13.1.1 Initiation of Breastfeeding Early initiation of breastfeeding is important for both the mother and the child. Early suckling stimulates the release of hormones which help in the production of milk. It also stimulates the contraction of the uterus after childbirth. Colostrum, which is the liquid produced from the breast in the first few days after delivery, provides natural immunity to the infant. Prelacteal feeding, the practice of giving other liquids to a child during the period immediately after birth before the mother’s milk is flowing freely, is discouraged. It limits the frequency of suckling by the infant and exposes the baby to the risk of infection. The results in Table 13.1 show that almost all Egyptian children are breastfed for some period of time. Differentials in the proportion of children ever breastfed are small, with 94 percent or more of children in every subgroup reported as ever breastfed. Among Egyptian children who were ever breastfed, Table 13.1 also shows that the majority began breastfeeding soon after birth; 88 percent of the children were put to the breast within the first day after delivery, and 56 percent within the first hour. Although breastfeeding is initiated early for the majority of children, prelacteal feeding is common; 47 percent of all children born in the five years prior to the survey received prelacteal feeds during the first three days after birth. Children who received prelacteal feeds were most often given sugar or glucose water or tea and other infusions; relatively small proportions were given milk other than breast milk or infant formula (Figure 13.1). Both medical assistance at delivery and delivery at a health facility are associated with lower proportions of children for whom breastfeeding was initiated within the first day of birth and with somewhat higher proportions of prelacteal feeding although the differentials are not large. 166 | Feeding Practices and Micronutrient Supplementation Table 13.1 Initial breastfeeding by background characteristics Percentage of children born in the five year period before the survey who were ever breastfed, and for the last children born in the five years preceding the survey ever breastfed, percentage who started breastfeeding within one hour and within one day of birth and percentage who received a prelacteal feed, by selected background characteristics, Egypt 2008 Percentage who started breastfeeding within: Background characteristic Percentage ever breastfed Number of children 1 hour of birth 1 day of birth1 Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Assistance at delivery Medically trained provider3 95.4 8,352 51.4 86.5 48.0 6,081 Daya 97.2 2,085 74.4 92.2 41.0 1,452 Other/none 99.6 132 64.7 87.3 44.1 95 Place of delivery Public health facility 93.8 2,851 51.5 85.5 47.1 2,015 Private health facility/NGO 96.0 4,746 48.0 86.1 50.3 3,489 Home/other 97.2 2,991 73.1 92.1 40.0 2,126 Sex Male 95.7 5,388 55.2 86.9 47.3 3,964 Female 95.9 5,202 56.7 88.4 45.9 3,668 Urban-rural residence Urban 95.2 3,924 51.3 88.9 46.2 2,900 Rural 96.1 6,666 58.7 86.8 46.8 4,732 Place of residence Urban Governorates 95.2 1,679 46.1 89.8 46.3 1,244 Lower Egypt 96.1 4,587 57.3 87.6 45.0 3,397 Urban 96.2 1,011 53.3 87.1 47.8 771 Rural 96.1 3,576 58.5 87.7 44.1 2,627 Upper Egypt 95.6 4,173 58.4 86.7 49.0 2,885 Urban 94.1 1,141 57.3 89.2 45.2 818 Rural 96.1 3,032 58.9 85.6 50.5 2,066 Frontier Governorates 95.7 151 56.2 90.2 35.9 107 Mother's education No education 96.1 2,735 60.2 85.7 48.7 1,931 Some primary 96.5 721 58.8 87.6 45.5 519 Primary complete/some secondary 94.9 1,624 57.0 87.4 45.0 1,193 Secondary complete/ higher 95.7 5,510 53.1 88.6 46.2 3,990 Work status Working for cash 94.2 1,168 50.9 87.2 43.9 854 Not working for cash 96.0 9,422 56.5 87.7 46.9 6,778 Wealth quintile Lowest 95.9 2,145 60.1 86.0 47.9 1,478 Second 96.2 2,125 59.0 85.7 48.6 1,516 Middle 95.1 2,251 56.9 87.6 45.7 1,599 Fourth 95.9 2,113 56.1 89.7 44.5 1,564 Highest 95.7 1,956 47.3 89.1 46.4 1,476 Total 95.8 10,590 55.9 87.6 46.6 7,632 Note: Total includes 5 children for whom information on assistance at delivery was missing and 3 children for whom information on place of delivery was missing. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life before the mother started to breastfeed regularly 3 Includes doctor or nurse/midwife Feeding Practices and Micronutrient Supplementation | 167 13.1.2 Introduction of Complementary Feeding The Ministry of Health has adopted the UNICEF recommendation that during the first six months of life, children should be exclusively breastfed; that is, they should be given only breast milk and not receive other complementary liquids (including plain water) or solids. Early complementary feeding is discouraged for a number of reasons. The early introduction of other liquids or foods increases the exposure of an infant to pathogens that may cause diarrheal disease. Malnutrition is another risk. The complementary foods given to a child may not provide all of the calories that the infant needs, particularly if they are watered down. Since the production of breast milk is influenced by the intensity and frequency of suckling, early complementary feeding may reduce breast milk output, again increasing the risk of malnutrition. Information was obtained in the EDHS on the current breastfeeding status of surviving children under age three who were living with the mother and on what other (if any) liquids or solids had been given to the child during the 24-hour period prior to the survey. These data are used to derive the information on the age patterns of breastfeeding and supplementation presented in Table 13.2 and Figure 13.2. The results indicate that breastfeeding continues for the majority of Egyptian children well beyond the first year of life. At age 12-17 months, around 80 percent of children are still being breastfed, and 35 percent of children 18-23 months continue to be breastfed. Exclusive breastfeeding is common but not universal in very early infancy in Egypt. Table 13.2 shows that, among infants under two months of age, 79 percent were reported to have received only breast milk. However, the proportion exclusively breastfed drops off rapidly among older infants. By age 4-5 months, around seven in ten babies are receiving some form of supplementation, with somewhat more than three in ten given complementary foods. 6 4 1 59 3 2 50 1 Milk other than breast milk Infant formula Plain water Sugar or glucose water Gripe water Sugar- salt-water solution Tea/ infusions Other 0 20 40 60 80 Percent Figure 13.1 Among Last Children Born in the Five Years Preceding the Survey Who Ever Received Prelacteal Feeds, Percentage Receiving Various Types of Liquids 1 Commercial preparation for soothing colicky babies 1 EDHS 2008 168 | Feeding Practices and Micronutrient Supplementation Table 13.2 Breastfeeding status by age Percent distribution of youngest children under age three living with the mother by breastfeeding status and the percentage currently breastfeeding and percentage of all children under three years using a bottle with a nipple, according to age in months, Egypt 2008 Breastfeeding and consuming Months since birth Not breast- feeding Exclusively breastfed Plain water only Non-milk liquids/ juice Other milk Comple- mentary foods Total percent Currently breast- feeding Number of youngest children under age 3 Percentage using a bottle with a nipple Number of all children under age 3 <2 2.1 78.9 9.7 3.3 5.0 0.9 100.0 97.9 299 10.1 309 2-3 2.5 57.5 18.5 6.3 8.9 6.3 100.0 97.5 404 20.7 408 4-5 6.0 28.8 24.7 5.2 5.4 30.0 100.0 94.0 387 15.8 393 6-8 8.7 12.3 11.8 2.2 1.6 63.5 100.0 91.3 703 16.7 716 9-11 7.8 3.9 4.6 0.6 1.7 81.4 100.0 92.2 555 14.1 568 12-17 22.4 0.7 2.2 0.1 0.4 74.3 100.0 77.6 1,048 10.0 1,080 18-23 65.5 0.4 0.3 0.0 0.0 33.7 100.0 34.5 969 4.9 1,080 24-35 95.9 0.1 0.0 0.0 0.0 3.9 100.0 4.1 1,515 1.7 2,002 0-3 2.3 66.6 14.8 5.1 7.2 4.0 100.0 97.7 703 16.1 717 0-5 3.6 53.2 18.3 5.1 6.6 13.2 100.0 96.4 1,090 16.0 1,110 6-9 8.8 10.9 10.8 1.9 1.5 66.2 100.0 91.2 891 16.7 907 10-11 6.9 3.1 3.3 0.7 1.9 84.1 100.0 93.1 368 12.7 377 12-23 43.1 0.6 1.3 0.0 0.2 54.8 100.0 56.9 2,017 7.5 2,160 Total 41.9 11.9 5.7 1.3 1.6 37.5 100.0 58.1 5,880 8.7 6,556 Note: Breastfeeding status refers to a 24-hour period (yesterday and last night). Children classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and water-based liquids and who do not receive complementary foods are classified in the water-based liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. Figure 13.2 Infant Feeding Practices by Age <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months 0 20 40 60 80 100 Exclusively breastfed Breastmilk and plain water only Breastmilk and non-milk liquids Breastmilk and other milk/formula Breastmilk and complementary foods Not breastfeeding EDHS 2008 Percent Feeding Practices and Micronutrient Supplementation | 169 In addition to information on the prevalence of exclusive breastfeeding, the results in Table 13.2 allow an assessment of whether or not complementary feeding is being introduced on a timely basis for older babies. WHO and UNICEF recommend that all children begin to receive complementary food by age six months since, at that age, the mother’s breast milk no longer provides adequate nutrition for the child. Table 13.2 shows that the majority of Egyptian children age 6 months and older are receiving other foods or milk in addition to breast milk. At 6-8 months, however, about one in three babies were not being given solid or semi-solid food in addition to breast milk and, at age 9-11 months, 19 percent of children were not yet eating solid or semi-solid food. Table 13.2 also provides information on the differentials in the percentage of children under age three who are being bottle-fed. Overall, a bottle with a nipple was used in feeding only 9 percent of the children less than three years of age during the 24 hours before the survey. 13.1.3 Median Durations and Frequency of Breastfeeding and Prevalence of Bottle-feeding Table 13.3 presents differentials in the median duration of breastfeeding among births in the three-year period before the survey, the frequency of breastfeeding among children under six months of age, and the prevalence of bottle-feeding among children under age three. The median duration of breastfeeding is 17.9 months. On average, children are exclusively breastfed or predominantly breastfed for less than the recommended six months; the median duration for which children are exclusively breastfed is 2.6 months and the median duration of predominant breastfeeding, i.e., when children receive only nonmilk liquids in addition to breast milk, is 4.8 months. The median amount of time that a child is breastfed is slightly shorter among children whose mothers were attended at delivery by a doctor or other health professionals and among children delivered in a health facility. Males are breastfed slightly longer on average than females. Residence is related to breastfeeding durations. The median breastfeeding duration is one month longer for rural children than urban children, and it ranges from a low of 15.7 months in the Urban Governorates to 19.3 months in rural Upper Egypt. Children born to mothers who never attended school are breastfed two months longer on average than children born to mothers who completed secondary school or higher. The median duration of breastfeeding among children in the highest wealth quintile is almost 3 months shorter than the duration for children in the lowest quintile. Differentials in the median durations of exclusive breastfeeding and predominant breastfeeding are shown in Table 13.3. The patterns are generally similar to the variations observed in the median durations of any breastfeeding. The frequency of breastfeeding during a 24-hour period before the survey also is examined in Table 13.3. It is important for an infant to breastfeed frequently as this improves milk production. In addition, the duration of postpartum amenorrhea for a mother is related to the frequency of breastfeeding. Among last-born children under age six months, 98 percent were breastfed at least six times during the 24-hour period before the survey. Mothers reported a mean number of 7.3 daytime feeds and 5.7 nighttime feeds. The largest differentials in the measures of breastfeeding frequency are by place of residence, with the highest mean feeding frequencies observed in the Frontier Governorates. Table 13.3 also provides information on the differentials in the percentage of children under age three who are being bottle-fed. Bottle-feeding is most common in the Urban Governorates (15 percent) and in the highest wealth quintile (13 percent). 170 | Feeding Practices and Micronutrient Supplementation Table 13.3 Median duration and frequency of breastfeeding and prevalence of bottlefeeding by background characteristics Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, percentage of last born children under six months of age living with the mother who were breastfed six or more times in the 24 hours preceding the interview, and the mean number of feeds (day/night) among last-born breastfed children under age 6 months, and percentage bottlefed among all children under age three, by background characteristics, Egypt 2008 Median breastfeeding duration (months) among all children born in the past three years1 Breastfeeding frequency among children under six months of age2 Bottle-feeding among all children under age 3 Background characteristic Any breast- feeding Exclusive breast- feeding Predomi- nant breast- feeding3 Number of children Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Percentage under three who are bottlefed Number of children Assistance at delivery Medically trained provider 17.6 2.6 4.7 5,426 98.0 7.3 5.7 849 9.6 5,304 Daya 19.7 2.6 5.9 1,205 97.6 7.6 6.1 184 4.8 1,169 Other/none 16.2 3.7 5.3 77 92.6 * * 14 6.6 75 Place of delivery Public health facility 17.2 2.2 4.4 1,828 98.1 7.0 5.7 278 10.1 1,771 Private health facility/NGO 17.7 2.8 4.7 3,124 98.0 7.4 5.7 485 9.9 3,069 Home/other 19.2 2.9 5.8 1,762 97.5 7.5 5.7 285 5.2 1,714 Sex Male 18.3 2.6 4.8 3,407 98.0 7.4 5.7 540 8.2 3,318 Female 17.6 2.6 4.9 3,309 97.7 7.3 5.8 508 9.2 3,237 Urban-rural residence Urban 17.3 2.1 4.3 2,535 97.4 7.3 5.9 380 11.7 2,475 Rural 18.3 3.0 5.2 4,181 98.2 7.3 5.6 668 6.9 4,081 Place of residence Urban Governorates 15.7 2.0 4.2 1,081 98.1 7.6 5.7 168 15.1 1,049 Lower Egypt 17.8 3.3 5.1 2,926 98.8 7.4 5.7 441 6.1 2,882 Urban 17.8 2.7 5.2 658 97.7 7.7 6.2 85 6.6 653 Rural 17.9 3.4 5.1 2,268 99.0 7.3 5.6 356 5.9 2,229 Upper Egypt 19.0 2.4 4.9 2,611 96.8 7.1 5.7 423 9.1 2,530 Urban 18.5 2.0 4.0 734 95.9 6.5 5.9 119 11.3 713 Rural 19.3 2.6 5.3 1,877 97.1 7.3 5.6 305 8.2 1,817 Frontier Governorates 18.2 2.2 3.7 98 100.0 7.6 6.8 15 9.7 95 Mother's education No education 19.5 2.9 5.9 1,644 97.0 7.3 5.5 256 5.8 1,605 Some primary 17.8 2.7 4.7 423 94.5 7.3 5.7 57 9.6 406 Primary complete/ some secondary 18.0 2.5 4.5 1,023 98.3 7.7 6.1 168 8.3 996 Secondary complete/higher 17.5 2.5 4.6 3,626 98.5 7.2 5.7 567 10.1 3,549 Work status Working for cash 17.7 1.6 3.4 691 96.1 6.6 5.3 90 13.4 672 Not working for cash 18.0 2.7 5.0 6,026 98.0 7.4 5.8 958 8.2 5,884 Wealth quintile Lowest 19.8 3.1 5.5 1,325 97.5 7.1 5.6 208 6.1 1,283 Second 19.0 3.0 5.2 1,350 96.8 7.5 5.5 217 6.6 1,312 Middle 17.6 2.6 5.3 1,400 98.7 7.3 5.8 240 7.4 1,369 Fourth 16.9 2.4 4.6 1,377 98.3 7.3 6.0 206 10.8 1,343 Highest 17.1 2.2 3.7 1,264 98.0 7.3 5.8 177 12.8 1,249 Total 17.9 2.6 4.8 6,716 97.9 7.3 5.7 1,048 8.7 6,556 Mean for all children 17.7 4.1 6.0 na na na na na na na Note: Median durations are based on current status. Includes children living and deceased at the time of the survey. Totals include 8 children for whom information on assistance at delivery is missing and 3 children for whom information on place of delivery is missing. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfed. 2 Excludes children who do not have a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only Feeding Practices and Micronutrient Supplementation | 171 13.2 DIETARY DIVERSITY AMONG CHILDREN AND WOMEN In the 2008 EDHS, women who had at least one child under the age of three living with them were asked questions about the types of foods and liquids they and their youngest child had consumed during a 24-hour period prior to the survey. Mothers were also asked about the number of times the child had eaten solid or semi-solid food during the period. The results of these questions are subject to a number of limitations. First, the results do not apply to the full universe of young children and women. Approximately 10 percent of all children under age three are excluded from consideration because they were not the youngest child under age three or because they were not living with the mother. Women who have one child under age three living with them constitute only a little more than one-third of all EDHS respondents and about a quarter of all women in the reproductive ages 15-49. The dietary data for both women and children also are subject to recall errors. In addition, the mother may not be able to report fully on the child’s intake of food and liquids if the child was fed by other individuals during the period. Despite these problems, the information collected in the 2008 EDHS on the types of foods and liquids mothers and young children are consuming is useful in assessing the dietary diversity for these key subpopulations. 13.2.1 Foods and Liquids Consumed by Infants and Young Children Appropriate nutrition includes feeding children a variety of foods to ensure that nutrient requirements are met. Vitamin-A rich fruits and vegetables should be consumed daily. Although eating a range of fruits and vegetables, especially those rich in vitamin A is important, studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients (WHO/UNICEF 1998). Therefore, it has been advised that meat, poultry, fish or eggs should be eaten daily, or as often as possible. Fat also is important in the diets of infants and young children because it provides essential fatty acids, facilitates absorption of fat-soluble vitamins (such as vitamin A) and enhances dietary energy density and palatability. Tea and coffee contain compounds that inhibit iron absorption and are not recommended for children. Sugary drinks and excessive juice consumption should be avoided because other than energy, they contribute little to the diet and as a result decrease the child’s appetite for more nutritious foods (PAHO/WHO 2003). Table 13.4 is based on information from women about the foods and liquids consumed during the 24-hour period prior to the survey by their youngest child. As expected, the proportions of children who consumed foods or liquids included in the various groups shown in the table rises with the age of the child. Children who are still breastfed also are less likely to consume the various types of foods than children who are not being breastfed. For example, 93 percent of not breastfeeding children age 6-23 months consumed foods made from grains in the 24-hour period prior to the survey compared with 73 percent of breastfeeding children in the age group. Of particular concern is the fact that the majority of children age 6-23 months, whether breastfeeding or not, did not consume any vitamin-A rich food during the 24-hour period before the survey. Substantial minorities of children in the age group also did not consume meat, poultry or fish or food made with oil, fat or butter. 172 | Feeding Practices and Micronutrient Supplementation Table 13.4 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under three years of age living with the mother who consumed foods from specific food groups in the past 24 hours (the day and night preceding the interview), by breastfeeding status and age, Egypt 2008 Age in months Infant formula Other milk1 Other liquids2, 3 Food made from grains4 Fruits and vege- tables rich in vitamin A5 Other fruits/ vege- tables Food made from roots/ tubers Food made from legumes and nuts Meat/ fish/ shellfish/ poultry/ eggs Cheese/ yogurt/ other milk products Food made with oil/ fat/ butter Sugary foods Any solid or semi- solid food Number of children BREASTFEEDING CHILDREN <2 3.1 2.9 5.2 0.8 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.4 0.9 293 2-3 4.5 9.2 11.6 1.7 0.3 0.3 0.7 0.1 0.4 3.5 0.7 0.7 5.6 394 4-5 4.0 13.5 20.5 13.9 2.1 2.7 10.0 3.7 7.5 21.9 6.1 5.4 30.8 364 6-8 3.6 31.9 38.3 46.7 14.7 16.4 40.7 12.0 31.4 47.0 31.5 24.1 68.3 642 9-11 5.3 40.8 57.8 71.1 25.2 31.5 49.6 26.9 62.8 62.3 57.6 43.0 87.6 512 12-17 2.1 49.7 60.5 86.4 36.0 39.5 60.7 42.3 73.0 71.2 72.8 51.1 95.5 813 18-23 3.0 50.9 68.2 91.8 37.2 37.6 66.9 44.3 76.6 71.7 72.6 50.2 97.9 334 24-35 0.6 58.9 72.3 87.4 33.9 40.2 65.8 58.0 68.5 66.0 75.5 52.2 94.8 62 6-23 3.4 42.9 54.8 72.7 27.8 31.0 53.5 30.8 59.7 62.5 57.9 41.6 86.5 2,301 Total 3.5 32.8 42.2 52.4 19.6 22.0 38.4 22.2 42.3 46.1 41.1 29.7 64.0 3,414 NON-BREASTFEEDING CHILDREN <6 (26.9) (57.7) (25.1) (12.8) (0.0) (2.5) (8.5) (5.0) (4.1) (19.3) (5.0) (8.2) (24.8) 39 6-8 38.6 70.6 50.9 64.2 22.7 27.6 44.7 10.8 40.0 59.6 46.1 36.8 80.9 61 9-11 20.0 69.0 63.8 72.2 28.5 29.4 55.0 28.0 54.7 60.5 61.6 46.4 91.3 43 12-17 8.9 67.2 75.5 93.9 37.9 40.4 66.4 47.0 79.6 72.6 78.8 52.4 99.1 234 18-23 2.2 62.8 71.3 97.1 44.2 47.5 65.9 53.8 85.2 74.4 85.5 59.5 99.4 635 24-35 3.1 60.1 75.7 96.6 46.6 50.1 70.4 58.7 85.7 73.7 85.1 58.7 99.5 1,453 6-23 6.9 64.7 70.7 93.2 40.6 43.7 64.2 48.3 79.6 72.4 80.4 55.8 97.8 974 Total 5.0 61.9 72.9 93.9 43.5 46.8 66.9 53.7 82.0 72.3 81.9 56.7 97.6 2,466 Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and the past night). Figures in parentheses are based on 25-49 unweighted cases. 1 Other milk includes fresh, tinned, and powdered milk from cows or other animals. 2 Does not include plain water 3 Includes sugary drinks 4 Includes fortified baby food and porridge or gruel 5 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, mangoes, cantaloupe, dark green leafy vegetables, and other locally grown fruits and vegetables that are rich in vitamin A 13.2.2 Appropriate Infant and Young Child Feeding Appropriate infant and young child feeding (IYCF) practices include timely initiation of feeding solid/semi-solid foods from age six months and increasing the amount of foods and frequency of feeding as the child gets older while maintaining frequent breastfeeding. Guidelines have been established with respect to appropriate infant and young child feeding (IYCF) practices for children age 6-23 months (PAHO/WHO 2003 and WHO 2005). Feeding Practices and Micronutrient Supplementation | 173 Table 13.5 presents a summary of indicators of appropriate feeding practices that describes the quality of infant and young child (age 6-23 months) feeding practices (IYCF) in Egypt. The indicators take into account the percentages of children for whom feeding practices met minimum standards with respect to both food diversity (i.e., the number of food groups consumed) and feeding frequency (i.e., the number of times the child was fed) as well the consumption of breast milk or breast milk substitutes. Breastfed children are considered as being fed appropriately if they consume at least three food groups1 and receive food or liquids other than breast milk at least twice per day in the case of infants 6-8 months and at least three times in the case of children 9-23 months. Non-breastfed children are considered to be fed appropriately if they consumed four food groups including milk products and are fed at least four times per day. According to the results presented in Table 13.5, 97 percent of youngest children age 6-23 months living with the mother received breast milk or breast milk substitutes during the 24-hour period prior to the survey, 69 percent had an adequately diverse diet, i.e., they had been fed foods from the appropriate number of food groups depending on their age and breastfeeding status, and half had been fed the minimum standard number of times appropriate for their age. Feeding practices for about 41 percent of children age 6-23 months met the minimum standard with respect to all three of these feeding practices (Figure 13.3). As Figure 13.3 shows, breastfed children were more likely than non-breastfed children to meet all three IYCF criteria. The results in Table 13.5 indicate that breastfed children were somewhat more likely to be fed the minimum number of times and somewhat less likely to receive foods from the minimum number of groups compared to non-breastfed children. As the child’s age increased, feeding practices were generally more likely to comply with minimum standards. Variations in feeding practices with the other characteristics shown in Table 13.5 are generally minor. 1 Food groups used in the assessment of appropriate feeding practices included: milk other than breast milk, cheese or yogurt; foods made from grains, roots, and tubers; vitamin A-rich fruits and vegetables; other fruits and vegetables; eggs; meat, poultry, fish, and shellfish (and organ meats); legumes and nuts; and foods made with oil, fat, butter 174 | Feeding Practices and Micronutrient Supplementation Table 13.5 Infant and young child feeding (IYCF) practices in Egypt Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based upon number of food groups received and number of times they were fed meals during the past 24 hours (the day and night preceding the survey), by breastfeeding status and background characteristics, Egypt 2008 Among breastfed youngest children 6-23 months living with mother, percentage fed Among all youngest children 6-23 months living with mother, percentage breastfed and receiving other foods according to minimum practices for breastfed children Among non-breastfed youngest children 6-23 months living with mother, percentage fed Background characteristic 3+ food groups1 Mini- mum number of times or more2 Both 3+ food groups and mini- mum times or more Number of breastfed children 6-23 months Milk or milk products3 4+ food groups 4+ times With 3 IYCF practices4 Number of non- breastfed children age 6-23 months Breast- milk/ milk products3 3+ or 4+ food groups5 Mini- mum number of times6 With 3 IYCF feeding practices Number of children 6-23 months Age in months 6-8 30.7 54.7 29.1 642 87.8 37.8 15.9 13.1 61 98.9 31.3 51.3 27.7 703 9-11 60.0 45.6 38.9 512 90.4 74.2 17.9 14.7 43 99.3 61.1 43.4 37.1 555 12-17 79.0 62.7 57.2 813 90.6 84.3 30.0 27.8 234 97.9 80.2 55.4 50.6 1,048 18-23 79.7 71.0 62.9 334 88.7 90.8 34.4 33.8 635 92.6 87.0 47.0 43.8 969 Sex Male 60.9 58.5 46.8 1,200 90.7 84.1 31.1 29.6 473 97.4 67.4 50.8 42.0 1,673 Female 62.0 57.2 45.3 1,101 87.8 86.1 31.8 30.8 500 96.2 69.6 49.2 40.8 1,602 Urban-rural residence Urban 61.7 62.1 48.9 816 91.0 84.4 36.3 34.8 445 96.8 69.7 53.0 43.9 1,262 Rural 61.3 55.6 44.6 1,485 87.7 85.8 27.4 26.4 528 96.8 67.7 48.2 39.8 2,014 Place of residence Urban Governorates 58.3 66.6 50.7 306 92.5 86.5 47.2 45.7 235 96.7 70.5 58.1 48.5 542 Lower Egypt 64.7 56.7 46.5 1,042 88.0 85.0 21.5 20.3 416 96.6 70.5 46.7 39.0 1,458 Urban 66.0 58.6 48.4 223 84.1 82.0 13.9 12.8 102 95.0 71.0 44.6 37.3 325 Rural 64.4 56.2 46.0 819 89.2 86.0 24.0 22.7 314 97.0 70.4 47.3 39.5 1,133 Upper Egypt 58.5 56.0 43.8 919 88.1 84.3 32.1 31.0 308 97.0 65.0 50.0 40.6 1,227 Urban 61.7 59.9 47.2 263 94.3 82.0 32.3 30.6 98 98.4 67.2 52.4 42.7 361 Rural 57.2 54.4 42.4 656 85.2 85.4 31.9 31.3 210 96.4 64.0 49.0 39.7 866 Frontier Governorates 68.0 65.4 55.1 34 93.9 85.9 49.7 46.8 14 98.2 73.2 60.8 52.7 48 Mother's education No education 55.4 54.5 42.3 573 82.3 83.0 30.6 29.4 175 95.9 61.9 48.9 39.3 748 Some primary 66.1 49.5 43.5 153 91.6 77.6 29.9 27.1 61 97.6 69.4 43.9 38.8 213 Primary complete/ some secondary 64.4 57.5 48.0 365 84.3 81.4 31.1 27.9 157 95.3 69.5 49.5 42.0 522 Secondary comp./ higher 62.8 60.6 47.6 1,210 92.3 87.6 32.0 31.4 582 97.5 70.8 51.3 42.4 1,792 Work status Working for cash 61.6 56.5 42.6 219 93.5 81.8 36.8 35.1 102 97.9 68.0 50.2 40.2 322 Not working for cash 61.4 58.0 46.5 2,082 88.7 85.5 30.8 29.6 871 96.7 68.5 50.0 41.5 2,953 Wealth quintile Lowest 58.6 56.1 44.4 496 87.2 83.4 32.0 30.9 127 97.4 63.7 51.2 41.6 624 Second 60.8 55.6 44.1 492 84.7 85.7 27.7 26.5 148 96.5 66.5 49.2 40.0 639 Middle 64.8 53.9 44.5 453 90.0 81.2 29.0 27.2 209 96.9 70.0 46.1 39.1 662 Fourth 56.8 59.4 43.9 449 86.6 85.2 33.0 31.6 254 95.2 67.1 49.8 39.4 703 Highest 66.8 65.4 54.8 411 95.1 89.2 34.1 33.3 236 98.2 75.0 54.0 47.0 647 Total 61.4 57.9 46.1 2,301 89.2 85.2 31.5 30.2 974 96.8 68.5 50.0 41.4 3,275 1 Food groups: a) infant formula, milk other than breast milk, cheese or yogurt or other milk products; b) foods made from grains, roots, and tubers, including porridge and, fortified baby food from grains; c) vitamin A-rich fruits and vegetables (and red palm oil); d) other fruits and vegetables; e) eggs; f) meat, poultry, fish, and shellfish (and organ meats); g) legumes and nuts; h) foods made with oil, fat, butter. 2 At least twice a day for breastfed infants age 6-8 months and at least three times a day for breastfed children age 9-23 months 3 Includes commercial infant formula, fresh, tinned and powdered animal milk, and cheese, yogurt and other milk products 4 Non-breastfed children age 6-23 months are considered to be fed with three IYFC practices if they receive other milk or milk products are fed at least the minimum number of times per day with at least the minimum number of food groups. 5 3+ food groups for breasted children and 4+ food groups for non-breastfed children 6 Fed solid or semisolid food at least twice a day for infants age 6-8 months, 3+ times a day for other breastfed children, and 4+ times a day for non-breastfed children Feeding Practices and Micronutrient Supplementation | 175 13.2.3 Foods and Liquids Consumed by Women Adequate maternal nutrition is important for the health and reproductive outcomes of women and child survival and development. Table 13.6 presents the data obtained from mothers of young children on the foods and liquids they consumed during a 24-hour period before the survey. The information on maternal eating patterns serves as a useful if imperfect proxy for assessing the quality of maternal diet. The results in Table 13.6 show that nine in ten mothers consumed foods made from grains during the 24-hour period prior to the survey and more than eight in ten ate meat, fish including shellfish, poultry or eggs and foods made with oil, fat or butter during the 24-hour period prior to the survey. The consumption of meat, fish, poultry and eggs is important since these foods are important sources of protein and iron. Less encouraging is the finding that around one-third of mothers of young children did not consume milk or milk products (important sources of calcium) and 53 percent did not have any vitamin A- rich fruits and vegetables during the 24-hour period prior to the survey interview. Considering the differentials in Table 13.6, there are only modest variations in the proportions of women consuming a number of the food groups including grains, roots or tubers, legumes and nuts, oil, fat or butter, and tea or coffee. These items are staples in the Egyptian diet. More marked variations are observed, particularly by wealth quintile, in the percentages consuming other food groups including milk and milk products, fruits and vegetables, particularly those rich in vitamin A, and meat, fish or shellfish, poultry, and eggs. Consumption of sugary foods varies markedly with the wealth quintile, with women in the highest quintile being more than twice as likely as women in lowest quintile to consume both sugary foods. 46 30 41 54 70 59 Breastfed Non-breastfed All 6-23 Months 0 20 40 60 80 100 Percent Fed with all 3 IYCF Practices Not Fed with all 3 IYCF Practices Figure 13.3 Infant and Young Child Feeding (IYCF) Practices EDHS 2008 176 | Feeding Practices and Micronutrient Supplementation Table 13.6 Foods and liquids consumed by mothers in the day or night preceding the interview by background characteristics Percentage of mothers whose youngest child is under three years of age and living with them, who consumed specific types of food groups in the day or night preceding the interview by background characteristics, Egypt 2008 Background characteristic Milk Coffee/ tea Other liquids Cheese/ yogurt/ other milk products Sugary foods Food made from grains Fruits and vegetables rich in vitamin A1 Other fruits/ vege- tables Food made from roots/ tubers Food made from legumes and nuts Meat/ fish/ shellfish/ poultry/ eggs Food made with oil/fat/ butter Number of mothers Age 15-19 54.7 77.1 41.5 64.9 12.4 87.5 53.8 47.1 66.4 58.6 85.9 81.4 266 20-24 51.6 78.2 40.0 66.2 13.8 90.0 52.8 47.9 64.3 57.0 85.7 82.4 1,699 25-29 54.2 80.9 42.2 68.0 19.1 90.5 53.9 51.7 64.5 62.1 87.3 85.5 2,027 30-34 53.0 81.3 45.4 66.7 15.7 89.3 52.9 46.3 66.0 61.7 86.8 83.4 1,136 35-39 53.0 82.1 44.9 69.3 17.1 90.0 48.9 49.1 66.2 62.0 86.6 86.5 543 40-44 49.9 78.0 35.5 69.8 16.5 93.2 48.0 47.4 66.5 60.5 80.5 81.1 187 45-49 (26.2) (83.3) (30.9) (55.1) (9.3) (91.4) (53.2) (43.3) (65.2) (67.6) (76.0) (69.5) 23 Urban-rural residence Urban 56.3 80.0 47.7 69.4 20.8 89.9 52.9 50.1 62.7 62.1 88.3 85.3 2,224 Rural 50.8 80.1 38.7 65.9 13.6 90.1 52.7 48.2 66.5 59.3 85.1 83.0 3,657 Place of residence Urban Governorates 60.7 78.4 54.7 71.4 20.1 90.0 49.7 49.9 62.3 61.8 87.5 83.5 943 Lower Egypt 55.5 78.2 39.8 69.0 16.3 91.3 54.0 57.0 69.2 59.7 89.2 85.8 2,610 Urban 56.2 77.5 42.8 68.3 20.3 90.2 54.8 57.8 65.0 62.6 91.7 87.0 586 Rural 55.3 78.4 39.0 69.1 15.1 91.6 53.8 56.8 70.4 58.9 88.4 85.5 2,024 Upper Egypt 46.0 82.7 39.6 63.4 14.8 88.6 52.6 38.9 61.2 60.2 82.3 81.8 2,244 Urban 49.4 84.6 42.2 67.8 22.2 89.9 55.8 42.6 60.9 61.5 86.2 86.2 641 Rural 44.7 82.0 38.5 61.7 11.8 88.1 51.3 37.4 61.4 59.6 80.8 80.0 1,603 Frontier Governorates 67.8 84.0 41.5 67.6 16.4 88.0 51.9 54.3 67.3 67.3 91.1 85.4 83 Education No education 46.0 82.2 35.8 63.4 12.1 89.6 46.7 39.9 63.5 58.4 81.7 80.3 1,423 Some primary 47.9 82.1 36.9 67.9 13.6 93.4 49.0 43.0 68.2 64.8 78.7 81.5 359 Primary complete/ some secondary 53.3 77.6 40.9 64.4 15.2 88.7 50.0 50.2 66.1 62.8 84.3 84.3 919 Secondary complete/ higher 56.4 79.6 45.9 69.7 18.8 90.2 56.7 53.3 65.0 60.0 89.9 85.7 3,180 Work status Working for cash 55.8 80.6 44.9 70.8 20.3 90.9 55.3 55.8 65.3 62.7 89.3 87.5 618 Not working for cash 52.5 80.0 41.8 66.8 15.8 89.9 52.5 48.1 65.0 60.1 86.0 83.5 5,262 Wealth quintile Lowest 43.9 82.8 35.7 65.8 9.9 88.1 46.3 35.7 62.3 56.6 77.3 76.9 1,135 Second 51.1 82.9 35.4 63.0 12.4 91.5 50.3 44.1 68.5 61.0 83.7 85.2 1,166 Middle 50.2 77.8 41.6 66.8 16.3 92.1 51.4 51.1 66.6 62.2 87.1 83.3 1,230 Fourth 54.9 77.2 46.2 65.2 17.1 89.2 58.1 55.2 63.8 62.8 89.7 86.1 1,228 Highest 64.5 79.9 51.9 75.8 26.0 89.1 57.4 57.9 63.8 58.7 93.6 87.8 1,120 Total 52.9 80.1 42.1 67.2 16.3 90.0 52.8 48.9 65.0 60.3 86.3 83.9 5,880 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, mangoes, cantaloupe, dark green leafy vegetables, and other locally grown fruits and vegetables that are rich in vitamin A 13.3 MICRONUTRIENT SUPPLEMENTATION Micronutrient deficiencies are a major contributor to childhood morbidity and mortality. Micronutrient deficiencies result from inadequate intake of micronutrient-rich foods and inadequate utilization of available micronutrients because of infections, parasitic infestations, or other factors in the diet such as phytates and tannins. Measures of micronutrient fortification (iodized household cooking salt) and micronutrient supplementation (vitamin A for children and women and iron for women) were obtained in the 2008 EDHS survey. Feeding Practices and Micronutrient Supplementation | 177 13.3.1 Use of Iodized Salt Iodine is an important micronutrient. Dietary deficiency of iodine constitutes a major global public health concern. A lack of sufficient iodine is known to cause goiter, cretinism (a neurological defect), spontaneous abortion, premature birth, infertility, stillbirth, and increased child mortality. Iodine deficiency disorder (IDD) is the single most common cause of preventable mental retardation and brain damage in the world. Egypt has adopted a program of fortifying salt with iodine to prevent iodine deficiency. In the 2008 EDHS, a rapid test was used to measure iodine content of the salt used for cooking in the household. The test kit consisted of ampoules of a stabilized starch solution and a weak acid-based solution. A drop of the starch solution was squeezed onto a salt sample obtained in the household, causing the salt to change color. The EDHS interviewer conducting the test matched the color of the salt to a color chart included with the test kit to determine the level of iodization. Table 13.7 shows the percentage of households using iodized salt. Overall, 79 percent of households were using adequately iodized salt, i.e., the iodine content of the salt 15 ppm or more (parts per million). Two percent of the households cooked with salt which the test indicated lacked iodine and 19 percent with salt where the iodine level was below 15 ppm. Table 13.7 Presence of iodized salt in household by background characteristics Among all households, percentage of households with salt tested for iodine content, percentage of households with no salt and, among households with salt tested, percent distribution of households by level of iodine in salt (parts per million), according to background characteristics, Egypt 2008 Among all households, percentage Among households with tested salt, the percent distribution by Iodine content of salt Background characteristic With salt tested With no salt Number of households None (0 ppm) Inadequate (<15 ppm) Adequate (15+ ppm) Total Number of households Urban-rural residence Urban 98.9 0.9 9,159 0.6 13.4 86.0 100.0 9,058 Rural 98.0 1.7 9,809 3.7 24.5 71.9 100.0 9,609 Place of residence Urban Governorates 99.3 0.5 4,182 0.4 13.6 86.0 100.0 4,153 Lower Egypt 99.1 0.8 8,348 1.4 17.7 80.9 100.0 8,272 Urban 98.8 1.1 2,466 0.4 11.3 88.3 100.0 2,435 Rural 99.2 0.7 5,881 1.8 20.4 77.8 100.0 5,837 Upper Egypt 96.9 2.5 6,204 4.4 24.8 70.7 100.0 6,010 Urban 98.3 1.2 2,338 1.1 15.1 83.8 100.0 2,299 Rural 96.0 3.3 3,865 6.5 30.9 62.6 100.0 3,710 Frontier Governorates 99.1 0.7 235 3.1 20.1 76.8 100.0 232 Wealth quintile Lowest 96.0 3.3 3,205 7.3 35.9 56.8 100.0 3,076 Second 98.5 1.4 3,262 3.1 26.0 70.9 100.0 3,212 Middle 98.7 1.1 3,849 1.3 20.0 78.7 100.0 3,798 Fourth 99.1 0.8 4,231 0.6 11.9 87.5 100.0 4,192 Highest 99.3 0.6 4,420 0.2 8.4 91.4 100.0 4,389 Total 98.4 1.3 18,968 2.2 19.1 78.7 100.0 18,668 Urban households were much more likely than rural households to be using salt considered to be adequately iodized (86 percent and 72 percent, respectively). By place of residence, the proportion of households using adequately iodized salt ranged from 63 percent in rural Upper Egypt to 88 percent in urban Lower Egypt. The percentage of households using adequately iodized salt also increased directly 178 | Feeding Practices and Micronutrient Supplementation with household wealth, from 57 percent among households in the lowest wealth quintile to 91 percent of households in the highest quintile. 