Ethiopia - Demographic and Health Survey - 2006

Publication date: 2006

Ethiopia Demographic and Health Survey 2005 Central Statistical Agency Addis Ababa, Ethiopia ORC Macro Calverton, Maryland, USA September 2006 The 2005 Ethiopia Demographic and Health Survey (2005 EDHS) is part of the worldwide MEASURE DHS project which is funded by the United States Agency for International Development (USAID). The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID. Additional information about the 2005 EDHS may be obtained from the Central Statistical Agency (CSA), P.O. Box 1143, Addis Ababa, Ethiopia; Telephone: (251) 111 55 30 11/111 15 78 41, Fax: (251) 111 55 03 34, E-mail: csa@ethionet.et. Additional information about the DHS project may be obtained from ORC Macro, 11785 Beltsville Drive, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@orcmacro.com, Internet: http://www.measuredhs.com. Suggested citation: Central Statistical Agency [Ethiopia] and ORC Macro. 2006. Ethiopia Demographic and Health Survey 2005. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ORC Macro. Contents | iii CONTENTS TABLES AND FIGURES . ix FOREWORD .xvii ACKNOWLEDGMENTS . xix NATIONAL STEERING COMMITTEE MEMBERS . xxi SUMMARY OF FINDINGS .xxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS, ETHIOPIA 2005 .xxix CHAPTER 1 INTRODUCTION 1.1 History, Geography, and Economy .1 1.2 Population.3 1.3 Health Priorities and Programming .4 1.4 Objectives of the Survey .5 1.5 Organization of the Survey .6 1.6 Sample Design.7 1.7 Questionnaires .7 1.8 Haemoglobin and HIV Testing.8 1.8.1 Haemoglobin Testing .8 1.8.2 HIV/AIDS Testing .9 1.9 Listing, Pretest, Training and Fieldwork .10 1.9.1 Listing .10 1.9.2 Pretest.10 1.9.3 Training and Fieldwork .10 1.10 Data Processing .11 1.11 Response Rates.12 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population By Age And Sex.13 2.2 Household Composition .14 2.3 Household Education .17 2.3.1 Educational Attainment of Household Population .17 2.3.2 School Attendance Ratios.19 2.4 Household Characteristics .23 2.5 Household Possessions .27 2.6 Socioeconomic Status Index .28 iv Ň Contents CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Characteristics of Survey Respondents .31 3.2 Educational Attainment and Literacy.33 3.3 Access to Mass Media .37 3.4 Employment .39 3.4.1 Employment Status .39 3.4.2 Occupation.42 3.4.3 Earnings, Employers and Continuity of Employment .44 CHAPTER 4 FERTILITY 4.1 Current Fertility .47 4.2 Fertility Differentials.48 4.3 Fertility Trends.50 4.4 Children Ever Born and Surviving.51 4.5 Birth Intervals .52 4.6 Age at First Birth .53 4.7 Teenage Pregnancy and Motherhood .55 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods .57 5.2 Ever Use of Contraceptive Methods .59 5.3 Current Use of Contraceptive Methods.61 5.3.1 Trends in Contraceptive Use .64 5.3.2 Number of Children at First Use of Contraception.64 5.4 Use of Social Marketing Brands.65 5.5 Knowledge of Fertile Period.66 5.6 Source of Family Planning Methods .66 5.7 Informed Choice .67 5.8 Contraceptive Discontinuation.69 5.9 Future Use of Contraception.70 5.10 Reasons for Not Intending to Use A Contraceptive Method in the Future.71 5.11 Preferred Method of Contraception for Future Use .72 5.12 Exposure to Family Planning Messages.72 5.13 Contact of Nonusers with Family Planning Providers.73 5.14 Husband's Knowledge of Wife's Use of Contraception .75 5.15 Men's Attitude about Contraception .76 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status .79 6.2 Polygyny.80 6.3 Age at First Marriage .82 6.4 Age at First Sexual Intercourse .83 6.5 Recent Sexual Activity.85 Contents | v 6.6 Postpartum Amenorrhoea, Abstinence and Insusceptibility .88 6.7 Menopause .90 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children.91 7.2 Need for Family Planning Services .95 7.3 Ideal Family Size.97 7.4 Fertility Planning .99 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Assessment of Data Quality.102 8.2 Levels and Trends in Infant and Child Mortality .103 8.3 Socioeconomic Differentials in Childhood Mortality .104 8.4 Demographic Differentials in Mortality .105 8.5 Perinatal Mortality .107 8.6 High-Risk Fertility Behaviour.108 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care.111 9.2 Delivery Care .116 9.3 Postnatal Care .119 9.4 Problems in Accessing Health Care .120 CHAPTER 10 CHILD HEALTH 10.1 Child’s Size at Birth.127 10.2 Vaccination Coverage .128 10.3 Acute Respiratory Infection.132 10.4 Fever .134 10.5 Prevalence of Diarrhoea .135 10.6 Diarrhoea Treatment .136 10.7 Feeding Practices.138 10.8 Knowledge of ORS Packets .139 10.9 Stool Disposal.140 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN 11.1 Initiation of Breastfeeding .143 11.2 Breastfeeding Status by Age .144 11.3 Duration and Frequency of Breastfeeding .147 11.4 Types of Supplemental Food.148 11.5 Foods Consumed by Mothers .149 11.6 Micronutrient Intake.150 11.6.1 Iodine Intake.151 11.6.2 Micronutrient Intake Among Children .151 11.6.3 Micronutrient Intake among Mothers .154 vi Ň Contents 11.7 Prevalence of Anaemia .156 11.7.1 Prevalence of Anaemia in Children .156 11.7.2 Prevalence of Anaemia in Women .157 11.8 Nutritional Status .159 11.8.1 Nutritional Status of Children .159 11.8.2 Trends in Children’s Nutritional Status .162 11.8.3 Nutritional Status of Women.163 CHAPTER 12 MALARIA 12.1 Introduction.165 12.1.1 Malaria Vector Control.165 12.1.2 Malaria Diagnosis and Treatment .174 CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 Knowledge of HIV/AIDS and of Transmission and Prevention Methods .179 13.1.1 Awareness of AIDS.179 13.1.2 Knowledge of Ways to Reduce HIV/AIDS Transmission .179 13.1.3 Knowledge about Transmission .181 13.1.4 Knowledge about Mother-to-Child Transmission .185 13.2 Stigma Associated with AIDS and Attitudes Related to HIV/AIDS .187 13.3 Attitudes Towards Negotiating Safer Sex .189 13.4 Higher-Risk Sex .191 13.4.1 Multiple Sexual Partners and Higher-Risk Sex.191 13.4.2 Paid Sex.195 13.5 Testing for HIV .195 13.6 Reports of Recent Sexually Transmitted Infections .199 13.7 Male Circumcision.200 13.8 Injections .200 13.9 HIV/AIDS-Related Knowledge and Behaviour among Youth.202 13.9.1 Knowledge about HIV/AIDS and Source for Condoms.202 13.9.2 Age at First Sex and Condom Use at First Sexual Intercourse .205 13.9.3 Recent Sexual Activity .207 13.9.4 Higher-Risk Sex.209 13.9.5 Age-Mixing in Sexual Relationships .210 13.9.6 Drunkenness during Sexual Intercourse.210 13.9.7 HIV Testing .212 Contents | vii CHAPTER 14 HIV PREVALENCE AND ASSOCIATED FACTORS 14.1 Coverage of HIV Testing in the EDHS .213 14.2 HIV Prevalence.215 14.2.1 HIV Prevalence by Age.216 14.2.2 HIV Prevalence by Socio-economic Characteristics .217 14.2.3 HIV Prevalence by Other Sociodemographic Characteristics .218 14.2.4 HIV Prevalence by Sexual Risk Behaviour .220 14.2.5 HIV Prevalence by Other Characteristics Related to HIV Risk .222 14.3 HIV Prevalence and Male Circumcision .223 14.4 HIV Prevalence among Couples.223 14.5 EDHS and ANC Surveillance Results .225 14.6 Effect of Nonresponse on the EDHS HIV Prevalence Results .229 CHAPTER 15 ADULT AND MATERNAL MORTALITY 15.1 Data Quality Issues .231 15.2 Adult Mortality .232 15.3 Maternal Mortality .233 CHAPTER 16 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOME 16.1 Employment and Form of Earnings.235 16.2 Control Over and Relative Magnitude of Women’s Earnings .236 16.3 Woman’s Participation in Decisionmaking .238 16.4 Attitude Towards Refusing Sex with Husband .241 16.5 Attitudes Towards Wife Beating .244 16.6 Current Use of Contraception by Women’s Status .247 16.7 Ideal Family Size and Unmet Need by Women’s status.247 16.8 Reproductive Health Care by Women’s Status.248 16.9 Early Childhood Mortality Rates by Women’s Status .249 16.10 Property Dispossession .250 16.11 Harmful Traditional Practices.252 REFERENCES . 261 APPENDIX A SAMPLE IMPLEMENTATION .265 APPENDIX B ESTIMATES OF SAMPLING ERRORS.271 APPENDIX C DATA QUALITY TABLES .289 APPENDIX D PERSONS INVOLVED IN THE 2005 ETHIOPIA DEMOGRAPHIC AND HEALTH SURVEY.297 APPENDIX E QUESTIONNAIRES .301 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators.3 Table 1.2 Results of the household and individual interviews.12 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence.13 Table 2.2 Household composition.14 Table 2.3 Children's living arrangements and orphanhood.15 Table 2.4 Succession planning.16 Table 2.5.1 Educational attainment of household population: female.18 Table 2.5.2 Educational attainment of household population: male.19 Table 2.6 School attendance ratios .20 Table 2.7 Grade repetition and dropout rates.22 Table 2.8 Household drinking water.24 Table 2.9 Household sanitation facilities.25 Table 2.10 Household characteristics .26 Table 2.11 Household possessions .27 Table 2.12 Wealth quintiles.28 Table 2.13 Birth registration of children under age five .29 Figure 2.1 Population pyramid .14 Figure 2.2 Age-Specific Attendance Rates .23 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents .32 Table 3.2.1 Educational attainment by background characteristics: women .33 Table 3.2.2 Educational attainment by background characteristics: men.34 Table 3.3.1 Literacy: women.35 Table 3.3.2 Literacy: men.36 Table 3.4.1 Exposure to mass media: women.37 Table 3.4.2 Exposure to mass media: men.38 Table 3.5.1 Employment status: women .40 Table 3.5.2 Employment status: men.41 Table 3.6.1 Occupation: women.42 Table 3.6.2 Occupation: men .43 Table 3.7.1 Type of employment: women.44 Table 3.7.2 Type of employment: men.45 CHAPTER 4 FERTILITY Table 4.1 Current fertility .47 x | Tables and Figures Table 4.2 Fertility by background characteristics .49 Table 4.3 Trends in age-specific fertility rates.50 Table 4.4 Trends in age-specific and total fertility rates .50 Table 4.5 Children ever born and living.51 Table 4.6 Birth intervals.53 Table 4.7 Age at first birth .54 Table 4.8 Median age at first birth by background characteristics.55 Table 4.9 Teenage pregnancy and motherhood.56 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence .48 Figure 4.2 Total Fertility Rates by Background Characteristics .49 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods .58 Table 5.2 Couples' knowledge of contraceptive methods.59 Table 5.3.1 Ever use of contraception: women.60 Table 5.3.2 Ever use of contraception: men.61 Table 5.4 Current use of contraception .62 Table 5.5 Current use of contraception by background characteristics .63 Table 5.6 Trends in current use of contraception.64 Table 5.7 Number of living children at first use of contraception .65 Table 5.8.1 Pill brands.65 Table 5.8.2 Condom brands.65 Table 5.9 Knowledge of fertile period.66 Table 5.10 Source of modern contraceptive methods.67 Table 5.11 Informed choice .68 Table 5.12 First-year contraceptive discontinuation rates .69 Table 5.13 Reasons for discontinuation .70 Table 5.14 Future use of contraception .70 Table 5.15 Reason for not intending to use contraception in the future .71 Table 5.16 Preferred method of contraception for future use.72 Table 5.17 Exposure to family planning messages .73 Table 5.18 Contact of nonusers with family planning providers .74 Table 5.19 Husbands/partners knowledge of women's use of contraception .75 Table 5.20 Men's attitude about contraception.76 Figure 5.1 Trends in Current Use of Contraception, Ethiopia 1990-2005.64 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status .80 Table 6.2 Number of co-wives and wives .81 Table 6.3 Age at first marriage .82 Table 6.4 Median age at first marriage.83 Table 6.5 Age at first sexual intercourse .84 Table 6.6 Median age at first intercourse .85 Table 6.7.1 Recent sexual activity: women.86 Table 6.7.2 Recent sexual activity: men.87 Table 6.8 Postpartum amenorrhoea, abstinence and insusceptibility.89 Tables and Figures | xi Table 6.9 Median duration of postpartum insusceptibility by background characteristics .90 Table 6.10 Menopause.90 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children .92 Table 7.2.1 Desire to limit childbearing: women .93 Table 7.2.2 Desire to limit childbearing: men.94 Table 7.3 Need for family planning .96 Table 7.4 Ideal number of children .97 Table 7.5 Mean ideal number of children.98 Table 7.6 Fertility planning status.99 Table 7.7 Wanted fertility rates. 100 Figure 7.1 Fertility Preferences of Currently Married Women Age 15-49 .92 Figure 7.2 Desire to Limit Childbearing Among Currently Married Women, by Number of Living Children, 2000 and 2005.94 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 103 Table 8.2 Early childhood mortality rates by socioeconomic characteristics. 105 Table 8.3 Early childhood mortality rates by demographic characteristics. 106 Table 8.4 Perinatal mortality. 108 Table 8.5 High-risk fertility behaviour . 109 Figure 8.1 Early Childhood Mortality Rates for the Period 0-4 Years Preceding the Survey, 2000 and 2005. 104 Figure 8.2 Under-Five Mortality by Selected Demographic Characteristics. 106 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care. 112 Table 9.2 Number of antenatal care visits and timing of first visit . 113 Table 9.3 Components of antenatal care . 114 Table 9.4 Tetanus toxoid injections . 115 Table 9.5 Place of delivery . 117 Table 9.6 Assistance during delivery . 118 Table 9.7 Timing and type of provider of first postnatal checkup . 120 Table 9.8 Problems in accessing health care . 121 Table 9.9.1 Knowledge and attitude concerning tuberculosis among women. 123 Table 9.9.2 Knowledge and attitude concerning tuberculosis among men . 124 Table 9.10 Use of tobacco: men . 125 CHAPTER 10 CHILD HEALTH Table 10.1 Child's size at birth . 128 Table 10.2 Vaccinations by source of information. 129 Table 10.3 Vaccinations by background characteristics . 131 xii | Tables and Figures Table 10.4 Vaccinations in the first year of life. 132 Table 10.5 Prevalence and treatment of symptoms of ARI . 133 Table 10.6 Prevalence and treatment of fever. 135 Table 10.7 Prevalence of diarrhoea . 136 Table 10.8 Diarrhoea treatment . 137 Table 10.9 Feeding practices during diarrhoea . 139 Table 10.10 Knowledge of ORS packets or prepackaged liquids . 140 Table 10.11 Disposal of children's stools. 141 Figure 10.1 Percentage of Children Age 12-23 Months with Specific Vaccinations. 129 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN Table 11.1 Initial breastfeeding. 144 Table 11.2 Breastfeeding status by age . 145 Table 11.3 Median duration and frequency of breastfeeding . 147 Table 11.4 Foods and liquids consumed by children in the day or night preceding the interview. 149 Table 11.5 Foods consumed by mothers in the day and night preceding the interview. 150 Table 11.6 Presence of iodized salt in household . 151 Table 11.7 Micronutrient intake among children . 153 Table 11.8 Micronutrient intake among mothers . 155 Table 11.9 Prevalence of anaemia in children . 157 Table 11.10 Prevalence of anaemia in women . 158 Table 11.11 Nutritional status of children . 160 Table 11.12 Nutritional status of women by background characteristics. 164 Figure 11.1 Breastfeeding Practices by Age . 146 Figure 11.2 Trends in Infant Feeding Practice for Children 0-5 Months and 6-9 Months, 2000 and 2005 . 146 Figure 11.3 Nutritional Status of Children Under Age Five . 162 CHAPTER 12 MALARIA Table 12.1 Household possession of mosquito nets . 166 Table 12.2 Use of mosquito nets by children. 168 Table 12.3 Use of mosquito nets by women. 169 Table 12.4 Use of mosquito nets by population age five and older . 171 Table 12.5 Coverage of spraying programs . 172 Table 12.6 Prophylactic use of antimalarial drugs and use of intermittent preventive treatment (IPT) by women during pregnancy. 174 Table 12.7 Prevalence and prompt treatment of children with fever . 175 Table 12.8 Type and timing of antimalarial drugs received by children with fever. 177 CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS. 179 Table 13.2 Knowledge of methods of HIV prevention. 181 Table 13.3.1 Misconceptions and comprehensive knowledge about AIDS: women . 183 Tables and Figures | xiii Table 13.3.2 Misconceptions and comprehensive knowledge about AIDS: men. 184 Table 13.4 Knowledge of prevention of mother to child transmission of HIV . 186 Table 13.5.1 Accepting attitudes toward those living with HIV: women. 188 Table 13.5.2 Accepting attitudes toward those living with HIV: men . 189 Table 13.6 Attitudes toward negotiating safer sex with husband. 190 Table 13.7.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: women . 192 Table 13.7.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: men . 193 Table 13.8 Payment by men for sexual intercourse. 195 Table 13.9.1 Coverage of prior HIV testing: women . 196 Table 13.9.2 Coverage of prior HIV testing: men. 197 Table 13.10 Pregnant women counselled and tested for HIV. 198 Table 13.11 Self-reported prevalence of sexually-transmitted infections (STI) and STI symptoms . 199 Table 13.12 Prevalence of male circumcision . 200 Table 13.13 Prevalence of injections . 201 Table 13.14 Comprehensive knowledge about AIDS and a source for condoms among youth . 203 Table 13.15 Adult support for education about condom use to prevent AIDS. 204 Table 13.16 Age at first sex among youth . 205 Table 13.17 Condom use at first sexual intercourse among youth. 207 Table 13.18 Premarital sexual intercourse and condom use among youth . 208 Table 13.19 Higher-risk sexual intercourse among youth . 209 Table 13.20 Drunkenness during sexual intercourse among youth. 211 Table 13.21 Recent HIV tests among youth . 212 Figure 13.1 Percentage of Women and Men Age 15-49 with Comprehensive Knowledge about AIDS. 185 Figure 13.2 Multiple Sexual Partners and Higher-Risk Sexual Intercourse in the Past 12 Months among Men Age 15-49 . 194 CHAPTER 14 HIV PREVALENCE AND ASSOCIATED FACTORS Table 14.1 HIV testing coverage by residence and region . 214 Table 14.2 HIV testing coverage by background characteristics. 215 Table 14.3 HIV prevalence by age. 217 Table 14.4 HIV prevalence by socioeconomic characteristics. 218 Table 14.5 HIV prevalence by demographic characteristics . 219 Table 14.6 HIV prevalence by sexual behaviour . 221 Table 14.7 HIV prevalence by STI status and prior HIV testing status . 222 Table 14.8 HIV prevalence by male circumcision . 223 Table 14.9 HIV prevalence among couples. 224 Table 14.10 HIV prevalence results from the EDHS and the National Antenatal Care Surveillance System . 226 Table 14.11 Observed and adjusted HIV prevalence among women and men . 229 Table 14.12 Observed and adjusted HIV prevalence among women and men by background characteristics . 230 Figure 14.1 HIV Prevalence among Women and Men Age 15-49. 216 xiv | Tables and Figures Figure 14.2 HIV Prevalence among EDHS Respondents by Antenatal Care Status and HIV Rate from ANC Surveillance Data . 226 Figure 14.3 2005 Ethiopia Sample Cluster Locations and 2005 HIV Sentinel Surveillance Sites . 228 Figure 14.4 HIV Prevalence by Distance from 2005 ANC Sentinel Sites, EDHS Respondents Age 15-49 . 229 CHAPTER 15 ADULT AND MATERNAL MORTALITY Table 15.1 Adult mortality rates. 232 Table 15.2 Direct estimates of maternal mortality . 233 CHAPTER 16 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOME Table 16.1 Employment and cash earnings of currently married women. 235 Table 16.2 Control over women's earnings and relative magnitude of women's earnings . 237 Table 16.3 Women's control over her own earnings and over those of her husband/ partner. 238 Table 16.4 Women's participation in decisionmaking . 239 Table 16.5 Women's participation in decisionmaking by background characteristics. 240 Table 16.6.1 Attitude toward refusing sexual intercourse with husband: women . 242 Table 16.6.2 Attitude toward refusing sexual intercourse with husband: men . 243 Table 16.7.1 Attitude toward wife beating: women . 245 Table 16.7.2 Attitude toward wife beating: men. 246 Table 16.8 Current use of contraception by women's status. 247 Table 16.9 Ideal number of children and unmet need for family planning by women’s status . 248 Table 16.10 Reproductive health care by women's status . 249 Table 16.11 Early childhood mortality rates by women's status . 250 Table 16.12 Widows dispossessed of property. 251 Table 16.13 Knowledge, prevalence, and support of female circumcision . 253 Table 16.14 Daughter's circumcision experience and type of circumcision . 254 Table 16.15 Knowledge, prevalence, and support of uvulectomy or tonsillectomy. 255 Table 16.16 Daughter's uvulectomy/tonsillectomy . 256 Table 16.17 Knowledge, prevalence, and support of marriage by abduction. 257 Table 16.18 Daughter's marriage by abduction. 258 Table 16.19 Prevalence of obstetric fistula . 259 Figure 16.1 Number of Household Decisions in Which Currently Married Women Participate . 241 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Sample implementation: women . 265 Table A.2 Sample implementation: men. 266 Table A.3 Coverage of HIV testing among eligible respondents by social and demographic characteristics: women . 267 Tables and Figures | xv Table A.4 Coverage of HIV testing among eligible respondents by social and demographic characteristics: men. 268 Table A.5 Coverage of HIV testing by sexual behaviour characteristics: women . 269 Table A.6 Coverage of HIV testing by sexual behaviour characteristics: men . 270 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 274 Table B.2 Sampling errors for national sample . 275 Table B.3 Sampling errors for urban sample. 276 Table B.4 Sampling errors for rural sample. 277 Table B.5 Sampling errors for Tigray Region. 278 Table B.6 Sampling errors for Affar Region. 279 Table B.7 Sampling errors for Amhara Region . 280 Table B.8 Sampling errors for Oromiya Region . 281 Table B.9 Sampling errors for Somali Region. 282 Table B.10 Sampling errors for Benishangul-Gumuz Region. 283 Table B.11 Sampling errors for SNNP Region. 284 Table B.12 Sampling errors for Gambela Region . 285 Table B.13 Sampling errors for Harari Region . 286 Table B.14 Sampling errors for Addis Ababa Region. 287 Table B.15 Sampling errors for Dire Dawa Region . 288 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 289 Table C.2.1 Age distribution of eligible and interviewed women . 290 Table C.2.2 Age distribution of eligible and interviewed men. 290 Table C.3 Completeness of reporting . 291 Table C.4 Births by calendar years . 292 Table C.5 Reporting of age at death in days . 293 Table C.6 Reporting of age at death in months. 294 Foreword | xvii FOREWORD The 2005 Ethiopia Demographic and Health Survey (EDHS) was conducted under the auspices of the Ministry of Health and implemented by the then Population and Housing Census Commission Office (PHCCO), now merged with the Central Statistical Agency (CSA). The key findings of the survey were released in a preliminary report in November 2005. This final report details the findings of the survey. The first ever Demographic and Health Survey (DHS) in Ethiopia was conducted in 2000. The 2005 EDHS differed from the 2000 EDHS mainly because it included testing for the prevalence of anaemia and HIV. Major stakeholders from various Ministries were closely involved in the management and oversight of the survey and analysis of the survey results. The primary objective of the 2005 EDHS was to provide up-to-date information for policy makers, planners, researchers and programme managers, which would allow guidance in the planning, implementation, monitoring and evaluation of population and health programmes in the country. The information obtained from the EDHS, in conjunction with statistical information obtained from the Welfare Monitoring Survey (WMS) and Household Income, Consumption and Expenditure Survey (HICES), will provide critical information for the monitoring and evaluation of the country’s Plan for Accelerated and Sustained Development to End Poverty (PASDEP), the various sector development policies and programmes, and assist in the monitoring of the progress towards meeting the Millennium Development Goals (MDGs). The 2005 EDHS collected information on the population and health situation, covering topics on family planning, fertility levels and determinants, fertility preferences, infant, child, adult and maternal mortality, maternal and child health, nutrition, malaria, women’s empowerment, and knowledge of HIV/AIDS. In addition the EDHS includes population estimates of HIV and anaemia prevalence in the country. Key indicators relating to each of the above topics are provided for the nine regional states and two city administrations. In addition, data are also provided by urban and rural residence for the country. Findings from the survey indicate some improvements in major health and demographic variables in the past five years. The CSA would like to acknowledge a number of organizations and individuals who contributed to the successful completion of the 2005 EDHS. The Agency is grateful for the commitment of the Government of Ethiopia and the generous funding support primarily by the United States Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR), the Dutch and Irish Governments, and the United Nations Population Fund (UNFPA). We also appreciate UNICEF for supplying weighing scales and salt test kits; and WHO/Ethiopia and the Japan International Cooperation Agency (JICA) for each lending a vehicle to support fieldwork. We would also like to thank ORC Macro in Maryland, U.S.A. for technical assistance in all aspects of the survey. The agency extends a special thanks to the Ministry of Health, to all the member institutions of the EDHS Steering Committee and to development partners and stakeholders, who contributed to the successful completion of the survey. Special thanks also goes to the Ethiopia Health and Nutrition Research Institute (EHNRI), which handled the testing of the blood samples for determining the HIV status of the surveyed population. We also wish to acknowledge the tireless effort of the CSA staff who made this survey a success. Finally, we highly appreciate the field staff and, more importantly, the survey respondents, who were critical to the successful completion of this survey. Samia Zekaria Director General Central Statistical Agency Acknowledgments | xix ACKNOWLEDGMENTS The following persons contributed to the preparation of this report Mrs. Samia Zekaria, Central Statistical Agency Mr. Gebeyehu Abelti, Central Statistical Agency Mr. Genene Bizuneh, Central Statistical Agency Mrs. Gezu Berhanu, Central Statistical Agency Mr. Behailu G/Medhin, Central Statistical Agency Mr. Mekonen Tesfaye, Central Statistical Agency Mr. Yehualashet Mekonen, Central Statistical Agency Mrs. Alemtsehay Biru, Central Statistical Agency Mrs. Genet Mengistu, National Office of Population Mr. Ambachew Medhin, Ministry of Health/ WHO Mrs. Hiwot Mengistu, Ministry of Health Dr. Yared Mekonen, Ethiopian Health and Nutrition Research Institute Mr. Woldemariam Girma, Ethiopian Health and Nutrition Research Institute Dr. Aseged Woldu, HIV/AIDS Prevention and Control Office Mr. Hailu Belachew, CORHA Dr. Pav Govindasamy, ORC Macro Dr. Ann Way, ORC Macro Mr. Albert Themme, ORC Macro Dr. Alfredo Aliaga, ORC Macro Dr. Sidney Moore, ORC Macro Ms. Kaye Mitchell, ORC Macro Ms. Anne Cross, ORC Macro Ms. Joy Fishel, ORC Macro National Steering Committee Members | xxi NATIONAL STEERING COMMITTEE MEMBERS Mrs. Samia Zekaria CSA Mr. Amare Isaias PHCCO Dr. Tesfanesh Belay MOH Mr. Misganaw Lijalen HAPCO Dr. Tsehaynesh Messele EHNRI Dr. Yared Mekonnen EHNRI Mr. Hiruy Mitiku NOP Mrs. Genet Mengistu NOP Dr. Yemane Teklay ESTA Mr. Hailu Belachew CORHA Mr. Genene Bizuneh CSA Mr. Kefene Asfaw CSA Mr. Behailu G/Medhin CSA Mrs. Gezu Berhanu CSA Mr. Gebeyehu Abelti CSA Dr. Monique Rakotomalala UNFPA Mr. Jude Edochie UNFPA Mrs. Mulugojjam Assaye UNFPA Mrs. Meron Tewfik UNFPA Dr. Alemach Teklehaimanot UNICEF Dr. Habtamu Argaw WHO Ms. Sue Anthony USAID Mrs. Mary Ann Abeyta-Behnke USAID Dr. Omer Ahmed Omer USAID Dr. Kidest Lulu USAID Dr. Pav Govindasamy ORC Macro Mr. Bernard Ghaleb ORC Macro Summary of Findings | xxiii SUMMARY OF FINDINGS The 2005 Ethiopia Demographic and Health Survey (EDHS) is a nationally representative survey of 14,070 women age 15-49 and 6,033 men age 15-59. The EDHS is the second comprehensive survey conducted in Ethiopia as part of the worldwide Demographic and Health Surveys (DHS) project. The primary purpose of the EDHS is to furnish policymakers and planners with detailed information on fertility, family planning, infant, child, adult and maternal mortality, maternal and child health, nutrition and knowledge of HIV/AIDS and other sexually transmitted infections. In addition, in one of two households selected for the survey, women age 15-49 and children age 6-59 months were tested for anaemia, and women age 15-49 and men age 15-59 were tested for HIV. The 2005 EDHS is the first survey in Ethiopia to provide population- based prevalence estimates for anaemia and HIV. FERTILITY Survey results indicate that there has been a decline in fertility from 6.4 births per woman in 1990 to 5.4 births per woman in 2005, a one child drop in the last 15 years. The decline was more pronounced in the 10 years between 1990 and 2000 than in the five years between 2000 and 2005 and in urban than in rural areas. Rural women on average have two and a half children more than urban women. There is a substantial differential in fertility by region ranging from a low of 1.4 children per woman in Addis Ababa to a high of 6.2 children per woman in Oromiya. Education and wealth have a marked effect on fertility, with uneducated mothers having three times as many children as women with at least some secondary education and women in the lowest wealth quintile having twice as many children as women in the highest wealth quintile. Childbearing starts early. At current age- specific rates of childbearing, an Ethiopian woman will have had more than half of her lifetime births by age 30, and nearly three- fourths by age 35. Marriage patterns are an important determinant of fertility levels in a population. Although there was a marked decline in the percentage of women in union from 72 percent in 1990 to 64 percent in 2000, little change was observed in women currently in union in the last five years. Similar trends were observed in the median age at marriage and the median age at first sexual intercourse, with obvious increases in the ten-year period between 1990 and 2000 and little change in the five-year period between 2000 and 2005. Ethiopian women generally begin sexual intercourse at the time of their first marriage. This can be seen from the identical medians in age at first marriage and age at first sexual intercourse (16.1). Men, on the other hand, are sexually active before marriage, although the difference in age at first intercourse and age at first marriage has narrowed over the past five years. The median age at first sexual intercourse for men is 21.2 years while the median age at first marriage is 23.8. In general, Ethiopian men marry nearly eight years later than women. Data from the 2005 EDHS show that 12 percent of currently married women are married to men who are in a polygynous union. Older women, rural women, women residing in Gambela, uneducated women, and women in the poorest wealth quintile are more likely to be in a polygynous union than other women. About one in fifteen men is in a polygynous union. The extent of polygyny has declined over the past five years. The interval between births is relatively long in Ethiopia. The median number of months since the preceding birth is 33.8. Twenty-one percent of nonfirst births occur within two years of a previous birth, 35 percent occur between 24 and 35 months later and 44 percent occur at least three years after a previous birth. Postpartum insusceptibility is one of the major factors contributing to the long birth interval in Ethiopia. The median duration of amenorrhea is 15.8 months, postpartum abstinence is 2.4 months, and insusceptibility is 16.7 months. xxiv | Summary of Findings FAMILY PLANNING Overall, knowledge of contraception has remained consistently high in Ethiopia over the past five years with 88 percent of currently married women and 93 percent of currently married men having heard of at least one method of contraception. The pill, injectables, and condom are the most widely known modern methods among both women and men. Currently married men are more than twice as likely to recognize the condom as a method of family planning than currently married women (84 percent versus 41 percent). Twenty-four percent of currently married women and 19 percent of currently married men have used a family planning method at least once in their lifetime. Fifteen percent of currently married women are using a method of contraception. Modern methods are more widely used than traditional methods, with 14 percent of currently married women using a modern method and 1 percent using a traditional method. The most popular modern method is the injectable used by one in ten currently married women. About four in five currently married women obtain modern methods from the public sector, while 17 percent and 3 percent, respectively, obtain their method from the private medical sector or other private sources. Use of contraceptive methods tripled in the fifteen-year period between 1990 and 2005 from 5 percent to 15 percent. The increase is especially marked for modern methods which more than doubled in the five years between 2000 and 2005. This trend is mostly attributable to the recent rapid rise in the use of injectables from 3 percent in 2000 to 10 percent in 2005. More than half of currently married women who were not using any family planning method at the time of the survey say they intend to use a method in the future. The majority of prospective users prefer injectables while a sizeable proportion cite the pill as their preferred method. The desire for more children is frequently mentioned by currently married nonusers as a reason for not intending to use a method of contraception in the future. The proportion of women who cited this reason for not wanting to use a method has dropped markedly over the past five years from 42 percent in 2000 to 18 percent in 2005. Family planning information is largely received through the radio with limited exposure through the television and print media. Twenty- nine percent of women heard about family planning on the radio compared with 11 percent who heard about it from television and 8 percent who read about it in newspapers or magazines. The majority of Ethiopian women (78 percent) and men (76 percent) prefer to space or limit the number of children they have, and have a potential need for family planning. One in three currently married women has an unmet need for family planning (34 percent). The need for spacing (20 percent) is higher than the need for limiting (14 percent). If all currently married women who say they want to space or limit the number of children were to use family planning, the contraceptive prevalence rate in Ethiopia would increase from 15 percent to 49 percent. Currently, only 31 percent of the demand for family planning is being met. CHILD HEALTH At current mortality levels, one in every 13 Ethiopian children dies before reaching age one, while one in every eight does not survive to the fifth birthday. Data from the 2005 EDHS show that infant mortality has declined by 19 percent over the past 15 years from 95 deaths per 1,000 live births to 77. Under-five mortality has gone down by 25 percent from 166 deaths per 1,000 live births to 123. The corresponding declines in neonatal and postneonatal mortality over the 15-year period are 15 percent and 22 percent, respectively. Mortality is consistently lower in urban areas than in rural areas. The lowest level is in Addis Ababa, the most urbanized part of the country, while the highest levels are in Benishangul- Gumuz, Gambela, and Amhara. Maternal education is strongly correlated with child mortality. Under-five mortality among children born to mothers with no education is more than twice as high as that among children born to mothers with secondary education or higher. Survival of infants and children is strongly influenced by the gender of the child, mother’s Summary of Findings | xxv age at birth, birth order, and birth interval. Male children experience higher mortality than female children and the gender difference is especially pronounced for infant mortality. Childhood mortality is relatively higher among children born to mothers under age 20 and over age 40. First births and births of order seven and higher also suffer significantly higher rates of mortality than births of order two to six. Children born within two years of a preceding birth are more than three times as likely to die within the first year of life as children born three or more years after an older sibling. Twenty percent of children age 12-23 months had been fully vaccinated at the time of the survey. Three in five have received the BCG vaccination, and 35 percent have been vaccinated against measles. The coverage for the first dose of DPT is relatively high (58 percent). However, only 32 percent go on to receive the third dose of DPT. Polio coverage is much higher than DPT coverage because of the success of the national immunization day campaigns during which polio vaccines are administered. Nevertheless, the dropout between the first and subsequent doses of polio is marked – a 40 percent decline between the first and third dose. Vaccination coverage in Ethiopia has improved over the past five years. The percentage of children 12-23 months fully vaccinated at the time of the survey increased by 43 percent from 14 percent in 2000 to 20 percent in 2005. However, the percentage who received none of the six basic vaccinations also increased from 17 percent in 2000 to 24 percent in 2005. Thirteen percent of children under age five showed symptoms of acute respiratory infection (ARI) in the two weeks before the survey. Use of a health facility for the treatment of symptoms of ARI is low, with only 19 percent of children taken to a health facility or provider. Nineteen percent of children under five were reported to have had fever, a major manifestation of malaria, in the two weeks before the survey. Less than one in five children was taken to a health facility or provider for treatment. A very small percentage of children with fever received antimalarial drugs (3 percent) or antibiotics (6 percent). The 2005 EDHS gathered information on the use of mosquito nets, both treated and untreated. The data show that only 6 percent of households in Ethiopia own a mosquito net, with 3 percent of households owning an insecticide-treated net (ITN). Consistent with the degree of risk of malaria, ownership of mosquito nets varies inversely with altitude. For instance, 36 percent of households living in areas below 1,000 metres own some type of net, while the corresponding figure for households at altitudes above 2,000 metres or more is only 2 percent. Only 2 percent of children under five slept under a net the night prior to the interview, while less than 2 percent slept under an ever-treated net and under an ITN. Use of nets varies inversely with altitude with 19 percent of children living at altitudes less than 1,000 metres sleeping under a net compared with 4 percent or less among children living at altitudes above 1,000 metres. Eleven percent of households occupying a dwelling had their inner walls sprayed with insecticide to prevent malaria, 2 percent had been sprayed in the 6 months preceding the survey, and 3 percent had white insecticide powder visible on the inner walls. Nationally, 18 percent of children under age five had diarrhoea at some time in the two weeks before the survey, while 6 percent had diarrhoea with blood during the same period. Around one in five of these children were taken to a health provider. Thirty-seven percent of children with diarrhoea were treated with some kind of oral rehydration therapy (ORT): 20 percent were treated with ORS (solution prepared from ORS packets); 19 percent were given recommended home fluids (RHF) prepared at home; and 9 percent were given increased fluids. About half of children with diarrhoea did not receive any type of treatment at all. MATERNAL HEALTH Twenty-eight percent of mothers who had a live birth in the five years preceding the survey received antenatal care from health professionals; less than 1 percent of mothers received antenatal care from trained and untrained traditional birth attendants. More than seven in ten mothers did not receive antenatal care. There was little improvement in the percentage of mothers who received antenatal care from a health professional in the five years between the 2000 and 2005 surveys. About one in ten women make four or more antenatal care visits during their entire pregnancy. The median duration of xxvi | Summary of Findings pregnancy for the first antenatal visit is 5.6 months, indicating that Ethiopian women start antenatal care at a relatively late stage of their pregnancy. Among mothers who received antenatal care 31 percent reported that they were informed about pregnancy complications during their antenatal care visits. Weight and blood pressure measurements were taken for 72 percent and 62 percent of mothers, respectively. About one- quarter of mothers gave urine and blood samples. For last live births in the five years preceding the survey, only one in three women was protected against neonatal tetanus. Most of these women (28 percent) had received two or more tetanus injections while pregnant with the last birth. Despite the low coverage, there is evidence of improvement over time. The percentage of women who received two or more tetanus injections during pregnancy for the last birth increased from 17 percent in 2000 to 28 percent in 2005. An overwhelming majority of births in the five years before the survey were delivered at home (94 percent). Five percent of births were delivered in a public facility and 1 percent in a private facility. Six percent of births were delivered with the assistance of a trained health professional, that is, a doctor, nurse, or midwife, while 28 percent were delivered by a traditional birth attendant (TBA). The majority of births (61 percent) were attended by a relative or some other person. Five percent of births were delivered without any type of assistance at all. Postnatal care is extremely low in Ethiopia. Nine in 10 mothers who had a live birth in the five years preceding the survey received no postnatal care at all and only 5 percent of mothers received postnatal care within the critical first two days after delivery. BREASTFEEDING AND NUTRITION Breastfeeding is nearly universal in Ethiopia, and the median duration of any breastfeeding is long (25.8 months). Exclusive breastfeeding, on the other hand, is relatively short, with a median duration of 2.1 months. Contrary to WHO recommendations, only around one in three children age 4-5 months is exclusively breastfed. The data also show that complementary foods are not introduced in a timely fashion for many children. At 6-8 months, only one in two children is receiving complementary foods. The use of a bottle with a nipple is not widespread in Ethiopia. However, the proportion of children who are bottle-fed rises from 8 percent among children age less than 2 months to 19 percent among children age 6-8 months, after which it declines gradually. More than half of Ethiopian children age 6- 59 months are classified as anaemic, with 21 percent mildly anaemic, 28 percent moderately anaemic, and 4 percent severely anaemic. The prevalence of anaemia among women is less pronounced than among children. Twenty-seven percent of women age 15-49 are anaemic, with 17 percent mildly anaemic, 8 percent moderately anaemic, and just over 1 percent severely anaemic. The level of malnutrition is significant with nearly one in two (47 percent) Ethiopian children under five years of age stunted (short for their age), 11 percent wasted (thin for their height), and 38 percent underweight. In general, rural children and children of uneducated mothers are more likely to be stunted, wasted, or underweight than other children. Regional variation in nutritional status of children is substantial. Stunting levels are above the national average in Amhara and SNNP. Wasting is higher than the national average in Somali, Benishangul-Gumuz, Amhara, Tigray and Dire Dawa. The percentage of underweight children is above the national average in Somali, Amhara, Tigray and Benishangul-Gumuz. Survey results show that the level of chronic energy deficiency among women in Ethiopia is relatively high. Twenty-seven percent of women fall below the cutoff of 18.5 for the body mass index (BMI), which utilizes both height and weight to measure thinness. Four percent of women are overweight or obese. HIV/AIDS AND STIs Knowledge of AIDS is widespread in Ethiopia. Ninety percent of women age 15-49 and 97 percent of men age 15-49 have heard of AIDS. Women and men are most aware that the chances of getting the AIDS virus can be reduced Summary of Findings | xxvii by limiting sex to one uninfected partner who has no other partners (63 percent and 79 percent, respectively) or by abstaining from sexual intercourse (62 percent and 80 percent, respectively). Knowledge of condoms and the role they can play in preventing transmission of the AIDS virus is much less common, particularly among women. Only 51 percent of women and 69 percent of men know that a healthy-looking person can have the AIDS virus. Also, many women and men erroneously believe that AIDS can be transmitted by mosquito bites. Larger proportions of respondents are aware that the AIDS virus cannot be transmitted by supernatural means or by sharing food. The EDHS results also show that a minority of women (16 percent) and men (30 percent) have comprehensive knowledge of HIV/AIDS transmission, that is, they know that both condom use and limiting sex partners to one uninfected partner are HIV prevention methods; that a healthy-looking person can have HIV; and reject the two most common local misconceptions about HIV/AIDS —that AIDS can be transmitted through mosquito bites and by sharing food with an infected person. Around one-fifth of women and one-third of men age 15- 24 have comprehensive knowledge about HIV/AIDS. Sixty-nine percent of women and 75 percent of men know that HIV can be transmitted by breastfeeding. About one-fifth of women and one-fourth of men know that the risk of mother- to-child transmission (MTCT) can be reduced through the use of certain drugs during pregnancy. Information on higher-risk sex (sexual intercourse with a partner who is neither a spouse nor a cohabiting partner) shows that less than 1 percent of women and 4 percent of men have had two or more partners during the 12 months preceding the survey, and 3 percent of women and 9 percent of men have had higher-risk sexual intercourse. Among respondents who engaged in higher-risk sexual intercourse, 24 percent of women and 52 percent of men reported condom use the last time they had sexual intercourse. Among the adult population age 15-49, 4 percent of women and 6 percent of men reported that they had been tested for HIV at some time, and the majority of them had received the results of their test. Three percent of women reported that they had received information and counselling about HIV/AIDS during antenatal care for their most recent birth. Two percent each of sexually active women and men reported that they had had an STI and/or STI symptoms in the 12 months prior to the survey. Results from the 2005 EDHS indicate that 1.4 percent of Ethiopian adults age 15-49 are infected with HIV. HIV prevalence among women is nearly 2 percent, while for men 15-49, it is just under 1 percent. HIV prevalence levels rise with age, peaking among women in their late 30s and among men in their early 40s. The age pattern suggests that young women are particularly vulnerable to HIV infection compared with young men. Urban residents have a significantly higher risk of HIV infection (6 percent) than rural residents (0.7 percent). The risk of HIV infection among rural women and men is almost identical, while urban women are more than three times as likely as urban men to be infected. Prevalence levels are highest in Gambela (6 percent) and Addis Ababa (5 percent). Other regions in which HIV prevalence exceeds the national average include Harari, Dire Dawa, Affar, Tigray and Amhara. HIV infection levels increase directly with education among both women and men and are markedly higher among those with a secondary or higher education compared with those having less education. Employed women and men are also more likely to be HIV infected than the unemployed, as are women and men in the highest wealth quintile compared with those in the other wealth quintiles. WOMEN’S STATUS The DHS data shed some light on the status of women in Ethiopia. While the majority of Ethiopians have little or no education, women are generally less educated than men. However, the male-female gap in education is more obvious at higher than at lower levels of education, indicating the government’s recognition and successful intervention to address gender disparity in more recent years. xxviii | Summary of Findings Marked differences were observed in the levels of employment by gender. The majority of men (86 percent) were employed at the time of the survey, compared with 29 percent of women. Nearly one in three currently married women was employed during the 12 months before the survey. Three-tenths of employed women earn cash only or cash and in-kind earnings. Nearly three-fifths of currently married women are not paid at all. Almost two-fifths of currently married women who receive cash earnings report that they alone decide how their earnings are used, while more that half of currently married women say that they decide jointly with their husband or partner. Information on women’s decisionmaking autonomy shows that almost 53 percent of currently married women make independent decision about daily household purchases. While 15 percent of women make sole decisions on their own health care, one-third say that their husband or partner makes such decisions. Decisions on large household purchases are typically made by the husband or partner alone or jointly with their husband or partner. More than two-thirds of women say that decisions to visit family or relatives are made jointly with their husband or partner. The majority of women and men agree that a woman is justified in refusing to have sexual intercourse with her husband or partner for at least one of three specified reasons. Only one in ten women and men is of the opinion that a woman cannot refuse sexual intercourse for any reason. On the other hand, a sizable proportion of women (44 percent) and to a lesser extent men (23 percent), believe that a husband is justified in beating his wife if she refuses to have sex with him. Overall, eight in ten women and around half of men believe that there are at least some situations in which a husband is justified in beating his wife. EDHS data indicate a positive relationship between women’s status and contraceptive use. Contraceptive use is highest among women who participate in most household decisions, who agree that a woman can refuse sexual intercourse with her partner for all three specified reasons, and who believe that wife beating is not justified for all five specified reasons. The data show that mean ideal family size declines as women’s status increases. Also, there is a correlation between women’s status and utilization of health services. The more empowered a woman, the more likely she is to receive antenatal, postnatal, and delivery care from a health professional. The relationship between childhood mortality and women’s empowerment is mixed. The EDHS provides insight into several harmful traditional practices existent in Ethiopia. The practice of female circumcision is widespread in Ethiopia, with three in four women age 15-49 circumcised. Six percent of circumcised women reported that their vagina had been sewn closed (infibulation). More than two in five Ethiopian women themselves have had a uvulectomy or tonsillectomy. More than two-fifths of women with at least one daughter have a daughter who has had a uvulectomy or tonsillectomy. Eight percent of women reported that they had been married by abduction and about 1 percent with at least one daughter reported that a daughter was married by abduction. Around one in four women interviewed in the EDHS had heard of obstetric fistula and 1 percent of women who have ever given birth reported having experienced obstetric fistula. A small percentage of women (less than 1 percent) reported that they had been treated for obstetric fistula. According to information gathered from women who have heard of the condition, 4 percent of other women resident in the household also suffer from obstetric fistula. Maternal mortality is relatively high in Ethiopia with more than one in five deaths to women age 15-49 in the seven years preceding the survey attributed to pregnancy or pregnancy- related causes. The maternal mortality ratio, which measures the obstetric risk associated with each live birth, is 673 deaths per 100,000 live births for the period 1994-2000. Direct estimates of male and female mortality obtained from the sibling history gathered in the EDHS show that there were more female than male deaths in the seven years preceding the survey (925 compared with 903). The female mortality rate is 6.4 deaths per 1,000 population, which is 8 percent higher than the male mortality rate of 5.9 deaths per 1,000 population. Millennium Development Goal Indicators | xxix Millennium Development Goal Indicators, Ethiopia 2005 Goal Indicator Value 1. Eradicate extreme poverty and hunger Prevalence of underweight children under five years of age Male: 38.9% Female: 37.9% Total: 38.4% 2. Achieve universal primary education Net enrolment ratio in primary education1 Male: 42.2% Female: 42.4% Total: 42.3% Proportion of pupils starting grade 1 who reach grade 51 Male: 73.7% Female: 83.5% Total: 78.0% Literacy rate of 15-24-year olds2 Male: 67.2% Female: 41.6% Total: 54.4% 3. Promote gender equality and empower women Ratio of girls to boys in primary and secondary education Primary education: 0.91 Secondary education: 0.65 Ratio of literate women to men, 15-24 years old 0.62 Share of women in wage employment in the non-agricultural sector3 76.5% 4. Reduce child mortality Under-five mortality rate (per 1,000 live births) 123 per 1,000 Infant mortality rate (per 1,000 live births) 77 per 1,000 Proportion of 1-year-old children immunised against measles Male: 36.4% Female: 33.2% Total: 34.9% 5. Improve maternal health Maternal Mortality Ratio (per 100,000 live births) 673 per 100,000 Proportion of births attended by skilled health personnel 5.7% 6. Combat HIV/AIDS, malaria, and other diseases Condom use rate of the contraceptive prevalence rate (any modern method, currently married women 15-49) 1.32% Condom use at last high-risk sex (population age 15-24)4 Male: 46.8% Female: 28.4% Percentage of population age 15-24 years with comprehensive knowledge of HIV/AIDS5 Male: 33.3% Female: 20.5% Contraceptive prevalence rate (any modern method, currently married women 15-49) 13.9% Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years 0.9 7. Ensure environmental sustainability Proportion of population using solid fuels6 Urban: 96.5% Rural: 99.9% Total: 99.5% Proportion of population with sustainable access to an improved water source, urban and rural7 Urban: 92.7% Rural: 55.5% Total: 60.0% Proportion of population with access to improved sanitation, urban and rural8 Urban: 22.6% Rural: 5.4% Total: 7.4% 1 Excludes children with parental status missing 2 Refers to respondents who attended secondary school or higher and women who can read a whole sentence 3 Wage employment includes respondents who receive wages in cash or in cash and kind. 4 High risk refers to sexual intercourse with a partner who neither was a spouse nor who lived with the respondent; time frame is 12 months preceding the survey. 5 A person is considered to have a comprehensive knowledge about AIDS when they say that use of condoms for every sexual intercourse and having just one uninfected and faithful partner can reduce the chance of getting the AIDS virus, that a healthy-looking person can have the AIDS virus, and when they reject the two most common local misconceptions. The most common misconceptions in Ethiopia are that AIDS can be transmitted through mosquito bites and that a person can become infected with the AIDS virus by sharing food or utensils with someone who is infected. 6 Charcoal, firewood, straw, dung, or crop waste 7 Improved water sources are: household connection (piped), public standpipe, borehole, protected dug well, protected spring, or rainwater collection. 8 Improved sanitation technologies are: connection to a public sewer, connection to septic system, pour-flush latrine, simple pit latrine, or ventilated improved pit latrine. Introduction | 1 INTRODUCTION 1 1.1 HISTORY, GEOGRAPHY, AND ECONOMY History Ethiopia is an ancient country with a rich diversity of peoples and cultures and a unique alphabet that has existed for more than 3,000 years. Palaeontological studies identify Ethiopia as one of the cradles of mankind. “Dinknesh” or “Lucy,” one of the earliest and most complete hominoids discovered through archaeological excavations, dates back to 3.5 million years. Ethiopia’s geo- graphical and historical factors have had a great influence on the distribution of its peoples and languages. The country is situated at the cross roads between the Middle East and Africa. Through its long history, Ethiopia has become a melting pot of diverse customs and varied cultures, some of which are extremely ancient. Ethiopia embraces a complex variety of nations, nationalities and peoples, and linguistic groups. Its peoples altogether speak over 80 different languages constituting 12 Semitic, 22 Cushitic, 18 Omotic and 18 Nilo-Saharan languages (MOI, 2004). The country has always maintained its independence, even during the colonial era in Africa. Ethiopia is one of the founding members of the United Nations. Ethiopia has been playing an active role in African affairs, specifically played a pioneering role in the formation of the Organization of African Unity (OAU). In fact, the capital city, Addis Ababa, has been a seat for the OAU since its establishment and continues serving as the seat for the African Union (AU) today. Ethiopia was ruled by successive emperors and kings with a feudal system of government until 1974. In 1974, the military took over the reign of rule by force and administered the country until May 1991. Currently, a federal system of government exists, and political leaders are elected every five years. The government is made up of two tiers of parliament, the House of Peoples’ Representatives and the House of the Federation. Major changes in the administrative boundaries within the country have been made three times since the mid-1970s, and at present Ethiopia is administratively structured into nine regional states, namely, Tigray, Affar, Amhara, Oromiya, Somali, Benishangul-Gumuz, Southern Nations, Nationalities and Peoples, Gambela and Harari regional states and two city administrations, that is, Addis Ababa and Dire Dawa Administration Council. Geography Ethiopia is situated in the Horn of Africa between 3 and 15 degrees north latitude and 33 and 48 degrees east longitude. It is a country with great geographical diversity; its topographic features range from the highest peak at Ras Dashen, which is 4,550 metres above sea level, down to the Affar Depression at 110 metres below sea level (CSA, 2000). The climatic condition of the country varies with the topography, with temperatures as high as 47 degrees Celsius in the Affar Depression and as low as 10 degrees Celsius in the highlands. The total area of the country is about 1.1 million square kilometres and Djibouti, Eritrea, Sudan, Kenya, and Somalia border it. A large part of the country is high plateaux and mountain ranges, with precipitous edges dissected by rushing streams of tributaries of famous rivers like the Abay (The Blue Nile), Tekeze, Awash, Omo, the Wabe Shebelie and the Baro-Akobo (MOI, 2004). As the country is located within the tropics, its physical conditions and variations in altitude have resulted in great diversity of terrain, climate, soil, flora, and fauna. Ethiopia’s major physical features are the result of extensive and spectacular faulting that cracked the old crystalline block of the African continent along the eastern side, producing the Great Rift Valley that stretches from the 2 | Introduction eastern end of the Mediterranean Basin down to Mozambique in the southeastern part of our continent (MOI, 2004). There are three principal climatic groups in Ethiopia, namely the tropical rainy, dry, and warm temperate climates. In Ethiopia the mean maximum and minimum temperatures vary spatially and temporally. Generally, the mean maximum temperature is higher from March to May and the mean minimum temperature is lower from November to December as compared to the other months (MOI, 2004). Ethiopia’s mean annual distribution of rainfall is influenced by the direction of both westerly and southeasterly winds. Thus, in Ethiopia the general pattern of annual rainfall distribution remains seasonal, varying in amount, space, and time, as the rain moves from the southwest to the northeast of the country (MOI, 2004). Economy Ethiopia is an agrarian country and agriculture accounts for 54 percent of the gross domestic product (GDP). Agriculture employs about 80 percent of the population and accounts for about 90 percent of the exports (CSA, 2000). The country is one of the least developed in the world, with a per capita gross national income (GNI) in 2004 of US$110 (World Bank, 2006). Coffee has remained the main export of the country; however, other agricultural products are currently being introduced on the international market. The Ethiopian currency is the Birr, and at present, 1 US dollar is equivalent to about 8.60 Birr. Between 1974 and 1991, the country operated a central command economy under the socialist banner of the Derg regime. However, since their overthrow, Ethiopia has moved toward a market-oriented economy. At present, the country has one commercial and two specialized government-owned banks and also six privately owned commercial banks; one government-owned insurance company and seven private insurance companies (NBE, 2000). There are also 15 microfinancing institutions established by private organizations. For the past three years the Ethiopian economy has shown mixed performance, with negative real GDP growth rate of 3.8 percent in 2002/03 as a result of drought, followed by strong positive performance of 11.3 percent and 8.9 percent during the past two years. Accordingly, during 2001/02- 2004/05 the annual real GDP growth averaged 5 percent. As usual, variability of growth was mostly a result of the variability in the output of the agricultural sector. Agricultural value-added declined by about 12 percent in 2002/03 and rebounded by 18 percent in the following year. Inflation stood at 15.1 percent in 2002/03, but declined to 9 percent in 2003/04 and 6.8 percent in 2004/05. Exports registered substantial growth in recent years, owing to both increases in volume and revival in the prices of major exports in the international market. In 2003/04 and 2004/05 the total value of exports grew by 25.0 and 36.0 percent, respectively (MoFED, 2005). Despite improvements in the past few years, sustaining long-term growth remains a challenge. Economic growth averaged about 5 percent per annum over the period 1999/2000 to 2004/05. Adjusting for population growth, the average per capita income rose by about 2.1 percent per annum. Major disruptions and shocks in the 1970s and 1980s resulted in economic decline, and the relatively good performance of the 1990s and early 2000s has only recently helped to reverse and raise incomes (MoFED, 2005). Ethiopia is one of the seven priority countries selected by the Millennium Project to prepare a scaled-up investment plan that would allow the country to meet the Millennium Development Goal (MDG) targets in 2005. Ethiopia is on the verge of embarking on the second poverty reduction strategy, which is referred to as the ”Plan for Accelerated and Sustained Development to End Poverty (PASDEP)” that supersedes the first strategy “Sustainable Development and Poverty Reduction Program (SDPRP). The PASDEP carries forward important strategic directions pursued under the SDPRP—related to human development, rural development, food security and capacity building—but also embodies some bold new directions (MoFED, 2005). The PASDEP, which is the government’s national development plan for the five years covering 2005/06- 2009/10, consists of eight strategic elements, namely: a massive push to accelerated growth, a geographically differentiated strategy, addressing the population challenge, unleashing the potential of Introduction | 3 Ethiopia’s women, strengthening the infrastructural backbone, managing risk and volatility, scaling- up to reach the MDG, and creating jobs. 1.2 POPULATION Despite its long history, there were no estimates of the total population of Ethiopia prior to the 1930s. However, population estimates for some towns like Axum, Lalibela and Debre Berhan are available from the 16th century onwards. Many of the estimates were made by travellers and were based on a general observation. The first ever population and housing census was conducted in 1984. The 1984 Census covered about 81 percent of the population of the country and official estimates were given for the remaining 19 percent that were not enumerated in the census. The second population and housing census was conducted in 1994. Unlike the first census, the second census covered the entire population. Table 1.1 provides a summary of the basic demographic indicators for Ethiopia from data collected in the two population and housing censuses. The population increased over the decade from 42.6 million in 1984 to 53.5 million in 1994. There was a slight decline in the population growth rate over the decade, from 3.1 percent in 1984 to 2.9 percent in 1994. Ethiopia is one of the least urbanized countries in the world, with less than 14 percent of the country urbanized in 1994. Female life expectancy is about two years higher than male life expectancy. Over the decade, life expectancy for both males and females did not improve. Table 1.1 Basic demographic indicators Indicator 1984 Census1 1994 Census2 Population (millions) 42.6 53.5 Intercensal grown rate (percent) 3.1 2.9 Density (pop./km2.) 