13.3.2 Micronutrient Intake among Young Children Data from the 2008 EDHS can be used to assess the extent to which young children are likely to be consuming adequate amounts of several important micronutrients including vitamin A, iron, and iodine. Vitamin A is considered essential for normal sight, growth, and development. Vitamin A protects the body against some infectious illnesses such as measles and diarrheal disease. Severe vitamin A deficiency (VAD) is associated with total loss of vision or with other vision impairments including night blindness. Iron deficiency is one of the most prevalent nutrient deficiencies in the world affecting an estimated two billion people. It slows cognitive development and is associated with increased morbidity and mortality. Finally, as discussed above, adequate levels of iodine are important to prevent mental retardation and to reduce child mortality. Ensuring that children have an adequate diet is one means of preventing iron and vitamin A deficiency. Foods rich in iron include meat (and organ meat), fish, poultry, and eggs. Vitamin A is found naturally in breast milk, other milks, liver, eggs, fish, butter, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. Since vitamin A is a fat-soluble vitamin, consumption of oils or fats is necessary for its absorption into the body. Foods rich in iron include meat (and organ meat), fish, poultry, and eggs. Vitamin A supplementation programs are another important tool in addressing VAD. Egypt has a program of vitamin A supplementation for young children. Beginning at age nine months (typically at the time the child receives the measles vaccination), young children are given one vitamin A capsule (100,000 international units). Two additional capsules (200,000 units) are given to children at age 18 months with the activated polio dose. Table 13.8 presents several indicators that are useful for assessing the likelihood that young children are receiving an adequate intake of vitamin A, iron, and iodine. They include the percentage of youngest children less than three years of age living with their mother who consumed fruits and vege- tables rich in vitamin A, the percentage of children 6-59 months who received vitamin A supplementation in the six-month period prior to the survey, and the percentage of children under age five who live in households that use adequately iodized salt. The results suggest that only slightly more than one-third of children age 6-35 months are con- suming foods rich in vitamin A on a daily basis. This figure is lower than the proportion of children age 6-35 months found to be consuming vitamin A-rich foods at the time of the 2005 EDHS (45 percent). Table 13.8 also found that 72 percent of children age 6-35 months were consuming iron-rich foods, around twice the proportion consuming vitamin-A rich foods. Consumption of both iron- and vitamin A- rich foods rises with the age of the child and is greater among not breastfeeding than breastfeeding children, reflecting the increasing diversity of children’s diets as they are weaned. Urban-rural residence is not strongly related to children’s consumption of foods rich in these two micronutrients but consumption levels do vary somewhat by place of residence; children in urban Upper Egypt have the highest level of consumption of vitamin A-rich foods, while children in urban Lower Egypt have the highest level of consumption of iron-rich foods. The likelihood that a child will consume iron- and vitamin A-rich foods rises with the education status of the mother and, particularly with the wealth quintile, indicating that economic factors play a role in shaping children’s diets. Feeding Practices and Micronutrient Supplementation | 179 Table 13.8 Micronutrient intake among children by background characteristics Among youngest children age 6-35 months living with the mother the percentage who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey; among all children age 6-59 months, the percentage who were given vitamin A supplements in the six months preceding the survey; and among children age 6-59 months living in households with salt tested, the percentage living in households using adequately iodized salt, by background characteristics, Egypt 2008 Among youngest children 6-35 months of age living with mother, percentage who consumed: Background characteristic Foods rich in vitamin A in past 24 hours1 Foods rich in iron in past 24 hours2 Number of children age 6-35 months Among children age 6-59 months, percentage given vitamin A supplement in past 6 months Number of children Percentage of children age 6-59 months living in households with adequately iodized salt3 Number of children Child's age 6-8 months 15.4 32.2 703 5.0 716 76.1 702 9-11 months 25.5 62.2 555 44.2 568 78.1 561 12-17 months 36.4 74.4 1,048 24.4 1,080 76.7 1,062 18-23 months 41.8 82.2 969 49.1 1,080 79.7 1,067 24-35 months 46.0 85.0 1,515 2.5 2,002 76.1 1,970 36-47 months na na na 0.5 1,928 75.8 1,907 48-59 months na na na 0.2 1,843 77.3 1,820 Sex Male 36.6 71.6 2,445 12.4 4,665 76.9 4,601 Female 35.8 71.9 2,345 12.4 4,552 76.8 4,487 Breastfeeding status Breastfeeding 28.0 59.9 2,363 26.5 2,422 76.5 2,383 Not breastfeeding 44.3 83.2 2,421 7.4 6,747 77.1 6,659 Missing 5.9 100.0 6 8.6 48 73.8 46 Urban-rural residence Urban 37.6 73.2 1,822 14.0 3,408 85.0 3,377 Rural 35.3 70.8 2,968 11.5 5,809 72.1 5,711 Place of residence Urban Governorates 33.9 72.6 766 15.9 1,441 85.9 1,432 Lower Egypt 36.6 74.4 2,150 12.4 4,039 81.2 4,026 Urban 39.2 76.5 496 13.7 905 89.2 898 Rural 35.8 73.7 1,654 12.0 3,134 78.9 3,128 Upper Egypt 36.7 68.1 1,807 11.0 3,605 68.4 3,499 Urban 42.0 70.9 516 11.4 979 80.6 965 Rural 34.6 67.0 1,291 10.9 2,626 63.8 2,534 Frontier Governorates 34.3 74.9 67 13.1 132 71.1 131 Mother's education No education 30.3 66.2 1,160 10.5 2,404 66.3 2,337 Some primary 32.5 64.2 295 11.7 631 67.1 617 Primary complete/ some secondary 35.2 69.8 744 12.5 1,400 79.2 1,391 Secondary complete/higher 39.5 75.6 2,591 13.5 4,782 82.7 4,742 Work status Working for cash 39.9 73.6 525 11.3 1,038 80.2 1,032 Not working for cash 35.7 71.5 4,265 12.6 8,179 76.5 8,056 Wealth quintile Lowest 30.6 63.7 920 10.6 1,862 56.2 1,805 Second 35.2 70.0 941 11.2 1,832 71.8 1,818 Middle 36.5 71.9 978 12.6 1,940 79.4 1,908 Fourth 38.0 73.8 1,016 12.7 1,851 87.7 1,837 Highest 40.4 79.0 935 15.2 1,732 89.7 1,719 Total 36.2 71.7 4,790 12.4 9,217 76.9 9,088 Note: Information on vitamin A supplements is based on health card and mother's recall. na = Not applicable 1 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mango, cantaloupe, and other locally grown fruits and vegetables that are rich in vitamin A 2 Includes meat, (including organ meat), fish, poultry, and eggs 3 Salt containing 15 ppm of iodine or more. Excludes children in households in which salt was not tested 180 | Feeding Practices and Micronutrient Supplementation The proportions receiving a vitamin A supplement presented in Table 13.8 are derived from information recorded on children’s vaccination records or from the mothers’ recall when records were not available (see Chapter 12 for a discussion of vaccination record coverage). Overall, a comparatively small proportion of children age 6-59 months received a vitamin A capsule during the six-month period prior to the DHS. The likelihood of supplementation is, however, strongly related with the child’s age. Approximately three in ten children age 9-24 months had received a capsule in the six-month period before the survey. The higher rates among children in the 9-24 month age group clearly reflect the impact of Egypt’s vitamin A supplementation program, which as noted above targets children in that age range. Finally, Table 13.8 shows that 77 percent of children age 6-59 months lives in households in which salt was tested and found to be adequately iodized. As noted above, availability of iodized salt is higher in urban than rural households and increases with both the mother’s education status and house- hold wealth. 13.3.3 Micronutrient Intake among Mothers Adequate micronutrient intake by women has important benefits for both the women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects mother and infant against anemia. It is estimated that one-fifth of perinatal mortality and one-tenth of maternal mortality are attributable to iron deficiency anemia (WHO, 2002). Anemia also results in an increased risk of premature delivery and low birth weight. Finally, as noted above, iodine deficiency is related to a number of adverse pregnancy outcomes. Table 13.9 includes a number of measures that are useful in assessing the extent to which women are receiving adequate intake of vitamin A, iron during pregnancy, and iodine. The first indicators focused on the percentages of women with children under age three who reported that they consumed foods rich in vitamin A and iron during the 24-hour period prior to the DHS. The results indicate that more than eight in ten mothers of young children consumed iron-rich foods (i.e., meat, poultry, fish and eggs) in the 24 hours preceding the survey, and 53 percent consumed vitamin A-rich fruits and vegetables. As was the case with children, consumption of iron- and vitamin A-rich foods is influenced by the place of residence, the woman’s education status, and household wealth. Consumption of iron-rich foods also is related to these factors. Overall, the highest rates of consumption of both iron- and vitamin A-rich foods are observed among mothers in the highest wealth quintile, and the lowest rate among women in the lowest wealth quintile. Table 13.9 also looks at the extent to which women receive vitamin A supplements following delivery. Just over half of women who gave birth during the five-year period before the 2008 EDHS reported that they had received a capsule in the two-month period following the delivery of their last-born child. Women living in urban Upper Egypt were the least likely to report receiving a supplement. With regard to iron supplementation during pregnancy, just over one-third of women who gave birth during the five-year period before the 2008 EDHS reported that they had taken iron tablets or syrup during the pregnancy preceding their last live birth. This represents a decline from the level reported in the 2005 EDHS (49 percent). Among women reporting that they took supplements, the majority said that they took the supplements for less than 60 days. Urban residents, particularly those living in the Urban Governorates, women with a secondary or higher education and women in the highest wealth quintile were considerably more likely to have taken iron tablets or syrup during pregnancy than other women. Nearly eight in ten who gave birth during the five-year period prior to the survey live in households in which the salt used in cooking was tested and found to be adequately iodized. Feeding Practices and Micronutrient Supplementation | 181 Table 13.9 Micronutrient intake among mothers by background characteristics Among ever-married women 15-49 with a child under the age of 3 living with them, the percentage who consumed vitamin A-rich and iron-rich foods in the 24 hours preceding the survey; among ever-married women 15-49 with a child born in the 5-year period preceding the survey, the percentage who received a vitamin A dose in the first two months after the birth of the last child and the percentage who took iron tablets or syrup for specific numbers of days during the pregnancy preceding the last birth; among ever-married women age 15-49 with a child born in the 5-year period preceding the survey and living in households where salt was tested, the percentage who live in households using adequately iodized salt, by background characteristics, Egypt 2008 Among women with birth in the five-year period before the survey Among women with child under age 3 living in household, percentage who consumed: Number of days iron tablets/syrup taken during pregnancy Background characteristic Vitamin A-rich foods1 Iron- rich foods2 Number of women with child under age 3 living in household Percentage who received vitamin A dose postpartum3 None <60 60-89 90+ Don't know/ missing Number of women with birth in five-year period before the survey Percentage of women with birth in five- year period before the survey living in households with adequately iodized salt4 Number of women with birth in 5-year period before the survey living in households where salt was tested Age 15-19 53.8 85.9 266 46.7 56.4 22.0 2.8 10.4 8.3 275 71.3 271 20-24 52.8 85.7 1,699 57.7 55.1 23.3 3.8 13.3 4.5 1,925 75.4 1,897 25-29 53.9 87.3 2,027 59.8 54.6 22.0 3.6 14.4 5.4 2,663 78.1 2,627 30-34 52.9 86.8 1,136 54.8 58.3 19.4 3.1 13.9 5.2 1,652 79.3 1,637 35-39 48.9 86.6 543 59.3 60.6 17.7 3.6 14.3 3.8 923 77.0 907 40-44 48.0 80.5 187 46.2 60.9 16.0 4.1 11.9 7.1 387 75.3 383 45-49 (53.2) (76.0) 23 46.4 55.2 14.9 7.1 19.9 2.9 72 78.0 70 Urban-rural residence Urban 52.9 88.3 2,224 56.9 48.2 18.5 4.8 22.8 5.7 3,012 85.1 2,988 Rural 52.7 85.1 3,657 56.9 61.7 22.4 2.8 8.3 4.8 4,883 72.3 4,805 Place of residence Urban Governorates 49.7 87.5 943 62.4 38.2 18.1 6.1 34.4 3.2 1,294 85.4 1,288 Lower Egypt 54.0 89.2 2,610 62.0 63.6 21.0 2.0 8.3 5.0 3,500 81.3 3,486 Urban 54.8 91.7 586 61.8 63.9 20.4 2.3 8.8 4.6 794 89.3 787 Rural 53.8 88.4 2,024 62.1 63.5 21.2 1.9 8.2 5.2 2,706 78.9 2,699 Upper Egypt 52.6 82.3 2,244 48.9 56.1 22.1 4.2 11.3 6.2 2,990 68.9 2,909 Urban 55.8 86.2 641 44.6 47.8 17.3 5.2 18.7 10.9 854 81.3 843 Rural 51.3 80.8 1,603 50.7 59.4 24.1 3.8 8.4 4.3 2,136 63.8 2,066 Frontier Governorates 51.9 91.1 83 47.5 61.6 17.6 4.8 13.7 2.3 111 72.7 111 Education No education 46.7 81.7 1,423 49.8 65.1 21.5 2.0 6.7 4.8 1,997 66.4 1,945 Some primary 49.0 78.7 359 55.7 63.0 18.1 3.0 11.5 4.4 528 66.8 518 Primary complete / some secondary 50.0 84.3 919 57.9 57.8 21.3 3.8 12.6 4.5 1,239 79.2 1,232 Secondary complete/ higher 56.7 89.9 3,180 60.2 51.3 20.9 4.3 17.9 5.6 4,132 83.0 4,099 Work status Working for cash 55.3 89.3 618 59.1 50.7 20.5 5.1 17.8 5.9 903 81.1 895 Not working for cash 52.5 86.0 5,262 56.6 57.3 21.0 3.4 13.3 5.0 6,993 76.7 6,898 Wealth quintile Lowest 46.3 77.3 1,135 48.2 66.0 22.8 2.4 5.5 3.2 1,525 56.3 1,480 Second 50.3 83.7 1,166 56.2 61.6 21.9 3.2 7.3 5.9 1,557 70.8 1,544 Middle 51.4 87.1 1,230 58.2 61.6 21.3 2.7 8.8 5.6 1,659 80.3 1,636 Fourth 58.1 89.7 1,228 62.1 53.3 19.9 3.4 18.9 4.4 1,626 87.4 1,613 Highest 57.4 93.6 1,120 59.6 39.9 18.6 6.3 28.7 6.5 1,528 89.8 1,520 Total 52.8 86.3 5,880 56.9 56.6 20.9 3.6 13.8 5.1 7,896 77.2 7,793 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, mango, cantaloupe, and other locally grown fruits and vegetables that are rich in vitamin A 2 Includes meat, (including organ meat), fish, poultry, and eggs 3 In the first two months after delivery 4 Salt containing 15 ppm or iodine or more. Excludes women in households in which salt was not tested Nutritional Status | 183 NUTRITIONAL STATUS 14 This chapter uses anthropometric data obtained in the 2008 EDHS to assess the nutritional status of young children, youth and adults in Egypt. Specially trained teams were responsible for taking the height and weight measurements1 during the survey. The measurements were collected for children under age six and youth and young adults age 10-19 years in all of the households included in the EDHS sample. In addition, in the subsample of households selected for the health issues survey, measurements were obtained for all women and men in the 20-59 age group while, in the remaining households in the sample, measurements were recorded for ever-married women age 20-49. 14.1 NUTRITIONAL STATUS OF CHILDREN Nutritional status is a primary determinant of a child’s health and well-being. The anthropometric data collected in the 2008 EDHS permit an assessment of the nutritional status of children under age five in Egypt. 14.1.1 Measurement of Nutritional Status among Young Children The anthropometric measurements obtained in the EDHS for young children as well as informa- tion on the children’s ages were used to construct the following three standard indices of physical growth: (1) height-for-age; (2) weight-for-height; and (3) weight-for-age. For the tables presented in this report, the anthropometric indices derived from 2008 EDHS are compared against new growth standards generated by WHO from data collected in a Multicentre Growth Reference Study (WHO 2006b). It should be noted that, because this is the first EDHS to use the WHO Multicentre Growth Reference Population, the results cannot be compared to earlier DHS surveys.2 Each of the indices measures somewhat different aspects of nutritional status. The height-for-age index provides an indicator of linear growth. Children whose height-for-age measures are below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age, or stunted. Children who are below minus three standard deviations (-3 SD) from the reference population are considered severely stunted. Stunting of a child’s growth may be the result of a failure to receive adequate nutrition over a long period of time or of the effects of recurrent or chronic illness. The weight-for-height index measures body mass in relation to body length. Children whose weight-for-height measures are below minus two standard deviations (-2 SD) from the median of the reference population are too thin for their height, or wasted, while those whose measures are below minus three standard deviations (-3 SD) from the reference population median are severely wasted. Wasting 1 The measuring boards used for the collection of the height data are specially produced by Shorr Productions for use in survey settings. Children younger than 24 months were measured lying on a measuring board, while standing height was measured for older children, adolescents and adult women and men. Weight data were obtained using lightweight, bathroom-type scales with a digital screen designed and manufactured under the authority of the United Nations Children’s Fund (UNICEF). 2 Comparisons were also made to indices for an international reference population defined by the U.S. National Center for Health Statistics (NCHS) and accepted by WHO and the U.S. Centers for Disease Control. These results are presented in Appemdix E. The NCHS/WHO/CDC population had served as the reference population for assessing children’s nutritional status in all previous DHS surveys in Egypt. 184 | Nutritional Status represents the failure to receive adequate nutrition during the period immediately before the survey. It may be the result of recent episodes of illness or acute food shortages. Weight-for-age is a composite index of height-for-age and weight-for-height. Children whose weight-for-age measures are below minus two standard deviations (-2 SD) from the median of the reference population are underweight for their age, while those whose measures are below minus three standard deviations (-3 SD) from the reference population median are severely underweight. A child can be underweight for his age, because he is stunted, he is wasted, or he is both stunted and wasted. 14.1.2 Results of Data Collection Measurements of height and weight were obtained for all children under age 6 living in the households selected for the EDHS sample. The results include children who were not biological offspring of the women interviewed in the survey. Although data was collected for all children under age six, for purposes of comparability with prior EDHS surveys, the analysis is limited to children under age five. Height and weight measurements were obtained for 99 percent of the 10,361 children in that age range present in EDHS households at the time of the survey. Of these children, 10 percent were considered to have implausibly high or low values for the height or weight measures or lacked data on the child’s age in months (not shown in table). The following analysis focuses on the 9,103 children for whom complete and plausible anthropometric and age data were collected. 14.1.3 Levels of Child Malnutrition An examination of the height-for-age data from the 2008 EDHS indicates that there is considerable chronic malnutrition among Egyptian children. Overall, the 2008 EDHS found that 29 percent of children under age five were stunted, and 14 percent were severely stunted. As Figure 14.1 shows, stunting was apparent even among children under six months of age. Stunting levels increased rapidly with age, from only 17 percent among children less than six months of age to 41 percent among children 18-23 months, before falling to 24 percent among children age four and older. Levels of stunting were slightly higher for male children than for female children. Stunting did not vary systematically with birth order or with the length of the birth interval. Stunting levels were higher among children who were considered by the mother to be very small or smaller than average at birth than among children who were average or larger. Nutritional Status | 185 Table 14.1 Nutritional status of children by children's characteristics Percentage of children under five who are classified as malnourished according to three anthropometric indices of nutritional status: height-for- age, weight-for-height, and weight-for-age, by background characteristics of the child, Egypt 2008 Height-for-age Weight-for-height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Number of children Child's age Under 6 months 7.4 16.8 (0.3) 5.9 11.9 0.5 1.3 6.3 0.1 867 6-8 11.0 21.9 (0.5) 2.4 6.5 0.6 0.6 5.2 0.0 804 9-11 10.6 22.0 (0.4) 1.8 5.8 0.6 2.9 5.5 0.2 324 12-17 14.2 28.1 (0.9) 1.3 5.2 0.7 0.6 4.4 0.1 947 18-23 22.9 40.8 (1.4) 3.6 8.2 0.6 2.3 7.5 (0.2) 960 24-35 16.8 34.9 (1.3) 3.2 7.3 0.6 0.9 6.5 (0.2) 1,755 36-47 14.9 31.8 (1.2) 3.3 6.8 0.6 1.5 6.0 (0.3) 1,748 48-59 10.5 24.3 (1.1) 3.0 6.4 0.6 1.2 5.9 (0.3) 1,697 Sex Male 15.7 30.7 (1.1) 3.2 8.0 0.5 1.5 7.1 (0.3) 4,540 Female 12.3 27.1 (0.9) 3.1 6.4 0.7 1.0 4.9 (0.1) 4,564 Birth order 1 13.8 27.7 (0.9) 3.4 7.2 0.6 1.3 5.6 (0.1) 2,935 2-3 14.3 29.3 (1.1) 3.1 7.3 0.6 1.1 6.0 (0.2) 4,217 4-5 13.8 30.2 (1.1) 2.8 8.1 0.5 1.6 6.8 (0.2) 1,343 6+ 12.5 28.7 (1.1) 3.2 5.7 0.5 1.2 5.5 (0.3) 510 Birth interval in months First birth2 13.9 27.8 (0.9) 3.4 7.2 0.6 1.4 5.7 (0.1) 2,991 Under 24 months 17.3 34.1 (1.3) 2.9 7.2 0.6 1.8 7.7 (0.3) 1,071 24-47 13.5 28.5 (1.0) 3.1 7.2 0.6 1.1 5.8 (0.2) 3,002 48+ 12.9 28.4 (1.0) 3.1 7.5 0.6 1.0 5.8 (0.1) 1,942 Size at birth3 Very small 15.2 35.6 (1.1) 4.1 10.0 0.3 2.3 8.0 (0.4) 282 Small 13.4 31.0 (1.2) 2.8 7.2 0.5 1.1 7.5 (0.3) 851 Average or larger 14.0 28.4 (1.0) 3.2 7.2 0.6 1.2 5.8 (0.1) 7,833 Missing 11.8 27.6 (1.1) 0.0 0.0 0.9 0.0 0.0 0.0 21 Mother’s interview status Interviewed 14.0 28.9 (1.0) 3.2 7.3 0.6 1.3 6.0 (0.2) 9,005 Not interviewed 16.8 30.7 (1.1) 2.9 3.2 0.7 2.4 7.1 (0.2) 98 In the household 10.3 23.8 (0.8) 2.8 3.6 0.8 0.0 1.3 0.1 41 Not in the household4 21.3 35.6 (1.4) 3.0 3.0 0.7 4.1 11.2 (0.4) 58 Total 14.0 28.9 (1.0) 3.2 7.2 0.6 1.3 6.0 (0.2) 9,103 Note: Table based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards reference population adopted in 2006. Thus, the indices in this table are not comparable to those based on the previously used NCHS/CDC/WHO standards. The percentage of children who are more than three or more than two standard deviations below the median of the International Reference Population (-3 SD and -2 SD) are shown according to background characteristics. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. The total includes children whose mothers were not interviewed in the survey. Information on the background characteristics shown in the table is not available for these children. The total also includes 6 children for whom information on the child's size at birth was not available. 1 Includes children who are below -3 standard deviations (SD) from the International Reference Population median. 2 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 3 Excludes children whose mothers were not interviewed or for whom size at birth information is not available. 4 Includes children whose mothers are deceased. 186 | Nutritional Status Table 14.2 shows that there were marked socioeconomic differentials in stunting. Children in rural areas were somewhat more likely to be stunted than urban children (30 percent and 27 percent, respectively). The percentage stunted varied markedly by place of residence, ranging from 22 percent in the Urban Governorates to 39 percent in urban Lower Egypt. Neither the mothers’ educational level nor the wealth quintile were systematically related to levels of stunting. The weight-for-height index provides a measure of wasting, or acute malnutrition. As described above, the weight-for-height index reflects the effects on a child’s nutritional status of recent food shortages or recent episodes of diarrheal or other illness that contribute to malnutrition. Overall, the 2008 EDHS results indicated that 7 percent of children under age five were wasted. Looking at the variation with the children’s characteristics presented in Table 14.1, the highest levels of wasting were observed for children under age 6 months (12 percent) and children who were reported by the mother to have been very small at birth (10 percent). Considering the socioeconomic differentials in Table 14.2, children in the Urban Governorates (10 percent) were most likely to be wasted. Reflecting the effects of both chronic and short-term malnutrition, 6 percent of children under age five were underweight for their age. Considering results in Table 14.1, children whose mothers were alive but not resident in the household (11 percent), children age 18-23 months (8 percent), and children who were considered by the mother to have been very small or small at birth (8 percent), were most likely to be underweight. Considering socioeconomic characteristics, Table 14.2 shows that low weight-for-age was slightly more common among children from Upper Egypt (7 percent) than children from other areas. Among children of whose mothers never attended school (8 percent) than among those whose mothers have at least some education, and among children living in the lowest wealth quintile (8 percent) compared to children from wealthier households. 1 Figure 14.1 Nutritional Status of Children by Age Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition and underweight reflects chronic and acute malnutrition or a combination of both. # ################### ############## ########### ############# ## ) ) ))))))))))))))))))) )))))))))))))))))))))))))))))))))))))) ) 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Age (months) 0 10 20 30 40 50 Percent Stunted Wasted Underweight) # EDHS 2008 Nutritional Status | 187 Table 14.2 Nutritional status of children by mother's characteristics Percentage of children under five who are classified as malnourished according to three anthropometric indices of nutritional status: height- for-age, weight-for-height, and weight-for-age, by selected background characteristics, Egypt 2008 Height-for-age Weight-for-height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Number of children Mother's age2 15-19 11.9 25.9 (0.7) 5.4 7.0 0.5 2.0 7.3 (0.1) 271 20-24 14.7 29.6 (1.0) 2.9 6.7 0.6 1.1 5.7 (0.1) 2,275 25-29 13.4 28.0 (1.0) 3.3 7.9 0.6 1.2 5.9 (0.2) 3,232 30-34 14.1 29.7 (1.1) 3.1 7.5 0.6 1.6 6.6 (0.2) 1,843 35-49 14.2 29.1 (1.0) 2.9 6.4 0.6 1.1 5.5 (0.2) 1,424 Missing 21.3 35.6 (1.4) 3.0 3.0 0.7 4.1 11.2 (0.4) 58 Urban-rural residence Urban 13.6 27.1 (0.9) 3.3 8.2 0.6 1.4 6.0 (0.1) 3,294 Rural 14.2 29.9 (1.1) 3.1 6.7 0.6 1.2 6.0 (0.2) 5,809 Place of residence Urban Governorates 12.0 22.3 (0.6) 4.1 9.8 0.6 1.4 5.9 0.0 1,372 Lower Egypt 18.8 34.2 (1.2) 3.2 6.8 0.8 1.3 5.5 (0.1) 3,959 Urban 21.2 39.3 (1.4) 2.8 6.3 1.0 1.5 5.2 (0.1) 878 Rural 18.2 32.7 (1.1) 3.4 6.9 0.8 1.2 5.6 (0.1) 3,081 Upper Egypt 9.5 25.7 (1.0) 2.8 6.8 0.4 1.2 6.7 (0.3) 3,664 Urban 8.8 22.7 (0.8) 2.8 8.0 0.4 1.4 7.1 (0.2) 983 Rural 9.7 26.9 (1.0) 2.7 6.3 0.4 1.1 6.5 (0.3) 2,681 Frontier Governorates 15.0 28.2 (0.9) 3.3 6.4 0.7 0.7 4.2 (0.0) 109 Mother's education2 No education 12.8 30.1 (1.0) 3.7 8.1 0.4 1.4 7.6 (0.3) 2,370 Some primary 12.9 28.4 (1.0) 2.6 6.2 0.6 1.2 5.5 (0.2) 623 Primary complete/ some secondary 15.6 30.1 (1.1) 3.3 7.0 0.6 1.3 5.7 (0.2) 1,354 Secondary complete/ higher 14.2 28.0 (1.0) 2.9 7.1 0.7 1.1 5.3 (0.1) 4,700 Missing 21.3 35.6 (1.4) 3.0 3.0 0.7 4.1 11.2 (0.4) 58 Work status3 Working for cash 15.4 29.4 (1.1) 2.2 5.6 0.8 1.2 5.8 (0.1) 994 Not working for cash 13.8 28.8 (1.0) 3.3 7.5 0.6 1.3 6.0 (0.2) 8,011 Missing 16.8 30.7 (1.1) 2.9 3.2 0.7 2.4 7.1 (0.2) 98 Wealth quintile Lowest 12.6 29.5 (1.0) 3.8 7.1 0.4 1.3 7.5 (0.3) 1,883 Second 14.7 30.5 (1.1) 2.7 7.9 0.5 1.5 6.0 (0.3) 1,835 Middle 12.4 27.3 (1.0) 3.9 8.0 0.6 1.4 5.9 (0.1) 1,928 Fourth 15.8 30.3 (1.1) 2.5 5.6 0.8 0.8 5.1 (0.0) 1,797 Highest 14.7 26.9 (0.9) 2.8 7.6 0.7 1.3 5.4 (0.0) 1,660 Total 14.0 28.9 (1.0) 3.2 7.2 0.6 1.3 6.0 (0.2) 9,103 Note: Table is based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards reference population adopted in 2006. Thus, the indices in this table are not comparable to those based on the previously used NCHS/CDC/WHO standards. The percentage of children who are more than three or more than two standard deviations below the median of the International Reference Population (-3 SD and -2 SD) are shown according to background characteristics. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. 1 Includes children who are below -3 standard deviations (SD) from the International Reference Population median. 2 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers were not listed in the household schedule. 3 Excludes children whose mothers were not interviewed. 188 | Nutritional Status 14.1.4 Trends in Child Nutrition Figure 14.2 presents recent trends in the nutritional status of children in Egypt using anthro- pometric data from EDHS surveys undertaken between 2000 and 2008 and the WHO Child Growth Standards.3 The survey results suggest that the nutritional status of young children in Egypt remained relatively stable during the period between the 2000 and 2005 surveys. Looking at the height-for-age measures, for example, the prevalence of stunting in young children was 23 percent in both 2000 and 2005. In 2008, however, the prevalence of stunting increased to 29 percent. The proportions of children who were found to be wasted and underweight were also higher in 2008 than in either of the two earlier EDHS surveys. The reasons for the increase in malnutrition among young children levels require further investi- gation, including an examination of the quality of the anthropometric data collected in the surveys and of the reporting of children’s ages. However, one factor which may in part be responsible for the increase was the abrupt disruption in the supplies of poultry and eggs that followed the culling of millions of chickens and other poultry in response to the avian influenza outbreak Egypt experienced in 2006 (see Chapter 16). Geerlings and others (2007) found that the culling had a significant and sustained impact on household consumption of poultry and eggs, especially young children, and also put considerable strain on household financial resources since poultry sales accounted for nearly half of the incomes of many Egyptian households prior to 2006 (Geerlings et al., 2007). 14.2 NUTRITIONAL STATUS OF NEVER-MARRIED YOUTH AND YOUNG ADULTS Height and weight measures also were collected for never-married youth and young adults age 10-19 in the 2008 EDHS. 3 A table is included in Appendix E showing trends in the nutritional status of children between 2000 and 2008 based upon comparisons with the NCHS/WHO/CDC reference population. Figure 14.2 Trend in Nutritional Status of Young Children (WHO Child Growth Standards) Egypt 2000-2008 23 23 29 3 5 7 4 5 6 2000 2005 2008 0 5 10 15 20 25 30 35 Percent Height-for-age (Stunting) Weight-for-height (Wasting) Weight-for-age (Underweight) Note: Data are for children under age five for whom the nutrition status measure fell below -2 SD from the WHO Child Growth Standards reference population median. Nutritional Status | 189 14.2.1 Measurement of Nutritional Status among Youth and Young Adults The assessment of the nutritional status of adolescents using height and weight measures is complicated by the fact that adolescents undergo significant changes in their body stature and mass as they go through puberty and that body proportions may deviate more across populations for adolescents than for young children making it difficult to establish a reference population (Woodruff and Duffield 2000). Approaches to assessing adolescent nutritional status are, thus, less standardized than those for assessing the status of young children. However, WHO has recommended the use of body-mass index (BMI) for age to assess the nutritional status of adolescents (WHO 1995). This is the approach adopted in this report using the 2000 CDC Growth Charts (CDC 2000). The body-mass index (BMI) is calculated by dividing weight in kilograms by height in meters squared (kg/m2). The same methods are used in calculating BMI for children, adolescents, and adults, but the results for children and adolescents are interpreted differently. For adults, the use of BMI to define nutritional status does not depend on age or gender. For children and adolescents age 2-20, however, assessments of nutritional status using CDC BMI growth charts are age- and gender-specific. These growth charts are used to rank individuals according to the percent of the reference population that the individual’s BMI equals or exceeds, i.e., according to the percentile in which the individual falls. For example, on the male BMI-for-age growth charts, the BMI for a 10-year-old boy ranked in the 75th percentile, is the same or more than the BMI of 75 percent of the reference population of 10-year-old boys. The following established percentile cutoff points are used to identify underweight and overweight adolescents using the CDC Growth charts: Underweight BMI-for-age < 5th percentile Normal BMI-for-age 5th percentile to < 85th percentile At risk of overweight BMI-for-age 85th percentile to < 95th percentile Overweight BMI-for-age > 95th percentile 14.2.2 Results of Data Collection Height and weight measurements needed to determine nutritional status were obtained for 98 percent of the 9,230 never-married males age 10-19 and 99 percent of the 8,505 never-married females age 10-19 eligible for the collection of the anthropometric data. 14.2.3 Levels of Malnutrition among Never-married Youth and Young Adults Tables 14.3.1 and 14.3.2 show the BMI-for-age percentile rankings for never-married female and male youth and young adults, respectively, according to selected background characteristics. The results indicate that 5 percent of never-married males age 10-19 and 6 percent of never-married females age 10- 19 in Egypt may be classified overweight, i.e., their BMI values were at or above the 95th percentile on the age and sex-specific BMI growth charts. The BMI values for an additional 15 percent of males and 19 percent of females fall between the 85th and 95th percentiles, indicating that they were classified as at risk of becoming overweight. At the other end of the scale, five percent of males and three percent of females were considered to be underweight, i.e., their BMI values fell below the 5th percentile on the growth charts. 190 | Nutritional Status Table 14.3.1 Nutritional status of never-married female youth and young adults by background characteristics Percentage with specific BMI levels among never-married females age 10-19, by background characteristics, Egypt 2008 Background characteristic Underweight (< 5th percentile) Normal (5th to <85th percentile) At risk of overweight (85th to <95th percentile) Overweight (≥95th percentile) Total percent Number of females Age of adolescent 10-11 5.2 74.1 15.4 5.3 100.0 1,817 12-13 4.0 71.5 17.8 6.6 100.0 1,792 14-15 1.6 70.1 21.8 6.5 100.0 1,701 16-17 0.9 70.9 21.5 6.7 100.0 1,635 18-19 1.0 73.8 20.9 4.3 100.0 1,438 Mother's age < 30 2.9 78.9 15.2 3.0 100.0 202 30-34 5.2 72.1 16.7 6.0 100.0 1,038 35-49 2.4 71.6 19.9 6.1 100.0 5,744 50+ 1.8 71.7 20.6 5.9 100.0 700 Mother not in household/no information available 1.6 74.4 18.6 5.5 100.0 699 Urban-rural residence Urban 2.6 67.8 21.3 8.3 100.0 3,477 Rural 2.7 75.1 18.0 4.2 100.0 4,906 Place of residence Urban Governorates 2.8 64.3 24.3 8.5 100.0 1,440 Lower Egypt 1.0 70.9 23.3 4.8 100.0 3,544 Urban 0.6 69.6 23.3 6.4 100.0 972 Rural 1.2 71.3 23.3 4.2 100.0 2,571 Upper Egypt 4.3 76.4 13.3 6.1 100.0 3,278 Urban 4.2 70.1 15.5 10.2 100.0 984 Rural 4.3 79.1 12.3 4.3 100.0 2,295 Frontier Governorates 4.1 81.6 10.8 3.5 100.0 122 Mother's education No education 2.9 73.3 18.4 5.4 100.0 3,473 Some primary 2.7 76.6 15.3 5.3 100.0 924 Primary complete/ some secondary 1.9 70.7 20.2 7.2 100.0 1,003 Secondary complete/higher 2.9 68.3 22.4 6.5 100.0 2,282 Mother not in household /no information possible 1.6 74.3 18.6 5.5 100.0 701 Mother's work status Working for cash 3.1 68.8 21.4 6.7 100.0 1,276 Not working for cash 2.8 72.5 18.9 5.8 100.0 5,671 Mother not in household /no information possible 1.7 73.2 19.5 5.6 100.0 1,436 Wealth quintile Lowest 3.8 79.3 13.5 3.4 100.0 1,889 Second 2.7 73.3 18.1 5.9 100.0 1,741 Middle 2.0 70.3 22.4 5.2 100.0 1,605 Fourth 1.6 69.9 21.4 7.1 100.0 1,589 Highest 2.9 65.9 22.7 8.5 100.0 1,559 Total 2.7 72.1 19.4 5.9 100.0 8,383 Note: Table is based on never-married females age 10-19 who stayed in the household the night before the interview. Nutritional Status | 191 Table 14.3.2 Nutritional status of never-married male youth and young adults by background characteristics Percentage with specific BMI levels among never-married males age 10-19 by background characteristics, Egypt 2008 Background characteristic Underweight (< 5th percentile) Normal (5th to <85th percentile) At risk of overweight (85th to <95th percentile) Overweight (≥95th percentile) Total percent Number of youths/ young adults Age of adolescent 10-11 6.9 71.6 14.4 7.1 100.0 1,838 12-13 6.0 72.2 16.3 5.4 100.0 1,885 14-15 5.6 72.5 18.4 3.5 100.0 1,734 16-17 3.7 78.5 13.9 4.0 100.0 1,813 18-19 3.2 82.8 10.6 3.4 100.0 1,730 Mother's age < 30 6.4 73.6 12.4 7.6 100.0 212 30-34 6.0 73.7 15.9 4.5 100.0 1,085 35-49 5.0 75.3 14.8 4.9 100.0 6,216 50+ 4.6 75.0 15.3 5.1 100.0 672 Mother not in household /no information possible 4.7 79.6 13.1 2.6 100.0 814 Urban-rural residence Urban 5.5 72.2 15.7 6.6 100.0 3,587 Rural 4.9 77.6 14.1 3.5 100.0 5,413 Place of residence Urban Governorates 5.8 70.2 16.4 7.7 100.0 1,530 Lower Egypt 2.1 75.1 18.4 4.4 100.0 3,766 Urban 2.1 74.1 18.1 5.7 100.0 971 Rural 2.2 75.4 18.5 3.9 100.0 2,795 Upper Egypt 7.9 77.9 10.3 3.9 100.0 3,580 Urban 8.4 72.9 12.7 6.1 100.0 1,004 Rural 7.7 79.9 9.4 3.0 100.0 2,577 Frontier Governorates 6.2 80.9 10.3 2.5 100.0 124 Mother's education No education 5.3 77.5 13.6 3.6 100.0 3,890 Some primary 4.3 75.5 15.3 5.0 100.0 986 Primary complete/ some secondary 4.7 74.6 14.5 6.1 100.0 962 Secondary complete/higher 5.4 70.8 17.1 6.6 100.0 2,347 Mother not in household /no information possible 4.8 79.6 13.0 2.6 100.0 815 Mother's work status Working for cash 5.6 71.2 16.9 6.2 100.0 1,295 Not working for cash 5.1 75.9 14.5 4.6 100.0 6,189 Mother not in household /no information possible 4.7 77.3 14.0 3.9 100.0 1,516 Wealth quintile Lowest 7.1 78.6 11.8 2.4 100.0 2,131 Second 4.7 79.0 13.1 3.2 100.0 1,975 Middle 4.4 74.4 16.3 4.9 100.0 1,749 Fourth 3.9 73.1 16.5 6.5 100.0 1,580 Highest 4.8 70.1 17.2 7.9 100.0 1,564 Total 5.1 75.4 14.7 4.7 100.0 9,000 Note: Table is based on never-married males age 10-19 who stayed in the household the night before the interview. Some variation in the BMI levels is observed across the population subgroups for which results are presented in Tables 14.3.1 and 14.3.2. For example, the proportions of both males and females classified in the overweight and at risk of overweight categories were higher among urban than rural residents. These proportions also increased with mother’s education status and with the wealth quintile. For example, 31 percent of never-married females in the highest wealth quintile were overweight or at risk of being overweight compared to 17 percent of never-married females in the lowest wealth quintile. 192 | Nutritional Status 14.3 NUTRITIONAL STATUS OF WOMEN AND MEN The height and weight data collected for women and men 15-59 in the subsample for the health issues survey can be used to assess their nutritional status. As with adolescents, the BMI index is used for assessing the nutritional status of women and men. However, the cutoffs defining the status do not vary with age. The BMI cutoff for assessing chronic energy deficiency is 18.5. At the other end of the BMI scale, women are considered overweight if their BMI ranges between 25.0 and 29.9 and obese if their BMI exceeds 30.0. Table 14.4 shows the distribution of women 15-59 as well as the distribution of all ever-married women age 15-49 interviewed in the main survey according to height, weight, and body mass (BMI) along with the means for these indi- cators. The latter data are presented to allow comparisons with the results in earlier EDHS surveys in which anthropometric measures were obtained only for ever-married women age 15-49. The weight and BMI measures presented in Table 14.4 exclude pregnant women and women who gave birth in the 2 months preceding the survey Height is an outcome of nutrition during childhood and adolescence. It is useful in predicting the risk of difficult delivery, since small stature is frequently associated with small pelvis size. The risk of low birth weight babies is also higher for short women. The cutoff point, i.e., the height below which a woman is considered to be at nutritional risk, is defined as 145 centimeters. The mean height of mothers measured in the 2008 EDHS was 158.4 centimeters. Two percent of women were shorter than 145 centimeters and, thus, classified as at nutritional risk. The mean weight was 72.5 kilograms. As Table 14.4 shows, excluding those who are pregnant or less than two months postpartum, the mean BMI of all women age 15-59 was 28.9. The majority of women had a BMI of 25.0 or higher and were considered overweight (28 percent) or obese (40 percent). Less than 2 percent of women had a BMI below 18.5, the level indicating chronic energy deficiency. Differentials in the women’s height and body mass index measures are shown in Table 14.5. There was little variation in women’s mean height. The proportions classified as obese increased directly with age, from a level of 10 percent among women age 15-19 to 65 percent or more among women in the 45-59 age groups. Urban women were more likely to be obese than rural women, and the percentage classified as obese ranged from 25 percent in rural Upper Egypt to 49 percent in the urban Lower Egypt. Women in the highest wealth quintile were almost twice as likely as women in the lowest quintile to be obese. Table 14.4 Anthropometric indicators of nutritional status of adult women Percent distribution of de facto women age 15-59 interviewed in the health issues survey and de facto ever-married women interviewed in the main survey by selected anthropometric indi- cators, Egypt 2008 Anthropometric indicators All women age 15-59 Ever-married women age 15-49 Height in centimeters 130.0-134.9 0.1 0.0 135.0-139.9 0.2 0.1 140.0-144.9 1.2 0.7 145.0-149.9 5.9 4.3 150.0-154.9 20.5 15.2 155.0-159.9 33.3 32.8 160.0-164.9 24.7 28.6 165.0-169.9 11.0 14.8 170.0-174.9 2.6 3.0 175.0-179.9 0.3 0.4 ≥180.0 0.2 0.0 Total percent 100.0 100.0 Number of women 6,129 16,404 Mean 158.4 159.6 Weight in kilograms 35.0-39.9 0.3 0.1 40.0-49.9 7.3 2.9 50.0-59.9 18.3 12.8 60.0-69.9 22.4 24.3 ≥70.0 51.7 59.9 Total percent 100.0 100.0 Number of women 5,684 14,559 Mean 72.5 74.4 BMI1 Thin 12.0-15.9 0.1 0.0 16.0-16.9 0.3 0.1 17.0-18.4 1.1 0.4 Normal 18.5-20.4 5.1 2.2 20.5-22.9 13.7 9.6 23.0-24.9 11.8 9.7 Overweight 25.0-26.9 12.4 15.9 27.0-28.9 11.0 15.6 29.0-29.9 4.9 6.9 Obese ≥30.0 39.6 39.6 Total percent 100.0 100.0 Number of women 5,678 14,547 Mean 28.9 29.2 1Excludes pregnant women and women with a birth in the preceding 2 months Nutritional Status | 193 Table 14.5 Nutritional status of defacto adult women age 15-59 by background characteristics Mean height and percentage under 145 centimeters (cm) among de facto adult women 15-59 and mean body mass index (BMI), and percentage with specific BMI levels among de facto adult women age 15-59 who were not pregnant and had not given birth within two months of the interview, by background characteristics, and mean height and percentage under 145 centimeters (cm) and mean body mass index (BMI) for ever-married women age 15-49 and percentage with specific BMI levels among ever-married women age 15-49 who were not pregnant and had not given birth within 2 months of the interview, Egypt 2008 Body Mass Index Height Background characteristic Mean height in cm Percent- age below 145 cm Number of adult women1 Mean Body Mass Index (BMI) 18.5- 24.9 (total normal) <18.5 (total thin) 17.0- 18.4 (mildly thin) 16.0- 16.9 (moder- at ely thin) <16 (severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of adult women1 Age 15-19 157.5 2.5 1,035 24.2 59.8 4.3 2.8 1.1 0.4 35.9 26.1 9.8 982 20-24 158.9 1.8 1,059 25.8 50.1 2.3 2.1 0.2 0.0 47.4 30.6 16.8 902 25-29 159.4 0.8 886 27.9 32.6 0.8 0.5 0.2 0.1 66.6 34.0 32.6 757 30-34 159.1 1.1 678 29.7 23.8 1.0 0.8 0.1 0.1 75.2 31.6 43.6 604 35-39 159.1 0.5 661 31.1 17.1 0.5 0.4 0.1 0.0 82.2 28.6 53.6 639 40-44 158.1 1.3 553 31.9 14.0 0.7 0.6 0.0 0.1 85.1 25.2 59.8 544 45-49 157.8 1.3 530 32.6 7.5 0.7 0.4 0.3 0.0 91.5 26.4 65.2 530 50-54 156.6 2.5 385 33.3 11.2 0.6 0.4 0.3 0.0 87.6 22.6 64.9 385 55-59 157.4 0.8 342 32.6 10.6 0.0 0.0 0.0 0.0 89.4 23.8 65.7 342 Urban-rural residence Urban 158.9 1.1 2,625 29.9 25.8 1.0 0.7 0.2 0.2 72.9 28.1 44.8 2,463 Rural 158.0 1.7 3,504 28.2 34.1 1.9 1.5 0.4 0.0 63.9 28.4 35.5 3,223 Place of residence Urban Governorates 159.0 0.8 1,207 30.1 22.4 1.3 0.7 0.3 0.3 76.1 29.5 46.6 1,133 Lower Egypt 159.4 0.8 2,673 29.8 26.0 1.1 0.9 0.3 0.0 72.7 28.2 44.5 2,487 Urban 160.1 0.6 670 30.8 23.8 0.7 0.7 0.0 0.0 75.2 25.9 49.3 627 Rural 159.2 0.9 2,003 29.4 26.7 1.3 0.9 0.4 0.0 71.9 28.9 42.9 1,860 Upper Egypt 156.8 2.6 2,164 27.4 40.4 2.1 1.7 0.3 0.1 57.4 27.8 29.6 1,987 Urban 157.6 2.1 693 29.0 32.5 0.9 0.5 0.3 0.2 66.3 27.9 38.4 652 Rural 156.4 2.8 1,471 26.6 44.2 2.7 2.2 0.4 0.1 53.1 27.8 25.3 1,335 Frontier Governorates 158.9 1.0 85 27.0 42.1 3.4 2.1 1.3 0.0 54.4 26.2 28.2 78 Education No education 157.3 1.8 1,845 29.7 25.6 1.3 1.1 0.2 0.0 73.0 26.8 46.2 1,734 Some primary 157.8 2.0 505 31.3 18.4 1.2 0.8 0.2 0.3 80.1 26.6 53.5 481 Primary complete/ some secondary 157.9 1.8 1,302 27.6 37.8 2.7 1.7 0.9 0.1 59.4 28.9 30.5 1,234 Secondary complete/ higher 159.5 0.9 2,477 28.5 32.9 1.2 0.9 0.2 0.1 65.7 29.5 36.2 2,236 Wealth quintile Lowest 156.7 2.5 1,083 26.5 43.2 3.4 2.8 0.5 0.1 53.5 28.8 24.7 1,008 Second 157.5 1.8 1,262 28.1 35.8 1.4 0.9 0.4 0.2 62.8 26.9 35.9 1,182 Middle 158.2 1.3 1,213 29.6 27.4 1.3 0.9 0.4 0.0 71.1 29.1 42.0 1,101 Fourth 159.1 1.1 1,248 30.6 22.6 0.9 0.7 0.0 0.2 75.9 27.3 48.6 1,155 Highest 160.1 0.7 1,323 29.7 25.3 1.0 0.6 0.3 0.1 73.7 29.4 44.3 1,240 Total all women age 15-59 158.4 1.5 6,129 28.9 30.5 1.6 1.1 0.3 0.1 67.8 28.3 39.5 5,685 Total ever-married women age 15-49 159.6 0.9 16,404 29.2 21.5 0.5 0.4 0.1 0.0 78.0 38.4 39.6 14,547 Note: The body mass index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding 2 months. 194 | Nutritional Status Table 14.6 presents information on the nutritional status of men. The mean height for men age 15-59 was 169.3 centimeters, about 10 centimeters taller than women in the same age group, and the mean weight for men was 74.3 kilograms, about 2 kilograms more than women. The mean BMI among men was 25.8, which was below that observed for nonpregnant women. The majority of men had a BMI of 25.0 or higher and were considered overweight (34 percent) or obese (18 percent). Three percent of men had a BMI below 18.5. Table 14.6 Anthropometric indicators of nutritional status of defacto men 15-59 Percent distribution of de facto men 15-59 interviewed in the health issues survey by selected anthropometric indicators, Egypt 2008 Anthropometric indicators Total Height in centimeters 135.0-139.9 0.1 140.0-144.9 0.2 145.0-149.9 0.5 150.0-154.9 1.8 155.0-159.9 6.0 160.0-164.9 15.9 165.0-169.9 27.9 170.0-174.9 28.0 175.0-179.9 13.6 ≥180.0 5.8 Total percent 100.0 Number of men 5,571 Mean 169.3 Weight in kilograms 35.0-39.9 0.4 40.0-49.9 2.6 50.0-59.9 13.3 60.0-69.9 26.5 ≥70.0 57.3 Total percent 100.0 Number of men 5,568 Mean 74.3 BMI Thin 12.0-15.9 0.4 16.0-16.9 0.4 17.0-18.4 2.4 Normal 18.5-20.4 7.6 20.5-22.9 19.9 23.0-24.9 16.8 Overweight 25.0-26.9 17.2 27.0-28.9 12.3 29.0-29.9 4.8 ≥30.0 18.2 Total percent 100.0 Number of men 5,573 Mean 25.8 Nutritional Status | 195 Differentials in the men’s height and body mass index measures are shown in Table 14.7. The patterns were generally similar to those observed for women. The proportion classified as obese increased from 6 percent among men age 15-19 to 33 percent of men age 55-59. Urban men were much more likely than rural men to be obese (22 percent and 15 percent, respectively). Around one-quarter of men in the two highest wealth quintiles were obese compared to 9 percent of men in the lowest quintile. Table 14.7 Nutritional status of defacto adult men age 15-59 by background characteristics Mean height among de facto adult men 15-59 in centimeters (cm) and mean body mass index (BMI), and percentage with specific BMI levels among men by background characteristics, Egypt 2008 Body Mass Index Height Background characteristic Mean height in cm Number of men Mean Body Mass Index (BMI) 18.5- 24.9 (total normal) <18.5 (total thin) 17.0- 18.4 (mildly thin) 16.0- 16.9 (moder- ately thin) <16 (severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of men Age 15-19 166.5 1,060 22.7 68.3 10.1 7.4 1.4 1.3 21.6 16.0 5.6 1,061 20-24 170.3 845 24.2 59.7 3.4 1.9 1.0 0.5 36.9 28.7 8.2 845 25-29 170.5 715 26.2 44.5 1.3 1.2 0.1 0.0 54.3 35.6 18.7 715 30-34 170.3 620 26.9 34.9 0.5 0.3 0.0 0.1 64.7 41.4 23.3 620 35-39 171.0 516 26.8 34.7 0.8 0.7 0.1 0.0 64.5 46.7 17.8 516 40-44 170.1 572 27.2 32.1 1.6 1.6 0.0 0.0 66.3 39.0 27.3 572 45-49 169.0 481 28.1 27.3 1.2 1.2 0.0 0.0 71.4 41.9 29.5 481 50-54 168.8 401 27.6 30.4 1.7 1.5 0.0 0.2 67.9 43.4 24.5 401 55-59 168.0 361 28.2 24.8 1.5 1.5 0.0 0.0 73.7 40.5 33.2 361 Urban-rural residence Urban 169.8 2,477 26.4 38.8 3.7 2.9 0.5 0.3 57.5 35.6 21.9 2,478 Rural 168.9 3,094 25.4 48.7 2.8 2.0 0.4 0.4 48.4 33.2 15.3 3,094 Place of residence Urban Governorates 169.6 1,125 26.3 39.5 3.1 2.6 0.3 0.2 57.4 36.8 20.6 1,125 Lower Egypt 169.8 2,420 26.4 42.4 1.5 1.2 0.1 0.2 56.1 35.5 20.6 2,420 Urban 170.7 605 27.3 36.5 1.3 1.3 0.0 0.0 62.1 33.1 29.1 605 Rural 169.5 1,816 26.0 44.3 1.6 1.1 0.2 0.3 54.1 36.3 17.8 1,816 Upper Egypt 168.4 1,934 25.0 49.2 5.2 3.8 0.8 0.7 45.6 31.6 14.0 1,935 Urban 169.3 684 25.7 38.8 6.5 4.7 1.1 0.7 54.7 36.5 18.2 685 Rural 167.9 1,250 24.6 54.8 4.6 3.3 0.6 0.6 40.6 29.0 11.7 1,251 Frontier Governorates 169.4 91 24.8 52.7 6.5 4.8 1.6 0.0 40.9 26.5 14.3 91 Education No education 167.5 696 25.9 45.3 2.4 1.9 0.0 0.4 52.4 34.3 18.1 696 Some primary 168.5 550 26.1 43.9 2.8 2.0 0.4 0.4 53.3 33.4 19.8 550 Primary complete/some secondary 167.8 1,535 24.5 53.3 6.7 5.0 0.8 0.9 40.0 27.0 13.0 1,536 Secondary complete/ higher 170.7 2,790 26.5 39.2 1.6 1.2 0.4 0.0 59.2 38.4 20.8 2,790 Wealth quintile Lowest 167.3 925 24.3 58.0 4.8 3.4 0.8 0.7 37.2 28.6 8.6 925 Second 168.6 1,139 24.9 53.2 4.0 2.8 0.4 0.9 42.7 30.4 12.4 1,139 Middle 168.8 1,169 26.0 42.8 2.4 1.9 0.5 0.0 54.8 35.6 19.2 1,170 Fourth 170.4 1,123 26.6 36.8 3.6 3.2 0.2 0.2 59.7 34.9 24.8 1,123 Highest 171.0 1,215 27.0 34.0 1.7 1.2 0.4 0.1 64.3 40.4 23.9 1,216 Total 169.3 5,571 25.8 44.3 3.2 2.4 0.4 0.4 52.5 34.3 18.2 5,573 Note: The body mass index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). Female Circumcision | 197 FEMALE CIRCUMCISION 15 Although the government has banned the practice, female circumcision (also referred to as female genital cutting) has been a tradition in Egypt since the Pharonic period, and adherence to the custom remains widespread. The 2008 EDHS obtained information from all survey respondents on their circum- cision status. The survey also asked all ever-married women about the circumcision status of their daughters age 17 and younger. In the case of circumcised women and daughters, additional questions were included on the age at which the circumcision took place and the person who performed the circumcision. The survey also investigated women’s and men’s attitudes toward the practice. 15.1 PREVALENCE OF FEMALE CIRCUMCISION AMONG WOMEN AGE 15-49 Because questions on female circumcision were asked of both ever-married women in the entire sample and never-married women in the health issues survey, the 2008 EDHS provides the first estimate ever obtained in a DHS survey of the prevalence of female circumcision among all Egyptian women age 15-49. Prior EDHS esti- mates of the prevalence of circumcision in this age group were based only on information from ever-married women. Table 15.1 confirms that the prevalence of female circumcision is widespread in Egypt; 91 percent of all women age 15-49 have been circumcised. However, the results also suggest that adherence to the practice may be declining in some population groups. For example, while exceeding 80 percent, female circumcision rates among women under age 25 are lower than rates in the 25-49 age groups, where 94-96 percent of women have been circum- cised. The rate also is lower among never-married than ever-married women (81 percent and 95 percent, respec- tively). It is possible that some of the younger, never- married women will be circumcised before they marry. However, as seen below, few Egyptian women are circum- cised after age 15. Table 15.1 shows that urban women are less likely to be circumcised than rural women (85 percent and 96 percent, respectively). The practice is much less common in the Frontier Governorates (66 percent) than in other areas in Egypt. The likelihood that a woman is circumcised also declines with the woman’s education level and is markedly lower among women in the highest wealth quin- tile than in other quintiles (78 percent versus 92 percent or higher). Table 15.1 Prevalence of female circumcision among all women 15-49 by background characteristics Percentage of all women 15-49 who have been circum- cised according to selected background characteristics, Egypt 2008 Background characteristic Percentage who have been circumcised Number of women age 15-49 Age 15-19 80.7 1,064 20-24 87.4 1,091 25-29 94.3 906 30-34 95.2 688 35-39 96.4 673 40-44 96.2 568 45-49 96.0 550 Marital status Ever-married 95.2 3,983 Never married 80.5 1,556 Urban-rural residence Urban 85.1 2,352 Rural 95.5 3,188 Place of residence Urban Governorates 85.9 1,073 Lower Egypt 92.9 2,415 Urban 84.1 603 Rural 95.8 1,812 Upper Egypt 92.6 1,970 Urban 86.2 623 Rural 95.6 1,347 Frontier Governorates 66.3 82 Education No education 97.6 1,461 Some primary 96.4 394 Primary complete/some secondary 88.8 1,248 Secondary complete/higher 87.4 2,436 Work status Working for cash 88.4 866 Not working for cash 91.5 4,674 Wealth quintile Lowest 95.4 1,001 Second 96.1 1,123 Middle 95.2 1,099 Fourth 91.8 1,105 Highest 78.3 1,212 Total 91.1 5,540 198 | Female Circumcision 15.2 WOMEN’S CIRCUMCISION EXPERIENCE Women who were circumcised were asked how old they were when they were circumcised and about the type of person who performed the circumcision. Table 15.2 presents the distribution of the circumcised women age 15-49 according to the age at circumcision. More than half were between seven and ten years of age at the time of circumcision, and virtually all of the women were circumcised before age 15. This reflects the fact that, in Egypt, traditionally girls are circumcised slightly before or at puberty (El-Gibaly et al. 2002). Table 15.2 Age at circumcision among all women age 15-49 by residence Percent distribution of all women age 15-49 who are circumcised by age at circumcision, according to urban-rural residence and place of residence, Egypt 2008 Lower Egypt Upper Egypt Age at circumcision Urban Rural Urban Gover- norates Total Urban Rural Total . Urban Rural Frontier Gover- norates Total < 3 0.6 1.1 0.2 0.2 0.0 0.2 2.1 1.7 2.2 0.0 0.9 3-4 1.3 1.5 0.8 0.3 0.6 0.3 3.1 3.0 3.2 2.5 1.4 5-6 5.0 6.8 4.8 3.2 2.7 3.3 10.2 7.4 11.4 6.5 6.1 7-8 15.8 13.0 17.5 11.7 13.1 11.3 15.3 15.3 15.3 18.2 14.1 9-10 45.6 42.3 44.8 47.2 49.7 46.5 38.4 42.3 36.8 49.8 43.6 11-12 23.0 22.5 25.0 24.1 21.6 24.8 20.0 21.6 19.3 16.5 22.7 13-14 3.0 4.4 2.5 4.2 3.9 4.2 4.1 3.0 4.6 4.8 3.9 15-17 1.0 1.7 0.9 1.6 1.9 1.6 1.5 0.4 2.0 1.0 1.4 18-19 0.1 0.1 0.0 0.1 0.0 0.1 0.1 0.3 0.1 0.0 0.1 20 or more 0.1 0.1 0.0 0.1 0.0 0.1 0.3 0.4 0.2 0.0 0.1 Don’t know/missing 4.5 6.5 3.5 7.4 6.6 7.7 4.9 4.5 5.1 0.8 5.7 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,000 3,044 922 2,244 507 1,737 1,825 537 1,288 54 5,044 Median age 10.2 10.3 10.3 10.4 10.3 10.5 10.1 10.2 10.0 10.0 10.3 Regarding the person performing the circumcision, Table 15.3 shows that the majority of circumcised women (63 percent) report that dayas were responsible for the procedure. Trained medical personnel (primarily doctors) performed most of the remaining circumcisions (32 percent). Table 15.3 Person performing circumcisions among all women by residence Percent distribution of all women age 15-49 years who are circumcised by persons performing the circumcision, according to urban- rural residence and place of residence, Egypt 2008 Lower Egypt Upper Egypt Person performing circumcision Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Doctor 27.5 22.1 23.1 24.1 30.7 22.1 25.0 31.6 22.3 24.9 24.2 Nurse/other health worker 10.6 5.8 10.3 7.9 11.9 6.7 6.1 9.7 4.6 7.4 7.7 Daya 57.3 66.3 62.0 61.5 51.0 64.6 64.5 55.4 68.3 65.7 62.7 Barber 1.4 2.6 0.8 2.7 2.7 2.8 2.0 1.3 2.3 0.4 2.1 Ghagaria 1.1 1.8 1.4 2.4 1.4 2.6 0.6 0.1 0.8 0.8 1.5 Other 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 Don't know 2.1 1.3 2.2 1.4 2.3 1.2 1.6 1.7 1.6 0.9 1.6 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,000 3,044 922 2,244 507 1,737 1,825 537 1,288 54 5,044 Female Circumcision | 199 15.3 PREVALENCE OF FEMALE CIRCUMCISION AMONG YOUNG GIRLS In addition to asking about a woman’s own circumcision status, the 2008 EDHS asked ever- married women age 15-49 for a complete circumcision history for daughters under age 18 at the time of the survey, i.e., women with surviving daughters were asked about the circumcision status of each of their daughters age 0-17 years. Women who reported that their daughter(s) was (were) not circumcised were asked about intentions to have their daughter(s) circumcised in the future. The inclusion of a complete circumcision history provides the basis for a direct estimate of the prevalence of circumcision among young girls. The estimate is not based on the entire population of girls 0-17 years since information is not available for girls whose mothers were not interviewed in the survey, either because they were age 50 and older or had died. However, the estimate is based on a large proportion of the female population in the age group. Overall, EDHS respondents reported on the circumcision status of 16,475 daughters age 0-17 years; this represented 96 percent of the 17,107 girls in the age range who were living in EDHS households (data not shown). Using the circumcision history data, Table 15.4 presents information on the preva- lence of circumcision among girls under age 18 in Egypt. The results indicate that 24 percent of girls age 0-17 years have been circumcised. This is slightly lower than the rate reported in the 2005 EDHS (28 percent). Girls age 9-10 are more than twice as likely as girls age 7-8 to have been circumcised (7 percent and 18 per- cent, respectively). The prevalence of circum- cision increases rapidly among older daughters to a peak of 74 percent among girls age 15-17. Table 15.4 also includes estimates of the total expected prevalence of circumcision at age 18 for each cohort of daughters and for the total population of daughters under age 18. These estimates were obtained by summing the percentage of daughters already circumcised and the percentage of daughters who were not yet circumcised but whose mothers expressed an intention to circumcise their daughter(s). The cohort differences in these estimates indicate that, over the next fifteen years in Egypt, there will be a steady decline in the proportions of young adult women who are circumcised, from a level of 77 percent among girls currently age 15-17 to a level around 45 percent when girls who are currently under age three reach their eighteenth birthday. Table 15.5 presents the daughters’ circumcision indicators by selected demographic and socio- economic background characteristics and the daughter’s age. Overall, the results show that residence is strongly associated with the likelihood a daughter will be circumcised by her 18th birthday. Forty-three percent of daughters age 0-17 years in urban areas have or will be circumcised by age 18 according to the mother’s report compared with 66 percent in rural areas. Looking at the variations by place of residence, the expected prevalence of female circumcision is lowest in the Urban Governorates (37 percent) and urban Lower Egypt(41 percent) and highest in rural Upper Egypt (74 percent). The proportion of girls who are currently circumcised or are expected to be circumcised in the future decreases with the mother’s educational attainment and with wealth status. Notably, 31 percent of girls in the highest wealth quintile are expected to be circumcised by the time they reach age 18 compared with 73 percent of girls in the lowest wealth quintile. Table 15.4 Current and expected prevalence of female circumcision among young girls Percentage of girls age 0-17 years who are reported by their mother to be currently circumcised, percentage who are not yet circumcised but whose mothers intend that the girl will be circumcised in the future, and percentage expected to be circumcised taking into account the current circumcision status and mother's intention, Egypt 2008 Daughter's current age Percentage circumcised Percentage whose mothers intend the daughter to be circumcised in the future Percentage expected to be circumcised Number of daughters < 3 years 0.4 44.2 44.6 3,237 3-4 years 1.9 45.8 47.7 1,854 5-6 years 3.6 47.1 50.7 2,111 7-8 years 7.4 45.1 52.6 1,849 9-10 years 17.8 38.2 56.0 1,868 11-12 years 41.8 23.3 65.1 1,779 13-14 years 63.7 8.0 71.7 1,615 15-17 years 74.4 2.3 76.7 2,162 Total 24.1 32.9 57.0 16,475 Ta bl e 15 .5 C ur re nt a nd e xp ec te d pr ev al en ce o f f em al e ci rc um ci sio n am on g gi rls b y ba ck gr ou nd c ha ra ct er ist ic s P er ce nt ag e of g irl s 0- 17 y ea rs w ho a re c ur re nt ly c irc um ci se d, p er ce nt ag e w ho a re n ot y et c irc um ci se d bu t w ho se m ot he rs i nt en d th at t he g irl w ill b e ci rc um ci se d in t he f ut ur e, a nd pe rc en ta ge e xp ec te d to b e ci rc um ci se d ta ki ng in to a cc ou nt th e cu rr en t c irc um ci sio n st at us a nd m ot he r's in te nt io n by th e gi rl' s cu rr en t a ge , a cc or di ng to s el ec te d ba ck gr ou nd c ha ra ct er ist ic s, Eg yp t 2 00 8 < 9 ye ar s 9- 12 y ea rs 13 -1 7 ye ar s To ta l B ac kg ro un d ch ar ac te ris tic Pe rc en ta ge ci rc um - ci se d Pe rc en ta ge w ho se m ot he rs in te nd th e da ug ht er to b e ci rc um - ci se d in th e fu tu re Pe rc en ta ge ex pe ct ed to b e ci rc um - ci se d Pe rc en ta ge ci rc um - ci se d Pe rc en ta ge w ho se m ot he rs in te nd th e da ug ht er to b e ci rc um - ci se d in th e fu tu re Pe rc en ta ge ex pe ct ed to b e ci rc um - ci se d Pe rc en ta ge ci rc um - ci se d Pe rc en ta ge w ho se m ot he rs in te nd th e da ug ht er to b e ci rc um - ci se d in th e fu tu re Pe rc en ta ge ex pe ct ed to b e ci rc um - ci se d Pe rc en ta ge ci rc um - ci se d Pe rc en ta ge w ho se m ot he rs in te nd th e da ug ht er to b e ci rc um - ci se d in th e fu tu re Pe rc en ta ge ex pe ct ed to b e ci rc um - ci se d N um be r of da ug ht er s M ot he r’ s ag e 15 -1 9 0. 6 55 .1 55 .7 na na na na na na 0. 6 55 .1 55 .7 14 0 20 -2 4 0. 7 48 .0 48 .7 na na na na na na 0. 7 48 .0 48 .7 1, 43 9 25 -2 9 2. 0 44 .3 46 .3 21 .4 45 .5 66 .9 52 .5 21 .3 73 .9 4. 3 44 .3 48 .6 3, 34 4 30 -3 4 4. 1 42 .6 46 .6 29 .1 30 .0 59 .1 73 .0 6. 2 79 .3 18 .6 35 .1 53 .7 3, 60 5 35 -3 9 3. 7 48 .8 52 .4 28 .8 31 .3 60 .1 71 .6 5. 4 77 .0 33 .1 29 .5 62 .7 3, 73 5 40 -4 4 4. 9 45 .8 50 .7 30 .1 27 .6 57 .6 68 .8 4. 6 73 .4 42 .4 21 .1 63 .4 2, 76 8 45 -4 9 7. 8 42 .5 50 .3 38 .6 25 .8 64 .4 67 .8 2. 9 70 .7 51 .3 14 .8 66 .1 1, 44 5 U rb an -r ur al U rb an 2. 3 33 .9 36 .2 22 .0 22 .8 44 .8 52 .9 4. 3 57 .2 18 .8 24 .3 43 .2 6, 32 8 Ru ra l 3. 3 52 .2 55 .5 34 .4 36 .2 70 .6 81 .1 5. 1 86 .2 27 .4 38 .2 65 .6 10 ,1 47 P la ce o f r es id en ce U rb an G ov er no ra te s 1. 5 30 .1 31 .7 16 .1 20 .7 36 .8 44 .3 3. 3 47 .6 14 .7 21 .9 36 .5 2, 57 6 Lo w er E gy pt 0. 5 43 .0 43 .4 23 .9 34 .9 58 .8 72 .3 5. 0 77 .3 22 .1 32 .5 54 .6 7, 14 0 U rb an 0. 4 32 .1 32 .5 17 .2 24 .7 41 .9 53 .9 5. 1 59 .0 17 .9 23 .5 41 .4 1, 77 8 R ur al 0. 5 46 .2 46 .7 26 .4 38 .6 65 .0 79 .2 5. 0 84 .2 23 .5 35 .4 59 .0 5, 36 2 U pp er E gy pt 6. 1 54 .5 60 .6 40 .9 31 .1 72 .1 78 .0 5. 1 83 .1 30 .2 38 .1 68 .3 6, 50 8 U rb an 5. 1 41 .2 46 .3 34 .7 24 .3 59 .0 63 .4 5. 1 68 .5 25 .4 28 .9 54 .3 1, 80 9 R ur al 6. 5 59 .5 66 .1 43 .3 33 .8 77 .1 83 .9 5. 1 89 .0 32 .1 41 .6 73 .7 4, 69 9 Fr on tie r G ov er no ra te s 1. 8 34 .1 35 .9 25 .2 19 .5 44 .7 56 .0 2. 4 58 .4 20 .3 23 .1 43 .4 25 1 E du ca tio n N o ed uc at io n 4. 6 59 .0 63 .7 35 .5 38 .4 73 .9 78 .5 5. 5 84 .0 34 .4 37 .9 72 .3 5, 81 2 So m e pr im ar y 3. 4 56 .4 59 .8 38 .2 31 .5 69 .7 81 .5 4. 3 85 .8 34 .7 35 .1 69 .8 1, 54 3 Pr im ar y co m p. /s om e se co nd ar y 3. 2 48 .2 51 .4 31 .7 29 .4 61 .1 72 .0 3. 8 75 .7 23 .2 35 .2 58 .4 2, 46 4 Se co nd ar y co m pl et e/ hi gh er 1. 6 34 .2 35 .8 19 .3 23 .1 42 .4 50 .3 4. 2 54 .6 13 .1 27 .1 40 .2 6, 65 6 W or k st at us W or ki ng fo r c as h 1. 5 35 .0 36 .6 21 .8 28 .7 50 .4 53 .0 4. 8 57 .8 21 .4 24 .8 46 .1 2, 42 5 N ot w or ki ng fo r c as h 3. 1 46 .9 49 .9 31 .1 31 .4 62 .5 73 .6 4. 7 78 .4 24 .6 34 .3 58 .9 14 ,0 50 W ea lth q ui nt ile Lo w es t 4. 8 60 .1 64 .9 35 .8 38 .2 74 .1 83 .6 6. 2 89 .8 30 .8 42 .2 73 .0 3, 72 0 Se co nd 3. 9 57 .1 61 .0 38 .9 34 .1 73 .0 81 .4 4. 4 85 .8 30 .0 39 .5 69 .5 3, 24 4 M id dl e 2. 6 46 .8 49 .3 32 .4 33 .7 66 .2 75 .0 4. 5 79 .6 24 .8 34 .7 59 .5 3, 35 5 Fo ur th 1. 7 36 .8 38 .5 19 .7 30 .4 50 .2 61 .2 5. 8 67 .0 18 .7 28 .6 47 .4 3, 20 2 H ig he st 1. 2 23 .1 24 .3 17 .8 14 .3 32 .1 42 .6 2. 4 45 .0 14 .4 16 .4 30 .8 2, 95 4 T ot al 2. 9 45 .4 48 .3 29 .5 30 .9 60 .5 69 .8 4. 7 74 .6 24 .1 32 .9 57 .0 16 ,4 75 na = N ot a pp lic ab le 200 | Female Circumcision Female Circumcision | 201 15.4 CIRCUMCISION EXPERIENCE OF YOUNG GIRLS As part of the circumcision history, EDHS respondents were asked about the age at circumcision and the person who performed the procedure for each of the daughters reported as circumcised. Table 15.6 presents the distribution of the circumcised daughters age 0-17 years by the age at circumcision. More than half of the girls were between seven and ten years of age at the time of circumcision, and virtually all of the girls were circumcised before age 13. The median age at the time of the circumcision for daughters was 10 years, with girls tending to be circumcised at a somewhat younger age in Upper Egypt and a somewhat older age in Lower Egypt than this average. Table 15.6 Age at circumcision among girls by residence Percent distribution of girls age 0-17 years reported by their mother to have been circumcised by age at circumcision, according to urban- rural residence and place of residence, Egypt 2008 Lower Egypt Upper Egypt Age at circumcision Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total < 3 4.3 4.7 2.2 0.2 0.0 0.2 8.7 9.2 8.6 1.2 4.6 3-4 2.2 3.6 0.2 0.5 0.0 0.6 5.9 5.3 6.0 2.9 3.2 5-6 8.0 10.0 6.1 1.7 2.1 1.5 16.4 13.8 17.2 6.5 9.4 7-8 17.0 14.0 16.3 11.9 12.5 11.8 16.8 20.2 15.7 22.4 14.9 9-10 42.1 38.7 45.0 51.3 57.1 49.8 29.4 28.9 29.6 41.3 39.8 11-12 22.9 21.7 25.7 27.3 24.7 27.9 17.1 19.9 16.3 22.9 22.1 13-14 2.5 4.7 3.4 5.1 2.2 5.8 3.4 2.0 3.8 1.7 4.1 15-17 0.4 0.4 0.1 0.7 1.3 0.5 0.3 0.2 0.4 0.0 0.4 Don’t know/missing 0.5 2.1 0.9 1.4 0.0 1.7 2.0 0.6 2.4 1.1 1.6 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,191 2,785 377 1,581 319 1,262 1,966 459 1,507 51 3,976 Median age 10.1 10.1 10.2 10.5 10.4 10.6 9.1 9.1 9.1 9.9 10.1 Regarding the person performing the daughter’s circumcision, Table 15.7 shows that trained medical personnel performed almost three-quarters of the circumcisions. Dayas (traditional birth attendants) performed the majority of the remaining circumcisions. Dayas performed more circumcisions in rural Upper Egypt than in other areas; however, even in rural Upper Egypt, the majority of circumcisions were performed by medical personnel. Table 15.7 Person performing circumcisions among girls by residence Percent distribution of girls age 0-17 years reported by their mother to have been circumcised by persons performing the circumcision, according to urban-rural residence and place of residence, Egypt 2008 Lower Egypt Upper Egypt Person performing circumcision Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Doctor 76.8 69.3 70.0 79.8 86.7 78.0 65.3 74.8 62.4 71.3 71.6 Nurse/other health worker 6.3 5.6 6.5 5.8 5.6 5.9 5.7 6.8 5.4 4.0 5.8 Daya 16.0 22.7 22.8 11.7 7.0 13.0 27.4 17.1 30.5 23.6 20.7 Barber 0.3 1.3 0.0 1.3 0.8 1.5 1.0 0.2 1.2 0.4 1.0 Ghagaria 0.0 0.3 0.0 0.5 0.0 0.6 0.1 0.0 0.1 0.0 0.2 Don't know 0.7 0.7 0.7 0.9 0.0 1.1 0.5 1.1 0.4 0.6 0.7 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,191 2,785 377 1,581 319 1,262 1,966 459 1,507 51 3,976 202 | Female Circumcision 15.5 SUPPORT FOR FEMALE CIRCUMCISION AMONG WOMEN AND MEN The 2008 EDHS obtained information from both women and men on several indicators of support for female circumcision including the belief that practice of circumcision is required by religious precepts and the belief that practice of female circumcision should be continued. In addition, women were asked if they thought men supported continuation of the practice while men were asked about what they perceived to be women’s attitudes. Table 15.8.1 shows that just under half of all women age 15-49 believe that female circumcision is a religious requirement and just over half feel that the practice of circumcision should continue. The table also shows that 41 percent of women think that men support the continuation of the practice of circumcision. Table 15.8.1 Attitude about continuation of female circumcision by background characteristics: All women age 15-49 Percentage of all women age 15-49 who believe circumcision is required by religious precepts and percent distributions of all women age 15-49 by own attitude and perception about men's attitude toward the continuation of the practice of female circumcision, according to selected background characteristics, Egypt 2008 Woman's attitude about practice Woman's perception about men's attitudes Background characteristic Percentage saying circumcision is required by religious precepts Continue Be stopped Not sure Total percent Continue Be stopped Not sure Total percent Number of women age 15-49 Age 15-19 34.7 34.1 46.4 19.5 100.0 22.7 19.0 58.3 100.0 1,064 20-24 42.6 47.0 41.5 11.5 100.0 34.4 21.1 44.5 100.0 1,091 25-29 51.0 57.0 33.9 9.1 100.0 45.7 21.8 32.5 100.0 906 30-34 55.1 60.4 29.9 9.7 100.0 47.4 22.4 30.2 100.0 688 35-39 56.0 65.4 26.0 8.6 100.0 51.4 20.5 28.0 100.0 673 40-44 61.4 69.3 21.7 9.0 100.0 53.1 16.2 30.7 100.0 568 45-49 58.2 63.8 28.1 8.1 100.0 52.4 22.7 25.0 100.0 550 Marital status Ever-married 54.9 62.5 28.3 9.2 100.0 49.4 20.8 29.8 100.0 3,983 Never married 34.3 32.3 50.3 17.4 100.0 20.9 20.0 59.1 100.0 1,556 Urban-rural residence Urban 41.0 42.7 47.7 9.5 100.0 32.7 30.7 36.7 100.0 2,352 Rural 55.0 62.3 24.8 12.9 100.0 47.8 13.1 39.1 100.0 3,188 Place of residence Urban Governorates 36.1 37.2 54.3 8.5 100.0 29.4 35.6 35.0 100.0 1,073 Lower Egypt 51.6 57.7 30.2 12.1 100.0 45.6 16.6 37.8 100.0 2,415 Urban 43.5 46.7 43.3 10.0 100.0 37.5 27.9 34.6 100.0 603 Rural 54.4 61.4 25.8 12.8 100.0 48.3 12.9 38.9 100.0 1,812 Upper Egypt 53.5 59.2 28.3 12.5 100.0 43.1 16.4 40.5 100.0 1,970 Urban 47.5 48.8 40.4 10.7 100.0 33.6 24.4 42.0 100.0 623 Rural 56.2 63.9 22.7 13.3 100.0 47.5 12.7 39.8 100.0 1,347 Frontier Governorates 38.9 40.0 52.1 7.9 100.0 33.5 40.3 26.1 100.0 82 Education No education 61.6 71.8 15.1 13.1 100.0 54.6 9.4 36.0 100.0 1,461 Some primary 55.7 66.8 21.0 12.2 100.0 51.4 11.8 36.9 100.0 394 Primary complete/ some secondary 44.9 49.3 36.7 14.1 100.0 37.0 18.0 45.0 100.0 1,248 Secondary complete/ higher 42.7 43.7 47.2 9.1 100.0 34.1 30.0 35.9 100.0 2,436 Work status Working for cash 43.9 46.5 45.6 7.9 100.0 37.3 30.4 32.3 100.0 866 Not working for cash 50.1 55.4 32.5 12.1 100.0 42.1 18.8 39.1 100.0 4,674 Wealth quintile Lowest 56.3 66.3 19.7 14.0 100.0 47.8 10.4 41.8 100.0 1,001 Second 56.1 62.9 25.0 12.0 100.0 47.2 13.8 39.0 100.0 1,123 Middle 51.7 57.8 28.1 14.1 100.0 46.1 15.0 38.9 100.0 1,099 Fourth 46.1 50.4 39.8 9.8 100.0 39.6 22.5 38.0 100.0 1,105 Highest 37.0 35.4 56.5 8.1 100.0 28.0 38.6 33.4 100.0 1,212 Total 49.1 54.0 34.5 11.5 100.0 41.4 20.6 38.0 100.0 5,540 Female Circumcision | 203 As Table 15.8.2 shows, men’s attitudes about the practice of female circumcision are generally similar to those of women. Around half of men age 15-49 say that circumcision is required by religion and 57 percent believe the practice should continue. Around 45 percent of men think that women want female circumcision to continue. Table 15.8.2 Attitude about continuation of female circumcision by background characteristics: All men age 15-49 Percentage of all men age 15-49 who believe circumcision is required by religious precepts and percent distributions of all men age 15-49 by own attitude and perception about women's attitude toward the continuation of the practice of female circumcision, according to selected background characteristics, Egypt 2008 Man's attitude about practice Man's perception about women's attitudes Background characteristic Percentage saying circumcision is required by religious precepts Continue Be stopped Not sure Total percent Continue Be stopped Not sure Total percent Number of men age 15-49 Age 15-19 33.3 36.1 26.5 37.4 100.0 26.9 20.3 52.7 100.0 1,087 20-24 46.8 50.9 31.0 18.1 100.0 40.7 26.4 32.9 100.0 869 25-29 56.8 63.7 27.3 9.0 100.0 50.2 25.6 24.1 100.0 729 30-34 57.5 62.9 28.2 8.9 100.0 52.2 26.4 21.3 100.0 634 35-39 60.8 66.0 24.4 9.7 100.0 53.7 21.3 25.0 100.0 535 40-44 61.7 68.7 22.2 9.1 100.0 55.2 23.1 21.7 100.0 581 45-49 62.7 69.5 23.7 6.8 100.0 58.0 23.5 18.5 100.0 494 Marital status Ever-married 60.0 67.0 24.2 8.8 100.0 54.5 23.9 21.6 100.0 2,640 Never married 41.8 44.8 29.4 25.9 100.0 35.0 23.6 41.5 100.0 2,290 Urban-rural residence Urban 48.7 51.4 34.6 13.9 100.0 42.2 31.7 26.1 100.0 2,170 Rural 53.8 60.8 20.3 18.9 100.0 48.0 17.4 34.6 100.0 2,760 Place of residence Urban Governorates 43.4 43.5 42.5 14.0 100.0 38.1 41.2 20.7 100.0 990 Lower Egypt 53.0 60.4 21.5 18.1 100.0 45.1 18.6 36.3 100.0 2,150 Urban 54.7 61.2 24.8 14.1 100.0 46.6 21.0 32.4 100.0 533 Rural 52.5 60.1 20.5 19.4 100.0 44.7 17.7 37.6 100.0 1,616 Upper Egypt 54.8 60.2 23.3 16.4 100.0 50.7 19.4 29.8 100.0 1,706 Urban 52.4 56.3 30.2 13.4 100.0 45.9 25.2 28.9 100.0 588 Rural 56.1 62.3 19.7 18.0 100.0 53.3 16.4 30.3 100.0 1,118 Frontier Governorates 42.3 45.6 36.6 17.8 100.0 31.1 36.3 32.5 100.0 84 Education No education 58.0 66.4 16.5 17.2 100.0 50.7 16.7 32.6 100.0 467 Some primary 54.4 66.9 17.6 15.5 100.0 52.3 19.3 28.4 100.0 458 Primary complete/ some secondary 45.9 50.4 23.6 26.0 100.0 39.2 19.4 41.4 100.0 1,414 Secondary complete/ higher 53.0 56.5 31.7 11.8 100.0 46.6 28.2 25.2 100.0 2,590 Work status Working for cash 56.5 62.4 25.7 11.9 100.0 50.7 24.0 25.3 100.0 3,685 Not working for cash 36.8 39.7 29.3 31.0 100.0 29.7 22.9 47.4 100.0 1,245 Wealth quintile Lowest 52.5 59.3 18.5 22.2 100.0 47.7 17.7 34.6 100.0 838 Second 51.4 59.5 20.4 20.1 100.0 44.5 15.9 39.5 100.0 1,010 Middle 54.2 59.3 22.6 18.1 100.0 49.0 18.3 32.7 100.0 1,036 Fourth 54.3 59.9 27.7 12.5 100.0 48.6 27.0 24.4 100.0 997 Highest 45.6 46.3 42.0 11.7 100.0 37.9 38.3 23.8 100.0 1,049 Total 51.5 56.7 26.6 16.7 100.0 45.4 23.7 30.9 100.0 4,930 Although support for circumcision is still widespread among women, Figure 15.1 shows that there has been considerable change since the mid-1990s in women’s attitudes about circumcision. The proportion of ever-married women age 15-49 who believe that circumcision should continue has dropped from 82 percent in 1995 to 63 percent at the time of the 2008 EDHS. Women were also much less likely to believe that men want the practice to continue in 2008 (49 percent) than in 2000 (61 percent). 204 | Female Circumcision Marked differences in the measures of the level of support for female circumcision are evident across population subgroups among women (Tables 15.8.1). Women under age 25 were less likely than older women to see circumcision as a religious requirement, want the practice to continue or believe that men want female circumcision to continue. Similarly never-married women were much less likely than ever-married women to believe circumcision is mandated by religion, support continuation of the practice themselves, or feel that men continue to support the practice. Support for the practice was more widespread among rural than urban women. Women in the Frontier Governorates were least supportive of the practice followed closely by women in the Urban Governorates. The proportion of women who felt that circumcision is mandated by religion decreased with both increased education and the wealth quintile while these characteristics were negatively related to the likelihood that a woman supports the continu- ation of the practice of circumcision or believes that men want the practice to be continued. Differentials in men’s attitudes toward the practice of circumcision presented in Table 15.8.2 are generally similar to those found among women. However, men not working for cash were much less likely than men working for cash to support female circumcision, which is the opposite of the pattern for women. These differences can be attributed to differences in the composition of the groups of women and men not working for cash. Among men, the group included a large proportion of younger, better educated individuals, while, among women, the group included a larger proportion of older, less educated indi- viduals. 15.6 REASONS FOR SUPPORT OF FEMALE CIRCUMCISION To gain a better understanding of the reasons for support for the practice of circumcision, the 2008 EDHS included several statements about female circumcision with which women and men were asked to agree or disagree. Two of the statements addressed factors that are often cited as primary rationales for the practice: “A husband will prefer his wife to be circumcised” and “Circumcision prevents adultery.” The other statements were related to health concerns associated with the practice: “Childbirth is more difficult for a woman who has been circumcised” and “Circumcision can cause serious conse- quences that can lead to a girl’s death.” 82 75 61 68 54 63 49 Wants practice to continue Believes men want practice to continue 0 20 40 60 80 100 Percent 1995 2000 2005 2008 Figure 15.1 Trends in Attitudes toward Female Circumcision among Ever-married Women Age 15-49, Egypt 1995-2008 Believes men want practice to continue Female Circumcision | 205 Tables 15.9.1 and 15.9.2 present differentials in the proportions of women and men in the 15-49 age group agreeing with the various statements. Men were more likely than women to think that a husband would prefer the wife to be circumcised (60 percent and 45 percent, respectively) and to agree that circumcision prevents adultery (39 percent and 34 percent, respectively). The results also show that, while nearly half of women agreed that circumcision can cause severe complications which may lead to a girl’s death, less than one-third of men recognized these potentially adverse consequences of circum- cision. Few women (6 percent) and men (3 percent) believed that childbirth is more difficult for circumcised women than for other women. Table 15.9.1 Beliefs about female circumcision by background characteristics: All women age 15-49 Percentage of all women age 15-49 who agree with various statements about female circumcision, according to selected background characteristics, Egypt 2008 Background characteristic Husbands prefer Prevents adultery Can lead to girl's death Makes childbirth difficult Number of women age 15-49 Age 15-19 20.2 16.1 56.8 4.2 1,064 20-24 37.6 26.9 52.9 5.7 1,091 25-29 50.7 38.3 50.0 6.2 906 30-34 53.4 42.1 46.1 6.2 688 35-39 57.4 42.9 41.0 7.1 673 40-44 57.3 44.8 38.4 6.8 568 45-49 58.3 44.2 41.0 5.2 550 Marital status Ever-married 55.4 41.3 43.6 6.7 3,983 Never married 17.8 15.6 59.9 3.4 1,556 Urban-rural residence Urban 35.6 28.3 57.5 5.8 2,352 Rural 51.6 38.3 41.3 5.8 3,188 Place of residence Urban Governorates 31.3 26.0 62.7 5.1 1,073 Lower Egypt 49.8 37.5 43.8 5.2 2,415 Urban 42.4 32.6 46.6 4.9 603 Rural 52.3 39.1 42.9 5.3 1,812 Upper Egypt 46.7 34.6 45.0 6.8 1,970 Urban 37.0 28.4 59.0 7.8 623 Rural 51.2 37.5 38.6 6.4 1,347 Frontier Governorates 30.5 26.8 64.4 5.9 82 Education No education 60.7 44.8 32.8 6.4 1,461 Some primary 58.0 47.9 40.5 3.7 394 Primary complete/some secondary 37.7 28.0 51.7 5.5 1,248 Secondary complete/higher 36.9 28.5 56.9 5.9 2,436 Work status Working for cash 40.1 32.8 53.0 6.2 866 Not working for cash 45.7 34.3 47.3 5.7 4,674 Wealth quintile Lowest 52.0 39.4 36.9 4.6 1,001 Second 52.5 39.1 39.3 5.5 1,123 Middle 48.9 37.2 45.1 5.8 1,099 Fourth 42.5 33.9 53.5 5.4 1,105 Highest 30.2 22.4 63.8 7.3 1,212 Total 44.8 34.1 48.2 5.8 5,540 206 | Female Circumcision The differentials shown in Table 15.9.1 and 15.9.2 indicate that women and men who were living in urban areas and those who were highly educated or in the highest wealth quintile were less likely than other women and men to believe that a husband would prefer his wife to be circumcised or to believe that circumcision prevents adultery. These same groups were more likely than other groups to believe that circumcision may have adverse or even fatal health consequences for a girl. Table 15.9.2 Beliefs about female circumcision by background characteristics: All men age 15-49 Percentage of all men age 15-49 who agree with various statements about female circumcision, according to selected background characteristics, Egypt 2008 Background characteristic Husbands prefer Prevents adultery Can lead to girl's death Makes childbirth difficult Number of men age 15-49 Age 15-19 39.3 25.3 29.8 2.0 1,087 20-24 56.1 36.5 36.0 3.1 869 25-29 67.7 43.4 31.4 3.9 729 30-34 64.9 42.6 36.5 3.4 634 35-39 70.1 41.2 26.5 3.8 535 40-44 72.6 44.5 30.9 2.6 581 45-49 72.2 49.7 31.6 3.6 494 Marital status Ever-married 70.3 44.2 31.2 3.2 2,640 Never married 48.8 32.1 32.9 2.9 2,290 Urban-rural residence Urban 55.0 37.2 36.1 2.5 2,170 Rural 64.5 39.7 28.7 3.5 2,760 Place of residence Urban Governorates 49.8 36.6 38.3 2.4 990 Lower Egypt 63.3 34.2 29.5 2.9 2,150 Urban 63.3 32.7 31.1 2.3 533 Rural 63.3 34.7 29.0 3.1 1,616 Upper Egypt 63.6 45.6 31.3 3.8 1,706 Urban 57.5 43.2 37.3 2.9 588 Rural 66.8 46.9 28.2 4.2 1,118 Frontier Governorates 42.2 32.7 32.0 0.6 84 Education No education 69.4 41.1 22.3 2.2 467 Some primary 72.6 49.5 24.7 2.9 458 Primary complete/some secondary 52.2 32.4 29.7 2.7 1,414 Secondary complete/higher 61.0 39.6 36.2 3.4 2,590 Work status Working for cash 66.3 42.4 32.0 3.2 3,685 Not working for cash 42.8 27.2 31.9 2.5 1,245 Wealth quintile Lowest 66.1 45.2 25.2 3.7 838 Second 62.5 35.1 25.8 3.0 1,010 Middle 62.0 41.9 28.9 3.5 1,036 Fourth 62.1 38.7 34.6 2.2 997 Highest 50.3 33.3 43.7 3.0 1,049 Total 60.3 38.6 32.0 3.1 4,930 Female Circumcision | 207 15.7 EXPOSURE TO INFORMATION ABOUT CIRCUMCISION Table 15.10.1 and 15.10.2 summarizes findings from the 2008 EDHS concerning women’s and men’s exposure to information about female circumcision and the channels through which they received information about circumcision during the six-month period prior to the survey. Around seven in ten women and about half of men in the 15-49 age group had received information about female circumcision during the six months prior to the survey. Typically, urban residents, those who were highly educated, and women in the highest wealth quintile were more likely than other women and men to have received information about circumcision during the period. Table 15.10.1 Exposure to information regarding female circumcision by background characteristics: All women age 15-49 Percentage of all women age 15-49 discussing female circumcision with relatives, friends or neighbors and receiving information about female circumcision during the year prior to the survey, and among women receiving information during the year prior to the survey, percentage naming various sources of information, according to background characteristics, Egypt 2008 Source from which women last saw/heard about female circumcision Background characteristic Percentage receiving information recently about female circumcision Number of women TV Other media1 Any medical provider contact Home visit by medical provider Facility visit to medical provider Husband/ other relatives/ friends/ neighbors Community meeting/ mosque/ church/ other Number of women receiving information about female circumcision recently Age 15-19 68.6 1,064 96.2 14.5 1.9 0.8 1.1 17.6 1.8 730 20-24 68.2 1,091 96.5 14.5 2.6 1.0 1.6 19.2 1.4 744 25-29 76.4 906 96.8 14.5 3.1 0.7 2.4 24.3 0.8 692 30-34 76.0 688 95.5 12.5 4.3 1.1 3.2 26.7 2.1 523 35-39 74.5 673 94.8 12.5 4.0 1.3 2.7 27.1 1.7 502 40-44 72.2 568 96.3 13.9 3.7 0.2 3.5 23.1 1.2 410 45-49 72.6 550 98.3 14.1 4.7 1.0 3.7 20.8 1.1 399 Marital status Ever-married 73.1 3,983 96.2 13.1 3.7 0.9 2.8 24.5 1.3 2,910 Never married 70.0 1,556 96.7 16.0 2.3 0.9 1.3 16.7 1.8 1,089 Urban-rural residence Urban 76.1 2,352 97.0 10.6 1.9 0.2 1.7 20.2 1.4 1,790 Rural 69.3 3,188 95.8 16.5 4.4 1.4 3.0 24.1 1.5 2,209 Place of residence Urban Governorates 80.1 1,073 98.3 7.2 1.3 0.1 1.2 21.2 1.0 860 Lower Egypt 76.3 2,415 97.9 20.2 3.1 0.5 2.5 18.3 0.6 1,842 Urban 76.0 603 96.8 19.6 1.5 0.0 1.5 16.8 1.3 458 Rural 76.4 1,812 98.3 20.4 3.6 0.7 2.9 18.8 0.3 1,385 Upper Egypt 63.3 1,970 92.7 9.6 5.1 2.0 3.1 29.4 3.1 1,246 Urban 70.4 623 94.9 8.4 3.5 0.7 2.8 22.2 2.3 438 Rural 60.0 1,347 91.6 10.3 5.9 2.7 3.2 33.3 3.5 808 Frontier Governorates 62.7 82 92.9 3.2 0.9 0.0 0.9 14.4 0.4 51 Education No education 63.6 1,461 93.6 12.0 4.1 1.4 2.7 23.1 1.5 930 Some primary 74.1 394 95.3 8.8 2.2 0.8 1.4 24.9 1.1 292 Primary complete/ some secondary 72.2 1,248 96.9 12.6 1.8 0.4 1.5 21.3 1.5 901 Secondary complete/ higher 77.0 2,436 97.5 16.2 3.7 0.9 2.9 22.1 1.4 1,877 Work status Working for cash 75.9 866 95.8 15.9 6.7 1.0 5.7 24.6 2.7 657 Not working for cash 71.5 4,674 96.4 13.5 2.6 0.9 1.8 21.9 1.2 3,343 Wealth quintile Lowest 58.3 1,001 90.0 13.2 5.5 1.8 3.7 28.9 1.8 584 Second 70.2 1,123 97.2 14.2 2.9 1.2 1.7 24.4 1.2 788 Middle 74.0 1,099 97.1 15.8 4.0 1.3 2.7 22.1 1.3 813 Fourth 76.7 1,105 98.2 12.1 2.2 0.2 2.0 18.9 1.2 848 Highest 79.8 1,212 97.0 14.0 2.6 0.3 2.3 19.9 1.6 967 Total 72.2 5,540 96.3 13.9 3.3 0.9 2.4 22.3 1.4 4,000 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster 208 | Female Circumcision Regarding sources of information about circumcision, television was the primary source of information. Among women, 96 percent received information about female circumcision on television, 22 percent had gotten information from their husbands, other relatives or friends and neighbors and 14 percent cited other mass media as a source of information about circumcision. Television was also the main source for information for men (97 percent), followed by other mass media (22 percent) and wives, other relatives, or friends and neighbors (16 percent). Table 15.10.2 Exposure to information regarding female circumcision by background characteristics: All men age 15-49 Percentage of all men age 15-49 discussing female circumcision with relatives, friends or neighbors and receiving information about female circumcision during the year prior to the survey, and among men receiving information during the year prior to the survey, percentage naming various sources of information, according to background characteristics, Egypt 2008 Source from which men last saw/heard about female circumcision Background characteristic Percentage receiving information recently about female circumcision Number of women TV Other media1 Any medical provider contact Home visit by medical provider Facility visit to medical provider Wife/ other relatives/ friends/ neighbors Community meeting/ mosque/ church/ other Number of men receiving information about female circumcision recently Age 15-19 39.0 1,087 96.0 22.7 0.8 0.1 0.7 10.9 2.1 424 20-24 52.6 869 97.4 20.7 1.4 0.5 0.9 13.4 2.2 457 25-29 54.3 729 96.4 20.9 1.9 0.0 1.9 12.6 2.4 396 30-34 59.6 634 97.3 23.5 1.4 0.3 1.1 18.4 3.2 378 35-39 55.1 535 97.6 19.5 3.4 0.9 2.5 17.4 1.9 295 40-44 56.0 581 94.8 20.6 4.3 0.9 3.4 23.6 2.3 325 45-49 55.9 494 97.7 23.7 1.7 0.3 1.4 16.8 2.9 277 Marital status Ever-married 55.8 2,640 96.7 21.7 2.6 0.5 2.1 18.7 2.3 1,473 Never married 47.1 2,290 96.8 21.7 1.2 0.3 1.0 11.7 2.5 1,077 Urban-rural residence Urban 48.8 2,170 97.2 19.8 1.7 0.2 1.5 14.4 2.1 1,059 Rural 54.0 2,760 96.4 23.0 2.2 0.5 1.7 16.6 2.6 1,491 Place of residence Urban Governorates 46.6 990 98.0 10.0 1.1 0.0 1.1 13.3 0.9 461 Lower Egypt 60.9 2,150 97.3 28.7 1.7 0.5 1.3 15.5 2.1 1,309 Urban 58.7 533 97.7 34.5 2.4 0.4 2.1 17.3 3.3 313 Rural 61.6 1,616 97.2 26.9 1.5 0.5 1.0 14.9 1.7 996 Upper Egypt 43.9 1,706 94.9 17.1 2.9 0.5 2.4 17.6 3.9 749 Urban 45.1 588 95.1 20.2 1.6 0.4 1.3 13.0 2.7 265 Rural 43.3 1,118 94.7 15.4 3.6 0.6 3.0 20.2 4.6 484 Frontier Governorates 37.5 84 97.1 8.9 5.5 0.0 5.5 16.0 1.0 31 Education No education 46.2 467 96.0 14.3 1.3 0.0 1.3 14.4 0.0 215 Some primary 45.6 458 96.0 17.5 0.6 0.6 0.0 14.6 1.7 209 Primary complete/ some secondary 43.1 1,414 96.1 20.9 0.8 0.3 0.5 12.0 2.2 609 Secondary complete/ higher 58.6 2,590 97.2 23.6 2.8 0.5 2.3 17.5 2.9 1,517 Work status Working for cash 54.1 3,685 97.0 21.6 2.2 0.4 1.8 16.5 2.4 1,994 Not working for cash 44.8 1,245 95.8 22.0 1.2 0.3 1.0 13.1 2.6 557 Wealth quintile Lowest 44.3 838 95.9 16.1 2.4 0.1 2.2 18.1 3.3 372 Second 51.8 1,010 95.9 18.7 1.3 0.4 1.0 15.7 2.2 523 Middle 52.5 1,036 96.8 23.3 2.8 0.9 1.9 16.4 1.9 544 Fourth 50.6 997 96.7 23.8 1.9 0.2 1.7 16.2 2.4 505 Highest 57.9 1,049 97.8 24.4 1.7 0.3 1.5 13.3 2.6 607 Total 51.7 4,930 96.7 21.7 2.0 0.4 1.6 15.7 2.4 2,551 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster Avian Influenza | 209 AVIAN INFLUENZA 16 Avian influenza (AI) emerged as a significant health concern in Egypt with the first case reported in 2006 (WHO 2006a). The Egyptian government took a number of immediate steps to address the potential threat and instituted a public education campaign to increase awareness among both poultry producers and consumers of avian influenza regarding practices that would reduce transmission (El- Zanaty and Associates 2007). To provide input into various AI programs, the 2008 EDHS obtained information during the household interview on extent of household ownership of poultry and other birds and on the ways in which poultry and birds are handled within households. A special avian influenza module was included as part of the special health issues interviews conducted in the 2008 EDHS. The module obtained informa- tion on the overall level of awareness of avian influenza, the channels of communication through which the Egyptian population is receiving information about avian influenza, knowledge about risks and symptoms of the disease in poultry or birds and in humans, the extent of understanding of modes of transmission and prevention, and attitudes toward avian influenza. 