34.0 48.6 Percent urban 11.4 13.7 Life expectancy Male 51.1 50.9 Female 53.4 53.5 1 Including Eritrea; CSA, 1991 2 CSA, 1998 The majority of the population lives in the highland areas of the country. The main occupation of the settled population is farming, while in the lowland areas, the mostly pastoral population moves from place to place with their livestock in search of grass and water. Among the nine regional states, Amhara, Oromiya and SNNP comprised about 80 percent of the total population of the country. Affar, Somali, Benishangul-Gumuz and Gambela regions are relatively underdeveloped. Christianity and Islam are the main religions; 51 percent of the population are Orthodox Christians, 33 percent are Muslims, and 10 percent are Protestants. The rest follow a diversity of other faiths. The country is home to about 80 ethnic groups that vary in population size from more than 18 million people to less than 100 (CSA, 1998). Efforts were made to generate reliable demographic data by conducting a number of demographic surveys. These include the 1981 Demographic Survey, the 1990 National Family and Fertility Survey, the 1995 Fertility Survey of Urban Addis Ababa, and the 2000 Ethiopia Demographic and Health Survey (EDHS). The 1990 National Family and Fertility Survey (NFFS) was the first nationally representative survey that incorporated wider information on fertility, family planning, contraceptive use and other related topics. In addition to the topics covered by the NFFS, the 2000 EDHS collected information on maternal and child health, nutrition and breastfeeding practices, HIV and other sexually transmitted diseases. 4 | Introduction Population Policy Population policies had been accorded a low priority in Ethiopia prior to the early 1990s. After the end of the Derg regime, the Transitional Government adopted a national population policy in 1993 (TGE, 1993b). The primary objective of the population policy was to harmonize the rate of population growth with socio-economic development to achieve a high level of welfare. The main long-term objective was to close the gap between high population growth and low economic productivity and to expedite socio-economic development through holistic integrated programs. Other objectives included preserving the environment and reducing rural-urban migration and reducing morbidity and mortality, particularly infant and child mortality. More specifically, the population policy was targeted to: i. Reduce the total fertility rate from 7.7 children per woman in 1990 to 4.0 children per woman in 2015; ii. Increase the prevalence of contraceptives from 4 percent in 1990 to 44 percent in 2015; iii. Reduce maternal, infant and child morbidity and mortality rates as well as promote the level of general welfare of the population; iv. Significantly increase female participation at all levels of the educational system; v. Remove all legal and customary practices that prevent women from the full enjoyment of economic and social rights, including the full enjoyment of property rights and access to gainful employment; vi. Ensure spatially balanced population distribution patterns with a view to maintaining environmental security and extending the scope of development activities; vii. Improve productivity in agriculture and introduce off-farm and non-agricultural activities for the purpose of employment diversification; viii.Mount an effective countrywide population information and education programme addressing issues pertaining to small family size and its relationship with human welfare and environmental security (TGE, 1993b). The policy indicated that population activities will be undertaken in Ethiopia under the framework that would be defined in the technical and programmatic guidelines to be developed by the Office of Population in consultation with the National Population Council. The policy also proposed the establishment of certain institutional structures for its implementation. In general, the national population policy covered all the major grounds that need to be covered in providing directives on the management of population dynamics in the interest of sustainable development. 1.3 HEALTH PRIORITIES AND PROGRAMMING The health system in Ethiopia is underdeveloped, and transportation problems are severe. The majority of the population resides in the rural areas and has little access to any type of modern health institution. It is estimated that about 75 percent of the population suffers from some type of communicable disease and malnutrition, which are potentially preventable (TGE, 1995). There was no health policy up through the 1950s; however, in the early 1960s, a health policy initiated by the World Health Organization (WHO) was adopted. In the mid-1970s, during the Derg regime, an elaborate health policy with emphasis on disease prevention and control was formulated. This policy gave priority to rural areas and advocated community involvement (TGE, 1993a). At present, the government health policy takes into account population dynamics, food availability, acceptable living conditions, and other requisites essential for health improvements (TGE, 1993a). The present health policy arises from the fundamental principle that health constitutes physical, mental, and social well- being for the enjoyment of life and for optimal productivity. To realize this objective, the government has established the Health Sector Development Programme (HSDP), which incorporates a 20-year health development strategy, through a series of five-year investment programmes (MOH, 1999). This programme calls for the democratisation and decentralization of health services; development of preventive health care; capacity building within the health service system; equitable access to health services; self-reliance; promotion of intersectoral activities and participation of the private sector, Introduction | 5 including non-governmental organizations (NGOs); and cooperation and collaboration with all countries in general and neighbouring countries in particular and between regional and international organizations (TGE, 1993a). The HSDP was implemented in two cycles, currently extending into the third programme (HSDP III). The focus of HSDP III will be on poverty-related health conditions, communicable diseases such as malaria and diarrhoea, and health problems that affect mothers and children. Efforts will be concentrated on rural areas and on extending services outwards from static facilities to reach villages and households. In addition, and more importantly, gender will be mainstreamed at all levels of the health system (MoFED, 2005). The main implementation modalities identified were: i. The Health Service Extension Programme (HSEP)—which involves the use of female workers to deliver 16 health care packages in four main areas, i.e., hygiene and environmental sanitation, disease prevention and control, family health services, and health education and communication on outreach basis. ii. The Accelerated Expansion of Primary Health Care Coverage—which has already been developed and endorsed by the government, with a view to achieving universal coverage of primary health care in the rural population by 2008. iii. A Health Care Financing Strategy—which aims at increasing resource flow to the health sector, improving efficiency of resource utilization, and ensuring sustainability of financing to improve the coverage and quality of health service; iv. The Health Sector Human Resource Development Plan—which aims at overcoming problems related to the absolute shortage, maldistribution and productivity of workforce. Despite the progress to date, coverage of the system remains inadequate, and the quality of services available, especially in rural areas, is variable. In line with the government’s current five-year national plan, the health sector will continue to emphasize primary health care and preventive services; with a big focus on extending these services to those who have not been reached, and improving the effectiveness of services, especially addressing difficulties in staffing and the flow of drugs. The major health outcome objectives envisaged in the five-year period include (MoFED, 2005): i. To cover all rural localities with the HSEP to achieve universal primary health care coverage by the year 2008; ii. To reduce the maternal mortality ratio from 871/100,000 to 600 per 100,000 live births; iii. To reduce under-five mortality from 140 to 85 per 1000 population, and the infant mortality rate from 97 to 45 per 1000 populations; iv. To reduce total fertility rate from 5.9 to 4.0 children per woman; v. To reduce the adult incidence of HIV from 0.68 to 0.65 and maintain the prevalence of HIV at 4.4 percent; vi. To reduce morbidity attributed to malaria from 22 percent to 10 percent; vii. To reduce the case fatality rate of malaria in age groups five years and above from 4.5 percent to 2 percent and the rate in children under five from 5 percent to 2 percent; and viii. To reduce mortality attributed to tuberculosis (TB) from 7 percent to 4 percent of all treated cases. 1.4 OBJECTIVES OF THE SURVEY The principal objective of the 2005 Ethiopia Demographic and Health Survey (DHS) is to provide current and reliable data on fertility and family planning behaviour, child mortality, adult and maternal mortality, children’s nutritional status, the utilization of maternal and child health services, knowledge of HIV/AIDS and prevalence of HIV/AIDS and anaemia. The specific objectives are to: • collect data at the national level which will allow the calculation of key demographic rates;G 6 | Introduction • analyze the direct and indirect factors which determine the level and trends of fertility; • measure the level of contraceptive knowledge and practice of women and men by method, urban-rural residence, and region;G • collect high quality data on family health including immunization coverage among children, prevalence and treatment of diarrhoea and other diseases among children under five, and maternity care indicators including antenatal visits and assistance at delivery; • collect data on infant and child mortality and maternal and adult mortality; G • obtain data on child feeding practices including breastfeeding and collect anthropometric measures to use in assessing the nutritional status of women and children; • collect data on knowledge and attitudes of women and men about sexually transmitted diseases and HIV/AIDS and evaluate patterns of recent behaviour regarding condom use;G • conduct haemoglobin testing on women age 15-49 and children under age five years in a subsample of the households selected for the survey to provide information on the prevalence of anaemia among women in the reproductive ages and young children; • collect samples for anonymous HIV testing from women and men in the reproductive ages to provide information on the prevalence of HIV among the adult population. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels. A long-term objective of the survey is to strengthen the technical capacity of the Central Statistical Agency to plan, conduct, process, and analyse data from complex national population and health surveys. Moreover, the 2005 Ethiopia DHS provides national and regional estimates on population and health that are comparable to data collected in similar surveys in other developing countries. The first ever Demographic and Health Survey (DHS) in Ethiopia was conducted in the year 2000 as part of the worldwide DHS programme. Data from the 2005 Ethiopia DHS survey, the second such survey, add to the vast and growing international database on demographic and health variables. Wherever possible, the 2005 EDHS data is compared with data from the 2000 EDHS. In addition, where applicable, the 2005 EDHS is compared with the 1990 NFFS, which also sampled women age 15-49. Husbands of currently married women were also covered in this survey. However, for security and other reasons, the NFFS excluded from its coverage Eritrea, Tigray, Asseb, and Ogaden autonomous regions. In addition, fieldwork could not be carried out for Northern Gondar, Southern Gondar, Northern Wello, and Southern Wello due to security reasons. Thus, any comparison between the EDHS and the NFFS has to be interpreted with caution. 1.5 ORGANIZATION OF THE SURVEY The 2005 EDHS was carried out under the aegis of the Ministry of Health and was implemented by the then Population and Housing Census Commission Office (PHCCO), now merged with the Central Statistical Agency (CSA). The testing of the blood samples for HIV status was handled by the Ethiopia Health and Nutrition Research Institute (EHNRI). ORC Macro provided technical assistance through its MEASURE DHS project. The resources for the conduct of the survey were committed by the Government of Ethiopia, and various international donor organizations and governments, namely, the United States Agency for International Development (USAID), the President’s Emergency Plan for AIDS Relief (PEPFAR), the Dutch and Irish Governments, and the United Nations Population Fund (UNFPA). A steering committee composed of major stakeholders drawn from the government, international organizations and NGOs was formed. The steering committee was responsible for coordination, oversight, advice and decision-making on all major aspects of the survey undertaking. Introduction | 7 Members of the steering committee include the Ministry of Health (MOH), PHCCO, EHNRI, the HIV/AIDS Prevention and Control Office (HAPCO), the National Office of Population (NOP), the Ethiopian Science and Technology Agency, the Consortium of Reproductive Health Associations (CORHA), USAID, UNFPA, UNICEF, and WHO. A technical committee was also formed from among the steering committee institutions. 1.6 SAMPLE DESIGN The 2005 EDHS sample was designed to provide estimates for the health and demographic variables of interest for the following domains: Ethiopia as a whole; urban and rural areas of Ethiopia (each as a separate domain); and 11 geographic areas (9 regions and 2 city administrations), namely: Tigray; Affar; Amhara; Oromiya; Somali; Benishangul-Gumuz; Southern Nations, Nationalities and Peoples (SNNP); Gambela; Harari; Addis Ababa and Dire Dawa. In general, a DHS sample is stratified, clustered and selected in two stages. In the 2005 EDHS a representative sample of approximately 14,500 households from 540 clusters was selected. The sample was selected in two stages. In the first stage, 540 clusters (145 urban and 395 rural) were selected from the list of enumeration areas (EA) from the 1994 Population and Housing Census sample frame. In the census frame, each of the 11 administrative areas is subdivided into zones and each zone into weredas. In addition to these administrative units, each wereda was subdivided into convenient areas called census EAs. Each EA was either totally urban or rural and the EAs were grouped by administrative wereda. Demarcated cartographic maps as well as census household and population data were also available for each census EA. The 1994 Census provided an adequate frame for drawing the sample for the 2005 EDHS. As in the 2000 EDHS, the 2005 EDHS sampled three of seven zones in the Somali Region (namely, Jijiga, Shinile and Liben). In the Affar Region the incomplete frame used in 2000 was improved adding a list of villages not previously included, to improve the region’s representativeness in the survey. However, despite efforts to cover the settled population, there may be some bias in the representativeness of the regional estimates for both the Somali and Affar regions, primarily because the census frame excluded some areas in these regions that had a predominantly nomadic population. The 540 EAs selected for the EDHS are not distributed by region proportionally to the census population. Thus, the sample for the 2005 EDHS must be weighted to produce national estimates. As part of the second stage, a complete household listing was carried out in each selected cluster. The listing operation lasted for three months from November 2004 to January 2005. Between 24 and 32 households from each cluster were then systematically selected for participation in the survey. Because of the way the sample was designed, the number of cases in some regions appear small since they are weighted to make the regional distribution nationally representative. Throughout this report, numbers in the tables reflect weighted numbers. To ensure statistical reliability, percentages based on 25 to 49 unweighted cases are shown in parentheses and percentages based on fewer than 25 unweighted cases are suppressed. 1.7 QUESTIONNAIRES In order to adapt the standard DHS core questionnaires to the specific socio-cultural settings and needs in Ethiopia, its contents were revised through a technical committee composed of senior and experienced demographers of PHCCO. After the draft questionnaires were prepared in English, copies of the household, women’s and men’s questionnaires were distributed to relevant institutions and individual researchers for comments. A one-day workshop was organized on November 22, 2004 at the Ghion Hotel in Addis Ababa to discuss the contents of the questionnaire. Over 50 participants attended the national workshop and their comments and suggestions collected. Based on these comments, further revisions were made on the contents of the questionnaires. Some additional questions were included at the request of MOH, the Fistula Hospital, and USAID. The questionnaires were finalized in English and translated into the three main local languages: Amharic, Oromiffa and 8 | Introduction Tigrigna. In addition, the DHS core interviewer’s manual for the Women’s and Men’s Questionnaires, the supervisor’s and editor’s manual, and the HIV and anaemia field manual were modified and translated into Amharic. The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor and roof of the house, ownership of various durable goods, and ownership and use of mosquito nets. In addition, this questionnaire was used to record height and weight measurements of women age 15-49 and children under the age of five, households eligible for collection of blood samples, and the respondents’ consent to voluntarily give blood samples. The Women’s Questionnaire was used to collect information from all women age 15-49 years and covered the following topics. • Household and respondent characteristics • Fertility levels and preferences • Knowledge and use of family planning • Childhood mortality • Maternity care • Childhood illness, treatment, and preventative actions • Anaemia levels among women and children • Breastfeeding practices • Nutritional status of women and young children • Malaria prevention and treatment • Marriage and sexual activity • Awareness and behaviour regarding AIDS and STIs • Harmful traditional practices • Maternal mortality The Men’s Questionnaire was administered to all men age 15-59 years living in every second household in the sample. The Men’s Questionnaire collected similar information contained in the Women’s Questionnaire, but was shorter because it did not contain questions on reproductive history, maternal and child health, nutrition and maternal mortality. 1.8 HAEMOGLOBIN AND HIV TESTING In one in two households selected for the 2005 EDHS, women age 15-49 and children age 6- 59 months were tested for anaemia. In addition, all eligible women and men in this subsample of households were tested for HIV. Anaemia and HIV testing were only carried out if consent was provided by the respondents and in the case of a minor, by the parent or guardian. Consent for HIV and anaemia was obtained separately. The protocol for haemoglobin and HIV testing was approved by the National Ethics Review Committee of the Ethiopia Science and Technology Commission in Addis Ababa, Ethiopia and the ORC Macro Institutional Review Board in Calverton, USA. 1.8.1 HAEMOGLOBIN TESTING Haemoglobin testing is the primary method of anaemia diagnosis. In the EDHS, testing was done using the HemoCue system. A consent statement was read to the eligible woman and to the parent or responsible adult of young children and women age 15-17. This statement explained the purpose of the test, informed prospective subjects tested and/or their caretakers that the results would Introduction | 9 be made available as soon as the test was completed, and requested permission for the test to be carried out, as well as consent to report their names to health personnel in the local health facility if their haemoglobin level was severe. Before the blood was taken, the finger was wiped with an alcohol prep swab and allowed to air-dry. Then the palm side of the end of a finger was punctured with a sterile, non-reusable, self- retractable lancet and a drop of blood collected on a HemoCue microcuvette and placed in a HemoCue photometer which displays the result. For children 6-11 months who were particularly undernourished and bony, a heel puncture was made to draw a drop of blood. The results were recorded in the Household Questionnaire, as well as on a brochure given to each woman, parent, or responsible adult, explaining what the results meant. For each person whose haemoglobin level was severe, and who agreed to have the condition reported, a referral was given to the respondent to be taken to a health facility. 1.8.2 HIV/AIDS TESTING Eligible women and men in the subsample of households selected for HIV testing who were interviewed were asked to voluntarily provide a few drops of blood for HIV testing. The protocol for the blood specimen collection and analysis was based on the anonymous linked protocol developed for DHS. The protocol allows for the merging of the HIV results to the socio-demographic data collected in the individual questionnaires, provided that information that could potentially identify an individual is destroyed before the linking takes place. This required that identification codes be deleted from the data file and that the back page of the Household Questionnaires that contain the bar code labels and names of respondents be destroyed prior to merging the HIV results with the individual data file. If, after explaining the procedure, the confidentiality of the data, and the fact that the test results would not be made available to the subject, a respondent consented to the HIV testing, a minimum of three blood spots was obtained from a finger prick and collected on a filter paper to which was affixed a bar code label unique to the respondent, but with no other identifying information attached. Each respondent who consented to being tested for HIV was given an information brochure on AIDS, a list of fixed sites providing voluntary counselling and testing (VCT) services throughout the country, and a voucher to access free VCT services at any of these sites for the respondent and/or the partner. Each dried blood spot (DBS) sample was given a bar code label, with a duplicate label attached to the Household Questionnaire on the line showing consent for that respondent. A third copy of the same bar code label was affixed to a Blood Sample Transmittal Form to track the blood samples from the field to the laboratory. Filter papers were dried overnight in a plastic drying box, after which the biomarker interviewer packed them in individual Ziploc bags for that particular sample point. Blood samples were periodically collected in the field along with the completed questionnaires and transported to the PHCCO headquarters in Addis Ababa for logging in, after which they were taken to EHNRI for HIV testing. In preparation for carrying out the HIV testing, an assessment was conducted jointly by EHNRI staff and Macro consultants (from the Zambia Tropical Disease Research Centre) of the equipment and staff training required for the testing of the DBS samples. In addition, the consultants together with a biomarker specialist from ORC Macro worked with laboratory scientists at EHNRI to conduct a validation study and set up the dried blood spot methodology to test for HIV using two Enzyme-Linked Immunosorbent Assay (ELISA) tests from different manufacturers. Several meetings with ORC Macro staff, EHNRI staff, and staff of PHCCO, were held to discuss the monitoring of sample collection in the field, the collection of samples from the field, and the delivery of the samples to the laboratory, with built-in checks to verify the samples collected and delivered. It was emphasized at the meeting that the period between the collecting of blood samples in the field and the time of refrigeration should not exceed 14 days. The DBS filter paper samples with barcodes were 10 | Introduction received by EHNRI. Upon receipt, the samples were counted and checked against the transmittal sheet to verify the barcode identifications and kept frozen until testing was started in September. All specimens were tested with a screening test, Vironostika HIV Uni-Form Plus O manufactured by BioMerieux (ELISA I). All samples positive on the first screening test as well as 10 percent of the negatives were further tested with Enzygnost Anti HIV-1/2 Plus manufactured by Dade Behring (ELISA 2). According to the testing algorithm, samples positive on both ELISAs were regarded as positive and samples negative for both ELISAs were regarded as negative. Samples that had discordant results on ELISA I and ELISA II were subject to a retest with both ELISAs. The results were obtained and interpreted in the same manner as indicated above for the repeat ELISA testing. Discordant samples from the repeat ELISAs, were tested with a confirmatory test, Genetic Systems HIV-1 Western Blot manufactured by Bio-Rad. The result on immunoblotting (Western Blot) was regarded as the final result. 1.9 LISTING, PRETEST, TRAINING AND FIELDWORK 1.9.1 Listing After the selection of the 540 clusters throughout the 11 administrative areas, a listing operation in the selected clusters starting from the month of October 2004 was conducted. For this purpose, training was conducted for 46 listers who had been recruited from all the regions to do the listing of households and delineation of EAs. A manual that described the listing procedure was prepared as a guideline and the training was conducted using classroom demonstrations and field practices. Instructions were given on the use of Global Positioning System (GPS) units to obtain locational coordinates for selected EAs. The listing was performed by organizing the listers into teams, with two listers per team. Seven field coordinators were also assigned from the head office to perform quality checks and handle all the administrative and financial issues of the listing staff. Supervision was carried out by the cartographic division of PHCCO to assess the quality of the field operation and the level of the accuracy of the GPS readings. Though the listing operation was aimed to be completed in three months, it was extended up to five months in some parts of the country, primarily because of a shortage of vehicles. 1.9.2 Pretest Prior to the start of the fieldwork, the questionnaires were pretested in all the three local languages, to make sure that the questions were clear and could be understood by the respondents. In order to conduct the pilot survey, 12 interviewers were recruited from the Amhara, Oromiya and Tigray regions. In addition to the new recruits, 14 senior staff members of PHCCO were trained for a period of three weeks to conduct the pilot fieldwork and serve as trainers for the main fieldwork. The pilot training which was conducted from January 24 to February 11, 2005, included training in blood sample collection for the anaemia and HIV testing. The pilot survey was conducted from 11-25 February 2005 in four selected sites. The areas selected for the pretest were urban Addis Ababa and both urban and rural parts of Mekele, Ambo and Debre Birhan areas. Based on the findings of the pretest, the household, the women’s and men’s questionnaires were further refined in all the three local languages. 1.9.3 Training and Fieldwork The recruitment of interviewers, editors and supervisors was conducted in the 9 regions and 2 city administrations taking into account language skills of the specific areas. Accommodation was arranged for the trainees as well as the trainers at a training site in Addis Ababa. The training of interviewers, editors and supervisors was conducted from March 14 to April 20, 2005. The Amharic questionnaires were used during the training, while the Tigrigna and Oromiffa versions were simultaneously checked against the Amharic questionnaires to ensure accurate translation. In addition Introduction | 11 to classroom training, trainees did several days of field practice to gain more experience on interviewing in the three local languages and fieldwork logistics. A total of 271 trainees were trained in five classrooms. In each class the training was conducted by two senior staff members of PHCCO. The Family Guidance Association of Ethiopia conducted a session demonstrating and explaining the different family planning methods, while UNFPA and CDC conducted a session on HIV/AIDS. After the training on how to complete the household, women’s and men’s questionnaires was completed, an exam was given to all trainees. On the basis of the scores on the exam and overall performances in the classroom, 240 trainees were selected to participate in the main fieldwork. From the group 30 of the best male trainees were selected as supervisors and 30 of the best female interviewers were identified as field editors. The remaining 180 trainees were selected to be interviewers. The trainees not selected to participate in the fieldwork were kept as reserve. After completing the interviewers’ training, the field editors and supervisors were trained for an additional three days on how to supervise the fieldwork and edit questionnaires in the field to ensure data quality. Thirty male interviewers and 30 female interviewers were selected to attend the biomarker training. In addition, the 30 field editors also attended the training, as a backup to the biomarker interviewers. Thirteen regional laboratory technicians who were recruited from Private Laboratory Consortium Unit (PLCU) to serve as regional coordinators for the HIV testing were also trained, of whom 11 were eventually selected to supervise the blood collection. During the one-week biomarker training, six experienced experts from ORC Macro and EHNRI provided theoretical training followed by practical classroom demonstrations of the techniques for testing of haemoglobin and collection of dried blood spots from a finger prick for HIV testing. In addition to the classroom training, trainees did several days of field practice to gain more experience on blood collection. A total of 30 data collection teams, each composed of four female interviewers, two male interviewers, one female editor, and a male team supervisor, were organized for the main fieldwork. Furthermore, the 30 field teams were organized into 11 regional groups, each headed by an experienced senior staff of PHCCO and accompanied by a regional coordinator from PLCU. The survey was fielded from April 27 to August 30, 2005. The fieldwork was closely monitored for data quality through regular field visits by senior staff from PHCCO, ORC Macro, and other member organizations of the Steering Committee. Data quality was also monitored through field check tables generated from completed clusters simultaneously data entered and produced during the fieldwork. Five senior experts from PHCCO were permanently assigned to monitor the fieldwork throughout the survey period by moving from one region to another. Continuous communication was maintained between the field staff and the headquarters through cell phones. Fieldwork was successfully completed in 535 of the 540 clusters, with the 5 clusters not covered primarily due to reasons of inaccessibility. Two of these clusters were located in rural Oromiya, one in rural Somali, one in rural SNNP and one in urban Gambela. DBS samples were collected in 534 out of the 535 clusters and delivered to EHNRI for analysis. In one cluster in the Gambela Region, households refused to be finger-pricked for cultural and traditional reasons. 1.10 DATA PROCESSING The processing of the 2005 EDHS results began soon after the start of fieldwork. Completed questionnaires were returned periodically from the field to the data processing department at the PHCCO headquarters. A total of 17 new recruits had been trained for office editing/coding and data entry of the questionnaires. Guidelines for the editing/coding procedures had been issued and questions, which needed coding, were identified and a list of codes prepared. After the actual entry of the data began, additional data entry operators were recruited and entry was performed in two shifts. A total of 22 data entry operators and 4 office editors carried out data entry and primary office editing 12 | Introduction activities. Each of the questionnaires was keyed twice by two separate entry clerks. Consistency checks were made and entry errors were manually checked by going back to the questionnaires. A secondary editing program was then run on the data to indicate questions that showed inconsistency and these were also corrected by secondary editors. The data entry for the 535 clusters that started on 9 May 2005 was completed on 24 September 2005. 1.11 RESPONSE RATES Table 1.2 shows the household and individual interview response rates for the survey. A total of 14,645 households were selected, of which 13,928 were occupied. The total number of households interviewed was 13,721, yielding a household response rate of 99 percent. A total of 14,717 eligible women were identified in these households and interviews were completed for 14,070 women, yielding a response rate of 96 percent. One in two households were selected for the male survey and 6,778 eligible men were identified in this subsample of households, of whom 6,033 were successfully interviewed, yielding a response rate of 89 percent. The response rates are higher in rural areas than urban areas for both males and females. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence, Ethiopia 2005 Residence Result Urban Rural Total Household interviews Households selected 3,989 10,656 14,645 Households occupied 3,762 10,166 13,928 Households interviewed 3,666 10,055 13,721 Household response rate 97.4 98.9 98.5 Interviews with women Number of eligible women 4,686 10,031 14,717 Number of eligible women interviewed 4,423 9,647 14,070 Eligible woman response rate 94.4 96.2 95.6 Household interviews for men Households selected 1,947 5,213 7,160 Households occupied 1,828 4,959 6,787 Households interviewed 1,785 4,904 6,689 Household response rate 97.6 98.9 98.6 Interviews with men Number of eligible men 1,948 4,830 6,778 Number of eligible men interviewed 1,628 4,405 6,033 Eligible man response rate 83.6 91.2 89.0 Household Population and Housing Characteristics | 13 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter provides a summary of the socioeconomic characteristics of households and respondents surveyed, including age, sex, place of residence, educational status, household facilities, and household characteristics. Information collected on the characteristics of the households and respondents is important in understanding and interpreting the findings of the survey and also provides indicators of the representativeness of the survey. The information is also useful in understanding and identifying the major factors that determine or influence the basic demographic indicators of the population. The 2005 EDHS collected information from all usual residents of a selected household (the de jure population) and persons who had stayed in the selected household the night before the interview (the de facto population). Since the difference between these two populations is very small and to maintain comparability with other DHS reports, all tables in this report refer to the de facto population unless otherwise specified. A household was defined as a person or group of related and unrelated persons who live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as head of the household, and who have common arrangements for cooking and eating. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Age and sex are important demographic variables and are the primary basis of demographic classification in vital statistics, censuses, and surveys. They are also very important variables in the study of mortality, fertility, and nuptiality. In general, a cross-classification with sex is useful for the effective analysis of all forms of data obtained in surveys. The distribution of the household population in the 2005 EDHS is shown in Table 2.1 by five- year age groups, according to urban-rural residence and sex. The total population counted in the survey was 67,556, with females slightly outnumbering males. The results indicate an overall sex ratio of 99 males per 100 females. The sex ratio is higher in rural areas (101 males per 100 females) than in urban areas (85 males per 100 females). 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 residence, Ethiopia 2005 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 10.3 8.9 9.5 16.9 16.5 16.7 16.1 15.5 15.8 5-9 11.5 10.6 11.0 17.9 17.5 17.7 17.2 16.6 16.9 10-14 13.7 12.0 12.8 15.8 14.7 15.3 15.6 14.3 15.0 15-19 14.3 16.2 15.3 10.0 9.1 9.5 10.4 10.1 10.2 20-24 12.0 12.7 12.4 6.9 7.1 7.0 7.5 7.8 7.7 25-29 8.4 10.2 9.4 5.7 7.3 6.5 6.0 7.7 6.9 30-34 6.1 5.8 5.9 5.2 5.3 5.3 5.3 5.4 5.3 35-39 5.4 5.4 5.4 4.4 4.8 4.6 4.5 4.8 4.7 40-44 4.3 3.8 4.0 3.4 3.5 3.4 3.5 3.5 3.5 45-49 4.1 3.9 4.0 3.0 3.3 3.1 3.1 3.4 3.3 50-54 2.6 3.2 2.9 2.5 2.8 2.7 2.5 2.9 2.7 55-59 1.7 2.2 2.0 1.7 2.6 2.1 1.7 2.5 2.1 60-64 2.2 2.0 2.1 2.3 2.2 2.3 2.3 2.2 2.2 65-69 1.2 1.1 1.2 1.6 1.1 1.4 1.6 1.1 1.3 70-74 1.2 0.7 0.9 1.2 1.1 1.1 1.2 1.0 1.1 75-79 0.4 0.5 0.5 0.6 0.4 0.5 0.6 0.4 0.5 80 + 0.6 0.8 0.7 0.9 0.7 0.8 0.9 0.7 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,752 4,425 8,177 29,903 29,475 59,378 33,656 33,900 67,556 14 | Household Population and Housing Characteristics The age structure of the household population is typical of a society with a youthful population. The sex and age distribution of the population is shown in the population pyramid in Figure 2.1. Ethiopia has a pyramidal age structure due to the large number of children under 15 years of age. Children under 15 years of age account for 48 percent of the population, a feature of populations with high fertility levels. Forty-nine percent of the population is in the age group 15-64 and about 4 percent are over 65. 2.2 HOUSEHOLD COMPOSITION Table 2.2 shows the distribution of households in the survey by the sex of the head of the household and by the number of household members in urban and rural areas. Households in Ethiopia are predominantly male headed, a common feature of most African countries. More than one in five households are headed by women with the proportion of female-headed households much higher in urban than in rural areas. The average household size observed in the survey is 5 persons, which is slightly higher than the 2000 EDHS (4.8 persons). Rural households have 5.2 persons per household and are larger than urban households (4.2 persons). Single-person households are more common in urban areas (13 percent) than in rural areas (4 percent). Only 7 percent of households have nine or more members. Detailed information on children’s liv- ing arrangements and orphanhood is presented in Table 2.3. In Ethiopia, 73 percent of children under 18 live with both parents, 12 percent live with only their mother, 4 percent live with only their father, Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size, according to residence, Ethiopia 2005 Residence Characteristic Urban Rural Total Household headship Male 61.4 79.9 77.2 Female 38.6 20.1 22.8 Total 100.0 100.0 100.0 Number of usual members 1 13.0 3.7 5.0 2 13.0 8.4 9.0 3 16.4 13.4 13.8 4 17.6 15.3 15.7 5 14.4 17.2 16.8 6 10.5 14.6 14.0 7 6.4 11.9 11.1 8 3.9 7.7 7.2 9+ 4.8 7.8 7.4 Total 100.0 100.0 100.0 Number of households 1,974 11,747 13,721 Mean size 4.2 5.2 5.0 Note: Table is based on de jure members, i.e., usual residents. Figure 2.1 Population Pyramid 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 0-4 0246810 0 2 4 6 8 10 EDHS 2005 Age Male Percent Female Household Population and Housing Characteristics | 15 and 10 percent live with neither parent. Seven percent of children live with their mother even though their father is alive, 2 percent of children live with their father even though their mother is alive, and 6 percent live with neither parent even though both of them are alive. Eight percent of children do not have a father alive and 4 percent do not have a mother alive. The percentage of children not living with their parents increases with age of the child. The proportion of children living with both parents varies little by sex. However, rural children are more likely to live with both parents than urban children. The highest proportion of children living with both parents is in Somali (79 percent), while the lowest proportion is in Addis Ababa (49 percent). Table 2.3 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by children's living arrangements and survival status of parents, according to background characteristics, Ethiopia 2005 Living with mother but not father Living with father but not mother Not living with either parent Background characteristic Living with both parents Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing informa- tion on father or mother Total Percentage with one or both parents dead Number of children Age <2 88.6 8.7 1.2 0.3 0.2 0.7 0.1 0.0 0.0 0.2 100.0 1.6 4,287 2-4 84.6 6.5 2.4 1.2 0.9 3.3 0.3 0.3 0.2 0.2 100.0 4.2 6,545 5-9 74.9 5.9 5.0 2.6 1.9 6.4 0.8 1.0 1.0 0.5 100.0 9.8 11,579 10-14 65.2 6.5 7.8 2.9 3.2 8.5 1.3 2.2 1.9 0.5 100.0 16.5 10,284 15-17 52.0 7.1 9.9 3.2 4.2 11.7 2.2 3.9 3.5 2.3 100.0 23.7 4,308 Sex Male 73.6 6.2 5.7 2.5 2.3 5.7 0.8 1.4 1.3 0.6 100.0 11.5 18,950 Female 72.1 7.1 5.3 1.9 2.0 7.1 1.1 1.4 1.3 0.7 100.0 11.2 18,052 Residence Urban 52.6 12.7 8.6 3.4 1.7 12.1 1.9 2.5 3.5 0.9 100.0 18.4 3,455 Rural 74.9 6.0 5.1 2.1 2.2 5.8 0.9 1.3 1.1 0.6 100.0 10.6 33,547 Region Tigray 70.0 12.9 5.0 2.1 1.8 4.5 1.0 0.9 1.4 0.5 100.0 10.1 2,344 Affar 75.2 7.1 5.8 2.1 3.1 3.3 1.3 0.7 1.2 0.3 100.0 12.0 408 Amhara 71.5 6.9 5.4 2.9 2.0 6.6 1.4 1.6 1.2 0.6 100.0 11.7 8,835 Oromiya 73.8 5.8 5.4 2.0 2.6 6.8 0.7 1.1 1.4 0.5 100.0 11.2 13,918 Somali 79.4 5.9 4.7 1.0 2.6 3.4 0.4 0.5 1.5 0.8 100.0 9.7 1,643 Benishangul-Gumuz 72.5 8.7 7.2 1.5 2.1 4.0 1.1 1.3 1.1 0.4 100.0 13.0 327 SNNP 74.8 5.7 5.5 2.1 1.6 6.0 1.0 1.8 0.9 0.7 100.0 10.8 8,449 Gambela 63.9 10.3 8.1 2.5 0.9 8.5 0.9 2.3 1.1 1.5 100.0 13.2 101 Harari 67.1 7.5 5.2 1.4 1.3 10.3 1.4 1.8 1.7 2.2 100.0 11.6 74 Addis Ababa 48.5 10.1 8.7 3.6 1.7 15.5 2.0 4.2 4.2 1.6 100.0 21.0 773 Dire Dawa 62.0 10.1 7.8 2.3 1.7 10.0 0.6 2.1 2.5 0.7 100.0 14.8 130 Wealth quintile Lowest 73.5 7.5 6.6 2.3 1.7 4.7 0.8 1.0 1.3 0.6 100.0 11.6 7,758 Second 73.9 6.9 5.6 1.8 2.4 4.9 1.3 1.4 0.9 0.8 100.0 11.6 7,534 Middle 74.7 5.7 4.8 2.2 2.5 6.2 0.9 1.5 1.1 0.4 100.0 10.8 7,574 Fourth 76.6 4.5 4.5 2.1 2.2 6.5 0.6 1.3 1.1 0.6 100.0 9.8 7,605 Highest 64.4 8.8 5.8 2.9 1.8 10.2 1.3 1.9 2.2 0.7 100.0 13.1 6,531 Total age <18 72.8 6.6 5.5 2.2 2.1 6.4 1.0 1.4 1.3 0.6 100.0 11.3 37,002 Total age <15 75.6 6.6 4.9 2.1 1.9 5.7 0.8 1.1 1.0 0.4 100.0 9.7 32,694 16 | Household Population and Housing Characteristics The EDHS administered three questions on succession planning to women and men. Women and men were first asked if they were primary caregivers to children under the age of 18, and if they were, an additional question was administered to ascertain if they had made any arrangements for someone to care for these children in the event of their illness or inability to care for their young children themselves. Information on succession planning is shown in Table 2.4. Three-fifths of women and men are primary caregivers to their children. Among primary caregivers, just under half (46 percent) had made provisions for someone else to take care of their children in case of their illness or inability to care for their own children. As the data show, younger, male, urban, highly educated and wealthy respondents are more likely than other respondents to make arrangements in the case of an eventuality. Succession planning varies markedly by region, with respondents residing in Harari (68 percent) most likely and respondents residing in Dire Dawa (34 percent) least likely to make plans in the case of an eventuality. Table 2.4 Succession planning Percentage of de facto women and men age 15-49 who are the primary caregivers of children under age 18 years, and among the primary caregivers, the percentage who have made arrangements for someone else to care for the children in the event of their own inability to do so because of illness or death, by background characteristics, Ethiopia 2005 Background Characteristics Percentage of women and men who are primary caregivers Number of women and men age 15-49 Percentage of caregivers who have made succession arrangements Number of primary caregivers Age 15-19 17.0 4,601 52.8 783 20-29 60.3 6,869 48.0 4,143 30-39 83.2 4,815 45.3 4,006 40-49 81.3 3,249 43.0 2,642 Sex Women 66.1 14,070 42.5 9,306 Men 41.5 5,464 61.7 2,268 Residence Urban 45.1 3,353 50.8 1,513 Rural 62.2 16,181 45.5 10,061 Region Tigray 61.4 1,235 55.8 758 Affar 60.6 205 45.7 124 Amhara 63.8 4,828 39.3 3,082 Oromiya 52.8 7,051 37.4 3,725 Somali 68.8 666 59.4 459 Benishangul-Gumuz 63.7 174 35.7 111 SNNP 67.0 4,138 60.2 2,774 Gambela 64.1 63 58.7 41 Harari 59.2 54 67.7 32 Addis Ababa 40.7 1,023 53.5 416 Dire Dawa 54.9 97 33.5 53 Education No education 71.9 11,436 42.4 8,217 Primary 44.1 5,263 52.8 2,322 Secondary and higher 35.7 2,641 61.5 943 Wealth quintile Lowest 65.9 3,373 45.2 2,225 Second 64.1 3,670 42.9 2,354 Middle 61.6 3,767 43.9 2,321 Fourth 60.2 3,727 45.3 2,245 Highest 48.6 4,996 53.4 2,429 Total 59.3 19,534 46.2 11,574 Household Population and Housing Characteristics | 17 2.3 HOUSEHOLD EDUCATION Studies show that education is one of the major socioeconomic factors that influence a person’s behaviour and attitude. In general, the higher the level of education of a woman, the more knowledgeable she is about the use of health facilities, family planning methods, and the health of her children. Ethiopia’s education system has been stable for a long time; however, recently a major restructuring and expansion programme was undertaken by the government. Following the free market oriented economic policy the education sector was opened to private investment. The current system of formal education is based on a three-tier system: eight years of primary education, followed by four years of secondary school and tertiary education. Prior to the change in the education policy, the education system was based on six years of primary education, followed by two years of junior secondary and four years of senior secondary education and tertiary education. Currently, several pre- university collages and various institutions operated by the government and the private sector offer vocational, technical and professional training in different parts of the country. The number of government universities, and private universities and vocational and technical schools has increased tremendously in various parts of the country. 2.3.1 Educational Attainment of Household Population Tables 2.5.1 and 2.5.2 show the percent distribution of the de facto female and male household population age six and over by highest level of education attended or completed, according to background characteristics. Survey results show that the majority of Ethiopians have little or no education, with females much less educated than males. Fifty-two percent of males and 67 percent of females have never attended school, and 32 percent of males and 25 percent of females have only some primary education. Four percent of males and 2 percent of females have completed primary education only, and 8 percent of males and 5 percent of females have attended, but not completed secondary education.1 Only 3 percent of males and 2 percent of females have completed secondary school or higher. Nevertheless, improvements in the education sector were observed since the 2000 EDHS, with the proportions of males and females with no education declining by 9 and 10 percentage points, respectively. The improvement is observed across all education categories. The male-female gap in education is more obvious at lower levels of education primarily because the proportion of males and females attending higher levels of education is so small. An investigation of the changes in educational attainment by successive age groups indicates the long-term trend of the country’s educational achievement. Survey results show that there has been a marked improvement in the educational attainment of women. For example, the proportion of women with no education has declined significantly from 99 percent among women age 65 and over to 41 percent among women age 10-14. A similar trend is noticeable among men, with the proportion of men with no education declining from 94 percent among those age 65 and over to 37 percent among those age 10-14. As expected, educational attainment is much higher among the urban than the rural population. For example, 83 percent of males and 69 percent of females in urban areas have some education, compared with only 42 percent of males and 27 percent of females in rural areas. Regarding regional variation, the proportion of men and women with no education is highest in the Somali Region (82 percent and 89 percent, respectively), followed by the Affar Region (80 percent and 87 percent, respectively), and is lowest in the capital city, Addis Ababa (13 percent and 25 percent, respectively). It is noticeable that in the majority of the regions (Affar, Amhara, Oromiya, Somali, Benishangul-Gumuz, SNNP, and Gambela) about 2 percent or less of women and 3 percent or less of men have completed secondary and higher education. In the most urbanized regions, Harari, Addis Ababa, and Dire Dawa, much higher proportions of women and men have secondary education. 1 Secondary education refers to both junior secondary (grades 7-8) and senior secondary (grades 9-12). 18 | Household Population and Housing Characteristics Table 2.5.1 Educational attainment of household population: female Percent distribution of the de facto female household population age six and over by highest level of education attended or completed, according to background characteristics, Ethiopia 2005 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Age 6-9 73.3 26.1 0.0 0.0 0.0 0.0 0.5 100.0 4,704 10-14 41.1 54.9 2.0 1.7 0.0 0.0 0.3 100.0 4,861 15-19 40.4 37.0 6.6 15.1 0.5 0.2 0.1 100.0 3,409 20-24 60.4 19.6 2.6 11.5 4.0 1.8 0.1 100.0 2,652 25-29 67.6 18.2 1.7 6.5 4.0 1.9 0.0 100.0 2,609 30-34 73.7 14.6 1.6 5.0 3.1 1.8 0.2 100.0 1,825 35-39 79.8 11.5 1.4 3.2 2.7 1.4 0.0 100.0 1,642 40-44 87.0 5.7 1.1 2.6 1.4 1.6 0.6 100.0 1,190 45-49 92.9 3.5 0.7 1.4 0.5 0.7 0.2 100.0 1,156 50-54 95.3 2.9 0.1 0.7 0.2 0.2 0.7 100.0 975 55-59 96.1 2.1 0.3 0.6 0.4 0.1 0.4 100.0 859 60-64 98.2 0.9 0.0 0.2 0.1 0.1 0.5 100.0 735 65+ 98.9 0.7 0.1 0.2 0.0 0.0 0.0 100.0 1,075 Residence Urban 30.7 28.6 5.5 22.1 8.7 4.3 0.1 100.0 3,951 Rural 72.8 23.8 1.3 1.7 0.1 0.1 0.3 100.0 23,750 Region Tigray 63.0 24.6 2.6 7.1 1.4 0.8 0.3 100.0 1,795 Affar 87.0 8.0 0.9 3.2 0.4 0.0 0.4 100.0 286 Amhara 69.5 24.2 1.4 3.3 0.9 0.5 0.2 100.0 6,937 Oromiya 66.1 26.5 1.8 4.3 0.9 0.3 0.2 100.0 9,919 Somali 88.8 6.6 0.5 1.5 0.9 0.3 1.5 100.0 1,063 Benishangul-Gumuz 67.9 26.7 1.6 2.4 0.5 0.7 0.3 100.0 240 SNNP 69.6 24.8 1.8 2.9 0.4 0.2 0.3 100.0 6,051 Gambela 58.6 32.4 3.2 4.4 0.5 0.2 0.7 100.0 79 Harari 49.4 21.5 2.9 15.6 8.0 2.2 0.4 100.0 69 Addis Ababa 24.6 26.8 5.5 22.9 11.9 8.0 0.2 100.0 1,143 Dire Dawa 52.9 22.4 3.9 14.0 5.3 1.4 0.1 100.0 119 Wealth quintile Lowest 84.1 14.7 0.3 0.5 0.0 0.0 0.4 100.0 5,426 Second 78.5 19.8 0.5 0.7 0.0 0.0 0.4 100.0 5,412 Middle 71.9 25.0 1.4 1.4 0.0 0.0 0.3 100.0 5,440 Fourth 65.0 30.4 1.9 2.4 0.0 0.0 0.2 100.0 5,334 Highest 38.0 31.6 4.7 16.6 5.8 3.1 0.2 100.0 6,088 Total 66.8 24.5 1.9 4.6 1.3 0.7 0.3 100.0 27,701 Note: Total includes 5 women missing information on age and not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level The proportion of female and male household members who have never attended school decreases with wealth. Seventy-three percent of men in the lowest wealth quintile have no education compared with only 24 percent in the highest quintile. Similarly, 84 percent of women in the lowest quintile have no education compared with 38 percent in the highest quintile. Household Population and Housing Characteristics | 19 Table 2.5.2 Educational attainment of household population: male Percent distribution of the de facto male household population age six and over by highest level of education attended or completed, according to background characteristics, Ethiopia 2005 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Age 6-9 73.7 25.6 0.0 0.0 0.0 0.0 0.7 100.0 4,865 10-14 37.0 57.7 3.1 2.1 0.0 0.0 0.2 100.0 5,247 15-19 26.8 42.4 9.0 20.7 0.7 0.2 0.2 100.0 3,512 20-24 35.5 30.4 6.3 21.2 4.1 2.3 0.2 100.0 2,527 25-29 43.0 31.3 5.0 12.5 5.0 2.7 0.6 100.0 2,019 30-34 46.9 29.1 6.7 9.7 5.4 2.1 0.0 100.0 1,789 35-39 49.4 27.6 6.3 9.1 4.1 3.2 0.3 100.0 1,527 40-44 59.5 21.0 3.2 8.0 4.1 4.0 0.3 100.0 1,179 45-49 65.4 16.8 3.8 7.4 2.7 3.7 0.2 100.0 1,041 50-54 74.7 14.7 2.9 3.2 2.2 1.7 0.6 100.0 838 55-59 78.9 14.8 1.7 2.5 0.8 1.3 0.0 100.0 567 60-64 88.2 8.3 0.4 1.3 0.5 1.0 0.4 100.0 781 65+ 93.8 3.7 0.4 0.6 0.4 0.4 0.7 100.0 1,406 Residence Urban 16.3 27.1 6.7 29.2 11.9 8.4 0.4 100.0 3,289 Rural 57.3 33.1 3.5 5.0 0.4 0.2 0.4 100.0 24,019 Region Tigray 53.7 30.3 3.3 9.3 1.6 1.6 0.2 100.0 1,669 Affar 80.0 13.7 1.3 3.3 1.2 0.2 0.3 100.0 303 Amhara 62.2 27.5 2.5 5.6 1.1 0.7 0.4 100.0 7,004 Oromiya 48.0 37.2 4.5 8.0 1.3 0.7 0.3 100.0 9,921 Somali 82.4 10.1 1.0 3.6 1.1 0.4 1.5 100.0 1,165 Benishangul-Gumuz 52.6 36.2 3.6 4.9 0.8 0.9 1.0 100.0 230 SNNP 47.3 38.0 4.9 7.9 1.1 0.5 0.3 100.0 5,798 Gambela 40.1 33.0 7.2 15.5 2.0 1.0 1.2 100.0 85 Harari 31.1 28.4 5.5 20.4 9.6 4.6 0.4 100.0 63 Addis Ababa 13.1 21.6 7.3 27.2 16.6 14.0 0.2 100.0 955 Dire Dawa 33.6 25.5 7.3 21.2 9.3 3.0 0.2 100.0 116 Wealth quintile Lowest 73.3 22.8 1.5 2.0 0.0 0.0 0.4 100.0 5,261 Second 61.8 31.9 2.9 2.9 0.1 0.0 0.4 100.0 5,387 Middle 56.0 35.5 3.3 4.6 0.2 0.0 0.3 100.0 5,447 Fourth 48.2 38.6 5.2 6.9 0.5 0.1 0.5 100.0 5,612 Highest 24.2 32.7 6.5 22.6 8.0 5.8 0.2 100.0 5,601 Total 52.4 32.4 3.9 7.9 1.8 1.2 0.4 100.0 27,308 Note: Total includes 8 men with missing information on age and not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level 2.3.2 School Attendance Ratios Data on net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by school level, sex, residence, region and wealth index are shown in Table 2.6. The NAR indicates participation in primary schooling for the population age 7-12 and secondary schooling for the population age 13-18. The GAR measures participation at each level of schooling among those of any age. The GAR is nearly always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level.2 An NAR of 100 percent would indicate that all those in the official age range for the level are attending at that level. The GAR can exceed 100 percent if there is significant overage or underage participation at a given level of schooling. 2 Students who are overage for a given level of schooling may have started school overage, may have repeated one or more grades in school, or may have dropped out of school and later returned. 20 | Household Population and Housing Characteristics Table 2.6 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by level of schooling and sex, according to background characteristics, Ethiopia 2005 Net attendance ratio1 Gross attendance ratio2Background characteristic Male Female Total Male Female Total Gender parity index3 PRIMARY SCHOOL Residence Urban 77.8 79.6 78.8 117.2 122.4 120.0 1.04 Rural 39.1 38.5 38.8 77.7 68.0 73.0 0.88 Region Tigray 48.6 52.7 50.6 78.3 84.1 81.1 1.07 Affar 19.1 11.0 15.3 34.9 21.0 28.5 0.60 Amhara 46.3 54.5 50.4 85.9 82.3 84.1 0.96 Oromiya 43.9 41.4 42.7 88.2 75.7 82.1 0.86 Somali 15.5 11.6 13.8 24.4 17.2 21.2 0.71 Benishangul-Gumuz 49.7 47.1 48.4 90.5 69.6 79.6 0.77 SNNP 37.2 31.8 34.5 76.3 63.7 70.0 0.84 Gambela 39.2 45.9 42.2 81.4 84.7 82.9 1.04 Harari 54.0 54.6 54.3 85.2 80.8 83.1 0.95 Addis Ababa 83.0 78.8 80.6 124.9 137.0 131.8 1.10 Dire Dawa 60.6 48.7 54.8 93.6 74.8 84.4 0.80 Wealth quintile Lowest 26.0 24.9 25.4 52.2 41.4 46.9 0.79 Second 35.9 34.7 35.3 71.8 60.8 66.6 0.85 Middle 42.8 40.2 41.5 83.9 76.0 80.1 0.91 Fourth 46.2 47.0 46.6 92.8 82.8 87.9 0.89 Highest 66.9 69.4 68.2 112.7 111.1 111.9 0.99 Total 42.2 42.4 42.3 80.9 73.3 77.1 0.91 SECONDARY SCHOOL Residence Urban 55.3 42.3 48.2 79.9 57.2 67.6 0.72 Rural 11.9 7.3 9.7 20.3 10.3 15.6 0.51 Region Tigray 19.6 17.6 18.6 32.8 26.1 29.3 0.80 Affar 6.7 4.1 5.3 12.6 7.9 10.2 0.62 Amhara 15.6 15.2 15.4 23.1 17.3 20.4 0.75 Oromiya 18.0 10.5 14.5 29.9 15.4 23.0 0.51 Somali 9.4 4.1 7.0 12.2 6.3 9.6 0.51 Benishangul-Gumuz 17.9 12.6 15.3 28.1 17.8 23.1 0.63 SNNP 14.2 9.6 11.9 25.0 15.1 20.2 0.60 Gambela 30.0 15.9 24.0 52.2 24.4 40.3 0.47 Harari 39.6 33.1 36.1 56.0 40.7 47.8 0.73 Addis Ababa 58.8 38.9 46.7 81.4 53.8 64.7 0.66 Dire Dawa 45.4 31.4 38.2 66.9 38.0 52.1 0.57 Wealth quintile Lowest 5.8 2.3 4.1 10.4 3.1 7.0 0.30 Second 8.3 3.3 5.8 15.2 4.9 10.1 0.32 Middle 9.4 7.0 8.2 18.8 9.3 14.1 0.49 Fourth 15.0 11.4 13.4 24.8 14.7 20.4 0.59 Highest 42.6 33.5 38.0 62.1 47.0 54.5 0.76 Total 17.7 13.3 15.6 28.2 18.3 23.5 0.65 1 The NAR for primary school is the percentage of the primary-school-age (7-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (13- 18 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The gender parity index for primary school is the ratio of the primary school GAR for females to the GAR for males. The gender parity index for secondary school is the ratio of the secondary school GAR for females to the GAR for males. Household Population and Housing Characteristics | 21 Forty-two percent of children who should be attending primary school are currently doing so. At the same time, only 16 percent of secondary-school-age youths are in school. Nevertheless, marked improvements in NAR are observed since the 2000 EDHS, with 12 and 4 percentage point improvements in the NARs for the primary and secondary levels, respectively. The NAR is higher among males than among females at the secondary level. Attendance ratios are much lower in rural areas than in urban areas and are the lowest in the Affar and Somali regions. The GAR is higher among males than females at both the primary and secondary levels, at 81 and 73 at the primary-school level, respectively, and 28 and 18 at the secondary-school level, respectively, indicating higher attendance among males than among females. Although the overall GAR at the primary-school level is 77, there are significant levels of overage and/or underage participation in the urban areas among both males (117) and females (122) and also in Addis Ababa (132), the highest among the regions. There is a strong relationship between household economic status and schooling that can be seen at both the primary and secondary levels and among males and females. For example, the NAR increases from 25 percent among students from poorer households (lowest wealth quintile) in primary school to 68 percent among students from richer households (highest wealth quintile). Similarly, the NAR rises from 4 percent among secondary attendees in the lowest wealth quintile to 38 percent among those in the highest wealth quintile. The Gender Parity Index (GPI) represents the ratio of the GAR for females to the GAR for males. It is presented at both the primary and secondary levels and offers a summary measure of gender differences in school attendance rates. A GPI less than one indicates that a smaller proportion of females than males attend school. In Ethiopia, the GPI is slightly less than one (0.9) for primary school attendance, but 0.7 for secondary school attendance, indicating that the gender gap is smaller at the primary than the secondary level. There are also marked differences in the GPI by place of residence and by region. The primary school GPI is markedly lower in Affar, Somali and Benishangul-Gumuz than in other regions, while a higher female to male index is observed in Tigray, Gambela and Addis Ababa. The Tigray Region has the highest secondary school GPI (0.8) and Gambela, Oromiya and Somali regions the lowest. Grade repetition and dropout rates for the de facto household population age 5-24 years who attended school in the previous school year is shown in Table 2.7. The repetition rate is defined as the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. Dropout rate refers to the percentage of students in a given grade in the previous school year who are not attending school in the current school year. School attendance ratios in combination with repetition and dropout rates fully describe the flow of students through the school system. In countries with an automatic promotion policy, where students are nearly always promoted to the next grade at the end of the school year, repetition rates may approach zero. However, in Ethiopia the school system does not support automatic promotion of students. Therefore, repetition and dropout rates measure and show current educational problems and impacts of education policies and programmes. Repetition rates are higher in lower grades, specifically highest in grade one (6 percent). Males have higher repetition rates up to grade three compared with female children. However, more female than male children repeat in grades 4 and 5. Dropout rates are higher for males than females in all grade categories. Rural children are more disadvantaged than their urban counterparts; in all grade levels dropout rates are much higher for rural than urban children. 22 | Household Population and Housing Characteristics Table 2.7 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 5-24 years who attended school in the previous school year by school grade, according to background characteristics, Ethiopia 2005 School grade Background characteristic 1 2 3 4 5 6 REPETITION RATE Sex Male 6.5 2.1 1.8 1.1 1.3 2.2 Female 4.7 1.2 1.1 2.5 2.0 1.5 Residence Urban 4.3 1.1 1.3 2.5 0.7 2.4 Rural 5.8 1.8 1.5 1.5 1.9 1.8 Region Tigray 1.8 2.1 1.0 0.8 1.7 0.0 Affar 2.1 (0.0) * * * * Amhara 6.6 1.2 1.8 0.6 2.2 0.0 Oromiya 6.5 2.2 0.6 2.4 1.4 3.2 Somali 1.6 (0.0) (0.0) (8.0) * * Benishangul-Gumuz 13.2 1.6 2.0 0.0 (2.3) 0.0 SNNP 3.8 1.4 2.7 1.5 0.8 0.0 Gambela 7.5 0.7 1.8 5.4 3.6 5.3 Harari 6.1 4.6 2.5 3.1 2.8 1.4 Addis Ababa 9.5 0.7 2.1 2.6 2.3 3.3 Dire Dawa 0.0 0.0 0.0 0.0 2.7 2.3 Wealth quintile Lowest 7.8 2.7 1.2 0.5 3.6 0.1 Second 5.2 3.0 4.0 1.6 3.5 4.9 Middle 6.3 1.3 0.0 1.3 0.1 3.1 Fourth 4.5 1.4 1.5 2.3 2.4 1.4 Highest 5.1 1.0 1.1 2.0 0.7 1.5 Total 5.7 1.7 1.5 1.7 1.6 2.0 DROPOUT RATE Sex Male 5.5 5.7 7.7 9.3 9.7 6.2 Female 3.6 5.4 3.9 4.0 5.2 4.8 Residence Urban 1.1 3.1 2.8 3.6 4.7 2.4 Rural 5.0 6.1 6.6 7.9 8.9 6.9 Region Tigray 2.5 4.1 7.0 8.1 6.8 5.0 Affar 2.3 4.8 * * * * Amhara 2.4 2.1 3.0 4.0 6.0 1.8 Oromiya 6.7 9.3 7.2 10.0 8.9 5.1 Somali 2.9 (1.4) (0.0) (6.8) * * Benishangul-Gumuz 2.6 8.2 6.6 8.9 8.0 7.9 SNNP 5.0 4.1 7.1 5.5 9.8 11.3 Gambela 5.8 10.1 10.8 11.1 6.9 14.1 Harari 5.6 8.1 2.2 8.7 7.9 4.7 Addis Ababa 1.4 2.1 3.9 2.8 7.4 4.6 Dire Dawa 5.3 0.0 4.7 6.6 3.2 3.9 Wealth quintile Lowest 5.7 8.7 5.7 10.1 6.6 15.2 Second 4.2 7.1 7.6 6.1 15.1 9.6 Middle 5.1 3.8 2.8 11.1 7.8 6.7 Fourth 4.9 5.4 9.2 4.9 8.9 5.2 Highest 3.3 4.8 4.1 6.0 4.6 3.1 Total 4.6 5.6 6.0 7.1 7.9 5.6 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Household Population and Housing Characteristics | 23 The age-specific attendance rates (ASARs) for the population age five and over by sex are shown in Figure 2.2. The ASAR indicates participation in schooling at any level, from primary to higher levels of education. Although the minimum age for schooling in Ethiopia is seven, there are some children enrolled prior to this age. Nevertheless, only 21 percent of children age seven are attending school, indicating that a large majority of children that age in Ethiopia have not entered the school system. However, a marked improvement in enrolment at age seven was observed since 2000 when 15 percent were attending school. There is little difference in the proportion of males and females attending school up to age 12; thereafter, a significantly higher proportion of males than females attends school. 2.4 HOUSEHOLD CHARACTERISTICS The physical characteristics and availability and accessibility of basic household facilities are important in assessing the general welfare and socioeconomic condition of the population. In the 2005 EDHS respondents to the household questionnaire were asked about household drinking water and household sanitation facilities that included questions on the source of drinking water, time taken to the nearest source, and the person that usually collects drinking water, water treatment prior to drinking and questions on sanitation facilities. Table 2.8 presents information on household drinking water. The majority (61 percent) of households in Ethiopia have access to an improved source of drinking water with access in urban areas much higher than in rural areas (94 percent and 56 percent, respectively). The most common source of improved drinking water in urban areas is piped water with 90 percent of households having access to this source. On the other hand, only 13 percent of rural households have access to piped water. The major source of improved drinking water in rural areas is a protected spring (39 percent). The proportion of households with access to piped water has increased from about 14 percent in 1994 (CSA, 1999) to 18 percent in 2000 and 24 percent in 2005. Figure 2.2 Age-Specific Attendance Rates 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 10 20 30 40 50 60 70 Percent Male Female EDHS 2005 24 | Household Population and Housing Characteristics Table 2.8 Household drinking water Percent distribution of households by source, time to collect, person who usually collects drinking water, and treatment of water, according to residence, and percent distribution of the de jure population by source, time to collect, person who usually collects drinking water, and treatment of drinking water, Ethiopia 2005 Households Characteristics of household drinking water Urban Rural Total De jure population Source of drinking water Improved source 93.7 56.0 61.4 60.0 Piped into dwelling 2.5 0.0 0.4 0.3 Piped into compound 45.0 0.2 6.6 5.7 Piped outside compound 42.6 12.3 16.7 15.8 Tube well or borehole 0.0 0.1 0.1 0.1 Protected dug well 1.2 4.5 4.0 4.1 Protected spring 2.3 38.7 33.5 33.7 Rainwater 0.0 0.2 0.2 0.2 Non-improved source 6.1 43.8 38.4 39.9 Unprotected dug well 0.8 6.0 5.3 5.4 Unprotected spring 4.1 7.5 7.0 7.3 Tanker truck 0.5 0.2 0.2 0.2 Surface water 0.8 30.1 25.9 26.9 Other 0.2 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 48.4 1.6 8.4 7.4 Less than 30 minutes 36.4 45.6 44.3 44.1 30 minutes or longer 14.6 52.1 46.7 47.9 Missing 0.6 0.7 0.6 0.6 Total 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult male age 15+ 7.1 5.7 5.9 4.8 Adult female age 15+ 38.6 80.5 74.4 75.0 Male child under age 15 1.8 2.5 2.4 2.7 Female child under age 15 3.0 9.0 8.1 9.6 Water on premises 48.4 1.6 8.4 7.4 Other 1.0 0.6 0.6 0.4 Missing 0.1 0.2 0.2 0.1 Total 100.0 100.0 100.0 100.0 Water treatment prior to drinking Boiled 2.9 2.4 2.4 2.5 Bleach/chlorine added 0.6 0.2 0.2 0.2 Strained through cloth 0.6 5.2 4.6 4.9 Ceramic, sand or other filter 0.6 0.3 0.3 0.4 Let it stand and settle 0.1 0.2 0.2 0.1 Other 0.3 0.3 0.3 0.3 No treatment 94.7 91.4 91.9 91.6 Don't know/missing 0.5 0.9 0.9 0.9 Total 100.0 100.0 100.0 100.0 Number 1,974 11,747 13,721 68,981 Only 8 percent of households reported having water on their premises. Households not having access on their premises were asked for the time taken to fetch water. Forty-four percent of all households (36 percent urban and 46 percent rural) take less than 30 minutes to fetch drinking water. In the majority (74 percent) of households, an adult female usually collects drinking water. Female children under age 15 are over three times more likely than male children the same age to fetch drinking water. Household Population and Housing Characteristics | 25 In the survey all households were asked whether they treat water prior to drinking. An overwhelming majority of households (92 percent) do not treat drinking water. Rural households are somewhat more likely than urban households to treat drinking water and this is mostly done by straining water through cloth. Table 2.9 presents information on household sanitation facilities by type of toilet/latrine. Sixty-two percent of Ethiopian households do not have a toilet facility. Overall a small proportion (7 percent) of households use improved toilets that are not shared. Urban households are more than three times as likely as rural households to have access to improved toilet facilities. In urban areas, a pit latrine with a slab (12 percent) is the major type of improved toilet facility. There has been a decline recently in the proportion of households with no toilet facilities from 82 percent in 2000 to 62 percent in 2005. The decline was observed in both urban and rural areas (from 30 percent to 12 percent in urban areas and from 92 percent to 70 percent in rural areas). Table 2.9 Household sanitation facilities Percent distribution of households by type of toilet/latrine facilities, according to residence and the percent distribution of the de jure population by toilet/latrine facilities, Ethiopia 2005 Households Type of toilet/ latrine facility Urban Rural Total De jure population Improved, not shared 18.0 4.9 6.8 7.4 Flush/pour flush to piped sewer system 1.1 0.0 0.2 0.1 Flush/pour flush to septic tank 1.3 0.0 0.2 0.2 Flush/pour flush to pit latrine 1.9 0.8 1.0 1.2 Ventilated improved pit (VIP) latrine 1.1 0.3 0.4 0.5 Pit latrine with a slab 11.5 0.8 2.3 2.5 Composting toilet 1.0 3.0 2.7 3.0 Not improved 81.9 95.0 93.1 92.5 Any facility shared with other households 51.1 5.9 12.4 9.8 Flush/pour flush not to sewer/septic tank/pit latrine 0.2 0.1 0.1 0.1 Pit latrine without slab/ open pit 18.1 18.6 18.5 20.3 Bucket 0.1 0.0 0.0 0.0 Hanging toilet/hanging latrine 0.1 0.0 0.1 0.0 No facility/bush/field 12.2 70.3 61.9 62.2 Other/missing 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 Number 1,974 11,747 13,721 68,981 Information on household characteristics such as availability of electricity, type of flooring material, number of rooms for sleeping, type of fuel used for cooking, place for cooking and type of fire/stove among households using biomass are shown in Table 2.10. Fourteen percent of households have electricity, but this varies widely by place of residence. Two percent of households in rural areas have access to electricity, compared with 86 percent of urban households. The proportion of households with electricity rose from 76 percent to 86 percent in urban areas between 2000 and 2005 and from 0.4 percent to 1.9 percent in rural areas. Sixty-five percent of households have earth or sand floors and 25 percent have dung floors. Rural houses are more likely than urban houses to have earth, sand, or dung floors, while urban houses are more likely than rural houses to have floors made with cement/bricks. 26 | Household Population and Housing Characteristics Table 2.10 Household characteristics Percent distribution of households by household characteristics, according to residence, Ethiopia 2005 Households Household characteristic Urban Rural Total De jure population Electricity Yes 85.7 1.9 14.0 12.0 No 14.3 98.0 85.9 87.9 Missing 0.0 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 Flooring material Earth/sand 32.8 70.6 65.2 65.7 Dung 12.8 27.5 25.4 25.7 Wood planks 1.1 0.1 0.3 0.3 Reed/bamboo 1.9 0.4 0.7 0.7 Parquet or polished wood 4.7 0.0 0.7 0.6 Vinyl 17.7 0.1 2.7 2.4 Ceramic tiles 1.8 0.0 0.3 0.2 Cement/bricks 23.3 0.5 3.8 3.5 Carpet 3.6 0.6 1.0 0.8 Other/missing 0.2 0.1 0.1 0.2 Total 100.0 100.0 100.0 100.0 Rooms for sleeping No bedrooms or only one 67.4 78.4 76.8 71.5 Two 25.3 18.2 19.2 22.8 Three or more 7.1 2.7 3.4 5.0 Missing 0.1 0.7 0.6 0.7 Total 100.0 100.0 100.0 100.0 Cooking fuel Electricity 1.0 0.0 0.2 0.2 LPG 0.4 0.0 0.1 0.0 Natural gas 0.6 0.0 0.1 0.1 Biogas 0.3 0.0 0.0 0.0 Kerosene 25.9 0.2 3.9 3.0 Charcoal 18.1 0.2 2.8 2.2 Wood 48.5 89.9 83.9 85.7 Straw/shrubs/grass 0.2 1.2 1.1 1.1 Animal dung 2.1 8.3 7.4 7.5 Other/missing 3.0 0.2 0.6 0.2 Total 100.0 100.0 100.0 100.0 Place for cooking In the house 31.1 74.1 67.9 66.4 In a separate building 53.5 21.0 25.7 27.6 Outdoors 12.4 4.8 5.9 5.8 Other/missing 2.8 0.1 0.5 0.2 Total 100.0 100.0 100.0 100.0 Number of households 1,974 11,747 13,721 68,981 Type of fire/stove among households using biomass fuel1 Open fire or stove whithout a chimney/hood 91.5 97.5 96.6 96.8 Open fire or stove with chimney/hood 5.9 2.1 2.6 2.6 Closed stove with chimney 1.7 0.1 0.4 0.3 Other 0.8 0.1 0.2 0.2 Missing 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 Number of households using biomass fuel 1,871 11,722 13,593 68,605 1 Biomass fuel includes kerosene, coal/lignite, charcoal, wood/straw/shrubs, and animal dung. Household Population and Housing Characteristics | 27 Data were collected on the number of sleeping rooms per household. Slightly over three- fourths of households have no bedrooms or have only one room for sleeping. Nineteen percent of households have two rooms and only 3 percent have three or more rooms for sleeping. Urban households are more likely than rural households to have two or more rooms for sleeping. The overwhelming majority of households (84 percent) use wood for cooking. Wood is the most common form of cooking fuel in rural areas (90 percent). In urban areas nearly half of the households use wood for cooking (49 percent), followed by kerosene (26 percent) and charcoal (18 percent). Slightly over two-thirds of households (68 percent) cook their meals in the house, while over a quarter use a separate building for cooking (26 percent). Slightly over half the households in urban areas (54 percent) use a separate building for cooking. Almost all households (99 percent) use a biomass fuel for cooking, that is, kerosene, charcoal, dung and wood/straw/shrubs, which generate smoke that is unhealthy when inhaled. In these households, almost all cooking is done over an open fire or stove with no chimney or hood to channel the smoke outside the house. 2.5 HOUSEHOLD POSSESSIONS Information on ownership of durable goods and other possessions is presented in Table 2.11. In general, ownership of household effects, means of transportation and agricultural land and farm animals is indicative of a household’s social and economic well-being. The survey results show that one-third of all households have a radio, about 5 percent have a television, 4 percent have a non- mobile telephone, 2 percent have a mobile telephone and 2 percent have a refrigerator. In general, households in rural Ethiopia are much less likely to possess consumer items like televisions, telephones, or refrigerators. Ethiopians in general are not very likely to own a means of transport, although urban households are more likely than rural households to own a means of transportation. Bicycles owned by 1 percent of households are the most commonly owned means of transportation. Most rural households in contrast to urban households own agricultural land (92 percent versus 11 percent) or farm animals (90 percent versus 24 percent). Table 2.11 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and farm animals, by residence, Ethiopia 2005 Households Possessions Urban Rural Total De jure population Household effects Radio 75.6 26.6 33.7 35.6 Television 33.1 0.1 4.9 4.9 Mobile telephone 11.4 0.0 1.7 1.8 Non-mobile telephone 28.2 0.1 4.2 4.4 Refrigerator 11.9 0.2 1.9 1.9 Means of transport Bicycle 5.5 0.5 1.2 1.5 Animal drawn cart 0.8 0.5 0.6 0.8 Motorcycle/scooter 0.2 0.0 0.0 0.1 Car/truck 3.0 0.0 0.5 0.6 Boat with a motor 0.2 0.0 0.0 0.0 Ownership of agricultural land 11.3 92.0 80.4 84.3 Ownership of farm animals1 23.8 89.5 80.1 85.4 Number of households 1,974 11,747 13,721 68,981 1 Cattle, cows, bulls, horses, donkeys, goats, sheep or chicken. 28 | Household Population and Housing Characteristics 2.6 SOCIOECONOMIC STATUS INDEX One of the background characteristics used throughout this report is an index of socio- economic status. The economic index used here was recently developed and tested in a large number of countries in relation to inequalities in household income, use of health services and health outcomes (Rutstein et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The economic index was constructed using household asset data including ownership of a number of consumer items ranging from a television to a bicycle or car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities and type of material used for flooring. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardized in relation to a normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed for the whole sample; separate indices were not prepared for the urban and rural population. Table 2.12 presents the wealth quintiles by residence and administrative regions. Ninety-three percent of the population in urban areas is in the highest wealth quintile in contrast to the rural areas where only 10 percent are in this category. The wealth quintile distribution among regions shows large variations, with a relatively high percentage of the population in the most urbanized regions in the highest wealth quintile—Addis Ababa (99 percent), Dire Dawa (66 percent), and Harari (65 percent). On the other hand, a significant proportion of the population in the more rural areas of the country such as in Somali (72 percent), Affar (67 percent) and Gambela (44 percent) are in the lowest wealth quintile. Table 2.12 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, according to residence and region, Ethiopia 2005 Wealth quintile Background characteristic Lowest Second Middle Fourth Highest Total De jure population Residence Urban 0.3 0.7 1.3 5.1 92.6 100.0 8,260 Rural 22.7 22.6 22.5 22.0 10.1 100.0 60,721 Region Tigray 31.6 23.5 17.5 10.2 17.2 100.0 4,410 Affar 67.3 8.2 7.8 3.3 13.5 100.0 738 Amhara 17.5 21.4 22.1 23.5 15.5 100.0 17,081 Oromiya 19.9 22.0 20.6 19.7 17.9 100.0 25,278 Somali 71.8 11.1 4.4 3.2 9.6 100.0 2,835 Benishangul-Gumuz 19.1 21.9 24.6 18.5 15.9 100.0 600 SNNP 10.7 19.5 24.2 26.9 18.6 100.0 15,110 Gambela 44.0 15.1 7.9 13.6 19.4 100.0 202 Harari 5.7 6.7 10.3 12.7 64.6 100.0 163 Addis Ababa 0.1 0.3 0.3 0.6 98.7 100.0 2,280 Dire Dawa 11.4 11.2 8.3 3.2 65.8 100.0 285 Total 20.0 20.0 20.0 20.0 20.0 100.0 68,981 Household Population and Housing Characteristics | 29 The registration of births is the inscription of the facts of the birth into an official log kept at the registrar’s office. A birth certificate is issued at the time of registration or later as proof of the registration of the birth. Although Ethiopia does not have a legal and administrative structure that performs official registration of births according to standard procedures, there exists in the urban parts of the country a practice where certificates of birth are issued without the event being officially registered. Birth certificates may also be issued by hospitals where the birth occurred, but this event again may not be officially recorded in a civil registry. In addition, some regional capitals in the country may also issue birth certificates that are not officially recorded by a civil registry. Thus the information in Table 2.13 should be interpreted in the light of the situation in Ethiopia. Information on the registration of births was collected in the household interview where respondents were asked if their child under age five had a birth certificate. If they responded that the child did not have a birth certificate, an additional question was posed to ascertain if the child’s birth had ever been registered with the municipal or local authorities. Seven percent of Ethiopian children under age five have had their births registered. However, most of these children (5 percent) did not have a birth certificate. Table 2.13 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, by background characteristics, Ethiopia 2005 Percentage of children whose births are registered: Background characteristic Had a birth certificate Did not have a birth certificate Total registered Number of children Age < 2 1.5 5.6 7.2 4,287 2 - 4 1.1 5.2 6.3 6,545 Sex Male 1.4 5.0 6.4 5,486 Female 1.2 5.7 6.9 5,345 Residence Urban 10.1 18.9 28.9 783 Rural 0.6 4.3 4.9 10,048 Region Tigray 3.4 4.1 7.5 694 Affar 1.5 2.8 4.3 102 Amhara 0.6 3.6 4.2 2,479 Oromiya 1.0 3.9 4.9 4,285 Somali 0.9 2.7 3.6 460 Benishangul-Gumuz 0.6 3.2 3.8 104 SNNP 0.9 9.1 10.0 2,467 Gambela 0.9 5.2 6.1 30 Harari 10.6 6.6 17.3 23 Addis Ababa 16.6 28.9 45.5 150 Dire Dawa 7.5 16.3 23.8 38 Wealth quintile Lowest 0.3 2.2 2.6 2,366 Second 0.1 3.6 3.8 2,308 Middle 0.6 5.2 5.7 2,356 Fourth 0.9 5.7 6.6 2,184 Highest 5.9 12.2 18.1 1,617 Total 1.3 5.4 6.6 10,831   Characteristics of Respondents | 31 CHARACTERISTICS OF RESPONDENTS 3 This chapter provides a demographic and socioeconomic profile of respondents interviewed in the 2005 EDHS. Such background information is essential to the interpretation of findings and for understanding the results presented later in the report. Basic characteristics collected include age, level of education, marital status, religion, ethnicity, and wealth status. Exposure to mass media and literacy status was examined and detailed information was collected on employment status, occu- pation, and earnings. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS The background characteristics of the 14,070 women age 15-49 and the 6,033 men age 15-59 interviewed in the 2005 EDHS are shown in Table 3.1. This table is important in that it provides the background for interpreting findings presented later in the report. Three in five women (59 percent) and one in two men (52 percent) are under age 30. In general, the proportion of women and men in each age group declines as age increases, reflecting the comparatively young age structure of the population in Ethiopia as a result of past high fertility levels. The majority of surveyed respondents (65 percent of women and 57 percent of men) are married or living together. The proportion not currently married varies by gender. One in four women has never married compared with two in five men. On the other hand, women are much more likely to be divorced, separated, or widowed (11 percent) than men (3 percent). Place of residence is another characteristic that determines access to services and exposure to information pertaining to reproductive health and other aspects of life. As expected, the majority of respondents reside in rural areas, with only 18 percent of women and 15 percent of men residing in urban areas. More than 80 percent of the respondents live in three major regions, namely: Amhara, Oromiya, and SNNP. Respondents from Tigray, Addis Ababa, and Somali constitute about 7 percent, 5 percent, and 3 percent, respectively, of the sample. One percent or less of respondents reside in other regions. Education is an important factor influencing an individual’s attitude and outlook on various aspects of life. Generally, educational attainment in Ethiopia is very low among both men and women, with women much more disadvantaged than men. Two-thirds of women compared with two- fifths of men do not have any formal education. The corresponding figures in the 2000 EDHS were 75 percent and 52 percent, respectively, indicating that the proportion of persons with no education has declined over the past five years. Nearly twice as many men as women have primary (37 percent of men compared with 22 percent of women) or secondary education (20 percent of men compared with 12 percent of women). The distribution of respondents by religious affiliation shows that half are Orthodox Christians and nearly 30 percent are Muslims. Protestant women and men account for about 19 percent and 17 percent, respectively. The ethnic composition of respondents indicates that a third of respondents belong to the Oromo ethnic group and about three out of ten are Amharas. Tigraways constitute 7 percent of the population. While there are more than 80 ethnic groups in Ethiopia, most are small in number and, therefore, are not shown separately. They are grouped under the category “Other.” 32 | Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men by selected background characteristics, Ethiopia 2005 Women Men Background characteristic Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15-19 23.2 3,266 3,252 22.1 1,335 1,278 20-24 18.1 2,547 2,617 17.6 1,064 1,039 25-29 17.9 2,517 2,557 12.3 741 830 30-34 12.8 1,808 1,754 12.5 754 759 35-39 11.4 1,602 1,629 10.8 651 650 40-44 8.4 1,187 1,181 8.2 497 496 45-49 8.1 1,143 1,080 7.0 422 420 50-54 na na na 5.5 335 339 55-59 na na na 3.9 235 222 Marital status Never married 25.0 3,516 3,830 40.1 2,419 2,460 Married 63.4 8,914 8,438 56.2 3,393 3,295 Living together 1.1 152 206 0.5 31 37 Divorced/separated 6.6 932 989 2.5 153 182 Widowed 4.0 556 607 0.6 37 59 Residence Urban 17.8 2,499 4,423 15.2 916 1,628 Rural 82.2 11,571 9,647 84.8 5,117 4,405 Region Tigray 6.5 919 1,257 6.1 366 512 Affar 1.0 146 789 1.1 65 314 Amhara 24.7 3,482 1,943 25.2 1,521 897 Oromiya 35.6 5,010 2,230 36.8 2,222 1,041 Somali 3.5 486 669 3.4 202 281 Benishangul-Gumuz 0.9 124 846 0.9 54 382 SNNP 21.3 2,995 2,087 20.6 1,244 880 Gambela 0.3 44 729 0.3 21 339 Harari 0.3 39 844 0.3 16 359 Addis Ababa 5.4 756 1,869 4.8 292 698 Dire Dawa 0.5 69 807 0.5 30 330 Education No education 65.9 9,271 8,454 42.9 2,589 2,434 Primary 22.2 3,123 2,966 37.3 2,252 1,946 Secondary 10.5 1,481 2,292 17.3 1,045 1,394 Higher 1.4 194 358 2.4 147 259 Religion Orthodox 49.2 6,920 6,809 49.3 2,974 2,916 Catholic 1.2 173 143 1.0 61 56 Protestant 18.9 2,654 2,301 17.2 1,038 876 Muslim 28.5 4,009 4,522 29.6 1,788 2,030 Other 2.2 313 295 2.9 172 155 Ethnicity Affar 0.7 104 603 0.8 46 249 Amhara 31.5 4,434 4,165 30.8 1,861 1,707 Guragie 4.6 648 786 4.4 268 343 Oromo 32.4 4,556 3,387 33.2 2,005 1,499 Sidamo 4.0 561 345 4.5 270 168 Somali 3.0 421 690 3.1 188 299 Tigraway 6.9 971 1,398 6.5 394 588 Welaita 2.6 361 266 2.2 132 103 Other 14.3 2,015 2,430 14.4 869 1,077 Total 100.0 14,070 14,070 100.0 6,033 6,033 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Respondents | 33 3.2 EDUCATIONAL ATTAINMENT AND LITERACY Tables 3.2.1 and 3.2.2 present detailed distribution of educational attainment, according to background characteristics. As can be seen from the table, most women with no education are older and reside primarily in rural areas. The urban-rural difference in level of education is pronounced at secondary or higher levels. For example, only 3 percent of women in rural areas have some secondary education, compared with nearly a third of their counterparts in urban areas. Regarding regional differentials in educational attainment, the highest proportions of women with no education are observed in the Somali and Affar regions (91 percent and 85 percent, respectively). The lowest proportion is observed in Addis Ababa, where only 18 percent of women have never attended formal education. Table 3.2.1 Educational attainment by background characteristics: women Percent distribution of women by highest level of schooling attained, and median number of years of schooling, according to background characteristics, Ethiopia 2005 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 women Median years of schooling Age 15-19 40.1 36.4 7.2 15.5 0.4 0.5 100.0 3,266 1.2 20-24 60.2 19.8 2.7 11.4 3.8 2.1 100.0 2,547 0.0 25-29 68.9 17.4 1.6 6.6 3.8 1.7 100.0 2,517 0.0 30-34 73.0 15.5 1.7 5.0 3.2 1.6 100.0 1,808 0.0 35-39 80.1 11.3 1.5 3.4 2.3 1.5 100.0 1,602 0.0 40-44 87.0 6.0 1.1 2.6 1.8 1.6 100.0 1,187 0.0 45-49 92.8 3.5 0.9 1.5 0.5 0.8 100.0 1,143 0.0 Residence Urban 24.7 17.8 6.7 31.5 12.5 6.9 100.0 2,499 6.2 Rural 74.8 19.5 2.2 3.2 0.1 0.2 100.0 11,571 0.0 Region Tigray 63.5 16.4 3.7 12.0 2.0 2.4 100.0 919 0.0 Affar 84.8 6.7 1.7 6.1 0.7 0.0 100.0 146 0.0 Amhara 75.6 13.7 2.1 5.7 1.7 1.1 100.0 3,482 0.0 Oromiya 64.4 22.4 3.3 8.0 1.5 0.5 100.0 5,010 0.0 Somali 90.6 3.3 1.0 2.4 2.2 0.6 100.0 486 0.0 Benishangul-Gumuz 73.2 17.6 2.8 4.2 0.8 1.4 100.0 124 0.0 SNNP 65.7 24.6 3.0 5.6 0.7 0.3 100.0 2,995 0.0 Gambela 59.5 27.4 4.7 6.9 1.4 0.1 100.0 44 0.0 Harari 39.9 14.4 3.0 25.1 13.0 4.6 100.0 39 3.8 Addis Ababa 17.6 18.6 5.7 29.8 16.7 11.6 100.0 756 7.3 Dire Dawa 46.7 15.0 4.5 22.3 9.1 2.4 100.0 69 2.1 Wealth quintile Lowest 88.2 10.2 0.4 1.2 0.0 0.0 100.0 2,428 0.0 Second 83.5 14.3 1.0 1.2 0.0 0.0 100.0 2,643 0.0 Middle 73.2 21.8 2.4 2.5 0.0 0.0 100.0 2,732 0.0 Fourth 66.2 25.6 3.5 4.5 0.1 0.1 100.0 2,647 0.0 Highest 32.4 22.1 6.2 25.1 8.9 5.3 100.0 3,621 4.2 Total 65.9 19.2 3.0 8.2 2.3 1.4 100.0 14,070 0.0 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level 34 | Characteristics of Respondents Table 3.2.2 Educational attainment by background characteristics: men Percent distribution of men by highest level of schooling attained, and median number of years of schooling, according to background characteristics, Ethiopia 2005 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 men Median years of schooling Age 15-19 21.2 43.3 11.4 22.9 0.6 0.7 100.0 1,335 3.5 20-24 32.7 30.4 7.7 22.0 4.4 2.8 100.0 1,064 3.1 25-29 42.2 31.4 5.2 12.5 5.2 3.5 100.0 741 1.4 30-34 44.6 32.1 7.4 9.5 4.8 1.6 100.0 754 1.3 35-39 49.1 28.1 6.3 8.8 5.0 2.7 100.0 651 0.2 40-44 57.0 22.2 3.6 8.6 3.2 5.3 100.0 497 0.0 45-49 66.9 16.8 3.1 6.6 2.5 4.1 100.0 422 0.0 50-54 73.0 16.8 2.7 3.3 2.1 2.1 100.0 335 0.0 55-59 77.0 19.7 0.3 1.7 0.7 0.6 100.0 235 0.0 Residence Urban 7.9 14.6 5.8 40.3 18.1 13.4 100.0 916 8.5 Rural 49.2 33.4 7.0 9.3 0.6 0.5 100.0 5,117 0.0 Region Tigray 46.9 24.0 6.1 14.2 4.2 4.7 100.0 366 0.7 Affar 71.4 14.2 2.9 6.4 4.0 1.2 100.0 65 0.0 Amhara 60.5 23.8 3.1 9.4 2.0 1.2 100.0 1,521 0.0 Oromiya 36.7 34.5 8.5 16.1 2.6 1.6 100.0 2,222 1.9 Somali 81.9 7.7 2.5 5.3 1.7 0.9 100.0 202 0.0 Benishangul-Gumuz 49.9 30.6 6.9 10.3 0.4 1.9 100.0 54 0.0 SNNP 32.6 42.7 9.4 12.5 1.6 1.2 100.0 1,244 2.3 Gambela 27.5 32.5 8.2 26.8 3.6 1.3 100.0 21 3.7 Harari 20.5 21.7 6.2 31.8 12.2 7.6 100.0 16 6.3 Addis Ababa 7.2 12.7 6.9 33.0 21.5 18.7 100.0 292 9.2 Dire Dawa 22.8 18.0 6.7 33.9 11.8 6.8 100.0 30 6.3 Wealth quintile Lowest 69.6 21.9 4.3 4.2 0.0 0.0 100.0 1,100 0.0 Second 55.4 34.2 4.8 5.4 0.2 0.1 100.0 1,184 0.0 Middle 47.4 35.9 7.2 9.4 0.1 0.1 100.0 1,081 0.3 Fourth 37.0 39.2 9.7 13.0 1.0 0.1 100.0 1,200 2.1 Highest 14.5 22.9 7.7 32.6 12.5 9.8 100.0 1,469 6.7 Total 42.9 30.5 6.8 14.0 3.3 2.4 100.0 6,033 1.3 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Not surprisingly, access to wealth equates with access to education. An analysis of the variation in the level of education by wealth quintile indicates that only those in the highest wealth quintile have the opportunity to complete secondary or higher levels of education. Likewise, only a third of the women in the highest quintile have never attended school, compared with 88 percent of women in the lowest quintile. The pattern of educational attainment among men is similar to that of women. However, men are more educated than women at every level. This gender disparity is more marked at higher than at lower levels, indicating the government’s recognition and successful intervention to address gender disparity in recent years. Characteristics of Respondents | 35 Literacy is widely acknowledged as benefiting the individual and the society and is associated with a number of positive outcomes for health and nutrition. In the 2005 EDHS, literacy status was determined based on the respondents’ ability to read all or part of a sentence. During data collection, interviewers carried a set of cards on which simple sentences were printed in five of the major languages for testing a respondent’s reading ability. Only those who had never been to school and those who had not completed primary level were asked to read the cards in the language they were most likely able to read; those who had attained middle school or above were assumed to be literate. Table 3.3.1 indicates that only 3 of 10 women in Ethiopia are literate and that literacy status varies greatly by place of residence. Three-fourths of women residing in urban areas are literate compared with only a fifth of their rural counterparts. The level of literacy by age exhibits a consistent decrease with increasing age, suggesting that the younger generation has had more opportunity for learning than the older generation. Half of the women age 15-19 are literate compared with only 8 percent of the women age 45-49. Table 3.3.1 Literacy: women Percent distribution of women by level of schooling attended and level of literacy, and percent literate, according to background characteristics, Ethiopia 2005 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Number of women Percent literate1 Age 15-19 16.4 22.4 10.7 47.5 2.7 0.0 0.2 100.0 3,266 49.5 20-24 17.3 7.8 6.4 66.1 2.3 0.0 0.1 100.0 2,547 31.5 25-29 12.1 7.1 6.9 73.2 0.5 0.1 0.1 100.0 2,517 26.1 30-34 9.8 6.1 8.9 74.2 1.0 0.1 0.0 100.0 1,808 24.8 35-39 7.2 5.2 7.3 78.8 1.6 0.0 0.0 100.0 1,602 19.6 40-44 5.9 2.7 5.7 84.0 1.6 0.0 0.0 100.0 1,187 14.4 45-49 2.8 1.2 4.0 90.9 1.1 0.0 0.0 100.0 1,143 8.0 Residence Urban 50.9 14.3 8.3 26.0 0.3 0.0 0.1 100.0 2,499 73.6 Rural 3.5 8.6 7.5 78.4 2.0 0.0 0.1 100.0 11,571 19.6 Region Tigray 16.5 10.0 7.2 66.3 0.0 0.0 0.0 100.0 919 33.7 Affar 6.8 4.6 4.1 84.3 0.1 0.0 0.0 100.0 146 15.6 Amhara 8.5 9.6 6.9 74.8 0.0 0.0 0.1 100.0 3,482 25.1 Oromiya 10.0 10.7 8.8 68.6 1.9 0.1 0.0 100.0 5,010 29.5 Somali 5.2 1.8 2.8 89.5 0.2 0.0 0.5 100.0 486 9.8 Benishangul-Gumuz 6.4 9.2 7.6 74.7 1.9 0.0 0.2 100.0 124 23.2 SNNP 6.7 8.4 7.3 73.0 4.5 0.1 0.0 100.0 2,995 22.4 Gambela 8.4 5.4 9.1 73.2 3.8 0.0 0.1 100.0 44 22.8 Harari 42.7 6.6 5.7 44.4 0.1 0.0 0.5 100.0 39 54.9 Addis Ababa 58.1 12.7 9.0 19.8 0.2 0.0 0.2 100.0 756 79.9 Dire Dawa 33.7 9.9 9.4 46.7 0.0 0.2 0.0 100.0 69 53.0 Wealth quintile Lowest 1.2 3.1 5.2 88.7 1.7 0.1 0.0 100.0 2,428 9.5 Second 1.2 5.7 5.2 85.3 2.5 0.0 0.0 100.0 2,643 12.1 Middle 2.6 9.3 8.8 77.8 1.5 0.1 0.0 100.0 2,732 20.6 Fourth 4.6 12.5 9.4 71.5 1.9 0.0 0.1 100.0 2,647 26.5 Highest 39.3 14.9 8.9 35.7 1.0 0.0 0.2 100.0 3,621 63.1 Total 11.9 9.6 7.6 69.1 1.7 0.0 0.1 100.0 14,070 29.2 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 36 | Characteristics of Respondents Regional differences in literacy are marked, with literacy being highest among women in predominantly urban Addis Ababa, (80 percent) and lowest in the predominantly rural Somali Region (10 percent). There is also a marked difference in literacy levels by women’s wealth status, ranging from a low of 10 percent among women in the lowest wealth quintile to a high of 63 percent among women in the highest wealth quintile. In general, men are more likely to be literate than women (Table 3.3.2). The urban-rural differential in literacy among men is smaller compared with women, suggesting that men in the rural areas have much greater opportunity for learning than women. Table 3.3.2 Literacy: men Percent distribution of men by level of schooling attended and level of literacy, and percent literate, according to background characteristics, Ethiopia 2005 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Number of men Percent literate1 Age 15-19 24.2 33.8 12.9 25.4 3.7 0.0 0.0 100.0 1,335 70.9 20-24 29.3 22.4 11.0 35.3 1.7 0.2 0.1 100.0 1,064 62.7 25-29 21.2 22.0 13.9 41.6 1.4 0.0 0.0 100.0 741 57.0 30-34 15.9 30.0 14.4 38.5 1.0 0.2 0.0 100.0 754 60.3 35-39 16.5 25.7 20.5 36.7 0.6 0.0 0.0 100.0 651 62.7 40-44 17.2 21.9 13.2 47.1 0.6 0.0 0.0 100.0 497 52.3 45-49 13.2 16.7 17.0 52.3 0.8 0.0 0.0 100.0 422 46.9 50-54 7.5 20.9 9.3 61.9 0.4 0.1 0.0 100.0 335 37.7 55-59 3.0 11.8 15.6 67.9 0.7 1.0 0.0 100.0 235 30.4 Residence Urban 71.8 15.7 6.2 6.0 0.2 0.0 0.1 100.0 916 93.7 Rural 10.4 27.0 15.3 45.3 1.9 0.1 0.0 100.0 5,117 52.7 Region Tigray 23.1 31.4 13.0 32.5 0.0 0.0 0.0 100.0 366 67.5 Affar 11.5 8.1 7.4 71.2 1.2 0.5 0.0 100.0 65 27.0 Amhara 12.6 30.0 11.5 45.6 0.2 0.1 0.0 100.0 1,521 54.0 Oromiya 20.3 22.7 18.6 37.8 0.6 0.1 0.0 100.0 2,222 61.5 Somali 7.9 7.8 6.3 77.1 0.9 0.0 0.0 100.0 202 22.0 Benishangul-Gumuz 12.6 25.6 9.2 51.5 0.8 0.0 0.3 100.0 54 47.4 SNNP 15.3 28.6 13.2 36.5 6.4 0.1 0.0 100.0 1,244 57.0 Gambela 31.7 15.9 9.8 41.3 1.2 0.0 0.0 100.0 21 57.5 Harari 51.6 22.5 4.3 20.6 0.6 0.0 0.3 100.0 16 78.4 Addis Ababa 73.2 16.5 3.9 6.1 0.0 0.0 0.3 100.0 292 93.6 Dire Dawa 52.5 13.4 10.6 22.7 0.4 0.4 0.0 100.0 30 76.6 Wealth quintile Lowest 4.2 16.2 13.5 64.9 0.9 0.3 0.0 100.0 1,100 33.9 Second 5.7 21.2 17.7 53.1 2.3 0.0 0.0 100.0 1,184 44.5 Middle 9.5 30.8 14.1 43.3 2.2 0.0 0.0 100.0 1,081 54.5 Fourth 14.1 37.1 15.1 31.5 2.0 0.2 0.0 100.0 1,200 66.3 Highest 54.9 21.5 9.9 12.5 1.0 0.0 0.1 100.0 1,469 86.4 Total 19.8 25.3 13.9 39.3 1.7 0.1 0.0 100.0 6,033 58.9 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Respondents | 37 3.3 ACCESS TO MASS MEDIA Exposure to mass media provides the opportunity to be acquainted with new ideas and knowledge that is useful in various aspects of everyday life. In the 2005 EDHS, exposure to media was assessed by asking respondents how often they listened to a radio, watched television, or read newspapers or magazines. This information is useful in determining which media may be more effective for disseminating health information to targeted audiences. The results are presented in Tables 3.4.1 and 3.4.2 by background characteristics. Table 3.4.1 Exposure to mass media: women Percentage of women who are exposed to specific media on a weekly basis, according to background characteristics, Ethiopia 2005 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number of women Age 15-19 5.3 11.0 19.9 1.3 72.6 3,266 20-24 2.7 10.3 19.6 1.1 76.2 2,547 25-29 1.9 6.8 15.2 0.7 81.2 2,517 30-34 1.4 5.4 13.0 0.7 84.3 1,808 35-39 0.9 4.8 13.4 0.3 84.4 1,602 40-44 1.3 5.0 11.2 0.7 86.6 1,187 45-49 0.7 5.7 11.6 0.6 85.3 1,143 Residence Urban 8.8 39.5 40.4 4.6 41.9 2,499 Rural 1.2 0.9 10.7 0.0 88.1 11,571 Region Tigray 2.8 7.3 13.4 0.9 82.2 919 Affar 0.5 4.4 8.3 0.0 88.4 146 Amhara 1.2 3.5 14.6 0.4 83.8 3,482 Oromiya 2.3 6.5 16.6 0.6 79.4 5,010 Somali 0.6 6.5 5.0 0.3 90.9 486 Benishangul-Gumuz 1.6 1.4 13.2 0.3 86.1 124 SNNP 1.6 2.5 11.3 0.2 86.6 2,995 Gambela 1.7 3.6 7.6 0.0 89.1 44 Harari 6.1 42.2 39.1 4.0 46.3 39 Addis Ababa 14.1 55.8 45.9 7.4 29.2 756 Dire Dawa 4.1 37.2 38.3 3.0 53.1 69 Education No education 0.0 1.5 8.1 0.0 91.0 9,271 Primary 3.6 7.4 21.2 0.3 72.8 3,123 Secondary and higher 14.3 43.5 50.1 6.6 31.6 1,675 Wealth quintile Lowest 0.3 0.2 2.2 0.0 97.2 2,428 Second 0.5 0.3 5.1 0.1 94.4 2,643 Middle 1.5 0.4 10.1 0.0 88.6 2,732 Fourth 1.5 1.1 15.6 0.0 82.8 2,647 Highest 6.9 28.7 37.9 3.3 48.9 3,621 Total 2.5 7.8 16.0 0.9 79.9 14,070 38 | Characteristics of Respondents Table 3.4.2 Exposure to mass media: men Percentage of men who are exposed to specific media on a weekly basis, according to background characteristics, Ethiopia 2005 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number of men Age 15-19 8.6 13.3 26.5 2.9 65.6 1,335 20-24 9.9 14.9 37.1 4.0 57.0 1,064 25-29 7.8 12.4 33.5 3.8 61.7 741 30-34 6.2 8.2 34.0 3.2 63.8 754 35-39 6.2 8.2 30.1 2.4 66.6 651 40-44 6.6 7.8 33.4 3.1 64.0 497 45-49 5.6 8.0 31.4 2.3 65.4 422 50-54 5.3 6.4 23.3 2.1 73.9 335 55-59 3.4 4.3 27.6 1.2 71.0 235 Residence Urban 27.3 49.9 62.8 17.6 21.9 916 Rural 3.9 3.7 25.7 0.5 71.6 5,117 Region Tigray 13.7 18.4 37.0 4.1 54.1 366 Affar 1.4 13.1 29.1 1.2 67.1 65 Amhara 4.6 5.7 24.9 1.4 71.4 1,521 Oromiya 6.5 10.2 35.6 2.9 61.0 2,222 Somali 2.0 3.4 22.0 1.2 77.0 202 Benishangul-Gumuz 1.9 6.8 35.0 0.3 61.9 54 SNNP 4.6 5.6 24.6 1.2 72.3 1,244 Gambela 5.4 8.4 33.4 1.6 62.6 21 Harari 22.2 41.8 70.9 15.0 22.1 16 Addis Ababa 37.5 54.7 55.7 20.7 21.4 292 Dire Dawa 17.5 34.2 51.9 9.7 38.9 30 Education No education 0.6 1.4 16.1 0.0 82.9 2,589 Primary 5.5 7.7 33.4 0.9 61.8 2,252 Secondary and higher 25.8 36.5 60.5 13.9 27.2 1,192 Wealth quintile Lowest 2.8 1.0 10.4 0.2 87.8 1,100 Second 1.7 2.9 18.6 0.4 79.5 1,184 Middle 6.3 3.6 25.0 0.3 70.3 1,081 Fourth 4.1 4.4 35.9 0.5 61.5 1,200 Highest 19.0 34.6 58.1 11.4 31.2 1,469 Total 7.4 10.7 31.3 3.1 64.0 6,033 The survey shows that exposure to media in Ethiopia is low, especially with regards to the print media. Respondents are more likely to be exposed to the radio than any other media. Men have greater access to mass media, particularly radio, than women. Specifically, men are twice as likely to listen to the radio as women (31 percent and 16 percent, respectively). Young women under 25 years of age are more likely to be exposed to mass media than older women, primarily because of their higher level of education. There is also a wide gap in exposure to mass media by place of residence. For example, the proportion of newspaper readers is highest among urban residents and those with some secondary or higher levels of education. When looking into the regional variation, women in Addis Ababa are more likely to read newspapers or magazines on a weekly basis than other women. Characteristics of Respondents | 39 There has been an increase in exposure to the media since 2000. The proportion of women who listen to the radio at least once a week has increased by 43 percent, from 11 percent in 2000 to 16 percent in 2005, while the proportion among men rose from 24 percent to 31 percent. There was also an increase in exposure to television, from 4 to 8 percent among women and from 8 to 11 percent among men. 3.4 EMPLOYMENT 3.4.1 Employment Status In the 2005 EDHS, respondents were asked a number of questions regarding their employment status, including whether they were working in the seven days preceding the survey and, if not, whether they had worked in the 12 months before the survey. The results for women and men are presented in Tables 3.5.1 and 3.5.2. At the time of the survey, about 3 of 10 women were currently employed and an additional 5 percent were not employed but had worked sometime during the preceding 12 months. Current employment generally increases with increasing age and women who are divorced, separated, or widowed are more likely to be employed than other women. Women who have four or less children are more likely to be employed than those with five or more children. There are notable variations in the proportion currently employed by place of residence and region. Urban women are more likely to be currently employed than rural women (40 percent compared with 27 percent).Women in Addis Ababa and Harari are most likely to be employed (44 percent and 41 percent, respectively), while Affar and Somali regions have the lowest proportions of employed women (11 percent each). Current employment increases with an increase in level of education; the proportion of employed women increases from 27 percent among uneducated women to 38 percent among those with some secondary education. There is also an increase in the percentage of employed persons by wealth quintile, with those in the highest quintile much more likely to be employed than those in the other four quintiles. A marked difference was observed in the level of employment by gender. The proportion currently employed is much higher among men than women. As can be seen from Table 3.5.2, the majority of men (86 percent) were employed at the time of survey. The majority of employed men are in rural areas and have little or no education. This is probably because the EDHS data collection took place during the peak agricultural season when most men in rural areas are likely to be engaged in farm work. Although the level of female employment is lower in 2005 than in 2000, the patterns for men are very similar. The marked difference in the percentage of women currently employed between 2000 (57 percent) and 2005 (29 percent) can be attributed to the difference in the way the data on current employment were collected for women in the two DHS surveys. There was no difference in the wording of the question on current employment for men between the two surveys. 40 | Characteristics of Respondents Table 3.5.1 Employment status: women Percent distribution of women by employment status, according to background characteristics, Ethiopia 2005 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 Total Number of women Age 15-19 24.0 4.2 65.8 6.0 100.0 3,266 20-24 29.6 5.9 60.5 3.9 100.0 2,547 25-29 28.8 6.1 60.5 4.6 100.0 2,517 30-34 30.2 5.7 60.6 3.5 100.0 1,808 35-39 31.2 4.6 59.2 4.9 100.0 1,602 40-44 33.0 6.6 56.0 4.4 100.0 1,187 45-49 31.6 5.1 60.6 2.8 100.0 1,143 Marital status Never married 31.2 3.4 60.2 5.2 100.0 3,516 Married or living together 25.5 6.0 63.9 4.6 100.0 9,066 Divorced/separated/widowed 44.3 6.0 47.2 2.5 100.0 1,488 Number of living children 0 30.4 4.7 60.0 4.9 100.0 4,554 1-2 29.5 6.4 60.1 4.0 100.0 3,226 3-4 29.7 5.7 60.2 4.4 100.0 2,981 5+ 25.5 5.0 64.8 4.6 100.0 3,309 Residence Urban 39.6 3.8 53.5 3.1 100.0 2,499 Rural 26.6 5.7 62.9 4.8 100.0 11,571 Region Tigray 27.6 16.8 51.5 4.1 100.0 919 Affar 11.3 0.6 82.5 5.6 100.0 146 Amhara 27.9 8.4 59.9 3.8 100.0 3,482 Oromiya 32.0 3.3 59.9 4.7 100.0 5,010 Somali 11.4 0.1 73.1 15.4 100.0 486 Benishangul-Gumuz 34.3 9.1 51.1 5.5 100.0 124 SNNP 24.5 3.0 68.3 4.2 100.0 2,995 Gambela 26.7 6.2 59.8 7.3 100.0 44 Harari 41.1 1.0 53.5 4.4 100.0 39 Addis Ababa 44.2 4.7 49.4 1.7 100.0 756 Dire Dawa 33.7 0.9 64.5 0.9 100.0 69 Education No education 27.2 5.6 62.5 4.6 100.0 9,271 Primary 29.1 4.9 60.9 5.1 100.0 3,123 Secondary and higher 38.0 4.6 54.5 2.9 100.0 1,675 Wealth quintile Lowest 23.5 5.7 64.4 6.4 100.0 2,428 Second 26.6 6.3 62.0 5.1 100.0 2,643 Middle 25.9 5.2 64.0 4.8 100.0 2,732 Fourth 29.6 5.3 61.9 3.2 100.0 2,647 Highest 35.9 4.6 55.9 3.7 100.0 3,621 Total 28.9 5.4 61.2 4.5 100.0 14,070 1 "Currently employed" is defined as having done work in the last seven days. Includes persons who did not work in the last seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Respondents | 41 Table 3.5.2 Employment status: men Percent distribution of men by employment status, according to background characteristics, Ethiopia 2005 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 Total Number of men Age 15-19 63.0 2.0 34.3 0.6 100.0 1,335 20-24 79.8 3.4 16.5 0.4 100.0 1,064 25-29 91.9 2.8 5.3 0.0 100.0 741 30-34 97.6 0.7 1.5 0.2 100.0 754 35-39 97.3 0.6 2.1 0.0 100.0 651 40-44 96.3 1.6 2.0 0.0 100.0 497 45-49 95.5 0.9 3.5 0.0 100.0 422 50-54 96.6 0.8 2.5 0.0 100.0 335 55-59 93.4 0.8 5.8 0.0 100.0 235 Marital status Never married 69.0 3.1 27.4 0.5 100.0 2,419 Married or living together 97.0 0.9 2.1 0.0 100.0 3,424 Divorced/separated/widowed 92.0 1.0 7.1 0.0 100.0 190 Number of living children 0 72.5 2.9 24.2 0.4 100.0 2,766 1-2 95.8 1.1 2.9 0.1 100.0 993 3-4 97.6 0.4 1.9 0.0 100.0 967 5+ 96.7 1.1 2.1 0.0 100.0 1,307 Residence Urban 62.1 5.5 32.0 0.4 100.0 916 Rural 89.8 1.2 8.8 0.2 100.0 5,117 Region Tigray 80.5 6.2 13.2 0.2 100.0 366 Affar 92.0 2.1 5.9 0.0 100.0 65 Amhara 91.3 0.7 8.0 0.0 100.0 1,521 Oromiya 84.1 1.2 14.5 0.1 100.0 2,222 Somali 87.2 1.9 10.5 0.3 100.0 202 Benishangul-Gumuz 91.0 1.6 7.5 0.0 100.0 54 SNNP 86.4 1.5 11.5 0.7 100.0 1,244 Gambela 82.1 6.1 11.8 0.0 100.0 21 Harari 81.0 3.1 15.7 0.2 100.0 16 Addis Ababa 68.9 7.3 23.6 0.1 100.0 292 Dire Dawa 68.8 6.1 25.2 0.0 100.0 30 Education No education 97.4 1.0 1.6 0.0 100.0 2,589 Primary 83.9 1.4 14.5 0.2 100.0 2,252 Secondary and higher 63.2 4.4 31.8 0.6 100.0 1,192 Wealth quintile Lowest 92.8 1.4 5.6 0.1 100.0 1,100 Second 91.8 1.2 6.9 0.1 100.0 1,184 Middle 90.7 0.9 7.9 0.5 100.0 1,081 Fourth 86.4 1.6 11.9 0.1 100.0 1,200 Highest 70.8 3.5 25.4 0.3 100.0 1,469 Total 85.6 1.8 12.4 0.2 100.0 6,033 1 "Currently employed" is defined as having done work in the last seven days. Includes persons who did not work in the last seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 42 | Characteristics of Respondents 3.4.2 OCCUPATION Respondents who were currently employed or had worked in the 12 months preceding the survey were further asked to specify their occupation. Tables 3.6.1 and 3.6.2 show data on employed women and men, respectively, by occupation according to background characteristics. Most employed persons are engaged in the agricultural sector. Specifically, more than half of employed women and 84 percent of employed men are engaged in agricultural jobs. Sales and service is an important occupation category, especially for women, employing nearly a third of the women and about 7 percent of the men. Table 3.6.1 Occupation: women Percent distribution of women employed in the 12 months preceding the survey by occupation, according to background characteristics, Ethiopia 2005 Manual labour Background characteristic Profes- sional/ technical/ managerial Clerical Sales and services Skilled Unskilled Agricul- ture Missing Total Number of women Age 15-19 0.3 0.3 35.6 4.9 5.0 52.2 1.6 100.0 922 20-24 3.9 2.0 35.4 4.6 6.4 45.6 2.1 100.0 905 25-29 6.1 1.1 33.6 5.7 6.1 47.0 0.5 100.0 879 30-34 5.8 1.8 28.3 6.3 4.8 51.8 1.3 100.0 648 35-39 4.6 1.1 28.2 7.6 3.8 54.1 0.6 100.0 574 40-44 3.4 1.2 24.7 8.1 2.4 58.4 1.6 100.0 470 45-49 2.1 0.4 24.7 7.2 3.6 61.0 1.0 100.0 419 Marital status Never married 5.1 2.7 43.6 5.5 6.9 35.0 1.3 100.0 1,217 Married or living together 3.6 0.6 24.8 5.0 3.1 61.8 1.2 100.0 2,854 Divorced/separated/widowed 2.2 1.0 36.3 10.8 8.8 39.5 1.5 100.0 748 Number of living children 0 4.4 2.1 40.6 5.9 6.2 39.3 1.5 100.0 1,596 1-2 5.8 1.4 29.1 5.6 6.2 50.6 1.2 100.0 1,157 3-4 3.2 0.3 25.5 6.5 3.8 59.8 0.9 100.0 1,056 5+ 1.0 0.3 25.2 6.2 2.6 63.4 1.3 100.0 1,010 Residence Urban 14.2 5.0 57.5 12.2 9.0 1.2 1.0 100.0 1,084 Rural 0.7 0.1 23.7 4.2 3.8 66.2 1.3 100.0 3,734 Region Tigray 5.5 1.6 15.3 4.5 20.1 52.1 0.9 100.0 408 Affar 8.1 3.5 37.0 10.3 19.7 20.8 0.5 100.0 17 Amhara 3.4 0.5 15.3 6.5 4.7 68.4 1.2 100.0 1,265 Oromiya 2.3 0.7 25.2 4.1 2.5 63.7 1.5 100.0 1,771 Somali 14.9 2.8 74.8 2.4 0.0 4.0 1.2 100.0 56 Benishangul-Gumuz 4.2 0.7 18.0 2.8 0.3 73.2 0.8 100.0 54 SNNP 1.0 0.4 58.8 9.5 2.0 27.5 0.8 100.0 824 Gambela 3.0 1.9 31.9 17.5 7.2 38.2 0.3 100.0 15 Harari 14.4 5.5 64.9 5.7 5.1 2.6 1.8 100.0 16 Addis Ababa 13.7 6.0 62.7 7.9 7.4 0.3 2.1 100.0 370 Dire Dawa 7.0 4.0 73.9 3.3 11.1 0.0 0.7 100.0 24 Education No education 0.1 0.0 25.8 5.6 4.4 62.8 1.3 100.0 3,042 Primary 0.0 0.4 37.8 6.4 6.0 48.1 1.4 100.0 1,063 Secondary and higher 25.0 7.3 45.1 7.3 5.7 8.5 1.2 100.0 714 Wealth quintile Lowest 0.0 0.0 19.0 3.0 5.3 70.3 2.3 100.0 709 Second 0.2 0.0 18.9 6.3 5.0 68.3 1.3 100.0 870 Middle 0.0 0.0 22.8 5.0 3.3 68.1 0.9 100.0 851 Fourth 0.0 0.2 28.8 3.7 3.7 62.4 1.2 100.0 924 Highest 12.2 3.7 51.2 9.3 6.5 16.0 1.1 100.0 1,465 Total 3.8 1.2 31.3 6.0 4.9 51.5 1.3 100.0 4,819 Characteristics of Respondents | 43 Table 3.6.2 Occupation: men Percent distribution of men employed in the 12 months preceding the survey by occupation, according to background characteristics, Ethiopia 2005 Manual labour Background characteristic Profes- sional/ technical/ managerial Clerical Sales and services Skilled Unskilled Agricul- ture Missing Total Number of men Age 15-19 0.1 0.1 6.4 2.0 2.6 88.3 0.6 100.0 869 20-24 1.9 0.2 9.8 4.2 3.8 79.6 0.6 100.0 884 25-29 2.7 0.3 8.0 4.3 3.6 80.3 0.7 100.0 702 30-34 1.8 0.0 5.1 5.7 1.9 84.5 0.9 100.0 741 35-39 3.9 0.4 7.5 2.1 1.4 84.0 0.6 100.0 637 40-44 5.8 0.1 5.9 3.2 1.5 82.1 1.4 100.0 487 45-49 4.7 0.1 4.4 2.2 2.0 85.8 0.7 100.0 407 50-54 3.2 0.1 2.8 1.4 1.7 90.3 0.6 100.0 326 55-59 1.7 0.2 7.2 1.3 2.5 87.1 0.0 100.0 221 Marital status Never married 1.9 0.2 9.2 5.0 3.9 79.3 0.5 100.0 1,745 Married or living together 2.9 0.2 5.5 2.2 1.7 86.7 0.8 100.0 3,353 Divorced/separated/widowed 4.4 0.0 5.6 5.6 4.0 79.9 0.5 100.0 177 Number of living children 0 1.8 0.2 8.6 4.6 3.6 80.9 0.4 100.0 2,084 1-2 3.9 0.2 8.9 4.9 2.5 78.3 1.3 100.0 963 3-4 4.1 0.3 5.0 1.2 2.0 86.5 1.0 100.0 948 5+ 1.8 0.1 3.5 1.5 1.0 91.7 0.5 100.0 1,279 Residence Urban 15.8 1.4 37.0 24.4 14.5 6.3 0.7 100.0 620 Rural 0.8 0.0 2.7 0.5 0.9 94.4 0.7 100.0 4,655 Region Tigray 4.0 0.8 8.0 3.3 5.1 78.4 0.5 100.0 317 Affar 4.6 1.1 15.2 4.7 4.4 67.9 2.2 100.0 61 Amhara 1.1 0.0 3.5 2.0 1.1 91.7 0.6 100.0 1,400 Oromiya 2.2 0.1 5.3 1.9 2.5 87.2 0.7 100.0 1,896 Somali 3.8 0.0 6.7 0.4 2.0 86.9 0.2 100.0 180 Benishangul-Gumuz 2.0 0.0 3.3 1.8 0.8 91.3 0.7 100.0 50 SNNP 1.6 0.0 5.4 1.5 1.7 89.0 0.9 100.0 1,093 Gambela 5.3 0.4 10.5 2.0 6.8 74.4 0.5 100.0 18 Harari 11.5 0.4 23.7 9.7 10.3 42.2 2.2 100.0 14 Addis Ababa 14.9 1.5 39.0 32.5 10.1 1.2 0.9 100.0 222 Dire Dawa 9.4 1.3 29.3 13.2 11.6 34.7 0.5 100.0 22 Education No education 0.1 0.0 3.0 0.5 1.1 94.8 0.6 100.0 2,547 Primary 0.3 0.0 6.1 2.0 2.6 88.2 0.7 100.0 1,922 Secondary and higher 15.9 1.1 20.1 15.1 6.6 40.1 1.1 100.0 806 Wealth quintile Lowest 0.0 0.0 1.9 0.0 0.7 96.8 0.5 100.0 1,037 Second 0.3 0.0 2.0 0.4 0.5 96.3 0.5 100.0 1,101 Middle 0.0 0.0 1.9 0.4 0.2 96.4 0.9 100.0 991 Fourth 0.7 0.0 3.2 0.7 1.7 93.2 0.5 100.0 1,055 Highest 11.4 0.8 24.0 14.4 8.9 39.4 1.0 100.0 1,091 Total 2.6 0.2 6.8 3.3 2.5 84.0 0.7 100.0 5,274 44 | Characteristics of Respondents Six percent of employed women are skilled manual workers, while 5 percent are engaged as unskilled manual workers. Only 4 percent of employed women work in the professional, technical, and managerial fields. Women are less likely to be highly educated and less likely to have attended vocational or technical schools. Therefore, their employment in the professional, technical, and managerial sector is somewhat low compared with men. The analysis of occupation by background characteristics suggests that the proportion of women with jobs in sales and services decreases as age increases and that married women are more likely to be employed in agricultural work than other women. Never-married women, on the other hand, are more likely to be employed in sales and services and in clerical work. Residence has a significant effect on the type of occupation. As expected, two-thirds of employed women and 94 percent of employed men in rural areas are engaged in agricultural work. Most educated women are employed in sales and services and professional, technical, and managerial occupations, whereas women with little or no education tend to be employed in the agricultural sector. Agriculture is by far the most important occupation for working women in the lower wealth quintiles. Employment outside the agricultural sector is greatest among men with secondary or higher education and men in the highest wealth quintile. 3.4.3 Earnings, Employers and Continuity of Employment Table 3.7.1 shows the percent distribution of employed women by type of earnings and employment characteristics. The table takes into account whether women are involved in agricultural or nonagricultural oc- cupations, because all of the employ- ment variables in the table are strong- ly influenced by the sector in which a woman is employed. An overwhelming majority (81 percent) of women engaged in agricultural work are unpaid workers most likely employed by family members at the peak of the agri- cultural season. Women are more likely to be paid in cash if they are employed in the nonagricultural sector; about three-fourths of the women employed in this sector are paid in cash. Overall, more than half (52 percent) of employed women are not paid at all and only 40 percent earn cash for their work. Six out of 10 employed women work for a family member, and about 27 percent are self- employed. Only 14 percent of em- ployed women work for someone outside the family. Table 3.7.1 Type of employment: women Percent distribution of 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), Ethiopia 2005 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 2.5 73.8 36.4 Cash and in-kind 3.6 2.7 3.1 In-kind only 12.6 2.7 7.8 Not paid 81.1 20.6 52.3 Missing 0.1 0.2 0.4 Total 100.0 100.0 100.0 Type of employer Employed by family member 75.4 42.5 59.5 Employed by nonfamily member 3.1 25.0 13.6 Self-employed 21.5 32.4 26.7 Missing 0.0 0.1 0.2 Total 100.0 100.0 100.0 Continuity of employment All year 5.8 63.0 33.2 Seasonal 88.5 14.1 52.6 Occasional 5.5 22.9 13.9 Missing 0.2 0.0 0.3 Total 100.0 100.0 100.0 Number of women 2,484 2,273 4,819 Note: Total includes women with missing information on type of employment who are not shown separately. Characteristics of Respondents | 45 Three-quarters of women working in the agricultural sector are working for a family member compared with 43 percent working in the nonagricultural sector. In addition, the proportion of women employed by someone outside the family is higher among those working in the nonagricultural sector than those in the agricultural sector (25 percent versus 3 percent). Generally, a third of employed women work all year round while 53 percent work seasonally. Those who work occasionally account for 14 percent. As in the case of type of earning and employer, continuity of employment also varies by sector of employment. Around 9 in 10 women employed in the agricultural sector are seasonal workers compared with only 14 percent among those working in the nonagricultural sector. On the other hand, continuity of employment is more assured for women engaged in nonagricultural work than those in agricultural work. For example, 63 percent of women working in the nonagri- cultural sector work all year compared with only 6 percent of women engaged in agri- cultural work. Male respondents were only asked questions on type of earning. Table 3.7.2 shows that only 3 in 10 employed men are paid in cash. Eighty-four percent of men employed in nonagricultural work are paid in cash compared with 18 percent among those engaged in agricultural work. Table 3.7.2 Type of employment: men Percent distribution of men employed in the 12 months preceding the survey by type of earnings, according to type of employment (agricultural or nonagricultural), Ethiopia 2005 Type of earnings Agricultural work Nonagricultural work Total Cash only 7.7 82.4 19.3 Cash and in-kind 10.5 1.9 9.2 In-kind only 23.6 1.1 20.1 Not paid 58.2 14.4 51.4 Missing 0.0 0.2 0.0 Total 100.0 100.0 100.0 Number of men 4,432 806 5,274 Note: Total includes men with missing information on type of employment who are not shown separately.   Fertility | 47 FERTILITY 4 Fertility is one of the three principal components of population dynamics that determine the size and structure of the population of a country. This chapter presents the 2005 EDHS results on the levels, trends, and differentials in fertility. The analysis is based on birth history information collected from women age 15-49 interviewed during the survey. Each eligible woman was asked a series of questions on the number of sons and daughters who were living with her, the number living elsewhere, and the number who had died, in order to obtain the total number of live births she had had in her lifetime. For each live birth, information was also collected on the name, sex, age and survival status of the child. For dead children, age at death was recorded. Information from the birth history is then used to assess current and completed fertility and factors related to fertility such as age at first birth, birth intervals, and adolescent childbearing. 4.1 CURRENT FERTILITY Measures of current fertility are presented in Table 4.1 for the three-year period preceding the survey, corresponding to the calendar period 2003- 2005. A three-year period was chosen because it reflects the most current information, while also allowing the rates to be calculated on a sufficient number of cases so as not to compromise the statistical precision of the estimate. Several measures of current fertility are shown. Age-specific fertility rates (ASFRs), expressed as the number of births per thousand women in a specified age group, are calculated by dividing the number of live births to women in a specific age group by the number of woman-years lived in that age group The total fertility rate (TFR) is a common measure of current fertility and is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed age- specific fertility rates. The general fertility rate (GFR) is the number of live births occurring during a specified period per 1,000 women age 15-44. The crude birth rate (CBR) is the number of births per 1,000 population during a specified period. Table 4.1 shows current fertility levels for Ethiopia as a whole, and for urban and rural areas. The total fertility rate for Ethiopia is 5.4 births per woman. As expected, fertility is considerably higher in the rural areas than urban areas. The TFR in the rural areas is 6.0, two and half times higher than the TFR in the urban areas (2.4). As the ASFRs show, this pattern of higher rural fertility is prevalent in all age groups (Figure 4.1). The urban-rural difference in fertility is especially pronounced among women age 20-34. The overall age pattern of fertility as reflected in the ASFRs indicates that childbearing begins early. Fertility is low among adolescents and increases to a peak of 241 births per 1,000 among women age 25-29 and declines thereafter. Table 4.1 Current fertility Age-specific and total fertility rate, the general fertility rate and the crude birth rate for the three years preceding the survey, by residence, Ethiopia 2005 Residence Age group Urban Rural Total 15-19 35 122 104 20-24 105 260 228 25-29 133 261 241 30-34 101 253 231 35-39 58 178 160 40-44 28 94 84 45-49 14 38 34 TFR (15-49) 2.4 6.0 5.4 GFR 77 200 179 CBR 23.4 37.3 35.7 Note: Age-specific fertility 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 4.2 FERTILITY DIFFERENTIALS Table 4.2 and Figure 4.2 present differentials in the total fertility rates, the percentage of women who are currently pregnant and the mean number of children ever born (CEB) to women age 40-49, by residence, region, education and wealth quintile. There are substantial differentials in fertility among regions, ranging from a low of 1.4 children per woman in Addis Ababa to a high of 6.2 children per woman in Oromiya. With the exception of Oromiya, Somali and SNNP, fertility levels in the other 8 regions are less than the national average. The level of fertility is inversely related to women’s educational attainment, decreasing rapidly from 6.1 children among women with no education to 2.0 children among women who have at least some secondary education. Fertility is also associated with wealth quintile. Women in the lowest wealth quintile have a TFR of 6.6, twice as high as that of women in the highest quintile (3.2). Table 4.2 also presents a crude assessment of trends in the various subgroups by comparing current fertility with a measure of completed fertility: the mean number of children ever born to women age 40-49. The mean number of children ever born to older women who are nearing the end of their reproductive period is an indicator of average completed fertility of women who began childbearing during the three decades preceding the survey. If fertility remained constant over time and the reported data on both children ever born and births during the three years preceding the survey are reasonably accurate, the TFR and the mean number of children ever born for women 40-49 are expected to be similar. When fertility levels have been falling, the TFR will be substantially lower than the mean number of children ever born among women age 40-49. The comparison suggests that fertility has fallen by more than one child during the past few decades, from 6.9 children per woman to 5.4. Fertility has declined in both rural and urban areas, in all regions, at all educational levels, and for all wealth quintiles. The difference between the level of current and completed fertility is highest in Addis Ababa (3 children), in all urban areas (2.7 children), and among women in the highest wealth quintile (2.7 children). � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Group 0 50 100 150 200 250 300 Births per 1,000 Women Urban Rural Total� EDHS 2005 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence Fertility | 49 Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Ethiopia 2005 Background characteristic Total fertility rate Percentage currently pregnant1 Mean number of children ever born to women age 40-49 Residence Urban 2.4 2.5 5.1 Rural 6.0 9.7 7.3 Region Tigray 5.1 8.6 6.8 Affar 4.9 8.9 5.8 Amhara 5.1 7.2 7.0 Oromiya 6.2 9.0 7.1 Somali 6.0 10.0 6.7 Benishangul-Gumuz 5.2 10.2 6.7 SNNP 5.6 10.2 7.5 Gambela 4.0 8.3 5.3 Harari 3.8 6.7 5.2 Addis Ababa 1.4 1.5 4.4 Dire Dawa 3.6 3.9 5.6 Education No education 6.1 10.1 7.1 Primary 5.1 6.7 5.8 Secondary and higher 2.0 2.2 4.2 Wealth quintile Lowest 6.6 10.2 6.9 Second 6.0 11.0 7.0 Middle 6.2 10.5 7.4 Fourth 5.7 8.3 7.6 Highest 3.2 3.8 5.9 Total 5.4 8.4 6.9 1 Women age 15-49 years 5.4 2.4 6.0 6.1 5.1 2.0 5.1 4.9 5.1 6.2 6.0 5.2 5.6 4.0 3.8 1.4 3.6 ETHIOPIA RESIDENCE Urban Rural REGION Tigray Affar Amhara Oromiya Somali Benishangul-Gumuz SNNP Gambela Harari Addis Ababa Dire Dawa EDUCATION No education Primary Secondary and higher 0.0 2.0 4.0 6.0 8.0 Number of Children EDHS 2005 Figure 4.2 Total Fertility Rates by Background Characteristics 50 | Fertility Table 4.2 shows the percentage of women who reported being pregnant at the time of the survey. This percentage may be underreported since women may not be aware of a pregnancy, especially at the very early stages, and some women who are early in their pregnancy may not want to reveal that they are pregnant. Eight percent of women were pregnant at the time of the survey. Rural women were almost four times as likely to be pregnant as urban women. The proportion of women currently pregnant declines as the level of education rises. Current pregnancy is highest in Benishangul-Gumuz, SNNP and Somali and lowest in Addis Ababa. 