16.1 HOUSEHOLD OWNERSHIP OF POULTRY AND OTHER BIRDS The 2008 EDHS found that around one in six households (16 percent) owned or kept poultry and/or other birds (Table 16.1). Figure 16.1 shows that the level of household ownership of poultry in 2008 was less than half the level reported two decades earlier in the 1988 Egypt DHS (33 percent). In part, the sharp decline in household ownership of poultry may be due to the extensive culling of poultry that took place in 2006; it is estimated that more than 25 million birds were culled at that time (International Federation of Red Cross and Red Crescent Societies 2008). Table 16.1 Household possession of poultry/birds Percent distribution of households by possession/ownership of poultry/birds according to background characteristics, Egypt 2008 Background characteristic Owns poultry/ birds only Owns poultry/birds and keeps for others for breeding Does not own, but keeps for others Does not own/ keep Total Number of households Urban-rural residence Urban 3.8 0.1 0.1 96.0 100.0 9,159 Rural 26.1 1.0 0.4 72.5 100.0 9,809 Place of residence Urban Governorates 1.5 0.0 0.1 98.4 100.0 4,182 Lower Egypt 15.0 0.6 0.2 84.1 100.0 8,348 Urban 4.0 0.1 0.1 95.8 100.0 2,466 Rural 19.6 0.8 0.3 79.3 100.0 5,881 Upper Egypt 25.0 0.9 0.3 73.7 100.0 6,204 Urban 7.5 0.1 0.0 92.4 100.0 2,338 Rural 35.7 1.4 0.5 62.4 100.0 3,865 Frontier Governorates 15.8 1.1 0.1 83.0 100.0 235 Wealth quintile Lowest 30.7 1.1 0.2 68.0 100.0 3,205 Second 26.9 0.9 0.2 72.0 100.0 3,262 Middle 17.4 0.6 0.4 81.6 100.0 3,849 Fourth 6.5 0.3 0.2 93.0 100.0 4,231 Highest 2.4 0.2 0.1 97.4 100.0 4,420 Total households 15.3 0.6 0.2 83.8 100.0 18,968 210 | Avian Influenza Table 16.1 shows that household ownership of poultry and birds was more common among rural than urban households (27 percent and 4 percent, respectively). Around one-quarter of households in Upper Egypt owned poultry and birds compared to around one-sixth of households in Lower Egypt and the Frontier Governorates and less than two percent in the Urban Governorates. Households in the lowest wealth quintile are more than ten times more likely to own poultry or birds than households in the highest wealth quintile (32 percent and 3 percent, respectively). The 2008 EDHS also obtained information on the types of poultry or birds that households owned. Nine in ten households who owned any poultry or birds owned chickens while around half that proportion (46 percent) owned ducks (Table 16.2). Twenty-seven percent of households owned geese, and 24 percent owned pigeons. Around two percent of households reported owning other types of poultry or birds (e.g., turkeys or song birds). Households in Lower Egypt were more likely than households in other areas to report owning ducks while households in Upper Egypt and the Frontier Governorates had the highest levels of ownership of pigeons. The mean number of poultry or birds owned per household was 15.2. The mean number of poultry or birds owned by households was somewhat higher in Lower Egypt than in other areas, and it was somewhat lower among households in the lowest wealth quintile than among other households. 6 40 48 33 2 16 26 16 Urban Governorates Lower Egypt Upper Egypt Total Egypt 0 10 20 30 40 50 60 Percent 1988 2008 Figure 16.1 Trend in Percentage of Households Owning Poultry by Place of Residence, 1988-2008 Avian Influenza | 211 Table 16.2 Type of poultry/birds owned Among households owning poultry or birds, percentage owning various types of poultry or birds, and the mean number of poultry/birds owned per household, according to background characteristics, Egypt 2008 Percentage of households owning any: Background characteristic Chickens Geese Ducks Pigeons Other poultry/ birds1 Mean number of poultry/birds owned per household Total households Urban-rural residence Urban 84.1 16.8 31.6 18.3 6.3 12.5 358 Rural 90.9 28.7 48.4 25.2 1.9 15.5 2,661 Place of residence Urban Governorates 79.7 14.6 37.3 6.9 4.8 8.9 66 Lower Egypt 89.3 27.3 61.5 11.8 2.8 17.4 1,303 Urban 85.2 17.8 39.8 7.0 12.1 13.5 102 Rural 89.6 28.1 63.3 12.2 2.0 17.8 1,201 Upper Egypt 91.0 28.0 34.7 35.2 1.9 13.6 1,609 Urban 84.4 17.1 25.3 29.1 3.3 13.1 178 Rural 91.9 29.4 35.8 35.9 1.7 13.7 1,431 Frontier Governorates 95.9 21.5 40.9 32.0 5.7 14.9 40 Wealth quintile Lowest 89.5 26.9 39.9 27.8 1.1 12.4 1,019 Second 91.9 29.6 49.0 25.3 2.2 16.5 908 Middle 89.9 28.7 52.1 22.6 2.6 17.1 693 Fourth 91.4 22.3 48.3 17.2 2.0 15.8 287 Highest 78.2 17.0 43.9 16.4 15.4 16.9 111 Total households 90.1 27.3 46.4 24.4 2.4 15.2 3,018 1 Includes quail, turkey, ornamental/song birds, or other poultry/birds 16.2 LOCATIONS WHERE POULTRY KEPT For households owning or keeping poultry or other birds, the 2008 EDHS included a number of questions on the location(s) where the poultry or other birds were kept and interviewers also observed, whenever possible, the cages or enclosures in which the poultry or other birds were kept. Table 16.3 shows that households most often reported that poultry or birds were kept in locations away from family living area, with the most common of these locations the rooftop of their dwelling (45 percent). Thirteen percent of households also mentioned keeping birds at a location separate from but near the dwelling and 5 percent kept poultry or birds in a location away from their dwelling. Around one in five households kept poultry or birds within the family living area, and one-third kept poultry or birds within the dwelling but away from the family living area. Ducks have been shown to carry the avian influenza virus for longer periods without visible symptoms than other birds (WHO 2004); consequently it is recommended that households owning ducks as well as other poultry or birds keep the ducks in locations separate from the locations in which they keep their other birds. Around 40 percent of the EDHS households who owned any poultry or birds, reported that they owned both ducks and other birds (data not shown). Among these households, 31 percent kept the ducks in the same location as other poultry or birds they owned (Table 16.3). Households who kept poultry or birds in or near their dwellings were asked if they kept the poultry or birds in cages or other enclosures. Those households who said they kept poultry or birds in cages or enclosures were also asked about when they put the poultry or birds in the enclosures. Finally households were asked if they had caged or enclosed their poultry or birds prior to the avian influenza outbreak in 2006. 212 | Avian Influenza Table 16.3 Locations where poultry/birds kept Among households owning and/or keeping poultry or birds, percentage reporting they keep poultry or birds in various locations and, among households owning and/or keeping both ducks and other poultry/birds, percentage reporting they kept ducks in same location as other poultry/birds, according to background characteristics, Egypt 2008 Percentage of households who keep poultry/birds Background characteristic Within family area In dwelling but away from family living area On the rooftop Outside near dwelling Elsewhere Number of households owning or keeping poultry/birds Percentage of households keeping ducks and other poultry/birds in same location Number of households owning or keeping both ducks and other poultry/birds Urban-rural residence Urban 19.2 33.2 53.9 9.7 3.5 364 21.9 103 Rural 21.1 34.2 44.2 13.7 5.0 2,696 32.7 1,202 Place of residence Urban Governorates 21.0 25.9 60.9 11.3 0.0 69 26.6 20 Lower Egypt 13.1 33.1 45.4 16.8 6.2 1,322 41.4 728 Urban 12.9 24.5 61.5 10.1 4.5 104 30.6 38 Rural 13.2 33.8 44.0 17.4 6.4 1,218 42.3 691 Upper Egypt 27.4 35.1 45.6 9.8 3.8 1,630 23.8 541 Urban 22.7 40.7 49.4 7.0 4.1 179 15.5 42 Rural 28.0 34.4 45.1 10.1 3.7 1,451 24.8 499 Frontier Governorates 8.3 43.2 7.9 39.9 9.4 40 19.9 15 Wealth quintile Lowest 33.2 37.1 33.1 13.1 2.6 1,026 27.4 370 Second 19.4 33.3 47.6 13.8 4.7 914 33.6 417 Middle 11.3 34.0 51.6 14.3 6.0 707 33.0 333 Fourth 9.5 29.5 61.7 12.2 7.6 296 37.6 140 Highest 11.0 26.8 56.7 6.2 10.5 116 24.0 46 Total households 20.9 34.1 45.4 13.2 4.8 3,061 31.4 1,305 Table 16.4 shows that around three in four households kept their poultry or birds in cages or enclosures at least part of the time each day, and nearly half said that the poultry or birds were kept in the cages or enclosures all of the time. Households were more likely to have kept poultry or birds in cages or enclosures at the time of the 2008 EDHS than prior to the avian influenza outbreak in 2006; only 41 percent of the households reported they kept poultry or birds in cages or enclosures prior to 2006. Looking at the variation by background characteristics, households in Lower Egypt were somewhat more likely than households in other areas to keep poultry or birds in cages or enclosures all of the time. The proportion of households keeping poultry or birds in cages or enclosures increased with the wealth quintile. Avian Influenza | 213 Table 16.4 Use of cages or enclosures for poultry/birds Among households keeping poultry or birds in or near dwelling, percent distribution by time household reported poultry or birds currently are kept in cages or other enclosures and percentage reporting they kept poultry or birds in cages or enclosures at least part of the time prior to the avian influenza outbreak in 2006, according to background characteristics, Egypt 2008 Time poultry/birds kept in cages or enclosures Background characteristic All of the time Only at night At night and other times1 Only at other times1 Never kept in cages/ enclosures Don't know/ missing Total percent Percentage kept poultry/birds in cages or enclosures prior to the avian influenza outbreak in 2006 Number of households owning or keeping poultry and birds in or near dwelling Urban-rural residence Urban 52.9 14.8 1.3 6.4 23.3 1.2 100.0 43.3 354 Rural 46.1 20.1 1.0 4.8 27.4 0.6 100.0 41.1 2,585 Place of residence Urban Governorates 44.7 14.1 0.5 6.8 34.0 0.0 100.0 48.4 68 Lower Egypt 55.4 18.8 1.0 4.1 20.4 0.3 100.0 48.9 1,249 Urban 71.4 9.0 3.7 4.2 11.9 0.0 100.0 56.6 101 Rural 54.0 19.7 0.7 4.1 21.2 0.3 100.0 48.2 1,148 Upper Egypt 40.3 20.3 1.1 5.5 31.7 1.0 100.0 35.2 1,586 Urban 46.4 18.3 0.4 7.0 25.5 2.4 100.0 34.9 174 Rural 39.6 20.6 1.1 5.4 32.5 0.8 100.0 35.2 1,412 Frontier Governorates 45.0 17.0 0.6 9.2 27.1 1.1 100.0 43.3 37 Wealth quintile Lowest 37.9 20.5 1.0 4.8 35.4 0.4 100.0 34.7 1,005 Second 46.5 21.9 0.6 5.1 25.0 0.9 100.0 42.7 880 Middle 52.0 17.9 1.4 4.8 23.2 0.7 100.0 43.2 669 Fourth 61.6 14.9 0.4 4.0 18.3 0.9 100.0 52.7 278 Highest 64.8 12.8 3.0 10.3 8.6 0.5 100.0 54.1 106 Total households 46.9 19.5 1.0 5.0 26.9 0.7 100.0 41.4 2,938 1 Includes during the day, when fed, if it is cold, and/or other times 16.3 AWARENESS OF AVIAN INFLUENZA All women and men age 15-59 interviewed in the special health issues component of the 2008 EDHS were asked if they had heard of avian influenza. If they had heard about avian influenza, they were also asked questions about the sources from which they had received information recently about the epidemic and about the symptoms of avian influenza in poultry or birds and humans. Table 16.5 shows that virtually all women and men interviewed in the special health issues component of the survey (99 percent) had heard about avian influenza. The results in the table also show that more than eight in ten of the respondents had heard or seen information about avian influenza during the six months prior to the interview (approximately October 2007 through March 2008). Television was by far the most frequently cited source of information among respondents who reported receiving information about avian influenza during the six-month period prior to the survey; 95 percent said they had gotten information on avian influenza through television, 28 percent cited relatives, friends or neighbors as a source of information, and 24 percent mentioned they had obtained information through radio or print media. Around one in nine respondents had received information during a contact with a health care provider. 214 | Avian Influenza Table 16.5 also shows that the proportion of respondents who received recent information about the avian influenza epidemic and the proportions of respondents who cited various sources of information about the disease generally did not vary markedly by background characteristics, although there were a few notable differentials. For example, women were more likely than men to report that they had heard or seen information about avian influenza during the six months prior to the survey (89 percent and 75 percent, respectively). Although television and other media were primary sources of information for both rural and urban respondents, respondents from rural areas were much more likely than urban respondents to have received information about avian influenza from relatives or friends and neighbors and from health providers. Table 16.5 Awareness of avian influenza and recent sources of information about AI by background characteristics Among all women and men age 15-59, percentage knowing about avian influenza (AI); among women and men knowing about AI, percentage who heard or saw any information about AI during the six months prior to the survey; and among women and men receiving information about AI within the last six months, percentage naming various sources of information, according to background characteristics, Egypt 2008 Percentage who heard or saw information about AI during the six months prior to the survey Medical provider Background characteristic Percent- age knowing about avian influenza Number of women and men age 15-59 Percentage of women and men knowing about AI receiving information about AI during the six months prior to the survey Number of women and men age 15-59 knowing about avian influenza TV Other media1 Any Home Visit Facility visit Spouse/ other relatives/ friends/ neighbors Community meeting/ mosque/ church/ other Number of women and men receiving information about AI during the six months prior to the survey Current age 15-19 98.5 2,151 79.5 2,119 95.5 24.3 9.3 6.6 2.6 25.7 1.2 1,684 20-29 99.3 3,595 82.9 3,571 96.0 24.1 12.4 8.7 3.7 27.7 0.4 2,959 30-39 99.1 2,531 86.2 2,509 94.3 23.3 13.1 9.2 3.9 28.3 0.2 2,164 40-49 99.0 2,192 83.3 2,170 95.8 23.2 11.9 8.1 3.8 28.9 0.5 1,808 50-59 98.4 1,539 78.5 1,514 94.2 22.2 11.2 7.8 3.4 28.0 0.4 1,189 Sex Women 99.1 6,290 89.0 6,235 95.8 20.1 12.4 9.4 3.0 25.7 0.4 5,547 Men 98.8 5,718 75.4 5,649 94.7 28.1 10.9 6.7 4.3 30.5 0.7 4,257 Urban-rural residence Urban 98.7 5,288 81.1 5,217 97.0 24.5 4.5 1.9 2.6 22.1 0.5 4,232 Rural 99.2 6,720 83.6 6,666 94.0 22.8 17.3 13.1 4.2 32.1 0.6 5,571 Place of residence Urban Governorates 97.8 2,445 79.1 2,392 98.2 18.9 2.0 0.7 1.3 18.9 0.2 1,893 Lower Egypt 99.5 5,212 84.8 5,185 96.1 28.6 12.2 9.0 3.2 25.3 0.4 4,397 Urban 99.3 1,311 84.3 1,301 97.1 35.7 5.6 1.6 4.0 20.8 0.5 1,097 Rural 99.6 3,901 85.0 3,884 95.8 26.2 14.4 11.4 3.0 26.7 0.4 3,300 Upper Egypt 99.0 4,168 81.7 4,127 92.7 19.9 16.8 11.7 5.1 36.3 0.9 3,372 Urban 99.6 1,409 81.8 1,403 95.1 23.6 7.4 4.0 3.5 28.8 1.0 1,148 Rural 98.7 2,759 81.7 2,724 91.5 18.0 21.6 15.7 6.0 40.2 0.8 2,224 Frontier Governorates 98.4 182 78.9 179 90.2 16.8 8.5 4.4 4.1 20.8 0.0 141 Education No education 98.0 2,588 82.0 2,537 93.3 12.6 15.4 13.0 2.4 30.3 0.4 2,081 Some primary 98.2 1,084 80.7 1,065 94.2 15.9 11.3 7.6 3.7 32.2 0.7 859 Primary complete/ some secondary 98.9 2,919 79.4 2,886 95.5 22.5 10.5 7.8 2.8 27.5 0.9 2,291 Secondary complete/ higher 99.6 5,417 84.7 5,396 96.3 30.6 10.8 6.4 4.4 25.9 0.4 4,572 Type of occupation Agricultural 98.6 1,004 78.8 989 93.7 16.7 17.4 13.8 3.5 37.6 0.5 780 Non-agricultural 99.2 4,461 78.6 4,424 95.0 30.0 10.7 5.6 5.2 28.1 0.6 3,477 Not employed/missing 98.9 6,543 85.7 6,470 95.7 20.5 11.6 9.1 2.5 26.2 0.5 5,547 Wealth quintile Lowest 98.2 2,042 79.6 2,005 91.1 15.3 19.5 14.8 4.7 35.3 0.9 1,597 Second 99.1 2,442 83.1 2,419 94.7 19.8 15.9 11.7 4.2 32.6 0.5 2,011 Middle 98.9 2,425 83.4 2,398 95.0 24.2 13.8 10.3 3.6 27.7 0.4 2,000 Fourth 99.2 2,440 82.2 2,421 97.3 24.6 6.4 3.9 2.5 24.4 0.4 1,989 Highest 99.3 2,659 83.6 2,642 97.2 31.4 5.3 2.4 3.0 20.9 0.5 2,207 Total 99.0 12,008 82.5 11,883 95.3 23.6 11.8 8.2 3.5 27.8 0.5 9,803 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster Avian Influenza | 215 16.4 AWARENESS OF AVIAN INFLUENZA SYMPTOMS IN POULTRY/BIRDS Table 16.6 presents information on the percentages of EDHS respondents knowing about avian influenza who reported they were aware of symptoms of avian influenza in poultry and birds and of the actions individuals should take if birds become ill with any of the symptoms of avian influenza or die suddenly. The results in Table 16.6 indicate that around seven in 10 respondents who had heard of avian influenza were knowledgeable about the symptoms of the disease to watch for in poultry or birds. Figure 16.2 shows that the symptoms in poultry or birds which these respondents most frequently cited included a blue crest/wattle and skin (75 percent), sudden death (72 percent), discharge from the nose (70 percent) and blowzy feathers (68 percent). Although knowledge of the symptoms of avian influenza in poultry or birds was fairly widespread among EDHS respondents, Table 16.6 shows that less than half were aware that ducks may have the avian influenza virus and not show any symptoms. Table 16.6 Knowledge of avian influenza symptoms in poultry or birds by background characteristics Among women and men age 15-59 knowing about avian influenza, percentage knowing of at least one symptom of the avian influenza virus, percentage knowing ducks may have avian influenza without looking ill, and percentage saying they know what action(s) to take if birds are sick or die, by background characteristics, Egypt 2008 Background characteristic Percentage reporting they know about the symptoms of AI in poultry/birds Percentage knowing ducks may have AI without looking ill Percentage reporting they know what to do if birds become ill with AI symptoms/ die suddenly Number of women and men knowing about avian influenza Current age 15-19 59.5 39.7 72.3 2,119 20-29 68.8 48.2 81.5 3,571 30-39 74.2 51.8 83.2 2,509 40-49 73.6 51.7 83.2 2,170 50-59 69.0 46.9 77.7 1,514 Sex Women 76.0 48.9 82.9 6,235 Men 61.6 46.8 76.9 5,649 Urban-rural residence Urban 65.9 51.8 76.6 5,217 Rural 71.8 44.9 82.7 6,666 Place of residence Urban Governorates 58.3 53.0 67.1 2,392 Lower Egypt 73.7 45.3 84.5 5,185 Urban 76.6 49.8 87.3 1,301 Rural 72.8 43.8 83.6 3,884 Upper Egypt 70.0 48.2 82.2 4,127 Urban 69.1 51.8 83.0 1,403 Rural 70.5 46.3 81.8 2,724 Frontier Governorates 64.0 50.1 72.8 179 Education No education 67.9 41.5 78.6 2,537 Some primary 63.8 44.1 74.9 1,065 Primary complete/some secondary 64.3 45.2 76.4 2,886 Secondary complete/ higher 73.5 53.2 83.7 5,396 Type of occupation Agricultural 63.5 38.2 76.4 989 Non-agricultural 66.5 52.5 79.7 4,424 Not employed/missing 71.9 46.3 80.8 6,470 Wealth quintile Lowest 66.3 41.4 78.2 2,005 Second 69.7 41.7 80.9 2,419 Middle 68.7 46.0 79.0 2,398 Fourth 69.4 52.5 80.6 2,421 Highest 71.2 56.0 81.0 2,642 Total 69.2 47.9 80.0 11,883 216 | Avian Influenza The EDHS also collected information on what actions respondents believed should be taken when birds became ill with any of the symptoms of avian influenza or died suddenly. Overall, Table 16.6 indicates that eight in ten respondents who had heard about avian influenza knew about the action(s) they should take if birds became ill or died. As Figure 16.3 shows, the actions most commonly cited by respondents were to put the bird in a sealed plastic bag (62 percent) or to bury the bird (52 percent). Figure 16.2 Awareness of Symptoms of Avian Influenza in Poultry or Birds 48 26 38 33 68 46 75 70 72 6 Weakness Fever Diarrhea Loss of appetite Blowzy feathers No egg pro- duction Crest/ wattle and skin blue Discharge from nose Sudden death Other/ missing 0 20 40 60 80 100 Percent EDHS 2008 Figure 16.3 Awareness of Actions to Take When Birds Are Ill or Die Suddenly 62 20 40 52 14 9 4 8 Put in sealed plastic bag Submerge in disinfectant Burn Bury Contact veterinary authorities Notify other authorities Warn other people Other/ missing 0 10 20 30 40 50 60 70 Percent EDHS 2008 Avian Influenza | 217 Finally, although the patterns are not totally consistent, the results in Table 16.6 suggest that re- spondents age 15-19, men, urban respondents, respondents from the Urban Governorates and the Frontier Governorates, and, surprisingly, respondents in agricultural occupations, to be the least knowledgeable about avian influenza symptoms in poultry or birds. 16.5 AWARENESS OF AVIAN INFLUENZA RISKS AND SYMPTOMS AMONG HUMANS EDHS respondents who had heard about avian influenza were asked a number of questions to gauge the level of awareness of the potential for humans to be infected with the disease and the symptoms of avian influenza in humans. Table 16.7 shows that respondents were generally fairly knowledgeable about avian influenza risks for humans. Ninety-five percent of respondents who had heard of avian influenza knew that humans could be infected with the virus and 86 percent were aware that the disease could be fatal in humans. With regard to symptoms of avian influenza in humans, around six in ten Table 16.7 Awareness of risks and symptoms of avian influenza infection in humans by background characteristics Among women and men age 15-59 knowing about avian influenza, percentage who are aware humans may be infected with the avian influenza virus, percentage knowing humans may die from avian influenza, and percentage knowing at least one symptom of avian influenza in humans, by background characteristics, Egypt 2008 Background characteristic Percentage knowing that humans can be infected with the avian influenza virus Percentage knowing humans can die from avian influenza Percentage knowing at least one symptom of avian influenza in humans Number of women and men knowing about avian influenza Current age 15-19 94.5 84.7 53.5 2,119 20-29 95.8 87.0 63.0 3,571 30-39 95.6 86.6 64.9 2,509 40-49 95.2 85.6 63.2 2,170 50-59 94.5 87.8 60.1 1,514 Sex Women 94.9 84.6 65.7 6,235 Men 95.6 88.2 56.6 5,649 Urban-rural residence Urban 96.5 89.6 65.1 5,217 Rural 94.2 83.8 58.4 6,666 Place of residence Urban Governorates 96.4 92.3 64.7 2,392 Lower Egypt 96.3 84.5 61.6 5,185 Urban 97.7 85.9 67.1 1,301 Rural 95.8 84.0 59.7 3,884 Upper Egypt 93.4 85.3 58.7 4,127 Urban 95.9 89.1 63.0 1,403 Rural 92.0 83.3 56.6 2,724 Frontier Governorates 92.3 84.3 69.5 179 Education No education 91.1 81.4 50.8 2,537 Some primary 95.1 87.2 47.7 1,065 Primary complete/some secondary 94.9 84.8 57.4 2,886 Secondary complete/higher 97.4 89.3 71.1 5,396 Type of occupation Agricultural 93.2 81.7 48.2 989 Non-agricultural 96.0 89.5 63.4 4,424 Not employed/missing 95.0 84.9 62.0 6,470 Wealth quintile Lowest 91.9 81.6 50.3 2,005 Second 93.6 82.9 53.8 2,419 Middle 95.6 85.2 58.1 2,398 Fourth 96.6 89.4 66.9 2,421 Highest 97.6 91.3 74.5 2,642 Total 95.2 86.3 61.3 11,883 218 | Avian Influenza respondents who had heard of avian influenza were able to name at least one symptom of avian influenza in humans. As Figure 16.4 shows, the most commonly cited symptom in humans was fever (77 percent). About three in ten respondents named various other symptoms including malaise (33 percent), red eyes or conjunctivitis (31 percent), coughing (30 percent), difficulty breathing (29 percent), or sore throat (29 percent). An examination of the differentials in the indicators presented in Tables 16.7 indicates that, regardless of the subgroup, more than nine in ten respondents who were aware of avian influenza knew that humans may contract the disease and more than eight in ten respondents were aware that the disease can be fatal for humans. EDHS respondents varied somewhat more with respect to the level of awareness of the symptoms of avian influenza in humans. For example, the percentage of respondents able to name at least one symptom of the disease in humans varied from 50 percent in the lowest wealth quintile to 75 percent in the highest quintile. 16.6 AWARENESS OF MODES OF TRANSMISSION AND PREVENTION EDHS respondents who knew that humans can be infected with the avian influenza virus were asked to name at least four ways in which a person might contract the virus and four ways in which the likelihood of transmission of the virus to humans might be reduced. Table 16.8 details the specific modes of transmission and prevention EDHS respondents mentioned. Contact with sick poultry or birds was the most frequently cited mode of transmission (78 percent), followed by contact with feces from sick birds or poultry (34 percent). Washing hands after contact with poultry or birds was mentioned most often as a means to reduce the likelihood of transmission of the avian influenza virus to humans, followed by wearing a face mask and wearing gloves or plastic bags over the hands during contact with poultry or birds (38 percent each). Figure 16.4 Awareness of Avian Influenza Symptoms in Humans 77 33 29 31 30 17 29 27 7 Fever General malaise Sore throat Red eyes/ eye infection (conjunctivitis) Coughing Chest pain Difficulty breathing Death Other/ missing 0 20 40 60 80 100 Percent EDHS 2008 Avian Influenza | 219 Table 16.8 Knowledge of modes of transmission and prevention for avian influenza Among women and men age 15-59 aware that humans may be infected with the avian influenza virus, percentage naming various ways in which the avian influenza virus may be transmitted to humans and ways in which the transmission of the virus to humans may be prevented, Egypt 2008 Modes of AI transmission and prevention Total Modes of transmission Contact with sick poultry/birds 78.2 Contact with feces from sick poultry/birds 34.3 Contact with poultry/birds 23.3 Eating undercooked eggs/poultry 23.7 Contact with contaminated water 9.0 Contact with person who has avian influenza 14.5 Other/missing 2.7 Modes of prevention Washing hands after contact with poultry/birds 51.2 Change and wash clothes after contact with poultry/birds 31.9 Wear face mask during contact with poultry/birds 38.1 Wear gloves/plastic bags during contact with poultry/birds 37.9 Do not let children handle poultry/birds 12.6 Do not let children handle poultry/bird's eggs 4.0 Do not let children handle feces/feathers from poultry/birds 4.4 Do not eat undercooked poultry/birds 20.7 Do not eat undercooked eggs 11.3 Do not eat birds that fall dead 1.4 Do not breed birds 8.9 Other/missing 0.5 Number of women and men aware that humans may be infected with the avian influenza virus 11,317 Note: Respondents may have named more than one AI symptom so percentages do not add to 100. As Table 16.9 shows, overall, most of the respondents who were aware that humans could con- tract the avian influenza virus were able to name at least one way in which a person might contract the virus and at least one way in which the risk of contracting the virus might be reduced. However, only 8 percent of respondents who were aware that humans may contract avian influenza were able to name at least four ways in which the virus might be transmitted to a person and only 21 percent were able to name at least four ways to limit the chance that a person might contract the virus. 220 | Avian Influenza Table 16.9 Awareness of modes of transmission and prevention for avian influenza infection in humans by background characteristics Among women and men age 15-59 knowing that humans can get avian influenza, percentage knowing at least one way and percentage knowing at least four ways in which a person can contract avian influenza and percentage knowing at least one way and percentage knowing at least four ways in which the likelihood of the spread of avian influenza can be reduced by background characteristics, Egypt 2008 Background characteristic Percentage knowing at least one way a person can contract avian influenza Percentage knowing four or more ways a person can contract avian influenza Percentage knowing at least one way in which the likelihood of avian influenza can be reduced Percentage knowing four or more ways in which the likelihood of avian influenza can be reduced Number of women and men knowing humans can get avian influenza Current age 15-19 85.2 7.7 85.4 19.0 2,003 20-29 89.8 7.6 89.5 21.9 3,419 30-39 92.0 8.7 90.3 22.7 2,398 40-49 90.8 8.7 89.4 21.8 2,066 50-59 87.3 7.2 86.6 17.2 1,430 Sex Women 90.4 11.3 93.5 26.8 5,918 Men 88.2 4.4 83.1 14.6 5,399 Urban-rural residence Urban 90.8 10.2 90.0 21.4 5,035 Rural 88.2 6.2 87.4 20.6 6,282 Place of residence Urban Governorates 89.5 12.1 87.3 22.4 2,306 Lower Egypt 90.1 5.9 87.3 20.0 4,993 Urban 91.7 8.1 90.2 21.1 1,271 Rural 89.6 5.2 86.3 19.6 3,722 Upper Egypt 88.7 7.6 91.0 21.0 3,853 Urban 93.2 7.8 94.7 19.1 1,346 Rural 86.2 7.5 89.0 21.9 2,507 Frontier Governorates 78.0 22.8 87.2 30.3 165 Education No education 84.9 8.1 86.1 20.8 2,311 Some primary 85.3 5.9 83.6 14.2 1,013 Primary complete/some secondary 86.5 8.2 86.3 18.7 2,739 Secondary complete/higher 93.5 8.3 91.8 23.5 5,255 Type of occupation Agricultural 86.5 3.5 78.2 13.8 922 Non-agricultural 90.5 6.2 87.4 18.1 4,246 Not employed/missing 89.0 10.0 90.9 24.0 6,149 Wealth quintile Lowest 84.7 6.6 85.0 20.6 1,842 Second 87.0 6.1 86.0 19.8 2,265 Middle 88.9 6.9 86.0 20.2 2,293 Fourth 91.2 8.7 91.8 20.3 2,339 Highest 93.3 11.1 92.7 23.5 2,579 Total 89.3 8.0 88.6 21.0 11,317 Avian Influenza | 221 16.7 ATTITUDES TOWARDS AVIAN INFLUENZA RISKS The 2008 EDHS included several questions designed to assess respondents’ attitudes with regard to the threat that avian influenza poses. Table 16.10 shows that the majority of the respondents recognized that avian influenza was extremely dangerous (81 percent) for any person who might be infected with the virus. While recognizing the seriousness of avian influenza infection, the majority of respondents also believed that it was not very likely (25 percent) or not likely at all (43 percent) that a member of their household would be infected with the virus. More than 60 percent were extremely or somewhat confident that the spread of avian influenza could be prevented and more than 80 percent were confident of their ability to protect themselves and other members of their families from infection. Table 16.10 Attitudes about avian influenza Among women and men age 15-59 knowing about avian influenza, percent distribution by the attitudes about the dangers of avian influenza, likelihood of a family member getting infected, confidence that the spread of avian influenza can be prevented, and confidence in the ability to protect self and family from becoming infected Egypt 2008 Attitudes about avian influenza Total Avian influenza infection dangerous for person infected Extremely dangerous 81.2 Somewhat dangerous 11.9 Not very dangerous 2.9 Not dangerous at all 0.7 Don't know/missing 3.3 Likelihood of household member being infected Extremely likely 3.0 Somewhat likely 20.0 Not very likely 25.2 Not likely at all 43.2 Don't know/missing 8.6 Level of confidence that spread of avian influenza can be prevented Extremely confident 26.4 Somewhat confident 37.5 Not very confident 16.0 Not confident at all 6.6 Don't know/missing 13.5 Level of confidence in ability to protect self and family from infection Extremely confident 45.5 Somewhat confident 35.0 Not very confident 7.6 Not confident at all 2.5 Don't know/missing 9.5 Total percent 100.0 Number of women and men knowing about avian influenza 11,883 Adult Health Issues | 223 ADULT HEALTH ISSUES 17 The special health issues interviews conducted with women and men age 15-59 in the 2008 EDHS included a series of questions designed to obtain information on a number of adult health issues including the use of tobacco, history of diabetes, cardiovascular disease, and stroke. In addition, respondents were asked about past diagnosis and treatment of hypertension and blood pressure measurements were taken during the interviews to provide additional information on the prevalence of hypertension among the adult population in Egypt. Respondents were also asked questions to assess potential exposure to bloodborne pathogens through medical procedures including surgery, blood transfusion and injections. Finally, information was obtained on the level of awareness of safe injection practices. 17.1 USE OF TOBACCO Smoking and the use of other tobacco products has been linked to a wide range of detrimental health outcomes including cancer, cardiovascular disease and respiratory illness (WHO 2008). The risks affect not only smokers themselves but other individuals who are exposed to second-hand tobacco smoke or “environmental” tobacco smoke (ETS); the latter has been shown to contribute to a number of adverse health effects including increased risk of respiratory and cardiovascular illnesses (WHO 2007). The 2008 EDHS collected information on use of tobacco by respondents and by other household members. To assess awareness of the problems of second-hand smoking, questions were also included on whether respondents had received information about the effects of second-hand smoke within a six-month period prior to the EDHS and, if so, what were the sources from which they had received the information. Table 17.1 presents the prevalence of use of tobacco products among the women and men age 15- 59 interviewed in the special health issues component of the survey. There is a very strong relationship between the use of tobacco products and a respondent’s gender. More than 40 percent of men reported using other tobacco products compared to less than one percent of women. The table shows that the majority of both male and female tobacco users smoked cigarettes. Among men, 35 percent reported smoking cigarettes only while 9 percent said they used other forms of tobacco, in some cases in addition to cigarettes. Among male cigarette smokers, the average (mean) number of cigarettes smoked per day was 19. Although women themselves rarely used tobacco products, many were potentially exposed to harmful effects of smoking. Table 17.1 shows that more than four in ten respondents reported that at least one other household member smoked or used another form of tobacco. Significantly, although very few women smoked, about more than half lived in households in which at least one household member smoked. 