4.3 FERTILITY TRENDS In addition to comparison of current and completed fertility, trends in fertility can be assessed in two other ways. First, the TFR from the 2005 EDHS can be compared with estimates obtained in earlier surveys. Second, fertility trends can be investigated using retrospective data from the birth histories collected in the same survey. One way of examining trends in fertility over time is to compare age-specific fertility rates from the 2005 EDHS for successive five-year periods preceding the survey, as presented in Table 4.3. The numerators of the rates are classified by five-year segments of time preceding the survey and the mother’s age at the time of survey. Because women 50 years and over were not interviewed in the survey, 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 35-39 for the period 15-19 years before the survey because these women would have been over age 50 at the time of the survey and were not interviewed. Fertility has fallen substantially among all age groups over the past two decades. This decline is most obvious in the 15 years preceding the survey, with the largest decline observed between the two most recent five-year periods. Fertility decline is steepest among the youngest cohort, with a 35 percent decline between the period 15-19 years before the survey and the period 0-4 years before the survey. The decline in fertility observed in Ethiopia can be attributed in part to increasing use of contracep- tion, which will be discussed in the next chapter. Another way to assess fertility trends is to compare estimates obtained in earlier surveys. Table 4.4 presents the ASFRs and TFRs from the 1990 NFFS, the 2000 EDHS, and the 2005 EDHS. There has been a decline in fertility from 6.4 births per woman in the 1990 NFFS to 5.4 births in the 2005 EDHS, a one-child drop in the past 15 years. The decline in fertility was more pronounced in the 10 years between 1990 and 2000 than in the five years between 2000 and 2005 and more pronounced in urban than rural areas. A comparison of the three-year TFR calculated from the 2000 EDHS and the 2005 EDHS shows little change for the country as a whole 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, Ethiopia 2005 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 109 160 186 168 20-24 242 304 311 288 25-29 253 321 309 298 30-34 240 281 290 [288] 35-39 166 220 [244] 40-44 96 [141] 45-49 [35] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Table 4.4 Trends in age-specific and total fertility rates Trends in age-specific and total fertility rates, Ethiopia Age group NFFS 19901 EDHS 20002 EDHS 2005 15-19 95 100 104 20-24 275 235 228 25-29 289 251 241 30-34 257 243 231 35-39 199 168 160 40-44 105 89 84 45-49 56 19 34 TFR 6.4 5.5 5.4 Note: Rates for NFFS 1990 are for the 12 months preceding the survey; rates for EDHS 2000 and EDHS 2005 are for the three years prior to the survey. 1 CSA, 1993 2 CSA and ORC Macro, 2001 Fertility | 51 (5.5 births in 2000 versus 5.4 births in 2005).1 With the exception of the 15-19 age group, fertility has declined in every age group over the past 15 years, with the largest decline—nearly 40 percent— among the oldest cohort (age 45-49). 4.4 CHILDREN EVER BORN AND SURVIVING Data on the number of children ever born reflect the accumulation of births over the past 30 years and therefore have limited relevance to current fertility levels, particularly when the country has experienced a decline in fertility. Moreover, the data are subject to recall error, which is typically greater for older than younger women. Nevertheless, the information on children ever born (or parity) is useful in looking at a number of issues. The parity data show how average family size varies across age groups. The percentage of women in their forties who have never had children also provides an indicator of the level of primary infertility or the inability to bear children.2 Voluntary childlessness is rare in developing countries like Ethiopia, so that married women in their late forties with no live births are predominantly those involuntarily so. Comparison of the differences in the mean number of children ever born and surviving reflects the cumulative effects of mortality levels during the period in which women have been bearing children. Table 4.5 shows the percent distribution of all women and currently married women by number of children ever born and mean number of children surviving. More than four-fifths of women age 15-19 (86 percent) have never given birth. However, this proportion declines to 13 percent for women age 25-29 and to 6 percent or less among women age 30 and above, indicating that childbearing among Ethiopian women is nearly universal. On the average, Ethiopian women nearing the end of their reproductive years have attained a parity of 7.3 children. This is 1.9 children more than the total fertility rate, a difference brought about by the dramatic decline in fertility during the 1980s and 1990s. Table 4.5 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, Ethiopia 2005 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 children living ALL WOMEN 15-19 86.4 9.9 3.1 0.4 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 3,266 0.18 0.15 20-24 39.7 26.2 19.6 9.6 3.8 0.8 0.3 0.0 0.0 0.0 0.0 100.0 2,547 1.15 1.01 25-29 12.8 11.4 17.2 22.5 18.7 10.5 4.6 1.5 0.6 0.1 0.0 100.0 2,517 2.85 2.50 30-34 5.9 4.7 7.8 12.6 16.8 18.9 16.5 9.3 4.4 2.2 0.8 100.0 1,808 4.48 3.81 35-39 2.7 3.0 4.8 7.3 11.4 13.0 17.9 13.9 14.2 6.0 5.7 100.0 1,602 5.78 4.74 40-44 2.7 2.3 4.5 4.6 6.0 9.3 13.4 17.7 14.9 11.5 13.0 100.0 1,187 6.63 5.25 45-49 1.6 2.5 4.0 3.6 5.2 9.8 11.3 12.4 13.9 12.2 23.6 100.0 1,143 7.25 5.50 Total 31.0 10.4 9.6 9.0 8.5 7.5 7.1 5.5 4.7 3.0 3.8 100.0 14,070 3.14 2.59 CURRENTLY MARRIED WOMEN 15-19 45.1 38.4 13.9 1.9 0.6 0.0 0.0 0.0 0.0 0.0 0.0 100.0 711 0.75 0.64 20-24 12.7 35.0 29.5 15.1 5.9 1.3 0.4 0.0 0.0 0.0 0.0 100.0 1,574 1.72 1.52 25-29 3.1 10.0 18.4 25.7 21.9 12.6 5.6 1.8 0.8 0.1 0.0 100.0 2,066 3.28 2.90 30-34 2.2 3.3 7.1 12.2 17.5 20.2 18.3 10.7 5.0 2.5 1.0 100.0 1,551 4.82 4.13 35-39 1.0 1.4 2.9 6.7 10.5 13.2 19.6 15.8 15.8 6.4 6.7 100.0 1,343 6.18 5.10 40-44 2.5 2.3 3.9 3.4 4.7 8.1 12.6 18.7 15.8 12.4 15.6 100.0 960 6.92 5.54 45-49 1.3 2.3 3.8 2.5 4.3 8.6 11.4 11.6 14.8 13.0 26.6 100.0 862 7.54 5.81 Total 7.3 12.6 12.8 12.3 11.5 10.2 9.8 7.7 6.4 3.9 5.3 100.0 9,066 4.29 3.57 1 A comparison of the five-year TFR shows a similar pattern. For the country as a whole (5.9 births in 2000 versus 5.7 births in 2005), there has been little change over the past five years. 2 The data does not address the level of secondary infertility which refers to women who may have had one or more births but are unable to have more children. 52 | Fertility The same pattern is replicated for currently married women, except that the mean number of children ever born is higher for currently married women (4.3 children) than for all women (3.1 children). The difference between all women and currently married women in the mean number of children ever born is due to a substantial proportion of young and unmarried women in the former category who exhibit lower fertility. Consistent with expectations, the mean number of children ever born and mean number of children surviving rise monotonically with increasing age of women. Comparison of the mean children ever born with the mean number of living children reveals the experience of child loss among Ethiopian women. By the end of their reproductive years (age 45-49), women in Ethiopia have given birth, on average, to 7.3 children, with 5.5 surviving. Voluntary childlessness is uncommon in Ethiopia and currently married women with no children are likely to be those who are unable to bear children. The level of childlessness among married women at the end of their reproductive period can be used as an indicator of the level of primary sterility. In Ethiopia, primary sterility among older currently married women is less than 2 percent. 4.5 BIRTH INTERVALS Birth interval is the length of time between two successive live births. Information on birth intervals provides insight into birth spacing patterns, which affect fertility as well as infant and childhood mortality. Studies have shown that children born too soon after a previous birth are at increased risk of dying at an early age, particularly when the interval between births is less than 24 months. Table 4.6 shows the percent distribution of non-first births in the five years preceding the survey by number of months since the preceding birth, according to background characteristics. The median birth interval in Ethiopia is 33.8 months. The median number of months since a preceding birth increases significantly with age, from a low of 26.1 months among mothers age 15-19 to a high of 38.8 months among mothers age 40-49. There is no substantial difference in the length of the median birth interval by birth order and sex of the preceding birth. Studies have shown that the death of a preceding child leads to a shorter birth interval than when the preceding child survived. The median birth interval is more than eight months shorter for children whose previous sibling is dead than for children whose previous sibling is alive (26.1 months and 34.6 months, respectively). It is presumed that the difference in the birth intervals is related to the desire of parents to replace a dead child, as well as to the loss of the fertility-delaying effects of breastfeeding. According to the 2005 EDHS data, urban women have slightly longer intervals between births (39.1 months) compared with rural women (33.6 months). Regional variations in birth intervals range from a low of 29 months in Affar to a high of 45.2 months in Addis Ababa. The median birth interval is longer among births to women with at least some secondary education than among births to women with lower levels of education. The birth interval does not vary consistently by wealth quintile. Fertility | 53 Table 4.6 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, according to background characteristics, Ethiopia 2005 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48-54 55-59 60+ Total Number of non- first births Median number of months since preceding birth Age 15-19 21.4 18.8 44.5 10.7 4.6 0.0 0.0 100.0 144 26.1 20-29 10.1 15.3 36.6 23.2 6.6 2.7 5.4 100.0 4,002 31.6 30-39 6.7 11.8 34.6 25.4 7.2 3.9 10.5 100.0 3,930 35.0 40-49 5.3 9.7 27.5 25.7 9.5 4.8 17.4 100.0 1,150 38.8 Birth order 2-3 8.7 13.8 34.3 24.1 6.8 3.2 9.1 100.0 3,347 33.5 4-6 8.3 12.8 35.3 24.0 7.2 3.7 8.6 100.0 3,659 33.6 7+ 7.5 12.6 34.4 25.0 7.7 3.4 9.5 100.0 2,220 34.3 Sex of preceding birth Male 8.2 13.0 34.9 24.4 7.4 3.2 8.9 100.0 4,711 33.7 Female 8.3 13.3 34.6 24.2 6.9 3.7 9.1 100.0 4,515 33.8 Survival of preceding birth Living 6.1 12.2 35.7 25.6 7.5 3.6 9.3 100.0 8,026 34.6 Dead 22.3 19.4 28.5 15.4 5.1 2.1 7.2 100.0 1,201 26.1 Residence Urban 9.0 11.5 24.6 16.9 8.9 2.7 26.5 100.0 551 39.1 Rural 8.2 13.2 35.4 24.8 7.1 3.5 7.9 100.0 8,675 33.6 Region Tigray 4.0 9.2 38.8 25.7 8.5 3.0 10.9 100.0 578 35.2 Affar 14.3 17.2 33.9 17.3 6.4 1.3 9.6 100.0 87 29.0 Amhara 5.4 8.5 31.5 30.4 8.4 4.0 11.7 100.0 2,109 37.0 Oromiya 9.3 16.3 37.4 21.7 5.5 2.9 7.0 100.0 3,719 31.0 Somali 13.4 19.0 31.4 18.5 6.7 2.3 8.8 100.0 402 29.6 Benishangul-Gumuz 9.8 14.2 35.8 22.7 6.2 3.1 8.2 100.0 83 32.2 SNNP 9.3 11.9 33.5 24.2 8.6 4.3 8.2 100.0 2,093 34.5 Gambela 6.0 10.1 27.4 23.6 11.1 5.6 16.2 100.0 25 38.2 Harari 10.8 17.1 31.4 18.9 5.4 2.1 14.2 100.0 16 31.4 Addis Ababa 5.0 12.3 19.4 17.3 10.4 3.6 32.1 100.0 86 45.2 Dire Dawa 8.9 17.0 32.5 20.9 6.3 0.3 14.0 100.0 28 31.5 Education No education 7.9 13.3 34.8 24.9 7.1 3.4 8.5 100.0 7,459 33.8 Primary 9.3 12.6 36.3 22.7 7.1 3.6 8.4 100.0 1,462 32.8 Secondary and higher 10.5 11.5 24.9 17.1 8.6 3.0 24.5 100.0 305 38.7 Wealth quintile Lowest 9.2 14.9 36.1 23.0 7.5 3.0 6.4 100.0 2,079 32.3 Second 7.4 12.1 35.7 25.2 6.7 3.7 9.2 100.0 1,956 34.0 Middle 7.8 13.3 34.1 24.8 7.2 4.4 8.3 100.0 2,070 34.1 Fourth 8.4 12.8 35.8 24.9 6.8 3.5 7.8 100.0 1,850 33.7 Highest 8.3 12.2 30.6 23.4 7.9 2.0 15.6 100.0 1,272 35.5 Total 8.2 13.1 34.7 24.3 7.2 3.4 9.0 100.0 9,226 33.8 Note: First-order births are excluded from this table. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 4.6 AGE AT FIRST BIRTH Early age at initiation of childbearing has a detrimental effect on the health of both mother and child. It also lengthens the reproductive period, thereby increasing the level of fertility. Table 4.7 shows the median age at first birth and the percentage of women who first gave birth by specific exact ages, by five-year age groups. 54 | Fertility Table 4.7 Age at first birth Percentage of women who gave birth by specific exact ages, and median age at first birth, by current age, Ethiopia 2005 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 1.7 na na na na 86.4 3,266 a 20-24 5.4 28.4 46.1 na na 39.7 2,547 a 25-29 8.5 38.0 58.1 73.0 83.3 12.8 2,517 19.2 30-34 10.0 40.9 59.7 74.9 87.6 5.9 1,808 18.9 35-39 9.9 40.3 58.3 75.2 89.1 2.7 1,602 19.0 40-44 11.2 41.2 60.3 74.7 86.8 2.7 1,187 19.0 45-49 10.5 45.4 60.3 73.4 86.7 1.6 1,143 18.7 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Childbearing begins early in Ethiopia. The median age at first birth is 19.2 years for the younger cohort (age 25-29) of women for whom a median age can be computed and varies between 18.7 and 19.0 years for the older cohorts. This suggests a small, recent rise in the median age at first birth. An examination of the percentage of women in various age groups who had a first birth by specific exact age indicates that the percentage increases as the exact age increases, as expected. The proportion of women in the age group 20-24 who had their first birth by exact age 20 (46 percent), for instance, is higher than by exact age 15 (5 percent) and 18 (28 percent). The data also show some evidence of a trend toward delayed onset of childbearing among younger women; for example, 41 percent of women age 30 and above had their first birth by exact age 18 while 28 percent and 38 percent of women in the age groups 20-24 and 25-29, respectively, had started childbearing at the same age. Table 4.8 shows median age at first birth by background characteristics and age at the time of the survey. The median age at first birth is higher in urban areas than in rural areas, with a difference of almost two years among women age 25-49. According to the data the urban-rural difference in median age at first birth is much wider among younger (25-29) than older women. Among regions, Addis Ababa has the highest median age at first birth (23.5 years) for women age 25-49, followed by Harari (21.0 years), while the Amhara Region has the lowest median age at first birth (18 years). This indicates that women in the Amhara Region initiated childbearing more than five years earlier on average than women in Addis Ababa. There is a positive relationship between educational attainment and median age at first birth, but the impact seems more significant at secondary and higher levels of education. Women with at least secondary education begin their childbearing more than four years (22.9 years) later than women with no education (18.7 years). Although the median age at first birth is consistently the highest among the wealthiest women, there is no clear pattern between the onset of childbearing and women’s wealth across age groups except among the younger cohort (25-29). Fertility | 55 Table 4.8 Median age at first birth by background characteristics Median age at first birth among women age 25-49 years, by current age and back- ground characteristics, Ethiopia 2005 Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 Women age 25-49 Residence Urban 23.6 21.0 20.0 18.8 19.3 20.7 Rural 18.8 18.7 18.9 19.0 18.5 18.8 Region Tigray 19.5 19.0 18.6 18.7 18.9 19.0 Affar 18.8 17.9 19.2 21.1 20.3 19.5 Amhara 18.1 18.3 18.0 18.1 17.6 18.0 Oromiya 19.1 18.9 19.7 19.3 18.9 19.2 Somali 18.8 18.6 20.8 21.1 22.8 20.0 Benishangul-Gumuz 17.9 18.0 18.5 18.2 17.1 18.1 SNNP 19.6 19.2 19.0 19.1 19.2 19.3 Gambela 17.8 18.2 18.8 17.9 17.3 18.1 Harari 22.9 20.7 20.0 19.6 20.4 21.0 Addis Ababa a 25.8 22.3 19.3 19.5 23.5 Dire Dawa 21.5 20.1 19.1 19.1 19.3 19.9 Education No education 18.8 18.6 18.7 18.9 18.6 18.7 Primary 18.7 18.6 19.9 19.9 18.8 18.9 Secondary and higher a 22.2 22.1 19.8 20.5 22.9 Wealth quintile Lowest 18.7 18.7 18.9 19.6 20.5 19.0 Second 18.3 18.5 19.1 19.3 18.4 18.6 Middle 19.0 18.9 19.5 19.1 19.0 19.1 Fourth 19.0 18.7 18.0 18.4 17.8 18.5 Highest 21.5 19.8 19.2 18.7 18.7 19.8 Total 19.2 18.9 19.0 19.0 18.7 19.0 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 4.7 TEENAGE PREGNANCY AND MOTHERHOOD In addition to the relatively high level of pregnancy complications among young mothers because of physiological immaturity, inexperience associated with child care practices also influences maternal and infant health. Moreover, an early start to childbearing greatly reduces the educational and employment opportunities of women and is associated with higher levels of fertility. Table 4.9 shows the proportion of women age 15-19 (teenagers) who are mothers or pregnant with their first child, by background characteristics. 56 | Fertility Table 4.9 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, by background characteristics, Ethiopia 2005 Percentage who: Background characteristic Have had a live birth Are pregnant with first child Percentage who have begun childbearing Number of women Age 15 1.5 0.4 1.9 729 16 4.9 3.2 8.1 667 17 10.9 3.1 14.0 556 18 20.4 4.3 24.7 862 19 36.1 4.7 40.8 451 Residence Urban 6.0 0.6 6.6 703 Rural 15.6 3.7 19.4 2,562 Region Tigray 12.9 1.8 14.7 229 Affar 14.6 5.7 20.3 31 Amhara 16.7 3.6 20.3 811 Oromiya 15.8 3.2 19.0 1,206 Somali 16.8 2.6 19.5 78 Benishangul-Gumuz 20.8 6.4 27.1 27 SNNP 8.1 2.9 11.0 652 Gambela 24.8 6.0 30.8 8 Harari 18.2 3.7 21.9 11 Addis Ababa 3.4 0.9 4.3 199 Dire Dawa 11.9 1.8 13.7 16 Education No education 24.9 4.0 28.9 1,308 Primary 7.4 3.1 10.4 1,423 Secondary and higher 2.3 0.7 3.0 535 Wealth quintile Lowest 19.7 4.1 23.8 448 Second 17.3 3.5 20.8 566 Middle 15.9 4.0 19.8 627 Fourth 13.9 4.5 18.3 603 Highest 7.2 1.0 8.2 1,022 Total 13.6 3.1 16.6 3,266 Seventeen percent of women age 15-19 have already become mothers or are currently pregnant with their first child, which is similar to the pattern seen from data collected in the 2000 EDHS (16 percent). The percentage of women who have begun childbearing increases rapidly with age, from 2 percent among women age 15, to 41 percent among women age 19. Nearly three times as many teenagers residing in rural areas as in urban areas have begun childbearing. Childbearing among teenagers is lowest in Addis Ababa (4 percent) and highest in the Gambela Region (31 percent). The level of teenage parenthood among teenagers with no education is nearly three times that among teenagers with primary education, while it is nearly ten times that of teenagers with secondary and higher education. The percentage of teenagers who have begun childbearing is three times higher among those in the poorest households (24 percent) compared with those in the wealthiest households (8 percent). Family Planning | 57 FAMILY PLANNING 5 This chapter presents information from the 2005 EDHS on contraceptive knowledge, attitudes and behaviour. Although the focus is on women, some results from the male survey are also presented because men play an important role in the realization of reproductive goals. Comparisons are also made, where appropriate, with findings from the 2000 EDHS to evaluate changes over the past five years. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Acquiring knowledge about family planning is an important step towards gaining access to and using a suitable contraceptive method in a timely and effective manner. Individuals who have adequate information about the available methods of contraception are better able to make choices about planning their families. Thus, one of the main objectives of the 2005 EDHS was to obtain information on knowledge of family planning methods among women and men in the reproductive age. Data on knowledge of contraception was collected in two ways. First, respondents were asked to mention all the methods of contraception that they had heard of spontaneously. For methods not mentioned spontaneously, the interviewer described and probed for whether the respondent recognized it. Information was collected for 10 modern contraceptive methods: female and male sterilization, the pill, the IUD, injectables, implants, condoms, diaphragm/foam/jelly, standard days method and lactational amenorrhoea method (LAM), and two traditional methods (periodic abstinence and withdrawal). In addition, provision was made in the questionnaire to record any other method named spontaneously by the respondents. Table 5.1 shows knowledge of contraception among all women age 15-49 and men age 15-59, as well as among those who are currently married and those unmarried and sexually active. Knowledge of contraceptive methods is high with 88 percent of currently married women and 93 percent of currently married men knowing at least one method of contraception. Modern methods are more widely known than traditional methods. For example, 87 percent of currently married women know of a modern method, and only 17 percent know of a traditional method. The pill is the most widely known method (84 percent), followed closely by injectables (83 percent). Currently married men are more than twice as likely to recognize the condom as a method of family planning as currently married women (41 percent versus 84 percent). The mean number of methods known is a rough indicator of the breadth of knowledge of family planning methods. Using this as a measure, contraceptive knowledge is highest among sexually active unmarried men (5.6 methods) and women (4.7 methods). Overall, knowledge of contraception has remained high in Ethiopia over the past five years. For example, knowledge of any modern method among currently married women was 85 percent in 2000 and 87 percent in 2005. Similarly, knowledge of any modern method among currently married men was 90 percent in 2000 and 91 percent in 2005. The most notable increases in knowledge of specific methods among currently married women are with respect to injectables and condoms—from 70 percent to 83 percent for injectables and from 29 percent to 41 percent for condoms between 2000 and 2005. Men also had significant gains in knowledge for these two methods. 58 | Family Planning Table 5.1 Knowledge of contraceptive methods Percentage of all women and men, currently married women and men, and sexually active unmarried women and men who know any contraceptive method, by specific method, Ethiopia 2005 Women Men Method All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 86.1 87.5 91.2 91.0 93.0 95.3 Any modern method 86.0 87.4 91.2 90.7 92.6 93.1 Female sterilisation 18.4 17.2 30.4 26.4 28.2 45.7 Male sterilisation 6.6 5.5 12.5 15.3 14.0 24.1 Pill 82.6 84.2 86.8 81.2 84.7 87.4 IUD 14.8 12.2 33.0 14.3 12.0 22.0 Injectables 80.9 82.6 87.4 79.0 82.9 89.5 Implants 22.4 20.0 47.3 23.0 22.3 40.0 Condom 46.1 40.6 69.8 84.2 84.2 90.1 Diaphragm/foam/jelly 5.9 4.4 4.5 8.8 6.3 16.3 Standard days method 4.3 3.4 4.7 6.3 5.3 11.6 Lactational amenorrhoea method (LAM) 9.2 8.9 20.9 7.9 8.2 14.6 Any traditional method 20.6 17.0 53.2 39.2 39.3 70.6 Rhythm 18.0 14.4 48.2 34.9 34.2 69.9 Withdrawal 11.8 9.3 28.6 21.3 19.8 50.9 Folk method 0.6 0.6 0.0 1.5 1.9 0.7 Mean number of methods known 3.2 3.0 4.7 4.0 4.0 5.6 Number 14,070 9,066 52 6,033 3,424 72 1 Had sexual intercourse in the month preceding the survey Table 5.2 shows the correspondence between the contraceptive knowledge of husbands and wives among the 2,972 couples interviewed in the 2005 EDHS. Knowledge of at least one method of contraception by both spouses is relatively high (84 percent). Among couples in which only one partner knows of a method, husbands are more likely to know the method than their wives. The discordance in knowledge with respect to specific modern methods is most noticeable for the condom—which is twice as likely to be known by men as women—and sterilization, especially male sterilization. Among married couples, men are also more likely to mention knowing a traditional method than women (38 percent and 17 percent, respectively). Family Planning | 59 Table 5.2 Couples' knowledge of contraceptive methods Percent distribution of couples by contraceptive knowledge, according to specific methods, Ethiopia 2005 Method Both know method Husband knows method, wife doesn't Wife knows method, husband doesn't Neither knows method Total Any method 84.3 8.6 4.5 2.6 100.0 Any modern method 84.0 8.5 4.6 3.0 100.0 Female sterilisation 6.9 20.5 11.1 61.5 100.0 Male sterilisation 1.7 11.3 3.2 83.9 100.0 Pill 75.4 9.1 9.9 5.6 100.0 IUD 4.3 7.2 7.6 81.0 100.0 Injectables 73.6 9.2 10.5 6.8 100.0 Implants 7.6 14.1 13.0 65.4 100.0 Condom 41.9 42.2 4.0 11.8 100.0 Diaphragm/foam/jelly 0.6 5.4 3.4 90.7 100.0 Standard days method 0.3 4.6 2.7 92.5 100.0 Lactational amenorrhoea method (LAM) 2.0 5.9 6.5 85.6 100.0 Any traditional method 10.6 27.8 6.2 55.5 100.0 Rhythm 8.0 25.3 6.3 60.4 100.0 Withdrawal 4.8 14.3 3.5 77.3 100.0 Other methods 0.0 1.5 0.7 97.8 100.0 Note: Table is based on 2,972 couples. 5.2 EVER USE OF CONTRACEPTIVE METHODS Ever use of contraception provides a measure of the cumulative experience of a population with family planning. The EDHS 2005 collected data on ever use of family planning methods from women by asking respondents whether they had ever used each of the methods that they have heard about. Table 5.3.1 presents ever use of contraception among three groups of women: all women; currently married women, and unmarried, sexually active women, by current age. The data indicate that 18 percent of all women and 24 percent of currently married women have used a method at some time. Women are much more likely to have used a modern method than a traditional method. For example, 23 percent of currently married women have used a modern method at some time compared with 2 percent who have used a traditional method. Injectables have been the most commonly used modern method (18 percent) among currently married women. Rhythm has been the most widely employed traditional method. Among currently married women ever use of any method rises from 16 percent among those age 15-19, peaks at 27 percent among those age 25-29, and remains consistently high until age 40-44, before falling markedly to 14 percent among the oldest age group. Although based on a small number of cases, ever use of any method is highest among sexually active unmarried women. Sixty-five percent of sexually active unmarried women have used a contraceptive method at some time in the past. 60 | Family Planning Table 5.3.1 Ever use of contraception: women Percentage of all women, currently married women, and sexually active unmarried women who have ever used any contraceptive method, by specific method and age, Ethiopia 2005 Modern method Traditional method Age Any method Any modern method Female sterili- sation Pill IUD Inject- ables Implants Condom Standard days method LAM Any tradi- tional method Rhythm With- drawal Folk method Number of women ALL WOMEN 15-19 4.7 4.5 0.0 1.4 0.0 3.2 0.0 0.7 0.0 0.0 0.5 0.4 0.1 0.0 3,266 20-24 18.9 17.7 0.0 9.3 0.2 13.2 0.3 1.5 0.0 0.0 2.7 2.4 0.6 0.0 2,547 25-29 25.6 24.4 0.1 11.7 0.2 18.7 0.4 0.9 0.0 0.6 2.8 2.1 1.0 0.2 2,517 30-34 24.7 23.9 0.2 12.4 0.6 18.1 0.2 1.4 0.0 0.6 2.3 1.7 0.8 0.1 1,808 35-39 24.5 23.9 0.2 13.9 1.0 16.7 0.6 0.5 0.0 0.5 1.8 1.2 0.7 0.1 1,602 40-44 23.9 23.2 0.6 12.6 0.9 16.3 0.3 0.8 0.0 0.6 2.1 1.5 0.7 0.2 1,187 45-49 13.8 12.6 0.5 7.2 0.9 7.7 0.1 0.4 0.0 0.1 1.9 1.1 0.7 0.4 1,143 Total 18.2 17.4 0.2 8.9 0.4 12.7 0.2 0.9 0.0 0.3 1.9 1.5 0.6 0.1 14,070 CURRENTLY MARRIED WOMEN 15-19 16.1 15.6 0.0 5.4 0.0 11.6 0.0 1.0 0.0 0.0 1.3 0.9 0.4 0.0 711 20-24 25.7 24.3 0.0 13.3 0.3 19.1 0.2 0.9 0.1 0.0 3.7 3.3 0.9 0.0 1,574 25-29 27.1 26.1 0.0 12.7 0.2 20.6 0.4 0.4 0.0 0.7 2.4 1.8 0.9 0.2 2,066 30-34 25.4 24.8 0.0 12.9 0.7 18.8 0.2 1.1 0.0 0.6 2.3 1.7 0.9 0.1 1,551 35-39 25.2 24.8 0.2 14.1 1.2 18.0 0.6 0.5 0.0 0.5 1.6 1.0 0.8 0.1 1,343 40-44 26.5 25.8 0.6 13.6 0.9 19.2 0.4 0.6 0.0 0.5 2.1 1.5 0.6 0.2 960 45-49 13.8 12.8 0.6 6.8 1.0 8.8 0.2 0.3 0.0 0.1 1.7 1.1 0.7 0.2 862 Total 24.1 23.2 0.2 12.0 0.6 17.7 0.3 0.7 0.0 0.4 2.3 1.7 0.8 0.1 9,066 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-24 62.2 51.7 0.0 16.8 0.0 12.9 0.0 42.3 0.0 0.0 15.0 13.5 1.5 0.0 28 25-49 68.7 55.5 0.0 25.8 0.0 37.7 0.4 29.7 0.0 0.0 16.7 16.7 0.4 0.0 25 Total 65.3 53.5 0.0 21.1 0.0 24.6 0.2 36.4 0.0 0.0 15.8 15.0 1.0 0.0 52 LAM = Lactational amenorrhoea method 1 Had sexual intercourse in the month preceding the survey The 2005 EDHS collected information on ever use of contraception from men as well as women, but with respect to the four male methods only, namely male sterilization, condoms, the rhythm method, and withdrawal. Table 5.3.2 shows that 19 percent of currently married men have used a male method of contraception at some time. Men have been more likely to use a traditional method, particularly rhythm (14 percent), than a modern method. Five percent of currently married men have used a condom at some time. Ever use of any method among currently married men rises from 14 percent among the youngest men to a peak of 23 percent among men 25-29 and then falls steadily to a low of 10 percent among those in the oldest cohort. Family Planning | 61 Table 5.3.2 Ever use of contraception: men Percentage of all men, currently married men, and sexually active unmarried men who have ever used any contraceptive method, by specific method and age, Ethiopia 2005 Modern method Traditional method Age Ever used any of four male methods Ever used condom or male sterili- sation Male sterili- sation Condom Ever used rhythm or with- drawal Rhythm With- drawal Number of men ALL MEN 15-19 3.1 2.3 0.1 2.2 1.2 0.9 0.3 1,335 20-24 13.3 9.7 0.2 9.5 7.2 5.7 2.8 1,064 25-29 21.9 10.8 0.2 10.6 16.2 14.5 6.2 741 30-34 23.9 10.0 0.1 9.9 18.7 15.6 7.5 754 35-39 20.7 7.0 0.6 6.6 16.7 14.7 3.9 651 40-44 20.2 6.9 0.4 6.5 17.3 14.6 4.8 497 45-49 15.2 4.1 0.3 3.8 13.1 11.8 2.5 422 50-54 10.9 1.9 0.5 1.3 10.6 8.8 4.1 335 55-59 9.9 1.9 0.8 1.1 8.1 6.7 2.1 235 Total 14.7 6.6 0.3 6.3 10.9 9.3 3.6 6,033 CURRENTLY MARRIED MEN 15-19 13.5 3.5 0.0 3.5 11.7 10.2 6.7 28 20-24 19.6 7.8 0.0 7.7 16.3 13.2 5.6 255 25-29 23.2 7.7 0.2 7.5 20.2 18.4 7.5 482 30-34 22.6 7.1 0.0 7.1 19.3 16.6 7.1 646 35-39 20.1 5.7 0.4 5.3 17.0 15.0 3.8 610 40-44 19.3 5.2 0.4 4.8 16.7 13.9 4.3 468 45-49 14.8 3.7 0.3 3.4 12.8 11.6 2.2 399 50-54 11.1 1.6 0.6 1.1 11.0 9.4 4.2 310 55-59 9.6 2.0 0.8 1.2 7.8 6.3 2.2 225 Total 18.7 5.5 0.3 5.2 16.1 14.0 4.9 3,424 SEXUALLY ACTIVE UNMARRIED MEN1 15-24 46.6 34.3 0.9 34.3 21.0 18.4 7.6 46 25-59 72.9 68.0 0.2 68.0 42.8 23.2 33.3 26 Total 56.2 46.5 0.6 46.5 28.9 20.2 16.9 72 1 Had sexual intercourse in the month preceding the survey 5.3 CURRENT USE OF CONTRACEPTIVE METHODS The current level of contraceptive use is a measure of actual contraceptive practice at the time of the survey. It takes into account all use of contraception, whether the concern of the user is permanent cessation of childbearing or a desire to space births. Current use of family planning services provides insight into one of the principal determinants of fertility. It also serves to assess the success of family planning programmes. This section focuses on the levels, differentials, and trends in current use of family planning methods in Ethiopia. Contraceptive use among all women, currently married women, and sexually active unmarried women, is presented in Table 5.4 by age group. The contraceptive prevalence rate for married Ethiopian women who are currently using a method of family planning is 15 percent. Almost all of these users are using modern methods. The most widely used method is injectables (10 percent) followed by the pill (3 percent). 62 | Family Planning Table 5.4 Current use of contraception Percent distribution of all women, currently married women, and sexually active unmarried women by contraceptive method currently used, according to age, Ethiopia 2005 Modern method Traditional method Age Any method Any modern method Female sterili- sation Pill IUD Inject- ables Implants Condom LAM Any tradi- tional method Rhythm With- drawal Not currently using Total Number of women ALL WOMEN 15-19 2.5 2.5 0.0 0.3 0.0 1.8 0.0 0.3 0.0 0.1 0.0 0.1 97.5 100.0 3,266 20-24 11.4 10.4 0.0 2.3 0.1 7.3 0.1 0.5 0.0 1.1 0.9 0.2 88.6 100.0 2,547 25-29 15.2 14.4 0.1 3.3 0.1 10.0 0.2 0.3 0.4 0.8 0.6 0.2 84.8 100.0 2,517 30-34 13.2 12.6 0.2 2.4 0.1 9.4 0.2 0.2 0.0 0.7 0.5 0.1 86.8 100.0 1,808 35-39 15.3 14.4 0.2 3.9 0.5 9.1 0.4 0.2 0.2 0.9 0.6 0.3 84.7 100.0 1,602 40-44 11.9 11.1 0.6 1.9 0.3 8.0 0.1 0.2 0.0 0.8 0.6 0.2 88.1 100.0 1,187 45-49 6.3 5.7 0.5 1.0 0.3 3.9 0.0 0.0 0.0 0.5 0.5 0.0 93.7 100.0 1,143 Total 10.3 9.7 0.2 2.1 0.1 6.8 0.1 0.3 0.1 0.7 0.5 0.2 89.7 100.0 14,070 CURRENTLY MARRIED WOMEN 15-19 8.9 8.6 0.0 1.3 0.0 7.0 0.0 0.3 0.0 0.3 0.0 0.3 91.1 100.0 711 20-24 16.7 15.4 0.0 3.7 0.1 11.2 0.2 0.1 0.0 1.3 1.0 0.3 83.3 100.0 1,574 25-29 16.9 16.2 0.0 3.9 0.1 11.3 0.2 0.2 0.5 0.7 0.4 0.3 83.1 100.0 2,066 30-34 14.4 13.7 0.0 2.8 0.1 10.3 0.2 0.2 0.0 0.7 0.5 0.2 85.6 100.0 1,551 35-39 17.2 16.4 0.2 4.3 0.5 10.5 0.4 0.1 0.3 0.9 0.5 0.4 82.8 100.0 1,343 40-44 14.2 13.2 0.6 2.1 0.4 9.8 0.2 0.1 0.0 1.0 0.7 0.3 85.8 100.0 960 45-49 8.1 7.4 0.6 1.3 0.4 5.0 0.0 0.0 0.0 0.7 0.7 0.0 91.9 100.0 862 Total 14.7 13.9 0.2 3.1 0.2 9.9 0.2 0.2 0.2 0.8 0.6 0.3 85.3 100.0 9,066 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-24 60.7 48.9 0.0 4.4 0.0 8.4 0.0 36.1 0.0 11.8 11.8 0.0 39.3 100.0 28 25-49 48.3 36.9 0.0 1.7 0.0 26.4 0.0 8.8 0.0 11.4 11.4 0.0 51.7 100.0 25 Total 54.9 43.3 0.0 3.1 0.0 16.9 0.0 23.3 0.0 11.6 11.6 0.0 45.1 100.0 52 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method 1 Had sexual intercourse in the month preceding the survey Use of contraception among the small number of sexually active unmarried women is higher than among all women and currently married women. Fifty-five percent of sexually active unmarried women are currently using contraception, with 43 percent using modern methods and 12 percent using traditional methods. The difference in use of modern methods among unmarried sexually active women and all other women may be attributed primarily to the greater use of condoms and injectables. As shown in Table 5.5, there are marked differences in the contraceptive prevalence rate among currently married women by background characteristics. Contraceptive use is associated with the number of living children a woman has; it is highest among currently married women with one or two children (17 percent) and lowest among women with no children (12 percent). As expected, contraceptive prevalence is more than four times higher in urban than in rural areas (47 percent versus 11 percent). There is also substantial variation in current use by region. Current use is highest in Addis Ababa (57 percent) and lowest in the Somali Region (3 percent). Urbanized areas like Dire Dawa and Harari also have much higher levels of current use (34 percent each) than the other regions. Family Planning | 63 Table 5.5 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Ethiopia 2005 Modern method Traditional method Background characteristic Any method Any modern method Female sterili- sation Pill IUD Inject- ables Im- plants Male con- dom LAM Any tradi- tional method Rhythm With- drawal Not currently using Total Number of women Number of living children 0 11.7 10.1 0.0 3.5 0.0 5.5 0.0 1.1 0.0 1.6 1.6 0.0 88.3 100.0 600 1-2 16.5 15.4 0.2 3.7 0.3 10.8 0.2 0.2 0.1 1.0 0.7 0.4 83.5 100.0 2,662 3-4 14.8 14.1 0.1 3.4 0.2 10.1 0.1 0.0 0.2 0.8 0.6 0.2 85.2 100.0 2,645 5+ 13.7 13.2 0.3 2.3 0.2 9.8 0.3 0.1 0.3 0.5 0.3 0.3 86.3 100.0 3,159 Residence Urban 46.7 42.2 1.3 10.7 1.8 25.9 0.7 1.4 0.4 4.5 3.7 0.8 53.3 100.0 959 Rural 10.9 10.6 0.0 2.2 0.0 8.0 0.1 0.0 0.1 0.4 0.2 0.2 89.1 100.0 8,107 Region Tigray 16.5 16.2 0.0 2.9 0.0 13.1 0.1 0.1 0.0 0.3 0.3 0.0 83.5 100.0 570 Affar 6.6 6.0 0.0 1.3 0.0 4.5 0.0 0.2 0.0 0.6 0.6 0.0 93.4 100.0 109 Amhara 16.1 15.7 0.1 3.6 0.2 11.6 0.1 0.1 0.0 0.4 0.3 0.1 83.9 100.0 2,330 Oromiya 13.6 12.9 0.2 3.4 0.2 8.6 0.1 0.1 0.3 0.7 0.4 0.4 86.4 100.0 3,300 Somali 3.1 2.7 0.0 0.0 0.0 2.7 0.0 0.0 0.0 0.4 0.4 0.0 96.9 100.0 363 Benishangul- Gumuz 11.1 10.4 0.3 1.3 0.0 8.5 0.0 0.1 0.0 0.7 0.6 0.1 88.9 100.0 92 SNNP 11.9 11.4 0.0 1.9 0.0 8.9 0.3 0.1 0.2 0.4 0.3 0.2 88.1 100.0 1,988 Gambela 15.9 15.8 0.0 2.5 0.0 12.9 0.0 0.5 0.0 0.1 0.1 0.0 84.1 100.0 31 Harari 33.5 29.1 0.0 5.8 1.6 20.1 0.0 0.8 0.8 4.4 4.2 0.2 66.5 100.0 22 Addis Ababa 56.9 45.2 1.8 10.6 3.9 23.5 2.0 2.1 1.3 11.7 9.2 2.5 43.1 100.0 224 Dire Dawa 34.0 31.5 0.3 6.7 0.6 21.4 1.0 1.5 0.0 2.4 2.2 0.2 66.0 100.0 37 Education No education 10.0 9.8 0.1 2.0 0.0 7.3 0.1 0.0 0.1 0.2 0.1 0.1 90.0 100.0 7,094 Primary 23.4 21.9 0.0 5.7 0.5 15.1 0.2 0.1 0.2 1.5 0.8 0.7 76.6 100.0 1,402 Secondary and higher 52.6 45.9 0.7 11.0 1.7 28.7 1.0 2.2 0.6 6.7 5.9 0.8 47.4 100.0 570 Wealth quintile Lowest 4.2 4.0 0.0 0.8 0.0 3.0 0.1 0.0 0.1 0.1 0.0 0.1 95.8 100.0 1,759 Second 6.6 6.5 0.0 1.1 0.0 5.4 0.0 0.0 0.0 0.1 0.1 0.0 93.4 100.0 1,892 Middle 12.0 11.6 0.1 2.7 0.0 8.5 0.1 0.0 0.2 0.4 0.3 0.1 88.0 100.0 1,903 Fourth 15.5 15.2 0.0 3.1 0.0 11.7 0.2 0.0 0.1 0.3 0.1 0.2 84.5 100.0 1,823 Highest 37.0 33.7 0.8 8.2 1.2 21.7 0.5 0.9 0.4 3.3 2.4 0.9 63.0 100.0 1,689 Total 14.7 13.9 0.2 3.1 0.2 9.9 0.2 0.2 0.2 0.8 0.6 0.3 85.3 100.0 9,066 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method Contraceptive use differs significantly across educational categories. Current use increases five-fold from 10 percent among women with no education to 53 percent among those with secondary and higher levels of education. Wealth has a positive effect on women’s contraceptive use, with use increasing markedly as wealth increases, from 4 percent among married women in the lowest wealth quintile to 37 percent among those in the highest wealth quintile. 64 | Family Planning 5.3.1 Trends in Contraceptive Use Results on contraceptive use from the 2005 EDHS are compared with similar surveys in Table 5.6 and Figure 5.1. Use of contraceptive methods tripled in the 15- year period between the 1990 NFFS and the 2005 EDHS from 5 percent to 15 percent. The increase is especially marked for modern methods in the five years between 2000 and 2005. This increase is attributed primarily to the rapid rise in the use of injectables from 3 percent in 2000 to 10 percent in 2005. 5.3.2 Number of Children at First Use of Contraception Family planning may be used to either limit family size or delay the next birth. Couples using family planning to limit family size adopt contraception when they have already had the number of children they want. When contraception is used to space births, couples may start using family planning earlier, with the intention of delaying a possible pregnancy. This may be done even before a couple has had their desired number of children. Women interviewed in the 2005 EDHS were asked how many children they had at the time they first used a contraceptive method. Table 5.7 shows the percent distribution of women by the number of living children at the time of first use of contraception, according to current age. Table 5.6 Trends in current use of contraception Percentage of currently married women who are currently using a contraceptive method, Ethiopia 2005 Method 1990 NFFS1 2000 EDHS2 2005 EDHS Any method 4.8 8.1 14.7 Any modern method 2.9 6.3 13.9 Pill 2.2 2.5 3.1 IUD 0.3 0.1 0.2 Injectables 0.0 3.1 9.9 Condom 0.1 0.3 0.2 Implants na 0.0 0.2 Lactational amenorrhoea (LAM) na na 0.2 Any traditional method 1.9 1.7 0.8 Rhythm 0.5 1.5 0.6 Withdrawal 0.1 0.2 0.3 Sexual abstinence3 1.2 na na Number 5,048 9,789 9,066 na = Not applicable 1 CSA, 1993 2 CSA and ORC Macro, 2001 3 Sexual abstinence was included as a method of contraception in the 1990 NFFS. 5 3 2 2 8 6 3 3 2 15 14 3 10 1 Any method Any modern method Pill Injectables Any traditional method 0 5 10 15 20 Percent 1990 NFFS 2000 EDHS 2005 EDHS Figure 5.1 Trends in Current Use of Contraception, Ethiopia 1990-2005 Injectables Family Planning | 65 The data show that one-third of users (6 percent of all women) first used a method of family planning when they had four or more children. Nearly one-fifth of users (3 percent of all the women) first used at the time they had no children, and 4 percent first used after the birth of their first child. The age pattern of first use of contraception shows that younger women are more likely to start using contraception at lower parities than older women. For example, most women below age 30 started using contraception after they had one child, suggesting the intention of younger women to space births at earlier parities than older women. Table 5.7 Number of living children at first use of contraception Percent distribution of women by number of living children at time of first use of contraception, Ethiopia 2005 Number of living children at time of first use of contraception Current age Never used 0 1 2 3 4+ Missing Total Number of women 15-19 95.3 3.1 1.4 0.1 0.0 0.0 0.1 100.0 3,266 20-24 81.1 6.5 7.1 3.9 1.3 0.0 0.0 100.0 2,547 25-29 74.4 3.8 6.9 6.2 4.2 4.5 0.1 100.0 2,517 30-34 75.3 2.6 4.1 3.1 4.3 10.4 0.1 100.0 1,808 35-39 75.5 1.9 2.8 3.3 2.4 14.2 0.0 100.0 1,602 40-44 76.1 1.2 2.1 2.4 1.2 17.0 0.0 100.0 1,187 45-49 86.2 0.3 1.0 1.2 0.6 10.7 0.0 100.0 1,143 Total 81.8 3.3 3.9 2.9 2.0 6.1 0.1 100.0 14,070 5.4 USE OF SOCIAL MARKETING BRANDS Current users of the pills and condoms were asked for the brand name of the pills and condoms they last used. This information is useful in monitoring the success of social marketing programmes that promote a specific brand. In Ethiopia, “Prudence” and “Choice” are the two brands of pills that are socially marketed, and “Hiwot” and “Sensation” are two brands of condoms that are socially marketed. Table 5.8.1 indicates that nearly one-third (29 percent) of users said that they use Prudence. This is much higher than the level reported in the 2000 EDHS (13 percent). Forty-one percent of pill users reported that they did not know the brand of pills they were using. Table 5.8.2 shows the percentage of men currently using condoms by brand used. About 39 percent of men use Hiwot, and 19 percent use Sensation. Nearly, one-third of condom users (30 percent) do not know the brand of condoms they are using. Table 5.8.1 Pill brands Percent distribution of women currently using the pill by brand used, Ethiopia 2005 Pill brand Pill users Microgynon 7.2 Lo-Feminol 1.7 Prudence 29.1 Choice 0.5 Other 2.6 Don't know 40.6 Missing 18.2 Total 100.0 Number 292 Table 5.8.2 Condom brands Percent distribution of men currently using condoms by brand used, Ethiopia 2005 Condom brand Condom users Hiwot 38.7 Sensation 18.7 Durex 0.2 Other 0.1 Don't know 30.2 Missing 12.0 Total 100.0 Number 40 66 | Family Planning 5.5 KNOWLEDGE OF FERTILE PERIOD A basic knowledge of the physiology of reproduction is especially useful for the successful practice of coitus-related methods such as periodic abstinence. The successful use of such methods depends in part on an understanding of when during the ovulatory cycle a woman is most likely to conceive. All women and men in the survey were asked about their knowledge of a woman’s fertile period. Specifically, they were asked whether there are certain days between two menstrual periods when a woman is more likely to become pregnant if she has sexual intercourse. Those who answered in the affirmative were further asked if this time is just before the period begins, during the period, right after the period ends, or halfway between the two periods. Table 5.9 shows that only 11 percent of women and 8 percent of men, interviewed in the EDHS, know that a woman is most likely to conceive halfway between her menstrual periods. Slightly over one-fifth of all women (22 percent) wrongly believe that the fertile period is just before her period begins or during her period or right after her period has ended. However, the great majority of women either do not know when the fertile period falls (35 percent) or believe that there is no specific time (32 percent). Regarding men, 43 percent say that they do not know when the fertile period falls and 27 percent believe that there is no specific time when a woman is more likely to conceive. As expected, users of the rhythm method are more likely than nonusers to know that the fertile time in a women’s menstrual cycle is halfway between periods. In addition, there has been a slight increase in knowledge of the fertile period over the past five years among users of the rhythm method (from 53 percent in 2000 to 62 percent in 2005). Table 5.9 Knowledge of fertile period Percent distribution of women currently using periodic abstinence, women not using periodic abstinence, and all women and all men by knowledge of the fertile period during the ovulatory cycle, Ethiopia 2005 Perceived fertile period Users of rhythm method Nonusers of rhythm method All women All men Just before her period begins 5.6 2.2 2.2 3.5 During her period 0.7 1.8 1.8 1.9 Right after her period has ended 20.1 17.8 17.8 16.2 Halfway between two periods 61.8 11.1 11.4 8.1 Other 3.2 32.0 31.9 27.1 Don't know 6.4 35.1 34.9 43.0 Missing 2.2 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 Number 69 14,001 14,070 6,033 5.6 SOURCE OF FAMILY PLANNING METHODS Information on sources of modern contraceptives is useful for family planning managers and implementers. Women who reported using a modern method of contraception at the time of the survey were asked where they obtained the method the last time and interviewers recorded the name and location of the source. To ensure accuracy in reporting, supervisors and editors were asked to verify the type of source from the written response. Table 5.10 shows that four-fifths of current users (80 percent) obtain methods from the public sector, 17 percent from the private medical sector, and 3 percent from other sources. The most important source of contraceptives in the public sector is the government health centre, providing methods to 37 percent of current users. Government health stations or clinics and government health Family Planning | 67 posts also play a major role in distributing contraceptives, being the source of 19 percent and 16 percent, of modern methods, respectively. The public sector is the leading source of injectables and the pill, distributed mainly through government health centres (39 percent and 36 percent, respectively). More than half of condom users get their supply from other sources, predominantly shops (42 percent). Over the years, the public sector has been the major source of family planning methods, particularly for injectables and the pill. While the overall contribution from other private sources has declined from 6 percent in 2000 to 3 percent in 2005, the contribution of shops in supplying condoms has increased substantially, from 23 percent in 2000 to 42 percent in 2005. The 2005 EDHS also gathered information on the cost of modern contraceptive methods. The data show that the majority of users who obtained a method from the public sector obtained it for free compared with 16 percent of users who obtained their method from the private medical sector (data not shown). Table 5.10 Source of modern contraceptive methods Percent distribution of users of modern contraceptive methods by most recent source of the method, Ethiopia 2005 Most recent source of method Pill IUD Injectables Condom Total Public sector 70.5 (64.9) 85.2 17.3 79.5 Government hospital 3.2 (47.1) 5.2 5.4 5.8 Government health centre 36.0 (14.1) 39.3 10.0 36.8 Government health post 11.8 (0.0) 18.6 0.1 16.1 Government health station/clinic 15.7 (0.0) 20.6 0.2 18.6 CBD worker 3.1 (3.6) 1.3 1.6 1.7 Other public 0.6 (0.0) 0.2 0.0 0.4 Private medical sector 27.0 (35.1) 13.5 20.3 17.1 Private hospital/clinic/doctor 6.4 (17.7) 5.0 0.4 5.5 Pharmacy 12.7 (0.0) 3.3 16.8 5.7 NGO Health facility 4.8 (6.8) 3.6 2.7 3.9 CBD worker/CBRHA 2.1 (10.6) 1.0 0.3 1.4 Other NGO 1.0 (0.0) 0.0 0.0 0.2 Other private medical 0.0 (0.0) 0.6 0.0 0.4 Other source 2.5 (0.0) 1.0 51.7 2.8 Drug vendor 0.8 (0.0) 0.5 0.0 0.5 Shop 1.3 (0.0) 0.4 42.4 1.9 Friends relatives 0.3 (0.0) 0.0 9.3 0.4 Other 0.0 (0.0) 0.3 10.7 0.6 Total 100.0 100.0 100.0 100.0 100.0 Number of women 292 20 954 40 1,324 Note: Table excludes female sterilisation and lactational amenorrhoea method (LAM). Total includes 24 users of implants who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. CBD = Community-based distribution CBRHA = Community-based reproductive health agent 5.7 INFORMED CHOICE Current users of modern methods who are well informed about the side effects and problems associated with methods and know of a range of method options are in a better position to make an informed choice about the method they would like to use. Current users of various modern contraceptive methods were asked whether, at the time they were adopting a particular method, they were informed about the possible side effects or problems they might have with the method and what to do if they experienced side effects. Table 5.11 shows the percentage of current users of modern methods who were informed about the side effects or problems with the method used, informed about what to do if they experienced side effects, and informed of other methods they could use, according to the type of method used and initial source of the method. 68 | Family Planning Four percent of users were informed about the side effects or problems associated with the method, 30 percent were informed about what to do if they experienced side effects, and 7 percent were informed of the availability of other methods. Table 5.11 Informed choice Among current users of modern contraceptive methods who started the last episode of use within the five years preceding the survey, the percentage who were informed about possible side effects or problems of that method, about what to do if they experienced side effects, and about other methods they could use, by method and initial source, Ethiopia 2005 Method/source/ background characteristic Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilisation (2.8) (84.7) (42.8) 6 Pill 1.9 31.5 2.8 265 IUD (0.0) (90.1) (4.0) 10 Injectables 3.9 28.1 7.7 914 Implants * * * 16 Total1 3.5 30.1 6.7 1,249 Initial source of method2 Public sector 3.7 30.0 7.0 972 Government hospital 7.2 41.6 13.2 65 Government health centre 2.6 33.2 8.0 452 Family planning clinic 2.8 28.2 5.2 209 Mobile clinic 5.7 21.2 5.4 231 Fieldworker * * * 14 Private medical sector 4.4 27.8 7.3 102 Private doctor 1.7 26.0 6.4 47 Private hospital or clinic (17.9) (59.8) (4.3) 16 Pharmacy * * * 3 Shop * * * 7 Church (0.0) (0.0) (0.0) 24 Friends relatives * * * 5 Other * * * 9 Missing 0.0 24.1 12.4 24 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Among users of female sterilisation, pill, IUD, injectables and implants 2 Source at start of current episode of use Family Planning | 69 5.8 CONTRACEPTIVE DISCONTINUATION Couples can realize their reproductive goals only when they use contraceptive methods continuously. A major concern for family planning programme managers is discontinuation of methods. In the 2005 EDHS “calendar” section, all segments of contraceptive use between September 2000 and the date of the interview were recorded, along with the reasons for any discontinuation. One-year contraceptive discontinuation rates based on the data from the calendar are presented in Table 5.12.1 Table 5.12 First-year contraceptive discontinuation rates Percentage of contraceptive users who discontinued use of a method within 12 months after beginning its use, by reason for discontinuation and specific method, Ethiopia 2005 Reason for discontinuation Method Method failure Desire to become pregnant Switched to another method Other reason Total Pill 2.4 11.6 21.8 25.1 60.9 Injectables 0.3 8.6 7.1 15.9 32.0 Male condom 1.3 9.5 13.7 17.3 41.8 Periodic abstinence 5.4 18.8 8.0 7.0 39.2 All methods 1.2 10.2 11.9 17.6 40.9 Note: Table is based on episodes of contraceptive use that began 3-59 months prior to the survey. LAM = Lactational amenorrhoea method 1Used 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 It can be seen from the table that four in ten contraceptive users discontinue using a method within 12 months of starting its use. About 10 percent of users discontinued to become pregnant and 12 percent switched to other methods. Just 1 percent of users stopped as a result of method failure, suggesting that this is not a major problem in Ethiopia. The discontinuation rate is highest among pill users (61 percent) and lowest among users of injectables (32 percent). Table 5.13 also presents reasons for contraceptive discontinuation, but from a different perspective. All of the 1,686 contraceptive discontinuations occurring in the five years preceding the survey, regardless of duration of use, are distributed by the main reason for discontinuation, according to method. The desire to become pregnant is the most prominent reason for contraceptive discontinuation (30 percent), followed by health concerns (26 percent). 1 The discontinuation rates presented here include only those segments of contraceptive use that began since September 2000. The rates apply to the period 3-59 months preceding the survey; exposure during the month of interview and the two months before the interview are excluded to avoid the biases that may be introduced by unrecognized pregnancies. These cumulative discontinuation rates represent the proportion of users discontinuing a method within 12 months after the start of use. The rates are calculated by dividing the number of women discontinuing a method by the number exposed at that duration. The single-month rates are then cumulated to produce a one-year rate. In calculating the rate, the various reasons for discontinuation are treated as competing risks. 70 | Family Planning Table 5.13 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason for discontinuation, according to specific method, Ethiopia 2005 FINAL Reason Pill IUD Injection Condom Rhythm With- drawal All methods Became pregnant while using 5.6 0.0 2.2 14.7 16.8 10.4 5.0 Wanted to become pregnant 23.8 14.2 33.1 25.4 47.6 46.6 30.2 Husband/partner disapproved 2.9 0.0 2.6 2.5 0.1 0.0 2.6 Side effects 3.4 4.2 4.5 3.8 0.9 0.0 3.7 Health concerns 33.2 51.7 25.3 2.1 2.0 0.0 26.0 Lack of access/too far 0.0 0.0 0.0 1.6 0.4 0.0 0.1 Wanted more effective method 6.9 11.9 2.3 6.7 14.7 32.3 5.6 Inconvenient to use 6.1 0.0 4.2 6.4 7.8 1.8 5.1 Infrequent sex/husband away 3.9 8.8 2.3 14.7 5.1 0.2 3.6 Cost too much 0.2 0.0 0.9 0.0 0.0 0.0 0.5 Fatalistic 0.1 0.0 0.2 0.0 1.0 0.0 0.2 Method not available 2.5 0.0 6.2 0.0 0.0 0.0 3.9 Difficult to get pregnant/menopausal 0.5 7.3 0.3 0.0 0.0 0.0 0.4 Marital dissolution/separation 2.7 2.0 4.1 3.1 0.0 0.0 3.2 Other 8.2 0.0 11.8 18.1 3.6 8.6 9.8 Missing 0.0 0.0 0.0 0.7 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 680 17 786 60 89 23 1,686 5.9 FUTURE USE OF CONTRACEPTION Intention to use a method of contraception is an important indicator of the potential demand for family planning services. Currently married women who were not using contraception at the time of the survey were asked about their intention to use family planning methods in the future. The results are presented in Table 5.14. Table 5.14 Future use of contraception 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, Ethiopia 2005 Number of living children1Intention to use in the future 0 1 2 3 4+ Total Intends to use 44.0 60.0 56.4 51.8 49.5 52.0 Unsure 5.6 1.9 4.4 5.1 3.9 4.0 Does not intend to use 50.4 37.8 38.9 43.0 46.4 43.9 Missing 0.0 0.3 0.3 0.0 0.1 0.1 Total 100.0 100.0 100.0 99.9 100.0 100.0 Number of women 530 1,091 1,133 1,098 3,880 7,732 1 Includes current pregnancy Family Planning | 71 More than half (52 percent) of currently married women who were not using any contraception at the time of the survey say that they intend to use a family planning method some time in the future. Forty-four percent do not intend to use any method, while 4 percent are unsure of their intention. The proportion of women who intend to use in the future varies by the number of living children, increasing from 44 percent for those with no living children to a peak at 60 percent among those with one child. These women are likely interested in spacing subsequent births. Over the past five years, there has been an increase in the proportion of married women not using at the time of the survey but who intend to use in the future (from 46 percent in 2000 to 52 percent in 2005). 5.10 REASONS FOR NOT INTENDING TO USE A CONTRACEPTIVE METHOD IN THE FUTURE An understanding of the reasons why people do not use family planning methods is critical in designing programmes that are effective in reaching women with unmet need and to improve the quality of family planning services. Table 5.15 shows currently married nonusers who do not intend to use a contraceptive method in the future by the main reasons for not intending to use family planning. Around 40 percent cited fertility-related reasons for not intending to use contraception. In particular, 18 percent cited the desire for as many children as possible as the main reason for not intending to use. The proportion of women who cited a desire for more children has dropped markedly from 42 percent in 2000 to 18 percent in 2005, suggesting that women are realizing the disadvantages of large family sizes. Table 5.15 Reason for not intending to use contraception in the future Percent of currently married women who are not using contraception and who do not intend to use in the future by main reason for not intending to use, Ethiopia 2005 Reason Nonusers who do not intend to use contraception Fertility-related reasons 37.5 Infrequent sex/no sex 2.9 Menopausal/had hysterectomy 6.3 Subfecund/infecund 10.4 Wants as many children as possible 17.8 Opposition to use 23.6 Respondent opposed 5.5 Husband/partner opposed 4.1 Others opposed 0.1 Religious prohibition 13.8 Lack of knowledge 11.2 Knows no method 8.6 Knows no source 2.6 Method-related reasons 13.6 Health concerns 10.2 Fear of side effects 2.6 Lack of access/too far 0.1 Costs too much 0.2 Inconvenient to use 0.1 Interferes with body's normal processes 0.2 Method not available 0.3 Other 11.1 Don’t know/missing 3.0 Total 100.0 Number of women 3,394 72 | Family Planning Nearly a quarter of women reported disapproval or opposition to use as the reason for not intending to use in the future. The majority of these women specifically cited religious prohibition as the main reason for not using in the future. Method-related reasons, largely health concerns, was cited by about 14 percent of nonusers not intending to use in the future, and lack of knowledge of method or source was cited by 11 percent. 5.11 PREFERRED METHOD OF CONTRACEPTION FOR FUTURE USE Demand for specific methods can be assessed by asking nonusers which methods they intend to use in the future. Table 5.16 presents information on method preference among currently married women who are not using a contraceptive method but say they intend to use in the future. The majority (72 percent) of prospective users prefer to use injectables, while a sizable propor- tion (19 percent) cite the pill as their preferred method. In the 2000 EDHS, the corresponding figures for injectables and pills are 46 percent and 38 percent, respectively. The data indicates a con- vergence in preference of methods to injectables, largely because of the convenience of use and duration of effectiveness. 