224 | Adult Health Issues Table 17.1 Use of tobacco Percent distribution of women and men age 15-59 by own use of tobacco products and use of tobacco products by other household members and, among those who smoke cigarettes, mean number of cigarettes smoked during the 24-hour period before the survey interview, Egypt 2008 Use of tobacco products Women Men Total Own use of tobacco products Use tobacco products 0.7 43.9 21.3 Cigarettes only 0.4 34.7 16.8 Other tobacco products only 0.2 5.6 2.7 Both cigarettes and other tobacco products 0.1 3.6 1.8 Does not use tobacco products 99.1 56.0 78.6 Don't know/missing 0.2 0.1 0.1 Total percent 100.0 100.0 100.0 Number 6,290 5,718 12,008 Mean number of cigarettes smoked in 24-hour period (14.0) 18.9 18.9 Number of cigarette smokers 22 2,174 2,196 Use of tobacco products by other household members Use tobacco products 54.1 31.6 43.4 Cigarettes only 44.6 26.0 35.7 Other tobacco products only 6.0 3.1 4.6 Both cigarettes and other tobacco products 3.5 2.6 3.0 Does not use tobacco products 45.5 67.8 56.1 Don't know/missing 0.4 0.6 0.5 Total percent 100.0 100.0 100.0 Number 6,290 5,718 12,008 Note: Figures in parentheses are based on 25-49 unweighted cases. Tables 17.2.1 and 17.2.2 show that women and men were somewhat less likely than other respondents to live in a household in which at least one household member smoked or used other form of tobacco if they were urban residents, lived in the Frontier Governorates, had a secondary or higher education, or were in the highest wealth quintile. Tables 17.2.1 and 17.2.2 also show that 39 percent of women and 37 percent of men had received information about the adverse health effects of second smoke in the six-month period prior to the 2008 EDHS. As was the case with other health-related information, television was the primary source of information about second-hand smoke among almost all of women (93 percent) and nine in ten men (87 percent) who had seen or heard about the subject recently. Adult Health Issues | 225 Table 17.2.1 Prevalence of smoking and exposure to information about health effects of second-hand smoke by background characteristics: Women Percentage of women age 15-49 who currently smoke or use any form of tobacco, percentage living in household where at least one member smokes or uses some other form of tobacco, percentage receiving information about health effects of second-hand smoke during the six-months prior to the survey, and among women receiving information about second-hand smoke, percentage receiving information from various sources, according to background characteristics, and percentage of women 50-59 and of all women 15-59 smoking or using other forms of tobacco and exposed to information about effects of second-hand smoke, Egypt 2008 Percentage who saw/heard about health effects of second- hand smoke from: Percentage currently smoking/using other form of tobacco Health worker Background characteristic Woman herself Other household member Percentage receiving information recently about health effects of second-hand smoke Number of women TV Other media1 Any contact Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Com- munity meeting/ other/ missing Number of women receiving information about second- hand smoke recently Age 15-19 0.3 56.2 39.4 1,064 91.3 24.5 1.8 0.1 1.7 13.4 8.0 419 20-29 0.6 54.2 40.7 1,997 93.8 22.2 3.3 0.4 3.2 11.1 4.7 812 30-39 0.7 51.6 40.0 1,362 95.3 19.4 3.0 0.6 2.4 11.8 5.0 545 40-49 1.1 57.6 41.2 1,117 91.5 17.3 3.2 0.8 2.9 12.2 4.3 460 Marital status Ever-married 0.8 54.8 39.4 3,983 94.6 18.7 3.2 0.6 3.0 11.3 4.4 1,571 Never-married 0.4 54.2 42.7 1,556 90.1 26.3 2.1 0.2 1.9 13.4 7.6 665 Urban-rural residence Urban 0.6 51.6 44.8 2,352 92.2 21.2 2.3 0.3 2.2 10.7 5.5 1,054 Rural 0.8 56.9 37.1 3,188 94.2 20.7 3.4 0.7 3.1 13.0 5.2 1,182 Place of residence Urban Governorates 0.8 56.0 44.2 1,073 90.2 23.3 2.1 0.4 2.0 11.5 7.8 475 Lower Egypt 0.6 52.2 38.9 2,415 93.4 27.6 4.0 0.7 3.7 11.9 3.9 939 Urban 0.1 46.1 41.2 603 91.1 29.7 3.6 0.0 3.6 12.2 5.3 248 Rural 0.7 54.3 38.1 1,812 94.3 26.8 4.1 0.9 3.7 11.8 3.3 691 Upper Egypt 0.7 56.9 40.5 1,970 94.8 12.1 2.2 0.3 1.9 12.5 5.7 797 Urban 0.4 49.3 50.2 623 95.9 11.4 1.8 0.3 1.5 8.8 2.3 313 Rural 0.9 60.4 35.9 1,347 94.1 12.5 2.5 0.4 2.2 14.8 7.8 484 Frontier Governorates 2.1 51.7 31.3 82 92.9 12.1 1.2 0.0 1.2 4.4 2.2 26 Education No education 1.1 61.5 31.3 1,461 92.4 16.3 2.9 1.2 2.3 12.1 4.1 457 Some primary 0.4 67.9 36.8 394 92.8 14.3 2.0 0.0 2.0 14.2 7.5 145 Primary complete/ some secondary 0.5 58.5 39.6 1,248 92.6 22.8 1.8 0.6 1.5 13.5 6.7 494 Secondary complete/ higher 0.6 46.4 46.8 2,436 93.9 22.9 3.5 0.2 3.4 10.9 4.9 1,140 Work status Working for cash 0.7 44.6 46.3 866 91.4 25.2 6.2 0.6 5.9 13.3 6.3 401 Not working for cash 0.7 56.5 39.3 4,674 93.6 20.0 2.2 0.5 1.9 11.6 5.1 1,835 Wealth quintile Lowest 1.0 58.0 31.2 1,001 92.8 15.4 1.6 0.6 1.1 13.8 5.1 312 Second 1.1 60.6 38.1 1,123 95.1 18.7 3.8 1.2 3.2 14.2 3.9 428 Middle 0.5 59.1 38.5 1,099 94.0 21.2 2.7 0.3 2.7 13.8 5.2 423 Fourth 0.3 56.6 43.4 1,105 93.2 18.1 2.0 0.3 2.0 10.4 6.7 480 Highest 0.5 40.5 48.9 1,212 91.7 27.7 3.8 0.2 3.5 9.2 5.4 593 Total women age 15-49 0.7 54.6 40.4 5,540 93.2 21.0 2.9 0.5 2.6 11.9 5.3 2,236 Women age 50-59 1.1 49.9 30.4 751 91.8 18.0 1.9 0.8 1.2 11.5 5.5 228 Total women age 15-59 0.7 54.1 39.2 6,290 93.1 20.7 2.8 0.5 2.5 11.9 5.3 2,465 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster 226 | Adult Health Issues Table 17.2.2 Prevalence of smoking and exposure to information about health effects of second-hand smoke by background characteristics: Men Percentage of men age 15-49 who currently smoke or use any form of tobacco, percentage living in household where at least one member smokes or uses some other form of tobacco, percentage receiving information about health effects of second-hand smoke during the six-months prior to the survey, and among men receiving information about second-hand smoke, percentage receiving information from various sources, according to background characteristics, and percentage of men 50-59 and of all men 15-59 smoking or using other forms of tobacco and exposed to information about effects of second-hand smoke, Egypt 2008 Percentage who saw/heard about health effects of second- hand smoke from: Percentage currently smoking/using other form of tobacco Health worker Background characteristic Man himself Other household member Percentage receiving information recently about health effects of second-hand smoke Number of men TV Other media1 Any contact Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Com- munity meeting/ other/ missing Number of men receiving information about second- hand smoke recently Age 15-19 18.9 50.9 31.3 1,087 88.1 25.5 1.6 0.4 1.1 28.0 7.9 340 20-29 43.2 41.9 38.4 1,598 86.4 22.9 2.0 0.2 1.8 27.9 9.8 613 30-39 51.8 16.1 39.4 1,169 88.3 24.0 4.7 0.7 4.2 26.1 8.4 461 40-49 55.4 16.8 38.3 1,075 86.9 22.5 7.7 0.8 7.2 25.2 12.0 412 Marital status Ever-married 53.8 16.8 38.4 2,640 87.2 22.6 5.5 0.6 5.1 26.4 10.4 1,014 Never-married 29.6 50.1 35.5 2,290 87.4 24.8 1.9 0.4 1.6 27.5 8.6 813 Urban-rural residence Urban 42.9 28.5 32.9 2,170 87.6 22.0 3.1 0.3 2.9 25.3 10.1 714 Rural 42.3 35.3 40.3 2,760 87.1 24.6 4.4 0.7 3.9 27.9 9.3 1,112 Place of residence Urban Governorates 45.2 29.6 32.8 990 88.9 15.1 2.0 0.1 1.9 15.6 10.5 325 Lower Egypt 43.0 32.0 44.0 2,150 88.6 25.4 3.9 0.3 3.6 26.2 6.9 946 Urban 41.6 21.6 37.8 533 89.5 24.5 4.0 0.0 4.0 36.8 9.9 202 Rural 43.5 35.4 46.0 1,616 88.3 25.7 3.9 0.4 3.5 23.3 6.1 744 Upper Egypt 40.6 34.4 31.7 1,706 84.2 25.7 5.1 1.1 4.5 35.3 13.9 541 Urban 40.5 33.0 30.2 588 83.5 31.8 4.3 0.8 3.8 30.8 9.6 178 Rural 40.7 35.1 32.5 1,118 84.5 22.7 5.4 1.2 4.8 37.5 16.0 363 Frontier Governorates 38.1 28.9 18.1 84 86.0 14.7 0.0 0.0 0.0 10.1 7.9 15 Education No education 58.3 33.6 35.5 467 88.3 13.4 3.3 0.3 3.3 22.4 8.5 166 Some primary 62.0 31.8 31.5 458 91.2 18.2 2.0 0.3 1.7 27.6 8.9 145 Primary complete/ some secondary 38.5 40.8 32.1 1,414 86.0 26.1 3.0 1.0 2.1 27.5 8.6 453 Secondary complete/ higher 38.5 27.5 41.0 2,590 87.2 24.8 4.6 0.4 4.4 27.2 10.3 1,063 Work status Working for cash 50.7 27.4 37.9 3,685 86.9 23.1 4.3 0.5 4.0 27.0 10.8 1,395 Not working for cash 18.3 46.9 34.6 1,245 88.6 25.0 2.4 0.4 2.0 26.4 5.7 431 Wealth quintile Lowest 43.2 38.8 31.3 838 86.7 17.1 3.3 0.9 2.7 32.7 9.8 262 Second 45.6 42.3 40.9 1,010 89.5 25.5 2.7 0.2 2.6 24.1 8.7 413 Middle 44.9 34.1 35.4 1,036 87.1 22.7 6.4 1.4 5.3 29.8 7.7 367 Fourth 44.1 28.1 33.1 997 85.1 24.9 3.1 0.1 2.9 27.0 10.0 330 Highest 35.3 19.6 43.4 1,049 87.4 25.3 3.9 0.1 3.8 23.6 11.6 455 Total men age 15-49 42.6 32.3 37.1 4,930 87.3 23.6 3.9 0.5 3.5 26.9 9.6 1,826 Men age 50-59 52.5 27.5 32.7 788 85.6 22.8 5.4 0.6 5.0 21.7 8.7 258 Total men age 15-59 43.9 31.6 36.5 5,718 87.1 23.5 4.1 0.5 3.7 26.2 9.5 2,084 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster Adult Health Issues | 227 17.2 HISTORY OF DIABETES AND CARDIOVASCULAR DISEASE Diabetes and cardiovascular diseases are major causes of adult morbidity and mortality in Egypt. Diabetes, a condition characterized by the presence of high levels of glucose (sugar) in the blood caused by problems in the production and/or use of insulin, affects an estimated 7 percent of the Egyptian population age 20-79 years (Ministry of Health and Population, nd). Cardiovascular diseases also are widespread in Egypt; according to the World Health Organization, Egypt lost 21 years of productive life per 1,000 population as a result of premature mortality or disability due to heart disease and 8 years of productive life per 1,000 population due to stroke (WHO, 2004). To obtain some information on the history of diabetes and cardiovascular illnesses among EDHS respondents, eligible women and men were asked if they had ever been diagnosed as having diabetes, a heart attack, or a stroke. Table 17.3 shows that 4 percent of women and 2 percent of men reported that they had diabetes, with almost all indicating that they were being treated with insulin or pills for the diabetes at the time of the survey. Around 1 percent of both women and men indicated they had been told by a medical provider that they had had a heart attack at some point prior to the survey, and a similar percentage reported having been told by a medical provider that they had had a stroke. Table 17.3 History of diabetes, heart attack and stroke Percent distribution of women and men age 15-59 by history of diabetes, heart disease and stroke, Egypt 2008 History of diabetes, heart attack and stroke Women Men Total History of diabetes Told had diabetes by medical practitioner1 3.6 2.3 3.1 Receiving treatment2 3.4 2.2 2.9 Not receiving treatment 0.2 0.1 0.2 Missing 0.0 0.0 0.0 Never told had diabetes 95.8 97.4 96.6 Don't know/missing 0.5 0.2 0.3 History of heart attack Told had heart attack by medical practitioner 0.8 1.0 0.9 Never told 99.2 98.9 99.1 Don't know/missing 0.0 0.1 0.0 History of stroke Told had stroke by medical practitioner 0.8 1.0 0.9 Never told 99.2 98.9 99.1 Don’t know/missing 0.0 0.1 0.0 Total percent 100.0 100.0 100.0 Number 6,290 5,718 12,008 1 Other than during pregnancy 2 Insulin/pills To gauge the extent to which they were aware they suffered from hypertension, EDHS respondents were asked if they had ever been told by a health provider that they had high blood pressure and, if so, the actions that they had taken to lower their blood pressure. Table 17.4 shows that 2 percent of respondents were told by a health care provider on at least one occasion that their blood pressure was high, and 7 percent were told they had high blood pressure on two or more occasions. Women were more 228 | Adult Health Issues than twice as likely as men to have been told by a health provider on one or more occasions that their blood pressure was high (13 percent and 6 percent, respectively). Sixty-five percent of the EDHS respondents who were told that their pressure was high reported taking some action to lower their blood pressure. More than half (55 percent) took medication and more than three in ten (31 percent) cut down on salt consumption. Furthermore, 15 percent of respondents with a high blood pressure made efforts to control or lose weight, 7 percent said they exercised, and 4 percent stopped smoking. The proportions taking prescribed medications were similar among women and men. Women were somewhat more likely than men to take actions to control their weight and to reduce salt in the diet, while men were more likely than women to stop smoking and to exercise. Table 17.4 History of hypertension and actions taken to lower blood pressure Percent distribution of women and men age 15-59 by history of hypertension (high blood pressure) and, among those told they had high blood pressure, percentage taking various actions to treat the illness, Egypt 2008 History of hypertension and actions taken to treat hypertension Women Men Total History of hypertension Told blood pressure was high 12.5 5.6 9.2 On one occasion 3.2 1.2 2.2 On two or more occasions 9.1 4.4 6.9 Unsure about number of times/missing 0.2 0.0 0.1 Never told 87.3 94.2 90.6 Don't know/missing 0.2 0.2 0.2 Total percent 100.0 100.0 100.0 Number 6,290 5,718 12,008 Actions taken to lower blood pressure Percentage taking some action to lower blood pressure 64.2 65.1 64.5 Taking prescribed medication 55.4 55.4 55.4 Controlling weight/losing weight 16.1 11.7 14.8 Cutting down on salt in diet 33.9 25.3 31.4 Exercising 5.1 11.3 6.9 Stopped smoking 0.9 10.8 3.8 Number with history of high blood pressure 782 324 1,106 17.3 HIGH BLOOD PRESSURE High blood pressure (hypertension) is associated with a range of serious medical conditions including heart and kidney disease and stroke. In the 2008 EDHS, blood pressure measurements were taken on women and men age 15-59 during the administration of the special health issues questionnaires. These measurements were intended to provide a cross-sectional assessment of the prevalence of high blood pressure readings in the surveyed population at the time of the EDHS interviews and were not intended to provide a medical diagnosis of hypertension.1 However, the 2008 EDHS results are useful in providing insight into the size and characteristics of the population at risk for hypertension. 1 Guidelines of the Egypt Hypertension Society recommend that the medical diagnosis of hypertension be based blood pressure readings on at least three or more separate occasions (Egypt Hypertension Society 2004). Adult Health Issues | 229 Blood pressure readings were taken by EDHS interviewers using fully automatic digital blood pressure monitors with upper arm automatic inflation (Life Source Digital Blood Pressure Monitors Models UA-767V and Model UA-789 for individuals with large arms). Interviewers were trained to use the monitors according to manufacturer’s instructions. Three blood pressure readings (systolic and dia- stolic pressure) were taken during the survey interview, at approximately 10 minute intervals. Prior to taking the blood pressure first reading, the interviewers measured the respondent’s arm circumference in order to determine the appropriate cuff size and monitor to use. Respondents were also asked for informa- tion about recent intake of food and caffeinated beverages as those factors can influence blood pressure readings. Virtually all eligible EDHS respondents participated in the blood pressure measurement. Measurements were not available due to refusal or technical problems during measurements for less than 1 percent of women and men (Table 17.5). Respondents were given information on their blood pressure measures at the end of the interview and referred to a health provider for additional screening where appropriate. Blood pressure is defined in terms of the force exerted by blood inside arteries. This force varies with each beat of the heart. Blood pressure is highest at the point the heart contracts and forces blood into the arterial system, and it is lowest when the heart muscle relaxes and allows blood to flow into the heart. The point at which pressure is highest is termed the systolic pressure and the point where the pressure is lowest is termed the diastolic pressure. The blood pressure measurements taken during the EDHS survey provided information on both systolic and diastolic blood pressure. Table 17.5 Availability of final blood pressure measurement Percent distribution of de facto population age 15-59 interviewed on health issues by availability of final blood pressure measurement according to sex, Egypt 2008 Availability of blood pressure measurement Total WOMEN Measurement available 99.4 Measurement not available 0.6 Refused 0.4 Technical problems during collection 0.1 Missing 0.0 Total percent 100.0 Number 6,290 MEN Measurement available 99.9 Measurement not available 0.1 Refused 0.1 Technical problems during collection 0.0 Missing 0.0 Total percent 100.0 Number 5,718 TOTAL Measurement available 99.6 Measurement not available 0.4 Refused 0.3 Technical problems during collection 0.1 Missing 0.0 Total percent 100.0 Number 12,008 230 | Adult Health Issues The average of the second and third blood pressure measurements was used to the blood pressure of EDHS respondents into the following categories:2 Categories Systolic pressure Diastolic pressure Optimal <120 <80 Normal 120-129 80-84 High normal 130-139 85-89 Mildly elevated (stage 1) 140-159 90-99 Moderately elevated (stage 2) 160-179 100-109 Severely elevated (stage 3) 180 or > 110 or > When a respondent’s systolic and diastolic pressures fell into different categories, the higher category was used. Respondents whose average systolic and diastolic measurements were greater than or equal to 140/90 were considered to be hypertensive. In addition, respondents were also considered to be hypertensive if they had a normal or optimal blood pressure reading but were taking medication to lower their blood pressure. Tables 17.6.1 and 17.6.2 present the prevalence of hypertension among EDHS respondents at the time of the survey according to selected socioeconomic characteristics. Overall, 13 percent of women and 11 percent of men were considered to be hypertensive. Hypertension levels for both women and men increased steadily with age. For example, women age 55-59 were more than three times as likely as women age 35-39 to be hypertensive (46 percent and 13 percent, respectively). Among both women and men, urban residents were slightly more likely to be hypertensive than rural residents. Among women, those living in urban Upper Egypt (17 percent) had the highest hypertension rate while, among men, the rate was highest among those living in the Frontier Governorates (13 percent). Among women, the rate of hypertension was markedly lower among women who had completed at least primary school compared with those with less or no education. Among men, the hypertension rate also was lower among those who had completed at least primary school than among those with less education, but the differential was not as marked as for women. There was some tendency for the prevalence of hypertension to increase with the wealth quintile among both women and men, but the variations were not large or uniform. 2 Categories reflect classifications used by WHO (1999a) and the Egypt Hypertension Society (2004). Adult Health Issues | 231 Table 17.6.1 Levels of hypertension by socioeconomic characteristics: Women Prevalence of hypertension among women age 15-59 and percent distribution of women by blood pressure status, according to socioeconomic characteristics, Egypt 2008 Classification of blood pressure Socioeconomic characteristics Prevalence of hyper- tension1 Optimal <120/ <80 mmHg Normal 120- 129/ 80-84 mmHg High normal 130-139/ 85-89 mmHg Mildly elevated (stage 1) 140-159/ 90-99 mmHg Moderately elevated (stage 2) 160-179/ 100-109 mmHg Severely elevated (stage3) 180+/ 110+ mmHg Normal BP and taking medi- cation Missing final BP level Total percent Number age 15-59 Age 15-19 3.8 52.0 36.0 7.8 2.9 0.3 0.0 0.5 0.5 100.0 1,064 20-24 4.7 46.7 39.2 8.6 3.0 0.2 0.1 1.4 0.8 100.0 1,091 25-29 5.0 46.2 38.8 9.2 3.1 0.2 0.0 1.6 0.8 100.0 906 30-34 7.7 41.7 38.1 12.5 4.1 0.8 0.0 2.7 0.0 100.0 688 35-39 13.3 40.3 34.6 11.5 7.5 1.4 0.0 4.4 0.2 100.0 673 40-44 16.8 29.0 38.4 15.1 8.4 2.4 0.3 5.7 0.7 100.0 568 45-49 22.1 25.4 32.1 19.5 10.1 3.4 0.4 8.2 0.9 100.0 550 50-54 37.1 21.4 26.2 14.2 16.7 2.7 1.5 16.3 1.1 100.0 403 55-59 45.6 16.6 20.9 16.7 20.6 5.5 2.1 17.4 0.2 100.0 348 Marital status Ever married 15.6 36.6 34.7 12.7 7.6 1.7 0.4 5.9 0.5 100.0 4,720 Never married 4.4 48.5 37.7 8.5 3.7 0.2 0.0 0.5 0.9 100.0 1,570 Urban-rural residence Urban 14.5 38.1 35.9 10.7 7.1 1.4 0.3 5.8 0.7 100.0 2,736 Rural 11.4 40.7 35.1 12.4 6.2 1.3 0.3 3.6 0.5 100.0 3,555 Place of residence Urban Governorates 14.1 36.9 38.0 10.5 6.5 1.7 0.3 5.7 0.5 100.0 1,276 Lower Egypt 10.9 36.6 40.1 12.3 5.2 1.1 0.2 4.3 0.2 100.0 2,731 Urban 13.8 33.9 40.0 11.5 7.0 1.0 0.3 5.6 0.6 100.0 689 Rural 9.9 37.5 40.1 12.5 4.6 1.2 0.2 3.9 0.1 100.0 2,041 Upper Egypt 14.5 44.9 28.1 11.4 8.4 1.5 0.3 4.3 1.1 100.0 2,195 Urban 16.5 44.3 28.2 9.7 8.4 1.3 0.5 6.3 1.3 100.0 713 Rural 13.6 45.2 28.0 12.2 8.4 1.5 0.3 3.4 1.0 100.0 1,482 Frontier Governorates 8.5 36.5 40.2 14.5 5.2 1.0 0.5 1.8 0.2 100.0 89 Education No education 18.1 33.8 33.0 14.8 9.6 2.1 0.4 6.0 0.4 100.0 1,873 Some primary 21.3 36.4 30.3 11.4 9.3 3.2 0.6 8.2 0.6 100.0 517 Primary complete/ some secondary 9.3 44.0 36.2 10.0 4.9 0.6 0.3 3.6 0.6 100.0 1,342 Secondary complete/ higher 9.0 42.1 37.9 10.3 4.7 0.8 0.1 3.3 0.7 100.0 2,559 Wealth quintile Lowest 11.0 44.1 31.7 12.5 7.1 1.4 0.1 2.4 0.6 100.0 1,095 Second 11.7 39.1 35.8 13.2 5.7 1.8 0.6 3.6 0.1 100.0 1,281 Middle 13.7 39.8 34.7 11.1 7.8 0.9 0.2 4.8 0.7 100.0 1,236 Fourth 13.3 37.3 37.1 11.8 6.4 1.2 0.2 5.4 0.4 100.0 1,279 Highest 13.7 38.2 37.2 9.9 6.0 1.3 0.2 6.1 1.0 100.0 1,399 Total 12.8 39.6 35.5 11.6 6.6 1.3 0.3 4.6 0.6 100.0 6,290 Note: The blood pressure measurements taken in the survey provide a cross-sectional assessment of the prevalence of high blood pressure readings in the surveyed population at the time of the EDHS interviews and do not represent a medical diagnosis of hypertension. 1 Blood pressure ≥140/90 mmHg or currently taking antihypertensive medication 232 | Adult Health Issues Table 17.6.2 Levels of hypertension by socioeconomic characteristics: Men Prevalence of hypertension among men age 15-59 and percent distribution of men by blood pressure status, according to socioeconomic characteristics, Egypt 2008 Classification of blood pressure Socioeconomic characteristics Prevalence of hyper- tension1 Optimal <120/ <80 mmHg Normal 120-129/ 80-84 mmHg High normal 130-139/ 85-89 mmHg Mildly elevated (stage 1) 140-159/ 90-99 mmHg Moderately elevated (stage 2) 160-179/ 100-109 mmHg Severely elevated (stage3) 180+/ 110+ mmHg Normal BP and taking medi- cation Missing final BP level Total percent Number age 15-59 Age 15-19 4.9 35.5 50.0 9.6 4.2 0.4 0.1 0.2 0.0 100.0 1,087 20-24 4.2 23.3 52.4 20.1 3.9 0.1 0.0 0.2 0.0 100.0 869 25-29 6.1 22.3 51.7 19.8 5.3 0.2 0.0 0.6 0.1 100.0 729 30-34 6.4 19.7 49.9 23.8 4.8 1.1 0.0 0.6 0.2 100.0 634 35-39 8.3 18.0 50.3 23.4 6.5 0.4 0.5 0.8 0.0 100.0 535 40-44 12.2 14.9 42.9 29.9 8.1 1.2 0.6 2.3 0.0 100.0 581 45-49 18.4 13.7 38.4 29.5 11.8 1.8 1.0 3.8 0.0 100.0 494 50-54 27.2 16.2 31.9 23.4 15.8 4.3 2.0 5.1 1.5 100.0 413 55-59 28.4 13.9 31.9 25.8 14.3 4.1 1.1 8.9 0.0 100.0 375 Marital status Ever married 14.3 17.7 42.2 25.5 9.1 1.7 0.7 2.8 0.2 100.0 3,425 Never married 4.8 27.9 52.6 14.7 4.2 0.2 0.0 0.3 0.0 100.0 2,293 Urban-rural residence Urban 11.2 20.6 49.8 18.1 6.8 1.3 0.6 2.5 0.3 100.0 2,552 Rural 9.9 22.7 43.6 23.7 7.4 1.0 0.3 1.2 0.0 100.0 3,165 Place of residence Urban Governorates 10.9 22.1 52.0 14.8 6.8 0.9 0.2 3.1 0.2 100.0 1,169 Lower Egypt 9.2 21.0 44.3 25.4 6.6 0.8 0.3 1.5 0.1 100.0 2,481 Urban 10.5 19.7 47.1 22.5 6.7 1.5 0.7 1.7 0.2 100.0 622 Rural 8.8 21.4 43.4 26.3 6.6 0.6 0.2 1.4 0.0 100.0 1,860 Upper Egypt 11.7 22.8 45.4 19.9 7.9 1.6 0.7 1.5 0.2 100.0 1,973 Urban 11.9 19.5 48.3 19.6 6.5 2.0 1.1 2.3 0.6 100.0 696 Rural 11.6 24.6 43.7 20.1 8.6 1.4 0.5 1.1 0.0 100.0 1,277 Frontier Governorates 12.7 17.8 52.2 17.3 10.2 1.5 0.3 0.8 0.0 100.0 93 Education No education 13.9 16.8 42.2 27.1 8.8 1.5 0.2 3.3 0.0 100.0 715 Some primary 15.3 18.2 43.1 23.4 9.7 3.1 0.5 2.0 0.0 100.0 568 Primary complete/ some secondary 7.2 28.9 46.3 17.6 5.0 0.9 0.2 1.0 0.0 100.0 1,577 Secondary complete/higher 10.5 19.9 48.1 21.2 7.4 0.8 0.6 1.8 0.3 100.0 2,857 Wealth quintile Lowest 9.4 22.8 47.2 20.5 7.0 1.1 0.2 1.1 0.0 100.0 947 Second 10.1 23.8 42.1 23.9 7.5 0.9 0.4 1.3 0.0 100.0 1,161 Middle 10.3 20.8 47.3 21.6 7.8 1.1 0.2 1.2 0.0 100.0 1,190 Fourth 9.9 20.2 48.3 21.6 6.6 1.4 0.2 1.8 0.0 100.0 1,161 Highest 12.4 21.5 47.1 18.4 6.8 1.2 1.1 3.3 0.6 100.0 1,260 Total 10.5 21.8 46.4 21.2 7.1 1.1 0.4 1.8 0.1 100.0 5,718 Note: The blood pressure measurements taken in the survey provide a cross-sectional assessment of the prevalence of high blood pressure readings in the surveyed population at the time of the EDHS interviews and do not represent a medical diagnosis of hypertension. 1 Blood pressure ≥140/90 mmHg or currently taking antihypertensive medication Tables 17.7.1 and 17.7.2 present the prevalence of hypertension among EDHS respondents at the time of the survey according to selected health status measures. As expected, a prior history of hyper- tension was related strongly to the rate of hypertension found in the survey as was a history of diabetes or of heart attack or stroke. The small number of women who used tobacco were much more likely than women who did not use tobacco to be hypertensive (22 percent and 13 percent, respectively). Among men, the hypertension rate was only slightly higher among those who used tobacco than among those who did not (11 percent and 10 percent, respectively Adult Health Issues | 233 Table 17.7.1 Levels of hypertension by health status measures: Women Prevalence of hypertension among women age 15-59 and percent distribution of women by blood pressure status, according to health status measures , Egypt 2008 Classification of blood pressure Health status measures Prevalence of hyper- tension1 Optimal <120/ <80 mmHg Normal 120-129/ 80-84 mmHg High normal 130-139/ 85-89 mmHg Mildly elevated (stage 1) 140-159/ 90-99 mmHg Moderately elevated (stage 2) 160-179/ 100-109 mmHg Severely elevated (stage3) 180+/ 110+ mmHg Normal BP and taking medi- cation Missing final BP level Total percent Number age 15-59 Use of tobacco products Use tobacco products (22.1) (41.9) (29.8) (6.2) (9.7) (3.3) (0.5) (8.6) 0.0 100.0 45 Does not use tobacco products 12.7 39.5 35.5 11.7 6.5 1.3 0.3 4.5 0.6 100.0 6,236 Don't know/missing * * * * * * * * * 100.0 10 History of hypertension Told had high blood pressure by medical practitioner 65.1 13.1 12.4 9.2 22.3 4.5 1.6 36.7 0.3 100.0 782 Once 26.8 27.5 28.8 16.9 13.6 1.6 1.1 10.5 0.0 100.0 199 On two or more occasions 78.5 8.0 6.5 6.7 25.3 5.4 1.7 46.0 0.3 100.0 573 Don't know/missing * * * * * * * * * 100.0 10 Never told 5.3 43.3 38.8 11.9 4.3 0.9 0.1 0.0 0.6 100.0 5,495 Don't know/missing * * * * * * * * * 100.0 13 History of diabetes Told had diabetes by medical practitioner 55.0 15.5 15.5 14.0 24.7 3.8 2.2 24.3 0.0 100.0 231 Never told had diabetes 11.1 40.5 36.2 11.6 5.8 1.3 0.2 3.8 0.6 100.0 6,029 Don't know/missing (28.4) (28.5) (39.9) (3.1) (14.7) (0.0) (0.0) (13.7) 0.0 100.0 30 History of heart attack/stroke Told had heart attack/stroke by medical practitioner 42.2 18.8 27.5 11.5 12.0 2.4 0.0 27.8 0.0 100.0 68 Never told 12.4 39.8 35.5 11.6 6.5 1.3 0.3 4.3 0.6 100.0 6,221 Don't know/missing * * * * * * * * * 100.0 2 Nutritional status Thin 2.1 47.7 36.6 12.0 1.7 0.0 0.0 0.4 1.6 100.0 88 Normal 5.3 51.0 35.2 7.5 3.3 0.3 0.1 1.6 0.9 100.0 1,735 Overweight 10.7 40.2 36.8 12.1 5.5 1.5 0.2 3.5 0.1 100.0 1,609 Obese 21.4 27.8 35.0 15.3 10.9 2.2 0.6 7.7 0.6 100.0 2,246 Not eligible (pregnant or recent birth) 5.4 55.3 29.2 9.3 2.5 0.5 0.0 2.3 0.9 100.0 446 Out of range/missing 19.3 26.4 46.8 7.2 6.1 1.8 0.0 11.4 0.3 100.0 167 Total 12.8 39.6 35.5 11.6 6.6 1.3 0.3 4.6 0.6 100.0 6,290 Note: The blood pressure measurements taken in the survey provide a cross-sectional assessment of the prevalence of high blood pressure readings in the surveyed population at the time of the EDHS interviews and do not represent a medical diagnosis of hypertension. An asterisk indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Blood pressure ≥140/90 mmHg or currently taking antihypertensive medication 234 | Adult Health Issues Table 17.7.2 Levels of hypertension by health status measures: Men Prevalence of hypertension among men age 15-59 and percent distribution of men by blood pressure status, according to health status measures, Egypt 2008 Classification of blood pressure Health status measures Prevalence of hyper- tension1 Optimal <120/ <80 mmHg Normal 120-129/ 80-84 mmHg High normal 130-139/ 85-89 mmHg Mildly elevated (stage 1) 140-159/ 90-99 mmHg Moderately elevated (stage 2) 160-179/ 100-109 mmHg Severely elevated (stage3) 180+/ 110+ mmHg Normal BP and taking medi- cation Missing final BP level Total percent Number age 15-59 Use of tobacco products Use tobacco products 11.4 18.8 44.6 25.1 8.2 0.9 0.5 1.8 0.1 100.0 2,511 Does not use tobacco products 9.8 24.0 47.8 18.2 6.3 1.3 0.4 1.8 0.2 100.0 3,201 Don't know/missing * * * * * * * * * 100.0 5 History of hypertension Told had high blood pressure by medical practitioner 72.2 5.5 8.3 13.3 29.8 6.1 4.6 31.7 0.7 100.0 324 Once 39.3 11.3 21.8 27.6 20.7 1.6 1.2 15.8 0.0 100.0 70 On two or more occasions 81.5 3.9 4.2 9.4 32.5 7.4 5.6 36.0 0.9 100.0 252 Don't know/missing * * * * * * * * * 100.0 2 Never told 6.8 22.8 48.7 21.6 5.8 0.8 0.2 0.0 0.1 100.0 5,383 Don't know/missing * * * * * * * * * 100.0 10 History of diabetes Told had diabetes by medical practitioner 46.3 10.4 21.5 21.8 18.3 7.9 0.4 19.8 0.0 100.0 137 Never told had diabetes 9.6 22.1 47.0 21.1 6.9 1.0 0.4 1.4 0.1 100.0 5,570 Don't know/missing * * * * * * * * * 100.0 11 History of heart attack/stroke Told had heart attack/stroke by medical practitioner 57.9 11.6 23.4 6.6 28.4 5.6 0.7 23.3 0.5 100.0 77 Never told 9.9 21.9 46.7 21.4 6.8 1.1 0.4 1.5 0.1 100.0 5,637 Don't know/missing * * * * * * * * * 100.0 4 Nutritional status Thin 4.1 38.5 46.1 11.3 2.9 1.2 0.0 0.0 0.0 100.0 179 Normal 6.0 27.4 49.1 17.4 4.7 0.4 0.2 0.7 0.0 100.0 2,470 Overweight 12.7 16.9 45.5 24.4 7.9 1.0 0.7 3.0 0.4 100.0 1,909 Obese 17.6 15.1 42.4 25.0 12.3 2.6 0.5 2.1 0.0 100.0 1,014 Out of range/missing 15.4 17.3 39.6 27.7 6.6 3.9 0.1 4.7 0.0 100.0 145 Total 10.5 21.8 46.4 21.2 7.1 1.1 0.4 1.8 0.1 100.0 5,718 Note: The blood pressure measurements taken in the survey provide a cross-sectional assessment of the prevalence of high blood pressure readings in the surveyed population at the time of the EDHS interviews and do not represent a medical diagnosis of hypertension. An asterisk indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Blood pressure ≥140/90 mmHg or currently taking antihypertensive medication Adult Health Issues | 235 As expected, nutritional status also was strongly related to the rate of hypertension for both women and men. Women classified as obese were around four times as likely (21 percent) as women with BMI within the normal range (5 percent) to be hypertensive, while women classified as overweight were twice as likely (11 percent and 5 percent, respectively). Among men, 18 percent of those who were obese and 13 percent of those who were overweight were hypertensive compared to only 6 percent of men whose BMI fell within the normal range. Figure 17.1 shows the level of awareness and treatment status among EDHS respondents who were hypertensive. Twenty-seven percent of hypertensive women and 15 percent of hypertensive men were being treated for hypertension and have brought their blood pressure under control. Another group of respondents, including 14 percent of hypertensive women and 11 percent of hypertensive men, were being treated but still had elevated blood pressure at the time of the survey. Of even greater concern were the substantial proportions of women and men who were aware they had high blood pressure but were not being treated (32 percent of women and 21 percent of men) or who were unaware of their condition (27 percent of women and 53 percent of men). 17.4 LIFETIME HISTORY OF MEDICAL PROCEDURES AND INJECTIONS EDHS respondents interviewed in the special health issues component of the survey were asked questions about whether or not they had ever had surgery, a blood transfusion, or dental treatment during their lifetime. They were also asked several questions about whether they received any injections, whether they ever had an injection to treat schistosomiasis (a disease caused by parasitic worms), and whether they ever had an injection in which the needle and syringe were reused. The questions were designed to provide a basic assessment of lifetime exposure to procedures that offer the potential for exposure to the risk of bloodborne pathogens. In particular, participation in injection-based schistosomiasis treatment campaigns has been identified as a risk factor for hepatitis C based on strong evidence to suggest that Figure 17.1 Awareness of Hypertension and Treatment Status among Hypertensive Women and Men Age 15-59 Aware, treated, and not controlled 14% Aware, treated, and controlled 27% Not aware, elevated 27% Aware, not treated 32% Aware, treated, and not controlled 11%Aware, not treated 21% Not aware, elevated 53% Aware, treated, and controlled 15% EDHS 2008 WOMEN MEN 236 | Adult Health Issues failure to adequately sterilize the syringes and needles in the large-scale campaigns undertaken to treat schistosomiasis between the 1950s and 1980s contributed to widespread transmission of the hepatitis C virus in Egypt (Strickland 2006 and Rao et al. 2002). Table 17.8 shows that 42 percent of all respondents age 15-59 reported they had a surgery at some point in their lives, 4 percent had had at least one blood transfusion, and 61 percent had some type of dental treatment. With regard to injections, a large majority of respondents had had injections—8 percent of respondents for the treatment of schistosomiasis and 93 percent for some other purpose. Around four in ten respondents reported that the syringe and needle used for at least one of the injections they had received during their lifetime was reused, i.e., another individual later received an injection using the same syringe and needle. Table 17.8 Lifetime prevalence of medical procedures by background characteristics Percentage of population age 15-59 who received various medical procedures during their lifetime by selected background characteristics, Egypt 2008 Percentage having ever had: Background characteristics Surgery Blood transfusion Dental treatment Injection to treat schistoso- miasis Any other injection Any injection in which needle and syringe reused Number Sex Women 48.6 4.3 58.3 4.9 94.0 45.3 6,290 Men 34.4 3.8 63.6 11.9 92.0 32.5 5,718 Age 15-19 23.8 1.6 42.6 5.3 87.1 22.0 2,151 20-24 33.8 2.7 50.5 4.3 91.8 31.5 1,960 25-29 44.1 3.5 60.3 5.1 93.7 41.3 1,635 30-34 44.4 3.9 63.6 7.5 96.6 42.5 1,322 35-39 50.6 4.3 69.6 9.5 94.6 48.5 1,209 40-44 48.4 5.9 71.3 12.3 94.8 44.8 1,148 45-49 50.9 6.1 72.0 11.8 95.1 46.9 1,044 50-54 53.3 6.7 74.8 15.4 94.7 50.0 815 55-59 56.0 7.2 75.2 14.8 96.4 53.3 723 Urban-rural residence Urban 45.3 4.9 65.8 3.9 91.9 42.9 5,288 Rural 39.1 3.4 56.8 11.7 94.0 36.3 6,720 Place of residence Urban Governorates 46.6 5.1 68.3 2.5 91.3 44.3 2,445 Lower Egypt 44.7 3.4 63.1 9.1 95.2 41.4 5,212 Urban 48.2 4.6 67.6 4.3 94.0 45.3 1,311 Rural 43.6 3.0 61.6 10.6 95.7 40.1 3,901 Upper Egypt 35.6 4.3 53.7 10.9 91.7 33.8 4,168 Urban 40.9 5.0 60.8 6.1 91.4 39.0 1,409 Rural 33.0 4.0 50.1 13.4 91.8 31.1 2,759 Frontier Governorates 36.1 3.4 53.6 3.0 86.7 33.8 182 Education No education 45.1 4.5 58.8 10.5 94.0 40.4 2,588 Some primary 45.1 4.6 63.2 13.0 93.4 42.6 1,084 Primary complete/some secondary 37.4 4.4 54.2 7.9 89.7 35.1 2,919 Secondary complete/ higher 42.0 3.6 64.8 6.5 94.4 40.2 5,417 Work status Working for cash 41.0 4.3 68.0 11.7 93.8 38.8 5,333 Not working for cash 42.5 3.8 55.0 5.5 92.5 39.6 6,675 Wealth quintile Lowest 31.3 3.6 48.7 13.2 93.2 29.3 2,042 Second 39.2 3.7 56.6 11.0 92.7 36.1 2,442 Middle 43.6 3.8 60.1 9.9 94.2 40.6 2,425 Fourth 46.6 4.5 63.9 4.9 93.1 43.6 2,440 Highest 46.3 4.7 71.6 3.6 92.2 44.4 2,659 Total 41.8 4.1 60.8 8.3 93.1 39.2 12,008 Adult Health Issues | 237 Women were markedly more likely to have had surgery than men (49 percent and 34 percent, respectively), while the rates of blood transfusion were similar among women and men. On the other hand, men were slightly more likely than women to report having dental treatment at some point in their lifetime (64 percent and 58 percent, respectively). Men were more than twice as likely as women to have been treated for schistosomiasis with an injection, and women were more likely than men to report having had an injection in which the syringe and the needle were reused. As expected, the likelihood that a respon- dent had had any of the medical procedures or an injection during their lifetime increased with age. Urban residents were more likely to have had surgery, blood transfusions and dental treatment than rural residents. On the other hand, rural resi- dents were three times as likely to report having ever received an injection to treat schistosomiasis and slightly more likely to report having ever received an injection for some other purpose as urban residents. Reuse of syringes and needles was more often reported by urban than rural residents (43 percent and 36 percent, respectively). Residents of rural Upper Egypt and the Frontier Governorates were less likely than residents of other areas to have had surgery or dental treatment. The proportion reporting they had an injection to treat schistosomiasis was highest in rural Upper Egypt and lowest in the Urban Governorates and the Frontier Governorates. Reuse of syringes and needles was reported most often by residents of urban Lower Egypt (45 percent) and least often by residents of rural Upper Egypt (31 percent). The proportion of respondents who had had an injection to treat schistosomiais decreased with the education and wealth quintile. The proportions of respondents who had had other medical procedures and injections or who reported reuse of syringes and needles generally increased with wealth quintile but did not vary in a uniform fashion with education. 17.5 RECENT HISTORY OF INJECTIONS EDHS respondents were also asked ques- tions about the number of injections that they had had in the six months prior to the survey, how many of those injections were administered by a health care provider, and where they had received the last medical injection. The results presented in Table 17.9 indicate that 16 percent of respondents had had at least one injection during the six-month period prior to the survey. Among those who had had an Table 17.9 Prevalence of injections during the six-month period prior to the survey Percent distribution of women and men age 15-59 by the number of injections and the number of medical injections, and the average number of injections and medical injections received during the past six months, and, among women and men who received any medical injection, the percentage reporting the provider used a new, unopened package for the last injection, Egypt 2008 Injection safety Women Men Total Number of injections No injections 72.8 82.8 77.6 1 3.8 2.4 3.2 2 4.4 1.1 2.9 3-4 4.5 2.6 3.6 5-9 4.5 1.7 3.2 10-19 2.3 1.1 1.7 20-29 0.7 0.3 0.5 30-59 0.4 0.2 0.3 60-94 0.2 0.1 0.2 95+ 1.0 0.4 0.7 Missing 5.4 7.2 6.2 Total percent 100.0 100.0 100.0 Number 6,290 5,718 12,008 Mean number received1 10.2 9.6 10.0 Number of medical injections2 No injections 72.8 82.8 77.6 No medical injections 6.9 2.5 4.8 1 3.3 2.3 2.8 2 3.8 1.0 2.5 3-4 2.9 1.9 2.4 5-9 2.4 1.1 1.7 10-19 1.4 0.8 1.1 20-29 0.3 0.2 0.2 30-59 0.2 0.1 0.2 60-94 0.1 0.1 0.1 95+ 0.5 0.1 0.3 Missing 5.4 7.2 6.2 Total percent 100.0 100.0 100.0 Number 6,290 5,718 12,008 Mean number received3 7.8 6.4 7.4 New, unopened package used for last medical injection Yes 83.2 85.7 84.0 No 15.3 12.8 14.5 Don't know 0.3 0.3 0.3 Missing 1.2 1.2 1.2 Total percent 100.0 100.0 100.0 Number receiving medical injection 935 430 1,364 1 Mean number among women and men receiving any injection(s) during the six-month period. 