5.12 EXPOSURE TO FAMILY PLANNING MESSAGES Exposure to family planning messages widens the horizon of understanding on issues related to contraceptive use and helps in the realization of its importance in achieving desired family size. Additionally, it contributes to the enhancement of the health of both children and mothers. Measuring the extent of exposure to such information helps programme managers and planners to effectively target population subgroups for information, education, and communication (IEC) activities. In the 2005 EDHS, both women and men were asked if they have heard or seen family planning messages on the radio or television or read about family planning in a newspaper or magazine in the few months prior to the survey. Family planning information is largely disseminated through radio with limited dissemination through television or the print media. For example, 29 percent of women heard about family planning on the radio compared with only 11 percent of women who got family planning information from the television and 8 percent who got such information from newspapers or magazines (Table 5.17). Consistent with the level of exposure to mass media, exposure to family planning messages varies by the gender of respondents. As can be seen from Table 5.17, men are more likely to be exposed to family planning messages than women for all media types. Nearly 4 out of 10 men compared with 3 out of 10 women heard family planning messages on the radio or seen them on television or read about family planning in newspapers or magazines. Significant variation is also observed in exposure to family planning messages by other characteristics. Younger women are more likely to be exposed to family planning messages than older women. Because of the limited infrastructural development in most rural communities, women and men in these parts of the country have little opportunity to be exposed to essential information on health and family planning. For example, women in urban areas are three times more likely to have heard family planning messages on the radio than their rural counterparts. The regional differential also suggests that women and men in relatively urbanized areas, namely, Addis Ababa, Dire Dawa and Harari, are more likely than other women and men to have been exposed to family planning Table 5.16 Preferred method of contra- ception for future use Percent distribution of currently married women who are not using a contra- ceptive method but who intend to use in the future by preferred method, Ethiopia 2005 Preferred method Nonusers who intend to use contraception in future Modern method Female sterilisation 0.2 Pill 18.7 IUD 0.3 Injectables 71.9 Implants 1.7 Condom 0.1 Lactation amenorrhoea method (LAM) 0.1 Traditional method Rhythm 0.5 Withdrawal 0.1 Folk method 3.3 Unsure of method 3.0 Total 100.0 Number of women 4,017 Family Planning | 73 messages from all three media sources. Interestingly, women in these three urbanized areas are more likely than men to be exposed to family planning messages on the radio and television. Women in Somali and Gambela regions have the lowest level of exposure to family planning messages. There is a marked difference in exposure to family planning messages by level of education. Three-quarters of men and 84 percent of women with some secondary education were exposed to family planning messages in at least one of the three media compared with only one-fourth of men and 18 percent of women with no education. The results also show that exposure to family planning messages varies by wealth quintile and is greatest among respondents in the wealthiest quintile. Table 5.17 Exposure to family planning messages Percentage of women who heard or saw a family planning message on the radio or television, or in a newspaper or magazine in the past few months, according to background characteristics, Ethiopia 2005 Women Men Background characteristic Radio Television Newspaper/ magazine None of the three media sources Number of women Radio Television Newspaper/ magazine None of the three media sources Number of men Age 15-19 34.5 15.0 13.6 61.4 3,266 32.3 14.4 16.0 64.1 1,335 20-24 33.0 15.1 11.5 65.1 2,547 42.9 21.1 19.4 54.4 1,064 25-29 28.9 10.8 7.5 70.0 2,517 40.0 14.8 15.3 58.4 741 30-34 25.2 8.8 5.4 73.8 1,808 46.5 15.3 14.2 51.8 754 35-39 25.5 8.3 4.8 73.2 1,602 39.6 12.5 14.1 59.1 651 40-44 25.4 7.5 3.9 73.7 1,187 36.8 13.9 14.8 61.5 497 45-49 24.2 6.2 2.3 75.3 1,143 36.8 11.2 8.0 61.3 422 50-54 na na na na na 31.8 8.1 11.5 66.8 335 55-59 na na na na na 32.0 4.5 6.3 67.8 235 Residence Urban 66.7 54.6 32.6 26.2 2,499 67.8 57.8 42.1 25.9 916 Rural 21.3 2.0 3.1 77.9 11,571 33.0 6.8 9.9 65.5 5,117 Region Tigray 34.8 13.9 11.5 63.1 919 36.9 17.6 18.9 60.1 366 Affar 20.2 11.3 4.7 78.9 146 35.4 18.0 10.3 63.1 65 Amhara 24.9 6.2 6.3 73.7 3,482 34.6 8.1 15.8 63.8 1,521 Oromiya 34.5 11.1 8.0 63.9 5,010 42.7 13.7 12.0 55.0 2,222 Somali 10.2 6.3 4.8 89.1 486 29.6 3.7 3.1 70.4 202 Benishangul-Gumuz 15.8 2.7 3.2 83.8 124 33.0 10.3 11.2 64.5 54 SNNP 18.2 3.7 4.5 80.6 2,995 30.0 13.0 12.1 68.8 1,244 Gambela 11.7 4.5 3.7 87.1 44 42.4 17.1 13.3 55.3 21 Harari 70.6 53.3 36.2 27.9 39 65.0 48.1 37.8 30.7 16 Addis Ababa 67.4 63.4 32.2 23.8 756 65.2 60.2 44.4 26.2 292 Dire Dawa 58.2 53.6 26.0 38.0 69 56.1 43.4 29.9 36.9 30 Education No education 17.9 2.4 0.4 81.6 9,271 23.3 1.9 2.3 76.3 2,589 Primary 38.1 12.3 11.5 58.5 3,123 39.0 10.9 14.5 58.4 2,252 Secondary and higher 76.6 59.3 46.4 16.3 1,675 69.6 48.8 42.5 25.1 1,192 Wealth quintile Lowest 10.2 0.5 0.7 89.7 2,428 17.0 2.0 4.1 81.5 1,100 Second 15.4 1.0 1.4 84.0 2,643 28.7 4.2 8.0 70.2 1,184 Middle 20.5 1.4 2.9 78.8 2,732 34.3 6.9 10.9 63.9 1,081 Fourth 27.9 1.8 4.2 70.9 2,647 41.3 8.4 12.6 57.0 1,200 Highest 60.4 40.7 25.6 34.2 3,621 62.6 42.9 33.0 33.3 1,469 Total 29.4 11.4 8.3 68.7 14,070 38.3 14.5 14.8 59.5 6,033 na = Not applicable 5.13 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS Given the importance of family planning services to the improvement of mother’s and children’s health, it is critical that every opportunity be fully exploited to inform potential users. In reality, however, even though there is ample opportunity to inform nonusers there are also many “missed opportunities.” Information on missed opportunities was gathered by asking female nonusers 74 | Family Planning if they had visited a health facility in the 12 months preceding the survey. Those who visited a health facility were asked whether anyone at the facility had discussed family planning with them during any of their visits. Women who were not using a family planning method were also asked whether they had been visited by a fieldworker who talked with them about family planning in the 12 months preceding the survey. The results are presented in Table 5.18. The majority of nonusers (90 percent) did not have any contact with health providers or fieldworkers with whom family planning was discussed. Only 6 percent of nonusers reported being visited by fieldworkers who discussed family planning issues. Though this seems low, it is still an improvement over the 2000 level which was practically nil. Only 5 percent of nonusers who visited a facility discussed family planning with a health worker, compared with 16 percent who visited a facility but did not discuss family planning. Variations across subgroups in the proportions of nonusers who had some contact with family planning providers are minor. Table 5.18 Contact of nonusers with family planning providers Percentage who were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who did not discuss family planning with a fieldworker or with someone at a health facility in the 12 months preceding the survey, by background characteristics, Ethiopia 2005 Women who visited a health facility and: Background characteristic Women who were visited by a fieldworker who discussed family planning Discussed family planning Did not discuss family planning Women who did not discuss family planning with a field- worker or at a health facility Number of women Age 15-19 3.3 2.1 11.9 95.2 3,182 20-24 6.1 5.4 19.1 89.9 2,256 25-29 7.8 5.9 19.6 87.7 2,135 30-34 9.2 8.2 17.6 85.3 1,569 35-39 7.4 6.6 17.1 87.3 1,357 40-44 7.4 6.2 17.4 88.3 1,046 45-49 5.4 4.9 13.8 91.1 1,071 Residence Urban 4.9 8.1 24.1 88.7 1,968 Rural 6.5 4.6 14.9 90.2 10,648 Region Tigray 6.7 9.5 13.8 86.5 816 Affar 3.9 1.7 22.3 95.0 137 Amhara 6.6 5.4 17.5 90.1 3,080 Oromiya 6.0 4.6 16.0 90.5 4,520 Somali 1.0 0.3 5.6 98.7 475 Benishangul-Gumuz 3.3 3.7 17.2 93.6 113 SNNP 7.9 5.3 14.2 88.2 2,750 Gambela 1.8 2.7 10.1 96.0 39 Harari 8.8 4.5 17.4 88.7 31 Addis Ababa 4.1 7.2 34.2 89.2 601 Dire Dawa 2.5 4.3 12.4 94.5 55 Education No education 6.1 4.4 15.5 90.7 8,526 Primary 7.0 6.1 14.8 88.2 2,769 Secondary and higher 5.4 7.8 25.1 88.8 1,321 Wealth quintile Lowest 6.2 3.8 11.9 91.2 2,352 Second 5.1 3.7 15.1 91.8 2,514 Middle 6.8 4.9 15.9 90.0 2,492 Fourth 7.4 5.0 15.6 89.3 2,351 Highest 5.9 7.9 22.1 88.0 2,907 Total 6.2 5.2 16.4 90.0 12,616 Family Planning | 75 5.14 HUSBAND'S KNOWLEDGE OF WIFE'S USE OF CONTRACEPTION Concealment of use of contraception is an indication of absence of communication or disagreement on use of family planning. To shed light on the extent of communication on the use of contraception among married couples, married women who were using contraception at the time of the survey were asked whether their husband knew of their use. An overwhelming majority (87 percent) of users reported that their husbands know about their use of contraception (Table 5.19). On the other hand, 8 percent of women mentioned that their husband did not know of their use of family planning. Husbands’ lack of knowledge of wives’ family planning use is relatively higher in Tigray, SNNP and Benishangul-Gumuz regions. Uneducated women are three times as likely to conceal the use of a method of family planning as women with secondary or higher levels of education. Concealment of use is also higher among women in the two lowest wealth quintiles and among those residing in rural areas. Table 5.19 Husbands/partners knowledge of women's use of contraception Percent distribution of currently married women who are using a contraceptive method by whether their husband/partner knows about their use of contraception, according to background characteristics, Ethiopia 2005 Background characteristic Husband/ partner knows about use Husband/ partner does not know about use Unsure whether husband/ partner knows Missing Total Number of women Age 15-19 88.0 8.7 0.0 3.3 100.0 63 20-24 85.9 7.3 0.0 6.8 100.0 262 25-29 89.0 6.0 0.2 4.9 100.0 348 30-34 87.3 7.8 0.0 4.9 100.0 223 35-39 89.2 6.8 0.3 3.7 100.0 231 40-44 79.5 12.9 0.0 7.7 100.0 136 45-49 81.6 13.8 0.0 4.5 100.0 70 Education No education 83.2 9.9 0.2 6.7 100.0 706 Primary 86.5 8.5 0.0 5.0 100.0 328 Secondary and higher 95.2 2.6 0.0 2.2 100.0 300 Wealth quintile Lowest 84.0 10.8 0.0 5.2 100.0 73 Second 81.2 14.0 0.0 4.9 100.0 126 Middle 84.8 8.0 0.3 6.9 100.0 228 Fourth 86.8 8.1 0.0 5.1 100.0 283 Highest 88.9 6.3 0.1 4.8 100.0 625 Residence Urban 91.8 4.7 0.2 3.3 100.0 448 Rural 84.2 9.5 0.1 6.2 100.0 887 Region Tigray 81.8 13.8 0.7 3.7 100.0 94 Affar (88.7) (0.0) (0.0) (11.3) (100.0) 7 Amhara 86.7 7.4 0.0 5.9 100.0 374 Oromiya 87.6 6.1 0.0 6.3 100.0 450 Somali * * * * * 11 Benishangul-Gumuz 80.2 10.0 0.0 9.8 100.0 10 SNNP 82.8 12.3 0.0 4.9 100.0 236 Gambela 92.3 1.5 0.0 6.2 100.0 5 Harari 83.0 2.5 0.5 14.0 100.0 7 Addis Ababa 94.2 5.1 0.0 0.7 100.0 127 Dire Dawa 90.6 7.0 0.0 2.4 100.0 12 Total 86.7 7.9 0.1 5.2 100.0 1,334 Note: Women who report use of male sterilisation, condoms, or withdrawal are included in the column, husband/partner knows about use. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 76 | Family Planning 5.15 MEN'S ATTITUDE ABOUT CONTRACEPTION Men’s attitude towards contraceptive use exerts an important influence on their partner’s attitude and eventual adoption of a method. In the 2005 EDHS men were asked if they agreed or disagreed with three stereotypical statements about contraceptive use in general. As shown in Table 5.20 nearly 15 percent of men who know about contraception think that contraception is women’s business and that it does not concern them. A similar proportion of men also believe that women should be the ones to get sterilized, as they are the ones who get pregnant. Thirteen percent of men believe that women who use contraception may become promiscuous. Table 5.20 Men's attitude about contraception Among men who know a family planning method, percentage who agree with three stereotypical statements about contraceptive use, by background characteristics, Ethiopia 2005 Background characteristic Contraception is women's business Women who use contraception may become promiscuous The woman is the one who becomes pregnant, so she should be the one to get sterilised Number of men Age 15-19 12.6 13.0 14.0 1,149 20-24 14.7 14.0 16.0 988 25-29 15.9 13.1 12.5 687 30-34 18.0 12.5 18.1 720 35-39 17.3 10.2 14.2 609 40-44 14.1 11.5 14.3 454 45-49 15.4 14.6 16.1 378 50-54 19.4 10.7 17.6 296 55-59 14.9 13.3 14.9 209 Marital status Never married 12.0 13.4 13.5 2,133 Married or living together 17.8 12.1 16.3 3,185 Divorced/separated/ widowed 13.0 15.7 14.4 172 Residence Urban 7.6 9.0 7.3 910 Rural 16.9 13.4 16.7 4,580 Region Tigray 7.3 6.9 8.6 359 Affar 8.5 7.9 6.8 58 Amhara 14.4 13.4 24.4 1,408 Oromiya 19.4 16.9 16.1 2,072 Somali 9.5 6.5 6.2 109 Benishangul-Gumuz 19.1 12.0 23.5 44 SNNP 14.9 7.3 7.0 1,089 Gambela 10.2 12.4 14.4 18 Harari 16.9 10.4 25.2 16 Addis Ababa 6.2 10.5 5.1 288 Dire Dawa 19.6 8.8 11.1 29 Education No education 17.2 13.2 18.3 2,195 Primary 16.9 13.3 15.7 2,104 Secondary and higher 9.3 10.5 8.3 1,191 Wealth quintile Lowest 15.9 11.0 13.2 895 Second 16.9 13.3 17.9 1,063 Middle 17.1 15.1 17.4 987 Fourth 17.8 14.0 18.3 1,118 Highest 10.8 10.7 10.2 1,427 Total 15.4 12.7 15.1 5,490 Family Planning | 77 Misconceptions about contraceptive use are relatively more widespread among men with little or no education and men residing in rural areas. Men in Dire Dawa, Oromiya and Benishangul- Gumuz are most likely to think that contraception is women’s business, men in Oromiya are also most likely to believe that using contraception might make a woman promiscuous, and men in Harari, Amhara and Benishangul-Gumuz are more likely than those in other regions to believe that women should be the ones to get sterilized, since they are the ones who get pregnant.   Other Proximate Determinants of Fertility | 79 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter addresses the principal factors other than contraception, that influence fertility. Marriage is the principal indicator of women’s exposure to the risk of pregnancy in Ethiopia. Early age at marriage in a population is usually associated with a longer period of exposure to the risk of pregnancy and higher fertility levels. The early initiation of childbearing associated with early marriage may also adversely affect the health of both women and children. The duration of postpartum amenorrhoea and postpartum abstinence affect the length of time a woman is insusceptible to pregnancy and thus, determine the interval between births. The onset of menopause marks the end of a woman’s reproductive life cycle. These factors taken together determine the duration of a woman’s reproductive life and the pace of childbearing, making them important in understanding fertility levels and differentials. 6.1 CURRENT MARITAL STATUS Table 6.1 shows the percent distribution of women and men by current marital status. The term “married” refers to both legal or formal marriage, while “living together” refers to informal unions in which a man and a woman live together, even if a formal civil or religious ceremony has not taken place. In later tables in this report, the term “currently married” includes those living together, if it is not listed as a separate category. Respondents who are widowed, divorced or separated are referred to as “formerly married.” The term “ever married” refers to respondents who are currently married or formerly married. The data indicate that 25 percent of Ethiopian women age 15-49 have never been married. Sixty-three percent are married, 1 percent live together, and 11 percent are separated, divorced or widowed. The low proportion (less than half a percent) of women age 45-49 that have never been married indicates that marriage is universal in Ethiopia. Compared with women, the proportion of men who have never been married is considerably higher (40 percent). Fifty-six percent of men are formally married, less than 1 percent are living together with a woman, and 3 percent are either divorced, separated or widowed. A significant proportion of men marry when they are age 25 or older, unlike women who tend to marry at younger ages. There has been little change over the past five years in the proportions of Ethiopian women and men who have never married, who are married, who are living together, or who are widowed. However, the proportion divorced among both women and men has nearly doubled, and there has been a substantial decline in the proportion separated. The increase in the proportion divorced may be attributed somewhat to greater urbanization and its effects on support from the extended family. The anomaly in the proportion divorced and the proportion separated may be due to larger proportions of women and men formalizing their separation and obtaining a divorce. 80 | Other Proximate Determinants of Fertility Table 6.1 Current marital status Percent distribution of women and men by current marital status, according to age, Ethiopia 2005 Age Never married Married Living together Divorced Separated Widowed Total Number WOMEN 15-19 73.3 21.1 0.7 4.0 0.6 0.2 100.0 3,266 20-24 30.3 60.1 1.7 5.6 1.8 0.6 100.0 2,547 25-29 9.7 81.0 1.0 4.1 2.1 2.0 100.0 2,517 30-34 3.5 84.6 1.2 4.7 2.2 3.8 100.0 1,808 35-39 1.9 82.8 1.0 5.0 2.3 7.0 100.0 1,602 40-44 0.8 79.4 1.4 4.0 3.0 11.4 100.0 1,187 45-49 0.4 74.9 0.6 7.3 2.4 14.5 100.0 1,143 Total 25.0 63.4 1.1 4.8 1.8 4.0 100.0 14,070 MEN 15-19 97.6 2.0 0.1 0.3 0.0 0.0 100.0 1,335 20-24 73.1 23.4 0.6 1.9 0.7 0.3 100.0 1,064 25-29 31.2 64.2 0.9 2.5 0.8 0.4 100.0 741 30-34 10.2 85.0 0.6 1.9 1.6 0.7 100.0 754 35-39 2.2 93.4 0.4 3.1 0.8 0.0 100.0 651 40-44 2.1 93.1 1.0 3.0 0.2 0.6 100.0 497 45-49 0.8 94.7 0.0 1.6 1.5 1.4 100.0 422 50-54 0.6 91.4 1.1 2.2 1.8 2.9 100.0 335 55-59 0.0 95.8 0.0 1.0 0.4 2.8 100.0 235 Total 40.1 56.2 0.5 1.8 0.8 0.6 100.0 6,033 6.2 POLYGYNY Polygyny (the practice of having more than one wife) has implications for the frequency of exposure to sexual activity and therefore fertility. The extent of polygyny is ascertained from responses of currently married women to questions on whether their husband or partner has other wives and if so how many. Similarly, currently married men are asked for the number of wives or partners they have. Table 6.2 shows the proportion of currently married women and men who are in polygynous unions by background characteristics. The data show that 12 percent of married women in Ethiopia are in polygynous unions. Seven percent say they have only one co-wife, while 5 percent say they have 2 or more co-wives. The percentage of women in polygynous unions tends to increase with age, from 4 percent among women age 15-19 to 17 percent among women age 45-49. Rural women are more likely to be in polygynous unions (13 percent) than urban women (7 percent). The regional distribution shows substantial variation. The prevalence of polygyny is highest in Gambela (27 percent) and lowest in Amhara and Addis Ababa (3 percent each). Polygyny is also high in Affar, Somali and Benishangul-Gumuz (21 percent each). The extent of polygyny has declined slightly over the past five years, from 14 percent to 12 percent. Other Proximate Determinants of Fertility | 81 Table 6.2 Number of co-wives and wives Percent distribution of currently married women by number of co-wives and percent distribution of currently married men by number of wives, according to background characteristics, Ethiopia 2005 Number of co-wives Number of wives Background characteristic 0 1 2+ Missing Total Number of women 1 2+ Total Number of men Age 15-19 96.0 2.5 1.4 0.1 100.0 711 (100.0) (0.0) (100.0) 28 20-24 93.7 3.8 2.1 0.4 100.0 1,574 99.9 0.1 100.0 255 25-29 90.6 5.6 3.6 0.2 100.0 2,066 98.5 1.5 100.0 482 30-34 83.9 8.7 7.1 0.3 100.0 1,551 95.2 4.8 100.0 646 35-39 82.4 9.9 7.5 0.2 100.0 1,343 94.0 6.0 100.0 610 40-44 83.0 9.5 7.4 0.0 100.0 960 87.2 12.8 100.0 468 45-49 83.0 9.9 7.2 0.0 100.0 862 90.8 9.2 100.0 399 50-54 na na na na na na 91.7 8.3 100.0 310 55-59 na na na na na na 89.8 10.2 100.0 225 Residence Urban 92.4 2.8 4.6 0.2 100.0 959 97.4 2.6 100.0 344 Rural 87.1 7.5 5.2 0.2 100.0 8,107 93.1 6.9 100.0 3,080 Region Tigray 95.9 2.2 1.6 0.2 100.0 570 98.8 1.2 100.0 206 Affar 78.3 8.8 12.2 0.6 100.0 109 84.2 15.8 100.0 42 Amhara 97.2 1.4 1.2 0.2 100.0 2,330 99.2 0.8 100.0 913 Oromiya 84.1 9.8 6.0 0.1 100.0 3,300 90.8 9.2 100.0 1,228 Somali 78.4 10.3 10.8 0.5 100.0 363 89.9 10.1 100.0 137 Benishangul-Gumuz 78.7 12.2 8.9 0.1 100.0 92 86.2 13.8 100.0 37 SNNP 81.8 9.9 7.9 0.4 100.0 1,988 90.5 9.5 100.0 730 Gambela 72.0 12.0 15.3 0.6 100.0 31 90.9 9.1 100.0 12 Harari 94.6 2.9 2.3 0.2 100.0 22 97.9 2.1 100.0 9 Addis Ababa 96.4 2.0 1.1 0.5 100.0 224 98.4 1.6 100.0 97 Dire Dawa 91.1 5.9 2.7 0.3 100.0 37 94.8 5.2 100.0 14 Education No education 86.6 7.5 5.7 0.2 100.0 7,094 93.8 6.2 100.0 1,912 Primary 89.8 7.0 3.2 0.0 100.0 1,402 91.4 8.6 100.0 1,099 Secondary and higher 96.3 0.7 2.4 0.6 100.0 570 97.8 2.2 100.0 413 Wealth quintile Lowest 83.7 8.4 7.5 0.4 100.0 1,759 94.1 5.9 100.0 659 Second 86.5 7.3 5.9 0.3 100.0 1,892 93.1 6.9 100.0 745 Middle 87.7 7.5 4.7 0.1 100.0 1,903 91.9 8.1 100.0 715 Fourth 88.7 7.6 3.5 0.2 100.0 1,823 93.2 6.8 100.0 669 Highest 91.9 4.0 4.0 0.1 100.0 1,689 95.5 4.5 100.0 637 Total 87.7 7.0 5.1 0.2 100.0 9,066 93.5 6.5 100.0 3,424 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable There is an inverse relationship between education and polygyny. The proportion of currently married women in a polygynous union decreases from 13 percent among women with no education to 3 percent among women with some secondary or higher education. Substantial differences are observed in the prevalence of polygyny among women in different wealth quintiles. Women in the lowest wealth quintile are twice as likely to be in a polygynous union as women in the highest wealth quintile. Data on polygynous unions among currently married men is also shown in Table 6.2. The data indicate that 7 percent of men report having two or more wives; however, this figure varies widely by region and urban-rural residence. The level of polygyny as reported by men has declined slightly over the past five years, from 9 percent in the 2000 EDHS to 7 percent in the 2005 EDHS. 82 | Other Proximate Determinants of Fertility 6.3 AGE AT FIRST MARRIAGE In Ethiopia, marriage marks the point in a woman’s life when childbearing becomes socially acceptable. Age at first marriage has a major effect on childbearing because women who marry early have on average a longer period of exposure to pregnancy and a greater number of lifetime births. Information on age at first marriage was obtained by asking respondents the month and year, or age, at which they started living with their first partner. Table 6.3 shows the percentage of women and men who have married by specific exact ages, according to current age. Marriage occurs relatively early in Ethiopia. Among women age 25-49, 66 percent married by age 18 and 79 percent married by age 20. The median age at first marriage among women age 25-49 is 16.1 years. The proportion of women married by age 15 has declined from 38 percent among women age 45-49 to 13 percent among women age 15-19, but there has been little change in the median age at marriage among women age 25-49 in the past five years. Table 6.3 Age at first marriage Percentage of women and men who were first married by specific exact ages and median age at first marriage, according to current age, Ethiopia 2005 Percentage first married by exact age: Current age 15 18 20 22 25 Percentage never married Number Median age at first marriage WOMEN 15-19 12.7 na na na na 73.3 3,266 a 20-24 23.9 49.2 62.4 na na 30.3 2,547 18.1 25-29 31.9 61.7 74.3 82.6 89.1 9.7 2,517 16.6 30-34 31.9 64.3 77.7 85.9 92.6 3.5 1,808 16.2 35-39 33.3 67.4 81.4 88.3 93.3 1.9 1,602 16.0 40-44 36.7 68.6 81.1 89.8 94.5 0.8 1,187 15.8 45-49 38.0 70.8 83.0 90.4 94.8 0.4 1,143 15.8 Women age 20-49 31.4 61.8 74.8 na na 10.4 10,804 16.5 Women age 25-49 33.7 65.6 78.6 86.6 92.2 4.2 8,257 16.1 MEN 15-19 na na na na na 97.6 1,335 a 20-24 na 5.7 13.6 na na 73.1 1,064 a 25-29 na 7.8 18.8 32.0 54.2 31.2 741 24.2 30-34 na 10.3 24.1 38.4 61.0 10.2 754 23.5 35-39 na 10.5 21.5 42.2 62.1 2.2 651 23.0 40-44 na 12.5 25.1 38.1 57.8 2.1 497 23.8 45-49 na 10.4 25.6 42.7 61.0 0.8 422 23.2 50-54 na 6.8 17.6 28.8 46.2 0.6 335 25.7 55-59 na 7.8 17.1 25.0 44.9 0.0 235 25.5 Men age 25-59 na 9.7 21.8 36.5 57.0 9.3 3,634 23.8 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women or men began living with their spouse/partner for the first time before reaching the beginning of the age group. Men tend to marry at much older ages than women. Among men age 25-59, only 10 percent were married by age 18 and 22 percent by age 20. The median age at marriage for men age 25-29 is 24.2 years, nearly eight years older than for women in the same age group. Other Proximate Determinants of Fertility | 83 Table 6.4 shows the median age at first marriage for women age 20-49 by current age and background characteristics; summary data are also given for men age 25-59. Data for women age 15- 19 and men age 15-24 have been omitted because fewer than 50 percent of respondents in these age groups were married. Urban women age 25-49 marry more than two years later than rural women. Women with at least some secondary education marry 5 years later than women with no education and women in the highest wealth quintile marry a year later than women in the lowest wealth quintile. The median age at marriage is highest in Addis Ababa (21.9 years) and lowest in Amhara (14.2 years). Similar differences by background characteristics are also observed among men. Table 6.4 Median age at first marriage Median age at first marriage among women age 20 (25)-49 and among men 25-49, by current age and background characteristics, Ethiopia 2005 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Men age 25-59 Residence Urban 3.3 21.6 18.7 17.2 15.8 16.1 19.4 18.2 a Rural 17.3 16.1 16.0 15.9 15.7 15.7 16.1 15.9 23.4 Region Tigray 16.9 16.0 15.7 15.3 15.0 15.5 15.7 15.6 24.7 Affar 17.4 16.9 16.0 15.7 15.9 17.8 16.7 16.4 23.9 Amhara 15.2 14.5 14.3 14.2 14.1 13.6 14.4 14.2 22.3 Oromiya 18.7 16.8 17.0 16.7 16.5 16.7 17.1 16.7 24.4 Somali 17.3 17.6 17.2 19.1 18.3 19.6 17.9 18.0 24.3 Benishangul-Gumuz 16.6 15.5 15.3 15.4 15.2 15.1 15.6 15.3 22.7 SNNP 19.5 17.5 17.2 16.9 16.8 16.6 17.6 17.2 23.2 Gambela 15.8 15.7 15.8 15.9 15.8 15.4 15.8 15.7 23.0 Harari 19.6 20.0 18.3 17.9 17.4 18.6 18.9 18.6 a Addis Ababa 8.5 2.5 23.8 21.2 16.9 16.8 a 21.9 a Dire Dawa a 19.3 17.3 16.8 17.0 17.1 18.3 17.8 a Education No education 16.5 16.0 15.9 15.7 15.6 15.7 15.9 15.8 23.5 Primary 20.0 16.6 15.9 17.1 17.1 16.0 17.4 16.5 23.3 Secondary and higher 6.4 24.1 20.7 19.8 18.3 19.1 a 21.2 a Wealth quintile Lowest 16.6 16.2 16.0 15.9 16.1 16.7 16.2 16.1 24.0 Second 16.7 15.6 15.8 15.8 16.0 15.4 15.9 15.7 23.4 Middle 17.2 16.4 16.3 16.1 15.6 15.9 16.4 16.1 23.1 Fourth 17.7 16.4 16.3 15.9 15.5 15.5 16.2 15.9 23.2 Highest a 19.4 17.0 16.3 15.7 15.9 18.2 17.0 a Total 18.1 16.6 16.2 16.0 15.8 15.8 16.5 16.1 23.8 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50 percent of the women/men began living with their spouse/partner for the first time before reaching the beginning of the age group. 6.4 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is often used as a proxy for first exposure to intercourse and risk of pregnancy. But the two events may not occur at the same time because some women may engage in sexual activity before marriage. In the 2005 EDHS, women and men were asked how old they were when they first had sexual intercourse. 84 | Other Proximate Determinants of Fertility Table 6.5 shows the percentage of women and men who first had sexual intercourse by specific exact ages. Among women age 25-49, 32 percent had sexual intercourse before age 15, 65 percent before age 18, and by age 25 most Ethiopian women have had sexual intercourse. The median age at first sexual intercourse for women age 25-49 years is 16.1 years, which is identical to the median age at first marriage. This suggests that Ethiopian women generally begin sexual intercourse at the time of their first marriage. The median age at first sexual intercourse has increased over the past two decades, from 15.7 years for women age 45-49 to 18.2 years for women age 20-24. Table 6.5 Age at first sexual intercourse Percentage of women and men who had first sexual intercourse by specific exact ages and median age at first sexual intercourse, according to current age, Ethiopia 2005 Percentage who had first sexual intercourse by exact age: Current age 15 18 20 22 25 Percentage who never had intercourse Number Median age at first intercourse WOMEN 15-19 11.1 na na na na 72.3 3,266 a 20-24 21.9 48.6 62.3 na na 27.4 2,547 18.2 25-29 29.3 61.2 72.5 81.1 87.0 8.1 2,517 16.6 30-34 29.9 63.3 74.4 82.1 86.8 2.4 1,808 16.4 35-39 30.1 65.9 79.1 84.7 89.4 0.6 1,602 16.1 40-44 35.7 69.8 80.3 87.9 90.2 0.3 1,187 15.7 45-49 37.4 71.0 83.1 88.4 91.1 0.3 1,143 15.7 Women age 20-49 29.3 61.3 73.4 na na 8.9 10,804 16.5 Women age 25-49 31.6 65.2 76.8 84.0 88.4 3.2 8,257 16.1 MEN 15-19 1.7 na na na na 92.7 1,335 a 20-24 1.7 14.1 29.3 na na 55.9 1,064 a 25-29 1.5 16.3 35.3 50.2 73.0 18.9 741 22.0 30-34 1.4 15.0 37.5 57.7 77.7 4.1 754 21.0 35-39 1.0 16.9 34.1 55.9 75.8 1.0 651 21.3 40-44 0.7 17.6 38.4 58.2 76.8 0.6 497 20.8 45-49 0.5 15.8 40.7 59.1 73.8 0.0 422 20.8 50-54 0.0 11.3 32.4 49.9 70.3 0.0 335 22.0 55-59 1.1 16.0 36.5 51.4 64.8 0.0 235 21.0 Men age 25-59 1.0 15.8 36.4 55.0 74.3 5.0 3,634 21.2 na = Not applicable due to censoring a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group The data show that men initiate sex at a later age than women. The median age at first intercourse for men age 25-59 is 21.2 years. An assessment of the median age at first intercourse across the different age cohorts indicates that there has not been any significant change in age at first sexual intercourse for men over the past 20 years. Table 6.6 presents differentials in the median age at first sexual intercourse by background characteristics for women and men. Urban women have their first sexual intercourse about two years later than rural women, while urban men have their first intercourse about a year earlier than rural men. Women with at least some secondary education have their first intercourse about five years later than women with no education. On the other hand, highly educated men initiate sex a year earlier than men with no education. Among women, age at first sexual intercourse is lowest in Amhara and highest in Addis Ababa; among men, it is lowest in Gambela and highest in Somali. Other Proximate Determinants of Fertility | 85 Table 6.6 Median age at first intercourse Median age at first sexual intercourse among women age 20-49 and men age 25-59, by current age and background characteristics, Ethiopia 2005 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Men age 25-59 Residence Urban a 20.7 18.5 17.4 16.1 15.8 18.7 18.0 20.4 Rural 17.5 16.1 16.1 15.9 15.7 15.7 16.2 15.9 21.4 Region Tigray 17.0 15.9 15.6 15.5 14.7 15.3 15.6 15.5 22.3 Affar 17.8 17.2 15.9 15.8 15.8 16.5 16.5 16.1 19.9 Amhara 15.5 14.7 14.7 14.6 14.5 14.1 14.7 14.6 20.3 Oromiya 18.7 17.1 17.1 17.3 16.4 16.3 17.3 16.9 21.6 Somali 17.9 18.2 17.1 19.3 18.4 19.0 18.3 18.4 23.9 Benishangul-Gumuz 16.6 15.8 15.8 15.6 15.3 15.2 15.8 15.6 20.8 SNNP 19.6 17.6 17.7 16.8 16.8 16.8 17.8 17.3 22.0 Gambela 15.9 15.8 15.7 15.7 15.7 15.6 15.8 15.7 18.3 Harari 19.4 19.6 18.4 18.0 18.0 18.5 18.8 18.6 21.0 Addis Ababa a 22.7 21.0 18.9 16.7 16.6 a 20.0 20.5 Dire Dawa 19.3 18.8 17.1 16.6 17.0 17.0 18.0 17.5 21.0 Education No education 16.7 16.0 16.0 15.8 15.6 15.7 15.9 15.8 21.3 Primary 19.6 16.7 16.5 17.4 16.7 16.1 17.5 16.8 21.6 Secondary and higher a 21.9 19.9 18.8 18.4 18.4 a 20.4 20.4 Wealth quintile Lowest 17.2 16.0 16.0 15.9 15.9 16.1 16.1 15.9 21.9 Second 17.0 15.7 16.0 15.8 15.7 15.4 15.9 15.7 21.5 Middle 17.3 16.4 16.6 16.3 15.6 15.9 16.4 16.1 21.5 Fourth 17.8 16.2 16.6 15.9 15.6 15.5 16.2 15.9 20.9 Highest a 19.6 17.0 17.1 15.9 15.7 18.1 17.2 20.6 Total 18.2 16.6 16.4 16.1 15.7 15.7 16.5 16.1 21.2 a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group 6.5 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the frequency of intercourse. Therefore, information on sexual activity can be used to refine measures of exposure to pregnancy. Women and men were asked how long ago their last sexual activity occurred to assess whether they had a sexual encounter in the past four weeks. Tables 6.7.1 and 6.7.2 show the percent distribution of women and men by recent sexual activity.1 Half of women age 15-49 were sexually activity in the four weeks before the survey, 15 percent had been sexually active in the 12-month period before the survey but not in the month prior to the interview, and 11 percent had not been sexually active for one or more years. Twenty-four percent of the women had never had sexual intercourse. 1 Questions on recent sexual activity were only administered to the subsample of women who were in house- holds selected for the male survey. 86 | Other Proximate Determinants of Fertility Table 6.7.1 Recent sexual activity: women Percent distribution of women by timing of last sexual intercourse, according to background characteristics, Ethiopia 2005 Timing of last sexual intercourse Background characteristic Within the last 4 weeks Within 1 year1 One or more years Missing Never had sexual intercourse Total Number of women Age 15-19 17.5 7.6 3.7 0.2 71.1 100.0 1,645 20-24 50.7 14.5 7.8 0.0 27.0 100.0 1,228 25-29 68.0 15.7 9.0 0.0 7.3 100.0 1,167 30-34 68.2 16.6 12.0 0.3 3.0 100.0 845 35-39 63.5 19.3 16.3 0.4 0.5 100.0 776 40-44 60.0 18.3 21.4 0.3 0.1 100.0 570 45-49 50.2 18.9 30.7 0.1 0.2 100.0 520 Marital status Never married 1.6 2.1 2.4 0.0 93.9 100.0 1,703 Married or living together 77.0 19.0 3.8 0.1 0.1 100.0 4,317 Divorced/separated/widowed 3.4 16.9 77.2 0.6 2.0 100.0 731 Marital duration2 Married only once 0-4 years 75.8 20.3 3.1 0.3 0.6 100.0 670 5-9 years 78.6 19.4 2.1 0.0 0.0 100.0 705 10-14 years 79.5 17.9 2.4 0.1 0.0 100.0 666 15-19 years 78.8 18.8 2.1 0.4 0.0 100.0 495 20-24 years 75.2 20.1 4.8 0.0 0.0 100.0 341 25+ years 67.8 20.4 11.8 0.0 0.0 100.0 413 Married more than once 78.5 17.7 3.7 0.2 0.0 100.0 1,026 Current contraceptive method Female sterilisation * * * * * 100.0 5 Pill 89.0 10.6 0.4 0.0 0.0 100.0 144 IUD * * * 8 * 100.0 6 Condom (76.3) (23.7) (0.0) (0.0) (0.0) 100.0 19 Periodic abstinence 85.0 14.5 0.5 0.0 0.0 100.0 30 Other method 86.3 10.3 2.6 0.8 0.0 100.0 505 No method 45.8 14.9 12.4 0.1 26.8 100.0 6,042 Residence Urban 30.6 11.3 18.7 0.5 38.8 100.0 1,173 Rural 54.1 15.2 9.9 0.1 20.8 100.0 5,579 Region Tigray 48.6 16.3 13.0 0.1 22.0 100.0 448 Affar 57.2 19.2 11.5 0.0 12.1 100.0 72 Amhara 53.3 16.2 14.4 0.0 16.1 100.0 1,640 Oromiya 51.0 14.8 9.2 0.1 24.9 100.0 2,368 Somali 52.0 14.2 14.5 1.4 18.0 100.0 243 Benishangul-Gumuz 59.0 16.2 8.7 0.1 16.0 100.0 62 SNNP 49.9 12.8 8.5 0.2 28.6 100.0 1,504 Gambela 38.7 20.7 24.9 1.0 14.7 100.0 23 Harari 39.4 18.7 13.3 0.0 28.6 100.0 20 Addis Ababa 26.6 8.0 19.4 0.3 45.7 100.0 339 Dire Dawa 42.0 11.2 20.7 0.0 26.1 100.0 33 Education No education 57.6 17.5 12.9 0.1 11.9 100.0 4,419 Primary 39.1 8.6 7.6 0.1 44.5 100.0 1,552 Secondary and higher 28.7 9.2 10.3 0.3 51.6 100.0 781 Wealth quintile Lowest 55.5 15.4 13.1 0.1 15.9 100.0 1,251 Second 53.5 17.3 10.0 0.0 19.2 100.0 1,321 Middle 52.6 16.3 8.9 0.3 21.9 100.0 1,273 Fourth 54.1 12.9 9.4 0.0 23.6 100.0 1,234 Highest 38.1 11.4 14.6 0.4 35.6 100.0 1,672 Total 50.0 14.5 11.4 0.2 24.0 100.0 6,751 Note: Only women in the subsample of households selected for the male survey were administered this question. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married Other Proximate Determinants of Fertility | 87 Table 6.7.2 Recent sexual activity: men Percent distribution of men by timing of last sexual intercourse, according to background characteristics, Ethiopia 2005 Timing of last sexual intercourse Background characteristic Within the last 4 weeks Within 1 year1 One or more years Missing Never had sexual intercourse Total Number of men Age 15-19 2.1 3.8 1.4 0.0 92.7 100.0 1,335 20-24 22.6 12.1 9.3 0.2 55.9 100.0 1,064 25-29 56.8 14.8 9.5 0.0 18.9 100.0 741 30-34 73.3 16.5 6.1 0.0 4.1 100.0 754 35-39 78.4 15.9 4.6 0.1 1.0 100.0 651 40-44 73.6 20.5 4.8 0.4 0.6 100.0 497 45-49 75.1 16.2 8.1 0.6 0.0 100.0 422 50-54 70.8 19.7 9.1 0.4 0.0 100.0 335 55-59 67.8 20.0 12.3 0.0 0.0 100.0 235 Marital status Never married 2.6 6.8 7.7 0.0 82.9 100.0 2,419 Married or living together 80.6 17.1 2.0 0.2 0.1 100.0 3,424 Divorced/separated/widowed 4.3 26.7 65.9 0.0 3.1 100.0 190 Marital duration2 Married only once 0-4 years 82.3 16.7 0.2 0.3 0.5 100.0 610 5-9 years 82.0 16.8 1.1 0.1 0.0 100.0 650 10-14 years 84.1 14.8 1.1 0.0 0.0 100.0 654 15-19 years 79.5 17.9 2.0 0.6 0.0 100.0 528 20-24 years 79.8 17.1 2.4 0.6 0.0 100.0 372 25+ years 74.8 19.5 5.6 0.1 0.0 100.0 611 Residence Urban 32.5 15.9 12.9 0.7 37.9 100.0 916 Rural 49.5 12.8 5.1 0.0 32.6 100.0 5,117 Region Tigray 47.6 16.4 4.0 0.0 32.1 100.0 366 Affar 50.3 26.0 7.8 0.0 16.0 100.0 65 Amhara 50.6 10.6 5.9 0.1 32.8 100.0 1,521 Oromiya 45.0 13.9 6.2 0.2 34.7 100.0 2,222 Somali 53.5 12.4 7.2 0.0 26.9 100.0 202 Benishangul-Gumuz 56.6 13.4 3.2 0.0 26.7 100.0 54 SNNP 47.9 12.3 4.6 0.1 35.1 100.0 1,244 Gambela 45.7 19.8 16.2 0.0 18.3 100.0 21 Harari 41.7 24.3 11.2 0.0 22.8 100.0 16 Addis Ababa 31.2 18.0 18.6 0.3 31.9 100.0 292 Dire Dawa 42.2 16.0 9.2 0.0 32.6 100.0 30 Education No education 59.4 14.4 6.4 0.1 19.8 100.0 2,589 Primary 40.8 11.6 4.3 0.0 43.4 100.0 2,252 Secondary and higher 31.4 14.0 10.0 0.5 44.1 100.0 1,192 Wealth quintile Lowest 48.6 12.8 5.5 0.2 33.0 100.0 1,100 Second 48.7 15.2 5.4 0.0 30.7 100.0 1,184 Middle 56.0 12.4 4.1 0.0 27.5 100.0 1,081 Fourth 47.2 12.0 4.4 0.0 36.4 100.0 1,200 Highest 37.3 13.7 10.9 0.4 37.8 100.0 1,469 Total 46.9 13.3 6.3 0.1 33.4 100.0 6,033 1 Excludes men who had sexual intercourse within the last 4 weeks 2 Excludes men who are not currently married 88 | Other Proximate Determinants of Fertility The proportion of women who were sexually active during the four weeks before the survey increases with age, from 18 percent at age 15-19 to 68 percent by age 25-34 and decreases thereafter until it reaches 50 percent at age 45-49. Women who are currently in union are much more likely to be sexually active in the four weeks preceding the survey than women who were formerly married or had never been married. Those married 25 years or more are less likely to be sexually active in the recent past than women married for shorter durations. In general, women using contraception are more likely to be sexually active than those not using contraception. Rural women are more likely to be sexually active (54 percent) than urban women (31 percent). Among the regions, women residing in Benishangul-Gumuz (59 percent) and Affar (57 percent) are proportionately more likely to be sexually active than women residing in Addis Ababa (27 percent). Women with no education (58 percent) are twice as likely to be sexually active in the recent past as women with some secondary education (29 percent). Women in the highest wealth quintile are much less likely to report being sexually active in the past four weeks than their counterparts. Among men, 47 percent were sexually active in the four weeks preceding the survey, 13 percent had had sexual intercourse in the year before the survey but not in the month prior to the survey, while 6 percent had not been sexually active for one year or more. Thirty-three percent of men said they had never had sex. As with women, sexual activity among men increases with age and peaks in the late thirties. Men in union are much more likely to be sexually active than those not in union. Men in urban areas are less likely (33 percent) to be sexually active in the recent past than those in rural areas (50 percent). Regional variation shows similar patterns with women. Recent sexual activity is highest among men living in Benishangul-Gumuz (57 percent) and lowest in Addis Ababa (31 percent). Comparison of data between the 2005 EDHS and the 2000 EDHS shows that there has been virtually no change in the level of recent sexual activity among women or men over the past five years. As with women, recent sexual activity is inversely related with men’s level of education. Recent sexual activity decreases from 59 percent among men with no education to 41 percent among men with some primary education, and decreases further to 31 percent among those with some secondary education. Recent sexual activity is lowest among the wealthiest men. 6.6 POSTPARTUM AMENORRHOEA, ABSTINENCE AND INSUSCEPTIBILITY Postpartum amenorrhoea is the interval between the birth of a child and the resumption of menstruation. It is the period following childbirth during which a woman becomes temporarily and involuntarily infecund. Postpartum protection from conception can be prolonged by the intensity and length of breastfeeding. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. A woman is considered insusceptible if she is not exposed to the risk of pregnancy, either because she is amenorrhoeic or because she is abstaining from sexual intercourse following a birth. Information was obtained about the duration of amenorrhoea and the duration of sexual abstinence following childbirth for births in the three years preceding the survey. Other Proximate Determinants of Fertility | 89 Table 6.8 shows the percentage of births in the three years preceding the survey for which mothers were postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth. The results show that Ethiopian women are amenorrhoeic for a median of 15.8 months, abstain for a median of 2.4 months, and are insusceptible to pregnancy for a median of 16.7 months. In general, the proportion of women who are amenorrhoeic or abstaining decreases with increasing months after delivery. The proportion amenorrhoeic drops from 96 percent in the first two months following a birth to 63 percent at 12-13 months and 17 percent at 24-25 months after birth. The majority of Ethiopian women (85 percent) abstain from sex during the first two months following birth. A comparison of data from the 2000 and 2005 EDHS surveys indicates that there has been a decline in the median duration of postpartum amenorrhoea from 19 months to around 16 months while there has been no change in the median duration of postpartum abstinence. The reduction in the duration of postpartum amenorrhoea is probably due to the shorter duration of breastfeeding (see chapter 11). Table 6.8 Postpartum amenorrhoea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Ethiopia 2005 Percentage of births for which the mother is: Months since birth Amenorrhoeic Abstaining Insusceptible Number of births < 2 95.5 85.2 96.2 344 2-3 85.6 43.7 88.8 493 4-5 81.2 22.5 86.0 380 6-7 77.2 13.3 78.3 435 8-9 78.0 12.1 78.7 404 10-11 70.1 8.8 72.4 291 12-13 63.2 7.2 65.1 482 14-15 54.2 9.9 57.7 382 16-17 45.7 6.0 47.6 357 18-19 41.6 5.2 45.2 336 20-21 43.0 8.7 45.8 288 22-23 28.9 11.2 34.6 234 24-25 17.2 4.9 20.2 388 26-27 15.0 2.7 17.1 427 28-29 9.5 3.5 12.0 330 30-31 12.8 2.8 14.5 345 32-33 12.3 3.2 13.1 329 34-35 5.2 2.3 7.5 255 Total 48.9 14.7 51.3 6,497 Median 15.8 2.4 16.7 na Mean 17.0 5.4 17.9 na Note: Estimates are based on status at the time of the survey. na = Not applicable Table 6.9 shows the median duration of postpartum amenorrhoea, abstinence, and insusceptibility by background characteristics. The duration of amenorrhoea is much shorter among urban women than among rural women, and is lower among women age 15-29, women with secondary and higher education, women in the highest wealth quintile and women residing in Addis Ababa. 90 | Other Proximate Determinants of Fertility Table 6.9 Median duration of postpartum insusceptibility by background charac- teristics Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Ethiopia 2005 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility Number of births Age 15-29 15.1 2.4 15.8 3,761 30-49 18.0 2.5 19.9 2,736 Residence Urban 9.1 2.4 10.0 489 Rural 16.4 2.4 17.7 6,008 Region Tigray 20.0 2.0 21.2 395 Affar 13.4 2.4 14.2 64 Amhara 20.8 2.4 21.4 1,519 Oromiya 14.5 2.5 15.0 2,612 Somali 15.5 3.2 16.3 276 Benishangul-Gumuz 14.4 2.5 14.5 60 SNNP 17.0 2.5 17.8 1,432 Gambela 17.1 11.1 22.9 17 Harari 10.1 2.4 10.2 14 Addis Ababa 9.3 2.1 10.7 85 Dire Dawa 10.8 2.5 11.4 22 Education No education 16.2 2.7 18.1 5,070 Primary 14.2 1.8 15.3 1,138 Secondary and higher 10.3 2.1 10.4 289 Wealth quintile Lowest 17.0 2.7 18.2 1,384 Second 20.9 3.0 21.2 1,382 Middle 16.4 2.8 18.5 1,456 Fourth 14.3 2.1 14.4 1,306 Highest 11.4 2.1 12.5 970 Total 15.8 2.4 16.7 6,497 Note: Medians are based on current status. 6.7 MENOPAUSE The risk of childbearing declines as age increases. The term infecundity denotes a process rather than a well-defined event. Although the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a group of women. Table 6.10 presents data on menopause, an indicator of decreasing exposure to the risk of pregnancy (infecundity) for women age 30 and over. In the context of the available survey data, women are considered menopausal if they are neither pregnant nor post- partum amenorrhoeic and have not had a menstrual period for at least six months preceding the survey. The proportion of women who are menopausal increases with age from 2 percent for women age 30-34 to 60 percent for women age 48-49. Overall, 16 percent of women age 30-49 are menopausal. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Ethiopia 2005 Age Percentage menopausal1 Number of women 30-34 2.4 1,808 35-39 5.4 1,602 40-41 14.4 697 42-43 22.5 356 44-45 31.9 557 46-47 51.0 329 48-49 60.3 393 Total 15.5 5,740 1 Percentage of all women who are not pregnant and not postpartum amenor- rhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 91 FERTILITY PREFERENCES 7 Information on fertility preference provides insight into a couple’s attitude towards future childbearing, desired completed family size, the extent of unwanted and mistimed pregnancies, and the prevailing demand for contraception. In the 2005 EDHS, women and men were asked a series of questions to ascertain their fertility preferences, including their desire to have another child, the length of time they would like to wait before having another child, and what they consider to be the ideal number of children. These data make it possible to quantify fertility preferences and, coupled with the data on contraceptive use allow estimation of the unmet need for family planning, for both spacing and limiting births. Nevertheless, interpretation of the results of fertility preferences is controversial since respondents’ reported preferences are, in most cases, hypothetical and thus subject to change and rationalization. 7.1 DESIRE FOR MORE CHILDREN In the 2005 EDHS currently married women and men were asked whether they want to have another child, and if so how soon. The wording of the question varied slightly if the female respondent or the wife or partner of a male respondent was pregnant to ensure that pregnant women (and men with pregnant partners) were not asked about the wantedness of the current pregnancy but the desire for subsequent children. Table 7.1 shows future reproductive intentions of currently married women and men by the number of living children. Sixteen percent of women want to have another child soon while 35 percent want another child two or more years later (Figure 7.1). Forty-two percent want no more children or have been sterilized. In general 78 percent of currently married women want to either stop or postpone childbearing. This implies that around four out of five currently married women are in need of family planning services. A similar pattern is observed for men, except that a relatively higher percentage of men want to have another child, either sooner or later. The desire to stop childbearing increases with the number of living children from 9 percent among women with no children to 72 percent among women with 6 or more children. Comparison between the two EDHS surveys show that the proportion of currently married women who want to stop childbearing has increased in the past five years for all categories of living children, with an overall increase from 32 percent in 2000 to 42 percent in 2005 (Figure 7.2). Tables 7.2.1 and 7.2.2 show that the desire to limit childbearing is higher among women and men in urban than rural areas, with the urban-rural difference higher overall among men than women. Regional differences are notable. Currently married women living in Addis Ababa, Oromia and Amhara are more likely to want to stop childbearing than women living in the other regions. A similar pattern is seen for currently married men as well. The percentage of currently married men who want to stop childbearing is lower than the percentage among women in all regions except Addis Ababa and Dire Dawa. The male-female difference in the desire to limit childbearing is especially pronounced in Gambela where only 24 percent of currently married men want to stop childbearing compared with 44 percent of women. Women and men living in the Somali Region are least likely to want to limit childbearing (10 percent and 4 percent, respectively). 92 | Fertility Preferences Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men by desire for children, according to number of living children, Ethiopia 2005 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total WOMEN Have another soon2 57.9 23.3 16.4 15.1 10.0 8.6 8.0 16.1 Have another later3 24.5 58.3 50.9 47.7 33.4 24.4 13.3 35.4 Have another, undecided when 3.0 2.5 3.5 3.7 3.3 2.7 2.4 3.0 Undecided 1.4 0.6 1.2 1.3 1.2 2.6 1.1 1.3 Want no more 8.5 14.2 26.5 31.3 49.7 57.9 72.1 41.9 Sterilised4 0.0 0.1 0.2 0.1 0.0 0.2 0.3 0.2 Declared infecund 4.8 0.9 1.2 0.7 2.2 3.6 2.8 2.1 Missing 0.0 0.0 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 Number of women 600 1,293 1,370 1,312 1,333 1,066 2,093 9,066 MEN Have another soon2 43.3 27.4 17.8 15.7 14.9 14.3 12.4 18.7 Have another later3 43.6 59.5 59.4 47.9 45.8 30.5 21.6 41.5 Have another, undecided when 2.5 2.3 2.2 2.4 2.1 2.4 3.4 2.6 Undecided 3.6 2.6 1.8 3.6 1.5 1.7 1.5 2.1 Want no more 5.8 8.2 18.0 28.6 35.4 49.9 59.6 34.1 Declared infecund 0.7 0.0 0.3 1.8 0.4 1.1 1.3 0.9 Missing 0.5 0.1 0.5 0.0 0.0 0.0 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 298 419 489 456 479 390 893 3,424 1 Includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilisation EDHS 2005 Figure 7.1 Fertility Preferences of Currently Married Women Age 15-49 Wants no more children/sterilised 42% Undecided 1% Declared infecund 2% Wants a child soon (within 2 years) 16% Wants a child later (after 2 years) 35% Wants a child, unsure of timing 3% Note: Percentages add to less than 100 due to rounding. Fertility Preferences | 93 Among women, the desire to limit childbearing decreases as the respondent’s education increases. The percentage of currently married women who want no more children decreases from 43 percent among women with no education to 37 percent among women with secondary and higher education. In contrast, the percentage of currently married men who want no more children increases from 33 percent among men with no education to 46 percent among men with secondary and higher education. The desire to limit childbearing rises with increasing access to resources. Both women and men in the highest wealth quintiles are more likely to want to limit childbearing than those living in poorer households. Table 7.2.1 Desire to limit childbearing: women Percentage of currently married women who want no more children, by number of living children by background characteristics, Ethiopia 2005 Number of living children1Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 7.8 18.1 45.8 51.3 72.9 74.9 83.4 47.8 Rural 8.6 13.7 23.5 29.2 47.5 56.5 71.8 41.4 Region Tigray 2.2 3.1 9.7 11.6 30.0 41.1 70.1 28.5 Affar 13.3 16.9 16.6 29.0 33.6 17.0 16.1 19.8 Amhara 15.2 18.1 32.0 39.2 60.5 65.9 80.4 47.5 Oromiya 5.3 13.7 31.7 33.5 54.0 65.1 78.7 47.1 Somali 0.0 1.1 10.0 7.8 8.2 15.3 14.9 10.3 Benishangul-Gumuz 10.6 14.6 28.8 41.5 56.0 61.0 71.1 40.8 SNNP 5.2 15.1 17.2 25.8 38.4 54.5 67.6 37.8 Gambela 14.2 32.8 36.9 47.5 62.7 68.5 59.3 43.5 Harari 4.9 15.6 35.7 52.7 58.5 73.8 75.4 40.8 Addis Ababa 0.0 14.2 48.4 54.8 70.6 92.3 95.6 47.7 Dire Dawa 2.1 10.2 28.1 42.6 62.5 57.6 65.2 36.0 Education No education 9.5 14.2 25.7 27.6 48.0 57.5 73.0 43.0 Primary 9.6 16.2 24.3 41.2 52.9 56.3 67.4 39.5 Secondary and higher 1.6 11.9 36.9 51.6 68.0 86.0 75.4 36.9 Wealth quintile Lowest 11.2 9.3 19.2 26.6 37.4 40.1 56.4 33.3 Second 6.0 15.4 24.9 22.1 47.7 56.3 70.4 39.0 Middle 10.2 15.0 23.4 34.3 46.1 66.5 78.5 43.7 Fourth 6.8 15.6 26.0 33.6 55.1 59.5 77.0 46.9 Highest 8.5 15.4 38.4 42.1 66.1 70.4 81.4 47.6 Total 8.5 14.3 26.7 31.4 49.8 58.1 72.4 42.1 Note: Women who have been sterilised are considered to want no more children. 1 Includes current pregnancy 94 | Fertility Preferences Table 7.2.2 Desire to limit childbearing: men Percentage of currently married men who want no more children, by number of living children by background characteristics, Ethiopia 2005 Number of living children Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 9.0 20.8 29.2 59.9 64.1 69.1 73.1 45.5 Rural 5.6 5.7 15.9 25.6 32.3 47.9 58.8 32.8 Region Tigray 0.0 0.0 5.3 20.4 27.5 49.2 57.1 28.0 Affar 2.5 21.0 24.8 13.3 26.6 3.9 13.5 15.1 Amhara 4.1 12.9 18.4 29.3 40.1 63.1 67.3 35.6 Oromiya 7.6 5.3 19.6 30.3 40.7 52.8 66.8 39.5 Somali 0.0 0.0 0.0 4.4 0.0 6.4 7.8 4.0 Benishangul-Gumuz 0.0 6.1 10.2 17.1 35.3 54.7 55.7 24.5 SNNP 9.9 7.0 14.9 28.3 21.1 34.6 54.2 29.5 Gambela 12.1 13.3 24.5 18.3 28.2 30.7 41.7 23.9 Harari 0.0 2.4 22.9 51.7 40.0 49.8 69.7 30.4 Addis Ababa 12.1 21.1 41.0 69.0 82.9 88.2 84.6 53.3 Dire Dawa 0.0 11.5 36.6 30.2 62.7 38.8 58.8 36.4 Education No education 3.5 5.1 18.0 22.0 33.3 48.5 56.5 33.3 Primary 8.5 9.7 15.7 27.3 29.1 42.8 61.4 31.0 Secondary and higher 9.4 15.0 22.3 55.2 59.4 70.8 82.4 45.8 Wealth quintile Lowest 9.0 3.6 15.1 19.5 23.7 32.4 43.7 25.1 Second 10.3 4.7 17.5 24.4 27.6 47.2 59.0 32.2 Middle 2.0 10.3 15.0 27.3 32.2 48.1 68.7 33.0 Fourth 0.0 3.9 12.9 26.8 42.3 56.5 58.5 37.0 Highest 6.2 15.6 27.1 46.9 54.7 66.6 72.0 43.7 Total 5.8 8.2 18.0 28.6 35.4 49.9 59.6 34.1 Note: Men who have been sterilised are considered to want no more children. Figure 7.2 Desire to Limit Childbearing Among Currently Married Women, by Number of Living Children, 2000 and 2005 9 14 27 31 50 58 72 5 9 18 26 39 47 65 0 1 2 3 4 5 6+ Number of Living Children 0 20 40 60 80 Percent 2000 2005 EDHS 2005 Note: Desire to limit childbearing includes respondents who stated that they did not want any more children and those who have been sterilised. Number of living children includes current pregnancy. Fertility Preferences | 95 7.2 NEED FOR FAMILY PLANNING SERVICES This section discusses the extent of need and the potential demand for family planning services. Currently married women who want to postpone their next birth for two or more years or who want to stop childbearing all together but are not using a contraceptive method are said to have an unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted. Similarly, amenorrhoeic women are categorized as having unmet need if their last birth was mistimed or unwanted. Women who are currently using a family planning method are said to have a met need for family planning. The total demand for family planning services comprises those who fall in the met need and unmet need categories. Table 7.3 shows the need for family planning among currently married women by select background characteristics. Thirty-four percent of currently married women have an unmet need for family planning, with 20 percent having an unmet need for spacing and 14 percent having an unmet need for limiting. Only 15 percent of women have a met need for family planning. If all currently married women who say that they want to space or limit their children were to use a family planning method, the contraceptive prevalence rate would increase three-fold to 49 percent. Currently, only 31 percent of the family planning needs of currently married women are being met. There has been little change in unmet need for family planning over the past five years, with unmet need in 2005 only slightly lower than it was in 2000 when it was 36 percent. On the other hand, met need has nearly doubled over the same period from 8 percent in 2000 to 15 percent in 2005, resulting in a concomitant rise in demand satisfied from 18 percent to 31 percent. Unmet need for spacing decreases with age while the opposite is true for unmet need for limiting, with the exception of women age 45-49. Overall, unmet need remains relatively high at all ages but falls sharply at age 45-49. Rural women have twice the unmet need of urban women and less than one in four rural women have the demand for family planning satisfied, compared with three in four urban women. Unmet need is lowest in Addis Ababa (10 percent) and highest in Oromiya (41 percent). Women with no education are twice as likely to have an unmet need for family planning as women with secondary or higher levels of education. Unmet need ranges from a low of 24 percent among women in the highest wealth quintile to a high of 38 percent among women in the second wealth quintile. 96 | Fertility Preferences Table 7.3 Need for family planning Percentage of currently married women with unmet need for family planning, and with met need for family planning, and the total demand for family planning, by background characteristics, Ethiopia 2005 Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning3 Background characteristic 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 30.1 8.0 38.0 7.1 1.8 8.9 37.3 10.0 47.2 19.4 711 20-24 28.8 5.6 34.4 12.6 4.0 16.7 41.6 9.7 51.3 32.9 1,574 25-29 25.3 10.5 35.8 9.9 7.0 16.9 35.4 17.6 53.0 32.4 2,066 30-34 20.9 15.0 35.9 5.9 8.4 14.4 27.0 23.5 50.6 29.0 1,551 35-39 16.8 20.6 37.4 4.1 13.1 17.2 21.1 33.7 54.8 31.7 1,343 40-44 6.9 25.6 32.4 0.9 13.3 14.2 7.9 39.1 47.1 31.0 960 45-49 1.5 14.9 16.3 0.1 8.0 8.1 1.6 22.9 24.5 33.2 862 Residence Urban 7.8 9.1 17.0 23.4 23.3 46.7 31.4 32.7 64.1 73.5 959 Rural 21.5 14.3 35.8 4.8 6.2 10.9 26.4 20.5 46.9 23.7 8,107 Region Tigray 16.4 7.6 24.1 9.3 7.2 16.5 25.9 14.8 40.7 40.9 570 Affar 8.8 4.6 13.4 2.3 4.3 6.6 11.1 8.9 20.0 33.0 109 Amhara 14.8 14.9 29.7 7.0 9.1 16.1 21.9 24.1 46.0 35.4 2,330 Oromiya 24.9 16.5 41.4 5.6 8.0 13.6 30.6 24.6 55.2 25.0 3,300 Somali 8.8 2.8 11.6 1.7 1.5 3.1 10.5 4.3 14.8 21.3 363 Benishangul-Gumuz 16.8 13.0 29.7 4.3 6.8 11.1 21.1 20.0 41.1 27.7 92 SNNP 24.0 13.4 37.4 5.8 6.1 11.9 30.0 19.6 49.6 24.6 1,988 Gambela 10.5 13.0 23.5 6.2 9.7 15.9 17.0 22.7 39.6 40.7 31 Harari 16.0 6.4 22.4 18.4 15.1 33.5 34.6 21.7 56.2 60.2 22 Addis Ababa 5.8 4.5 10.3 30.4 26.4 56.9 37.1 31.1 68.2 84.8 224 Dire Dawa 9.5 5.3 14.8 21.3 12.7 34.0 30.9 18.0 48.9 69.8 37 Education No education 19.7 14.8 34.5 3.8 6.1 10.0 23.7 21.0 44.7 22.8 7,094 Primary 25.7 11.3 37.0 11.0 12.4 23.4 36.8 23.7 60.5 38.8 1,402 Secondary and higher 10.3 6.7 16.9 32.4 20.2 52.6 43.2 27.1 70.2 75.9 570 Wealth quintile Lowest 20.1 13.0 33.1 1.6 2.6 4.2 21.7 15.7 37.3 11.3 1,759 Second 24.3 13.5 37.9 3.3 3.4 6.6 27.7 16.9 44.6 15.1 1,892 Middle 21.5 15.3 36.8 5.3 6.7 12.0 26.9 22.2 49.1 25.1 1,903 Fourth 21.2 15.0 36.2 5.7 9.8 15.5 27.2 24.8 52.0 30.4 1,823 Highest 12.5 11.5 24.0 18.7 18.3 37.0 31.4 30.0 61.3 60.9 1,689 Total 20.1 13.7 33.8 6.7 8.0 14.7 26.9 21.8 48.7 30.7 9,066 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrhoeic women who are not using family planning and whose last birth was mistimed or whose last birth was unwanted but now say they want more children, and fecund women who are neither pregnant nor amenorrhoeic, 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 fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhoeic women who are not using family planning, whose last child was unwanted and who do not want any more children, and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and who want no more children. Excluded from the unmet need category are pregnant and amenorrhoeic women who became pregnant while using a method (these women are in need of a better method of contraception). 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 Nonusers who are pregnant or amenorrhoeic and women whose pregnancy was the result of a contraceptive failure are not included in the category of unmet need, but are included in total demand for contraception (since they would have been using had their method not failed). Fertility Preferences | 97 7.3 IDEAL FAMILY SIZE Information on ideal family size was collected in two ways: respondents who did not have any children were asked how many children they would like to have if they could choose the number of children to have. Respondents with children were asked how many children they would like to have if they could go back to the time when they did not have any children and choose exactly the number of children to have. Even though these questions are based on hypothetical situations they provide an idea of the total number of children women who have not started childbearing will have in the future. For older and high parity women, this information provides a measure of unwanted fertility. Responses to these questions are summarized in Table 7.4 for both women and men. The majority of women and men were able to provide a numeric response to these questions. However, 10 percent of women and 7 percent of men gave non-numeric responses such as “it is up to God,” “any number” or “do not know.” The proportion unable to specify an ideal number of children has declined since the 2000 EDHS in which 18 percent of women and 11 percent of men failed to provide a numeric response. Table 7.4 Ideal number of children Percent distribution of all women and all men by ideal number of children, and mean ideal numbers of children for all women, for currently married women, for all men and for currently married men, according to number of living children, Ethiopia 2005 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total WOMEN 0 11.2 7.7 10.1 8.1 11.4 12.8 14.6 11.0 1 1.1 1.8 0.7 0.2 0.1 0.2 0.1 0.7 2 23.2 11.2 6.9 3.0 3.2 2.1 1.4 10.3 3 12.6 10.4 5.4 3.6 1.5 2.0 1.9 6.7 4 29.0 31.6 31.8 26.9 24.3 16.7 14.4 25.5 5 7.4 9.8 11.6 12.7 7.6 6.8 5.4 8.4 6+ 10.3 17.8 23.0 35.2 39.7 45.4 44.4 26.9 Non-numeric responses 5.3 9.6 10.4 10.3 12.1 14.1 17.8 10.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 4,336 1,633 1,645 1,475 1,521 1,186 2,274 14,070 Mean ideal number children for:2 All women 3.3 4.1 4.5 5.1 5.2 5.6 5.9 4.5 Number 4,107 1,475 1,474 1,323 1,336 1,019 1,869 12,602 Currently married women 3.9 4.3 4.6 5.2 5.3 5.6 5.9 5.1 Number 556 1,160 1,234 1,174 1,166 908 1,728 7,928 MEN 0 2.8 1.2 1.9 2.7 2.1 3.8 4.4 2.8 1 0.8 1.8 0.1 0.3 0.0 0.0 0.0 0.6 2 23.6 9.0 4.5 2.5 3.8 2.2 0.8 12.7 3 19.8 18.8 8.4 6.4 2.4 4.7 1.7 12.6 4 29.4 31.5 34.1 22.8 17.9 10.8 12.3 24.7 5 8.1 12.4 15.5 17.9 13.6 9.6 7.1 10.3 6+ 11.4 20.4 29.6 37.9 48.7 60.9 60.6 29.5 Non-numeric responses 4.1 4.8 5.9 9.5 11.5 8.1 13.1 6.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 2,766 477 516 478 489 401 906 6,033 Mean ideal number children for:2 All men 3.8 4.7 5.1 5.9 6.5 6.8 8.5 5.2 Number 2,654 454 485 433 433 368 787 5,615 Currently married men 4.4 4.8 5.2 5.9 6.5 6.9 8.5 6.4 Number 291 399 460 414 424 359 776 3,123 1 Includes current pregnancy 2 Means are calculated excluding the respondents giving non-numeric responses. 98 | Fertility Preferences Three out of five women preferred an ideal family size of four or more children with only three in ten favouring less than four children. More than one in ten women did not want any children at all. The mean ideal number of children is 4.5 among all women who gave a numeric response, and it is half a child more among currently married women (5.1). The mean ideal number of children is 5.2 among all men and 6.4 among currently married men. As can be observed, the mean ideal number of children among currently married men is more than one child higher than that among currently married women. The survey shows that ideal family size has declined over the past five years by nearly a child among women (all women and currently married) and by more than a child among all men and currently married men. The mean ideal family size increases with the number of living children among both women and men, rising from 3.3 among child- less women to 5.9 among women with six or more children and from 3.8 among childless men to 8.5 among men with six or more children. This positive association between actual and ideal number of children could be due to two principal reasons. First, to the extent that women are able to implement their fertility desires, women who want smaller families will tend to achieve smaller families. Second, some women may have difficulty admitting their desire for fewer children if they could begin childbearing again and may in fact report their actual number as their preferred number. Despite this tendency to rationalize, the 2005 EDHS data provide evidence of unwanted fertility with more than a third of women (38 percent) with six or more children wanting an ideal family size of fewer than six children. Table 7.5 shows the mean ideal num- ber of children for all women and men by select background variables. The mean ideal number of children increases with age, for both men and women. It ranges from a low of 3.3 children among women age 15-19 to a high of 5.7 among women age 45-49, and from 3.8 to 6.8 among men in the same age groups. An interesting finding is that women and men age 20-34 have nearly identical ideals for the number of children they desire, indi- cating a narrowing of the male-female gap in ideal family size for this group. Fertility is highest among women in this age group and the similar fertility intentions of women and men in this age group may have the desired effect of lowering fertility in the long run. Table 7.5 Mean ideal number of children Mean ideal number of children for all women and men, by age and background characteristics, Ethiopia 2005 Background characteristic Mean Number of women Mean Number of men Age 15-19 3.3 3,069 3.8 1,287 20-24 4.1 2,343 4.0 1,014 25-29 4.7 2,292 4.8 700 30-34 5.2 1,619 5.1 695 35-39 5.2 1,355 6.6 588 40-44 5.5 998 6.7 456 45-49 5.7 927 6.8 380 50-54 na na 7.4 277 55-59 na na 9.0 218 Residence Urban 3.4 2,387 3.6 895 Rural 4.7 10,215 5.6 4,720 Region Tigray 4.7 886 4.8 346 Affar 7.8 137 11.3 62 Amhara 4.1 3,206 4.9 1,470 Oromiya 4.2 4,338 4.8 2,057 Somali 9.8 400 12.9 166 Benishangul-Gumuz 5.0 119 6.7 51 SNNP 4.7 2,655 5.7 1,116 Gambela 4.7 40 6.0 20 Harari 4.2 31 4.2 15 Addis Ababa 3.3 727 3.3 283 Dire Dawa 5.3 63 4.0 28 Education No education 5.1 7,998 6.6 2,347 Primary 3.6 2,966 4.7 2,112 Secondary and higher 3.3 1,638 3.5 1,156 Wealth quintile Lowest 6.0 2,055 6.9 999 Second 4.7 2,305 5.5 1,094 Middle 4.4 2,467 5.3 1,002 Fourth 4.5 2,368 5.1 1,114 Highest 3.6 3,407 4.0 1,406 Total 4.5 12,602 5.2 5,615 na = Not applicable Fertility Preferences | 99 The mean ideal number of children is higher in rural than in urban areas for both women and men. There is a wide variation among regions. As was the case in the 2000 EDHS, women and men living in the nomadic regions of Somali and Affar have a relatively higher mean ideal number of children than those living in the other regions. For example, women in the Somali Region have nearly three times the mean ideal number of children as women in Addis Ababa. The mean ideal number of children varies inversely with education. Women with no education have a mean ideal of 5.1 children whereas those who have at least a secondary level education reported a mean ideal of 3.3 children. A similar pattern is seen by wealth quintile, with women in the lowest quintile desiring a mean ideal of one and a half more children than women in the highest wealth quintile. 