2 Includes injections given by a doctor, nurse, pharmacist, dentist or other health worker 3 Mean number among women and men receiving any medical injection(s) during the six-month period 238 | Adult Health Issues injection, 70 percent had received at least one medical injection, i.e., an injection administered by a doctor, nurse, pharmacist or other health care provider. Eighty-four percent of those respondents who had had a medical injection said that the last time they had a medical injection the provider had taken the syringe and needle from a new unopened package. Table 17.10 presents the variation in the percentages receiving any injection and any medical injection in the six months prior to the survey by background characteristics. Although not uniform, the results show that the likelihood of receiving an injection was higher among women than men. It also was higher in Upper Egypt than in other areas. Table 17.10 Injection prevalence by background characteristics Percentage of women and men age 15-59 who received at least one injection and at least one injection from a health care provider in the past six months according to background characteristics, and injection prevalence among women and men age 50-59 and age 15-59, Egypt 2008 Women Men Total Background characteristics Percentage who received an injection in the past 6 months Percentage who received an injection from a health care provider in the past 6 months Number Percentage who received an injection in the past 6 months Percentage who received an injection from a health care provider in the past 6 months Number Percentage who received an injection in the past 6 months Percentage who received an injection from a health care provider in the past 6 months Number Age 15-19 12.3 9.5 1,064 5.3 4.1 1,087 8.7 6.8 2,151 20-24 19.5 14.8 1,091 7.4 6.2 869 14.1 11.0 1,960 25-29 23.0 17.7 906 10.2 7.9 729 17.3 13.3 1,635 30-34 23.7 16.1 688 12.7 10.5 634 18.4 13.4 1,322 35-39 26.5 18.3 673 12.3 9.6 535 20.2 14.5 1,209 40-44 26.6 17.4 568 10.3 7.1 581 18.4 12.2 1,148 45-49 25.9 15.3 550 11.1 6.9 494 18.9 11.3 1,044 50-54 23.5 12.9 403 15.0 11.5 413 19.2 12.2 815 55-59 25.5 12.3 348 14.8 9.0 375 19.9 10.6 723 Marital status Ever-married 26.0 18.3 3,983 11.5 8.7 2,640 20.2 14.5 6,623 Never-married 9.6 7.1 1,556 6.7 5.2 2,290 7.9 5.9 3,846 Urban-rural residence Urban 21.6 14.6 2,352 8.8 7.1 2,170 15.4 11.0 4,521 Rural 21.3 15.6 3,188 9.6 7.1 2,760 15.9 11.6 5,948 Place of residence Urban Governorates 20.0 14.4 1,073 7.1 5.7 990 13.8 10.2 2,063 Lower Egypt 18.1 12.7 2,415 7.1 5.1 2,150 12.9 9.1 4,565 Urban 19.5 12.6 603 5.8 5.2 533 13.1 9.1 1,136 Rural 17.6 12.7 1,812 7.5 5.0 1,616 12.9 9.1 3,429 Upper Egypt 26.4 18.6 1,970 13.3 10.5 1,706 20.3 14.9 3,676 Urban 26.5 17.0 623 14.5 11.5 588 20.7 14.3 1,211 Rural 26.3 19.4 1,347 12.8 10.0 1,118 20.2 15.1 2,466 Frontier Governorates 19.5 15.1 82 6.2 4.7 84 12.8 9.8 165 Education No education 23.8 16.7 1,461 10.5 7.7 467 20.6 14.5 1,928 Some primary 26.3 18.5 394 12.2 9.8 458 18.7 13.9 853 Primary complete/ some secondary 17.6 12.5 1,248 6.2 4.6 1,414 11.6 8.3 2,662 Secondary complete/ higher 21.2 15.1 2,436 10.2 7.8 2,590 15.5 11.3 5,027 Wealth quintile Lowest 20.4 14.8 1,001 9.8 7.3 838 15.6 11.4 1,839 Second 20.6 15.4 1,123 9.9 6.9 1,010 15.5 11.4 2,132 Middle 23.7 17.1 1,099 9.2 7.2 1,036 16.6 12.3 2,135 Fourth 21.0 14.5 1,105 8.2 7.2 997 14.9 11.0 2,102 Highest 21.4 14.1 1,212 9.3 6.8 1,049 15.8 10.7 2,260 Total age 15-49 21.4 15.2 5,540 9.3 7.1 4,930 15.7 11.4 10,469 Age 50-59 24.4 12.6 751 14.9 10.3 788 19.5 11.4 1,539 Total age 15-59 21.8 14.9 6,290 10.0 7.5 5,718 16.2 11.4 12,008 Adult Health Issues | 239 17.6 AWARENESS OF SAFE INJECTION PRACTICES The 2008 EDHS collected information from respondents in the special health issues interviews to assess the coverage of recent IEC efforts designed to increase population awareness about safe injection practices. Table 17.11.1 and 17.11.2 present these results. Twenty-seven percent of women and 19 percent of men age 15-59 reported that they had received information about what people should do to be sure that injections are given safely in the six months prior to the survey. Among women, the proportion reporting they had heard a message was highest among those from urban Upper Egypt (36 percent), while among men it was highest in rural Lower Egypt (25 percent). Television was by far the principal source of information for both women and men who had heard about injection safety issues (89 percent each). Table 17.11.1 Exposure to information regarding injection safety by background characteristics: Women Percentage of women age 15-59 receiving information about injection safety during the six-month period prior to the survey, and percentage receiving any information who named various sources of information, according to background characteristics, and percentage age 50-59 and of all women age 15-59 exposed to information about injection safety, Egypt 2008 Percentage who saw/heard about injection safety from: Background characteristics Percentage receiving information recently about injection safety Number of women TV Other media1 Any contact with health worker Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Community meeting/ other Number of women receiving information about injection safety Age 15-19 28.0 1,064 92.4 16.6 7.9 1.4 6.5 7.3 1.1 298 20-24 26.6 1,091 89.7 14.9 11.0 3.2 8.5 4.8 1.2 290 25-29 28.5 906 90.4 20.4 12.5 1.4 11.5 3.8 1.1 258 30-34 27.9 688 89.8 15.2 14.8 3.5 11.5 4.4 4.0 192 35-39 27.1 673 88.4 19.0 10.4 1.5 9.5 9.4 0.2 183 40-44 28.2 568 87.9 9.6 13.7 4.0 11.0 11.4 0.7 160 45-49 21.2 550 88.9 10.9 14.5 1.5 13.8 10.6 4.7 117 50-54 22.8 403 82.4 18.8 22.0 3.0 19.8 11.7 3.1 92 55-59 23.9 348 83.4 17.5 11.3 4.2 7.3 10.8 0.0 83 Marital status Ever-married 26.5 3,983 89.6 15.2 12.3 2.4 10.6 6.8 1.7 1,057 Never-married 28.3 1,556 90.8 17.4 10.0 2.2 7.8 6.7 1.4 441 Urban-rural residence Urban 29.2 2,352 88.7 14.6 11.8 1.7 10.3 6.3 2.0 686 Rural 25.5 3,188 91.0 16.9 11.5 2.8 9.4 7.2 1.3 812 Place of residence Urban Governorates 28.5 1,073 88.8 13.8 11.5 1.1 10.4 6.4 2.5 306 Lower Egypt 25.6 2,415 91.3 22.6 9.6 2.2 8.2 4.5 0.4 618 Urban 23.2 603 88.0 26.7 11.6 1.5 10.1 3.9 1.0 140 Rural 26.4 1,812 92.3 21.4 9.0 2.4 7.6 4.7 0.2 478 Upper Egypt 28.1 1,970 89.0 9.5 14.0 3.2 11.4 9.6 2.5 554 Urban 36.1 623 88.7 8.1 12.5 2.7 10.6 7.9 2.0 225 Rural 24.4 1,347 89.2 10.6 15.0 3.5 12.0 10.8 2.8 329 Frontier Governorates 24.3 82 90.8 12.3 8.0 0.0 8.0 3.2 1.4 20 Education No education 21.9 1,461 88.2 14.2 13.6 3.7 11.4 8.0 1.0 321 Some primary 22.6 394 93.9 10.4 13.0 1.7 11.2 4.2 0.0 89 Primary complete/ some secondary 27.8 1,248 91.7 16.6 7.5 1.5 6.4 8.3 1.7 346 Secondary complete/ higher 30.4 2,436 89.4 16.9 12.5 2.2 10.5 5.9 2.0 741 Wealth quintile Lowest 21.4 1,001 87.1 10.1 14.2 4.6 10.2 9.6 1.8 214 Second 28.3 1,123 94.4 17.0 10.2 2.4 7.9 5.9 1.2 317 Middle 26.3 1,099 89.0 17.1 11.6 2.0 10.7 6.3 0.9 289 Fourth 26.5 1,105 90.3 14.4 8.8 0.7 8.8 6.2 1.4 293 Highest 31.7 1,212 88.3 18.3 13.4 2.4 11.3 6.8 2.5 384 Total women age 15-49 27.0 5,540 89.9 15.8 11.6 2.3 9.8 6.8 1.6 1,498 Women age 50-59 23.3 751 82.9 18.2 16.9 3.6 13.8 11.3 1.6 175 Total women age 15-59 26.6 6,290 89.2 16.1 12.2 2.4 10.2 7.2 1.6 1,673 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster 240 | Adult Health Issues Table 17.11.2 Exposure to information regarding injection safety by background characteristics: Men Percentage of men age 15-59 receiving information about injection safety during the six-month period prior to the survey, and percentage receiving any information who named various sources of information, according to background characteristics, and percentage age 50-59 and of all men age 15-59 exposed to information about injection safety, Egypt 2008 Percentage who saw/heard about injection safety from: Background characteristics Percentage receiving information recently about injection safety Number of men TV Other media1 Any contact with health worker Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Community meeting/ other Number of men receiving information about injection safety Age 15-19 17.4 1,087 89.8 26.6 6.5 0.3 6.2 9.9 1.2 190 20-24 20.2 869 90.6 23.6 9.7 1.1 8.9 5.7 0.0 176 25-29 22.3 729 90.8 16.8 7.3 1.2 6.2 6.7 0.3 163 30-34 20.3 634 89.2 26.2 7.8 0.8 7.0 8.7 0.0 129 35-39 21.2 535 90.6 21.0 18.7 3.9 15.6 4.4 0.0 114 40-44 20.7 581 87.5 13.5 14.2 0.8 14.2 12.9 1.7 120 45-49 15.5 494 89.3 18.3 6.1 3.3 4.4 8.4 2.3 77 50-54 16.3 413 80.3 21.8 23.8 6.0 18.8 9.5 5.4 67 55-59 18.1 375 83.9 21.1 15.8 3.7 12.0 9.7 0.0 68 Marital status Ever-married 19.6 2,640 88.3 19.2 11.9 2.0 10.5 8.6 0.8 519 Never-married 19.6 2,290 91.5 24.0 7.3 0.7 6.7 7.4 0.5 448 Urban-rural residence Urban 18.6 2,170 88.4 20.3 9.6 1.4 8.5 6.4 0.6 405 Rural 20.4 2,760 90.8 22.2 9.9 1.4 8.9 9.2 0.8 562 Place of residence Urban Governorates 21.1 990 89.0 16.0 8.9 1.5 7.4 4.8 0.2 209 Lower Egypt 22.7 2,150 93.0 25.7 5.4 0.4 5.3 6.2 0.7 487 Urban 15.8 533 88.3 31.7 6.2 0.0 6.2 6.2 1.8 84 Rural 24.9 1,616 93.9 24.4 5.2 0.4 5.1 6.2 0.4 403 Upper Egypt 15.2 1,706 84.4 18.5 18.5 3.1 16.4 14.2 1.1 260 Urban 17.6 588 86.9 21.1 13.8 2.1 12.7 9.9 0.5 104 Rural 14.0 1,118 82.7 16.8 21.7 3.9 18.8 17.1 1.6 156 Frontier Governorates 12.7 84 92.5 2.5 11.7 2.9 8.8 6.6 0.0 11 Education No education 20.0 467 91.9 11.3 7.4 0.5 7.4 5.1 0.0 93 Some primary 17.4 458 96.8 19.6 5.2 0.0 5.2 4.7 1.9 80 Primary complete/some secondary 17.3 1,414 91.5 23.3 7.7 0.7 7.5 7.9 0.3 245 Secondary complete/ higher 21.2 2,590 87.7 22.5 11.7 2.0 10.0 9.1 0.8 549 Wealth quintile Lowest 17.2 838 91.3 13.0 8.5 0.5 8.0 8.0 0.7 144 Second 23.1 1,010 93.7 21.4 8.3 0.5 7.7 9.3 1.0 233 Middle 19.7 1,036 91.9 17.7 8.0 2.7 6.4 7.9 0.4 204 Fourth 14.3 997 86.5 22.9 12.2 3.0 10.3 6.8 0.6 142 Highest 23.2 1,049 85.3 28.6 12.0 0.7 11.3 7.8 0.6 243 Total men age 15-49 19.6 4,930 89.8 21.4 9.7 1.4 8.7 8.1 0.7 967 Men age 50-59 17.1 788 82.1 21.5 19.7 4.9 15.4 9.6 2.7 135 Total men age 15-59 19.3 5,718 88.9 21.4 11.0 1.8 9.6 8.2 0.9 1,102 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster Knowledge and Prevalence of Hepatitis C | 241 KNOWLEDGE AND PREVALENCE OF HEPATITIS C 18 Infection with the hepatitis C virus (HCV) is a major public health problem in Egypt. The high level of HCV infection has been attributed in part to the use of inadequately sterilized needles during mass campaigns undertaken to treat schistosomiasis (Rao et al., 2002 and Nafeh et al., 2000). The 2008 EDHS collected information on the extent to which the women and men age 15-59 interviewed in the special health issues component of the survey knew about hepatitis C and, among those who had heard about hepatitis C, their understanding of the modes of transmission and prevention of the virus, and the sources from which they had recently received information about hepatitis C. The women and men eligible for the special health issues interviews were also asked to provide venous blood samples for laboratory testing for the hepatitis C virus. This chapter presents results from both the survey interviews and the HCV tests. 18.1 HEPATITIS C KNOWLEDGE Table 18.1.1 and 18.1.2 show both the level of awareness of hepatitis C among EDHS respondents age 15-59 and the sources from which respondents have recently received information about the illness. The results indicate that 80 percent of women and 85 percent of men were aware of hepatitis C. Among women who had heard about hepatitis C, 67 percent had received information about the illness within the six-month period before the survey. This proportion was somewhat lower among men (61 percent). Television was the main channel through which both women and men received information about hepatitis C (91 percent and 88 percent, respectively) followed by personal contacts with the respondent’s spouse, other relatives, friends, or neighbors (26 percent and 33 percent, respectively) and other media (14 percent and 18 percent, respectively). Tables 18.2.1 and 18.2.2 present information on the avenues of transmission of the hepatitis C virus recognized by women and men who had heard about hepatitis C. The percentages naming various transmission routes may add to more than 100 percent because respondents were asked to name all of the ways in which hepatitis C may be spread from one person to another. The results presented in Table 18.2.1 show that 70 percent of the women who knew about hepatitis C were able to name at least one way the illness can be transmitted. Of the women able to name an avenue of transmission for hepatitis C, 85 percent said that it could be contracted through a blood transfusion, 69 percent mentioned unclean needles, and 40 percent cited other contact with the blood of an infected person. Other avenues of transmission mentioned by women included having sexual relations with an infected person (18 percent) and having other casual physical contact including shaking hands or sharing food (22 percent). Men were somewhat more knowledgeable than women about modes in which hepatitis C virus can be transmitted. Seventy-nine percent of men knowing about hepatitis C were able to name at least one way in which the virus can be transmitted. Similar to the pattern observed for women, the three modes of transmission mentioned most often by men were blood transfusions (81 percent), use of unclean needles (71 percent), and other contact with the blood of an infected person (54 percent). Around one in six men also mentioned having sexual relations with an infected person or having other physical contacts as ways in which hepatitis C may be transmitted. 242 | Knowledge and Prevalence of Hepatitis C Table 18.1.1 Knowledge of hepatitis C by background characteristics: Women Percentage of women age 15-49 knowing about hepatitis C; among women knowing about hepatitis C, percentage receiving information about hepatitis C during the six months prior to the survey, and percentage of women receiving any information naming various sources of information, according to background characteristics, and percentage of women 50-59 and of women 15-59 knowing about hepatitis C and receiving information about hepatitis C from various sources Egypt 2008 Percentage who saw/heard about hepatitis C from: Background characteristic Percentage knowing about hepatitis C Number of women Percentage receiving information recently about hepatitis C Number of women knowing about hepatitis C TV Other media1 Any contact with medical provider Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Com- munity meeting/ other Number of women receiving information about hepatitis C recently Age 15-19 74.0 1,064 67.4 787 90.2 13.0 1.5 0.1 1.5 23.6 2.0 531 20-24 82.0 1,091 63.5 895 91.6 16.2 4.9 0.7 4.6 22.0 1.3 568 25-29 84.9 906 67.7 769 91.6 16.4 6.0 0.6 5.4 25.5 0.6 521 30-34 83.7 688 66.7 576 94.7 11.9 5.3 0.5 5.1 25.1 2.1 384 35-39 80.1 673 67.9 540 91.1 13.6 5.0 0.4 4.6 21.6 1.3 367 40-44 78.0 568 69.7 443 88.6 14.1 4.9 0.8 4.1 34.0 1.7 309 45-49 79.5 550 70.8 437 89.3 13.8 6.7 0.7 6.7 29.5 1.0 309 Marital status Ever married 80.5 3,983 67.0 3,209 91.4 13.2 5.2 0.5 4.9 26.1 1.0 2,149 Never married 79.6 1,556 67.8 1,238 90.5 17.3 3.4 0.6 3.1 23.1 2.4 840 Urban-rural residence Urban 86.6 2,352 67.9 2,037 93.4 15.3 4.7 0.7 4.4 20.4 1.8 1,382 Rural 75.6 3,188 66.6 2,410 89.2 13.5 4.8 0.4 4.4 29.4 1.0 1,606 Place of residence Urban Governorates 86.8 1,073 72.2 931 95.5 13.7 3.9 0.4 3.7 18.0 2.1 672 Lower Egypt 86.7 2,415 70.6 2,093 91.6 17.9 5.0 0.6 4.6 26.6 1.1 1,478 Urban 92.8 603 68.7 559 94.5 24.2 5.5 0.8 5.2 21.7 2.4 384 Rural 84.6 1,812 71.3 1,534 90.6 15.6 4.8 0.5 4.4 28.3 0.7 1,094 Upper Egypt 69.4 1,970 58.9 1,368 86.8 8.9 5.0 0.5 4.6 29.4 1.3 806 Urban 81.9 623 59.4 510 87.5 8.5 5.6 1.1 4.8 25.2 0.6 303 Rural 63.7 1,347 58.6 858 86.4 9.2 4.7 0.1 4.5 31.9 1.8 502 Frontier Governorates 67.4 82 60.2 55 89.9 3.4 4.6 0.0 4.6 13.1 0.0 33 Education No education 64.7 1,461 65.8 945 87.9 9.4 3.0 0.0 3.0 30.6 0.6 622 Some primary 72.3 394 66.8 285 87.7 9.1 3.0 0.0 3.0 27.3 0.0 191 Primary complete/ some secondary 78.5 1,248 65.2 979 92.2 11.3 2.8 0.1 2.8 22.5 1.3 638 Secondary complete/ higher 91.8 2,436 68.8 2,237 92.4 18.3 6.5 1.0 5.8 23.9 2.0 1,538 Work status Working for cash 90.2 866 70.9 781 92.1 20.4 10.9 1.9 9.9 26.4 3.2 553 Not working for cash 78.4 4,674 66.4 3,666 90.9 13.0 3.3 0.2 3.2 25.0 1.0 2,436 Wealth quintile Lowest 60.4 1,001 59.4 605 87.0 9.6 2.0 0.0 2.0 30.1 1.3 359 Second 74.7 1,123 67.1 839 89.7 12.1 4.3 0.6 3.7 29.8 1.2 563 Middle 80.2 1,099 69.0 881 90.7 14.8 4.8 0.4 4.4 26.0 0.4 608 Fourth 88.9 1,105 66.8 983 92.5 12.7 4.6 0.8 4.2 24.0 1.9 656 Highest 94.0 1,212 70.5 1,139 93.2 19.1 6.3 0.6 6.2 20.3 2.0 803 Total 15-49 80.3 5,540 67.2 4,447 91.1 14.3 4.7 0.5 4.4 25.2 1.4 2,989 Age 50-59 77.1 571 68.9 579 90.3 12.9 5.1 0.8 4.4 27.4 1.1 399 Total 15-59 79.9 6,290 67.4 5,026 91.0 14.2 4.8 0.6 4.4 25.5 1.4 3,388 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster Knowledge and Prevalence of Hepatitis C | 243 Table 18.1.2 Knowledge of hepatitis C by background characteristics: Men Percentage of men age 15-49 knowing about hepatitis C; among men knowing about hepatitis C, percentage receiving information about hepatitis C during the six months prior to the survey, and percentage of men receiving any information naming various sources of information, according to background characteristics, and percentage of men 50-59 and of men 15-59 knowing about hepatitis C and receiving information about hepatitis C from various sources, Egypt 2008 Percentage who saw/heard about hepatitis C from: Background characteristic Percentage knowing about hepatitis C Number of men Percentage receiving information recently about hepatitis C Number of men knowing about hepatitis C TV Other media1 Any contact with medical provider Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Com- munity meeting/ other Number of men receiving information about hepatitis C recently Age 15-19 74.6 1,087 57.5 812 89.3 18.8 2.3 0.8 1.6 29.5 5.1 467 20-24 86.1 869 59.5 748 92.0 17.8 3.7 0.8 2.9 29.2 1.1 445 25-29 89.9 729 60.8 655 88.3 13.7 7.1 0.2 7.0 35.1 0.9 398 30-34 89.2 634 64.6 565 87.4 18.3 4.9 0.0 4.9 31.3 0.8 365 35-39 88.9 535 59.1 476 89.4 17.8 10.0 0.6 9.4 38.4 0.9 281 40-44 90.5 581 63.9 526 86.3 15.8 7.3 1.3 6.2 34.5 2.1 336 45-49 88.4 494 60.6 437 90.0 20.2 7.9 0.8 7.1 36.3 1.7 265 Marital status Ever married 88.6 2,640 61.8 2,338 87.9 17.2 7.2 0.6 6.6 36.0 1.4 1,445 Never married 82.1 2,290 59.2 1,881 90.6 17.6 3.9 0.7 3.3 28.9 2.7 1,113 Urban-rural residence Urban 87.4 2,170 57.8 1,896 90.3 18.7 5.0 0.6 4.4 25.7 2.1 1,097 Rural 84.1 2,760 62.9 2,322 88.1 16.4 6.3 0.7 5.8 38.3 1.8 1,460 Place of residence Urban Governorates 84.9 990 55.2 840 92.2 14.1 2.4 0.5 1.9 13.7 1.8 464 Lower Egypt 91.1 2,150 66.4 1,958 91.1 18.0 5.4 0.4 5.0 38.3 1.9 1,301 Urban 96.5 533 62.4 515 91.3 21.1 6.3 0.2 6.2 38.0 2.7 321 Rural 89.3 1,616 67.9 1,443 91.0 17.0 5.0 0.4 4.7 38.4 1.6 980 Upper Egypt 79.4 1,706 56.1 1,354 83.7 18.4 8.5 1.3 7.4 35.5 2.1 760 Urban 84.0 588 58.9 494 86.3 23.2 7.9 1.3 6.6 30.8 1.8 291 Rural 77.0 1,118 54.6 861 82.1 15.5 8.9 1.2 7.9 38.4 2.3 470 Frontier Governorates 78.6 84 48.6 66 86.1 16.7 5.3 0.0 5.3 29.6 1.8 32 Education No education 68.9 467 62.9 321 88.7 8.7 5.0 0.2 5.0 38.7 0.0 202 Some primary 77.6 458 57.2 356 84.6 11.4 5.7 0.3 5.5 40.6 1.4 204 Primary complete/ some secondary 79.3 1,414 56.0 1,121 86.9 13.6 4.4 0.7 3.7 32.2 3.1 627 Secondary complete/ higher 93.4 2,590 63.0 2,420 90.6 20.9 6.4 0.7 5.8 31.4 1.8 1,524 Work status Working for cash 86.9 3,685 61.1 3,201 88.6 16.6 6.3 0.6 5.8 34.5 1.3 1,955 Not working for cash 81.7 1,245 59.2 1,017 90.4 20.0 4.1 0.8 3.3 27.6 4.0 603 Wealth quintile Lowest 73.7 838 61.2 618 85.8 12.0 6.8 0.2 6.6 32.2 1.9 378 Second 82.6 1,010 61.7 834 88.6 13.3 4.8 0.2 4.8 39.7 1.2 515 Middle 85.4 1,036 58.1 885 89.3 18.1 7.6 0.9 6.8 35.5 1.7 514 Fourth 89.3 997 58.2 891 90.1 18.3 3.6 0.9 2.7 32.2 1.9 518 Highest 94.4 1,049 63.8 990 90.2 22.6 6.2 0.9 5.4 26.2 2.7 631 Total 15-49 85.6 4,930 60.6 4,218 89.0 17.4 5.8 0.6 5.2 32.9 1.9 2,557 Age 50-59 84.4 788 60.5 665 84.5 20.7 8.8 0.8 8.1 35.6 1.3 403 Total 15-59 85.4 5,718 60.6 4,884 88.4 17.8 6.2 0.7 5.6 33.3 1.9 2,960 1 Includes radio, newspaper, magazine, pamphlet, brochure or poster 244 | Knowledge and Prevalence of Hepatitis C Table 18.2.1 Knowledge of the ways a person can contract hepatitis C by background characteristics: Women Percentage of women age 15-49 knowing about hepatitis C who can name at least one way in which an individual can contract hepatitis C and percentage of women knowing about a way hepatitis C can be contracted who named various routes of transmission, according to selected background characteristics, and percentage of women age 50-59 and of women age 15-59 knowing about the ways a person can contract hepatitis C, Egypt 2008 Percentage naming various routes of transmission Background characteristic Percentage of women knowing about hepatitis C who can name at least one way the illness can be contracted Number of women knowing about hepatitis C Hetero- sexual relations Homo- sexual relations Blood trans- fusions Unclean needle Other contact with blood of infected person Mother- to-child trans- mission Other casual physical contact with infected person Mosquito / other insect bites/ other Number of women who know one way hepatitis C can be contracted Age 15-19 68.5 787 15.1 1.3 83.2 68.9 39.5 8.6 23.3 2.5 540 20-24 72.7 895 16.5 2.7 85.4 67.6 40.8 10.9 20.5 2.9 650 25-29 72.9 769 18.3 2.1 85.3 72.4 41.2 11.8 20.7 3.5 561 30-34 70.6 576 18.7 4.3 86.4 68.9 41.9 7.9 17.5 2.9 407 35-39 72.1 540 21.9 2.7 86.7 74.3 47.1 8.1 24.5 5.0 389 40-44 68.2 443 19.6 1.7 85.5 67.9 37.4 12.2 24.1 3.7 302 45-49 69.7 437 15.3 3.2 82.7 65.8 35.9 6.7 24.4 4.9 305 Marital status Ever married 69.7 3,209 18.3 2.9 85.5 69.8 40.6 9.5 20.9 3.6 2,236 Never married 74.1 1,238 16.3 1.7 84.1 68.9 41.3 10.1 24.2 3.1 917 Urban-rural residence Urban 78.3 2,037 23.3 2.7 86.2 73.1 41.2 10.3 22.4 3.6 1,595 Rural 64.7 2,410 12.0 2.4 83.9 65.9 40.4 9.0 21.3 3.3 1,559 Place of residence Urban Governorates 79.3 931 33.9 2.3 85.5 77.0 40.8 13.1 21.4 4.8 738 Lower Egypt 72.0 2,093 12.0 3.1 85.9 70.0 43.3 7.0 17.2 1.6 1,507 Urban 81.0 559 14.9 4.2 87.8 75.9 45.9 7.3 15.9 1.1 453 Rural 68.7 1,534 10.8 2.6 85.1 67.5 42.2 6.9 17.7 1.9 1,054 Upper Egypt 63.6 1,368 14.0 1.8 83.3 62.2 36.4 10.8 30.1 5.6 869 Urban 73.8 510 13.6 1.8 85.9 62.0 36.1 7.8 31.7 4.5 377 Rural 57.4 858 14.3 1.9 81.2 62.4 36.6 13.1 28.9 6.4 493 Frontier Governorates 71.4 55 14.4 0.5 82.6 71.8 41.8 20.3 25.3 3.3 39 Education No education 54.2 945 13.8 1.1 79.6 60.3 35.4 11.4 22.9 6.1 512 Some primary 54.9 285 12.6 1.7 82.3 62.5 32.2 7.8 21.4 4.7 157 Primary complete/ some secondary 68.6 979 14.9 2.5 81.5 69.2 38.6 8.3 23.2 3.5 671 Secondary complete/higher 81.1 2,237 20.3 3.0 88.2 72.8 43.8 9.8 21.1 2.6 1,814 Work status Working for cash 81.2 781 21.9 4.1 86.8 73.9 44.7 11.6 24.4 4.1 634 Not working for cash 68.7 3,666 16.7 2.1 84.6 68.4 39.8 9.2 21.2 3.3 2,520 Wealth quintile Lowest 56.8 605 10.8 1.1 82.0 63.1 35.5 11.6 26.8 7.5 344 Second 62.9 839 10.4 1.3 82.2 62.1 37.0 10.6 21.1 2.1 528 Middle 65.2 881 14.7 1.9 84.7 68.4 40.5 9.3 20.1 3.4 575 Fourth 75.6 983 20.3 3.0 86.9 75.3 39.9 9.6 20.6 3.3 743 Highest 84.6 1,139 24.0 3.8 86.5 72.1 45.6 8.8 22.5 3.0 964 Total 15-59 70.9 4,447 17.7 2.5 85.1 69.5 40.8 9.7 21.9 3.5 3,154 Age 50-59 64.3 579 19.9 3.8 85.6 61.1 36.2 7.4 19.0 3.4 371 Total 15-59 70.2 5,026 18.0 2.7 85.1 68.6 40.3 9.4 21.6 3.5 3,526 Knowledge and Prevalence of Hepatitis C | 245 Table 18.2.2 Knowledge of the ways a person can contract hepatitis C by background characteristics: Men Percentage of men age 15-49 knowing about hepatitis C who can name at least one way in which an individual can contract hepatitis C and percentage of men knowing about a way hepatitis C can be contracted who named various routes of transmission, according to selected background characteristics, and percentage of men age 50-59 and of men age 15-59 knowing about the ways a person can contract hepatitis C, Egypt 2008 Percentage naming various routes of transmission Background characteristic Percentage of men knowing about hepatitis C who can name at least one way the illness can be contracted Number of men knowing about hepatitis C Hetero- sexual relations Homo- sexual relations Blood trans- fusions Unclean needle Other contact with blood of infected person Mother- to-child trans- mission Other casual physical contact with infected person Mosquito/ other insect bites/other Number of men who know one way hepatitis C can be contracted Age 15-19 74.5 812 15.3 1.5 74.8 68.1 54.8 8.3 19.6 1.0 604 20-24 76.4 748 16.8 2.8 79.7 72.1 53.5 6.3 14.8 1.4 571 25-29 80.2 655 16.3 1.4 83.8 73.3 53.5 6.5 16.3 2.7 525 30-34 79.8 565 17.8 3.2 84.8 71.6 47.3 6.8 13.4 0.8 451 35-39 83.8 476 17.8 4.8 82.7 66.7 55.2 10.0 15.1 1.7 399 40-44 81.6 526 15.8 2.3 81.2 71.0 55.8 8.3 16.4 4.4 429 45-49 77.6 437 16.3 2.0 82.2 72.8 56.5 5.5 15.4 1.6 339 Marital status Ever married 79.7 2,338 16.1 2.7 83.0 70.5 53.9 7.2 15.5 2.3 1,864 Never married 77.4 1,881 17.0 2.2 78.4 71.1 53.4 7.6 16.7 1.4 1,455 Urban-rural residence Urban 84.7 1,896 21.3 3.4 81.5 74.7 54.0 8.8 15.2 1.7 1,607 Rural 73.7 2,322 12.1 1.6 80.5 67.1 53.4 6.0 16.8 2.1 1,712 Place of residence Urban Governorates 84.3 840 29.4 4.4 80.7 75.0 47.2 8.8 13.5 2.1 708 Lower Egypt 79.3 1,958 12.7 1.7 81.2 70.2 56.8 8.4 14.8 1.8 1,552 Urban 86.5 515 13.5 1.9 81.5 78.3 60.8 11.2 12.6 1.5 445 Rural 76.7 1,443 12.4 1.6 81.1 67.0 55.2 7.2 15.7 1.9 1,107 Upper Egypt 73.7 1,354 13.2 2.3 81.3 68.4 52.9 4.5 19.0 1.8 999 Urban 82.9 494 15.8 3.1 83.6 70.0 57.4 5.7 19.8 0.9 409 Rural 68.5 861 11.3 1.8 79.7 67.3 49.9 3.6 18.5 2.4 590 Frontier Governorates 90.6 66 17.7 3.3 72.2 76.0 62.7 13.4 26.9 4.6 60 Education No education 66.4 321 14.3 0.4 75.9 61.9 44.6 8.1 17.2 3.3 214 Some primary 65.9 356 16.1 2.2 75.2 61.0 44.1 6.7 16.3 2.4 234 Primary complete/ some secondary 73.6 1,121 15.4 2.9 74.0 66.4 51.1 7.9 16.9 2.0 825 Secondary complete/ higher 84.5 2,420 17.2 2.6 85.0 74.6 56.8 7.2 15.5 1.6 2,046 Work status Working for cash 78.6 3,201 17.0 2.6 81.9 70.1 52.7 7.3 15.6 1.9 2,516 Not working for cash 79.0 1,017 15.0 2.1 78.2 72.8 56.7 7.6 17.5 1.8 804 Wealth quintile Lowest 64.3 618 9.2 1.4 78.9 70.3 49.1 4.3 17.4 2.3 397 Second 73.7 834 12.7 1.9 79.2 63.1 51.7 5.5 15.8 2.2 615 Middle 76.8 885 16.5 2.1 78.4 71.3 51.7 5.3 14.3 2.0 680 Fourth 85.1 891 19.7 2.0 81.4 71.8 53.3 11.1 14.6 2.3 758 Highest 87.8 990 19.8 4.1 84.8 75.1 59.1 8.5 18.2 1.0 869 Total 15-59 78.7 4,218 16.5 2.5 81.0 70.8 53.7 7.4 16.0 1.9 3,319 Age 50-59 78.4 665 20.4 3.7 77.4 70.9 53.8 7.2 22.1 2.6 522 Total 15-59 78.6 4,884 17.0 2.6 80.5 70.8 53.7 7.4 16.8 2.0 3,841 246 | Knowledge and Prevalence of Hepatitis C The results in Tables 18.1.1, 18.1.2, 18.2.1 and 18.2.2 indicate that, among both women and men, the level of awareness of hepatitis C and knowledge about ways in which hepatitis C can be transmitted were more widespread in urban than in rural areas. The percentages knowing about at least one way hepatitis C can be contracted also increased with education and wealth. 18.2 SELF-REPORTED PREVALENCE OF HEPATITIS C AND LIVER DISEASE In addition to collecting information on the level of knowledge of hepatitis C, respon- dents were asked in the special health issues component of the 2008 EDHS if they them- selves had ever been tested and diagnosed with hepatitis C, if they had symptoms of or been diagnosed with liver disease, and if any other household members had ever had liver disease. The results presented in Table 18.3 indicate that relatively few respondents had ever been tested for the hepatitis C virus (2 percent of women and 6 percent of men). One percent of women and 2 percent of men reported having had a positive hepatitis C test result, with around half of those who tested positive saying that they received treatment. The results in Table 18.3 also show that only very small proportions of respondents had ever had jaundice (2 percent of women and 1 percent of men) or dark urine (4 percent for both women and men), which are symptoms of liver disease. The proportion of women and men who reported they had ever been diag- nosed as having liver disease also was small (1 percent each) and most of those respondents said they were currently suffering from the disease. With respect to other household mem- bers, 4 percent of women and 3 percent of men reported that other household members had liver disease. Table 18.3 Self-reported prevalence of hepatitis infection, symptoms of liver disease, and liver disease Percent distribution of population age 15-59 by whether or not they were ever tested for the hepatitis C virus, they had a positive hepatitis C test, they had a positive test and were treated for hepatitis C, they had ever had jaundice or dark urine, they were ever told they had liver disease, or they reported another household member had had liver disease, by sex, Egypt 2008 Women Men Total Ever tested for hepatitis C virus Yes 2.0 5.9 3.8 No 77.9 79.6 78.7 Never heard about hepatitis C 20.1 14.6 17.5 Missing 0.0 0.0 0.0 Ever had positive hepatitis C test according to doctor or health professional Tested, yes 0.8 2.0 1.4 Tested, no 1.2 3.9 2.5 Not tested 77.9 79.6 78.7 Never heard about hepatitis C 20.1 14.6 17.5 Missing 0.0 0.0 0.0 Treated for hepatitis C after test Positive test and treated 0.4 1.0 0.7 Negative test/not tested 79.1 83.5 81.2 Never heard about hepatitis C 20.1 14.6 17.5 Missing 0.4 0.9 0.7 Ever had jaundice Yes 2.0 1.4 1.7 No 96.4 97.7 97.0 Don't know 1.6 0.8 1.2 Missing 0.0 0.0 0.0 Ever had dark urine Yes 3.9 4.2 4.1 No 94.0 94.8 94.4 Don't know 2.1 1.0 1.6 Missing 0.0 0.0 0.0 Respondent ever had any liver disease Yes 0.9 1.0 1.0 No 99.0 99.0 99.0 Missing 0.0 0.0 0.0 Currently have liver disease Yes 0.7 0.8 0.7 No 0.2 0.2 0.2 Never had liver disease 99.1 99.0 99.0 Other household members had liver disease Yes 3.7 2.5 3.1 No 96.3 97.5 96.9 Missing 0.0 0.0 0.0 Total percent 100.0 100.0 100.0 Number age 15-59 6,290 5,718 12,008 Knowledge and Prevalence of Hepatitis C | 247 18.3 HEPATITIS C TESTING IN THE 2008 EDHS In addition to responding to questions about hepatitis C, women and men age 15-59 years living in the subsample of households selected for the health issues survey were asked to provide blood samples for hepatitis C testing. A specially trained team of three individuals including at least one physician and one laboratory technician were responsible for obtaining the venous blood samples from the eligible respondents. The following describes the hepatitis C testing protocol in more detail and presents information on the coverage of the testing among eligible women and men. 18.3.1 Hepatitis C Testing Protocol The hepatitis C testing component of the EDHS involved the collection of venous blood samples for later testing in the Central Laboratory of the Ministry of Health. A blood specimen was collected only after informed consent to the hepatitis C testing was obtained from each respondent and, in the case of an unmarried minor age 15-17, from a parent or other guardian. Additionally, any individual providing a blood sample was asked to consent to anonymous storage of their serum sample for unspecified testing that might be undertaken after the survey was completed. Respondents were told during the consent process that, if they tested positive for the HCV virus, they would be given a referral to for additional screening and counseling at a special Liver Treatment Center. They also were advised during the consent process that, because the hepatitis C testing would be conducted at the Central Laboratory in Cairo, the result of the testing would not be returned to them for around three months. Permission also was requested from each respondent to leave the hepatitis C test result in a sealed envelope with another household member if the respondent was not at home at the time the call back visits were made to return the test results. At the time of the survey, all respondents, whether or not they consented to the testing, were given an informational brochure about the hepatitis C virus. The protocol for the hepatitis C testing was approved by the Scientific and Research Ethics Committee of the Ministry of Health and the Institutional Review Board at Macro International. If an EDHS respondent consented to the testing, the laboratory technician drew approximately 7 ml of venous blood in an EDTA vacutainer tube. The blood tube was labeled with a preprinted bar-coded identification number; labels with the same bar code ID were also pasted on the Household Questionnaire and on the form used by EDHS biomarker staff to track the collection of specimens from eligible respondents. Before starting work in a given area, each EDHS biomarker team established a temporary field laboratory. The tubes of blood collected during the fieldwork each day were stored in cool boxes prior to their transfer to the temporary field laboratory. In the field laboratory, the EDHS biomarker staff centrifuged the blood and transferred the serum to three microvials, labeled with the same bar code identification as the original vacutainer tube. The microvials containing the serum were stored in liquid nitrogen tanks. Samples were collected twice weekly or oftener and transferred in coolers on dry ice to the Central Health Laboratory in Cairo. The hepatitis C testing protocol at the Central Laboratory included an initial round of testing to detect the presence of antibodies to the hepatitis C virus. The presence of antibodies indicated that the individual had been exposed to the hepatitis C virus at some point. A third generation Enzyme Immunoassay (ELISA), Adlatis EIAgen HCV Ab test was used for the determination of antibodies to Hepatitis C Virus (anti-HCV). A more specific assay, Chemiluminescent Microplate Immunoassay (CIA) was used to test for antibodies to HCV for all positive samples and approximately 5 percent of the negative samples from the first ELISA screening test. Any discordant samples after the initial screening were retested with ELISA and CIA. Samples that were found to be positive on both ELISA and CIA tests, or that remained discordant after retesting, were further tested to identify individuals with active (current) hepatitis infection. Quantitative Real Time PCR was used at the Central Laboratory for the detection of HCV RNA, which is indicative of active (current) infection. 248 | Knowledge and Prevalence of Hepatitis C As a quality control measure, the ELISA screening was repeated at the Theodor Bilharz Institute (TBRI) for five percent of all samples. In addition, all samples that were found to be negative and 5 percent of the samples that were found to be positive during the PCR testing at the Central Laboratory were retested at TBRI using the Abbott m2000 system. Primarily due to the greater sensitivity of the equipment at TBRI, some of the samples that were negative on the PCR test at the Central Laboratory were found to be positive at TBRI. Some additional retesting was carried out on a subsample of the samples for which the results at the Central Laboratory and TBRI were discordant. Based on the results of this further retesting, it was decided to accept the TBRI result for all of the discordant samples. 18.3.2 Coverage of the HCV Testing Tables 18.4 and 18.5 provide information on the coverage of the HCV testing among women and men. Among the de facto population of women and men age 15-59 who were eligible for the testing, 88 percent provided a venous sample that was subsequently tested in the Central Laboratory. Six percent refused to provide a sample, and 5 percent were not home at the time of the EDHS survey or any of the subsequent call back visits.1 Specimens from the remaining respondents (1 percent) either could not be collected or tested for various reasons (e.g., inadequate volume of blood, etc.). Women were more likely to have provided a sample for testing than men (91 percent and 84 percent, respectively). Virtually all of the difference between the coverage rates for women and men was due to the higher proportion of men absent from the household at the time of the EDHS survey. Looking at the variation in coverage rates by age, Table 18.4 shows that respondents age 20-24 were least likely and those age 55-59 were most likely to agree to the testing (85 percent and 91 percent, respectively). The results in Table 18.5, which presents the HCV coverage by background characteristics, indicate that coverage was higher in rural areas (92 percent) than in urban areas (81 percent). By place of residence, the proportion with a sample tested was highest in rural Lower Egypt (93 percent) followed closely by rural Upper Egypt (92 percent) and lowest in the Urban Governorates (77 percent) and the Frontier Governorates (79 percent). The proportion of the eligible population from which a sample was obtained and tested decreased from 92 percent among respondents who had never attended school to 85 percent among respondents who had completed the secondary level or higher. Coverage also decreased with the wealth quintile, from 91 percent in the lowest quintile to 78 percent in the highest quintile. 1 Typically, at least three call-back visits were made. Knowledge and Prevalence of Hepatitis C | 249 Table 18.4 Coverage of hepatitis C testing among the de facto population age 15-59 years by age Percent distribution of de facto population age 15-59 years eligible for hepatitis C testing by testing status, according to age (unweighted), Egypt 2008 Testing status Age Sample tested1 Refused to provide blood Absent at time of blood collection Other/ missing2 Total percent Number WOMEN 15-19 91.0 5.5 2.5 1.0 100.0 1,140 20-24 88.9 6.7 3.5 0.9 100.0 1,223 25-29 91.0 6.7 1.6 0.7 100.0 951 30-34 92.2 6.3 0.5 0.9 100.0 748 35-39 92.3 6.7 0.6 0.4 100.0 703 40-44 90.6 7.7 1.2 0.5 100.0 607 45-49 90.7 6.6 1.4 1.3 100.0 560 50-54 87.6 9.2 1.7 1.5 100.0 412 55-59 90.8 7.3 1.4 0.6 100.0 358 Total 90.6 6.7 1.8 0.9 100.0 6,702 MEN 15-19 85.4 5.8 7.8 1.0 100.0 1,161 20-24 80.2 6.1 13.3 0.4 100.0 955 25-29 82.7 4.2 12.6 0.5 100.0 791 30-34 83.9 5.8 9.4 0.9 100.0 669 35-39 83.8 5.4 10.2 0.5 100.0 588 40-44 87.0 5.0 7.2 0.8 100.0 600 45-49 83.6 8.4 7.4 0.6 100.0 513 50-54 84.1 6.5 7.8 1.6 100.0 434 55-59 90.5 4.6 4.9 0.0 100.0 367 Total 84.1 5.7 9.4 0.7 100.0 6,078 TOTAL 15-19 88.1 5.6 5.2 1.0 100.0 2,301 20-24 85.1 6.4 7.8 0.7 100.0 2,178 25-29 87.2 5.6 6.6 0.6 100.0 1,742 30-34 88.3 6.1 4.7 0.9 100.0 1,417 35-39 88.5 6.1 5.0 0.5 100.0 1,291 40-44 88.8 6.4 4.1 0.7 100.0 1,207 45-49 87.3 7.5 4.3 0.9 100.0 1,073 50-54 85.8 7.8 4.8 1.5 100.0 846 55-59 90.6 5.9 3.2 0.3 100.0 725 Total 87.5 6.2 5.4 0.8 100.0 12,780 1 Includes all serum samples undergoing testing at the laboratory and for which there is a final result for both the antibody and PCR RNA testing, i.e., positive, negative, or indeterminate. Indeterminate means that the sample went through testing, but the final result was incon- clusive. 2 Includes: 1) other results of blood collection (e.g., technical problem in the field), 2) lost specimens, 3) non-corresponding bar codes, 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. and 5) persons for whom a final result of the testing is missing 250 | Knowledge and Prevalence of Hepatitis C Table 18.5 Coverage of hepatitis C testing among the de facto population age 15-59 years by selected background characteristics Percent distribution of de facto population age 15-59 years eligible for hepatitis C testing by testing status, according to selected background characteristics (unweighted), Egypt 2008 Testing status Background characteristic Sample tested1 Refused to provide blood Absent at time of blood collection Other/ missing2 Total percent Number WOMEN Urban-rural residence Urban 84.7 11.1 3.0 1.2 100.0 2,827 Rural 94.9 3.5 1.0 0.6 100.0 3,875 Place of residence Urban Governorates 82.2 12.2 3.9 1.7 100.0 1,079 Lower Egypt 93.4 5.0 1.0 0.7 100.0 2,486 Urban 88.8 8.4 1.6 1.2 100.0 668 Rural 95.0 3.7 0.7 0.5 100.0 1,818 Upper Egypt 92.5 5.4 1.3 0.8 100.0 2,749 Urban 86.4 11.0 1.8 0.8 100.0 829 Rural 95.2 3.0 1.1 0.7 100.0 1,920 Frontier Governorates 82.7 11.9 5.2 0.3 100.0 388 Education No education 93.7 4.1 1.2 1.0 100.0 2,062 Some primary 94.3 3.7 0.9 1.1 100.0 563 Primary complete/some secondary 91.1 6.5 1.6 0.7 100.0 1,399 Secondary complete/higher 87.1 9.5 2.6 0.7 100.0 2,675 Missing * * * * 100.0 3 Wealth quintile Lowest 95.0 3.3 0.9 0.8 100.0 1,323 Second 93.8 3.5 1.9 0.8 100.0 1,441 Middle 93.4 4.9 1.1 0.7 100.0 1,326 Fourth 90.4 6.8 2.1 0.7 100.0 1,213 Highest 80.7 15.0 3.1 1.1 100.0 1,399 Total 90.6 6.7 1.8 0.9 100.0 6,702 MEN Urban-rural residence Urban 77.7 10.0 11.4 0.9 100.0 2,660 Rural 89.1 2.3 8.0 0.6 100.0 3,418 Place of residence Urban Governorates 71.6 13.5 13.8 1.1 100.0 979 Lower Egypt 88.7 3.1 7.8 0.4 100.0 2,259 Urban 84.5 5.8 9.2 0.5 100.0 608 Rural 90.2 2.1 7.3 0.4 100.0 1,651 Upper Egypt 86.4 4.2 8.5 0.9 100.0 2,433 Urban 80.9 8.6 9.4 1.1 100.0 795 Rural 89.0 2.1 8.1 0.9 100.0 1,638 Frontier Governorates 75.7 10.8 13.5 0.0 100.0 407 Education No education 86.2 3.8 8.7 1.4 100.0 852 Some primary 86.0 3.9 9.3 0.7 100.0 557 Primary complete/ some secondary 84.9 5.2 9.2 0.7 100.0 1,604 Secondary complete/higher 82.8 6.8 9.8 0.6 100.0 3,063 Missing * * * * 100.0 2 Wealth quintile Lowest 86.4 2.8 9.7 1.1 100.0 1,155 Second 87.5 2.2 9.8 0.5 100.0 1,293 Middle 89.3 3.8 6.5 0.4 100.0 1,236 Fourth 82.1 6.7 10.4 0.8 100.0 1,125 Highest 75.3 13.0 10.9 0.9 100.0 1,269 Total 84.1 5.7 9.4 0.7 100.0 6,078 Continued… Knowledge and Prevalence of Hepatitis C | 251 Table 18.5—Continued Testing status Background characteristic Sample tested1 Refused to provide blood Absent at time of blood collection Other/ missing2 Total percent Number TOTAL Urban-rural residence Urban 81.3 10.6 7.0 1.0 100.0 5,487 Rural 92.2 3.0 4.3 0.6 100.0 7,293 Place of residence Urban Governorates 77.2 12.8 8.6 1.4 100.0 2,058 Lower Egypt 91.1 4.1 4.2 0.6 100.0 4,745 Urban 86.8 7.1 5.3 0.9 100.0 1,276 Rural 92.7 2.9 3.9 0.5 100.0 3,469 Upper Egypt 89.6 4.8 4.7 0.8 100.0 5,182 Urban 83.7 9.8 5.5 1.0 100.0 1,624 Rural 92.3 2.6 4.3 0.8 100.0 3,558 Frontier Governorates 79.1 11.3 9.4 0.1 100.0 795 Education No education 91.5 4.0 3.4 1.1 100.0 2,914 Some primary 90.2 3.8 5.1 0.9 100.0 1,120 Primary complete/Some secondary 87.8 5.8 5.7 0.7 100.0 3,003 Secondary complete/Higher 84.8 8.1 6.4 0.6 100.0 5,738 Missing * * * * 100.0 5 Wealth quintile Lowest 91.0 3.0 5.0 1.0 100.0 2,478 Second 90.8 2.9 5.6 0.7 100.0 2,734 Middle 91.4 4.4 3.7 0.5 100.0 2,562 Fourth 86.4 6.7 6.1 0.8 100.0 2,338 Highest 78.1 14.1 6.8 1.0 100.0 2,668 Total 87.5 6.2 5.4 0.8 100.0 12,780 Note: An asterisk indicates that a figure is based on fewer than unweighted 25 cases and has been suppressed. 1 Includes all serum samples undergoing testing at the laboratory and for which there is a final result for both the antibody and PCR RNA testing, i.e., positive, negative, or indeterminate. Indeterminate means that the sample went through testing, but the final result was inconclusive. 2 Includes: 1) other results of blood collection (e.g., technical problem in the field), 2) lost specimens, 3) non-corresponding bar codes, 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. and 5) persons for whom a final result of the testing is missing 18.3.3 Return of the Results of the HCV Testing After the testing of the blood samples was completed, a special field exercise was undertaken to return the test results to all respondents who had provided blood samples. Results were returned to all but 12 respondents. At the time that results were returned, respondents who were found to be positive on either the antibody and/or the RNA tests were referred to special national Liver Centers or other health facilities for further screening and counseling. 