7.4 FERTILITY PLANNING Data from the EDHS can be used to estimate the level of unwanted fertility. Women age 15- 49 were asked a series of questions about each of their children born to them in the preceding five years, as well as any current pregnancy, to determine whether the birth or pregnancy was wanted then (planned), wanted later (mistimed), or not wanted at all (unplanned) at the time of conception. In assessing these results, it is important to recognize that women may declare a birth or current pregnancy as wanted once the child is born, and this rationalization of a current birth or pregnancy as wanted may in fact result in an underestimate the true extent of unwanted births. Table 7.6 shows the percent distribution of births (including current pregnancy) in the five years preceding the survey by birth order and age of mothers at birth. According to the data, two- thirds of births in the five years preceding the survey were planned, 19 percent were mistimed, and 16 percent were unplanned. One in five births of order four or higher is unplanned, twice the level among births of order three or below. The percentage of unplanned births also increases with mother’s age at birth. More than two in five births to mothers who were age 45-49 at the time of the birth were not planned compared with one in ten births to mothers age 25 or younger. Table 7.6 Fertility planning status Percent distribution of births in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother's age at birth, Ethiopia 2005 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 72.8 15.7 11.0 0.6 100.0 2,120 2 71.4 18.8 9.6 0.2 100.0 1,917 3 68.0 21.1 10.8 0.1 100.0 1,754 4+ 59.4 19.0 21.3 0.3 100.0 6,556 Age at birth <20 68.5 20.4 10.7 0.4 100.0 1,842 20-24 68.9 20.2 10.6 0.3 100.0 3,252 25-29 66.5 20.1 13.1 0.3 100.0 3,058 30-34 62.7 17.7 19.3 0.3 100.0 2,205 35-39 56.0 14.2 29.5 0.3 100.0 1,310 40-44 51.2 13.7 34.6 0.5 100.0 581 45-49 51.1 3.6 45.3 0.0 100.0 99 Total 64.8 18.7 16.2 0.3 100.0 12,347 100 | Fertility Preferences The extent of unplanned births can also be estimated utilizing information on ideal family size to estimate what the total fertility rate would be if all unwanted births were avoided. This measure may also be an underestimate to the extent that women may not report an ideal family size lower than their actual family size. Table 7.7 shows wanted fertility rates calculated in the same way as the total fertility rate but excluding unwanted births from the numerator. In this case, unwanted births are those that exceed the number mentioned as ideal by the respondent. This rate represents the level of fertility that would have prevailed in the five years preceding the survey if all unwanted births had been avoided. The data show that women on average have 1.4 children more than their ideal number. The gap between wanted and observed fertility rates is greater among women living in rural than in urban areas. The difference in the two rates is largest in Oromiya (a two-child difference) and smallest in Addis Ababa. Women with little or no education tend to want 1.5 children less than their actual number compared with women with at least secondary education who want just 0.5 children less than they actually have. There is also an inverse relationship between wealth and wanted fertility. The gap between wanted and actual fertility is from 1.5 children in the first four wealth quintiles to less than one child in the highest wealth quintile. Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Ethiopia 2005 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 1.8 2.4 Rural 4.5 6.0 Region Tigray 4.0 5.1 Affar 4.5 4.9 Amhara 3.7 5.1 Oromiya 4.3 6.2 Somali 5.7 6.0 Benishangul-Gumuz 4.0 5.2 SNNP 4.2 5.6 Gambela 3.2 4.0 Harari 3.4 3.8 Addis Ababa 1.2 1.4 Dire Dawa 3.2 3.6 Education No education 4.6 6.1 Primary 3.5 5.1 Secondary and higher 1.5 2.0 Wealth quintile Lowest 5.1 6.6 Second 4.5 6.0 Middle 4.5 6.2 Fourth 4.3 5.7 Highest 2.3 3.2 Total 4.0 5.4 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 | 101 INFANT AND CHILD MORTALITY 8 This chapter describes levels, trends, and differentials in early childhood mortality and high- risk fertility behaviour of women in Ethiopia. Information on infant and child mortality rates con- tributes to a better understanding of a country’s socioeconomic situation and sheds light on the quality of life of the population. This information is disaggregated by socioeconomic and demographic characteristics since studies have shown the existence of differentials in mortality by these characteristics and the disaggregation helps to identify subgroups that are at high risk. Preparation, implementation, and monitoring and evaluation of population, health, and other socioeconomic programmes and policies depend to a large extent on target population identification. Childhood mortality in general and infant mortality in particular are often used as broad indicators of social development or as specific indicators of health status. Childhood mortality analyses are thus useful in identifying promising directions for health programmes and advancing child survival efforts. Measures of childhood mortality are also useful for population projections. One of the targets of the millennium development goal is a two-third reduction in infant and child mortality by 2015, to be achieved through upgrading the proportion of births attended by skilled health personnel, increasing immunization against the six vaccine preventable diseases, and upgrading the status of women through education and enhancing their participation in the labour force. Results from the 2005 EDHS are timely in evaluating the impact of some of the major national policies, such as the National Population Policy, the National Policy on Ethiopian Women, and the National Health Policy, on the achievement of the MDG goal. The mortality rates presented in this chapter are computed from information gathered from the birth history section of the Women’s Questionnaire. Women in the age group 15-49 were asked whether they had ever given birth, and if they had, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of their children in chronological order starting with the first child. Women were asked whether a birth was single or multiple; the sex of the child; the date of birth (month and year); survival status; age of the child on the date of the interview if alive; and if not alive, the age at death of each live birth. Since the primary causes of childhood mortality change as children age, mostly biological factors to environmental factors, childhood mortality rates are expressed by age categories and are customarily defined as follows: • Neonatal mortality (NN): the probability of dying within the first month of life • Postneonatal mortality (PNN): the difference between infant and neonatal mortality • Infant mortality (1q0): the probability of dying between birth and the first birthday • Child mortality (4q1): the probability of dying between exact ages one and five • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday. The rates of childhood mortality are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one. In addition to questions on live births, women were asked about pregnancies that ended in miscarriage, abortion, or stillbirth. This information was collected for the five years preceding the survey to minimize recall errors. Information on stillbirths and deaths that occurred within seven days 102 | Infant and Child Mortality of birth is used to estimate perinatal mortality, which is the number of stillbirths and early neonatal deaths per 1,000 stillbirths and live births. 8.1 ASSESSMENT OF DATA QUALITY The accuracy of mortality estimates depends on the sampling variability of the estimates and on nonsampling errors. Sampling variability and sampling errors are discussed in detail in Appendix A. Nonsampling errors depend on the extent to which the date of birth and age at death are accurately reported and recorded and the completeness with which child deaths are reported. Omission of births and deaths affects mortality estimates, displacement of birth and death dates impacts mortality trends, and misreporting of age at death may distort the age pattern of mortality. Typically, the most serious source of nonsampling errors in a survey that collects retrospective information on births and deaths is the underreporting of births and deaths of children who were dead at the time of the survey. It may be that mothers are reluctant to talk about their dead children because of the sorrow associated with their death, or they may live in a culture that discourages discussion of the dead. The possible occurrence of these data problems in the 2005 EDHS is discussed with reference to the data quality tables in Appendix C. Underreporting of births and deaths is generally more severe the further back in time an event occurred. An unusual pattern in the distribution of births by calendar years is an indication of omission of children or age displacement. Table C.4 shows that the overall percentage of births for which a month and year of birth was reported is relatively complete, with incomplete information being only slightly higher for children who have died than those who are alive (97 percent versus 99 percent), and slightly lower as one moves further back in time. Nevertheless, there is clear indication of omission of deaths in the most recent period. For example, the proportion of births for which the child was no longer alive at the time of the survey declines from 15 percent in the period 1996-2000 to 9 percent during the period 2001-2005. Some of this decline is likely due to a real decrease in mortality in the most recent period, although some is due to the fact that younger children have been exposed to the risk of dying for a shorter period. Nevertheless, such a sharp decline in the proportion of deaths since 1996 may suggest some amount of underreporting in the most recent period. However, when compared with the 2000 EDHS, underreporting in the 2005 EDHS is less of a problem. Age displacement is common in surveys that include both demographic and health information for children under a specified age. In the Ethiopia DHS survey, the cutoff date for asking health questions was Meskerem 1992 in the Ethiopian calendar (which roughly corresponds to September 1999 in the Gregorian calendar). Table C.4 shows that there is some age displacement across this boundary for both living and dead children. The distribution of living children and the total number of children shows a deficit in 2000 and an excess in 1999, as denoted by the calendar year ratios. A similar excess is seen in 2001. The deficit in 2000 can be attributed to the transference of births by interviewers out of the period for which health data were collected. Transference is proportionally higher for dead children than living children, and this displacement may affect mortality rates. The excess in 2001 is, however, puzzling. The transference of children and especially deceased children out of the five-year period preceding the survey is likely to underestimate the true level of childhood mortality for that period. The overall sex ratio of 108 is also higher than expected, indicating that there may be some underreporting of female births, especially female children who are no longer alive. The sex ratio for dead children is 125 compared with 104 for living children. The data also show heaping in 2001, although this is not as severe as in 1999. Underreporting of deaths is usually assumed to be higher for deaths that occur very early in infancy. Omission of deaths or misclassification of deaths as stillbirths may also be more common among women who have had several children or in cases where death took place a long time ago. In order to assess the impact of omission on measures of child mortality, two indicators are used: the percentage of deaths that occurred under seven days to the number that occurred under one month and the percentage of neonatal to infant deaths. It is hypothesized that omission will be more prevalent among those who died immediately after birth than those who lived longer and that it will be more Infant and Child Mortality | 103 serious for events that took place in the distant past rather than those in the more recent past. Table C.5 shows data on age at death for early infant deaths. Selective underreporting of early neonatal deaths would result in an abnormally low ratio of deaths within the first seven days of life to all neonatal deaths. Early infant deaths have not been severely underreported in the Ethiopia DHS survey as suggested by the high ratio of deaths in the first seven days of life to all neonatal deaths. Table C.6 shows the percentage of neonatal to infant deaths. Neonatal deaths are slightly lower than would be expected, suggesting that there may be some underreporting of deaths under one month but not in the first week of life. Heaping of the age at death on certain digits is another problem that is inherent in most retrospective surveys. Misreporting of age at death biases age pattern estimates of mortality if the net result is the transference of deaths between age segments for which the rates are calculated; for example, child mortality may be overestimated relative to infant mortality if children who died in the first year of life are reported as having died at age one or older. In an effort to minimize misreporting of age at death, interviewers were instructed to record deaths under one month in days and under two years in months. In addition, they were trained to probe deaths reported at exactly 1 year or 12 months to ensure that they had actually occurred at 12 months. The distribution of deaths under 2 years during the 20 years prior to the survey by month of death shows that there is definite heaping at 6, 12, and 18 months of age with corresponding deficits in adjacent months (Table C.6). However, heaping is less pronounced for deaths in the five years preceding the survey, for which the most recent mortality rates are calculated. In addition to recall errors for the more distant retrospective periods, there are structural reasons for limiting mortality estimation to recent periods, preferably to the 0-4, 5-9, and 10-14 years before the survey. In fact, except for the first period, the others are slightly biased estimates because they are based on the child mortality experience of women age 15-44 and 15-39, respectively, instead of women age 15-49 as in the period 0-4 years prior to the survey. Therefore, estimating mortality for the periods further than 10-15 years before the survey is not advisable. 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Table 8.1 presents neonatal, postneonatal, infant, child, and under-five mortality rates for the three recent five-year periods before the survey. Neonatal mortality in the most recent period is 39 per 1,000 live births. This rate is similar to postneonatal deaths (38 per 1,000 live births) during the same period; that is, the risk of dying for any Ethiopian child who survived the first month of life is the same as in the remaining 11 months of the first year of life. Thus 50 percent of infant deaths in Ethiopia occur during the first month of life. A similar pattern was observed in the 2000 EDHS. The infant mortality rate in the five years preceding the survey is 77 and under-five mortality is 123 deaths per 1,000 live births for the same period. This means that one in every thirteen Ethiopian children dies before reaching age one, while one in every eight does not survive to the fifth birthday. Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Ethiopia 2005 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q0) Under-five mortality (5q0) 0-4 39 38 77 50 123 5-9 42 42 83 63 141 10-14 46 49 95 77 165 1 Computed as the difference between infant and neonatal mortality rates 104 | Infant and Child Mortality Mortality trends can be examined in two ways: by comparing mortality rates for three five- year periods preceding a single survey and by comparing mortality estimates obtained from various surveys. However, these comparisons should be interpreted with caution because quality of data, time references and sample coverage varies. In particular, sampling errors associated with mortality estimates are large and should be taken into account when examining trends between surveys. Data from the 2005 EDHS show that infant mortality has declined by 19 percent over the 15- year period preceding the survey from 95 deaths per 1,000 live births to 77. Under-five mortality has gone down by 25 percent from 165 deaths per 1,000 live births to 123. The corresponding decline in neonatal and postneonatal mortality over the 15-year period are 15 percent and 22 percent, respectively. Mortality trends can also be examined by comparing data from the 2005 EDHS with data from the 2000 EDHS. Infant and under-five mortality rates obtained for the five years preceding the two surveys confirm a declining trend in mortality. Under-five mortality declined from 166 deaths per 1,000 live births in the 2000 survey to 123, while infant mortality declined from 97 deaths per 1,000 live births in the 2000 survey to 77 for the 2005 survey (Figure 8.1). However, data from the 2005 survey for the same period (1996-2000) show lower mortality, indicating a potential underestimate of mortality in the 2001-2005 period. The data also show a ten-point decline in neonatal and postneonatal mortality between the two surveys over the same period. 8.3 SOCIOECONOMIC DIFFERENTIALS IN CHILDHOOD MORTALITY To minimize sampling errors associated with mortality estimates and to ensure a sufficient number of cases for statistical reliability, the mortality rates shown in Tables 8.2 and 8.3 are calculated for a ten-year period. Table 8.2 shows differentials in childhood mortality by four socioeconomic variables: place of residence, region, mother’s education, and wealth quintile. From the table it is apparent that infant and child survival is influenced by the socioeconomic characteristics of mothers. Mortality in urban areas is consistently lower than in rural areas. For example, infant mortality in urban areas is 66 deaths per 1,000 live births compared with 81 deaths Figure 8.1 Early Childhood Mortality Rates for the Period 0-4 Years Preceding the Survey, 2000 and 2005 49 48 97 77 166 39 38 77 50 123 Neonatal mortality Postneonatal mortality Infant mortality Child mortality Under-five mortality 0 50 100 150 200 Deaths per 1,000 2000 2005 Infant and Child Mortality | 105 per 1,000 live births in rural areas. The urban-rural difference is even more pronounced in the case of child mortality. Wide regional differentials in infant and under-five mortality are observed. For example, under-five mortality ranges from a low of 72 per 1,000 live births in Addis Ababa to a high of 157 per 1,000 live births in Benishangul-Gumuz. Under-five mortality is also relatively higher in Amhara and Gambela. As expected, mother’s education is inversely related to a child’s risk of dying. Under-five mortality among children born to mothers with no education (139 per 1,000 live births) is more than twice that of children born to mothers with secondary and higher level of education (54 per 1,000 live births). The beneficial effect of educating mothers is obvious for all childhood mortality rates. With respect to wealth and mortality, the relationship is not consistent, although children born to mothers in the highest wealth quintile clearly are at much lower risk of dying than children born to mothers in the other quintiles. Table 8.2 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 background characteristic, Ethiopia 2005 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q0) Under-five mortality (5q0) Residence Urban 35 32 66 34 98 Rural 41 40 81 58 135 Region Tigray 40 26 67 42 106 Affar 33 28 61 66 123 Amhara 50 44 94 66 154 Oromiya 40 36 76 51 122 Somali 27 30 57 39 93 Benishangul-Gumuz 44 40 84 80 157 SNNP 36 49 85 63 142 Gambela 42 51 92 70 156 Harari 35 30 66 40 103 Addis Ababa 23 22 45 28 72 Dire Dawa 29 42 71 70 136 Mother's education No education 41 42 83 62 139 Primary 45 34 78 35 111 Secondary and higher 21 16 37 18 54 Wealth quintile Lowest 39 41 80 54 130 Second 38 47 86 64 144 Middle 47 38 86 63 144 Fourth 45 39 84 60 139 Highest 30 30 60 34 92 Total 41 40 80 56 132 1 Computed as the difference between infant and neonatal mortality rates 8.4 DEMOGRAPHIC DIFFERENTIALS IN MORTALITY Infant and child mortality is influenced to a considerable extent by the demographic charac- teristics of mothers and children including the sex of the child, mother’s age at birth, birth order, length of the previous birth interval, and the size of the child at birth. The relationship between these demographic characteristics and mortality is shown in Table 8.3 and Figure 8.2. Male children in general experience higher mortality than female children. The gender difference is especially pronounced for infant mortality, where 1 in 11 boys dies before his first birthday, compared with 1 in 14 girls. 106 | Infant and Child Mortality Table 8.3 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, Ethiopia 2005 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q0) Under-five mortality (5q0) Child's sex Male 48 43 91 56 142 Female 33 37 70 56 122 Mother's age at birth <20 57 48 106 62 161 20-29 38 37 75 54 124 30-39 34 38 72 56 124 40-49 50 46 96 63 153 Birth order 1 52 45 97 50 142 2-3 32 39 71 53 120 4-6 39 37 76 57 128 7+ 47 42 89 67 149 Previous birth interval2 <2 years 68 66 134 85 208 2 years 32 30 62 53 112 3 years 24 27 51 43 92 4+ years 17 20 38 30 66 Birth size3 Small/very small 37 36 73 na na Average or larger 39 38 78 na na 1 Computed as the difference between infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey na = Not applicable 142 122 161 124 124 153 208 112 92 66 SEX OF CHILD Male Female AGE OF MOTHER <20 20-29 30-39 40-49 BIRTH INTERVAL <2 Years 2 Years 3 Years 4+ Years 0 50 100 150 200 250 Deaths per 1,000 Live Births EDHS 2005 Note: Rates are for the 10-year period preceding the survey. Figure 8.2 Under-Five Mortality by Selected Demographic Characteristics Infant and Child Mortality | 107 As expected, the relationship between maternal age at birth and childhood mortality is generally U-shaped, being relatively higher among children born to mothers under age 20 and over age 40 than among mothers in the middle age groups. This pattern is especially obvious in the case of infant and under-five mortality. In general, first births and births of order 7 and higher also suffer significantly higher rates of mortality than births of orders 2 through 6. For example, 1 in 10 first births did not survive to the first year, compared with 1 in 14 second and third order births. Short birth intervals also significantly reduce a child’s chance of survival. For example, children born within two years of a preceding birth are more than three times as likely to die within the first year of life as children born three or more years after an older sibling. Studies have shown that a child’s birth weight is an important determinant of its survival chances. Since most births in Ethiopia occur at home where children are often not weighed at birth, data on birth weight is available for only a few children. However, mothers in the Ethiopia DHS survey were asked whether their child was very large, larger than average, average, smaller than average, or small at birth since this has been found to be a good proxy for the child’s weight. The data show little variation in mortality by size of child at birth. 8.5 PERINATAL MORTALITY The 2005 Ethiopia DHS survey asked women to report on any pregnancy loss that occurred in the five years preceding the survey. For each pregnancy that did not end in a live birth, the duration of pregnancy was recorded. In this report, perinatal deaths include pregnancy losses of at least seven months’ gestation (stillbirths) and deaths to live births within the first seven days of life (early neonatal deaths). The perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the sum of all stillbirths and live births. Information on stillbirths and deaths to infants within the first week of life are highly susceptible to omission and misreporting. Nevertheless, retrospective surveys in developing countries provide more representative and accurate perinatal death rates than the vital registration systems and hospital-based studies in developing countries. Table 8.4 shows that out of the 11,280 reported pregnancies of at least seven months’ gestation reported during the five years preceding the survey, 117 were stillbirths and 303 were early neonatal deaths, yielding an overall perinatal mortality rate of 37 per 1,000 stillbirths and live births. Comparable data from the 2000 EDHS show that perinatal mortality has declined from 52 per 1,000 stillbirths and live births to its current level. Perinatal mortality is significantly higher among women whose age at birth was under 20 years or 40-49 years. First pregnancies and pregnancies that occur after an interval of less than 15 months are much more likely than pregnancies that occur after longer intervals to end in a stillbirth or early neonatal death. Rural women are more likely to experience perinatal losses than urban women, as are women who reside in Amhara and (surprisingly) Addis Ababa. Educated mothers are less likely to experience pregnancy losses than uneducated mothers. Perinatal mortality is highest among women in the middle wealth quintile. 108 | Infant and Child Mortality Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Ethiopia 2005 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 22 88 64 1,736 20-29 47 142 33 5,775 30-39 29 53 26 3,150 40-49 18 21 63 618 Previous pregnancy interval in months First pregnancy 29 89 62 1,896 <15 6 34 62 630 15-26 34 69 40 2,570 27-38 9 70 26 3,000 39+ 40 40 25 3,183 Residence Urban 7 30 45 822 Rural 110 273 37 10,458 Region Tigray 4 10 20 702 Affar 1 1 16 108 Amhara 64 85 56 2,685 Oromiya 22 130 34 4,433 Somali 2 12 30 480 Benishangul-Gumuz 2 3 42 107 SNNP 17 58 30 2,517 Gambela 0 1 24 31 Harari 0 0 25 22 Addis Ababa 5 3 48 158 Dire Dawa 0 1 24 38 Mother's education No education 110 233 38 8,947 Primary 5 59 34 1,860 Secondary and higher 3 11 29 473 Wealth quintile Lowest 11 43 22 2,451 Second 30 47 32 2,386 Middle 28 100 51 2,514 Fourth 29 64 42 2,251 Highest 18 48 40 1,678 Total 117 303 37 11,280 1 Foetal deaths occurring in pregnancies of seven or more months duration 2 Deaths at age 0-6 days among live-born children. 3 The number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months duration. 8.6 HIGH-RISK FERTILITY BEHAVIOUR The survival of infants and children depends in part on the demographic and biological characteristics of their mothers. Typically, the probability of dying in infancy is much greater among children born to mothers who are too young (under age 18) or too old (over age 34), children born after a short birth interval (less than 24 months after the preceding birth), and children born to mothers of high parity (more than three children). The risk is elevated when a child is born to a mother who has a combination of these risk characteristics. Infant and Child Mortality | 109 The first column in Table 8.5 shows the percentage of births occurring in the five years before the survey that fall into the various risk categories. Two-thirds of births in Ethiopia are at an elevated risk of dying that is avoidable while 22 percent are in a “risk-free” category. First births, which make up 12 percent of births, are in the unavoidable risk category. Forty-one percent of births are in a single high-risk category and 25 percent in a multiple high-risk category. The most common single high-risk category is births of order 3 and higher (29 percent), while the most common multiple high-risk category is births to mothers older than 34 years and of birth order 3 and above (13 percent). The risk ratios displayed in the second column of Table 8.5 denote the relationship between risk factors and mortality. In general, risk ratios are higher for children in a multiple high- risk category than in a single high-risk category. The most vulnerable births are those to two groups of women: births to women age 34 or older, with a birth interval less than 24 months and birth order of three or higher; and births at an interval less than 24 months and of birth order 3 and higher. These children are more than three times as likely to die as children not in any high-risk category. Two percent and 9 percent of births, respectively, fall into these two cate- gories. The last column of Table 8.5 shows the distribution of currently mar- ried women who have the potential for having a high-risk birth by category. This column is purely hypothetical and does not take into consideration the protection provided by family planning, postpartum insusceptibility, and pro- longed abstinence. However, it provides an insight into the magnitude of high- risk births. More than one in four births (27 percent) is to women who are or would be too old, and have or would have too many children. A substantially higher proportion of women (49 per- cent) have the potential of having a birth in a multiple high-risk category than in a single high-risk category (32 percent). Table 8.5 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey 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, Ethiopia 2005 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 category 21.9 1.00 13.5a Unavoidable risk category First-order births between ages 18 and 34 years 11.9 1.85 5.5 Single high-risk category Mother’s age <18 6.3 2.63 1.4 Mother’s age >34 0.5 0.34 2.5 Birth interval <24 months 5.9 2.41 9.5 Birth order >3 28.6 1.13 18.7 Subtotal 41.4 1.53 32.0 Multiple high-risk category Age <18 and birth interval <24 months2 0.8 1.88 0.5 Age >34 and birth interval <24 months 0.0 * 0.1 Age >34 and birth order >3 13.1 1.43 26.7 Age >34 and birth interval <24 months and birth order >3 2.0 3.21 7.1 Birth interval <24 months and birth order >3 8.9 3.19 14.5 Subtotal 24.9 2.22 49.0 In any avoidable high-risk category 66.3 1.79 81.0 Total 100.0 na 100.0 Number 11,163 na 9,066 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. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 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 sterilised women na = Not applicable   Maternal Health | 111 MATERNAL HEALTH 9 The health care that a mother receives during pregnancy, at the time of delivery and soon after delivery is important for the survival and well-being of both the mother and the child. This chapter presents findings on several areas of importance to maternal health: antenatal, delivery, and postnatal care; problems in accessing health care and awareness and attitudes concerning tuberculosis. These findings are important to policymakers and programme implementers in formulating programmes and policies and in designing appropriate strategies and interventions to improve maternal and child health care services. 9.1 ANTENATAL CARE Antenatal care (ANC) coverage can be described according to the type of provider, number of ANC visits, and stage of pregnancy at the time of the first visit, as well as content of services and information provided during ANC. In the 2005 EDHS information on ANC coverage was obtained from women who had a birth in the five years preceding the survey. For women with two or more live births during the five-year period, data refer to the most recent birth only. Table 9.1 shows the percent distribution of mothers in the five years preceding the survey by source of antenatal care received during pregnancy, according to selected characteristics. Women were asked to report on all persons seen for antenatal care for the last birth. However, for the purpose of presenting the results, if a woman was seen by more than one provider, only the provider with the highest qualification is considered. Twenty-eight percent of mothers received antenatal care from health professionals (doctor, nurse, midwife) for their most recent birth in the five years preceding the survey, and less than 1 percent of mothers received antenatal care from a traditional birth attendant (trained or untrained). More than seven in ten mothers (72 percent) received no antenatal care for births in the preceding five years. Differences in antenatal care by women’s age at birth are not large. Differences by birth order however are more pronounced. Mothers are more likely to receive care from a health professional for first births (34 percent) than for births of order six and higher (22 percent). There are large differences in the use of antenatal care services between urban and rural women. In urban areas, health professionals provide antenatal care for 69 percent of mothers, whereas they provide care for only 24 percent of mothers in rural areas. It is important to note that three in four mothers in rural areas, receive no antenatal care at all. Regional differences in the source of antenatal care are quite significant; 88 percent of mothers in Addis Ababa received antenatal care from a health professional, compared with less than one in ten mothers in the Somali Region. The use of antenatal care services is strongly related to the mother’s level of education. Women with at least secondary education are more likely to receive antenatal care from a health professional (81 percent) than women with primary education (39 percent) and those with no education (22 percent). There is also a positive relationship between increasing wealth and receiving antenatal care from a health professional, with women in the highest wealth quintile nearly five times more likely to receive antenatal care from a health professional than women in the lowest wealth quintile. 112 | Maternal Health Table 9.1 Antenatal care Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth, according to background characteristics, Ethiopia 2005 Background characteristic Health professional Trained traditional birth attendant Traditional birth attendant/ other No one Missing Total Number of women Age at birth <20 27.3 0.7 0.4 71.5 0.2 100.0 994 20-34 29.1 0.2 0.6 70.1 0.0 100.0 4,923 35-49 22.7 0.0 0.5 76.6 0.2 100.0 1,391 Birth order 1 34.4 0.5 0.5 64.5 0.0 100.0 1,190 2-3 31.1 0.4 0.6 67.8 0.1 100.0 2,089 4-5 25.8 0.1 0.5 73.5 0.0 100.0 1,692 6+ 22.4 0.0 0.6 76.9 0.1 100.0 2,336 Residence Urban 68.9 0.3 0.5 30.1 0.1 100.0 634 Rural 23.7 0.2 0.5 75.4 0.1 100.0 6,674 Region Tigray 35.3 0.4 1.8 62.5 0.0 100.0 480 Affar 15.0 1.7 0.3 83.0 0.0 100.0 68 Amhara 26.5 0.2 0.3 73.1 0.0 100.0 1,856 Oromiya 24.8 0.2 0.4 74.5 0.2 100.0 2,723 Somali 7.4 0.0 0.4 92.0 0.2 100.0 288 Benishangul-Gumuz 24.5 0.2 0.2 74.3 0.8 100.0 69 SNNP 30.3 0.4 0.7 68.5 0.0 100.0 1,632 Gambela 36.6 0.6 1.6 61.0 0.2 100.0 23 Harari 40.7 0.9 0.4 58.0 0.0 100.0 15 Addis Ababa 88.3 0.3 0.0 11.5 0.0 100.0 129 Dire Dawa 52.9 0.0 1.4 45.7 0.0 100.0 25 Education No education 21.7 0.3 0.6 77.3 0.1 100.0 5,734 Primary 39.4 0.1 0.4 60.0 0.0 100.0 1,205 Secondary and higher 80.9 0.1 0.4 18.5 0.2 100.0 368 Wealth quintile Lowest 12.7 0.1 0.8 86.4 0.0 100.0 1,520 Second 18.6 0.5 0.4 80.4 0.2 100.0 1,553 Middle 25.2 0.4 0.4 74.1 0.0 100.0 1,586 Fourth 30.6 0.0 0.5 68.8 0.2 100.0 1,451 Highest 58.0 0.2 0.7 41.0 0.1 100.0 1,196 Total 27.6 0.2 0.5 71.5 0.1 100.0 7,307 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. There has been little improvement over the past five years in the proportion of mothers who receive antenatal care from a health professional, increasing from 27 percent in 2000 to 28 percent in 2005. However, there seems to have been a shift in the regional pattern of antenatal care coverage. The proportions of women receiving professional antenatal care increased over the past five years in Amhara and Addis Ababa. On the other hand, use of professional antenatal care declined over the past five years in Affar, Somali, Gambela, Harari and Dire Dawa, with the greatest decline seen in the Somali Region. There was little change in the other regions. Number and Timing of Antenatal Visits Antenatal care is more beneficial in preventing adverse pregnancy outcomes when it is sought early in the pregnancy and is continued through to delivery. Health professionals recommend that the first antenatal visit should occur within the first three months of pregnancy and continue on a monthly basis through the 28th week of pregnancy and fortnightly up to the 36th week (or until birth). If the Maternal Health | 113 first antenatal visit is made at the third month of pregnancy and as regularly as recommended, there would be a total of at least 12 to 13 antenatal visits. Under normal circumstances, WHO recommends that a woman without complications have at least four ANC visits to provide sufficient care. It is possible during these visits to detect health problems associated with a pregnancy. In the event of any complications, more frequent visits are advisable and admission to a health facility may be necessary. Table 9.2 shows that slightly more than one in ten (12 percent) women make four or more antenatal care visits during their entire pregnancy. There is marked variation between women residing in urban areas (55 percent) and those in rural areas (8 percent). Only 6 percent of women make their first antenatal care visit before the fourth month of pregnancy. The median duration of pregnancy for the first antenatal care visit is 5.6 months. This indicates that in Ethiopia women start antenatal care at a relatively late stage of their pregnancy. The median duration of pregnancy for the first antenatal care visit is 4.2 months for urban women compared with 6.0 for rural women. There was little change in the timing of the first visit over the past five years. Components of Antenatal Care The content of antenatal care is important in assessing the quality of antenatal care services. Pregnancy complications are an important source of maternal and child morbidity and mortality, and thus teaching pregnant women about the danger signs associated with pregnancy and the appropriate action to take are essential components of antenatal care. Table 9.3 presents information on the percentage of women who took iron tablets and intestinal parasite drugs during their last pregnancy in the five years preceding the survey. The table also shows the percentage of women who were informed about the signs of pregnancy complications and the percentage who received routine antenatal care services among women receiving ANC. Among women with a live birth in the past five years, 10 percent took iron tablets while pregnant with the last birth. There are few variations by age at birth and birth order. However, there are substantial variations by place of residence, region, education and wealth quintile, with urban women, women in Harari and Addis Ababa, and better educated and wealthier women much more likely to have taken iron supplements. Only 4 percent of women took intestinal parasite drugs during their pregnancy. Variations by background characteristics are small. Thirty-one percent of mothers who received antenatal care reported that they were informed about pregnancy complications during their visits. Weight and blood pressure measurements were taken on 72 percent and 62 percent of mothers, respectively. About one-quarter of mothers gave urine and blood samples. Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent birth, and by the timing of the first visit according to residence, Ethiopia 2005 Residence Number and timing of ANC visits Urban Rural Total Number of ANC visits None 30.1 75.4 71.5 1 2.9 4.8 4.6 2-3 11.8 11.3 11.3 4+ 54.5 8.1 12.2 Don't know/missing 0.7 0.4 0.4 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 30.1 75.4 71.5 <4 32.4 3.9 6.4 4-5 25.0 8.2 9.7 6-7 10.7 8.9 9.1 8+ 1.4 3.1 3.0 Don't know/missing 0.3 0.4 0.4 Total 100.0 100.0 100.0 Median months pregnant at first visit (for those with ANC) 4.2 6.0 5.6 Number of women 634 6,674 7,307 114 | Maternal Health Table 9.3 Components of antenatal care Among women with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy for the most recent birth, and among women receiving antenatal care for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Ethiopia 2005 Among women with a live birth in the past five years, the percentage who during the pregnancy for their last birth Among women who received antenatal care for their most recent birth in the past five years, the percentage receiving specific services: Background characteristic Took iron tablets Took intestinal parasite drugs Number of women Informed of signs of pregnancy compli- cations Weighed Blood pressure measured Urine sample taken Blood sample taken Number of women Mother’s age at birth <20 9.7 3.9 994 28.2 71.1 56.2 22.8 27.0 282 20-34 10.6 4.0 4,923 32.0 72.3 63.8 27.2 26.2 1,472 35-49 10.4 4.0 1,391 31.7 69.8 58.1 26.5 25.1 323 Birth order 1 9.8 3.1 1,190 34.9 73.4 61.0 32.4 30.1 422 2-3 10.6 3.4 2,089 32.8 74.2 65.8 31.8 30.3 671 4-5 9.6 5.0 1,692 28.0 69.4 60.3 19.9 21.9 448 6+ 11.3 4.3 2,336 29.8 69.1 59.0 20.7 21.5 536 Residence Urban 20.1 5.3 634 51.8 91.4 84.8 64.6 59.0 442 Rural 9.5 3.9 6,674 25.9 66.4 55.7 16.2 17.3 1,634 Region Tigray 12.2 1.8 480 40.8 84.1 79.9 21.4 30.8 180 Affar 9.4 5.2 68 29.7 66.7 65.3 44.5 39.9 12 Amhara 8.4 1.5 1,856 31.9 56.3 40.8 20.0 16.3 500 Oromiya 10.3 5.3 2,723 26.1 71.5 62.0 26.0 26.3 690 Somali 8.3 3.3 288 (52.8) (87.3) (86.6) (80.7) (67.4) 22 Benishangul-Gumuz 7.5 3.9 69 23.5 60.7 43.4 16.8 15.3 17 SNNP 12.0 5.0 1,632 26.8 76.0 67.6 16.0 16.1 513 Gambela 17.0 7.2 23 28.7 70.0 58.4 23.2 21.1 9 Harari 20.1 5.4 15 58.5 93.4 81.0 77.6 68.0 6 Addis Ababa 20.3 8.8 129 62.8 97.6 93.8 95.1 92.0 114 Dire Dawa 12.5 3.6 25 35.9 90.2 83.1 68.6 64.8 13 Education No education 9.4 3.6 5,734 25.1 65.2 53.6 17.6 18.0 1,296 Primary 11.6 5.0 1,205 33.5 77.0 68.3 26.6 30.5 481 Secondary and higher 22.8 6.2 368 55.6 91.4 87.4 64.7 54.7 299 Wealth quintile Lowest 6.1 2.7 1,520 23.5 57.3 51.9 14.4 18.0 207 Second 8.5 3.8 1,553 23.5 70.3 55.8 13.5 14.5 302 Middle 10.5 3.3 1,586 23.7 65.4 52.3 14.1 17.0 411 Fourth 11.1 5.0 1,451 27.9 65.6 54.9 16.4 14.1 451 Highest 17.4 5.7 1,196 43.9 84.1 77.5 49.3 46.7 705 Total 10.4 4.0 7,307 31.4 71.7 61.9 26.5 26.2 2,076 Note: Figures in parentheses are based on 25-49 unweighted cases. The quality of antenatal care is particularly affected by mother’s education, mother’s wealth, residence and region. For example, women with secondary or higher education, women in the highest wealth quintile and urban women are twice as likely as women with no education, women in the lowest wealth quintile and rural women to be informed about pregnancy complications. Regional variations in the proportion of women who were informed about pregnancy complications during ANC visits are marked, ranging from a high of 63 percent among women in Addis Ababa to a low of 24 percent in Benishangul-Gumuz. Similar patterns are observed for the other routine tests and procedures. Maternal Health | 115 There has been a small increase in the percentage of women who have received the various components of antenatal care over the past five years. For example, 31 percent of women with a birth in the five years preceding the survey in 2005 were informed of the signs of pregnancy complications compared with 27 percent in 2000. Tetanus Toxoid Vaccination Tetanus toxoid injections are given during pregnancy for the prevention of neonatal tetanus, a major cause of death among infants. For full protection, a pregnant woman should receive at least two doses during each pregnancy. If a woman has been vaccinated during a previous pregnancy, however, she may only require one dose for the current pregnancy. Five doses are considered to provide lifetime protection. Table 9.4 presents the percent distribution of women who had a live birth in the five years preceding the survey by whether the last birth was protected against neonatal tetanus. Table 9.4 Tetanus toxoid injections Percent distribution of women who had a live birth in the five years preceding the survey by whether the last birth was protected against neonatal tetanus and by number of injections, according to background characteristics, Ethiopia 2005 Protected Not protected Background characteristic Two or more injections One plus one additional injection in the 10 years prior to the pregnancy None, but at least 5 lifetime TT injections Total protected One and no TT injection in the 10 years prior to the pregnancy None, less than 5 lifetime TT injections Total not protected Don't know/ missing Total Number of women Mother’s age at birth <20 28.1 2.0 0.5 30.6 7.3 61.3 68.6 0.8 100.0 994 20-34 29.6 2.8 1.5 33.9 6.1 58.5 64.7 1.4 100.0 4,923 35-49 22.5 3.2 1.7 27.3 4.4 65.0 69.4 3.3 100.0 1,391 Birth order 1 32.0 1.8 0.7 34.6 8.2 56.0 64.3 1.2 100.0 1,190 2-3 31.2 3.2 1.3 35.6 6.6 56.1 62.7 1.7 100.0 2,089 4-5 27.5 2.8 1.6 31.8 5.0 61.8 66.8 1.4 100.0 1,692 6+ 23.6 2.8 1.8 28.2 4.9 64.6 69.5 2.2 100.0 2,336 Residence Urban 51.9 5.1 3.5 60.5 7.8 28.7 36.5 3.0 100.0 634 Rural 25.8 2.5 1.2 29.5 5.8 63.1 68.9 1.6 100.0 6,674 Region Tigray 28.9 4.3 6.6 39.8 5.7 52.2 57.9 2.3 100.0 480 Affar 10.9 0.0 0.0 10.9 4.5 78.5 83.0 6.1 100.0 68 Amhara 24.6 4.0 1.2 29.8 6.6 61.1 67.7 2.5 100.0 1,856 Oromiya 28.4 2.0 0.8 31.1 5.1 62.8 67.9 1.0 100.0 2,723 Somali 9.1 0.0 0.3 9.4 1.3 87.4 88.8 1.8 100.0 288 Benishangul-Gumuz 18.2 2.0 0.3 20.5 4.7 70.8 75.5 4.0 100.0 69 SNNP 33.0 2.6 1.3 36.9 7.4 54.6 62.0 1.1 100.0 1,632 Gambela 22.7 1.0 0.5 24.2 5.8 66.4 72.1 3.7 100.0 23 Harari 33.0 2.6 2.1 37.8 3.7 55.9 59.5 2.6 100.0 15 Addis Ababa 57.7 6.3 3.8 67.7 10.0 15.9 25.9 6.4 100.0 129 Dire Dawa 49.8 1.1 0.8 51.7 3.4 42.3 45.7 2.7 100.0 25 Education No education 23.5 2.5 1.2 27.2 5.6 65.5 71.2 1.7 100.0 5,734 Primary 40.3 2.6 1.6 44.6 6.8 47.1 53.8 1.6 100.0 1,205 Secondary and higher 58.8 7.0 4.1 70.0 8.7 18.5 27.3 2.8 100.0 368 Wealth quintile Lowest 17.5 1.5 1.1 20.2 3.9 73.9 77.7 2.1 100.0 1,520 Second 22.2 2.3 1.3 25.8 6.6 66.2 72.8 1.4 100.0 1,553 Middle 26.3 1.9 1.1 29.4 7.0 62.5 69.4 1.2 100.0 1,586 Fourth 31.0 3.9 1.3 36.2 5.1 56.7 61.8 2.0 100.0 1,451 Highest 47.7 4.5 2.5 54.7 7.5 35.9 43.4 1.8 100.0 1,196 Total 28.0 2.7 1.4 32.2 6.0 60.1 66.1 1.7 100.0 7,307 116 | Maternal Health Last births were protected against neonatal tetanus for only 32 percent of women. Most of these women (28 percent) had received two or more tetanus toxoid injections while pregnant with the last birth. This indicates that births to women in Ethiopia are not routinely protected against neonatal tetanus. Births to relatively younger mothers age 20-34 years and lower order births (3 and below) are slightly more likely to be protected against tetanus than births to older mothers and higher order births. Twice as many births in urban areas (61 percent) as in rural areas (30 percent) are protected against tetanus. The proportion of births protected against tetanus varies substantially by region. Tetanus toxoid coverage is highest among mothers in Addis Ababa (68 percent) and lowest among mothers in the Somali and Affar regions (9 percent and 11 percent, respectively). There are marked differences by education and wealth index in the proportion of births protected against tetanus. Despite the low overall coverage, there is evidence of improvement over time. The percentage of women who received two or more tetanus injections during the pregnancy leading to their most recent birth increased from 17 percent in 2000 to 28 percent in 2005. 9.2 DELIVERY CARE Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that may cause the death or serious illness of the mother and the baby or both. Hence, an important component in the effort to reduce the health risks of mothers and children is to increase the proportion of babies delivered in a safe and clean environment and under the supervision of health professionals. Data on delivery care were obtained for all births that occurred in the five years preceding the survey. Table 9.5 presents the percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. An overwhelming majority of births (94 percent) in the five years before the survey were delivered at home. Five percent of births were delivered in a public facility and less than 1 percent of births were delivered in a private facility. Delivery in a health facility is more common among younger mothers (age less than 35), mothers with first order births, and mothers who have had at least 4 antenatal visits. Children born in urban areas are 20 times more likely to be delivered in a health facility than children born in rural areas. The proportion of births delivered in a health facility is generally low in most of the regions (6 percent or less) with the exception of the Gambela and Harari regions and in Addis Ababa and Dire Dawa. In these four areas, the proportion of births delivered in a health facility ranges from 15 percent in the Gambela Region to 79 percent in Addis Ababa. There is also a strong association between mother’s education and place of delivery. The proportion of births delivered in a health facility is only 2 percent among uneducated mothers, compared with 52 percent among mothers with secondary and higher education. Not surprisingly, deliveries in a private health facility are most common among educated women residing in Addis Ababa. There has been no change in the proportion of births taking place in health facilities over the past five years. Data from the 2000 EDHS show that 5 percent of births took place in a health facility. Maternal Health | 117 Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics, Ethiopia 2005 Health facility Background characteristic Public sector Private sector Home Other Missing Total Number of births Mother's age at birth <20 5.9 0.4 93.1 0.4 0.2 100.0 1,715 20-34 5.0 0.4 93.9 0.4 0.2 100.0 7,702 35-49 2.5 0.9 95.6 0.5 0.4 100.0 1,746 Birth order 1 12.2 0.9 86.0 0.5 0.3 100.0 1,933 2-3 5.3 0.5 93.8 0.3 0.1 100.0 3,351 4-5 2.4 0.2 96.8 0.4 0.2 100.0 2,620 6+ 1.8 0.4 97.0 0.4 0.4 100.0 3,259 Antenatal care visits1 None 1.6 0.2 97.8 0.4 0.0 100.0 5,225 1-3 7.1 1.2 91.2 0.6 0.0 100.0 1,164 4+ 28.4 2.2 69.1 0.4 0.0 100.0 888 Residence Urban 39.5 2.9 56.9 0.4 0.3 100.0 815 Rural 2.0 0.3 97.0 0.4 0.2 100.0 10,348 Region Tigray 6.1 0.0 93.9 0.1 0.0 100.0 698 Affar 3.9 0.0 95.8 0.3 0.0 100.0 107 Amhara 3.5 0.0 96.3 0.0 0.1 100.0 2,621 Oromiya 3.7 0.6 95.2 0.3 0.3 100.0 4,411 Somali 4.6 0.4 93.9 0.0 1.1 100.0 477 Benishangul-Gumuz 4.7 0.0 80.7 13.7 1.0 100.0 105 SNNP 3.3 0.4 95.6 0.7 0.1 100.0 2,500 Gambela 13.2 2.0 81.1 3.4 0.2 100.0 31 Harari 31.1 0.4 66.5 0.8 1.1 100.0 22 Addis Ababa 67.5 11.0 21.0 0.5 0.0 100.0 153 Dire Dawa 24.5 1.4 74.2 0.0 0.0 100.0 37 Education No education 2.1 0.1 97.1 0.4 0.2 100.0 8,838 Primary 6.9 1.1 91.3 0.4 0.4 100.0 1,855 Secondary and higher 47.0 4.6 47.8 0.2 0.4 100.0 470 Wealth quintile Lowest 0.5 0.1 98.3 0.7 0.4 100.0 2,440 Second 1.2 0.0 98.3 0.3 0.2 100.0 2,356 Middle 1.8 0.1 97.8 0.1 0.2 100.0 2,486 Fourth 3.2 0.9 95.3 0.4 0.2 100.0 2,222 Highest 22.8 1.8 74.7 0.5 0.1 100.0 1,660 Total 4.8 0.5 94.1 0.4 0.2 100.0 11,163 Note: Total includes 47 births missing information on antenatal care visits not shown separately. 1 Includes only the most recent birth in the five years preceding the survey Assistance during Delivery Obstetric care from a trained provider during delivery is recognized as critical for the reduction of maternal and neonatal mortality. Births delivered at home are usually more likely to be delivered without assistance from a health professional, whereas births delivered at a health facility are more likely to be delivered by a trained health professional. Table 9.6 shows the type of assistance during delivery by selected background characteristics. Only 6 percent of births are delivered with the assistance of a trained health professional, that is, a doctor, nurse, or midwife, and 28 percent are delivered by a traditional birth attendant. The majority of births are attended by a relative or some other person (61 percent). Five percent of all births are delivered without any type of assistance at all. 118 | Maternal Health Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery and percent delivered by caesarean-section, according to background characteristics, Ethiopia 2005 Person providing assistance during delivery Background characteristic Health professional Traditional birth attendant Relative/ other No one Don't know/ missing Total Percentage delivered by C-section Number of births Mother's age at birth <20 6.9 31.8 58.5 2.7 0.1 100.0 1.1 1,715 20-34 5.8 28.3 60.5 5.2 0.2 100.0 1.1 7,702 35-49 3.8 23.9 62.8 9.1 0.4 100.0 0.5 1,746 Birth order 1 13.7 27.8 55.9 2.2 0.3 100.0 3.1 1,933 2-3 6.6 26.7 62.9 3.9 0.0 100.0 1.0 3,351 4-5 2.7 29.5 61.0 6.4 0.4 100.0 0.2 2,620 6+ 2.4 28.6 60.4 8.2 0.3 100.0 0.4 3,259 Place of delivery Health facility 97.3 1.5 0.9 0.3 0.0 100.0 18.8 589 Elsewhere 0.6 29.6 63.8 5.7 0.2 100.0 0.0 10,574 Residence Urban 44.6 22.9 30.6 1.4 0.4 100.0 9.4 815 Rural 2.6 28.5 62.9 5.8 0.2 100.0 0.3 10,348 Region Tigray 6.0 13.8 79.4 0.7 0.0 100.0 0.9 698 Affar 4.5 42.5 50.2 1.3 1.4 100.0 0.6 107 Amhara 3.7 29.6 64.6 1.9 0.1 100.0 0.6 2,621 Oromiya 4.8 32.5 57.7 4.7 0.3 100.0 0.7 4,411 Somali 5.2 71.6 20.9 1.2 1.1 100.0 1.0 477 Benishangul-Gumuz 5.1 20.4 49.8 23.8 1.0 100.0 0.1 105 SNNP 4.2 14.8 68.6 12.4 0.1 100.0 1.0 2,500 Gambela 15.3 19.3 54.5 10.5 0.4 100.0 1.7 31 Harari 31.4 61.5 5.3 0.9 0.9 100.0 3.3 22 Addis Ababa 78.8 4.2 16.0 0.9 0.1 100.0 16.0 153 Dire Dawa 26.7 72.4 0.5 0.3 0.1 100.0 3.5 37 Education No education 2.3 29.4 62.0 6.0 0.2 100.0 0.4 8,838 Primary 8.5 25.5 62.1 3.7 0.2 100.0 0.9 1,855 Secondary and higher 57.7 14.2 26.3 1.4 0.5 100.0 13.1 470 Wealth quintile Lowest 0.7 36.8 55.2 6.9 0.4 100.0 0.0 2,440 Second 1.3 27.5 64.9 6.1 0.2 100.0 0.3 2,356 Middle 1.9 26.8 66.7 4.4 0.2 100.0 0.2 2,486 Fourth 4.5 25.4 65.2 4.7 0.2 100.0 0.5 2,222 Highest 26.6 21.9 46.6 4.7 0.2 100.0 5.3 1,660 Total 5.7 28.1 60.5 5.4 0.2 100.0 1.0 11,163 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Births to young mothers (less than 35 years) and first births are more likely to be assisted by trained health professionals. Nearly one in two births (45 percent) in urban areas was assisted by a trained health professional, compared with only 3 percent of births in rural areas. Additionally, 63 percent of births to women in rural areas were delivered with the help of a relative or some other person, compared with 31 percent of births to women residing in urban areas. In most regions, the proportion of births assisted by a trained health professional is quite low (less than 10 percent). However, about one in seven births in Gambela, one in four births in Dire Dawa, one in three births in Harari, and nearly four in five births in Addis Ababa are delivered by a trained health professional. Maternal Health | 119 As expected, mother’s education has a positive relationship with delivery care. Births to women with primary education are almost four times (9 percent) more likely and births to women with secondary or higher education are 25 times (58 percent) more likely to receive delivery assistance from a health professional than births to women with no education (2 percent). Similarly, assistance by a trained health professional varies by economic status of women. Births to women in the highest wealth quintile are much more likely to be assisted by a trained health professional (27 percent) than births to women in the lowest wealth quintile (1 percent). Table 9.6 shows that deliveries by caesarean section are not common in Ethiopia. If they do occur, they are mostly among highly educated women (13 percent), urban women (9 percent), and women in Addis Ababa (16 percent). 9.3 POSTNATAL CARE A large proportion of maternal and neonatal deaths occur during the 48 hours after delivery. Thus, postnatal care is important for both the mother and the child to treat complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. Safe motherhood programmes have recently increased emphasis on the importance of postnatal care, recommending that all women receive a check on their health within two days of delivery. To assess the extent of postnatal care utilization, respondents were asked for the last birth in the five years preceding the survey whether they had received a health check after the delivery, the timing of the first check, and the type of health provider. This information is presented according to background characteristics in Table 9.7. According to data collected in the 2005 EDHS, postnatal care coverage is extremely low in Ethiopia. More than nine in ten mothers received no postnatal care at all and only 5 percent received postnatal care within the critical first two days after the delivery. There are no marked variations by mother’s age in the utilization of postnatal care services within the first two days of birth. A higher percentage of mothers who delivered for the first time than mothers with two or more children received postnatal care within the first two days. Thirty-one percent of mothers in urban areas received postnatal care within two days of the birth compared with 2 percent of mothers in rural areas. The utilization of timely postnatal care ranges from a low of 3 percent of mothers in the Somali Region to a high of 49 percent in Addis Ababa. Similarly, mother’s education seems to influence the utilization of postnatal care. Two percent of mothers with no education received timely postnatal care, compared with 41 percent of mothers with at least some secondary education. There are significant differences between women in the receipt of postnatal care within two days by wealth quintile, with only 1 percent of women in the lowest wealth quintile receiving timely postnatal care compared with 20 percent of women in the highest wealth quintile. Table 9.7 presents information on the type of postnatal care providers by mother’s background characteristics. Health professionals provided postnatal care for 6 percent of mothers. About 1 percent of mothers received postnatal care from traditional birth attendants. Health professionals are more likely to provide postnatal care to mothers of first order births, mothers with at least some secondary education, and mothers to the wealthiest households. Likewise, mothers in urban areas and those in Addis Ababa are more likely to have received postnatal care from a health professional. 