18.4 PREVALENCE OF HEPATITIS C Tables 18.6, 18.7, and 18.8 present the results of the testing of the blood samples collected from EDHS respondents for antibodies for the hepatitis C virus (HCV-antibody test). The tables also show the results of the PCR testing undertaken to detect the presence of HCV RNA in the sample. As discussed above, the HCV antibody test does not provide information on whether the infection is current (active) or chronic but simply indicates the proportion who had been exposed to the HCV virus at some point prior to the EDHS survey. The HCV-RNA test identifies those respondents with an active HCV infection. However, the HCV-RNA test is subject to some error since it cannot detect the virus in individuals who 252 | Knowledge and Prevalence of Hepatitis C have been recently infected (i.e., within 1-2 weeks of the survey interview) or individuals for whom the viral load has fallen below the detection limits for the test. Table 18.6 shows that, overall, 15 percent of the EDHS respondents age 15-59 had antibodies to the HCV virus in their blood, indicating that they had been exposed to the virus at some point. Ten percent were found to have an active infection. Men were more likely to be infected than women and, the levels of infection increased sharply with age among both women and men (Figure 18.1). The much higher levels of infection among the older cohorts may be partially explained by their exposure to the schistosomiasis treatment programs during the 1960s-1980s which, as noted above, are believed to have been a major transmission route. Table 18.6 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by age Percentage of de facto population age 15-59 years provided venous blood samples for HCV testing for whom results were positive on the antibody and the RNA tests by age and sex, Egypt 2008 Age Percentage HCV antibody positive Percentage positive on HCV RNA test Number tested WOMEN 15-19 2.7 1.9 996 20-24 5.4 2.9 1,009 25-29 4.6 3.0 844 30-34 10.2 6.4 637 35-39 13.2 9.3 634 40-44 21.3 12.8 520 45-49 23.6 15.4 506 50-54 26.9 16.9 355 55-59 35.1 24.1 327 Total 12.2 7.8 5,828 MEN 15-19 5.6 3.7 1,000 20-24 4.3 3.2 795 25-29 8.0 4.9 691 30-34 13.4 10.3 594 35-39 14.4 10.7 499 40-44 24.6 17.0 541 45-49 34.4 23.0 442 50-54 49.0 33.2 379 55-59 43.5 30.5 357 Total 17.4 12.1 5,298 TOTAL 15-19 4.1 2.8 1,995 20-24 4.9 3.0 1,804 25-29 6.1 3.9 1,535 30-34 11.8 8.3 1,232 35-39 13.8 9.9 1,133 40-44 23.0 15.0 1,061 45-49 28.6 18.9 948 50-54 38.3 25.3 734 55-59 39.4 27.4 684 Total 14.7 9.8 11,126 Note: The HCV-antibody test identifies respondents exposed to the HCV virus at some point in time prior to the EDHS survey. The HCV-RNA test identifies those respondents with an active HCV infection. Knowledge and Prevalence of Hepatitis C | 253 Table 18.7 provides additional information on the variation in the prevalence of HCV infection with socioeconomic characteristics. The table shows that HCV infection was higher among rural than urban residents (12 percent compared with 7 percent). Considering the variation by place of residence, the prevalence of HCV infection was highest in rural Lower and rural Upper Egypt (12 percent and 11 per- cent, respectively), while it was lowest in the Frontier Governorates and the Urban Governorates (3 percent and 6 percent, respectively). Individuals with no or less than primary education (17 and 13 percent, respectively) were markedly more likely to be infected with the HCV virus than the more educated population (7-8 percent). The likelihood of HCV infection also decreased with the wealth quintile from 12 percent among respondents in the lowest wealth quintile to 7 percent among respondents in the highest wealth quintile. + + + + + + + + + ) ) ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 0 10 20 30 40 Women Men) + EDHS 2008 Figure 18.1 Percentage of Women and Men Positive on the RNA Test for the Hepatitis C Virus by Age 4 3 5 10 11 17 23 33 31 24 17 15 13 9 6 332 254 | Knowledge and Prevalence of Hepatitis C Table 18.7 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by socioeconomic characteristics Percentage of de facto population age 15-59 years provided venous blood samples for HCV testing for whom results were positive on the antibody and the RNA tests by socioeconomic characteristics according to sex, Egypt 2008 Socioeconomic characteristic Percentage HCV antibody positive Percentage positive on HCV RNA test Number tested WOMEN Urban-rural residence Urban 8.0 5.5 2,476 Rural 15.2 9.6 3,353 Place of residence Urban Governorates 7.6 5.1 1,182 Lower Egypt 15.0 8.9 2,530 Urban 10.0 6.7 611 Rural 16.5 9.7 1,919 Upper Egypt 11.7 8.3 2,034 Urban 7.3 5.4 631 Rural 13.7 9.6 1,403 Frontier Governorates 2.5 1.8 82 Education No education 21.7 14.5 1,782 Some primary 16.1 10.1 498 Primary complete/some secondary 7.1 4.3 1,264 Secondary complete/higher 6.7 4.1 2,284 Work status Working for cash 13.7 9.1 870 Not working for cash 11.9 7.6 4,959 Wealth quintile Lowest 15.8 10.1 1,043 Second 15.7 10.5 1,209 Middle 13.8 8.6 1,171 Fourth 9.5 6.1 1,220 Highest 6.6 4.3 1,185 Total 12.2 7.8 5,828 MEN Urban-rural residence Urban 12.7 9.0 2,323 Rural 21.1 14.4 2,974 Place of residence Urban Governorates 11.5 7.4 1,084 Lower Egypt 20.3 14.3 2,299 Urban 13.7 11.1 560 Rural 22.4 15.3 1,739 Upper Egypt 17.9 12.4 1,828 Urban 14.6 10.3 619 Rural 19.6 13.5 1,209 Frontier Governorates 5.0 4.7 87 Education No education 30.0 21.6 676 Some primary 24.3 15.2 532 Primary complete/some secondary 15.3 10.6 1,480 Secondary complete/higher 13.9 9.7 2,610 Work status Working for cash 19.9 13.8 4,070 Not working for cash 9.0 6.2 1,228 Wealth quintile Lowest 21.9 15.1 892 Second 18.7 12.4 1,098 Middle 19.0 13.2 1,143 Fourth 13.9 10.2 1,085 Highest 14.2 9.9 1,079 Total 17.4 12.1 5,298 Continued… Knowledge and Prevalence of Hepatitis C | 255 Table 18.7—Continued Socioeconomic characteristic Percentage HCV antibody positive Percentage positive on HCV RNA test Number tested TOTAL Urban-rural residence Urban 10.3 7.2 4,799 Rural 18.0 11.9 6,327 Place of residence Urban Governorates 9.5 6.2 2,266 Lower Egypt 17.5 11.5 4,829 Urban 11.8 8.8 1,171 Rural 19.3 12.3 3,658 Upper Egypt 14.7 10.2 3,862 Urban 10.9 7.8 1,250 Rural 16.4 11.4 2,612 Frontier Governorates 3.8 3.3 169 Education No education 24.0 16.5 2,458 Some primary 20.4 12.7 1,030 Primary complete/some secondary 11.5 7.7 2,744 Secondary complete/higher 10.5 7.1 4,893 Work status Working for cash 18.8 13.0 4,939 Not working for cash 11.3 7.3 6,187 Wealth quintile Lowest 18.6 12.4 1,935 Second 17.1 11.4 2,308 Middle 16.4 10.9 2,314 Fourth 11.6 8.0 2,305 Highest 10.2 6.9 2,264 Total 14.7 9.8 11,126 Note: The HCV-antibody test identifies respondents exposed to the HCV virus at some point in time prior to the EDHS survey. The HCV-RNA test identifies those respondents with an active HCV infection. Table 18.8 looks at the variation in the prevalence of HCV infection according to respondent’s lifetime exposure to various medical procedures that can increase the risk of exposure to bloodborne pathogens. The table shows the HCV infection rate were higher among individuals who reported that they had had surgery a blood transfusion, dental treatment or injections. Figure 18.2 shows that active infection rates were particularly high among individuals who reported receipt of at least one injection to treat schistosomiasis compared to those who had not received such an injection. Some caution must be used in interpreting these results since other factors that are associated with increased risk are not controlled for in looking at the relationship between the HCV infection and the various procedures. However, the results tend to support the assumption that improper infection control procedures during schistosomiasis treatment campaigns played an important role in the spread of hepatitis C infection in Egypt. 256 | Knowledge and Prevalence of Hepatitis C Table 18.8 Outcome of testing for hepatitis C virus (HCV) among the population age 15- 59 years by lifetime history of medical procedures and injections Percentage of de facto population age 15-59 years provided venous blood samples for HCV testing for whom results were positive on the antibody and the RNA tests by lifetime history of medical procedures and injections, according to sex, Egypt 2008 History of medical procedures and injections Percentage HCV antibody positive Percentage positive on HCV RNA test Number tested WOMEN Surgery Yes 13.6 9.2 2,878 No 10.8 6.4 2,942 Don't know/missing * * 9 Blood transfusion Yes 22.2 14.1 244 No 11.7 7.5 5,562 Don't know/missing (11.4) (11.4) 22 Dental treatment Yes 13.2 8.6 3,392 No 10.7 6.7 2,427 Don't know/missing * * 10 Injection to treat schistosomiasis Yes 25.3 16.7 300 No 11.2 7.2 5,428 Don't know/missing 23.9 15.4 100 Injection for any purpose other than treatment of schistosomiasis Yes 12.2 7.9 5,493 No 11.3 6.4 328 Don't know/missing * * 7 Injection in which needle and syringe reused Yes 15.3 7.3 217 No 12.2 8.1 5,122 Never had injection 10.6 5.5 298 Don't know/missing 10.3 6.3 191 Total 12.2 7.8 5,828 Continued… Knowledge and Prevalence of Hepatitis C | 257 Table 18.8—Continued Percentage of de facto population age 15-59 years provided venous blood samples for HCV testing for whom results were positive on the antibody and the RNA tests by lifetime history of medical procedures and injections, according to sex, Egypt 2008 History of medical procedures and injections Percentage HCV antibody positive Percentage positive on HCV RNA test Number tested MEN Surgery Yes 22.1 15.5 1,845 No 14.9 10.2 3,450 Don't know/missing * * 3 Blood transfusion Yes 26.7 18.2 214 No 17.0 11.8 5,076 Don't know/missing * * 8 Dental treatment Yes 20.1 14.0 3,331 No 12.9 8.8 1,965 Don't know/missing * * 2 Injection to treat schistosomiasis Yes 31.5 21.1 646 No 15.6 10.9 4,555 Don't know/missing 10.2 5.2 97 Injection for any purpose other than treatment of schistosomiasis Yes 17.9 12.4 4,880 No 11.9 7.8 416 Don't know/missing * * 2 Injection in which needle and syringe reused Yes 31.8 26.7 101 No 17.7 12.3 4,680 Never had injection 10.4 6.9 372 Don't know/missing 17.2 7.6 144 Total 17.4 12.1 5,298 TOTAL Surgery Yes 16.9 11.7 4,723 No 13.0 8.5 6,392 Don't know/missing * * 11 Blood transfusion Yes 24.3 16.0 458 No 14.3 9.6 10,639 Don't know/missing (11.2) (11.2) 29 Dental treatment Yes 16.6 11.3 6,723 No 11.7 7.6 4,392 Don't know/missing * * 11 Injection to treat schistosomiasis Yes 29.6 19.7 946 No 13.2 8.9 9,983 Don't know/missing 17.2 10.4 197 Injection for any purpose other than treatment of schistosomiasis Yes 14.9 10.0 10,373 No 11.6 7.2 744 Don't know/missing * * 9 Injection in which needle and syringe reused Yes 20.6 13.5 318 No 14.8 10.1 9,802 Never had injection 10.5 6.3 671 Don't know/missing 13.3 6.9 335 Total 14.7 9.8 11,126 Note: The HCV-antibody test identifies respondents exposed to the HCV virus at some point in time prior to the EDHS survey. The HCV-RNA test identifies those respondents with an active HCV infection. An asterisk indicates figure based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 258 | Knowledge and Prevalence of Hepatitis C Figure 18.2 Percentage of Women and Men Age 15-59 Positive on HVC-RNA Test by Receipt of Injection to Treat Schistomiasis 17 7 21 11 Received injection to treat schistosomiais Did not receive injection 0 5 10 15 20 25 Percent Women Men EDHS 2008 Knowledge and Attitudes about HIV/AIDS | 259 KNOWLEDGE AND ATTITUDES ABOUT HIV/AIDS 19 Acquired immunodeficiency syndrome (AIDS) is one of the most serious public health and development challenges facing the world today. The disease is caused by the human immunodeficiency virus (HIV). Although the HIV infection rate is low in Egypt, there is a need to educate Egyptians about AIDS. To assist in these efforts, the 2008 EDHS collected information to assess the prevalence of knowledge of modes of HIV transmission and prevention and attitudes towards persons living with AIDS. 19.1 KNOWLEDGE OF HIV/AIDS To obtain information on the extent of HIV/AIDS knowledge, women and men interviewed in the special health issues component of the 2008 EDHS were asked a general question about whether they had heard of the illness. Those who knew about HIV/AIDS were asked additional questions about modes of prevention including whether it is possible to reduce the chance of getting the AIDS virus by having just one faithful sexual partner, using a condom at every sexual encounter, and abstaining from sex. To get at possible misconceptions, respondents also were asked whether they think it is possible for a healthy- looking person to have the AIDS virus and whether a person can get AIDS from mosquito bites or sharing food with a person who has AIDS. The responses to these questions are used to assess the extent to which EDHS respondents had comprehensive knowledge of HIV/AIDS. Comprehensive knowledge of HIV/AIDS is defined as: 1) knowing that both condom use and limiting sex partners to one uninfected partner are HIV prevention methods, 2) being aware that a healthy-looking person can have HIV, and 3) rejecting the two common local misconceptions—that HIV/AIDS can be transmitted through mosquito bites and by sharing food. The results in Tables 19.1.1 and 19.1.2 show that 73 percent of women and 87 percent of men age 15-59 have heard about HIV/AIDS. Although many women and men had a basic knowledge of AIDS, the proportions aware of ways in which the risk of infection can be reduced were generally low. Both women and men were most likely to see limiting sex to one uninfected partner as a means of reducing the risk of transmission (58 percent and 73 percent, respectively). More than half of women and 40 percent of men were unaware that a healthy-looking person can have AIDS. Men were somewhat more likely than women to reject two common misconceptions about how the AIDS virus can be transmitted, i.e., through mosquito bites (62 percent and 48 percent, respectively) or sharing food with an infected person (62 percent and 48 percent, respectively). Overall, only 7 percent of women and 18 percent of men were classified as having comprehensive correct knowledge about AIDS. Tables 19.1.1 and 19.1.2 present differentials in the levels of the various AIDS knowledge indicators by background characteristics. There generally is greater variability in women’s than men’s awareness across the subgroups for which results are presented in the table. For example, AIDS awareness was markedly lower among rural than urban women (68 percent and 85 percent, respectively) while rural men were almost as likely as urban men to have heard about AIDS (88 percent and 90 percent, respectively). Looking at the variation by place of residence, AIDS awareness was lowest among both women and men in rural Upper Egypt than in other regions. The level of AIDS awareness rose with education and the wealth quintile among both women and men. 260 | Knowledge and Attitudes about HIV/AIDS Table 19.1.1 Knowledge of AIDS by background characteristics: Women Percentage of women age 15-49 who have heard of AIDS, percentage who responded to prompted questions by saying that people can reduce the risk of getting the AIDS virus by using condom, by having sex with just one uninfected, faithful partner, and by abstaining from sex, percentage who responded to prompted question by saying that a health-looking person can have the AIDS virus, percentage who know the AIDS virus cannot be transmitted by mosquito bites or sharing food with an infected person, and percentage with comprehensive knowledge about AIDS by background characteristics, and among women age 50-59 and all women age 15-59, percentage with knowledge of AIDS, Egypt 2008 Percentage who say people can reduce the risk of getting the AIDS virus by: Percentage who know the AIDS virus cannot be transmitted by: Background characteristic Percent- tage who have heard of AIDS Using a condom every time they have sex Limiting sex to one unin- fected partner Abstaining from sexual inter- course Using a condom and having one uninfected faithful partner Percent- tage who know a healthy- looking person can have AIDS Mosquito bites Sharing food with an infected person Percentage who reject two common mis- conceptions and know that a healthy- looking person can have the AIDS virus Percent- age with compre- hensive knowledge about AIDS1 Number of women Age 15-19 73.6 8.9 50.1 15.0 8.5 40.7 44.1 41.7 21.1 3.1 1,064 20-24 79.3 17.2 62.9 15.9 15.3 46.1 52.2 53.3 27.1 6.4 1,091 25-29 81.5 23.9 67.7 18.1 21.9 53.8 57.4 56.5 32.1 10.1 906 30-34 79.2 21.3 63.7 18.6 19.5 47.7 55.7 56.6 30.2 9.7 688 35-39 73.7 20.0 61.3 18.3 18.6 48.6 49.5 49.1 29.4 9.4 673 40-44 68.4 17.7 53.9 14.3 14.9 47.4 41.8 43.6 26.8 7.2 568 45-49 65.3 17.3 54.0 11.8 17.0 37.0 42.2 44.1 22.3 7.8 550 Marital status Ever married 74.6 19.6 60.3 15.9 17.7 46.0 49.3 49.3 26.8 7.9 3,983 Never married 77.3 12.7 56.7 16.6 12.1 46.1 50.3 50.2 27.3 5.9 1,556 Urban-rural residence Urban 85.3 23.4 70.4 18.0 21.9 56.6 61.4 65.5 38.2 12.0 2,352 Rural 68.0 13.4 51.1 14.8 11.8 38.2 40.8 37.9 18.7 4.0 3,188 Place of residence Urban Governorates 86.9 24.8 73.5 18.3 23.5 60.8 59.9 67.4 41.9 13.2 1,073 Lower Egypt 78.7 18.5 62.0 17.1 17.0 42.8 54.1 50.8 25.2 7.1 2,415 Urban 87.2 24.4 71.5 18.2 23.1 49.9 68.6 68.8 34.9 13.0 603 Rural 75.9 16.5 58.8 16.8 15.0 40.5 49.3 44.8 22.0 5.2 1,812 Upper Egypt 65.1 12.6 48.3 13.8 11.0 42.1 38.5 38.4 21.0 4.5 1,970 Urban 81.3 20.1 64.4 17.3 18.3 56.9 57.8 59.6 35.9 9.3 623 Rural 57.6 9.1 40.9 12.2 7.6 35.2 29.6 28.7 14.1 2.3 1,347 Frontier Governorates 72.3 19.2 59.5 13.5 15.3 42.4 44.2 48.6 24.8 6.3 82 Education No education 48.6 8.2 34.3 7.7 6.8 25.9 24.4 21.1 10.2 2.3 1,461 Some primary 63.9 9.1 46.0 13.1 7.7 33.4 30.0 33.0 14.4 3.0 394 Primary complete/ some secondary 77.2 13.7 55.9 15.5 12.5 44.1 48.0 45.8 24.0 5.0 1,248 Secondary complete/ higher 92.3 26.7 78.2 22.0 24.9 61.2 68.6 71.3 40.5 12.3 2,436 Work status Working for cash 84.9 26.8 70.6 20.5 25.4 58.5 63.8 67.7 41.0 13.7 866 Not working for cash 73.6 15.9 57.2 15.3 14.4 43.7 46.9 46.2 24.3 6.2 4,674 Wealth quintile Lowest 49.7 7.3 32.6 10.7 6.1 26.4 25.0 22.5 10.2 1.8 1,001 Second 65.4 11.4 48.5 12.4 10.2 33.2 37.4 33.5 16.1 4.5 1,123 Middle 74.8 17.2 58.7 19.3 15.0 44.2 47.0 43.8 22.8 5.7 1,099 Fourth 89.5 22.1 72.2 18.9 20.3 56.7 62.4 63.4 33.2 8.1 1,105 Highest 93.4 28.2 80.1 18.8 27.0 66.0 71.7 79.5 48.8 15.6 1,212 Total women age 15-49 75.4 17.6 59.3 16.1 16.1 46.0 49.6 49.6 26.9 7.4 5,540 Women age 50-59 58.2 13.1 44.3 12.7 11.5 35.8 33.8 34.4 18.6 5.2 751 Total women age 15-59 73.3 17.1 57.5 15.7 15.6 44.8 47.7 47.8 25.9 7.1 6,290 1 Comprehensive knowledge means knowing that use of condom and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions. Knowledge and Attitudes about HIV/AIDS | 261 Table 19.1.2 Knowledge of AIDS by background characteristics: Men Percentage of men age 15-49 who have heard of AIDS, percentage who responded to prompted questions by saying that people can reduce the risk of getting the AIDS virus by using condom, by having sex with just one uninfected, faithful partner, and by abstaining from sex, percentage who responded to prompted question by saying that a health-looking person can have the AIDS virus, percentage who know the AIDS virus cannot be transmitted by mosquito bites or sharing food with an infected person, and percentage with comprehensive knowledge about AIDS by background characteristics, and among men age 50-59 and all men age 15-59, percentage with knowledge of AIDS, Egypt 2008 Percentage who say people can reduce the risk of getting the AIDS virus by: Percentage who know the AIDS virus cannot be transmitted by: Background characteristic Percent- tage who have heard of AIDS Using a condom every time they have sex Limiting sex to one unin- fected partner Abstaining from sexual inter- course Using a condom and having one uninfected faithful partner Percent- tage who know a healthy- looking person can have AIDS Mosquito bites Sharing food with an infected person Percentage who reject two common mis- conceptions and know that a healthy- looking person can have the AIDS virus Percent- age with compre- hensive knowledge about AIDS1 Number of men Age 15-19 82.7 27.8 62.5 19.7 25.2 54.9 56.4 53.1 32.6 16.0 1,087 20-24 92.8 40.9 79.5 27.3 36.1 66.8 68.0 67.8 44.6 21.2 869 25-29 92.7 37.4 79.4 25.5 34.1 67.8 68.3 68.9 45.5 21.0 729 30-34 91.1 38.3 77.8 25.9 33.3 66.6 68.3 70.0 43.6 19.1 634 35-39 90.3 41.2 74.9 21.1 35.0 60.1 64.6 67.3 38.7 18.7 535 40-44 88.0 39.1 74.6 22.9 35.0 63.0 64.7 61.9 40.8 19.7 581 45-49 83.6 38.3 70.6 22.1 33.1 56.1 59.5 60.8 37.2 18.1 494 Marital status Ever married 88.4 38.7 74.8 23.5 34.1 61.6 64.4 64.5 40.3 19.4 2,640 Never married 88.8 34.4 72.1 23.4 30.7 62.5 63.4 62.5 39.9 18.5 2,290 Urban-rural residence Urban 89.8 38.4 75.3 23.2 34.1 71.3 68.6 69.2 48.3 22.3 2,170 Rural 87.6 35.4 72.2 23.7 31.3 54.8 60.2 59.1 33.7 16.4 2,760 Place of residence Urban Governorates 87.0 33.6 74.4 17.8 30.0 72.1 65.1 66.6 47.5 18.8 990 Lower Egypt 91.6 44.9 75.6 28.3 40.1 59.4 67.3 65.9 39.7 24.4 2,150 Urban 93.7 53.4 77.5 29.8 47.9 72.7 75.7 73.8 52.5 35.2 533 Rural 90.9 42.1 74.9 27.9 37.6 55.0 64.5 63.3 35.5 20.8 1,616 Upper Egypt 85.8 28.1 70.5 21.2 24.2 59.2 58.8 58.7 36.0 12.1 1,706 Urban 90.8 32.3 74.5 27.4 27.9 68.7 67.5 69.1 45.4 15.8 588 Rural 83.2 25.9 68.4 17.9 22.3 54.2 54.3 53.2 31.0 10.1 1,118 Frontier Governorates 85.6 39.2 73.8 11.5 35.4 68.6 67.1 66.7 47.6 23.2 84 Education No education 70.7 19.2 55.0 14.9 15.4 37.7 37.5 33.2 15.4 7.0 467 Some primary 75.6 29.2 59.9 22.0 23.4 45.4 40.2 42.7 19.1 6.1 458 Primary complete/ some secondary 83.9 31.8 65.2 21.0 28.0 56.1 56.7 52.7 31.1 14.5 1,414 Secondary complete/ higher 96.6 43.9 83.9 26.6 39.7 72.6 76.8 78.7 53.2 25.9 2,590 Work status Working for cash 89.0 38.3 75.1 24.2 33.7 63.3 63.8 64.1 40.5 19.3 3,685 Not working for cash 87.3 32.1 68.8 21.4 28.9 58.4 64.2 62.2 39.1 18.1 1,245 Wealth quintile Lowest 77.1 25.5 60.1 17.5 21.5 46.1 44.7 41.8 22.3 9.2 838 Second 86.2 35.7 70.7 24.0 30.7 53.8 57.3 54.7 31.1 16.1 1,010 Middle 88.2 35.8 73.2 24.7 31.7 55.2 64.0 63.9 35.3 15.8 1,036 Fourth 93.2 41.9 77.2 24.3 36.9 72.8 69.1 72.0 48.0 24.1 997 Highest 96.0 42.6 83.9 25.8 39.6 79.2 80.6 81.2 60.3 27.8 1,049 Total men age 15-49 88.6 36.7 73.5 23.5 32.5 62.0 63.9 63.6 40.1 19.0 4,930 Men age 50-59 79.8 30.9 66.0 19.2 28.4 54.7 50.3 51.1 30.6 12.6 788 Total men age 15-59 87.4 35.9 72.5 22.9 31.9 61.0 62.0 61.9 38.8 18.1 5,718 1 Comprehensive knowledge means knowing that use of condom and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions. 262 | Knowledge and Attitudes about HIV/AIDS Finally, one of the Millennium Development Goals is to combat HIV/AIDS, malaria and other diseases and one of the principal indicators for tracking progress to that goal is the extent to which youth and young adults age 15-24 in countries have comprehensive correct knowledge of AIDS (United Nations Development Group 2003). Table 19.2 shows that only around one in 20 young women and around one in five young men had such knowledge. The proportions of female and male youth and young adults with comprehensive correct AIDS knowledge was higher in urban than in rural areas (Figure 19.1). These proportions also rose with education and the wealth quintile. The highest level of AIDS knowledge was observed among male youth and young adults living in urban Lower Egypt (33 percent). Table 19.2 Comprehensive knowledge of AIDS among youth by background characteristics Percentage of all women and men age 15-24 with comprehensive knowledge about AIDS, by background characteristics, Egypt 2008 Background characteristic Percentage of women with comprehensive knowledge about AIDS1 Number of women Percentage of men with comprehensive knowledge about AIDS1 Number of men Age 15-19 3.1 1,064 16.0 1,087 20-24 6.4 1,091 21.2 869 Marital status Ever married 4.2 806 17.0 106 Never married 5.1 1,349 18.3 1,850 Urban-rural residence Urban 7.2 856 22.0 853 Rural 3.2 1,299 15.4 1,103 Place of residence Urban Governorates 8.2 386 22.4 404 Lower Egypt 5.1 916 22.5 795 Urban 8.5 192 32.7 178 Rural 4.3 724 19.6 617 Upper Egypt 2.8 824 11.2 724 Urban 4.7 260 13.3 248 Rural 1.9 565 10.1 476 Frontier Governorates 6.3 29 20.4 33 Education No education 1.4 285 11.2 87 Some primary 2.7 87 4.6 82 Primary complete/ some secondary 3.5 763 14.1 856 Secondary complete/higher 6.9 1,020 24.0 931 Work status Working for cash 7.2 187 18.4 848 Not working for cash 4.6 1,967 18.2 1,108 Wealth quintile Lowest 1.8 413 9.0 345 Second 3.1 481 15.7 444 Middle 5.0 419 14.4 416 Fourth 5.4 416 24.1 357 Highest 8.8 425 28.2 393 Total age 15-24 4.8 2,154 18.3 1,956 1 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 19.1.1 and 19.1.2. Knowledge and Attitudes about HIV/AIDS | 263 19.2 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION To assess the extent to which women and men were aware of the ways in which AIDS can be transmitted from a mother to her child, EDHS respondents were asked if the virus that causes AIDS can be transmitted during pregnancy, at delivery, or when breastfeeding. As Tables 19.3.1 and 19.3.2 show, 57 percent of women age 15-59 and 71 percent of men in the same age group knew the virus can be transmitted from mother to child during pregnancy, and half of women and 54 percent of the men were aware the virus can be transmitted during delivery. Both women and men were less likely to know that the HIV virus can be transmitted by breastfeeding (33 percent and 35 percent, respectively) than during pregnancy or at delivery. Differentials in the level of awareness of the modes of mother-to-child transmission are also shown in Tables 19.3.1 and 19.3.2. Knowledge of pregnancy, delivery and breastfeeding as potential modes of transmission for the HIV virus was higher among urban women and men than among their rural counterparts. Considering the differences by place of residence, awareness of these paths of transmission was lowest among women and men in rural Upper Egypt. Although the pattern is not totally uniform, the level of awareness of pregnancy, delivery and breastfeeding as modes of mother-to-child transmission also increased with educational attainment and the wealth quintile among both women and men. Figure 19.1 Percentage of Youth and Young Adults with Comprehensive AIDS Knowledge by Sex and Urban-Rural Residence 7 3 22 15 Urban Rural Urban Rural 0 5 10 15 20 25 Percent EDHS 2008 Women Age 15-24 Men Age 15-24 264 | Knowledge and Attitudes about HIV/AIDS Table 19.3.1 Knowledge of prevention of mother-to-child transmission (PMTCT) of HIV by background characteristics: Women Percentage of all women age 15-49 who know that HIV can be transmitted from mother to child during pregnancy, delivery or by breastfeeding, by background characteristics, and among women age 50-59 and all women age 15-59, percentage with knowledge of PMTCT, Egypt 2008 HIV can be transmitted from a mother to her baby during: Background characteristic Pregnancy Delivery Breastfeeding Number of women Age 15-19 51.4 41.7 29.9 1,064 20-24 62.9 51.5 35.4 1,091 25-29 66.7 57.2 37.9 906 30-34 63.6 54.3 34.5 688 35-39 61.2 51.0 36.5 673 40-44 50.2 45.4 29.8 568 45-49 48.7 45.7 30.1 550 Marital status Ever married 59.0 50.4 34.4 3,983 Never married 57.1 47.6 31.9 1,556 Urban-rural residence Urban 67.3 59.6 37.1 2,352 Rural 52.0 42.3 31.1 3,188 Place of residence Urban Governorates 66.2 63.7 43.7 1,073 Lower Egypt 61.0 48.6 32.9 2,415 Urban 70.7 56.0 33.1 603 Rural 57.8 46.2 32.8 1,812 Upper Egypt 51.4 43.3 29.1 1,970 Urban 66.7 56.8 29.6 623 Rural 44.3 37.0 28.8 1,347 Frontier Governorates 53.1 48.1 37.2 82 Education No education 34.2 29.9 24.7 1,461 Some primary 48.4 42.8 32.2 394 Primary complete/some secondary 56.4 47.6 34.2 1,248 Secondary complete/higher 75.8 63.6 39.0 2,436 Work status Working for cash 70.4 60.7 35.8 866 Not working for cash 56.3 47.6 33.3 4,674 Wealth quintile Lowest 37.5 30.9 25.6 1,001 Second 48.7 38.6 30.3 1,123 Middle 56.7 47.6 35.3 1,099 Fourth 69.8 60.7 39.3 1,105 Highest 76.2 67.0 37.0 1,212 Total women age 15-49 58.5 49.6 33.7 5,540 Women age 50-59 44.9 40.0 29.8 751 Total women age 15-59 56.9 48.5 33.2 6,290 Knowledge and Attitudes about HIV/AIDS | 265 Table 19.3.2 Knowledge of prevention of mother-to-child transmission (PMTCT) of HIV by background characteristics: Men Percentage of all men age 15-49 who know that HIV can be transmitted from mother to child during pregnancy, delivery or by breastfeeding, by background characteristics, and among men age 50-59 and all men age 15-59, percentage with knowledge of PMTCT, Egypt 2008 HIV can be transmitted from a mother to her baby during: Background characteristic Pregnancy Delivery Breastfeeding Number of men Age 15-19 58.8 43.0 29.6 1,087 20-24 75.3 57.8 38.2 869 25-29 79.4 61.7 35.3 729 30-34 75.5 57.4 36.3 634 35-39 77.0 58.1 37.9 535 40-44 71.8 56.1 33.8 581 45-49 68.6 54.3 37.5 494 Marital status Ever married 73.9 57.0 35.7 2,640 Never married 68.5 51.6 34.2 2,290 Urban-rural residence Urban 75.1 60.8 37.1 2,170 Rural 68.5 49.6 33.4 2,760 Place of residence Urban Governorates 73.8 64.5 44.5 990 Lower Egypt 74.5 52.8 33.5 2,150 Urban 79.6 57.1 30.7 533 Rural 72.8 51.3 34.4 1,616 Upper Egypt 66.2 51.0 31.6 1,706 Urban 73.3 58.5 30.8 588 Rural 62.4 47.0 32.0 1,118 Frontier Governorates 70.2 53.7 32.4 84 Education No education 52.5 37.0 29.9 467 Some primary 58.2 44.9 36.1 458 Primary complete/some secondary 61.9 46.8 33.5 1,414 Secondary complete/higher 82.3 63.6 36.6 2,590 Work status Working for cash 73.5 56.9 36.4 3,685 Not working for cash 65.3 47.6 31.0 1,245 Wealth quintile Lowest 55.8 41.6 31.2 838 Second 65.7 47.0 32.6 1,010 Middle 71.2 53.4 35.6 1,036 Fourth 78.2 59.4 37.1 997 Highest 83.1 68.4 37.9 1,049 Total men age 15-49 71.4 54.5 35.0 4,930 Men age 50-59 67.4 51.1 35.8 788 Total men age 15-59 70.8 54.0 35.1 5,718 19.3 ACCEPTING ATTITUDES TOWARDS PEOPLE LIVING WITH AIDS In the 2008 EDHS, women and men age 15-59 who had heard of AIDS were asked questions to assess the extent of stigma associated with HIV/AIDS. The results shown in Tables 19.4.1 and 19.4.2 indicate that relatively few women and men were willing to care for a relative with AIDS at home (23 percent and 20 percent, respectively), buy fresh vegetables from a shopkeeper with AIDS (14 percent and 19 percent, respectively), or allow a female teacher with AIDS to keep teaching (13 percent and 9 percent, respectively). Only 38 percent of women and 34 percent of men said that they would be open about having an HIV-positive family member. Accepting attitudes were expressed on all four indicators by only 1 percent of women and men, indicating that some degree of stigma is almost universally associated with HIV/AIDS within Egyptian society. 266 | Knowledge and Attitudes about HIV/AIDS Table 19.4.1 Accepting attitudes toward those living with HIV by background characteristics: Women Among women who have heard of HIV/AIDS, percentage expressing accepting attitudes toward people with HIV, by background characteristics, and among women age 50-59 and all women age 15-59, percentage with accepting attitudes towards those living with AIDS, Egypt 2008 Percentage of women who: Background characteristic Are willing to care for a family member with HIV at home Would buy fresh vegetables from shopkeeper who has HIV Believe HIV- positive female teacher should be allowed to keep teaching Would not want HIV+ status of a family member to remain a secret Percentage expressing acceptance attitudes on all four indicators Number of women who have heard of HIV/AIDS Age 15-19 25.4 14.9 12.2 34.6 0.5 782 20-24 23.7 12.1 12.2 36.4 0.9 865 25-29 21.1 15.1 13.5 39.5 1.6 739 30-34 24.6 14.9 12.9 40.6 1.0 545 35-39 21.3 14.2 12.8 36.7 1.0 496 40-44 22.4 15.6 12.0 40.2 1.8 388 45-49 22.4 13.7 13.4 41.4 0.6 359 Marital status Ever married 22.1 13.4 11.9 39.0 1.1 2,971 Never married 25.9 16.3 14.5 35.4 0.9 1,203 Urban-rural residence Urban 19.7 15.9 13.7 45.7 1.2 2,006 Rural 26.4 12.7 11.7 30.9 0.9 2,168 Place of residence Urban Governorates 17.7 17.7 14.1 54.2 0.6 932 Lower Egypt 23.1 14.0 11.9 33.3 1.1 1,900 Urban 19.8 15.0 14.6 40.3 1.6 525 Rural 24.3 13.6 10.9 30.5 1.0 1,375 Upper Egypt 28.0 12.3 13.1 32.2 1.1 1,283 Urban 24.1 14.0 12.9 34.5 1.8 506 Rural 30.6 11.2 13.2 30.7 0.7 776 Frontier Governorates 8.3 10.5 7.0 58.7 0.5 59 Education No education 27.1 9.4 7.2 34.5 0.1 710 Some primary 25.3 10.7 10.7 35.0 1.4 252 Primary complete/ some secondary 22.9 12.5 11.3 37.5 0.5 963 Secondary complete/ higher 21.8 16.9 15.2 39.6 1.5 2,249 Work status Working for cash 24.0 21.0 16.8 41.4 2.5 735 Not working for cash 23.0 12.8 11.8 37.2 0.7 3,439 Wealth quintile Lowest 30.8 12.9 10.2 27.1 0.7 497 Second 28.7 12.6 9.7 27.3 0.7 734 Middle 25.7 13.1 12.8 36.8 1.2 822 Fourth 18.3 12.8 11.8 45.0 0.6 989 Highest 18.7 18.0 16.4 44.4 1.6 1,132 Total women age 15-49 23.2 14.2 12.7 38.0 1.0 4,174 Women age 50-59 22.3 11.9 10.3 42.7 0.6 437 Total women age 15-59 23.1 14.0 12.5 38.4 1.0 4,611 Knowledge and Attitudes about HIV/AIDS | 267 Table 19.4.2 Accepting attitudes toward those living with HIV by background characteristics: Men Among men who have heard of HIV/AIDS, percentage expressing accepting attitudes toward people with HIV, by background characteristics, and among men age 50-59 and all men age 15-59, percentage with accepting attitudes towards those living with AIDS, Egypt 2008 Percentage of men who: Background characteristic Are willing to care for a family member with HIV at home Would buy fresh vegetables from shopkeeper who has HIV Believe HIV- positive female teacher should be allowed to keep teaching Would not want HIV+ status of a family member to remain a secret Percentage expressing acceptance attitudes on all four indicators Number of men who have heard of HIV/AIDS Age 15-19 20.0 18.4 7.9 32.6 0.6 899 20-24 20.2 18.4 8.0 38.2 0.5 807 25-29 20.8 21.3 11.0 32.2 1.0 675 30-34 20.5 19.6 10.9 39.0 2.2 578 35-39 19.3 19.0 8.9 30.7 0.9 483 40-44 20.8 18.3 7.6 32.7 0.8 511 45-49 16.7 20.7 9.9 34.5 1.3 413 Marital status Ever married 19.1 18.5 8.9 34.2 1.2 2,334 Never married 20.9 20.1 9.2 34.6 0.7 2,033 Urban-rural residence Urban 19.8 21.7 12.0 38.9 1.4 1,948 Rural 20.0 17.3 6.7 30.7 0.6 2,418 Place of residence Urban Governorates 21.2 25.7 18.0 45.5 1.8 861 Lower Egypt 13.6 17.3 6.5 23.8 0.7 1,969 Urban 14.1 16.7 5.9 17.9 1.1 500 Rural 13.4 17.5 6.8 25.8 0.5 1,469 Upper Egypt 27.9 18.3 7.1 41.7 0.8 1,465 Urban 23.5 20.4 8.4 47.8 1.1 534 Rural 30.3 17.1 6.3 38.1 0.7 930 Frontier Governorates 16.8 16.9 10.9 43.5 2.4 72 Education No education 19.0 13.2 2.6 30.9 0.3 330 Some primary 17.3 11.7 4.9 29.8 0.4 347 Primary complete/ some secondary 19.5 17.3 7.0 32.3 1.0 1,186 Secondary complete//higher 20.6 22.1 11.4 36.5 1.1 2,503 Work status Working for cash 19.7 19.3 9.0 34.6 1.1 3,280 Not working for cash 20.6 19.2 9.1 33.8 0.7 1,086 Wealth quintile Lowest 25.8 15.3 5.4 33.2 0.4 646 Second 21.4 17.2 5.8 31.8 0.7 871 Middle 19.9 18.0 8.2 29.3 0.8 913 Fourth 14.2 18.0 8.8 36.6 1.1 929 Highest 20.2 25.9 15.2 40.0 1.6 1,007 Total men age 15-49 19.9 19.3 9.0 34.4 1.0 4,366 Men age 50-59 20.5 16.7 8.5 32.9 1.1 629 Total men age 15-59 20.0 19.0 9.0 34.2 1.0 4,995 268 | Knowledge and Attitudes about HIV/AIDS 19.4 KNOWLEDGE OF A SOURCE FOR HIV TESTING Another important aspect of AIDS awareness which was assessed in the 2008 EDHS was the level of knowledge of a place where HIV testing is available. Table 19.5 shows that 12 percent of women and 20 percent of men age 15-59 knew where to go for an HIV test. Among women age 15-49, knowledge of a source where HIV testing is available was highest among women working for cash (22 percent) and women in the highest wealth quintile (21 percent). Among men, knowledge was highest among those living in urban Lower Egypt (31 percent) and those in the highest wealth quintile (28 percent). Table 19.5 Knowledge of a place where HIV testing available by background characteristics Percentage of all women and men age 15-49 who know a place where HIV testing is available by background characteristics, and, among women and men age 50-59 and all women and men age 15-59, percentage who know a place where HIV testing is available, Egypt 2008 Background characteristic Percentage of women knowing place where HIV testing is available Number of women Percentage of men knowing place where HIV testing is available Number of men Age 15-19 8.8 1,064 11.7 1,087 20-24 13.8 1,091 18.7 869 25-29 15.8 906 23.1 729 30-34 12.7 688 21.5 634 35-39 12.2 673 24.1 535 40-44 12.6 568 22.5 581 45-49 12.1 550 21.7 494 Marital status Ever married 12.6 3,983 22.6 2,640 Never married 12.3 1,556 15.9 2,290 Urban-rural residence Urban 13.7 2,352 19.4 2,170 Rural 11.6 3,188 19.6 2,760 Place of residence Urban Governorates 13.7 1,073 16.3 990 Lower Egypt 15.2 2,415 24.6 2,150 Urban 18.4 603 31.4 533 Rural 14.1 1,812 22.4 1,616 Upper Egypt 9.0 1,970 15.2 1,706 Urban 10.0 623 13.8 588 Rural 8.5 1,347 15.9 1,118 Frontier Governorates 3.5 82 14.1 84 Education No education 5.1 1,461 14.2 467 Some primary 5.9 394 7.7 458 Primary complete/some secondary 9.8 1,248 13.1 1,414 Secondary complete/higher 19.4 2,436 26.0 2,590 Work status Working for cash 21.6 866 20.6 3,685 Not working for cash 10.9 4,674 16.3 1,245 Wealth quintile Lowest 7.6 1,001 12.1 838 Second 9.8 1,123 18.9 1,010 Middle 10.8 1,099 18.4 1,036 Fourth 12.1 1,105 18.7 997 Highest 21.1 1,212 27.8 1,049 Total age 15-49 12.5 5,540 19.5 4,930 Total age 15-59 12.2 6,290 19.7 5,718 Knowledge and Attitudes about HIV/AIDS | 269 19.5 SOURCES OF INFORMATION ABOUT AIDS Men and women age 15-59 reporting that they had heard about AIDS were asked about whether they had received any information about AIDS during the six months prior to the EDHS. Tables 19.6.1 and 19.6.2 show that 31 percent of women and 24 percent of men had received information about AIDS during the period. When asked about the source(s) from which they had obtained information during the period, virtually all of the women and men cited television broadcasts. The differentials shown for women and men age 15-49 in the tables indicate that recent exposure to information about AIDS was greatest among urban residents, especially those living in the Urban Governorates. Table 19.6.1 Sources of information about AIDS by background characteristics: Women Percentage of all women age 15-49 knowing about AIDS who heard, saw or received any information about AIDS in the six months prior to the survey and percentage of women receiving information about AIDS within the last six months, naming various sources of information, according to background characteristics, and among women age 50-59 and all women age 15-59, percentage receiving information about AIDS recently, Egypt 2008 Percentage of women who saw/heard/received information about AIDS from: Background characteristic Percentage of women knowing about AIDS saying they had received information about AIDS recently Number of women knowing about AIDS TV Other media1 Any contact with health worker Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Community meeting/ other Number of women receiving information about AIDS recently Age 15-19 33.5 782 92.1 15.2 3.0 1.0 2.0 6.0 3.9 262 20-24 27.5 865 93.7 13.4 3.9 0.5 3.9 9.4 1.3 238 25-29 31.6 739 94.9 15.2 5.6 0.0 5.6 5.8 1.3 233 30-34 31.2 545 95.8 13.9 4.4 1.5 2.9 7.0 1.9 170 35-39 31.5 496 96.1 9.2 2.1 0.0 2.1 5.9 0.3 156 40-44 32.5 388 93.3 11.9 3.3 0.0 3.3 11.9 1.5 126 45-49 28.6 359 91.1 21.7 8.3 0.9 8.3 8.8 4.4 103 Marital status Ever married 29.3 2,971 94.5 12.6 4.1 0.5 3.8 7.8 1.5 871 Never married 34.7 1,203 92.6 17.4 4.2 0.7 3.8 6.8 3.3 418 Urban-rural residence Urban 38.6 2,006 94.7 15.6 4.1 0.2 4.0 6.9 2.1 774 Rural 23.7 2,168 92.8 12.0 4.3 1.1 3.4 8.5 2.0 514 Place of residence Urban Governorates 47.8 932 96.8 14.0 4.3 0.1 4.2 7.5 1.7 446 Lower Egypt 21.7 1,900 90.1 15.8 5.5 0.4 5.4 5.8 2.3 413 Urban 25.1 525 87.8 22.8 6.0 0.0 6.0 6.9 3.1 132 Rural 20.4 1,375 91.2 12.5 5.3 0.6 5.1 5.3 1.9 281 Upper Egypt 31.9 1,283 94.6 12.9 2.7 1.3 1.7 9.5 2.4 410 Urban 35.7 506 94.3 14.9 2.3 0.5 2.3 5.5 2.7 181 Rural 29.5 776 94.8 11.3 3.0 1.8 1.2 12.6 2.1 229 Frontier Governorates 34.2 59 95.9 10.3 3.1 0.0 3.1 2.4 0.0 20 Education No education 22.3 710 96.0 5.4 1.8 0.5 1.3 8.7 0.0 158 Some primary 29.8 252 95.8 5.2 0.4 0.0 0.4 6.2 0.6 75 Primary complete/some secondary 30.3 963 93.8 14.6 1.0 0.5 0.4 6.2 2.8 291 Secondary complete/ higher 34.0 2,249 93.4 16.7 6.2 0.6 5.9 7.9 2.4 764 Work status Working for cash 38.7 735 91.6 21.2 11.1 1.0 10.8 10.4 3.4 285 Not working for cash 29.2 3,439 94.6 12.2 2.2 0.4 1.8 6.7 1.7 1,004 Wealth quintile Lowest 28.9 497 96.2 10.3 2.6 2.5 0.1 9.1 1.6 144 Second 22.5 734 94.6 8.6 3.6 0.4 3.2 6.1 1.6 165 Middle 23.8 822 90.5 14.9 4.0 0.8 3.8 9.4 1.4 195 Fourth 35.4 989 96.1 12.1 3.0 0.0 3.0 6.0 2.8 350 Highest 38.4 1,132 92.7 18.9 5.9 0.3 5.8 7.8 2.1 434 Total women age 15-49 30.9 4,174 93.9 14.2 4.2 0.5 3.8 7.5 2.1 1,289 Women age 50-59 28.8 437 94.4 17.1 5.3 0.0 5.3 4.5 1.4 126 Total women age 15-59 30.7 4,611 94.0 14.4 4.3 0.5 3.9 7.2 2.0 1,415 1 Includes radio, newspaper, magazine, pamphlet, brochure, or poster 270 | Knowledge and Attitudes about HIV/AIDS Table 19.6.2 Sources of information about AIDS by background characteristics: Men Percentage of all men age 15-49 knowing about AIDS who heard, saw or received any information about AIDS in the six months prior to the survey and percentage of men receiving information about AIDS within the last six months, naming various sources of information, according to background characteristics, and among men age 50-59 and all men age 15-59, percentage receiving information about AIDS recently, Egypt 2008 Percentage of men who saw/heard/received information about AIDS from: Background characteristic Percentage of men knowing about AIDS saying they had received information about AIDS recently Number of men knowing about AIDS TV Other media1 Any contact with health worker Home visit Facility visit Spouse/ other relatives/ friends/ neighbors Community meeting/ other Number of men receiving information about AIDS recently Age 15-19 21.1 899 91.1 14.9 2.1 0.0 2.1 12.2 3.3 189 20-24 24.1 807 91.8 16.9 1.6 0.4 1.1 10.1 2.0 195 25-29 24.0 675 96.1 14.2 3.6 0.4 3.2 10.7 0.8 162 30-34 29.2 578 89.4 15.7 2.3 0.0 2.3 10.1 1.0 169 35-39 26.2 483 97.2 10.1 4.2 0.0 4.2 6.1 0.9 127 40-44 26.1 511 91.0 18.5 4.4 0.9 3.5 8.5 1.7 133 45-49 20.4 413 90.1 15.5 8.4 0.4 8.1 5.4 2.7 84 Marital status Ever married 25.0 2,334 92.5 14.3 3.8 0.3 3.5 7.8 1.1 583 Never married 23.4 2,033 92.2 16.3 2.7 0.3 2.4 11.6 2.6 477 Urban-rural residence Urban 28.6 1,948 92.3 15.5 2.4 0.2 2.2 8.5 1.9 558 Rural 20.7 2,418 92.4 14.9 4.3 0.4 4.0 10.7 1.7 502 Place of residence Urban Governorates 38.4 861 95.4 12.9 1.7 0.1 1.6 4.1 0.7 330 Lower Egypt 19.9 1,969 92.7 11.5 2.1 0.0 2.1 5.3 1.9 392 Urban 18.9 500 87.5 16.4 3.7 0.0 3.7 8.7 3.4 95 Rural 20.2 1,469 94.3 9.9 1.6 0.0 1.6 4.2 1.4 297 Upper Egypt 22.0 1,465 89.2 22.5 6.3 0.7 5.6 19.8 2.6 323 Urban 23.0 534 88.6 22.2 3.2 0.4 2.8 18.9 3.4 123 Rural 21.5 930 89.6 22.6 8.3 0.9 7.3 20.4 2.0 200 Frontier Governorates 19.9 72 84.9 7.9 4.3 2.1 2.2 17.3 4.1 14 Education No education 21.6 330 95.7 1.8 1.8 0.0 1.8 7.4 0.0 71 Some primary 18.6 347 95.0 5.8 0.0 0.0 0.0 8.7 0.0 65 Primary complete/some secondary 20.3 1,186 93.7 10.1 1.4 0.1 1.3 9.8 2.3 241 Secondary complete/ higher 27.2 2,503 91.3 19.3 4.4 0.4 4.0 9.7 1.9 682 Work status Working for cash 24.8 3,280 92.7 14.3 3.6 0.4 3.2 9.4 1.2 812 Not working for cash 22.7 1,086 91.2 18.2 2.4 0.0 2.4 9.8 3.8 247 Wealth quintile Lowest 20.8 646 91.0 14.0 2.2 0.0 2.2 15.5 0.6 135 Second 20.5 871 94.8 11.0 2.2 0.0 2.2 11.4 1.6 179 Middle 22.5 913 91.0 13.6 4.2 0.2 4.0 9.0 1.6 206 Fourth 23.8 929 93.1 8.2 4.4 0.9 3.5 9.8 1.5 221 Highest 31.7 1,007 91.9 24.0 3.0 0.2 2.8 6.1 2.7 319 Total men age 15-49 24.3 4,366 92.4 15.2 3.3 0.3 3.0 9.5 1.8 1,059 Men age 50-59 22.1 629 91.9 14.7 3.7 0.7 3.0 10.9 4.4 139 Total men age 15-59 24.0 4,995 92.3 15.2 3.3 0.3 3.0 9.7 2.1 1,198 1 Includes radio, newspaper, magazine, pamphlet, brochure, or poster Health Care Expenses and Health Care Coverage | 271 HEALTH CARE EXPENSES AND HEALTH CARE COVERAGE 20 The 2008 EDHS collected information from women and men age 15-59 eligible for interview in the special health issues component of the survey on expenses they may have incurred for outpatient visits to health care providers and for hospital stays. These respondents also were asked questions about health insurance coverage. Finally, during the ever-married women’s interviews, information was obtained on the costs of maternal health care services from women who had had a birth during the five years before the survey. This chapter presents the data on health care expenses and health insurance coverage obtained in the 2008 EDHS. The results do not offer a comprehensive picture of the costs Egyptian households are incurring for health care services or the extent to which those costs are covered by health insurance. However, they provide some insights into the amounts that families are spending for health care both for regular outpatient care and for several types of specialized services like hospital stays and maternity care services. The results also provide some insight into the extent to which adults in Egypt are covered by health insurance. 20.1 EXPENSES ASSOCIATED WITH HEALTH PROVIDER VISITS The 2008 EDHS included questions to determine if women and men age 15-59 eligible for interview in the special health issues component of the survey had visited a health provider in the four- week period before the survey and if so, what type of provider they had visited the last time and the costs they had incurred for the visit and for any drugs or laboratory tests they had in conjunction with the visit. Table 20.1 shows that 8 percent of respondents age 15-59 had gone to a health care provider during the four-week period prior to the survey. The proportion of respondents who had visited a health care provider generally increased with age. Women were more than twice as likely as men to report that they had visited a health provider (11 percent and 5 percent, respectively). There was no difference between urban and rural residents in the proportions who had seen a provider. Looking at the place of residence, respondents from Upper Egypt were more likely to have gone to a provider than respondents from other regions. The proportion of respondents visiting a provider generally decreased with education but did not vary in a uniform fashion with the wealth quintile. The majority (63 percent) of respondents seeking health care during the four weeks prior to the survey saw a private medical provider for the last visit, while about one-third (34 percent) went to a government facility. Respondents from the Frontier Governorates (39 percent) were least likely to report having seen a private provider, while respondents in rural Lower Egypt (68 percent) were the most likely. Among the other sub-groups, respondents in the highest wealth quintile (70 percent) were most likely to have visited a private provider. Respondents who had seen a health provider during the four-week period before the survey were asked about the amount they had paid to the provider for the consultation and any additional costs incurred to obtain drugs or for laboratory tests. As Table 20.2 shows, nine in ten respondents had incurred at least some expense for the consultation on their last visit, and 12 percent paid 60 pounds or more for the consultation. The median amount paid for the consultation was 15.6 pounds. 272 | Health Care Expenses and Health Care Coverage Table 20.1 Visit to health provider recently Percentage of the population age 15-59 who visited health care provider in the four-week period before the survey, and, among those visiting a health provider, the percent distribution by the type of provider last visited, Egypt 2008 Among respondents visiting a provider, percent distribution by type of provider last consulted Background characteristic Percentage visiting health provider Number of respondents Government facility NGO provider Private medical provider Other Don’t know/ missing Total percent Number visiting health provider Age 15-19 4.6 2,151 35.0 0.0 65.0 0.0 0.0 100.0 100 20-24 6.7 1,960 32.9 1.5 61.1 4.5 0.0 100.0 131 25-29 8.1 1,635 32.2 2.2 64.4 0.2 0.9 100.0 132 30-34 7.5 1,322 40.5 0.0 59.2 0.3 0.0 100.0 100 35-39 10.1 1,209 28.4 0.5 69.3 1.7 0.0 100.0 122 40-44 8.7 1,148 29.6 0.5 67.4 1.3 1.2 100.0 100 45-49 10.2 1,044 28.1 0.4 67.3 4.2 0.0 100.0 107 50-59 11.9 1,539 42.0 1.3 52.3 4.4 0.0 100.0 183 Sex Women 11.3 6,290 31.9 1.1 64.1 2.6 0.3 100.0 712 Men 4.6 5,718 40.1 0.4 58.0 1.5 0.0 100.0 262 Urban-rural residence Urban 8.1 5,288 35.7 1.1 59.2 3.9 0.0 100.0 427 Rural 8.1 6,720 32.8 0.8 65.0 1.0 0.4 100.0 547 Place of residence Urban Governorates 7.8 2,445 38.9 0.8 54.6 5.8 0.0 100.0 191 Lower Egypt 5.8 5,212 31.4 1.3 65.8 0.8 0.8 100.0 303 Urban 4.8 1,311 41.9 1.9 56.3 0.0 0.0 100.0 63 Rural 6.2 3,901 28.6 1.1 68.2 1.0 1.0 100.0 241 Upper Egypt 11.2 4,168 33.3 0.7 64.2 1.9 0.0 100.0 467 Urban 11.7 1,409 29.2 1.0 66.4 3.5 0.0 100.0 165 Rural 11.0 2,759 35.5 0.5 62.9 1.0 0.0 100.0 302 Frontier Governorates 6.7 182 58.1 3.4 38.5 0.0 0.0 100.0 12 Education No education 10.6 2,588 34.5 0.2 61.9 3.0 0.4 100.0 275 Some primary 9.5 1,084 38.0 2.7 56.3 3.1 0.0 100.0 104 Primary complete/some secondary 7.0 2,919 40.8 0.2 56.5 2.4 0.0 100.0 203 Secondary complete/ higher 7.2 5,417 29.3 1.3 67.5 1.6 0.3 100.0 392 Wealth quintile Lowest 8.6 2,042 38.8 0.4 58.2 2.6 0.0 100.0 175 Second 8.0 2,442 36.0 0.7 60.7 2.1 0.6 100.0 196 Middle 8.5 2,425 38.1 0.5 57.3 3.5 0.6 100.0 206 Fourth 7.4 2,440 30.8 1.7 66.0 1.5 0.0 100.0 180 Highest 8.1 2,659 27.5 1.2 69.5 1.8 0.0 100.0 217 Total 8.1 12,008 34.1 0.9 62.5 2.3 0.2 100.0 974 NGO = Nongovernmental Health Care Expenses and Health Care Coverage | 273 Table 20.2 also presents information on additional costs respondents incurred for drugs or laboratory tests. The results show that among respondents who saw a health care provider during the four- week period prior to the survey, 77 percent said they had also bought drugs. Overall, the median amount paid for drugs by all respondents (including those who paid nothing) was 30.4 pounds, roughly twice the average amount paid for the consultation with the provider. Table 20.2 Expenses for last health care consultation Percent distribution of respondents reporting a consultation with a health provider during the four weeks before the survey by the amount paid at the time of the last consultation for all services received from the provider and for any additional drugs or laboratory tests obtained from other sources, Egypt, 2008 Amount paid Consultation Drugs Laboratory fees Paid nothing 10.4 22.5 79.8 < 5 pounds 15.4 0.8 0.3 5-9 pounds 9.0 3.5 2.2 10-14 pounds 10.7 4.0 2.0 15-19 pounds 13.4 4.4 1.6 20-24 pounds 11.7 6.7 1.4 25-29 pounds 6.7 5.7 1.4 30-34 pounds 4.0 6.7 1.3 35-39 pounds 1.3 6.4 0.6 40-49 pounds 1.3 7.7 1.5 50-59 pounds 3.8 7.9 1.5 60 pounds or more 12.3 23.5 6.3 Don't know/missing 0.1 0.1 0.0 Total percent 100.0 100.0 100.0 Number having health care consultation 974 974 974 Median amount paid 15.6 30.4 a a Omitted because less than 50 percent paid fees. Respondents were much less likely to have incurred costs for laboratory tests than for drugs. Only one in five respondents had expenses for laboratory tests. The majority of those respondents who incurred costs for lab tests paid more than 25 pounds for the tests. Table 20.3 considers how the total expenses including consultation fees and the costs for drugs and laboratory tests (if any) varied with the type of health care provider. The median amount paid for care was considerably lower among respondents who consulted a government health care provider than among respondents who obtained care from non-governmental providers (20.0 and 71.5 pounds, respectively). 274 | Health Care Expenses and Health Care Coverage Table 20.3 Total expenses incurred for last health care consultation by type of provider consulted Percent distribution of respondents reporting a consultation with a health provider during the four weeks before the survey by the amount paid at the time of the last consultation for all services received from the provider and for any additional drugs or laboratory tests obtained from other sources, according to type of provider, Egypt 2008 Total expenses incurred Government Private/ NGO/other All Free/paid nothing 9.3 3.4 5.4 < 5 pounds 22.3 0.6 8.0 5-9 pounds 6.2 1.9 3.3 10-14 pounds 6.9 1.5 3.4 15-19 pounds 5.3 2.1 3.2 20-24 pounds 7.1 3.6 4.8 25-29 pounds 6.0 1.6 3.1 30-34 pounds 4.6 4.4 4.4 35-39 pounds 2.1 5.0 4.0 40-49 pounds 4.5 9.3 7.6 50-59 pounds 2.9 7.4 5.8 60 pounds or more 22.8 58.9 46.7 Don't know/missing 0.0 0.4 0.2 Total percent 100.0 100.0 100.0 Number having health care consultation 332 640 974 Median amount paid 20.0 71.5 52.7 NGO = Nongovernmental organization 20.2 EXPENSES ASSOCIATED WITH HOSPITAL STAYS Respondents eligible for the health issues component of the survey were asked if they had been hospitalized for at least one night at any point during the 12 months prior to the survey and, if so, how much they had paid for the stay the last time that they were hospitalized. Three percent of respondents had been hospitalized during the year before the survey. There are no major variations in the proportion of respondents that were hospitalized by various background characteristics. The majority (69 percent) of respondents stayed in a government facility (Table 20.4). Health Care Expenses and Health Care Coverage | 275 Table 20.4 Hospital stays in past 12 months Percent of the population age 15-59 who were admitted to a hospital for at least one night during the 12-month period before the survey and, among those hospitalized, percent distribution by the type of hospital where they were admitted the last time, according to background characteristics, Egypt 2008 Among respondents hospitalized, percent distribution by type of hospital where admitted the last time Background characteristic Percentage hospitalized for at least one night in past 12 months Number of respondents Government facility Private provider Other Don’t know/ missing Total percent Number hospitalized in past 12 months Age 15-29 2.4 5,746 63.5 35.6 0.0 0.9 100.0 137 30-44 2.5 3,680 68.1 31.2 0.7 0.0 100.0 91 45-59 3.5 2,583 79.9 17.8 2.3 0.0 100.0 89 Sex Women 3.3 6,290 64.4 33.7 1.3 0.6 100.0 209 Men 1.9 5,718 79.1 20.9 0.0 0.0 100.0 108 Urban-rural residence Urban 3.0 5,288 66.7 32.0 1.3 0.0 100.0 159 Rural 2.3 6,720 72.1 26.8 0.4 0.8 100.0 158 Place of residence Urban Governorates 3.2 2,445 71.0 26.4 2.6 0.0 100.0 78 Lower Egypt 2.1 5,212 65.2 33.6 0.0 1.2 100.0 107 Urban 2.1 1,311 (61.1) (38.9) (0.0) (0.0) 100.0 27 Rural 2.0 3,901 66.6 31.8 0.0 1.6 100.0 80 Upper Egypt 3.1 4,168 71.8 27.7 0.5 0.0 100.0 127 Urban 3.6 1,409 62.8 37.2 0.0 0.0 100.0 51 Rural 2.8 2,759 77.9 21.3 0.8 0.0 100.0 76 Frontier Governorates 2.3 182 * * * * 100.0 4 Education No education 3.3 2,588 85.2 14.8 0.0 0.0 100.0 86 Some primary 3.1 1,084 (79.3) (12.7) (8.0) (0.0) 100.0 34 Primary complete/some secondary 2.4 2,919 68.5 31.5 0.0 0.0 100.0 70 Secondary complete/higher 2.4 5,417 56.7 42.4 0.0 1.0 100.0 128 Wealth quintile Lowest 2.1 2,042 91.4 8.6 0.0 0.0 100.0 43 Second 2.8 2,442 77.0 19.6 3.4 0.0 100.0 69 Middle 2.8 2,425 67.8 30.4 0.0 1.8 100.0 67 Fourth 2.6 2,440 61.5 38.0 0.5 0.0 100.0 63 Highest 2.8 2,659 57.6 42.4 0.0 0.0 100.0 74 Total 2.6 12,008 69.4 29.4 0.8 0.4 100.0 317 Note: An asterisk indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 276 | Health Care Expenses and Health Care Coverage Table 20.5 shows that 35 percent of respondents who had been hospitalized did not pay anything for the last hospital stay. The median cost of the last hospitalization was 95.1 pounds. 20.3 EXPENSES ASSOCIATED WITH MATERNAL HEALTH SERVICES The 2008 EDHS collected information from women who had had at least one birth during the 5-year period before the survey on the expenses that women incurred for antenatal, delivery and postnatal care services for their last birth. Women were asked not only about the fees paid to providers for these services but also about any expenses they may have had for drugs or laboratory services. Table 20.6 shows that most women who received antenatal care prior to the last birth incurred some expenses for the services; only 8 percent of the women said that they had paid nothing for the antenatal services. The median amount paid for antenatal care services for the last birth, including provider fees and costs of drugs and laboratory tests, was 140.2 pounds. On average, women who obtained services from government providers paid considerably less than women who received antenatal care services from private providers (9.9 pounds and 180.5 pounds, respectively). Table 20.6 Total expenses incurred relating to antenatal care services Percent distribution of respondents who received antenatal care services prior to last birth by total expenses incurred for the antenatal services including consultation(s) with provider, drugs and laboratory services, and median amount paid, according to place where services were provided, Egypt 2008 Expenses for antenatal services Government only Private/ NGO/other Both All Free 30.2 1.0 4.6 7.9 < 20 pounds 30.1 0.7 4.1 7.7 20-49 pounds 18.6 6.0 5.6 9.0 50-74 pounds 7.0 6.6 8.3 6.7 75-99 pounds 3.6 7.0 7.3 6.2 100-124 pounds 1.4 8.6 9.0 6.9 125-149 pounds 0.8 8.1 5.3 6.3 150-199 pounds 1.4 15.4 9.8 12.0 200-299 pounds 1.1 19.1 16.1 14.8 300 pounds or more 3.1 24.0 23.0 19.1 Don't know/missing 2.6 3.4 6.8 3.3 Total percent 100.0 100.0 100.0 100.0 Number 1,374 4,362 124 5,861 Median amount paid 9.9 180.5 150.9 140.2 NGO = Nongovernmental organization The 2008 EDHS also obtained information on the costs of delivery care. The results presented in Table 20.7 indicate that women almost always incurred some expenses for delivery care, with only 4 percent reporting that they had not paid anything for the delivery care they received. The median amount women paid for delivery care was 181 pounds. Delivery care expenses were substantially lower for women who delivered in a governmental facility than women delivering in a private or nongovernmental facility or at home (100.1 and 250.7 pounds, respectively). Table 20.5 Total expenses incurred relating to last hospitalization Percent distribution of respondents reporting that they were hospitalized during the last 12 months by cost of last hospitalization, Egypt 2008 Total expenses incurred All Free/paid nothing 34.7 <100 pounds 7.1 100-499 pounds 13.1 500-999 pounds 10.5 1000-1999 pounds 9.7 2000-10,000 pounds 8.2 Don't know/missing 16.8 Total percent 100.0 Number hospitalized 317 Median amount paid 95.1 Health Care Expenses and Health Care Coverage | 277 Table 20.7 Total expenses incurred relating to delivery services Percent distribution of respondents having a birth in the five years prior to the survey by total expenses incurred for delivery, drugs and for laboratory services, and median amount paid, according to place where delivery occurred, Egypt 2008 Expenses for delivery care Government Private/ NGO/ home/other All Free 9.1 2.4 4.3 < 50 pounds 12.5 9.3 10.2 50-74 pounds 14.6 11.3 12.2 75-99 pounds 6.1 2.3 3.4 100-124 pounds 10.5 5.3 6.7 125-149 pounds 3.0 1.3 1.8 150-199 pounds 7.5 5.1 5.8 200-299 pounds 8.0 8.9 8.7 300-399 pounds 4.6 7.4 6.6 400-499 pounds 2.0 4.3 3.7 500 pounds or more 8.7 30.1 24.3 Don't know/missing 13.4 12.0 12.4 Total percent 100.0 100.0 100.0 Number 2,112 5,683 7,796 Median amount paid 100.1 250.7 181.0 Women who had a separate postnatal care visit following delivery were much less likely to pay for that care than for antenatal services or delivery care. Table 20.8 shows that around one-third of women incurred no costs for the first postnatal care visit they had. The median amount women paid for a postnatal visit was 10.6 pounds. Similar to antenatal and delivery care, women receiving postnatal care from a private provider paid considerably more for the care than women who obtained care from a private provider (17 pounds and 2.9 pounds, respectively). Table 20.8 Total expenses incurred relating to postnatal care services Percent distribution of respondents receiving postnatal care services after last birth by total expenses incurred for postnatal services, including consultation(s), drugs and laboratory services, and median amount paid, according to place where service occurred, Egypt 2008 Expenses for postnatal care Government Private/ NGO/ home/other All Free 24.7 37.6 34.7 < 5 pounds 35.4 0.6 8.3 5-9 pounds 7.1 1.5 2.7 10-14 pounds 1.5 4.4 3.8 15-19 pounds 2.7 4.0 3.7 20-24 pounds 3.9 9.6 8.3 25-29 pounds 2.9 4.3 4.0 30-34 pounds 3.3 5.6 5.1 35-39 pounds 2.2 3.1 2.9 40-49 pounds 0.4 3.7 2.9 50-59 pounds 3.9 5.8 5.5 60 pounds or more 5.5 14.9 12.8 Don't know/missing 6.5 4.9 5.5 Total percent 100.0 100.0 100.0 Number 303 1,067 1,378 Median amount paid 2.9 17.0 10.6 278 | Health Care Expenses and Health Care Coverage 20.4 HEALTH INSURANCE COVERAGE The special health issues interviews conducted in the 2008 EDHS included questions to assess insurance coverage among respondents age 15-59. As Table 20.9 shows that slightly more than one in four respondents (28 percent) indicated that they had health insurance. Around six in ten respondents who were insured had coverage from the General Health Insurance Authority, 27 percent had coverage through their own or another family member’s employer, 10 percent (primarily among those under age 25) had insurance through a university, and 4 percent through a syndicate. Table 20.9 Health insurance coverage Percent distribution of the population age 15-59 by health insurance coverage, and, among those with health insurance, percentage covered by various health insurance plans, Egypt 2008 Among respondents having health insurance, percentage reporting they were insured by: Background characteristic Percentage covered by any health insurance Number of respondents Own employer Another family member's employer General Insurance Agency Syndicate University Other Missing Number with health insurance Age 15-19 49.8 2,151 0.8 2.2 80.0 0.4 16.7 0.8 0.6 1,070 20-24 16.0 1,960 20.8 4.4 27.2 5.3 44.9 1.1 0.6 314 25-29 13.5 1,635 45.2 2.9 42.0 7.3 4.3 0.9 0.9 221 30-34 20.8 1,322 42.9 3.4 48.2 8.3 0.0 0.5 0.0 275 35-39 23.8 1,209 39.7 3.0 53.8 4.9 0.0 0.4 0.1 288 40-44 30.6 1,148 31.6 4.7 63.4 2.1 0.0 0.9 0.2 351 45-49 33.2 1,044 33.8 2.9 61.5 2.3 0.6 0.0 0.9 346 50-59 29.0 1,539 31.9 6.5 60.1 5.8 0.6 0.7 0.2 446 Sex Women 18.0 6,290 17.8 8.8 58.9 4.5 12.9 1.4 0.4 1,132 Men 38.1 5,718 26.4 0.8 62.4 3.0 8.6 0.3 0.5 2,179 Urban-rural residence Urban 34.4 5,288 26.2 5.2 54.8 4.9 12.1 0.7 0.3 1,819 Rural 22.2 6,720 20.1 1.5 68.9 1.8 7.6 0.6 0.6 1,492 Place of residence Urban Governorates 34.3 2,445 25.9 8.1 51.0 5.0 14.1 0.4 0.3 838 Lower Egypt 27.0 5,212 22.8 2.1 63.3 3.7 8.8 0.7 0.3 1,405 Urban 35.2 1,311 24.9 2.9 58.1 6.0 9.9 0.7 0.0 461 Rural 24.2 3,901 21.7 1.7 65.8 2.6 8.3 0.7 0.4 944 Upper Egypt 24.4 4,168 22.8 1.9 65.7 2.0 8.9 1.0 0.9 1,017 Urban 34.1 1,409 28.6 2.7 56.4 3.8 11.7 1.4 0.6 481 Rural 19.4 2,759 17.6 1.2 74.0 0.3 6.4 0.5 1.1 536 Frontier Governorates 27.9 182 15.7 1.3 80.1 2.5 2.7 0.0 1.2 51 Education No education 4.3 2,588 26.2 12.5 56.9 0.0 0.0 2.1 3.1 111 Some primary 11.6 1,084 39.7 8.3 50.0 0.9 1.6 0.0 0.3 125 Primary complete/ some secondary 36.7 2,919 9.3 2.3 85.5 0.6 2.0 1.1 0.4 1,072 Secondary complete/higher 37.0 5,417 29.9 3.4 49.1 5.4 15.5 0.4 0.4 2,003 Wealth quintile Lowest 13.9 2,042 10.5 1.5 78.7 0.0 7.9 0.7 1.0 284 Second 19.1 2,442 16.7 1.0 75.8 0.3 6.0 0.4 0.9 467 Middle 24.2 2,425 18.4 0.9 66.8 1.3 11.7 0.9 0.9 586 Fourth 29.5 2,440 27.7 3.4 58.1 2.2 10.3 0.4 0.0 721 Highest 47.2 2,659 28.9 6.3 50.9 7.2 11.2 0.9 0.2 1,254 Total 27.6 12,008 23.5 3.5 61.2 3.5 10.1 0.7 0.5 3,311 Health Care Expenses and Health Care Coverage | 279 Health insurance coverage was much more common for 15-19 year olds (50 percent) than for respondents in other age groups. Men were more than twice as likely as women to be insured (38 percent and 18 percent, respectively). Around one-third of urban residents had insurance compared to slightly more than one-fifth of rural residents. Residents in rural Upper Egypt were less likely to have health insurance than residents in other areas (Figure 20.1). Respondents who had at least a primary education (37 percent) were much more likely than respondents who had never been to school (4 percent) or who had not completed a primary education (12 percent) to have health insurance. The proportion of respondents with health insurance increased with the wealth quintile, from 14 percent in the lowest quintile to 47 percent in the highest quintile. 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Appendix A │ 285 PERSONS INVOLVED IN THE 2008 EGYPT DEMOGRAPHIC AND HEALTH SURVEY Appendix A Technical and Administrative Staff Technical Director Fatma Hassan El-Zanaty Senior Technical Staff Mohamed Ahmed El-Ghazaly, Assistant Survey Director Noha Ahmed El-Ghazaly, Assistant Director for Training Rashad Hamed, Assistant Director for Data Processing Senior Data Processing Staff Moaz Salah El Deen, Supervisor for Data Processing Mohamed Husseen Awad Allh, Assistant Supervisor for Data Processing Anthropometric Consultants Magdy Mohamed Shehata Assem El Sharkawy Central Laboratory Aly Abdelstar Amal Naguib (ELISA) Ahmed Safwat (PCR) Theodor Bilharz Institute Mohamed Aly Saber (PCR) Effat EL-Sherbiny (ELISA) Nevein Fam( ELISA) Senior Field Staff Mounir Mohamed Ibrahim, Field Coordinator Yasser Khalifa Metwaly, Assistant Field Coordinator Wael Mahmoud Ibrahim, Assistant Field Coordinator Mahmoud Abdel Aziz, Health Technician, Field Monitoring Rabie Mohamed El Hussaini, Health Technician, Field Monitoring Saad Mohamed Saad, Field Monitoring Amr Abdel Salam, Field Monitoring Research Assistants Sameh Said Amin, Senior Assistant Mohamed Azab Gouda 286 | Appendix A Macro International Staff Ann Way, Country Monitor Alfredo Aliaga, Sampling Specialist Jasbir Sangha, Health Specialist Dean Garrett, Health Specialist Barbara Yang, Biomarker Procurement Specialist Jeanne Cushing, Senior Data Processing Specialist Avril Armstrong, Technical Reviewer Monica Kothari, Technical Reviewer Zhuzhi Moore, Technical Review Sri Poedjastoeti, Technical Reviewer Lyndsey Wilson-Williams, Technical Reviewer Sidney Moore, Senior Editor Kaye Mitchell, Document Production Specialist Christopher Gramer, Document Production Specialist Office Staff Mohamed Farag Allah, Supervisor Mohamed Ahmed Ismail Mahmoud Shehata Nagwa Metwaly Fahmy Rehab Fawzy Mahmoud Asmaa Sanhoury Administrative Staff Wegdan Yehya Husseen, Accountant Mohamed Farouk Ali, Accountant Azza Saad Abou El Eyoun, Secretary Quick Count and Re-Quick Count Staff Supervisors Abdel Wahab Hassan Abdel Wahab Mohamed Abdel Raheem Hassan Amr Shokry Mohamed Mohamed Mahros Mahros Anwar Mahmoud Ibrahim Mohamed Salem Husseen Ashraf Gaber Abdel Aziz Mostafa Farag Allah Raghby Emad El Deen Mostafa Husseen Osman Awad Osman Hany Said Ameen Mahmoud Saad Mohamed Saad Mohamed Husseen Farag Allah Raghby Waleid El-Gameel El-Sayed Mohamed Abdel Hady Amer Counters Abdel Basset El Sayed Salama Abdel Rahman Mohamed Abdel Rahman Mohamed Abdel Naby Mohamed Mohamed Abdel Hameed Abdel Wahab Ahmad Abdel Salam Abdel Kareem Mohamed Abdo El Dawi Mahmoud Ahmad Hegazy Noaman Hegazy Mohamed Adel Abdel Monem Abdo Ahmad Mohamad Mohamad Hassan Mohamed Ali Mahmoud Hashim Ahmad Mostafa Dakrory Mohamed Hegazy Noaman Hegazy Amr Abdel Salam Abdel Kareem Mohamed Mahmoud Mahmoud Ayman Adel Ramadan Ibrahim Mohamed Osaman Mohamed Ali Bassam Abdel Hady Amer Ghanem Mostafa Abo Serea Salama Mohamed Emad Ibrahim El-Sayed El Deeb Mostafa Salem Husseen Khattab Eslam Hashim Abdel Khaleq Nabeel Emam Abdel Razeq Hasab Allah Hisham Abdel Hafeez Emam Osama Mohamed Farag Allah Raghby Hossam Husseen Mohamed Ali Sameh Abdel Fattah Yunus Mohamed Mahmoud Abdo Hassan Ali Waleed Mohamed Metwaly Ibrahim Mohamed Abdel Fattah Abdel Monaem Waleed Salah El Deen Sayed Hassan Appendix A │ 287 Listing and Re-Listing Staff Supervisors Abdel Basset El Sayed Salama Rezq Mohamed Salem Husseen Abdel Wahab Hassan Abdel Wahab Mohamed Mahros Mahros Ahmad Mohamed Mohamed Hassan Mohamed Abdel Hady Amer Amr Abdel Salam Abdel Kareem Mostafa Farag Allah Raghby Amr Shokry Mohamed Osman Awad Osman Anwar Mahmoud Ibrahim Saad Mohamed Saad Mohamed Ashraf Gaber Abdel Aziz Mahmoud Waleed El-Gameel El-Sayed Husseen Farag Allah Raghby Listers Abdel Rahman Mohamed Abdel Rahman Mohamed Abdel Raheem Hassan Ahmad Abdel Salam Abdel Kareem Mohamed Abdo El Dawi Mahmoud Ahmad Hegazy Noaman Hegazy Mohamed Adel Abd El-Monem Ahmad Mostafa Dakrory Mohamed Mohamed Hassan Abd El-Aal Amr Awaad Ali Mohamed Hegazy Noaman Hegazy Ashraf Fathy Toson Mohamed Mohamed Osaman Mohamed Osman Bassam Abdel Haday Amer Ghanem Mohamed Yusuf Mostafa Emad Ibrahim El- Sayed El Deeb Mostafa Abo Sree Salama Hany Mohamed Ali Mostafa Salem Husseen Hisham Abdel Hafeez Emam Nabil Emam Abdel Razeq Hisham Salama Zaky Osama Mohamed Farag Allah Hossam Husseen Mahmoud Ali Sameh Abdel Fattah Yunus Mohamed Islam Hashim Abdel Khaleq Ali Waleed Salah El Deen Mohamed Abdel Fattah Abdel Monem Yasser Mohamed Abdel Salam Mohamed Abdel Hamid Abdel Wahab Yasser Salah Sawy Ibrahim Mohamed Abdel Naby Mohamed Interviewing and Reinterviewing Staff Supervisors Abdel Wahab Hassan Abdel Wahab Mohamed Abdel Hady Amer Amr Shokry Mohamed Mohamed Mahros Mahros Anwar Mahmoud Ibrahim Mohamed Salem Husseen Ashraf Gaber Abdel Aziz Osman Awad Osman Gamal Hashim Said Wael Abd El-Karim Mohamed Mahmoud Mohamed Yassen Waleed El-Gameel El-Sayed Mohamed Abd El-Kader Mohamed Waleed Mostafa Hashim Field Editors Amal Gad Ibrahim Mona Mohamad Abdel Aziz Amany Mohamed Mabrouk Raghda Yehya Abdel Maksoud Areeg Abdel Latif Mohamed Rehab Fathy Ali El Shimaa Mohamed Salah Rofeya Adel Hamed Hagar Radwan Mohamed Ali Samah Abdel Raouf Abdel Moghny Hamdya Mohamed Mohamed Sara Saad Ahmad Marwa Mohamed Mousa Shimaa Ahmad Ibrahim Maryana Mamdouh Faiq 288 | Appendix A Interviewers Abdel Basset El Sayed Salama Mohamed Abdel Naby Mohamed Ahmad Abdel Salam Abdel Kareem Mohamed Abdel Raheem Ahmad Mohamed Mohamed Mohamed Adel Abdel Monaem Almotasem Bellah Said Mohamed Hosny Atyea Amr Awaad Ali Mohamed Mahmoud Ibrahim Bassam Abdel Hady Amer Mohamed Osman Mohamed Husseen Farag Allah Raghby Mohamed Abdel Fattah Abdel Monaem Mostafa Abo Serea Mostafa Farag Allah Raghby Ahlam Labib Zaky El Sayed Asmaa Said Mohamed Amal Salah Mahmoud Mehany Basma Fekry Hamid Amani Kamal Abdel Latif Basma Saad Abdel Wahab Amira El Sayed Atteya Doaa Ibrahim Abdel Monaem Elham Mohamed Ahmad El Shikh Nadia Said Abdel Rahman Eman El Gameel El Sayed Nermeen Adel Abdel Qader Eman Mahmoud Hamed Sobeeh Nesma Mohamed Ezzat Mostafa Fatma Said Mohamady Neveen Jouseif Gerges Hasnaa Gamal Mohamed Omneya Mohamed Kamal Heba Ahmad Mohamed Mohamed Rabab Yehya Abdel Maksoud Heba Ahmad Nour El Deen Ranya El Sayed Mohamed Hebt Allah Husseen Hassan Ranya El Sayed Nasr Kawthar Hassan Bakry Ranya Fadl Aiad Lobna Mohamed Abdel Aziz Saly Mohamed El Basheer Maha Yousry Abdel Hamid Shereifa Saleh Mahmoud Mai Reda Ahmad El Refaay Wafaa Abdo Mohamed Martha Eshaq Morees Walaa El Said Ali Marwa Farouq Abdel Maksoud Walaa Emad Shabaan Esmaeel Marwa Fawzy Mahmoud Walaa Nabeel Mohamed Ezz Marwa Mohamed Abdel Azeem Yara Abd Allah Abdel Maaboud Marwa Mohamed Abdel Rahim Yara Mawuad Mohamed Ali Mona Sobhy Mohamed Biomarker Field Staff Abd Allah Ahmad Zaghlol Khairy Abdel Hameed Abdel Wahaab Abdel Rahman Abdel Salam Ibrahim Khaled Abdel Razek Abdel Wahed Ahmad Abdel Azzem El Desouky Kheder Mahmoud Khamis Ahmad Attya Abdel Monaem Mahasen Abdel Salam Taha Alhouseny Ismaeel Abdel Aziz Mahmoud Abdel Rahman Abdel Moeez Amira El Mohamady Ahmad Maysara Mostafa Abdel Maksoud Dalia Farouk Korany Awaad Mohamed Farouk Mohamed Shalaby Dina Ahmad Abdel Aziz Mohamed Fathy Mohamed Awad Doaa Lotfy Abdel Fadeel Saad Mohamed Husseen Ahmad Eman Berty Laban Hanna Mohamed Mahmoud Ibrahim Saad Eman Hassan Hassan Ali Mohamed Omar Zedan Abo Zeed Eman Shaban Abd Allah Mohamed Sayed Korany Eslam Ali Ahmad Amer Mona Mohsen Ameen Ibrahim Faten Ameen Ibrahim Mahmoud Nasr Mahmoud Nasr Fatma Mostafa Hassanin Rabab Yehya Abdel Maksoud Hany Abdel Mageed Ahmad Ranya Ramadan Sayed Hassanin Hany Mohamed El Sayed Ahmad Said Hasan Mohamed Hany Mosaad Ibrahim Shaimaa Sobhy Abdel Fattah Huda Mohamed Afify Sherief Atteya Mohamed Ahmad Husseen Abdo Husseen Hassan Tamer Abdel Halim Abdel Halim Husseen Mohamed Husseen Zainab Ismaeel Mohamed Ismaeel Mahmoud Mohamed Appendix A │ 289 Office Editing Staff Editors Coders Amany Mohamed Mabrouk Ahmed Gomaa Abd El-Aal Asmaa Sanhoury Eman Mohamed Fouaad Hanaa Soliman Abd El-Razek Hanaan Ahmed Fawzy Marwa Hassan Mahmoud Mohamed Ahmed Ismail Nagwa Metwaly Fahmy Mohamed Azab Gouda Rabab Yeheya Abdel Maksoud Reham Ali Mohamed Rehab Fawzy Mahmoud Shimaa Omr Sayed Data Processing Staff Dina Sayed Shabaan Nahed Abd El-Razik Mohamed Hamdy Abd El-Badia Ahmed Neamat Ahmad Hend Mahmoud Moawad Reham Ali Mohamed Huda Mahmoud Moawad Shahira Hamdy Mohamed Moamena Farag Kasem Suzan Mahmoud Mohamed Nagwa Metwaly Fahmy Central Laboratory ELISA Laboratory Azza Hasan Abdel Rahman Amal Hasan Nashed Magda Abdel Wahed Riham Ahmed Abdallah Nesrin Hamdy Mahmoud Mohamed Abo El-Mahasen Yara Ibrahim Shamekh Mahmoud Hamed Morsy Wesam Abdel Hamid PCR Laboratory Sahar Mohamed Ragheb Mohamed Ahmed Abdallah Shams Abo Daif Aly El-Shandaweely Ahmed Allam Ahmed Abdel Motteleb Appendix B │ 291 SAMPLE DESIGN Appendix B The sample for the 2008 Demographic and Health Survey was designed to obtain population and health data for two groups. The primary population surveyed was the universe of all ever-married women aged 15-49 in Egypt. In addition, the survey also targeted women and men age 15-59 who were interviewed on a range of special health topics and were also asked to participate in hepatitis C testing and blood pressure measurement. Because of the costs and complexity of the hepatitis C testing, the special health issues component of the survey was conducted only in a subsample of one quarter of the households selected for the 2008 EDHS. The sample design for the 2008 EDHS took into account the need to provide information on various population and health indicators of interest for the country as a whole and for six major subdivisions (Urban Governorates, urban Lower Egypt, rural Lower Egypt, urban Upper Egypt, rural Upper Egypt and the Frontier Governorates).1 In addition, the sample was designed to provide for sufficient numbers of households in governorates other than the Frontier Governorates and Luxor to allow for governorate-level estimates of many of the variables for which data was obtained during the ever- married women’s interviews. However, the governorate-level samples were too small to allow for separate estimates of some variables derived from the ever-married women data including fertility and mortality rates and child immunization rates. In addition, the subsample of households selected for the special health issues component of the EDHS was too small to allow for governorate-level estimates. To achieve the above objectives, a three stage probability sample was designed. The following is a detailed description of the 2008 EDHS sample design. A description of the field activities involved in the implementation of the sample design is included in Chapter 1 of this report. B.1 SAMPLE FRAME The sample frame for the 2008 EDHS was based upon the 2006 Egypt Population Census. The census provided information for the basic administrative units into which Egypt is divided.2 In addition, for the 2006 census, subdivisions called enumeration areas (EAs) were created based on the number of dwelling units. However, these EAs were not defined in terms of easily identifiable boundaries, and sketch maps of these areas were not available. For these reasons, EAs were not considered suitable to use as primary sampling units (PSUs) for the three previous EDHS surveys or the current survey. Consequently, shiakhas and villages were used as the basic sampling units, and additional sampling stages were introduced to obtain the final sampling units from which the household sample was drawn. Administrative changes which took place after 2006 census but prior to September 2007 were taken into consideration in the preparation of the sample frame for the 2008 EDHS survey.3 1 The Frontier Governorates were not included in 1988 and 1992 DHS surveys nor in the 1997, 1998 and 2003 interim surveys. However, they were part of the 1995, 2000 and 2005 EDHS samples. The inclusion of the Frontier Governorates in the 2008 EDHS will not affect comparisons of the 2008 results with the results of earlier surveys in which these governorates were not part of the samples since only around 1 percent of the Egyptian population resides in the Frontier Governorates. 2Administratively, Egypt is divided into 26 governorates. In turn, each governorate is divided into kisms and marquezes. Each kism is subdivided into shiakhas (urban areas), and each marquez into villages (rural areas) and a major town (urban area called medina). These divisions allow the country as a whole to be easily separated into rural and urban areas; the urban area includes all shiakhas and medinas, and the rural area includes all villages. 3 Luxor, which was originally a part of Qena governorate but was given a new status as a special administrative unit prior to the 2008 EDHS, was included as a separate unit in the sample frame. Because Luxor has a very small population in comparison to other governorates in Upper Egypt, it continues is combined with Qena governorate for analysis purposes. In May 2008, two new governorates: 6th of October and Helwan, were created from Cairo and Giza governorates, respectively. These two governorates were not accounted for separately in the 2008 EDHS sample frame because they had not yet been created at the time fieldwork for the 2008 EDHS survey was conducted. 292 | Appendix B B.2 MINIMUM SAMPLE SIZE PER DOMAIN A primary objective in determining the sample size for the 2008 EDHS survey was to ensure a sufficient number of cases in each domain to allow for estimates of adequate precision. For a given number of cases in a particular domain, the relative precision of estimates will vary depending on the characteristic being estimated. If the proportion is small, the relative precision of the estimate will be low compared with a estimate of a larger proportion. In addition, if the proportion to be estimated varies greatly between PSUs, the relative precision will be low compared with a situation where there is little variation between PSUs. The sampling design considerations also took into account the fact that EDHS samples are typically stratified, clustered and selected in several stages. Sampling errors in such designs have two components: one corresponding to variation BETWEEN PSUs and the other to variation WITHIN PSUs; however, the major component is usually the variation BETWEEN PSUs. The between PSUs variation is usually greater for urban areas than for the rural areas, but the within PSUs variation may be lower. The total number of PSUs is an important factor in controlling the total sampling variation, since the variation BETWEEN PSUs depends on this number. However, it should be noted that an increase in the number of selected PSUs reduces the sampling error, but not proportionally; for example, by doubling the number of units, the sampling error is reduced to about 70 percent of the original value (i.e., a reduction of only 30 percent). Taking into account these considerations as well as a concern to avoid oversampling which can result in unnecessarily high costs and increased problems in controlling the quality of the interviewing process, DHS sampling policy is to recommend approximately 1,000 cases per domain. This number of cases allows for a reasonably precise estimate of the total fertility rate for the domain. Therefore, given an optimal sample take of about 25-30 HHs per PSU, it is recommended that there should be a minimum of 40 PSUs per major domain in order to ensure an adequate number of cases for analysis. This guideline was observed for all of the major domains of interest in the 2008 EDHS. B.3 SAMPLE ALLOCATION Based on the above considerations of the minimum number of cases required for each domain, the target number of households for the 2008 EDHS was set at about 19,500. Information on sampling errors for five key variables from the 2005 EDHS was used to help determine the most efficient allocation of the target number of interviews by domain. In order to provide an adequate population for the calcula- tion of infant and child mortality rates, the minimum allocation per major domain was 1,000 households. The target number of households was distributed by governorate as shown in Table B.1. . B.4 STRATIFICATION Prior to the selection of the primary sampling units for the 2008 EDHS, the lists of shiakhas, medinas (urban areas) and villages (rural areas) which comprised the sample frame were grouped by governorate within four major domains (Urban Governorates, Upper Egypt, Lower Egypt, and Frontier Governorates). The combination of these criteria (governorate and urban-rural residence) provided for a direct stratification. In order to provide for implicit stratification by geographic location in each governorate, the lists of shiakhas, medinas, and villages also were arranged in serpentine order geographically, beginning from the northwest corner of the governorate; this stratification was done independently for urban and rural areas. Appendix B │ 293 Table B.1 Sample allocation for the 2008 EDHS Urban Rural Total Governorate Target number of households Segments PSUs Segments PSUs Segments PSUs Urban Governorates Cairo 1,600 100 50 _ _ 100 50 Alexandria 1,000 62 31 _ _ 62 31 Port Said 500 32 16 _ _ 32 16 Suez 500 32 16 _ _ 32 16 Subtotal 3600 226 113 _ _ 226 113 Lower Egypt Damietta 550 14 7 20 10 34 17 Dakalhia 1,000 18 9 44 22 62 31 Sharkia 1,000 14 7 48 24 62 31 Kalubia 1,000 28 14 34 17 62 31 Kafr El Shiek 650 10 5 30 15 40 20 Gharbeya 1,000 18 9 44 22 62 31 Menoufia 800 10 5 40 20 50 25 Behira 1,000 12 6 50 25 62 31 Ismailia 500 14 7 18 9 32 16 Subtotal 7,500 138 69 328 164 466 233 Upper Egypt Giza 1,000 36 18 26 13 62 31 Beni Suef 800 12 6 38 19 50 25 Fayoum 800 12 6 38 19 50 25 Minya 1,000 12 6 50 25 62 31 Assiut 1,000 16 8 46 23 62 31 Sougah 1,000 14 7 48 24 62 31 Qena 800 10 5 40 20 50 25 Aswan 550 14 7 20 10 34 17 Luxor 500 16 8 16 8 32 16 Subtotal 7,450 142 71 322 161 464 232 Frontier Governorates Red Sea 230 14 7 0 0 14 7 New Valley 150 4 2 6 3 10 5 Matrouh 260 12 6 4 2 16 8 North Sinai 270 10 5 6 3 16 8 South Sinai 120 4 2 4 2 8 4 Subtotal 1,030 44 22 20 10 64 32 Total 19,580 550 275 670 335 1,220 610 B.5 SAMPLE SELECTION During the first stage selection, a total of 610 primary sampling units (275 shiakhas/towns and 335 villages) were chosen for the 2008 EDHS sample. The second stage of selection in the 2008 EDHS involved several steps. First, for each of the primary sampling units (PSU), maps were obtained and divided into a number of parts of roughly equal size (assuming approximately 5,000 persons per part). In very large shiakhas/towns or villages (approxi- mately 100,000 and more population), three parts were selected from each PSU. In shiakhas or villages with 20,000-99,999 population, two parts were selected. In the remaining smaller shiakhas/towns and villages, one part was selected. A quick count was carried out in the selected parts in each PSU to provide the information needed to divide the parts into a number of segments of roughly equal size. After the quick count, a total of 1,287 segments were chosen from the parts in each shiakha/town and village in the 2008 EDHS sample (i.e., three segments from 48 PSUs, two segments were selected from 561 PSUs, and one segment from one PSU). A household listing was obtained for each segment. Using the household lists, a systematic sample of households was chosen for the 2008 EDHS. 294 | Appendix B B.6 SAMPLE IMPLEMENTATION Table B.2.1 presents results of the sample implementation for the entire household sample selected for the 2008 EDHS and for the ever-married women age 15-49 in those households. Table B.2.2 presents similar information for the subsample of households selected for the special health issues component of the survey and for the women and men age 15-59 who were elgible for the special health issues interviews in those households. Table B.2.1 Sample implementation for ever-married women component of the 2008 EDHS Percent distribution of households and ever-married women age 15-49 by results of the household and individual interviews, and household, eligible ever-married women and overall response rates, according to urban-rural residence and region, Egypt 2008 Residence Lower Egypt Upper Egypt Result Urban Rural Urban Gover- norates Total Urban Rural Total Urban Rural Frontier Gover- norates Total Selected households Completed (C) 94.2 97.8 93.5 96.4 94.0 97.5 97.5 95.8 98.4 93.2 96.1 Household present but no competent respondent at home (HP) 0.9 0.1 1.3 0.4 0.7 0.2 0.3 0.6 0.1 0.5 0.5 Postponed (P) 0.2 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Refused (R) 0.6 0.1 0.9 0.3 0.6 0.1 0.1 0.2 0.1 0.2 0.3 Dwelling not found (DNF) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 Household absent (HA) 1.5 0.6 1.6 1.1 1.8 0.8 0.7 1.1 0.5 1.3 1.0 Dwelling vacant/address not a dwelling (DV) 2.2 1.1 2.1 1.6 2.3 1.3 1.2 1.9 0.8 3.5 1.7 Dwelling destroyed (DD) 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other (O) 0.5 0.1 0.2 0.2 0.6 0.1 0.2 0.5 0.1 1.4 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 9,395 10,344 3,627 7,578 2,401 5,177 7,500 2,614 4,886 1,034 19,739 Household response rate (HRR)1 98.3 99.7 97.3 99.3 98.6 99.6 99.6 99.2 99.8 99.3 99.1 Ever-married women age 15-49 (EW) Completed (EWC) 99.7 99.8 99.9 99.9 99.8 99.9 99.7 99.6 99.7 98.5 99.7 Not at home (EWNH) 0.2 0.2 0.0 0.1 0.2 0.0 0.3 0.3 0.3 1.2 0.2 Refused (EWR) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 Partly completed (EWPC) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Incapacitated (EWI) 0.1 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.0 0.1 0.0 Other (EWO) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 6,699 9,872 2,421 6,522 1,742 4,780 6,703 1,927 4,776 925 16,571 Ever-married women response rate (EWRR)2 99.7 99.8 99.9 99.9 99.8 99.9 99.7 99.6 99.7 98.5 99.7 Overall response rate (ORR)3 98.0 99.5 97.3 99.2 98.4 99.6 99.3 98.8 99.5 97.8 98.8 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100*C ——————————— C + HP + P + R + DNF 2 Using the number of eligible respondents falling into specific response categories, the eligible respondent response rate (ERR) is calculated as: 100 * EWC ———————————————————————— EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as ORR = HRR * EWR/100 Appendix B │ 295 Table B.2.2 Sample implementation for health issues component of the 2008 EDHS Percent distribution of households and women and men age 15-59 by results of the household and individual i