120 | Maternal Health Table 9.7 Timing and type of provider of first postnatal checkup Among women giving birth in the five years preceding the survey, the percent distribution by time after delivery and type of provider of the mother's first postnatal health checkup for the last live birth, according to background characteristics, Ethiopia 2005 Time after delivery of mother's first postnatal checkup Type of health provider of mother's first postnatal checkup Background characteristic Less than 4 hours 4-23 hours 2 days 3-41 days Don't know/ missing Health profes- sional Traditional birth attendant Other Don't know/ missing No check- up Total Number of women Mother’s age at birth <20 3.0 1.5 0.3 1.2 0.6 5.9 0.6 0.1 0.0 93.4 100.0 994 20-34 3.1 1.4 0.6 1.4 0.3 5.9 0.7 0.1 0.1 93.2 100.0 4,923 35-49 1.4 1.0 0.3 0.8 0.7 3.8 0.2 0.3 0.0 95.7 100.0 1,391 Birth order 1 5.4 3.3 0.3 2.9 0.5 11.4 0.8 0.2 0.0 87.6 100.0 1,190 2-3 3.8 1.5 0.7 1.4 0.3 6.4 1.0 0.1 0.1 92.4 100.0 2,089 4-5 1.7 0.6 0.4 0.9 0.6 3.6 0.5 0.0 0.1 95.8 100.0 1,692 6+ 1.3 0.7 0.5 0.6 0.4 3.1 0.2 0.2 0.0 96.6 100.0 2,336 Residence Urban 18.3 9.9 2.7 5.3 0.9 36.1 0.4 0.0 0.5 62.9 100.0 634 Rural 1.3 0.5 0.3 0.9 0.4 2.6 0.6 0.1 0.0 96.7 100.0 6,674 Region Tigray 4.1 2.4 0.4 1.7 0.1 8.2 0.4 0.1 0.0 91.3 100.0 480 Affar 2.1 1.0 1.5 0.7 0.8 6.0 0.1 0.0 0.0 93.9 100.0 68 Amhara 2.2 0.8 0.3 1.0 0.2 3.6 0.8 0.0 0.2 95.5 100.0 1,856 Oromiya 2.6 0.5 0.6 1.1 0.6 4.5 0.6 0.2 0.0 94.7 100.0 2,723 Somali 0.4 2.3 0.5 1.4 0.2 4.7 0.0 0.0 0.2 95.1 100.0 288 Benishangul-Gumuz 2.3 0.7 0.2 0.9 0.0 4.1 0.0 0.0 0.0 95.9 100.0 69 SNNP 1.9 0.7 0.3 1.4 0.6 4.2 0.6 0.2 0.0 95.1 100.0 1,632 Gambela 7.9 0.7 1.9 2.2 0.3 12.6 0.4 0.0 0.0 87.0 100.0 23 Harari 8.5 15.0 0.2 2.9 0.7 25.9 0.7 0.7 0.0 72.7 100.0 15 Addis Ababa 23.6 22.8 3.0 6.6 0.5 55.9 0.3 0.0 0.3 43.4 100.0 129 Dire Dawa 9.9 11.6 1.1 1.0 0.3 23.0 1.0 0.0 0.0 76.1 100.0 25 Education No education 1.1 0.5 0.2 0.8 0.4 2.4 0.4 0.1 0.0 97.0 100.0 5,734 Primary 4.1 1.6 0.9 1.9 0.4 7.7 1.2 0.0 0.1 91.0 100.0 1,205 Secondary and higher 24.2 13.4 3.2 6.4 0.9 46.4 1.2 0.0 0.4 52.0 100.0 368 Wealth quintile Lowest 0.6 0.1 0.4 0.3 0.6 1.3 0.5 0.0 0.0 98.1 100.0 1,520 Second 0.8 0.6 0.0 0.5 0.3 1.8 0.4 0.0 0.0 97.9 100.0 1,553 Middle 0.8 0.5 0.2 1.3 0.1 2.1 0.7 0.1 0.0 97.0 100.0 1,586 Fourth 1.4 0.5 0.4 1.0 0.5 3.1 0.5 0.3 0.0 96.2 100.0 1,451 Highest 12.2 5.9 1.8 3.8 0.7 23.1 1.0 0.2 0.3 75.5 100.0 1,196 Total 2.8 1.3 0.5 1.3 0.4 5.5 0.6 0.1 0.1 93.7 100.0 7,307 9.4 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers women may face in seeking care during pregnancy and at the time of delivery. In the 2005 Ethiopia DHS survey, women were asked whether each of the following factors would be a big problem or not a big problem in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to a health facility, having to take transport, not wanting to go alone, concern that there may not be a female health provider, concern that there may not be a health provider, and concern that there may be no one to complete the household chores. The results are shown in Table 9.8. Maternal Health | 121 Table 9.8 Problems in accessing health care Percentage of women who reported they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Ethiopia 2005 Problems in accessing health care Background characteristic Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern there may not be a female provider Concern there may not be a health provider Concern there may be no one to complete household chores Any of the specified problems Number of women Age 15-19 35.0 68.9 63.4 65.7 57.5 71.0 78.9 59.2 93.8 3,266 20-29 34.5 74.6 67.9 71.0 62.4 72.6 81.3 72.5 95.7 5,064 30-39 34.9 78.9 69.4 74.6 62.1 71.9 79.2 72.2 96.1 3,410 40-49 33.4 82.4 70.9 76.6 63.6 75.1 83.0 72.2 97.4 2,330 Number of living children 0 32.9 67.3 60.5 62.4 57.5 70.0 79.3 60.7 93.8 4,554 1-2 34.1 76.8 67.5 71.3 62.9 72.7 80.2 71.6 95.5 3,226 3-4 34.3 80.0 71.4 76.6 62.6 72.6 80.2 76.0 96.9 2,981 5+ 37.5 82.0 74.5 80.0 64.1 75.5 82.7 72.7 97.2 3,309 Marital status Never married 33.5 66.8 59.4 60.5 56.7 69.6 79.3 59.5 93.4 3,516 Married or living together 36.1 77.8 71.8 76.5 63.0 74.2 81.5 73.5 96.3 9,066 Divorced/separated/ widowed 27.7 83.1 62.2 68.0 62.2 68.9 77.2 66.8 96.8 1,488 Employment Not employed 35.3 75.6 69.4 73.1 60.6 71.7 79.6 68.9 95.4 9,251 Working for cash 21.9 66.9 46.9 51.2 50.4 62.6 73.0 60.2 92.5 1,904 Not working for cash 40.5 81.4 75.9 80.2 70.9 81.4 88.3 76.3 98.6 2,896 Missing 35.6 76.9 77.1 77.1 62.5 71.9 76.1 82.6 94.5 19 Residence Urban 16.0 53.4 31.1 33.5 40.7 53.7 71.2 57.2 88.6 2,499 Rural 38.5 80.4 75.6 79.8 65.8 76.5 82.5 71.9 97.2 11,571 Region Tigray 11.5 69.3 49.8 52.9 37.6 37.8 46.9 25.1 87.1 919 Affar 24.5 72.6 81.7 83.5 56.6 66.5 70.6 44.5 97.9 146 Amhara 22.0 67.0 61.3 65.6 48.9 66.1 75.8 63.7 94.3 3,482 Oromiya 48.6 83.0 76.0 80.9 74.8 78.9 83.5 78.9 96.4 5,010 Somali 36.0 89.3 82.7 82.6 68.4 70.9 76.2 63.1 96.2 486 Benishangul-Gumuz 37.1 78.4 63.8 69.1 51.7 72.6 83.3 64.2 96.6 124 SNNP 40.1 80.6 73.7 78.7 65.4 85.0 90.2 77.7 98.3 2,995 Gambela 32.4 73.3 64.6 64.2 58.1 56.9 82.4 61.6 97.3 44 Harari 22.7 55.3 36.7 39.9 43.7 66.5 94.5 62.0 97.2 39 Addis Ababa 7.5 47.2 33.4 28.5 44.5 59.9 91.0 64.3 96.8 756 Dire Dawa 25.2 67.6 32.3 33.7 26.7 26.4 44.7 36.5 81.7 69 Education No education 38.1 82.1 74.3 78.7 64.9 75.2 81.2 71.7 97.3 9,271 Primary 34.9 72.8 65.2 69.1 62.7 74.1 82.1 69.7 95.4 3,123 Secondary and higher 14.2 45.2 35.7 36.9 39.4 54.4 73.7 55.1 86.8 1,675 Wealth quintile Lowest 38.0 86.0 81.9 84.2 67.9 74.2 78.5 65.0 98.0 2,428 Second 37.8 82.6 76.4 80.4 64.6 74.8 80.4 69.7 97.5 2,643 Middle 40.4 81.3 76.3 81.3 66.4 78.1 85.8 74.9 97.7 2,732 Fourth 37.8 77.8 71.8 76.7 65.6 79.2 85.4 75.8 97.3 2,647 Highest 23.1 57.7 42.3 45.6 47.7 60.5 74.3 62.8 90.0 3,621 Total 34.5 75.6 67.7 71.6 61.4 72.5 80.5 69.3 95.7 14,070 122 | Maternal Health The most important reason for not seeking health care was concern that there may not be a health provider (81 percent). Concern about getting money for treatment, concern that there may not be a female health provider, concern about having to take transport, and concern that there may be no one to complete the household chores were cited by about seven in ten women. Distance to a health facility and not wanting to go alone are perceived as big problems by more than three in five women. Only one in three (35 percent) women perceived getting permission to go for treatment to be a big problem. Older women, women with more than two living children, women who were married or living together and women working but not for cash are more likely to cite concern that there may not be a health provider as a big problem than their counterparts. Women in rural areas and those residing in Harari, Addis Ababa and SNNP are also more likely than urban women and women residing in the other regions to mention this as a big problem. Women with no education, women who are married or living with a man, and women working but not for cash are more likely to perceive the problem of not having a female health care provider as a big problem than their counterparts. More than eight in ten (85 percent) women residing in the SNNP Region also mentioned this as a big problem. As expected, 80 percent of women in rural areas perceived having to take transport as a big problem, compared with only 34 percent of women in urban areas. Knowledge and Attitudes Concerning Tuberculosis Tuberculosis (TB) is a leading cause of death in the world and a major health problem in the developing world. TB is caused by the bacteria mycobacterium tuberculosis whose transmission is mainly airborne through droplets coughed or sneezed out by infected persons. The infection is primarily concentrated in the lungs but in some cases it can be transmitted to other areas of the body. The very young and very old and persons with a suppressed immune system (brought on from HIV infection or other causes) are especially prone to contracting the disease when exposed to it. The 2005 EDHS collected information from women and men on the level of their awareness of TB. Specifically, respondents were asked whether they had ever heard of the illness, how it spreads from one person to another, whether it can be cured, and whether they would want to keep the information secret if a member of their family got TB. This information is useful in policy formulation and implementation of programmes designed to combat and limit the spread of the disease. Tables 9.9.1 and 9.9.2 show the percentage of women and men who have heard of TB, and among those who have heard of it, their knowledge and attitudes concerning TB, according to background characteristics. Three in four women and four in five men have heard of TB. Awareness is slightly higher among women and men in the older age groups, respondents with some secondary or higher education as well as among those in the highest wealth quintile. Ninety-four percent of women in urban areas, compared with 71 percent of women in rural areas have heard of TB. There are marked differences between regions in the knowledge of TB. Most women (about 95 percent) in Harari, Addis Ababa, and Dire Dawa have heard of tuberculosis. Awareness of TB is relatively low in Benishangul- Gumuz, Somali and Gambela, where only about one in two women are aware of TB. A similar pattern is observed for men. Sixty-five percent of women and 79 percent of men reported that TB is spread through the air when coughing or sneezing. Education is strongly associated with knowledge of how TB can be spread. Nearly all women and men with secondary and higher education know that TB is spread through the air when coughing or sneezing. Wealthier women and women in urban areas are also more likely to know how the disease is spread. Maternal Health | 123 Table 9.9.1 Knowledge and attitude concerning tuberculosis among women Percentage of women who have heard of tuberculosis, and among women who have heard of TB, the percentage who know that TB is spread through the air by coughing or sneezing, who believe that TB can be cured, and who would want to keep secret that a family member has TB, by background characteristics, Ethiopia 2005 Among women who have heard of TB, the percentages who: All women Background characteristic Percentage who have heard of TB Number of women Report that TB is spread through the air by coughing or sneezing Believe that TB can be cured Would want a family member's TB kept secret Number of women Age 15-19 71.7 3,266 70.4 75.0 23.2 2,342 20-34 73.8 6,872 63.7 76.1 22.8 5,073 35-49 78.7 3,933 61.4 76.3 20.4 3,095 Residence Urban 93.7 2,499 83.9 87.9 16.2 2,342 Rural 70.6 11,571 59.0 72.5 23.9 8,168 Region Tigray 85.9 919 55.7 84.2 20.6 790 Affar 72.4 146 55.6 78.4 26.3 106 Amhara 73.1 3,482 56.1 74.6 19.5 2,545 Oromiya 78.3 5,010 68.4 75.7 21.1 3,920 Somali 52.1 486 38.2 75.2 22.0 253 Benishangul-Gumuz 48.3 124 66.2 75.5 23.2 60 SNNP 66.0 2,995 65.6 69.9 32.6 1,977 Gambela 55.7 44 63.6 82.1 28.8 25 Harari 95.8 39 84.7 90.5 8.6 37 Addis Ababa 96.6 756 87.8 86.5 11.1 731 Dire Dawa 95.1 69 81.6 92.5 10.2 66 Education No education 68.2 9,271 52.8 71.2 23.0 6,323 Primary 81.5 3,123 76.6 76.9 23.4 2,545 Secondary and higher 98.0 1,675 91.0 92.3 16.8 1,642 Wealth quintile Lowest 65.2 2,428 49.4 72.1 23.9 1,582 Second 69.1 2,643 55.1 69.8 24.6 1,827 Middle 69.0 2,732 59.1 70.4 25.7 1,886 Fourth 75.1 2,647 64.5 75.2 20.8 1,987 Highest 89.1 3,621 80.5 84.9 18.6 3,228 Total 74.7 14,070 64.5 75.9 22.2 10,510 Seventy-six percent of women and 85 percent of men believe that TB can be cured. Women’s belief that TB can be cured varies by education, wealth quintile, and place of residence. Eighty-eight percent of women in urban areas, compared with 73 percent of women in rural areas believe that TB can be cured. About nine in ten women in Dire Dawa and Harari believe that TB can be cured, compared with seven in ten women in SNNP. Ninety-two percent of women with some secondary education and 85 percent of women in the highest wealth quintile believe that TB can be cured compared with 71 percent of women with no education and 72 percent of those in the lowest wealth quintile. A similar pattern is observed for men. 124 | Maternal Health Table 9.9.2 Knowledge and attitude concerning tuberculosis among men Percentage of men who have heard of tuberculosis, and among men who have heard of TB, the percentage who know that TB is spread through the air by coughing or sneezing, who believe that TB can be cured, and who would want to keep secret that a family member has TB, by background characteristics, Ethiopia 2005 Among men who have heard of TB, the percentages who: All men Background characteristic Percentage who have heard of TB Number of men Report that TB is spread through the air by coughing or sneezing Believe that TB can be cured Would want a family member's TB kept secret Number of men Age 15-19 74.2 1,335 82.7 82.6 31.8 990 20-34 83.4 2,558 80.2 86.3 30.2 2,133 35-49 87.2 2,139 76.2 84.4 28.9 1,865 Residence Urban 94.0 916 93.7 91.7 24.1 861 Rural 80.6 5,117 76.2 83.4 31.3 4,126 Region Tigray 94.2 366 69.8 89.1 8.0 345 Affar 78.6 65 67.0 90.5 19.8 51 Amhara 78.5 1,521 74.3 84.6 16.5 1,194 Oromiya 83.0 2,222 83.2 84.7 37.7 1,844 Somali 78.9 202 58.2 79.6 30.2 160 Benishangul-Gumuz 70.3 54 74.7 82.4 22.0 38 SNNP 82.4 1,244 80.1 82.1 41.2 1,025 Gambela 75.7 21 72.0 87.2 22.9 16 Harari 96.5 16 92.1 93.2 40.4 16 Addis Ababa 93.6 292 96.1 92.2 25.9 273 Dire Dawa 89.8 30 89.6 95.6 31.4 27 Education No education 77.1 2,589 65.9 79.7 31.4 1,996 Primary 81.7 2,252 83.8 84.3 30.4 1,840 Secondary and higher 96.7 1,192 94.9 94.6 27.1 1,152 Wealth quintile Lowest 76.1 1,100 66.4 82.6 30.0 837 Second 79.6 1,184 76.0 80.6 30.5 942 Middle 78.2 1,081 75.5 81.5 28.1 846 Fourth 85.4 1,200 79.9 86.3 33.4 1,024 Highest 91.1 1,469 91.2 90.1 28.4 1,338 Total 82.7 6,033 79.2 84.8 30.0 4,988 More than a fifth of women and three-tenths of men believe that if a family member got TB they would want to keep it a secret. Less educated respondents, women in the lower (lowest to middle) wealth quintiles, respondents who reside in rural areas, and those who reside in SNNP are more likely than their counterparts to want to keep secret the fact that a member of their family has the disease. Use of Tobacco Smoking has a negative effect on the health of a person. Women and men interviewed in the 2005 EDHS were asked about their smoking habits. The data show that very few women in Ethiopia (less than 2 percent) smoke (data not shown). Maternal Health | 125 Table 9.10 shows the percentage of men who smoke cigarettes or tobacco and the percent distribution of cigarette smokers by number of cigarettes smoked in the preceding 24 hours, according to background characteristics. Smoking is not common in Ethiopia. Only 9 percent of men smoke cigarettes and 5 percent consume other forms of tobacco. Use of tobacco is more common among older men age 35 and above, men living in rural areas, men with no education and men in the lowest wealth quintile. Regional variations are significant, with use of tobacco being highest in Affar, where nearly one in two men use tobacco, and lowest in Tigray, where less than 2 percent of men reported using tobacco. The majority of men who smoked consumed as much as 3-5 or 10 or more cigarettes a day (about 30 percent each). Table 9.10 Use of tobacco: men Percentage of men who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Ethiopia 2005 Number of cigarettes Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of men 0 1-2 3-5 6-9 10+ Don't know/ missing Total Number of cigarette smokers Age 15-19 1.0 0.0 0.6 98.3 1,335 4.3 17.3 52.9 10.5 14.6 0.3 100.0 14 20-34 7.2 0.0 3.2 90.6 2,558 4.1 14.0 29.6 16.5 33.7 2.1 100.0 185 35-49 14.7 0.1 9.4 79.3 2,139 6.6 15.2 27.3 17.7 30.1 3.0 100.0 314 Residence Urban 8.1 0.0 0.9 91.2 916 6.0 8.7 35.2 12.0 38.0 0.1 100.0 74 Rural 8.6 0.0 5.5 87.8 5,117 5.6 15.9 27.8 17.9 29.8 3.0 100.0 439 Region Tigray 1.4 0.0 0.0 98.6 366 0.0 0.0 31.0 14.9 37.3 16.9 100.0 5 Affar 25.4 0.0 27.8 52.0 65 0.0 7.3 41.1 23.4 28.2 0.0 100.0 17 Amhara 2.3 0.0 2.1 96.0 1,521 6.4 27.3 11.6 10.7 39.3 4.8 100.0 34 Oromiya 11.7 0.1 6.2 84.6 2,222 3.3 17.6 28.6 20.1 28.5 1.9 100.0 259 Somali 24.8 0.0 3.3 73.5 202 1.4 2.3 8.8 16.0 71.0 0.5 100.0 50 Benishangul-Gumuz 13.4 0.0 15.1 74.8 54 2.1 8.6 24.9 28.8 33.5 2.0 100.0 7 SNNP 7.9 0.0 6.5 87.7 1,244 15.2 14.0 43.7 11.2 10.4 5.5 100.0 98 Gambela 15.5 0.8 13.0 76.0 21 3.1 13.7 39.7 6.7 33.7 3.1 100.0 3 Harari 25.2 0.0 3.6 72.5 16 0.0 2.1 11.8 19.4 65.3 1.3 100.0 4 Addis Ababa 9.9 0.0 0.6 89.8 292 7.7 13.2 31.5 14.1 33.5 0.0 100.0 29 Dire Dawa 20.7 0.0 6.1 75.4 30 0.0 3.5 27.9 15.5 53.1 0.0 100.0 6 Education No education 10.8 0.0 8.1 83.5 2,589 5.2 17.7 23.6 19.3 31.2 3.1 100.0 281 Primary 6.8 0.1 3.2 91.5 2,252 6.7 9.4 35.2 15.7 30.0 3.0 100.0 153 Secondary and higher 6.7 0.0 0.8 92.7 1,192 5.1 15.4 35.2 12.0 32.2 0.1 100.0 79 Wealth quintile Lowest 12.5 0.0 10.4 80.2 1,100 1.7 13.4 28.6 20.4 33.2 2.7 100.0 138 Second 9.5 0.2 6.2 87.4 1,184 12.2 11.9 23.5 22.9 23.9 5.6 100.0 112 Middle 8.5 0.0 3.9 89.0 1,081 4.1 16.3 29.2 15.8 31.0 3.6 100.0 92 Fourth 6.4 0.0 3.4 91.0 1,200 4.2 26.1 23.2 13.3 33.1 0.1 100.0 77 Highest 6.4 0.0 1.4 92.3 1,469 6.3 9.8 39.8 9.6 34.4 0.1 100.0 94 Total 8.5 0.0 4.8 88.3 6,033 5.6 14.9 28.8 17.1 31.0 2.6 100.0 513   Child Health | 127 CHILD HEALTH 10 This chapter presents findings on several areas of importance to child health; characteristics of the neonate (birth weight and size at birth), vaccination status of children and important childhood illnesses and their treatment. The information on birth weight and birth size is important for the design and implementation of programmes aimed at reducing neonatal and infant mortality. Vaccination coverage information focuses on the age group 12-23 months. Overall coverage levels at the time of the survey and by 12 months of age are shown for this age group. Additionally, the source of the vaccination information (whether based on a written vaccination card or on the mother’s recall) is shown. Differences in vaccination coverage between subgroups of the population aid in programme planning. Treatment practices and contact with health services among children with the three most important childhood illnesses (acute respiratory infection, fever, and diarrhoea) help in the assessment of national programmes aimed at reducing the mortality impact of these illnesses. Information is provided on the prevalence and treatment of ARI and its treatment with antibiotics and the prevalence of fever and its treatment with antimalarial drugs and antibiotics. The treatment of diarrhoeal disease with oral rehydration therapy (including increased fluids) aids in the assessment of programmes that recommend such treatment. Because appropriate sanitary practices can help prevent and reduce the severity of diarrhoeal disease, information is also provided on the manner of disposing of children’s faecal matter. 10.1 CHILD’S SIZE AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to the risk of childhood illnesses and the chances of survival. Children whose birth weight is less than 2.5 kilogrammes, or children reported to be ‘very small’ or ‘smaller than average’ are considered to have a higher than average risk of early childhood death. For births in the five years preceding the survey, birth weight was recorded in the questionnaire if available from either a written record or the mother’s recall. Since birth weight may not be known for many babies, the mother’s estimate of the baby’s size at birth was also obtained. Even though it is subjective, it can be a useful proxy for the weight of the child. Table 10.1 presents information on child’s size at birth according to background characteristics. Only 3 percent of children in Ethiopia are weighed at birth. This is not surprising because the majority of births do not take place in a health facility, and children are less likely to be weighed at birth. Among children born in the five years before the survey with a reported birth weight, 14 percent weighed less than 2.5 kg at birth. Birth weight is lower among children born to older women (age at birth 35-49), children at higher birth orders (6 and above), and children of women with no education. The birth weight of a child also varies by mother’s place of residence. Twenty-three percent of births in rural areas compared with 10 percent in urban areas have a reported birth weight less than 2.5 kg. In the absence of birth weight a mother’s subjective assessment of the size of the baby at birth may be useful. Twenty-one percent of births were reported to be very small and 7 percent were reported as smaller than average. Births to mothers with no education and rural births are more likely to be reported as very small or smaller than average than births to educated mothers and births in urban areas. Nearly two-fifths of births (37 percent) in Affar are reported to be very small or smaller than average. 128 | Child Health Table 10.1 Child's size at birth Among live births in the five years preceding the survey with a reported birth weight, the percent distribution by birth weight and among all live births in the five years preceding the survey, the percent distribution by mother's estimate of baby's size at birth, according to background characteristics, Ethiopia 2005 Percent distribution of all live births by size of child at birth Percent distribution of births with a reported birth weight1 Background characteristics Less than 2.5 kg 2.5 kg or more Total Number of births Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 14.4 85.6 100.0 50 21.3 7.9 70.5 0.3 100.0 1,715 20-34 12.6 87.4 100.0 263 20.1 7.2 72.3 0.4 100.0 7,702 35-49 19.0 81.0 100.0 30 21.2 7.2 71.0 0.6 100.0 1,746 Birth order 1 10.1 89.9 100.0 135 21.9 7.8 69.7 0.7 100.0 1,933 2-3 12.9 87.1 100.0 141 20.5 7.7 71.7 0.2 100.0 3,351 4-5 14.7 85.3 100.0 37 18.9 7.4 73.3 0.4 100.0 2,620 6+ 28.6 71.4 100.0 31 20.9 6.5 72.1 0.5 100.0 3,259 Residence Urban 10.2 89.8 100.0 255 16.7 5.0 77.9 0.4 100.0 815 Rural 23.0 77.0 100.0 88 20.8 7.5 71.4 0.4 100.0 10,348 Region Tigray (0.0) (100.0) 100.0 27 20.1 13.5 65.8 0.6 100.0 698 Affar * * 100.0 3 27.2 9.9 62.6 0.3 100.0 107 Amhara * * 100.0 37 23.9 9.0 66.5 0.5 100.0 2,621 Oromiya (20.5) (79.5) 100.0 100 20.0 5.7 74.0 0.3 100.0 4,411 Somali * * 100.0 13 15.9 8.6 73.6 1.9 100.0 477 Benishangul-Gumuz * * 100.0 2 18.2 11.7 68.6 1.5 100.0 105 SNNP (19.7) (80.3) 100.0 39 18.9 5.9 75.0 0.2 100.0 2,500 Gambela 14.0 86.0 100.0 4 12.9 6.5 80.2 0.4 100.0 31 Harari 5.6 94.4 100.0 6 20.3 4.9 73.5 1.3 100.0 22 Addis Ababa 12.8 87.2 100.0 106 16.0 7.2 76.4 0.5 100.0 153 Dire Dawa 5.9 94.1 100.0 8 13.0 5.0 81.7 0.3 100.0 37 Mother's education No education 24.3 75.7 100.0 76 21.1 7.7 70.8 0.4 100.0 8,838 Primary 18.4 81.6 100.0 74 19.7 5.3 74.6 0.3 100.0 1,855 Secondary and higher 7.3 92.7 100.0 193 12.0 7.5 79.8 0.6 100.0 470 Wealth quintile Lowest * * 100.0 3 22.4 8.3 68.7 0.6 100.0 2,440 Second * * 100.0 7 21.6 7.7 70.3 0.5 100.0 2,356 Middle * * 100.0 21 22.3 7.1 70.1 0.4 100.0 2,486 Fourth (38.3) (61.7) 100.0 28 18.0 6.6 75.2 0.3 100.0 2,222 Highest 10.2 89.8 100.0 285 16.4 6.4 76.8 0.4 100.0 1,660 Total 13.5 86.5 100.0 343 20.5 7.3 71.8 0.4 100.0 11,163 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Based on either a written record or the mother's recall. The percentage of low birth weight babies has increased in the past five years from 8 percent in 2000 to 14 percent in 2005. The percentage of babies assessed by mothers as being very small at birth has increased over the same period from 6 percent to 21 percent. 10.2 VACCINATION COVERAGE Universal immunisation of children against the six vaccine-preventable diseases (namely, tuberculosis, diphtheria, whooping cough, tetanus, polio, and measles) is crucial to reducing infant and child mortality. Differences in vaccination coverage among subgroups of the population are useful for programme planning and targeting resources to areas most in need. Additionally, information on immunization coverage is important for the monitoring and evaluation of the Expanded Programmes on Immunization (EPI). Child Health | 129 The EDHS 2005 collected information on vaccination coverage for all living children born in the five years preceding the survey. According to the guidelines developed by the World Health Organization, children are considered fully vaccinated when they have received a vaccination against tuberculosis (BCG), three doses each of the DPT and polio vaccines, and a measles vaccination by the age of 12 months. BCG should be given at birth or at first clinical contact, DPT and polio require three vaccinations at approximately 4, 8, and 12 weeks of age, and measles should be given at or soon after reaching 9 months of age. Information on vaccination coverage was collected in two ways in the EDHS: from vaccination cards shown to the interviewer and from mothers’ verbal reports. If the cards were available, the interviewer copied the vaccination dates directly onto the questionnaire. When there was no vaccination card for the child or if a vaccine had not been recorded on the card as being given the respondent was asked to recall the vaccines given to her child. Table 10.2 and Figure 10.1 show the percentage of children age 12-23 months who have received the various vaccinations by source of information, that is, from vaccination card or mother’s report. This is the youngest cohort of children who have reached the age by which they should be fully vaccinated. Table 10.2 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, Ethiopia 2005 DPT PolioSource of information BCG 1 2 3 0 1 2 3 Measles All2 No vacci- nations Number of children Vaccinated at any time before survey Vaccination card 33.4 36.5 31.3 25.1 13.2 35.8 31.0 24.9 22.2 17.3 0.0 692 Mother's report 27.0 21.7 15.7 6.7 4.2 38.5 33.7 19.8 12.6 3.0 24.0 1,185 Either source 60.4 58.2 47.0 31.9 17.4 74.3 64.6 44.7 34.9 20.4 24.0 1,877 Vaccinated by 12 months of age3 57.4 54.9 43.9 29.0 16.9 70.0 60.2 41.0 28.5 16.7 28.0 1,877 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 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 vaccination. Figure 10.1 Percentage of Children Age 12-23 Months with Specific Vaccinations 60 58 47 32 17 74 65 45 35 20 24 BCG 1 2 3 0 1 2 3 Measles No vacci- nations 0 20 40 60 80 100 Pe rc en ta ge va cc in a t ed at an y tim e be fo re th e su r v ey Note: Based on health cards and mothers' reports 1 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio 0) DPT Polio 1All EDHS 2005 130 | Child Health Twenty percent of children age 12-23 months were fully vaccinated at the time of the survey, 60 percent had received the BCG vaccination, and 35 percent had been vaccinated against measles. The coverage for the first dose of DPT is relatively high (58 percent). However, only 32 percent went on to receive the third dose of DPT. Even though DPT and polio vaccines are often administered at the same time, polio coverage is much higher than DPT coverage. Three in four children received the first dose of polio, two in three received the second dose, and more than four in ten received the third dose. This is primarily due to the success of the national immunization day campaigns during which polio vaccines are administered. Nevertheless, the dropout between the first and third doses of polio is marked—a 40 percent decline. Table 10.3 shows the vaccination coverage among children age 12-23 months, according to information from the vaccination card or mother’s report, by background characteristics. This information may give some indication of the success of the immunization programme in reaching out to all population subgroups. Boys are slightly more likely than girls to be fully immunized (23 percent versus 18 percent). Birth order has a close relationship with vaccination coverage; as birth order increases, vaccination coverage generally decreases. Twenty-seven percent of first-born children have been fully immunized, compared with 18 percent of children of birth order six and above. There are marked urban-rural differences in vaccination coverage. For example, children residing in urban areas are almost three times (49 percent) as likely to be fully immunized as children in rural areas (18 percent). Similarly, there are substantial differences in coverage among regions. The percentage of children fully immunized ranges from a low of less than 1 percent in the Affar Region to 70 percent in Addis Ababa. The percentage of children fully immunized increases with mother’s education. Seventeen percent of children whose mothers have no education are fully immunized, compared with 42 percent of children born to mothers who have at least some secondary education. Children in households in the lowest wealth quintile are less likely to have been fully immunized than children in households in the highest wealth quintile. Table 10.3 shows that a vaccination card was seen for 37 percent of children age 12-23 months. The actual percentage of children who have a vaccination card may be higher because in some areas the cards are kept at the health centre and not by mothers. Cards were more likely to have been shown for male children, first-order births, children living in urban areas, children in Addis Ababa, children of mothers with at least some secondary education, and children of mothers in the highest wealth quintile. Data from the EDHS generally show vaccination coverage to be lower than data collected from the 2004 Welfare Monitoring Survey and data reported in the service statistics from the Ministry of Health. However, when comparing data from various sources, consideration should be given to differences in the sampling frame, design, sample size, representativeness of the sample, and selection methodology, as well as differences in the source of information, phrasing of questions, and reporting of data that could explain these differences. Child Health | 131 Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Ethiopia 2005 DPT Polio1 Background characteristic BCG 1 2 3 0 1 2 3 Measles All2 No vacci- nations Percentage with a vaccina- tion card seen Number of children Sex Male 63.8 60.7 49.0 34.5 18.3 75.1 66.0 46.1 36.4 22.5 23.1 38.7 959 Female 56.9 55.6 45.0 29.1 16.5 73.5 63.2 43.3 33.2 18.2 25.1 35.0 917 Birth order 1 65.9 66.7 52.2 40.5 21.1 78.1 66.1 46.6 39.5 26.8 21.7 45.3 359 2-3 63.9 61.4 51.8 34.4 21.4 75.9 66.6 48.2 35.2 21.1 20.9 41.7 543 4-5 55.4 54.0 44.0 28.1 15.9 67.8 59.3 39.7 32.8 17.4 30.0 32.1 448 6+ 57.3 52.7 41.2 26.5 12.1 75.7 66.0 44.0 33.1 17.7 23.7 30.3 527 Residence Urban 84.0 84.9 78.6 65.7 43.1 86.9 80.8 69.3 65.4 49.3 11.3 62.0 147 Rural 58.4 55.9 44.3 29.0 15.2 73.3 63.3 42.6 32.2 17.9 25.1 34.7 1,729 Region Tigray 77.4 85.9 70.9 51.6 19.6 89.8 77.3 56.6 63.3 32.9 7.2 58.4 135 Affar 27.6 13.5 8.7 2.8 4.6 58.2 36.9 19.9 8.1 0.6 38.8 4.0 18 Amhara 62.3 57.2 46.7 31.5 11.0 78.1 70.7 45.6 34.8 17.1 20.6 33.3 482 Oromiya 57.8 54.2 43.7 28.5 18.5 73.7 61.5 41.1 29.4 20.2 25.5 38.8 691 Somali 17.1 14.9 11.1 5.6 5.2 19.8 17.7 10.2 6.4 2.8 78.0 8.1 78 Benishangul-Gumuz 53.5 49.6 41.4 30.7 9.4 70.0 59.4 36.7 33.4 18.5 28.5 28.7 16 SNNP 64.2 64.8 50.4 33.2 21.0 75.3 66.6 50.2 37.7 20.3 21.7 35.5 408 Gambela 49.3 39.8 29.8 20.3 26.2 68.1 59.5 41.4 30.7 15.9 31.9 22.5 5 Harari 67.4 64.6 56.5 45.8 33.0 74.7 61.9 52.0 39.9 34.9 23.7 41.0 4 Addis Ababa 93.5 93.8 90.5 83.8 71.3 97.7 92.7 85.5 78.8 69.9 2.3 68.3 32 Dire Dawa 75.4 69.6 68.3 61.4 33.6 81.8 79.2 65.1 55.7 43.4 18.2 54.8 7 Education No education 56.5 54.5 42.5 27.9 14.6 71.2 61.0 39.8 30.0 17.2 27.3 34.4 1,456 Primary 70.7 68.3 59.5 40.7 19.6 83.3 74.5 58.7 48.4 28.6 14.2 42.3 328 Secondary and higher 85.8 80.9 73.6 62.2 54.5 92.5 86.0 71.5 63.4 41.5 7.5 56.8 93 Wealth quintile Lowest 50.0 47.4 37.2 25.6 16.0 68.6 57.9 38.2 24.9 14.1 30.0 31.3 450 Second 60.9 57.0 44.9 26.8 11.7 71.7 60.6 38.3 29.0 16.7 28.1 31.2 399 Middle 59.6 59.3 45.0 33.0 15.3 75.4 64.2 45.2 37.6 21.8 22.4 39.2 381 Fourth 65.4 60.3 50.6 30.6 17.4 78.5 72.3 48.8 36.1 17.9 17.9 35.2 345 Highest 70.6 72.2 62.9 47.9 29.8 80.2 71.8 57.5 52.5 35.6 18.9 51.7 302 Total 60.4 58.2 47.0 31.9 17.4 74.3 64.6 44.7 34.9 20.4 24.0 36.9 1,877 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) Trends in Vaccination Coverage One way of measuring trends in vaccination coverage is to compare coverage among children of different ages in the 2005 EDHS. Table 10.4 shows the percentage of children who have received vaccinations during the first year of life by current age. This type of data can provide information on trends in vaccination coverage over the past four years. 132 | Child Health Table 10.4 Vaccinations in the first year of life Percentage of children under five years of age at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Ethiopia 2005 DPT Polio1 Current age in months BCG 1 2 3 0 1 2 3 Measles All2 No vacci- nations Percentage with a vaccina- tion card seen Number of children 12-23 57.4 54.9 43.9 29.0 16.9 70.0 60.2 41.0 28.5 16.7 28.0 36.9 1,877 24-35 45.3 39.1 30.0 19.7 10.7 60.0 50.7 35.8 18.8 10.4 39.2 22.2 1,892 36-47 42.4 34.5 27.5 17.5 9.6 53.9 47.1 35.4 17.8 8.0 43.7 13.9 2,105 48-59 36.2 30.1 24.9 15.8 7.4 47.7 42.1 30.5 15.3 7.2 51.3 11.6 2,013 Total 46.9 40.6 32.3 20.9 11.2 60.0 52.0 37.4 20.8 10.7 38.4 20.8 7,887 Note: Information was obtained from the vaccination card or if there was no written record, from the mother. 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. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) There are notable changes in vaccination coverage over the past five years. The percentage of children who have received no vaccinations at all by 12 months of age has declined significantly over the past four years from 51 percent among children age 48-59 months at the time of the survey to 28 percent among children age 12-23 months. The percentage fully immunized by age 12 months has increased from 7 percent to 17 percent. Not surprisingly, vaccination cards were shown for 37 percent of children age 12-23 months but for only 12 percent of children age 48-59 months. This may be because vaccination cards for older children have been discarded. Trends in vaccination coverage can be seen by comparing similarly collected data in the 2000 EDHS with the data from the 2005 EDHS. The data show that vaccination coverage in Ethiopia has improved over the past five years. The percentage of children age 12-23 months fully vaccinated at the time of the survey increased by 43 percent from 14 percent in 2000 to 20 percent in 2005. However, the percentage who had received none of the six basic vaccinations increased from 17 percent in 2000 to 24 percent in 2005. With the exception of Polio 1, the percentage of children who received all the other vaccinations has increased in the past five years, with the largest increase seen in the percentage of children under five who received DPT 3 by 12 months of age. 10.3 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths caused by ARI. In the 2005 Ethiopia DHS survey, the prevalence of ARI was estimated by asking mothers whether their children under age five had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These symptoms are compatible with ARI. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Table 10.5 shows that 13 percent of children under five years of age showed symptoms of ARI at some time in the two weeks preceding the survey. Prevalence of ARI varies by age of child. Children age 6-11 months are most likely to show symptoms of ARI (18 percent), compared with children in the other age groups. There are small differences in the prevalence of ARI by gender of the child and wealth quintile. Children living in households that use wood/straw or animal dung for cooking are proportionately more likely to exhibit symptoms of ARI than children living in households using other sources of cooking fuel. Child Health | 133 Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI), in the two weeks preceding the survey and the percentage with symptoms of ARI who took specific treatments according to background characteristics, Ethiopia 2005 Children under age five with symptoms of ARI Children under age five Background characteristic Percentage with symptoms of ARI1 Number of children Percentage for whom treatment was sought from a health facility or provider2 Percentage who took antibiotics Number of children Age in months <6 13.8 1,152 21.6 5.2 159 6-11 17.7 1,071 19.2 4.3 190 12-23 14.6 1,877 22.4 3.9 274 24-35 13.1 1,892 20.2 6.5 247 36-47 10.8 2,105 17.2 6.1 226 48-59 8.5 2,013 9.7 2.8 172 Sex Male 12.6 5,129 18.9 4.3 646 Female 12.5 4,980 18.5 5.5 623 Residence Urban 8.5 752 45.6 11.0 64 Rural 12.9 9,357 17.3 4.6 1,205 Region Tigray 14.4 653 13.9 7.0 94 Affar 5.3 96 * * 5 Amhara 9.3 2,312 14.7 1.6 215 Oromiya 14.2 4,017 20.3 5.1 572 Somali 7.0 432 (7.6) (3.7) 30 Benishangul-Gumuz 9.6 95 23.0 12.6 9 SNNP 14.4 2,273 19.6 5.6 328 Gambela 10.4 29 (35.4) (7.0) 3 Harari 9.3 21 (34.9) (4.4) 2 Addis Ababa 6.1 146 * * 9 Dire Dawa 2.4 34 * * 1 Cooking fuel Electricity or gas (0.2) 12 * * 0 Kerosene 4.7 128 * * 6 Charcoal 10.2 167 (51.8) (9.8) 17 Wood/straw3 12.8 9,025 18.1 5.0 1,156 Animal dung 11.6 768 16.7 0.0 89 Other/missing (2.5) 9 * * 0 Mother's education No education 12.5 7,951 15.4 4.1 997 Primary 13.5 1,709 27.6 7.2 231 Secondary and higher 9.2 450 (50.1) (11.8) 41 Wealth quintile Lowest 12.3 2,218 18.6 4.2 272 Second 11.4 2,122 12.3 3.9 241 Middle 14.6 2,210 20.7 5.5 323 Fourth 13.1 2,015 13.2 5.2 265 Highest 10.8 1,544 33.1 5.9 167 Total 12.6 10,109 18.7 4.9 1,269 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Symptoms of ARI (cough accompanied by short rapid breathing which was chest-related) is considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 3 Includes grass, shrubs, crop residues. 134 | Child Health Cough and rapid breathing were higher among children in rural areas (13 percent) than children in urban areas (9 percent). Prevalence of ARI ranges from a high of 14 percent among children under five living in Tigray, Oromiya and SNNP to a low of 2 percent among children in Dire Dawa. ARI prevalence is lower for children whose mothers have at least some secondary education. Only 19 percent of all children under five with symptoms of ARI were taken to a health facility or provider. There are differences in the proportion of children with ARI symptoms taken to a health facility by child’s age; children under age six months and children age 12-23 months are more likely to be taken to a health facility than other children. There is no gender difference in children taken to a health facility or provider. Children of women with primary or secondary education are more likely to be taken to a health facility or provider when they have ARI than other children. The proportion of children with cough and rapid breathing who were taken to a health facility is much higher in urban areas (46 percent) than in rural areas (17 percent). Five percent of children with symptoms of ARI received antibiotics. Compared with 2000, far fewer children in 2005 were reported to have ARI in the two weeks preceding the survey, and a slightly higher proportion were taken for treatment. 10.4 FEVER Fever is a major manifestation of malaria and other acute infections in children. Malaria and fever contribute to high levels of malnutrition and mortality. While fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Since malaria is a major contributory cause of death in infancy and childhood in many developing countries, the so- called presumptive treatment of fever with anti-malarial medication is advocated in many countries where malaria is endemic. Malaria is discussed in greater detail in Chapter 12. Table 10.6 shows the percentage of children under five with fever during the two weeks preceding the survey and the percentage receiving various treatments, by selected background characteristics. Nineteen percent of children under five were reported to have had fever in the two weeks preceding the survey. The prevalence of fever varies by age of child. Children age 6-11 months and 12-23 months are more commonly sick with fever (28 percent and 23 percent, respectively) than other children. There are no significant variations in the prevalence of fever by sex of the child, place of residence, or wealth quintile of the household. The prevalence of fever among children under five varies from a low of 12 percent in Dire Dawa to a high of 24 percent in SNNP. The prevalence of fever is also relatively high among children living in Tigray (20 percent) and Oromiya (19 percent). Less than one in five (18 percent) children with fever were taken to a health facility or provider for treatment. Younger children, male children, and children of mothers with some secondary or higher education were more likely to be taken to a health facility or provider for treatment of fever than other children. Likewise, children of mothers in the highest wealth quintile, children living in urban areas, and children living in Addis Ababa were more likely to be treated in a health facility or by a provider. A very small percentage of children with fever received anti-malarial drugs (3 percent) or antibiotic drugs (6 percent). Child Health | 135 Table 10.6 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey and the percentage with fever for whom treatment was sought from a health facility or provider, who took antimalarial drugs and who took antibiotic drugs, by background characteristics, Ethiopia 2005 Children under age five with fever Children under age five Background characteristic Percentage with fever Number of children Percentage for whom treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 16.8 1,152 19.0 0.6 7.2 194 6-11 27.6 1,071 20.3 4.4 6.8 295 12-23 23.3 1,877 18.3 2.7 6.4 438 24-35 21.6 1,892 16.5 1.9 6.4 408 36-47 15.1 2,105 17.0 3.5 6.2 317 48-59 11.6 2,013 14.0 4.9 5.7 233 Sex Male 18.2 5,129 19.2 2.7 6.6 935 Female 19.1 4,980 15.9 3.2 6.3 951 Residence Urban 16.0 752 45.3 4.2 13.3 121 Rural 18.9 9,357 15.6 2.9 6.0 1,765 Region Tigray 20.3 653 10.1 0.0 6.4 132 Affar 17.0 96 12.1 9.0 7.6 16 Amhara 14.2 2,312 12.6 2.4 2.3 329 Oromiya 19.0 4,017 20.2 1.5 7.2 764 Somali 14.0 432 4.4 0.0 1.9 60 Benishangul-Gumuz 15.3 95 21.0 4.0 7.9 15 SNNP 23.5 2,273 18.5 6.3 7.8 534 Gambela 17.8 29 28.0 11.2 4.1 5 Harari 13.7 21 23.1 1.2 6.1 3 Addis Ababa 16.1 146 50.9 3.3 20.4 23 Dire Dawa 12.3 34 (28.6) (0.0) (6.8) 4 Mother's education No education 18.3 7,951 13.0 2.5 4.9 1,457 Primary 21.3 1,709 29.4 4.9 11.2 364 Secondary and higher 14.4 450 53.9 4.1 14.1 65 Wealth quintile Lowest 19.1 2,218 10.8 0.5 4.8 422 Second 19.5 2,122 14.2 2.7 2.8 413 Middle 19.7 2,210 16.6 3.6 9.0 436 Fourth 17.7 2,015 16.4 3.5 6.8 357 Highest 16.7 1,544 37.0 5.7 10.0 258 Total 18.7 10,109 17.5 3.0 6.4 1,886 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner 10.5 PREVALENCE OF DIARRHOEA Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children although the condition can be easily treated with oral rehydration therapy (ORT). Exposure to diarrhoea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. In interpreting the findings of the 2005 Ethiopia DHS survey, it should be borne in mind that prevalence of diarrhoea varies seasonally. 136 | Child Health Table 10.7 shows the percentage of children under five with diarrhoea in the two weeks preceding the survey according to selected background characteristics. Overall, 18 percent of all children under five had diarrhoea while 6 percent had diarrhoea with blood. The occurrence of diarrhoea varies by age of the child. Young children age 6-23 months are more prone to diarrhoea than children in the other age groups. There are no variations in the prevalence of diarrhoea by child’s sex. Diarrhoea is more common among rural children (19 percent) than urban children (12 percent). There are also variations in the prevalence of diarrhoea by regions. Children living in the SNNP Region are more susceptible to episodes of diarrhoea (25 percent) than children living in the other region. Children living in Dire Dawa and Somali have the lowest prevalence of diarrhoea when compared with children living in the other regions (12 percent). The prevalence of diarrhoea with blood follows a pattern similar to that observed for diarrhoea in general. 10.6 DIARRHOEA TREATMENT In the 2005 EDHS, mothers of children who had diarrhoea were asked about what was done to treat the illness. Table 10.8 shows the percentage of children with diarrhoea who received specific treatments according to back- ground characteristics. Twenty-two per- cent of children with diarrhoea were taken to a health provider. Nearly one in two children (45 percent) of mothers with some secondary or higher education and more than one in three children (37 percent) of mothers in the highest wealth quintile were taken to a health provider. Notable differences also exist by place of residence. The proportion of children in urban areas taken to a health facility is 35 percent whereas only 22 percent of children in rural areas were taken to a health provider. There are slight variations between regions. More than two-fifths of children living in Gambela were taken to a health provider in contrast to less than one in ten children living in Affar and Somali. Table 10.7 Prevalence of diarrhoea Percentage of children under age five who had diarrhoea in the two weeks preceding the survey, by background characteristics, Ethiopia 2005 Diarrhoea in the two weeks preceding the survey Background characteristic All diarrhoea Diarrhoea with blood Number of children Age in months <6 13.9 1.9 1,152 6-11 29.3 6.7 1,071 12-23 28.3 10.2 1,877 24-35 18.5 7.6 1,892 36-47 12.4 5.2 2,105 48-59 10.0 4.4 2,013 Sex Male 17.9 6.2 5,129 Female 18.0 6.2 4,980 Residence Urban 12.1 3.3 752 Rural 18.5 6.4 9,357 Region Tigray 12.8 5.4 653 Affar 13.7 3.0 96 Amhara 14.6 6.5 2,312 Oromiya 17.7 4.9 4,017 Somali 12.2 2.5 432 Benishangul-Gumuz 21.3 7.2 95 SNNP 25.1 9.6 2,273 Gambela 15.1 2.9 29 Harari 18.8 3.5 21 Addis Ababa 12.9 2.7 146 Dire Dawa 11.6 2.2 34 Mother's education No education 18.1 6.3 7,951 Primary 19.4 6.8 1,709 Secondary and higher 9.8 1.9 450 Wealth quintile Lowest 17.8 5.2 2,218 Second 20.2 7.0 2,122 Middle 19.7 6.7 2,210 Fourth 16.8 7.5 2,015 Highest 14.3 4.0 1,544 Source of drinking water1 Improved 16.6 5.2 5,798 Non-improved 19.9 7.6 4,294 Other/missing (27.3) (7.0) 18 Toilet facility2 Improved, not shared 22.0 9.7 605 Not improved 17.7 6.0 9,504 Total 18.0 6.2 10,109 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 See Table 2.7 for definition of categories. 2 See Table 2.8 for definition of categories. Child Health | 137 Table 10.8 Diarrhoea treatment Among children under age five who had diarrhoea in the two weeks preceding the survey, the percentage who were taken for treatment to a health provider, the percentage who received oral rehydration therapy (ORT), and the percentage given other treatments, by background characteristics, Ethiopia 2005 Oral rehydration therapy (ORT) Other treatments Background characteristic Percentage of children with diarrhoea taken to a health provider1 ORS packets or pre- packaged liquid Recom- mended home fluids (RHF) Either ORS or RHF Increased fluids Any ORT Anti- biotic drugs Anti- motility drugs Zinc supple- ments Home remedy/ other Missing No treat- ment Number of children with diarrhoea Age in months <6 15.9 5.1 13.5 16.8 2.4 19.2 10.5 0.0 0.0 15.2 0.4 63.9 160 6-11 17.9 17.3 21.4 32.7 8.3 37.7 7.4 1.6 0.0 10.8 0.0 56.7 314 12-23 26.5 27.5 18.9 37.7 5.8 40.1 10.6 0.4 0.3 16.9 0.0 47.4 531 24-35 20.3 18.6 16.4 28.8 8.8 34.9 10.4 1.1 0.7 19.1 0.2 47.8 350 36-47 22.1 20.4 21.9 32.7 12.6 39.1 16.0 0.0 0.0 14.6 0.6 41.1 261 48-59 26.5 17.4 19.7 32.4 17.7 43.5 7.3 1.4 0.0 18.6 0.0 41.7 202 Sex Male 24.8 21.4 20.2 33.9 7.7 38.5 12.0 1.0 0.4 15.5 0.3 47.5 920 Female 19.6 18.4 17.5 30.0 9.9 35.6 8.8 0.5 0.1 16.5 0.0 50.6 898 Type of diarrhoea Non bloody 20.1 17.6 17.9 29.9 8.8 34.4 10.2 1.0 0.2 14.8 0.3 51.9 1,192 Bloody 26.3 24.3 20.8 36.0 8.7 42.2 10.7 0.3 0.3 18.2 0.0 43.4 626 Residence Urban 35.0 45.7 33.1 56.6 8.1 59.2 10.1 0.0 0.0 17.5 0.0 34.8 91 Rural 21.6 18.6 18.1 30.7 8.8 35.9 10.4 0.8 0.2 15.9 0.2 49.7 1,727 Region Tigray 18.8 21.1 25.6 41.5 23.3 53.5 12.4 0.0 0.0 2.9 0.7 42.5 84 Affar 9.2 8.8 11.8 16.3 23.9 40.2 5.3 0.0 0.0 6.8 1.5 51.6 13 Amhara 27.1 19.9 18.8 32.3 1.0 32.9 9.0 0.6 0.5 15.9 0.0 53.1 337 Oromiya 23.5 22.6 19.6 35.7 10.7 40.4 11.7 1.7 0.2 13.4 0.2 47.1 709 Somali 8.5 15.8 35.1 40.7 2.9 40.7 0.8 0.0 1.4 17.2 1.3 49.8 53 Benishangul-Gumuz 29.6 24.9 28.5 39.6 5.0 40.8 8.6 0.0 0.0 16.8 0.0 48.4 20 SNNP 18.6 15.9 14.3 23.8 9.2 31.0 10.5 0.0 0.0 21.2 0.0 50.8 571 Gambela 40.2 27.6 23.6 41.7 3.4 41.7 11.2 1.5 0.0 14.4 0.0 45.6 4 Harari 31.3 22.6 28.7 40.3 30.9 57.3 7.6 1.0 0.0 16.2 1.3 30.5 4 Addis Ababa (44.6) (45.3) (47.7) (66.0) (9.4) (70.9) (7.0) (0.0) (0.0) (18.7) (0.0) (23.4) 19 Dire Dawa (25.7) (31.3) (10.6) (40.4) (9.6) (45.5) (0.0) (0.0) (0.0) (8.9) (0.0) (51.8) 4 Mother's education No education 18.9 17.0 17.0 28.9 8.5 33.7 9.4 0.8 0.2 15.9 0.2 51.8 1,443 Primary 33.6 28.4 23.9 41.0 9.2 46.9 13.2 0.8 0.5 16.6 0.0 40.4 332 Secondary and higher 44.6 51.6 41.8 64.9 16.0 73.0 21.7 0.0 0.0 13.7 0.0 21.6 44 Wealth quintile Lowest 14.3 13.5 15.0 25.4 6.1 28.9 10.4 0.7 0.2 16.1 0.2 56.3 395 Second 17.1 13.5 19.0 27.1 9.3 32.3 7.9 0.7 0.0 15.8 0.4 51.5 428 Middle 27.1 23.1 18.2 32.8 10.9 38.9 13.4 1.1 0.4 14.2 0.0 45.6 436 Fourth 21.8 19.8 16.7 31.4 7.7 36.8 9.5 0.5 0.0 16.4 0.2 50.5 339 Highest 37.2 37.8 30.2 52.5 10.3 57.6 10.6 0.9 0.7 19.2 0.0 35.5 221 Total 22.2 19.9 18.9 32.0 8.8 37.1 10.4 0.8 0.2 16.0 0.2 49.0 1,819 Note: ORT includes solution prepared from oral rehydration salt (ORS) packets or prepackaged liquids, recommended home fluids (RHF), and increased fluids. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop and traditional practitioner Thirty-seven percent of children with diarrhoea were treated with some kind of oral re- hydration therapy (ORT): 20 percent were treated with ORS prepared from an ORS packet, 19 percent were given recommended home fluids, and 9 percent were given increased fluids. 138 | Child Health Ten percent of children were given antibiotic drugs and 16 percent were given home remedies or other treatments. However, about half (49 percent) of children with diarrhoea did not receive any treatment at all. Diarrhoea treatment does not vary significantly by age. Male children and children who had diarrhoea with blood are more likely to receive ORT than others. Large variations exist by mother’s education and wealth quintile. There are also marked differences between urban and rural areas. Three-fifths of children in urban areas (59 percent) received ORT compared with just over one-third of children in rural areas (36 percent). Children living in SNNP are least likely to receive ORT. Comparable data from the 2000 EDHS show that only 13 percent of children with diarrhoea were taken to a health provider in 2000 compared with 22 percent in 2005. On the other hand, a higher percentage of children with diarrhoea in 2005 than in 2000 did not receive any treatment (49 percent versus 39 percent). 10.7 FEEDING PRACTICES Mothers are encouraged to continue feeding children with diarrhoea normally and to increase the amount of fluids. These practices help to reduce dehydration and minimize the adverse consequences of diarrhoea on the child’s nutritional status. Mothers were asked whether they gave the child less, the same amount, or more fluids and food than usual when their child had diarrhoea. Table 10.9 shows the percent distribution of children under five who had diarrhoea in the past two weeks by feeding practices, according to background characteristics. Nineteen percent of children who had diarrhoea were given the same amount of liquid as usual, 9 percent were given more, 32 percent were given somewhat less than the usual amount, and 26 percent were given much less than the usual amount. Fourteen percent of children who had diarrhoea were given no liquids. Regarding the amount of food offered to children who had diarrhoea, 14 percent were given the same as usual, only 1 percent were given more, 30 percent were given somewhat less than the usual amount of food, 26 percent were given much less than the usual amount of food, and 18 percent did not receive food during their illness, presumably because these children had not yet started eating solid food. Older children age 36 months and above, children who did not have bloody diarrhoea, children of the most educated mothers, children in the highest wealth quintile and children residing in Tigray are more likely to receive more or the same amount of liquid during episodes of diarrhoea than other children. A similar pattern is seen regarding the amount of food offered during diarrhoea. Child Health | 139 Table 10.9 Feeding practices during diarrhoea Percent distribution of children under five years who had diarrhoea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, according to background characteristics, Ethiopia 2005 Amount of liquids offered Amount of food offered Background characteristic More Same as usual Some- what less Much less None Don't know Total More Same as usual Some- what less Much less None Never gave food Don't know Total Number of children with diarrhoea Age in months <6 2.4 24.5 17.2 27.1 28.9 0.0 100.0 0.1 7.2 4.9 2.1 0.1 84.7 0.9 100.0 160 6-11 8.3 16.6 30.2 26.9 17.5 0.6 100.0 0.9 12.3 15.8 17.5 14.4 38.9 0.2 100.0 314 12-23 5.8 19.9 32.8 26.2 14.1 1.2 100.0 1.8 11.4 31.4 28.6 15.2 11.0 0.7 100.0 531 24-35 8.8 19.6 32.3 28.5 10.4 0.4 100.0 0.5 15.7 34.6 36.3 11.6 0.6 0.6 100.0 350 36-47 12.6 18.4 37.1 23.4 6.8 1.8 100.0 1.7 16.7 42.6 25.3 11.4 0.5 1.9 100.0 261 48-59 17.7 11.4 39.2 22.5 9.2 0.0 100.0 1.5 18.6 39.1 35.1 5.6 0.0 0.0 100.0 202 Sex Male 7.7 20.2 32.1 25.3 14.2 0.4 100.0 1.1 13.6 30.1 25.3 11.3 18.0 0.6 100.0 920 Female 9.9 16.8 32.3 26.7 13.1 1.2 100.0 1.3 13.5 28.8 26.9 11.6 17.2 0.8 100.0 898 Type of diarrhoea Non bloody 8.8 21.8 33.2 22.5 12.4 1.2 100.0 1.1 15.6 29.6 22.4 9.9 20.6 0.8 100.0 1,192 Bloody 8.7 12.2 30.2 32.8 16.1 0.0 100.0 1.3 9.6 29.3 33.2 14.4 11.7 0.5 100.0 626 Residence Urban 8.1 21.3 40.7 21.3 8.5 0.0 100.0 0.2 14.8 38.1 25.3 2.5 19.1 0.0 100.0 91 Rural 8.8 18.4 31.7 26.3 14.0 0.8 100.0 1.2 13.5 29.0 26.2 11.9 17.5 0.7 100.0 1,727 Region Tigray 23.3 23.1 28.6 18.5 2.4 4.1 100.0 4.5 14.6 34.7 28.4 8.5 7.6 1.8 100.0 84 Affar 23.9 21.5 29.1 12.3 13.3 0.0 100.0 9.6 26.6 12.8 30.0 2.5 18.6 0.0 100.0 13 Amhara 1.0 21.0 31.5 26.0 20.5 0.0 100.0 0.6 17.1 27.0 25.2 15.6 14.1 0.4 100.0 337 Oromiya 10.7 17.1 29.8 25.2 15.7 1.5 100.0 0.7 13.1 26.2 26.4 13.8 19.3 0.6 100.0 709 Somali 2.9 3.1 37.1 52.4 4.4 0.0 100.0 1.8 2.9 32.6 50.2 0.0 12.5 0.0 100.0 53 Benishangul-Gumuz 5.0 23.0 41.5 19.6 10.9 0.0 100.0 4.2 16.9 35.7 21.8 10.9 10.4 0.0 100.0 20 SNNP 9.2 18.7 35.3 26.6 10.2 0.0 100.0 1.4 12.1 33.8 23.8 7.9 20.1 0.9 100.0 571 Gambela 3.4 34.1 41.0 5.8 15.6 0.0 100.0 0.6 20.9 46.5 8.0 10.2 12.8 1.0 100.0 4 Harari 30.9 10.1 33.3 18.0 3.9 3.9 100.0 11.2 10.1 34.0 27.4 6.5 6.9 3.9 100.0 4 Addis Ababa (9.4) (36.3) (27.3) (23.1) (3.9) (0.0) (100.0) (0.0) (26.4) (26.4) (31.7) (7.2) (8.3) (0.0) (100.0) 19 Dire Dawa (9.6) (22.0) (45.3) (23.1) (0.0) (0.0) (100.0) (1.8) (7.4) (52.7) (8.0) (8.7) (21.3) (0.0) (100.0) 4 Mother's education No education 8.5 18.1 31.9 27.2 13.5 0.8 100.0 1.3 13.3 29.8 26.7 10.9 17.2 0.9 100.0 1,443 Primary 9.2 19.6 33.9 21.4 15.2 0.7 100.0 0.7 14.4 27.1 23.8 15.3 18.7 0.0 100.0 332 Secondary and higher 16.0 25.1 30.9 21.0 7.0 0.0 100.0 0.3 17.1 35.7 24.3 0.7 21.9 0.0 100.0 44 Wealth quintile Lowest 6.1 17.2 33.8 25.5 17.1 0.3 100.0 0.9 11.0 28.4 27.0 14.2 17.0 1.4 100.0 395 Second 9.3 19.0 34.8 25.2 11.4 0.5 100.0 1.2 14.9 25.5 29.3 12.2 15.7 1.1 100.0 428 Middle 10.9 15.1 33.8 24.9 14.2 1.2 100.0 0.6 12.0 35.1 22.1 10.9 19.4 0.0 100.0 436 Fourth 7.7 18.6 25.7 31.9 15.2 1.0 100.0 1.8 15.1 24.5 27.1 9.8 21.2 0.6 100.0 339 Highest 10.3 26.8 31.3 21.9 8.7 1.1 100.0 2.0 16.3 35.4 24.8 8.5 13.1 0.0 100.0 221 Total 8.8 18.5 32.2 26.0 13.7 0.8 100.0 1.2 13.6 29.5 26.1 11.4 17.6 0.7 100.0 1,819 Note: Figures in parentheses are based on 25-49 unweighted cases. 10.8 KNOWLEDGE OF ORS PACKETS A simple and effective response to dehydration caused by diarrhoea is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy, which may include the use of a solution prepared from packets of oral rehydration salts (ORS). To ascertain how widespread knowledge of ORS is in Ethiopia, respondents were asked whether they know about ORS packets. 140 | Child Health Table 10.10 shows that slightly less than half of women (46 percent) who gave birth in the five years preceding the survey know about ORS packets. There are significant differences in knowledge of ORS packets between women residing in urban and rural areas. Knowledge is twice as high among urban women (85 percent) than among rural women (43 percent). Knowl- edge of ORS also varies by region. More than nine in ten mothers in Addis Ababa (94 percent) and about four in five mothers in Tigray, Harari, and Dire Dawa know about ORS packets, compared with slightly more than three in ten mothers in the Amhara and Benishangul- Gumuz regions. There are marked differences in knowledge of ORS packets by mother’s level of education; 89 percent of mothers with some secondary or higher education know about ORS packets compared with 41 percent of mothers with no education. Similarly, knowledge of ORS packets is widespread among mothers in the highest wealth quintile (73 percent), compared with mothers in the lowest wealth index (41 percent). There has been a steep decline in the proportion of mothers who have heard about ORS, from 66 percent in 2000 to 46 percent in 2005. 10.9 STOOL DISPOSAL If human faeces are left uncontained, disease may spread by direct contact or by animal contact with the faeces. Hence, the proper disposal of children’s stools is extremely important in preventing the spread of disease. Table 10.11 presents information on the disposal of the stools of children under five, by background characteristics. Sixty-seven percent of children’s stools are left uncontained: 7 percent are put or rinsed into a drain or ditch, 11 percent are thrown into the garbage, and 49 percent are left in the open. Slightly more than one in five children’s stools are disposed of hygienically. Two percent of children under five use a toilet or latrine. Additionally, 17 percent of children’s stool are disposed of in the toilet or latrine, and 2 percent are buried in the yard. There are pronounced differences by mother’s level of education and type of toilet facilities in the way stools are disposed of. For more than half the children (51 percent) of mothers with secondary and higher education, stools are disposed of hygienically (child uses toilet, child’s stool thrown in toilet, or buried in yard), compared with 17 percent of children of mothers with no education. Similarly, 51 percent of children in households with improved toilets that are not shared with other households, have their stools contained compared with 19 percent of children in the households using non- improved or shared toilet facilities. Table 10.10 Knowledge of ORS packets or pre- packaged liquids Percentage of mothers who gave birth in the five years preceding the survey who know about ORS packets or pre-packaged liquids for treatment of diarrhoea, by background characteristics, Ethiopia 2005 Background characteristic Percentage of mothers who know about ORS packets or prepackaged liquids Number of mothers Age 15-19 42.2 440 20-24 50.5 1,473 25-29 46.4 1,961 30-34 43.2 1,428 35-49 45.8 2,006 Residence Urban 85.3 634 Rural 42.5 6,674 Region Tigray 80.8 480 Affar 54.0 68 Amhara 31.7 1,856 Oromiya 49.9 2,723 Somali 45.5 288 Benishangul-Gumuz 36.1 69 SNNP 41.8 1,632 Gambela 50.0 23 Harari 80.0 15 Addis Ababa 94.1 129 Dire Dawa 79.1 25 Education No education 41.4 5,734 Primary 55.7 1,205 Secondary and higher 88.9 368 Wealth quintile Lowest 41.1 1,520 Second 39.2 1,553 Middle 41.0 1,586 Fourth 42.4 1,451 Highest 73.1 1,196 Total 46.2 7,307 ORS = Oral rehydration salts Child Health | 141 Children’s stools are more likely to be contained in urban areas (52 percent) than in rural areas (19 percent). This marked difference could be attributed to the fact that toilet facilities are more available in urban areas. The table also shows that 69 percent of children’s stools in rural areas are thrown in the garbage, rinsed in a drain, or left in the open compared with 44 percent in urban areas. There are large variations in the way the child’s faeces are disposed of. For example, the percentage of children whose stools are contained ranges from a low of 11 percent in Somali to a high of 68 percent in Addis Ababa. Furthermore, 61 percent of children’s stools are left in the open in the Tigray and Somali regions, compared with 5 percent in Addis Ababa. Table 10.11 Disposal of children's stools Among mothers whose youngest child under age five is living with her, percent distribution by the manner of disposing of the child's last faecal matter, according to background characteristics, Ethiopia 2005 Children's stools contained Children's stools uncontained Background characteristic Child used toilet or latrine Put/rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Left in the open Other Don't know Total Number of mothers Age of child in months < 6 0.3 11.2 1.3 10.1 7.6 49.9 18.9 0.7 100.0 1,142 6-11 1.0 16.5 1.8 7.0 11.8 48.9 12.2 0.9 100.0 1,057 12-17 0.6 17.7 2.5 7.6 12.2 48.0 10.6 0.8 100.0 1,091 18-23 0.8 21.2 1.6 6.1 12.7 49.5 7.2 0.7 100.0 718 24-35 1.4 17.5 1.6 6.0 12.9 51.5 8.2 1.0 100.0 1,442 36-59 6.6 20.6 1.9 5.4 9.3 46.5 8.5 1.2 100.0 1,529 Toilet facilities Improved, not shared1 7.9 40.8 2.1 8.1 3.2 28.7 8.5 0.7 100.0 420 Not improved or shared 1.7 15.9 1.8 6.9 11.4 50.3 11.0 0.9 100.0 6,559 Residence Urban 5.4 44.8 1.6 12.6 13.6 17.7 4.2 0.1 100.0 586 Rural 1.8 14.9 1.8 6.4 10.7 51.9 11.5 1.0 100.0 6,393 Region Tigray 0.9 10.2 5.3 3.5 16.0 60.9 2.5 0.7 100.0 466 Affar 2.5 14.8 2.1 6.3 19.1 53.8 1.4 0.0 100.0 63 Amhara 1.7 11.7 1.8 6.6 9.8 55.9 11.9 0.6 100.0 1,737 Oromiya 1.5 9.4 1.4 9.3 12.5 52.6 12.1 1.1 100.0 2,630 Somali 1.3 6.8 2.8 1.2 23.3 60.8 2.0 1.8 100.0 273 Benishangul-Gumuz 3.1 20.8 0.7 2.1 7.1 54.0 10.8 1.4 100.0 65 SNNP 3.9 37.3 1.2 5.0 6.1 32.8 12.8 0.9 100.0 1,567 Gambela 1.8 14.5 0.6 5.7 17.8 54.2 4.3 1.0 100.0 22 Harari 2.8 22.5 4.7 3.8 21.2 32.9 10.3 1.8 100.0 14 Addis Ababa 3.7 63.2 0.6 15.3 6.9 5.4 4.4 0.6 100.0 118 Dire Dawa 2.3 39.8 3.2 6.1 6.3 40.5 1.5 0.3 100.0 24 Education No education 1.6 13.3 1.9 6.7 11.5 52.9 11.2 0.9 100.0 5,485 Primary 3.1 29.1 1.2 6.2 9.4 38.3 11.4 1.3 100.0 1,147 Secondary and higher 6.4 43.1 1.3 13.4 7.7 23.0 4.8 0.2 100.0 348 Wealth quintile Lowest 0.5 4.5 2.7 7.0 13.0 59.3 11.8 1.2 100.0 1,476 Second 0.7 9.8 1.8 7.2 11.1 55.4 12.9 1.1 100.0 1,477 Middle 1.9 18.2 1.2 6.1 11.4 50.2 10.1 0.9 100.0 1,514 Fourth 3.2 21.4 2.0 6.2 9.5 45.8 11.0 0.9 100.0 1,389 Highest 5.0 38.4 1.0 8.6 9.1 29.5 7.9 0.4 100.0 1,123 Total 2.1 17.4 1.8 6.9 10.9 49.0 10.9 0.9 100.0 6,979 1 Non-shared facilities that are of the types flush or pour flush into a piped sewer system/septic tank/pit latrine, ventilated, improved pit (VIP) latrine, pit latrine with a slab and composting toilet.   Nutrition of Children and Women | 143 This chapter covers the nutritional status of children and women. The section on children covers the following related topics: infant and young child feeding practices, including breastfeeding and feeding with solid/semi-solid foods; diversity of foods fed; frequency of feeding; micronutrient intake among children and women; and prevalence of anaemia. The sections on nutritional status cover anthropometric assessment of the nutritional status of children under five years of age and the nutritional status of women 15 to 49 years of age. Adequate nutrition is critical to child development. The period from birth to two years of age is important for optimal growth, health and development, especially since it is during this period that children are particularly vulnerable to growth retardation, micronutrient deficiencies, and common childhood illnesses such as diarrhoea and acute respiratory infections (ARI). A woman’s nutritional status has important implications for her health as well as the health of her children. Malnutrition in women results in reduced productivity, an increased susceptibility to infections, retarded recovery from illness, and heightened risk of adverse pregnancy outcomes. A woman who has poor nutritional status as indicated by a low body mass index (BMI), short stature, anaemia, or other micronutrient deficiency, has a greater risk of obstructed labour, having a baby with a low birth weight, producing lower quality breast milk, death due to postpartum haemorrhage, and illness for herself and her baby. 11.1 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the contraction of the uterus and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 11.1 shows the percentage of all children born in the five years before the survey by breastfeeding status and the timing of initial breastfeeding, by background characteristics. Breastfeeding is nearly universal in Ethiopia, with 96 percent of children born in the five years preceding the survey having been breastfed at some time. The proportion of children ever breastfed ranges from a low of 93 percent in Addis Ababa to a high of 99 percent in Harari. However, the percentage of children ever breastfed does not vary much by other background characteristics. More than two in three children are breastfed within one hour of birth (69 percent) and 86 percent within one day of birth. Twenty-nine percent of children were given a prelacteal feed, that is, something other than breast milk during the first three days of life. Forty-five percent of children were given the first milk. The percentage of children who are breastfed early has increased in the past five years, the increase being more pronounced for children breastfed within 1 hour. There is no difference in the timing of initial breastfeeding by gender of the child. However, other characteristics of the infant and mother, such as type of assistance at delivery, place of delivery, have important influences on early breastfeeding practices. Rural children are more likely than urban children to start breastfeeding within one hour and within one day of birth, as are children born in Dire Dawa and Somali compared with children in the other regions. Highly educated mothers are less likely than those with little or no education to put their newborn to the breast within the first hour or day of birth. Differences in early breastfeeding by wealth are small. Early initiation of breastfeeding is more common among children whose mothers were assisted at delivery by a trained traditional birth attendant and among children delivered at home. NUTRITION OF CHILDREN AND WOMEN 11 144 | Nutrition of Children and Women Table 11.1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed and for last-born children ever breastfed in the five years preceding the survey, the percentage who started breastfeeding within one hour and within one day of birth and the percentage who received a prelacteal feed, according to background characteristics, Ethiopia 2005 Percentage who started breastfeeding: Background characteristic Percentage ever breastfed Number of children Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a prelacteal feed2 Percentage who received the first milk Number of children ever breastfed Sex Male 96.0 5,723 68.4 85.2 29.5 44.9 3,668 Female 95.9 5,440 69.8 86.3 28.4 45.7 3,441 Residence Urban 95.0 815 64.8 81.9 38.8 43.8 608 Rural 96.0 10,348 69.5 86.1 28.0 45.5 6,501 Region Tigray 98.5 698 52.9 73.7 30.6 55.8 475 Affar 97.2 107 86.4 91.1 36.8 68.3 67 Amhara 97.1 2,621 62.6 77.4 44.6 44.8 1,823 Oromiya 94.8 4,411 72.1 88.5 26.0 45.8 2,624 Somali 95.1 477 91.4 94.0 19.2 53.7 275 Benishangul-Gumuz 96.7 105 72.1 80.3 19.0 45.4 67 SNNP 96.4 2,500 71.4 92.7 15.4 39.3 1,596 Gambela 95.9 31 72.7 80.8 28.3 43.0 22 Harari 99.0 22 73.7 88.2 48.6 75.9 15 Addis Ababa 92.9 153 66.2 86.7 49.4 42.1 120 Dire Dawa 98.1 37 91.4 94.4 34.2 66.5 24 Mother's education No education 96.2 8,838 70.4 86.2 28.8 46.4 5,594 Primary 95.1 1,855 64.8 84.6 28.2 38.5 1,157 Secondary and higher 95.4 470 63.0 81.5 34.8 51.0 357 Wealth quintile Lowest 96.4 2,440 72.1 85.4 30.7 49.3 1,486 Second 95.8 2,356 69.7 85.5 27.3 46.5 1,510 Middle 95.8 2,486 69.9 85.6 26.8 45.6 1,541 Fourth 95.3 2,222 67.0 86.4 28.5 43.5 1,415 Highest 96.6 1,660 65.8 85.8 32.3 40.7 1,157 Assistance at delivery Health professional3 93.2 644 62.2 84.4 30.0 49.5 487 Trained traditional birth attendant 95.5 734 70.8 88.2 28.6 41.0 445 Untrained traditional birth attendant 96.3 2,399 68.7 84.1 35.2 50.4 1,480 Other 96.0 6,756 69.2 85.6 28.0 43.3 4,261 No one 97.1 607 75.6 92.8 17.1 47.7 430 Missing 100.0 23 46.2 46.2 0.0 29.9 7 Place of delivery Health facility 93.4 589 61.4 84.9 29.6 49.2 444 At home 96.1 10,502 69.7 85.9 28.9 45.0 6,631 Other 94.9 45 52.2 82.0 32.0 53.7 28 Missing 100.0 26 34.1 34.8 0.6 34.8 6 Total 96.0 11,163 69.1 85.7 29.0 45.3 7,109 Note: Table is based on births in the five years preceding the survey whether the children are living or dead. 1 Includes children who started breastfeeding within one hour of birth. 2 Received something other than breast milk during the first three days of life, before the mother started breastfeeding regularly. 3 Doctor, nurse/midwife, or auxiliary midwife 11.2 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first 6 months of life and that children be given solid or semisolid complementary food in addition to continued breastfeeding from six months on. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of Nutrition of Children and Women | 145 life. In addition, the mother's antibodies in breast milk provide immunity to disease. Early supple- mentation is discouraged for several reasons. First, it exposes infants to pathogens and increases their risk of infection, especially disease. Second, it decreases infants' intake of breast milk and therefore suckling, which reduces breast milk production. Third, in a harsh socioeconomic environment, supplementary food is often nutritionally inferior. Information on supplementation was obtained by asking mothers about the current breast- feeding status of all children under five years of age and, for the youngest child born in the three-year period before the survey and living with the mother, food (liquids or solids) given to the child the day before the survey. Table 11.2 shows the percent distribution of youngest children under three years living with the mother by breastfeeding status and percentage of children under three years using a bottle with a nipple, according to age in months. The data presented in Table 11.2 and Figure 11.1 shows that not all children under 6 months are exclusively breastfed. Contrary to WHO's recommendations only one in three Ethiopian children age 4-5 months is exclusively breastfed. The table also shows that just over two-thirds of children under 2 months of age are exclusively breastfed, 10 percent consume breast milk and plain water, 5 percent consume breast milk and other non-milk liquids, and 11 percent consumed breast milk and other milk. Six percent of children under 2 months are given complementary foods. The EDHS results also indicate that complementary foods are not introduced in a timely fashion for many children. At 6-8 months of age, 14 percent of children continue to be exclusively breastfed, 9 percent receive plain water in addition to breast milk, 6 percent consume other water-based liquids, 20 percent consume other milk, and 50 percent consume complementary foods. The proportion of exclusively breastfed children drops to 1 in 20 by age 9-11 months, and continues to decline thereafter. Table 11.2 Breastfeeding status by age Percent distribution of youngest children under three years living with the mother by breastfeeding status, and percentage of all children under three years using a bottle with a nipple, according to age in months, Ethiopia 2005 Breastfeeding and consuming: Age in months Not breast- feeding Exclusively breastfed Plain water only Non-milk liquids/ juice Other milk Comple- mentary foods Total Number of children Percentage using a bottle with a nipple1 Number of children <2 1.6 67.3 9.9 5.0 10.6 5.6 100.0 328 7.6 331 2-3 1.2 49.4 14.4 7.0 15.1 12.9 100.0 458 13.2 461 4-5 1.3 31.6 18.7 3.2 23.8 21.5 100.0 355 17.9 360 6-8 1.6 14.1 9.0 5.5 19.8 50.0 100.0 598 18.7 608 9-11 5.2 4.7 6.3 1.5 8.4 74.0 100.0 459 17.0 463 12-17 6.5 2.3 3.3 1.1 2.9 83.9 100.0 1,091 10.7 1,115 18-23 11.9 0.5 1.5 0.8 1.8 83.5 100.0 718 8.4 762 24-35 38.8 0.2 0.6 0.5 0.5 59.4 100.0 1,442 7.6 1,892 <4 1.4 56.8 12.5 6.1 13.2 9.9 100.0 787 10.9 791 <6 1.3 49.0 14.5 5.2 16.5 13.5 100.0 1,142 13.0 1,152 6-9 2.5 12.7 8.4 4.5 17.5 54.4 100.0 791 17.4 804 12-23 8.6 1.6 2.6 1.0 2.5 83.7 100.0 1,809 9.7 1,877 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children who are 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 non-milk liquids and who do not receive complementary foods are classified in the non-milk 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. 1 Based on all children under 3 years. 146 | Nutrition of Children and Women Figure 11.2 shows the breastfeeding status of children 0-5 months and 6-9 months for the years 2000 and 2005. Exclusive breastfeeding declined slightly among children under six months while complementary feeding increased between the two surveys. Bottle-feeding is discouraged at any age. It is usually associated with increased risk of illness, and especially diarrhoeal disease, because of the difficulty in sterilizing the nipples properly. Bottle- feeding also shortens the period of postpartum amenorrhoea and increases the risk of pregnancy. The practice of bottle-feeding with a nipple is not widespread in Ethiopia. However, the proportion of children who are bottle-fed rises from 8 percent among children age less than two months to 19 percent among children age 6-8 months, after which it declines gradually to 8 percent among children 18-35 months of age. Figure 11.1 Breastfeeding 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 in Months 0 20 40 60 80 100 Exclusively breastfed Breast milk and plain water Breast milk and non-milk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding EDHS 2005 Figure 11.2 Trends in Infant Feeding Practice for Children 0-5 Months and 6-9 Months, 2000 and 2005 2000 2005 2000 2005 0 20 40 60 80 100 Exclusively breastfed Breast milk and plain water Breast milk and non-milk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding 0-5 months 6-9 months Percent Nutrition of Children and Women | 147 11.3 DURATION AND FREQUENCY OF BREASTFEEDING Table 11.3 shows the median duration of breastfeeding by selected background characteristics. The estimates of median and mean durations of breastfeeding are based on current status data, that is, the proportion of last-born children in the three years preceding the survey who were being breastfed at the time of the survey. Table 11.3 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Ethiopia 2005 Breastfeeding children under six months2 Median duration (months) of breastfeeding1 Background characteristic Any breast- feeding Exclusive breast- feeding Predominant breast- feeding3 Number of children Percentage breastfed 6+ times in last 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 25.5 2.1 4.5 3,428 96.2 6.8 5.5 602 Female 26.2 2.1 4.3 3,120 94.3 6.4 5.7 507 Residence Urban 24.8 1.8 3.2 491 93.4 6.4 5.3 71 Rural 25.9 2.1 4.5 6,057 95.4 6.7 5.6 1,038 Region Tigray 25.9 1.6 6.3 397 99.0 6.2 4.8 62 Affar 24.5 0.4 0.7 65 98.0 7.6 6.9 10 Amhara •36.0 4.3 7.1 1,527 96.3 7.1 5.5 280 Oromiya 24.6 1.6 3.4 2,633 93.4 6.1 5.7 399 Somali 21.8 0.5 2.9 279 100.0 8.6 5.8 43 Benishangul-Gumuz 23.1 1.6 4.0 61 91.5 6.6 5.2 12 SNNP 26.1 1.8 3.2 1,447 95.3 6.7 5.6 280 Gambela •36.0 1.6 4.0 17 (100.0) (7.7) (6.3) 3 Harari 20.6 0.8 3.1 14 93.0 6.3 4.7 3 Addis Ababa 25.7 0.6 0.9 87 (97.3) (7.0) (5.0) 13 Dire Dawa 20.3 0.5 5.0 23 (100.0) (7.9) (6.4) 4 Mother's education No education 26.2 2.3 4.7 5,116 95.4 6.7 5.6 876 Primary 24.9 1.7 3.8 1,142 94.0 6.5 5.6 192 Secondary and higher 23.3 1.6 2.1 290 99.0 6.1 5.0 41 Wealth quintile Lowest 25.1 0.7 3.4 1,403 97.0 7.1 6.0 221 Second 27.1 2.6 5.2 1,386 96.5 6.4 5.4 220 Middle 25.4 3.0 4.6 1,470 96.3 6.5 5.8 251 Fourth 25.9 2.4 4.5 1,316 91.1 6.6 5.2 263 Highest 25.3 2.2 3.2 974 96.6 6.8 5.8 154 All children 25.8 2.1 4.4 6,548 95.3 6.6 5.6 1,109 Mean for all children 25.5 4.0 6.0 na na na na na Note: Median and mean durations are based on current status. The median duration of any breastfeeding is shown as •36.0 for groups in which the exact median cannot be calculated because the proportion of breastfeeding children does not drop below 50 percent in any age group for children under 36 months of age. Includes children living and deceased at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 1 It is assumed that non-last-born children or last born child not currently living with the mother are not currently breastfeeding 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, non-milk based liquids, and/or juice only 148 | Nutrition of Children and Women The median duration of breastfeeding is 25.8 months, while the mean duration is 25.5 months. There is little difference in the duration of breastfeeding by sex of the child. Rural children are breastfed for a slightly longer duration than urban children, as are children living in SNNP compared with children in other regions. Highly educated mothers breastfeed their children for a shorter duration than mothers with little or no education. Both duration and frequency of breastfeeding can affect the length of postpartum amenor- rhoea. Table 11.3 shows that the overwhelming majority (95 percent) of children under six months of age were breastfed 6 or more times in the 24 hours preceding the survey. In line with expectations, breastfeeding is slightly more frequent in the daytime than at night, with the mean number of feeds in the daytime being 6.6 compared with 5.6 at night. Breastfeeding in the day is more frequent among children residing in the Somali Region than in the other regions, while night feeds are most frequent among children in Affar. 11.4 TYPES OF SUPPLEMENTAL FOOD Table 11.4 shows information on the types of food given to the youngest child under three years of age living with the mother on the day and night preceding the survey, according to their breastfeeding status. The introduction of other liquids such as water, juice, and formula takes place earlier than the recommended age of about 6 months. Even among the youngest breastfeeding children (<2 months), 10 percent consume other liquids, and 12 percent drink milk other than breast milk. Consumption of liquids other than milk increases gradually with age, and by age 24-35 months more than one in two children receives liquid supplements other than milk. Consumption of milk, other than breast milk and infant formula, peaks at 6-8 months (48 percent) and then declines thereafter. Supplementing with infant formula at any age is uncommon in Ethiopia. WHO recommends the introduction of solid food to infants around the age of 6 months because by that age breast milk by itself is no longer sufficient to maintain a child's optimal growth. The percentage receiving solid or semisolid food increases gradually; by age two most children are fed solid or semisolid foods. Nevertheless, it is disconcerting to note that even at 6-8 months of age, only one in two children are consuming solid or semisolid food. At age 6-23 months, the proportion of children consuming foods made from grains (70 percent) is the highest, compared with the consumption of other types of solid or semisolid foods. Only 14 percent of children less than three years of age consumed vitamin A-rich foods in the day and night preceding the survey. Meat, fish, poultry and eggs have bodybuilding substances essential to good health; they are important for balanced physical and mental development. The introduction of these foods in the diet is late and few children consume them. For instance, at age 6-23 months, only one in ten children consume meat, fish, shellfish, poultry or eggs. As expected, the percentage of non-breastfeeding children who consume supplements at an earlier age is higher than the percentage of breastfeeding children. Nutrition of Children and Women | 149 Table 11.4 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 specific foods in the day or night preceding the interview, by breastfeeding status and age, Ethiopia 2005 Solid or semi-solid foods Liquids Age in months Infant formula Other milk Other liquids Fortified baby foods Foods made from grains Fruits and vegetables rich in vitamin A Other fruits and vegetables Food made from roots/ tubers Food made from legumes and nuts Meat/ fish/ shellfish/ poultry/ eggs Cheese, yogurt, other milk product Any solid or semi- solid food Foods made with oil/ fat/ butter Number of children BREASTFEEDING CHILDREN <2 0.2 12.2 10.0 0.1 3.4 0.5 0.0 0.0 0.3 0.0 0.1 5.7 0.6 323 2-3 1.2 20.4 12.4 0.7 6.6 1.7 0.0 2.1 0.6 1.7 0.9 13.1 0.9 453 4-5 0.6 31.0 13.3 1.7 16.1 1.4 1.4 1.0 1.7 0.0 1.9 21.7 2.7 351 6-8 1.3 47.5 30.1 2.5 40.2 4.0 2.6 8.1 8.2 5.5 8.6 50.6 13.1 588 9-11 0.2 43.2 33.6 5.3 67.1 11.2 6.0 17.8 18.1 5.4 11.6 77.7 27.6 435 12-17 0.8 35.2 46.1 4.4 78.7 17.5 5.5 24.3 30.6 12.2 15.7 89.5 39.2 1,021 18-23 1.1 31.0 49.8 3.4 87.5 18.0 5.8 23.9 42.0 14.2 15.5 94.4 49.7 632 24-35 1.6 30.2 53.1 2.7 88.1 21.6 5.0 24.2 46.1 9.8 16.4 97.1 47.6 882 6-23 0.9 38.2 41.4 3.9 70.4 13.6 5.0 19.6 26.3 10.1 13.4 80.2 34.0 2,676 Total 1.0 32.7 36.5 2.9 58.9 12.2 3.9 16.0 23.9 7.8 11.0 67.4 28.7 4,685 NONBREASTFEEDING CHILDREN 0-11 11.1 63.3 57.1 5.9 54.0 8.2 8.7 26.2 17.3 22.2 31.2 60.0 37.2 49 12-17 1.5 61.2 81.6 4.3 82.9 36.0 8.3 40.1 22.5 20.3 12.6 95.2 34.0 71 18-23 2.1 62.4 63.6 5.2 82.8 18.8 10.4 30.9 27.7 22.4 27.8 99.1 48.6 85 24-35 1.1 40.3 60.5 2.4 91.4 25.9 9.0 26.9 41.8 15.2 22.7 98.9 48.9 560 6-23 4.0 63.1 70.4 5.5 80.3 24.0 10.0 34.8 25.3 23.4 24.9 93.8 42.7 189 Total 1.9 46.2 62.6 3.1 87.3 24.9 9.1 28.5 36.9 17.0 22.9 96.1 46.7 765 Note: Breastfeeding status and food consumed refer to a "24-hour" period (yesterday and last night). 1 Other milk includes fresh, tinned and powdered cow or other animal milk 2 Does not include plain water 3 Includes fortified baby food 4 Includes pumpkin, carrots, squash, sweet potatoes, dark green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A 11.5 FOODS CONSUMED BY MOTHERS The quality and quantity of food that mothers consume influences their health and that of their children, especially the health of breastfeeding children. The 2005 EDHS included questions on the type of foods consumed by mothers of children under age three during the day and night preceding the interview. Table 11.5 shows that most mothers of young children consume foods made from grains (88 percent), one in two mothers consume foods made from legumes and nuts, one-third consume foods made from roots or tubers and vitamin A-rich fruits and vegetables. Smaller proportions of mothers consume cheese, yogurt, milk or other milk products (23 percent) and meat, fish, shellfish, poultry and eggs (14 percent). Eighty-six percent of mothers drink tea or coffee and 56 percent consume foods made with oil, fat or butter. 150 | Nutrition of Children and Women Table 11.5 Foods consumed by mothers in the day and night preceding the interview Percentage of mothers of children under three years of age who consumed specific types of foods in the day and night preceding the interview, by background characteristics, Ethiopia 2005 Background characteristic Foods made from grains Foods made from roots/ tubers Foods made from legumes/ nuts Meat/ fish/ shellfish/ poultry/ eggs Cheese/ yogurt/ milk/ milk products Fruits/ vegetables rich in vitamin A Other fruits/ vegetables Foods made with oil/ fat/ butter Sugary foods Tea/ coffee Number of mothers Age at birth <20 89.2 29.5 52.0 12.2 20.2 28.6 5.3 56.8 2.6 84.1 760 20-24 90.4 29.3 49.5 15.5 21.4 29.4 6.3 57.7 3.1 82.4 1,402 25-29 87.8 35.5 48.6 14.9 25.4 32.5 6.5 56.3 3.2 87.0 1,415 30-34 83.9 32.8 44.4 14.9 22.8 36.5 7.5 53.6 2.7 87.5 968 35-49 86.8 32.4 50.6 12.1 25.4 28.1 3.3 55.7 2.8 89.4 905 Residence Urban 97.1 38.9 63.5 31.5 23.5 39.2 19.8 81.2 8.8 92.3 411 Rural 87.1 31.5 47.7 12.8 23.1 30.5 4.8 54.1 2.5 85.4 5,038 Region Tigray 96.6 4.0 68.8 24.6 6.9 9.5 8.5 76.9 3.4 78.3 348 Affar 92.2 5.1 25.1 18.6 73.4 11.4 3.9 69.3 3.3 92.5 51 Amhara 94.4 23.1 76.2 19.3 13.8 13.2 3.3 67.5 2.2 86.6 1,296 Oromiya 92.6 23.9 49.1 12.9 29.1 33.2 5.6 57.7 3.1 85.4 2,137 Somali 94.0 11.8 9.2 7.6 41.1 4.6 2.0 48.8 8.5 70.6 214 Benishangul-Gumuz 90.0 12.1 48.0 22.6 14.7 27.8 7.4 53.7 3.8 83.2 50 SNNP 67.8 68.4 21.0 7.9 22.3 57.4 7.0 34.2 1.8 90.9 1,231 Gambela 95.3 26.7 33.6 24.9 25.3 56.5 12.8 55.3 4.1 68.7 15 Harari 100.0 30.6 49.7 16.3 25.3 42.7 17.9 60.6 3.1 79.7 12 Addis Ababa 99.4 41.5 74.5 27.3 21.7 35.9 34.6 90.2 11.5 94.2 77 Dire Dawa 94.8 39.1 31.4 15.1 41.6 28.8 20.5 57.1 6.3 60.0 19 Education No education 87.4 30.3 47.4 12.5 22.2 29.2 4.2 53.8 2.7 84.6 4,262 Primary 87.5 37.8 52.1 15.8 25.9 38.0 9.5 60.0 1.4 89.3 932 Secondary and higher 96.6 40.8 62.1 37.0 29.1 38.7 21.9 81.5 13.3 95.6 255 Wealth quintile Lowest 89.0 18.6 44.1 12.6 26.3 19.7 3.8 48.5 2.6 78.2 1,154 Second 86.2 30.9 48.3 9.7 21.6 31.6 4.5 48.9 2.7 84.1 1,192 Middle 86.9 32.0 46.3 12.9 23.1 31.3 4.9 55.5 2.4 87.5 1,196 Fourth 85.6 41.2 49.8 13.9 19.7 36.0 5.9 59.8 2.0 90.2 1,086 Highest 92.9 40.9 59.0 25.2 25.8 39.8 12.6 73.4 5.9 91.4 822 Total 87.8 32.1 48.9 14.2 23.2 31.1 5.9 56.1 2.9 85.9 5,450 Note: Table refers to foods consumed in the preceding "24-hour" period (yesterday and last night) 1 Includes pumpkin, carrots, squash, sweet potatoes, dark green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A 11.6 MICRONUTRIENT INTAKE Micronutrient deficiencies are a result of inadequate intake of micronutrient-rich foods and the inadequate utilization of available micronutrients in the diet as a result of infections, parasitic infestations, and other factors. Measures of micronutrient fortification through the use of iodized household salt, micronutrient supplementation with iron and vitamin A, consumption of vitamin A- rich and iron-rich foods, and micronutrient status in terms of anaemia and night blindness are discussed in the following section for both women and children. Nutrition of Children and Women | 151 11.6.1 Iodine Intake Insufficient iodine in the diet can lead to serious health problems. Disorders arising from iodine deficiency range from goiter to mental and neurological disorders. Deficiency of iodine also causes abortion, stillbirth, low birth weight in infants, and premature birth. The principal cause of iodine deficiency is inadequate iodine in foods. Since iodine cannot be stored for long periods by the body, tiny amounts are needed regularly (100-150 micrograms per day per person). In the 2005 EDHS cooking salt in households was tested for the presence of iodine using salt testing kits supplied by UNICEF. Salt that contains at least 15 parts per million (ppm) of iodine is considered to be adequately iodized. Of the 99 percent of households in which an iodine test was carried out, only 20 percent had salt that was adequately iodized. Wealth and place of residence make little difference in iodine fortification (Table 11.6). Households in Dire Dawa are most likely to consume salt that is adequately iodized (62 percent) while households in Benishangul-Gumuz least likely (14 percent). Table 11.6 Presence of iodized salt in household Percent distribution of households with salt tested for iodine content by level of iodine in salt (parts per million), percentage of households tested, and percentage of households with no salt, according to background characteristics, Ethiopia 2005 Iodine content of salt in households tested: Among all households, the percentage: Background characteristic None (0 ppm) Inadequate (<15 ppm) Adequate (15+ ppm) Total Number of households With salt tested With no salt Number of households Residence Urban 46.1 32.9 21.0 100.0 1,939 98.2 0.1 1,974 Rural 45.6 34.7 19.7 100.0 11,606 98.8 0.1 11,747 Region Tigray 43.7 28.3 28.0 100.0 932 99.2 0.4 940 Affar 39.0 38.0 23.0 100.0 136 98.8 0.0 138 Amhara 53.4 31.7 14.9 100.0 3,658 98.6 0.1 3,709 Oromiya 40.3 37.7 22.0 100.0 4,749 99.1 0.0 4,790 Somali 41.8 33.6 24.7 100.0 535 99.0 0.0 540 Benishangul-Gumuz 58.7 27.7 13.6 100.0 127 99.4 0.0 128 SNNP 45.9 35.6 18.5 100.0 2,746 98.0 0.2 2,802 Gambela 34.9 27.4 37.6 100.0 45 96.7 0.4 47 Harari 41.5 29.7 28.8 100.0 38 98.0 0.0 39 Addis Ababa 50.4 31.7 17.9 100.0 516 98.4 0.0 525 Dire Dawa 8.3 29.4 62.3 100.0 63 98.5 0.0 64 Wealth quintile Lowest 43.4 34.5 22.1 100.0 2,733 99.1 0.1 2,757 Second 48.0 33.4 18.7 100.0 2,813 99.1 0.0 2,838 Middle 44.0 36.2 19.8 100.0 2,636 98.7 0.0 2,670 Fourth 45.9 35.0 19.1 100.0 2,492 98.5 0.1 2,531 Highest 46.9 33.3 19.9 100.0 2,872 98.2 0.1 2,925 Total 45.7 34.4 19.9 100.0 13,546 98.7 0.1 13,721 11.6.2 Micronutrient Intake Among Children A serious contributor to childhood morbidity and mortality is micronutrient deficiency. Children can receive micronutrients from foods, food fortification, and direct supplementation. Table 11.7 looks at measures relating to intake of several key micronutrients among children. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficieny (VAD) can cause eye damage. VAD can also increase severity of infections such as measles and diarrheal diseases in children and slows recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, 152 | Nutrition of Children and Women fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Periodic dosing (usually every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD. The EDHS collected information on the consumption of vitamin A-rich foods and on the coverage of supplements. Table 11.7 shows that 26 percent of last-born children living with the mother consumed vitamin A-rich foods in the 24-hour period before the survey. Consumption of vitamin A-rich foods increases from 8 percent among children age 6-8 months to 33 percent among children age 24-35 months. There is no gender difference in the consumption of vitamin A-rich foods and no discernible difference by birth order. Not surprisingly, breastfeeding children are much less likely to consume vitamin A-rich foods than nonbreastfeeding children. Urban children are nearly twice as likely to consume vitamin A-rich foods as rural children. Children living in Gambela and Addis Ababa are more likely than children living in other regions to consume vitamin A-rich foods. Children born to mothers with at least some secondary education are more likely to have received foods rich in vitamin A than children born to mothers with little or no education. Children living in the wealthiest households are much more likely to consume vitamin A-rich foods than children living in other households. Eleven percent of young children consume foods rich in iron. Noticeable differences by background characteristics are also seen in the consumption of iron-rich foods by young children. Consumption of iron-rich foods rises to peak of 15 percent among children age 18-23 months, is slightly higher among female than male children, and among lower than higher order births. Differences by other background variables are similar to those seen for the consumption of vitamin A- rich foods. Nearly one in two children age 6-59 months received a vitamin A supplement in the six months before the survey. Differences in the consumption of vitamin A supplements by gender, birth order, breastfeeding status and mother’s age at birth are small. The urban-rural difference in vitamin A intake is marked, with rural children much less likely to receive vitamin A supplements than children in urban areas. Children residing in Benishangul-Gumuz are least likely to receive vitamin A supplements compared with children in the other regions. Vitamin A supplementation children rises as mother’s education and household wealth increases. As discussed earlier, inadequate amounts of iodine in the diet are related to serious health risks for young children. The EDHS results show that 19 percent of children 6-59 months live in households using adequately iodized salt. Children under age one, rural children, and children living in Dire Dawa are more likely than their counterparts to live in households using adequately iodized salt. There is no clear pattern by mother’s age at birth or wealth quintile in the percentage of children living in households using adequately iodized salt. Nutrition of Children and Women | 153 Table 11.7 Micronutrient intake among children Percentage of last-born children age 6-35 months living with the mother who consumed foods rich in vitamin A and iron in the 24 hours preceding the survey, and percentage of children age 6-59 months who received vitamin A supplements in the six months preceding the survey, and percentage of children under five living in households with adequately iodized salt, by background characteristics, Ethiopia 2005 Last-born children age 6-35 months Children age 6-59 months Children age 6-59 months in households with salt tested Background characteristic Consumed foods rich in vitamin A in past 24 hours1 Consumed foods rich in iron in past 24 hours2 Number of children Given vitamin A supplements in past 6 months Number of children Household salt adequately iodized3 Number of children Child’s age in months 6-8 8.4 5.4 598 41.8 608 21.2 603 9-11 18.3 7.5 459 38.9 463 21.9 455 12-17 28.0 12.8 1,091 45.2 1,115 16.3 1,101 18-23 29.4 15.2 718 49.6 762 18.4 753 24-35 32.5 11.9 1,442 46.2 1,892 19.1 1,876 36-47 na na na 47.9 2,105 19.6 2,081 48-59 na na na 44.9 2,013 18.7 1,986 Mother's age at birth <20 26.4 12.1 599 44.3 1,314 15.6 1,294 20-24 27.4 13.5 1,103 45.5 2,427 18.9 2,400 25-29 25.1 11.7 1,106 44.9 2,206 20.1 2,170 30-34 30.3 10.5 773 48.1 1,607 20.2 1,597 35-49 20.3 7.6 727 46.4 1,404 19.3 1,394 Sex Male 26.0 10.6 2,206 45.7 4,508 18.5 4,467 Female 26.0 12.0 2,102 45.9 4,450 19.5 4,388 Birth order 2-3 27.7 13.4 703 45.8 1,474 17.5 1,459 4-5 27.5 13.8 1,239 46.3 2,726 19.3 2,692 6+ 26.8 9.8 1,048 48.0 2,122 19.4 2,091 Breastfeeding status Breastfeeding 23.2 10.1 3,558 44.5 3,976 18.4 3,931 Not breastfeeding 39.2 17.1 739 47.3 4,881 19.4 4,825 Residence Urban 44.2 28.7 335 62.0 673 14.4 668 Rural 24.5 9.9 3,973 44.5 8,285 19.4 8,186 Region Tigray 25.1 20.7 286 65.3 591 25.0 588 Affar 9.3 6.8 41 33.3 85 23.5 84 Amhara 19.2 12.1 1,010 43.2 2,026 14.2 1,995 Oromiya 26.4 10.9 1,721 43.0 3,599 21.1 3,576 Somali 7.9 6.6 166 38.8 383 22.6 378 Benishangul-Gumuz 31.1 16.2 38 27.4 83 13.7 83 SNNP 35.4 8.4 948 49.9 1,986 17.4 1,948 Gambela 38.2 16.3 12 39.1 26 32.2 25 Harari 33.9 21.4 9 36.1 18 27.1 18 Addis Ababa 37.9 20.5 64 53.2 130 11.8 130 Dire Dawa 23.9 18.6 15 46.7 31 53.0 31 Mother's education No education 22.9 9.0 3,371 43.8 7,052 19.1 6,967 Primary 33.1 14.9 727 50.3 1,502 19.6 1,488 Secondary and higher 51.1 35.4 210 63.6 404 14.4 400 Wealth quintile Lowest 16.9 6.9 926 39.5 1,990 20.4 1,969 Second 26.1 8.7 964 42.1 1,893 17.4 1,872 Middle 24.0 10.6 940 45.6 1,953 18.7 1,934 Fourth 28.9 11.6 818 49.6 1,744 20.7 1,719 Highest 37.9 22.1 659 55.4 1,378 17.5 1,360 Total 26.0 11.3 4,308 45.8 8,958 19.0 8,855 Note: Information on vitamin A supplements is based on mother's recall. Total includes 98 children with missing information on breastfeeding status who are not shown separately. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mango, papaya, 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. 154 | Nutrition of Children and Women 11.6.3 Micronutrient Intake among Mothers A mother's nutritional status during pregnancy is important both for the child's intrauterine development and for protection against maternal morbidity and mortality. Night blindness is an indicator of severe vitamin A deficiency, and pregnant women are especially prone to suffer from it. Table 11.8 shows the micronutrient intake among mothers of young children by background characteristics. Two-fifths of mothers consumed vitamin A-rich foods and 14 percent consumed iron- rich foods. Twenty-one percent of mothers received vitamin A supplements postpartum. One in five mothers reported having difficulty seeing at night but when adjusted for those mothers who had no difficulty seeing in the daytime, only 6 percent of mothers are considered to have suffered from night blindness during their pregnancy. The majority of mothers did not take iron supplements during their pregnancy (89 percent). Nineteen percent of mothers live in households using adequately iodized salt. Consumption of vitamin A-rich foods is higher among mothers whose age at birth was 30-34, mothers residing in urban areas, mothers living in Gambela, mothers with at least secondary education, and mothers in the highest wealth quintile. Urban residence, education, and wealth also exert a positive influence on the consumption of iron-rich foods. Consumption of iron-rich foods is highest in Addis Ababa, Gambela, and Tigray and lowest in SNNP and Somali. Night blindness during pregnancy is more prevalent among older mothers (age 30 and above), mothers of higher order births, rural mothers, mothers residing in Amhara, mothers with no education, and mothers in the poorest households. Nutrition of Children and Women | 155 Table 11.8 Micronutrient intake among mothers Percentage of women with a child under age three years living with her who consumed foods rich in vitamin A and iron in the 24 hours preceding the survey, and among women with a birth in the five years preceding the survey, percentage who received a vitamin A dose in the first two months after delivery, percentage who suffered from night blindness during pregnancy, percentage who took iron tablets or syrup for specific number of days, and percentage who live in households with adequately iodized salt, by background characteristics, Ethiopia 2005 Mothers with a living child under age 3 years who consumed: Number of days iron tablets taken during pregnancy Women in households with salt tested Night blindness during pregnancy Background characteristics Foods rich in vitamin A1 Iron- rich foods2 Number of women Received vitamin A dose post- partum3 Reported Adjusted4 None <60 60-89 90+ Don't know/ missing Number of women with a birth in the 5 years preceding the survey Percentage with salt adequately iodized5 Number of women Age at birth <20 36.3 12.2 760 19.9 14.1 4.3 90.2 8.3 0.4 0.0 1.1 994 15.2 974 20-24 40.2 15.5 1,402 19.9 18.6 5.7 90.7 7.9 0.0 0.2 1.2 1,822 17.3 1,808 25-29 42.7 14.9 1,415 21.7 22.3 6.1 88.3 10.4 0.1 0.0 1.2 1,781 20.0 1,754 30-34 46.8 14.9 968 20.6 24.8 7.3 88.2 10.5 0.1 0.2 1.0 1,320 19.8 1,300 35-49 38.0 12.1 905 20.7 29.5 6.9 89.4 9.5 0.0 0.1 1.0 1,391 19.6 1,380 Number of children ever born 1 40.2 14.8 909 19.7 12.9 4.8 90.2 8.2 0.2 0.0 1.5 1,190 16.1 1,177 2-3 41.1 15.5 1,606 20.7 19.5 6.1 89.1 9.2 0.3 0.2 1.2 2,089 18.4 2,065 4-5 41.7 13.4 1,318 22.2 23.3 6.1 90.2 9.0 0.0 0.0 0.7 1,692 19.5 1,668 6+ 41.2 13.2 1,616 19.8 28.2 6.8 88.6 10.2 0.0 0.1 1.1 2,336 19.3 2,306 Residence Urban 54.4 31.5 411 36.0 11.5 3.1 79.7 15.9 0.4 0.2 3.8 634 14.8 629 Rural 40.0 12.8 5,038 19.1 23.1 6.4 90.3 8.7 0.1 0.1 0.9 6,674 18.9 6,587 Region Tigray 32.5 24.6 348 17.5 24.9 8.3 87.8 10.1 0.0 0.2 1.9 480 25.6 478 Affar 22.8 18.6 51 18.4 14.4 4.1 89.7 6.1 0.0 0.0 4.2 68 20.9 67 Amhara 30.1 19.3 1,296 16.2 21.2 11.7 91.5 7.3 0.0 0.1 1.2 1,856 14.1 1,827 Oromiya 40.7 12.9 2,137 23.9 24.4 4.6 89.5 9.5 0.1 0.1 0.7 2,723 20.1 2,702 Somali 10.2 7.6 214 14.5 17.4 4.5 91.0 6.9 0.5 0.0 1.6 288 19.8 285 Benishangul-Gumuz 41.5 22.6 50 13.2 12.7 5.8 90.6 7.1 0.0 0.0 2.3 69 12.2 68 SNNP 61.2 7.9 1,231 22.1 22.1 2.6 87.8 11.1 0.1 0.0 1.0 1,632 18.5 1,598 Gambela 64.1 24.9 15 25.4 6.3 2.0 81.4 15.3 0.3 0.2 2.7 23 31.1 22 Harari 48.9 16.3 12 26.0 10.5 1.2 79.9 18.2 0.5 0.0 1.5 15 27.3 15 Addis Ababa 49.0 27.3 77 21.8 3.1 0.9 79.6 15.4 0.6 0.7 3.7 129 13.8 129 Dire Dawa 35.0 15.1 19 28.9 6.8 1.9 87.5 10.0 0.2 0.4 1.9 25 55.4 25 Education No education 38.8 12.5 4,262 18.2 23.7 6.8 90.4 8.5 0.1 0.1 1.0 5,734 18.9 5,663 Primary 46.8 15.8 932 25.8 19.0 4.1 88.3 10.7 0.0 0.0 1.0 1,205 18.1 1,189 Secondary and higher 58.4 37.0 255 41.2 7.9 2.8 77.1 17.6 1.2 0.2 3.9 368 15.4 364 Wealth quintile Lowest 30.3 12.6 1,154 15.8 27.1 8.6 93.8 5.0 0.0 0.3 1.0 1,520 20.4 1,504 Second 39.0 9.7 1,192 16.7 22.7 6.5 91.1 7.8 0.1 0.0 1.0 1,553 17.6 1,534 Middle 42.0 12.9 1,196 19.9 23.9 7.1 89.4 9.9 0.1 0.2 0.4 1,586 18.2 1,568 Fourth 45.2 13.9 1,086 22.3 20.0 3.6 88.5 10.6 0.0 0.0 0.8 1,451 19.0 1,432 Highest 52.8 25.2 822 30.7 15.0 4.1 82.5 14.4 0.4 0.1 2.7 1,196 17.4 1,177 Total 41.1 14.2 5,450 20.6 22.1 6.1 89.4 9.3 0.1 0.1 1.1 7,307 18.6 7,216 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, mango, papaya, and other locally grown fruits and vegetables that are rich in vitamin A. 2 Includes meat (and organ meat), fish, poultry, eggs. 3 In the first two months after delivery. 4 Women who reported night blindness but did not report difficulty with vision during the day. 5 Salt containing 15 ppm of iodine or more. 156 | Nutrition of Children and Women 11.7 PREVALENCE OF ANAEMIA The most common causes of anaemia in developing countries are inadequate intake of iron, folate, vitamin B12 or other nutrients. Anaemia can also result from sickle cell disease, malaria, and intestinal worm infestation. Anaemia may be the underlying cause of maternal mortality, spontaneous abortion, premature birth, and low birth weight. Iron and folic acid supplementation and anti-malarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bednets by pregnant women and children under five, and six-month de-worming for children are some of the important measures to reduce anaemia prevalence among vulnerable groups. Anaemia is characterized by a low level of haemoglobin in the blood. The 2005 EDHS measured haemoglobin levels to identify anaemia in children and women. The resulting data are the first of its kind in Ethiopia. 11.7.1 Prevalence of Anaemia in Children Table 11.9 shows the percentage of children age 6-59 months classified as having anaemia, by background characteristics. More than half (54 percent) of Ethiopian children 6-59 months old are anaemic, with 21 percent mildly anaemic, 28 percent moderately anaemic, and 4 percent severely anaemic. Severe anaemia is highest among children age 9-11 months, male children, children of mothers who were not interviewed and not in the household at the time of the interview, children living in the Somali Region, children of mothers with little or no education, and children in the poorest households. Surprisingly, severe anaemia does not vary much by urban-rural residence. This indicates the widespread nature of the problem and the need to intensify the various components of the anaemia control strategy. Nutrition of Children and Women | 157 Table 11.9 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteristics, Ethiopia 2005 Anaemia status Background characteristic Any anaemia Mild (10.0- 10.9 g/dl) Moderate (7.0- 9.9 g/dl) Severe (>7.0 g/dl) Number of children Age in months 6-8 77.2 20.8 53.1 3.4 226 9-11 73.3 23.1 41.9 8.3 199 12-17 73.7 26.2 41.4 6.1 521 18-23 62.2 24.1 33.6 4.5 344 24-35 50.7 20.7 26.5 3.5 882 36-47 48.1 23.4 22.2 2.5 1,002 48-59 38.2 16.1 18.5 3.6 965 Sex Male 55.0 21.6 28.9 4.6 2,055 Female 52.1 21.1 27.7 3.3 2,083 Mother’s status Interviewed 53.9 21.4 28.6 3.9 3,846 Not interviewed but in household 47.6 20.9 26.1 0.5 111 Not interviewed and not in household2 49.5 20.9 23.2 5.4 182 Residence Urban 46.8 18.4 24.8 3.5 270 Rural 54.0 21.6 28.5 3.9 3,868 Region Tigray 56.5 23.9 28.8 3.8 288 Affar 58.5 25.3 28.8 4.4 32 Amhara 52.0 20.0 26.6 5.4 858 Oromiya 56.0 22.3 30.2 3.5 1,717 Somali 85.6 19.7 51.7 14.1 124 Benishangul-Gumuz 54.3 24.6 25.2 4.4 39 SNNP 46.2 20.7 23.5 2.0 1,004 Gambela 61.8 25.3 32.5 4.0 10 Harari 56.1 23.6 29.3 3.1 7 Addis Ababa 37.5 9.6 23.9 4.0 45 Dire Dawa 60.7 20.0 29.1 11.5 14 Mother's education1 No education 54.5 21.8 28.7 4.0 3,122 Primary 51.4 20.9 26.8 3.7 685 Secondary and higher 47.9 15.0 31.5 1.4 149 Wealth quintile Lowest 59.9 22.2 32.3 5.4 923 Second 55.7 22.3 28.8 4.6 888 Middle 52.8 19.8 29.4 3.6 899 Fourth 49.1 20.8 25.1 3.2 853 Highest 47.8 21.7 24.0 2.0 576 Total 53.5 21.4 28.3 3.9 4,138 Note: Table is based on children who stayed in the household the night before the interview. Prevalence is adjusted for altitude using formulas recommended by CDC (CDC, 1998). Haemoglobin is measured as grams per decilitre (g/dl). 1 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers were not listed in the household schedule. 2 Includes children whose mothers are deceased 11.7.2 Prevalence of Anaemia in Women Table 11.10 shows the prevalence of anaemia among women age 15-49, which is less pronounced than among children. Twenty-seven percent of women are anaemic, with 17 percent mildly anaemic, 8 percent moderately anaemic, and just over 1 percent severely anaemic. Lack of education, being pregnant, and living in poor households are associated with higher prevalence. Anaemia is also higher among rural than urban women. Women residing in Affar, Somali and Dire Dawa are much more likely to be severely anaemic than women living in the other regions. 158 | Nutrition of Children and Women Table 11.10 Prevalence of anaemia in women Percentage of women with anaemia, by background characteristics, Ethiopia 2005 Anaemia status Background characteristic Any anaemia Mild anaemia Moderate anaemia Severe anaemia Number of women Age1 15-19 24.8 16.6 7.4 0.9 1,489 20-29 24.5 15.9 7.4 1.2 2,163 30-39 30.6 19.9 8.8 1.9 1,489 40-49 27.7 18.2 8.3 1.3 1,000 Children ever born2 None 21.5 14.9 5.6 1.0 1,909 1 29.0 18.3 9.8 0.9 593 2-3 28.2 17.8 8.6 1.8 1,101 4-5 28.6 16.4 11.2 1.0 1,012 6+ 29.4 20.5 7.2 1.6 1,526 Maternity status2 Pregnant 30.6 14.7 13.0 3.0 520 Breastfeeding 29.8 20.2 8.3 1.3 2,222 Neither 23.9 16.0 6.8 1.0 3,398 Residence Urban 17.8 13.4 3.7 0.7 948 Rural 28.2 18.1 8.6 1.4 5,193 Region Tigray 29.3 22.4 6.3 0.6 411 Affar 40.4 26.2 10.9 3.4 55 Amhara 31.0 21.4 8.1 1.5 1,486 Oromiya 24.9 15.7 8.0 1.2 2,177 Somali 39.8 20.1 14.9 4.8 181 Benishangul-Gumuz 31.3 20.7 9.9 0.8 59 SNNP 23.5 14.8 7.7 1.0 1,437 Gambela 42.0 29.4 10.8 1.7 21 Harari 22.4 15.2 6.7 0.5 16 Addis Ababa 14.6 10.7 3.1 0.8 271 Dire Dawa 25.8 17.9 5.4 2.5 26 Education1 No education 29.4 18.4 9.5 1.4 4,045 Primary 23.0 16.2 5.3 1.5 1,447 Secondary and higher 17.0 13.6 3.1 0.3 649 Smoking status2 Yes 35.2 16.4 18.8 0.0 91 No 26.4 17.4 7.7 1.3 6,046 Wealth quintile Lowest 31.8 18.6 11.7 1.5 1,138 Second 30.3 19.2 9.6 1.4 1,218 Middle 26.7 17.6 7.9 1.3 1,206 Fourth 28.5 18.5 8.4 1.7 1,165 Highest 17.4 13.9 2.8 0.7 1,414 Total 26.6 17.4 7.9 1.3 6,141 Note: Table is based on women who stayed in the household the night before the interview. Prevalence is adjusted for altitude using formulas recommended by CDC (CDC, 1998). Women with <7.0 g/dl of haemoglobin have severe anaemia, women with 7.0-9.9 g/dl have moderate anaemia, and pregnant women with 10.0-10.9 g/dl and nonpregnant women with 10.0-11.9 g/dl have mild anaemia. Total includes 5 women missing information on smoking status who are not shown separately. 1 For women who were not interviewed, information is taken from the Household Questionnaire. 2 Excludes women who were not interviewed Nutrition of Children and Women | 159 11.8 NUTRITIONAL STATUS The nutritional status of young children and women of reproductive age reflects household, community, and national development. Children and women are most vulnerable to malnutrition in developing countries because of low dietary intakes, infectious diseases, lack of appropriate care, and inequitable distribution of food within the household. 11.8.1 Nutritional Status of Children The 2005 EDHS included information on the nutritional status of children under five years of age for three indices, namely, weight-for-age, height-for-age and weight-for-height, taking age and sex into consideration. Weight measurements were taken using a lightweight electronic SECA scale designed and manufactured under the guidance of UNICEF, and height measurements were carried out using a measuring board produced by Shorr Productions. Children younger than 24 months were measured lying down (recumbent length) on the board, while standing height was measured for older children. The scale allowed for the weighing of very young children through an automatic mother- child adjustment that eliminated the mother’s weight while she was standing on the scale with her baby. As recommended by WHO, the anthropometric measurements of children in the survey were compared with an international reference population defined by the U.S. National Centre for Health Statistics (NCHS) and accepted by the U.S. Centres for Disease Control and Prevention (CDC). Each of the three nutritional status indicators described below are expressed in standard deviation units (Z- scores) from the median of the reference population. The use of this reference population is based on the finding that well nourished young children in all population groups (for which data exist) follow very similar growth patterns. The reference populations are useful for comparison, facilitating the examination of differences in the anthropometric status of subgroups in a population and changes in nutritional status over time. In any large population, there is variation in height and weight; this variation approximates a normal distribution. Each of these indices—height-for-age, weight-for-height, and weight-for-age—provides dif- ferent information about growth and body composition, which is used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the median of the reference population are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for- age, therefore, represents the long-term effects of malnutrition in a population and does not vary according to recent dietary intake. The weight-for-height index measures body mass in relation to body length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) from the median of the reference population are considered thin (wasted) for their height and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely wasted. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations from the median of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. 160 | Nutrition of Children and Women Height and weight data were collected in all the households that were included in the male subsample of households. A total of 5,280 children under five were identified in the households. Five percent of children had missing information on height or weight, 8 percent had height or weight measures considered to be out of the range for their ages, and less than 1 percent had incomplete age information. The final analysis on nutritional status is based on the remaining 4,586 (87 percent) children. The results are shown in Table 11.11. Table 11.11 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Ethiopia 2005 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 Age in months <6 1.3 8.1 (0.1) 1.0 6.4 0.3 0.0 4.4 0.2 389 6-8 3.8 26.6 (1.0) 1.8 10.3 (0.2) 4.8 19.1 (1.0) 243 9-11 12.3 32.7 (1.4) 0.5 14.2 (0.6) 13.8 38.2 (1.6) 211 12-17 18.6 46.3 (1.7) 4.3 18.8 (0.9) 15.0 47.5 (1.8) 510 18-23 31.2 61.7 (2.2) 2.6 16.6 (0.8) 14.9 48.2 (1.9) 326 24-35 27.7 51.3 (1.9) 1.7 9.0 (0.6) 12.7 42.2 (1.7) 901 36-47 30.5 52.5 (2.1) 2.4 8.5 (0.7) 13.2 40.9 (1.7) 1,016 48-59 31.3 54.1 (2.1) 2.4 8.5 (0.6) 9.5 42.6 (1.7) 989 Sex Male 24.1 47.2 (1.8) 2.8 11.4 (0.6) 11.5 38.9 (1.6) 2,317 Female 24.2 45.8 (1.8) 1.7 9.6 (0.5) 10.7 37.9 (1.5) 2,269 Birth order2 1 18.5 38.2 (1.5) 1.9 9.6 (0.5) 8.4 33.9 (1.3) 661 2-3 21.7 44.7 (1.7) 2.4 9.9 (0.6) 10.5 35.7 (1.5) 1,286 4-5 25.9 48.5 (1.9) 2.2 12.9 (0.7) 13.4 41.6 (1.6) 1,019 6+ 26.8 50.5 (1.9) 1.9 9.8 (0.6) 10.8 41.2 (1.6) 1,330 Birth interval in months2 First birth3 18.5 38.2 (1.5) 1.9 9.6 (0.5) 8.4 33.9 (1.3) 661 <24 28.6 52.8 (2.0) 0.9 11.4 (0.5) 13.2 42.4 (1.6) 711 24-47 25.4 48.2 (1.9) 1.8 9.5 (0.6) 11.1 39.7 (1.6) 2,262 48+ 18.2 41.6 (1.5) 4.9 13.9 (0.7) 10.7 35.1 (1.5) 661 Size at birth2 Very small 27.8 52.7 (2.0) 2.6 15.5 (0.8) 15.6 49.5 (1.8) 841 Small 25.9 48.3 (1.8) 4.4 16.3 (0.9) 16.0 45.6 (1.8) 341 Average or larger 22.5 44.5 (1.7) 1.8 8.6 (0.5) 9.1 34.8 (1.4) 3,106 Mother's age4 15-19 18.6 38.4 (1.2) 0.2 6.7 (0.3) 7.6 30.0 (1.0) 204 20-24 19.9 41.3 (1.6) 2.6 12.2 (0.6) 11.2 37.8 (1.4) 835 25-29 22.6 45.9 (1.8) 1.5 9.7 (0.5) 9.2 36.2 (1.5) 1,233 30-34 26.0 48.5 (1.9) 1.9 10.9 (0.7) 13.5 40.2 (1.6) 919 35-49 27.1 49.9 (1.9) 2.9 10.6 (0.6) 11.5 41.5 (1.6) 1,217 Mother's nutritional status Underweight (BMI <18.5) 25.5 50.4 (2.0) 2.0 15.0 (0.9) 13.5 49.6 (1.8) 805 Normal (BMI 18.5 - 24.9) 22.3 45.2 (1.7) 2.5 9.9 (0.5) 10.8 36.5 (1.5) 2,664 Overweight (BMI >= 25) 18.7 40.5 (1.5) 2.4 6.0 (0.0) 4.1 19.9 (0.9) 120 Missing 3.0 26.9 (1.4) 0.0 12.1 (0.8) 0.0 37.0 (1.5) 20 Mother’s status Interviewed 23.8 46.4 (1.8) 2.1 10.5 (0.6) 11.0 38.5 (1.5) 4,296 Not interviewed but in household 26.3 43.8 (1.8) 1.8 11.1 (0.5) 13.9 38.5 (1.5) 112 Not interviewed and not in household5 30.6 51.3 (1.8) 5.3 9.7 (0.7) 12.3 35.7 (1.6) 178 Continued. Nutrition of Children and Women | 161 Table 11.11—Continued Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Ethiopia 2005 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 Residence Urban 10.2 29.8 (1.1) 2.5 6.3 (0.3) 4.8 22.9 (0.9) 362 Rural 25.3 47.9 (1.8) 2.2 10.9 (0.6) 11.6 39.7 (1.6) 4,224 Region Tigray 16.7 41.0 (1.7) 1.9 11.6 (1.0) 11.3 41.9 (1.7) 316 Affar 21.6 40.8 (1.5) 2.9 9.9 (0.4) 12.9 34.1 (1.2) 46 Amhara 26.5 56.6 (2.1) 3.0 14.2 (0.8) 15.0 48.9 (1.9) 973 Oromiya 21.8 41.0 (1.6) 2.4 9.6 (0.5) 8.2 34.4 (1.4) 1,867 Somali 30.3 45.2 (1.8) 5.1 23.7 (1.0) 17.8 50.9 (1.8) 177 Benishangul-Gumuz 19.7 39.7 (1.6) 3.9 16.0 (1.0) 15.4 44.6 (1.8) 46 SNNP 29.1 51.6 (2.0) 0.9 6.5 (0.4) 11.9 34.7 (1.5) 1,057 Gambela 12.6 29.3 (1.1) 3.8 6.8 (0.5) 4.1 26.7 (1.1) 11 Harari 17.0 38.7 (1.3) 0.0 9.1 (0.4) 5.8 26.7 (1.1) 10 Addis Ababa 5.4 18.4 (0.7) 0.0 1.7 (0.2) 1.5 11.0 (0.6) 67 Dire Dawa 13.8 30.8 (1.0) 4.4 11.4 (0.9) 8.4 29.6 (1.3) 16 Mother's education No education 26.3 49.1 (1.9) 2.3 11.2 (0.6) 12.3 41.4 (1.6) 3,450 Primary 17.9 39.8 (1.6) 1.7 10.1 (0.4) 7.6 32.0 (1.3) 754 Secondary and higher 4.7 24.0 (1.0) 0.0 1.3 0.0 2.6 13.6 (0.6) 204 Wealth quintile Lowest 26.5 47.9 (1.8) 3.3 13.0 (0.8) 12.6 42.9 (1.7) 1,014 Second 27.5 54.0 (2.0) 3.4 13.4 (0.7) 15.2 43.6 (1.7) 994 Middle 27.3 45.8 (1.8) 1.8 10.7 (0.5) 10.7 38.3 (1.5) 942 Fourth 20.1 46.4 (1.8) 0.8 7.6 (0.5) 8.9 34.8 (1.5) 944 Highest 16.8 34.9 (1.4) 1.6 6.2 (0.4) 6.4 29.4 (1.2) 692 Total 24.1 46.5 (1.8) 2.2 10.5 (0.6) 11.1 38.4 (1.5) 4,586 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 NCHS/CDC/WHO International Reference Population. 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. Total includes 6 children missing information on birth size who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children who are below -3 standard deviations (SD) from the International Reference Population median. 2 Excludes children whose mothers were not interviewed 3 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 4 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers were not listed in the household schedule. 5 Includes children whose mothers are deceased Forty-seven percent of children under five are stunted and 24 percent are severely stunted. Eleven percent of children under five are wasted and 2 percent are severely wasted. The weight for- age indicator shows that 38 percent of children under five are underweight and 11 percent are severely underweight. Table 11.11 and Figure 11.3 indicate that stunting is apparent even among children less than 6 months of age (8 percent). Stunting increases with the age of the child; this is evidenced by the increase in stunting from 27 percent among children age 6-8 months to 62 percent among children age 18-23 months. The level then declines slowly to between 51 and 54 percent among children age two years and older. There is very little difference in the level of stunting by gender. Stunting increases with increasing birth order of the child but decreases with increasing birth interval. Size at birth is an important indicator of the nutritional status of children. Stunting is higher among children who were reported to have been very small at birth (53 percent) than among children who were small, average, 162 | Nutrition of Children and Women or larger in size at birth. The percentage of children stunted decreases with increasing level of mother’s education and increases with increasing age of mother. Children whose biological mothers were not in the household are more likely to be stunted (51 percent) than children whose mothers were interviewed (46 percent). The relationship between stunting and wealth status is not uniform, though children in the highest wealth quintile are least likely to be stunted compared with those in the other wealth quintiles than those in the other groups. Rural children are more stunted (48 percent) than urban children (30 percent). Regional variation in nutritional status of children is substantial. Stunting levels are above the national average in the Amhara (57 percent) and SNNP (52 percent) regions. The prevalence of wasting is higher than the national average among children age 9-23 months. The percentage of children classified as wasted is highest among children of birth order 4 and 5 (13 percent). The proportion of children wasted is higher in rural areas (11 percent) than in urban areas (6 percent). Wasting is higher than the national average in Somali (24 percent), Benishangul- Gumuz (16 percent), Amhara (14 percent), Tigray (12 percent) and Dire Dawa (11 percent). The level of wasting decreases with increasing wealth. Table 11.11 and Figure 11.3 show that the percentage of children underweight increases sharply from 4 percent among children under age 6 months to 19 percent among children age 6-8 months, doubles among children age 9-11 months, and peaks at 48 percent among children age 12-23 months with very small decreases thereafter. This may be due to inappropriate and/or inadequate feeding practices because increasing levels of children underweight by age coincides with the age at which normal complementary feeding starts. The percentages of underweight children in Somali (51 percent), Amhara (49 percent) and Benishangul-Gumuz (45 percent) are above the national average. Differentials for the other background characteristics are very similar to those discussed under stunting and wasting. 11.8.2 Trends in Children’s Nutritional Status Data from the 2005 EDHS can be compared with similarly collected data from the 2000 EDHS. A comparison of the data shows that there have been some improvements in the nutritional status of children in the past five years. The percentage of children stunted fell by 10 percent from 52 percent in 2000 to 47 percent in 2005. Similarly, the percentage of children underweight declined by 19 percent from 47 percent in 2000 to 38 percent in 2005. There was, however, no change over the five-year period in the percentage of children wasted. Figure 11.3 Nutritional Status of Children Under Age Five � � ��� � � � � � � � � � �� �������������� ������������ �� ��������� �� ����� � � �� ���� �� �� ����������������������������������������� ������� 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Age in months 0 10 20 30 40 50 60 70 Percent Stunted average Wasted average Underweight average� � EDHS 2005 Nutrition of Children and Women | 163 11.8.3 Nutritional Status of Women The 2005 EDHS collected information on the height and weight of women in the reproductive age group. The data are used to derive a measure of adult nutritional status known as body mass index (BMI). In this report, two indicators of nutritional status are presented—height and body mass index (BMI). The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. A woman’s height is used to predict the risk of difficulty in delivery because small stature is often associated with small pelvis size and the potential for obstructed labour. The risk of giving birth to a low birth weight baby is influenced by the mother’s nutritional status. The cutoff point for the height at which mothers can be considered at risk varies between populations but normally falls between 140 and 150 centimetres. As in other DHS surveys, a cutoff point of 145 cm is used for the 2005 EDHS. The index used to measure thinness or obesity is known as the body mass index (BMI), or the Quetelet index. BMI is defined as weight in kilogrammes divided by height squared in metres (kg/m2). A cut-off point of 18.5 is used to define thinness or acute undernutrition and a BMI of 25 or above usually indicates overweight or obesity. Table 11.12 presents the mean values of the two indicators of nutritional status and the proportions of women falling into high-risk categories, according to background characteristics. Women for whom there was no information on height and/or weight and for whom a BMI could not be estimated are excluded from this analysis. The data analysis on BMI is based on 5,901 women, while the height analysis is based on 6,636 women age 15-49 years. The mean height of women is 157 centimetres, which is above the critical height of 145 centimetres. Overall, 3 percent of women are shorter than 145 cm. There are very small differences in the mean height of women by background characteristics. Women in the Somali and Gambela regions, on the average are taller than women in the other regions. Women in Amhara have the shortest mean height and, along with Affar, the highest proportion below 145 cm. Women with at least some secondary education are at least 1 cm taller than women who have not attended school. There is no clear difference in the pattern of height by other characteristics. Table 11.12 shows that there are large differentials across background characteristics in the percentage of women assessed as malnourished (BMI less than 18.5) or “thin” and overweight (BMI 25 or higher). Twenty-seven percent of women were found to be chronically malnourished (BMI less than 18.5), while only 4 percent were overweight or obese. Three in ten women age 15-19 and women age 45-49 are thin or undernourished. Variation between urban and rural women is marked. More women have a BMI less than 18.5 in rural areas (28 percent) than in urban areas (19 percent). However, the percentage of overweight or obese women is higher in urban areas (14 percent) than in rural areas (2 percent). Gambela (39 percent) and Tigray (38 percent) have the highest percentage of undernourished women and Addis Ababa has the lowest percentage (15 percent). The percentage of overweight or obese women increases with increasing educational level. It is also elevated for the highest wealth quintile. 164 | Nutrition of Children and Women Table 11.12 Nutritional status of women by background characteristics Among women age 15-49, mean height, percentage under 145 cm, mean body mass index (BMI), and percentage with specific BMI levels, by background characteristics, Ethiopia 2005 Height BMI (kg/m2) Background characteristic Mean height in cm Percent- age below 145 cm Number of women Mean BMI 18.5- 24.9 (normal) <18.5 (thin) 17.0- 18.4 (mildly thin) <17.0 (moder- ately and severely thin) •25.0 (over- weight or obese) 25.0- 29.9 (over- weight) •30.0 (obese) Number of women Age 15-19 155.5 4.8 1,608 19.7 64.5 32.5 17.0 15.5 3.0 2.8 0.1 1,517 20-29 156.8 3.1 2,358 20.3 75.8 20.8 15.6 5.2 3.4 3.0 0.4 2,002 30-39 156.9 2.4 1,596 20.4 68.9 24.8 17.6 7.2 6.3 5.4 0.9 1,359 40-49 156.9 2.1 1,074 20.2 63.2 30.9 23.0 7.9 6.0 4.2 1.8 1,024 Residence Urban 156.9 1.9 1,145 21.5 67.0 18.8 11.6 7.2 14.2 11.9 2.3 1,112 Rural 156.4 3.4 5,492 19.9 69.6 28.3 19.1 9.1 2.2 1.8 0.3 4,789 Region Tigray 156.8 2.8 443 19.3 60.8 37.5 22.0 15.6 1.6 1.6 0.0 390 Affar 156.4 4.3 69 20.0 62.9 33.0 18.5 14.4 4.1 3.6 0.5 61 Amhara 155.1 4.3 1,609 19.9 70.5 27.0 17.6 9.4 2.4 2.0 0.4 1,471 Oromiya 156.9 2.2 2,331 20.4 71.1 24.3 17.6 6.7 4.6 3.9 0.7 2,036 Somali 162.0 1.9 230 20.1 55.4 34.9 17.5 17.4 9.7 8.6 1.1 202 Benishangul-Gumuz 156.5 1.6 61 19.6 65.3 32.9 22.6 10.3 1.8 1.8 0.0 53 SNNP 156.3 4.1 1,490 20.0 70.2 26.7 18.5 8.2 3.0 2.9 0.2 1,295 Gambela 160.5 1.2 23 19.4 59.5 38.5 23.2 15.3 2.0 1.9 0.2 20 Harari 158.6 1.7 19 21.0 69.4 20.6 13.3 7.3 10.0 6.7 3.4 17 Addis Ababa 156.8 2.1 329 22.0 67.2 15.4 9.8 5.5 17.5 13.0 4.5 325 Dire Dawa 158.7 1.3 32 21.3 61.4 24.2 14.7 9.5 14.3 10.8 3.6 31 Education No education 156.5 3.3 4,336 20.0 69.7 27.4 19.3 8.1 2.9 2.4 0.4 3,761 Primary 156.1 3.8 1,535 20.0 68.4 28.1 16.3 11.8 3.5 3.1 0.4 1,393 Secondary and higher 157.7 1.5 766 21.4 67.1 18.8 12.3 6.5 14.1 11.4 2.7 747 Wealth quintile Lowest 157.1 3.3 1,225 19.8 68.5 29.9 19.9 10.0 1.6 0.9 0.7 1,071 Second 155.3 3.9 1,295 19.8 66.6 30.2 20.8 9.4 3.2 2.8 0.4 1,104 Middle 156.3 3.7 1,251 19.8 69.0 29.3 18.8 10.5 1.7 1.5 0.2 1,068 Fourth 156.6 3.7 1,223 19.9 71.6 26.6 17.9 8.7 1.8 1.8 0.1 1,091 Highest 157.2 1.7 1,642 21.1 69.6 19.5 13.2 6.3 10.9 9.2 1.7 1,567 Total 156.5 3.2 6,636 20.2 69.1 26.5 17.7 8.8 4.4 3.7 0.7 5,901 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilogrammes to the square of height in metres (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding 2 months Malaria | 165 MALARIA 12 12.1 INTRODUCTION Malaria is a leading public health problem in Ethiopia. In 2004-05, the disease was reported as the primary cause of health problems, accounting for 17 percent of outpatient visits, 15 percent of hospital admissions, and 29 percent of in-patient deaths (MOH, 2005a). Almost 75 percent of the land is malarious and an estimated 50 million people (68 percent) live in areas at risk of malaria. Areas at altitude below 2000 metres above sea level are generally considered malarious. However, local transmission has also been detected in areas at altitudes as high as 2,500 metres. The transmission pattern is unstable and often characterized by focal and cyclic large scale epidemics. The most recent malaria epidemic, which occurred in 2003, affected 211 districts where more than 2 million clinical cases were recorded (Negash et al., 2005). The malaria transmission season runs from September to December, following the major rainy season from June to August, with a minor transmission season from April to May in areas that receive rains during the short rainy season from February to March. Localized or widespread malaria epidemics can occur during the transmission season. The widespread epidemics have a cyclical pattern of 5 to 8 years that follows major climatic changes. The 2005 EDHS was fielded from the end of April 2005 to the end of August 2005, before the main malaria transmission season began. The type and application of malaria prevention and control interventions is determined by the transmission characteristics of the disease in different parts of the country. Insecticide treated nets (ITNs) are generally distributed in areas where malaria transmission occurs for more than 3 months of the year. The ITN distribution system through the public sector gives priority for free distribution to pregnant mothers and children under five years of age in targeted high priority areas. A private sector ITN distribution at subsidized or market prices also operates in Ethiopia (MOH, 2004a). Indoor residual spraying with DDT or Malathion, as per WHO recommendations, is generally limited to localities in the highland fringe areas that are prone to epidemics. Implementation of the first five-year strategic plan for malaria prevention and control (2001- 2005) was completed in December 2005. The period is in line with the DHS surveys conducted in 2000 and 2005. Findings from the EDHS 2005 provide population-based estimates on the current coverage of major malaria prevention and control interventions and can be used as a baseline for the next plans. 12.1.1 Malaria Vector Control Ownership of Mosquito Nets The use of ITNs is one of the major components of the selective vector control strategy in Ethiopia. The effectiveness of this intervention depends on high coverage and effective utilization. The ITN distribution in Ethiopia primarily targets households with children less than five years of age and pregnant women in targeted areas (MOH, 2004a). In Ethiopia there are various types of ITNs distributed through the public and private sector. This includes the ordinary ITNs that require re- treatment with insecticide every 6 months and the long-lasting insecticide treated nets (LLINs) that can retain effective concentration of insecticides for up to 20 washes. During the EDHS 2005 survey, information was collected on the ownership and use of mosquito nets, both treated and untreated. In an effort to make mosquito nets more affordable and to ensure equitable distribution, the government of Ethiopia endorses a segmented market approach whereby the most vulnerable and at- 166 | Malaria risk groups are given free ITNs. In addition, in selected areas the private sector subsidizes the sale of ITNs. To boost ITN distribution through both the public and private sectors, the government has since 2002 reduced the tax and tariff on ITNs. Table 12.1 shows the percentage of households with at least one and with more than one mosquito net (treated or untreated) and the percentage of households with at least one and with more than one ITN by background characteristics. The data show that only about 6 percent of households in Ethiopia own a mosquito net whether treated or untreated. The percentage of households having more than one net is about 1 percent. Five percent of households own at least one ever-treated net. Urban households are more likely to own any kind of net (11 percent) compared with rural households (5 percent). Mosquito net ownership is highest in the Gambela Region (31 percent) and lowest in Addis Ababa (1 percent). Comparable data from the 2000 EDHS show that only 1 percent of households in Ethiopia had bednets at that time, with urban households slightly more likely than rural households to possess bednets (3 percent and 1 percent, respectively). In 2000, households in the Affar, Gambela, and Somali regions were more likely to have bednets (31 percent, 12 percent, and 6 percent, respectively) primarily because the prevalence of malaria is high in those regions. Table 12.1 Household possession of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), ever-treated mosquito net, and insecticide- treated net (ITN), and the average number of nets per household, by background characteristics, Ethiopia 2005 Any type mosquito net Ever-treated mosquito net1 Insecticide-treated mosquito net2 (ITNs) Background characteristics Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ever-treated nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Number of households Residence Urban 10.8 2.8 0.1 8.4 1.9 0.1 5.4 1.0 0.1 1,974 Rural 4.8 0.6 0.1 3.8 0.3 0.0 3.1 0.2 0.0 11,747 Region Tigray 16.3 3.0 0.2 13.5 2.4 0.2 8.9 1.2 0.1 940 Affar 21.4 6.2 0.3 9.5 2.0 0.1 6.3 0.9 0.1 138 Amhara 3.8 1.0 0.0 2.3 0.6 0.0 1.3 0.3 0.0 3,709 Oromiya 2.8 0.5 0.0 2.4 0.3 0.0 1.9 0.1 0.0 4,790 Somali 6.6 1.4 0.1 4.8 0.9 0.1 4.2 0.8 0.1 540 Benishangul-Gumuz 15.4 2.3 0.2 8.3 1.2 0.1 4.5 0.7 0.1 128 SNNP 8.2 0.4 0.1 7.5 0.3 0.1 6.6 0.2 0.1 2,802 Gambela 30.6 12.9 0.5 17.9 6.7 0.3 10.8 3.8 0.2 47 Harari 6.0 0.4 0.1 3.5 0.2 0.0 1.9 0.1 0.0 39 Addis Ababa 1.0 0.1 0.0 0.3 0.0 0.0 0.0 0.0 0.0 525 Dire Dawa 22.4 0.3 0.2 18.6 0.3 0.2 17.0 0.1 0.2 64 Wealth quintile Lowest 4.7 0.6 0.1 3.5 0.4 0.0 2.9 0.2 0.0 2,757 Second 3.4 0.5 0.0 2.5 0.2 0.0 2.1 0.1 0.0 2,838 Middle 4.3 0.6 0.1 3.2 0.3 0.0 2.9 0.2 0.0 2,670 Fourth 5.1 0.4 0.1 4.4 0.2 0.0 3.4 0.1 0.0 2,531 Highest 10.5 2.4 0.1 8.3 1.6 0.1 5.5 0.8 0.1 2,925 Altitude 0 - 999 36.1 13.3 0.5 22.5 6.9 0.3 14.1 3.4 0.2 279 1000 - 1499 12.4 2.5 0.2 10.7 2.1 0.1 7.8 0.9 0.1 853 1500 - 1999 9.0 1.1 0.1 7.1 0.6 0.1 5.8 0.3 0.1 5,085 2000+ 1.5 0.2 0.0 1.2 0.1 0.0 0.8 0.1 0.0 7,376 Total 5.7 0.9 0.1 4.4 0.6 0.1 3.4 0.3 0.0 13,721 Note: Total includes 138 households missing information on altitude and not shown separately. 1 An ever-treated net is a pretreated net or a non-pretreated net which has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pretreated net obtained within the last 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. Malaria | 167 Consistent with the degree of risk of malaria, ownership of mosquito net varies inversely with altitude. For example, 36 percent of households in areas below 1,000 metres own some kind of net, while the corresponding figure for households at and above 2,000 metres is only 2 percent. Three percent of households reported owning an ITN. Households in Addis Ababa reported almost no ownership of ITNs, while those in the Dire Dawa Administrative Council have the highest level of ITN ownership (17 percent), followed by the Gambela Region (11 percent). Subsequent to the fielding of the 2005 EDHS, the largest ever distribution campaign in Ethiopia was conducted from September to December 2005, in which more than 3 million ITNs were distributed. Sixty percent of these nets were LLINs. Use of Mosquito Nets by Children Children under five years of age are especially vulnerable to malaria and are targeted as a high priority group for ITNs. Therefore, households in targeted areas with children under five years of age have a greater chance of getting free ITNs through the public distribution system. Table 12.2 presents information on the percentage of children under age five who slept under a mosquito net (treated or untreated) the night before the survey. Overall, just over 2 percent of children slept under a net the night prior to the survey, while less than 2 percent slept under ever- treated nets and ITNs the night prior to the survey. Little variation was observed in the use of nets by age or sex of children. Children in urban areas are almost five times as likely to sleep under a mosquito net (9 percent) as children in rural areas (2 percent). The proportion of children who sleep under any type of mosquito net is highest in Dire Dawa (20 percent), followed by Affar (14 percent) and Gambela (12 percent). It is lowest is in Addis Ababa (1 percent). The proportion sleeping under a net is highest among children in the highest wealth quintile. This could be indicative of high income as a contributor to better awareness and ability to buy nets. This emphasizes the need for better communication to improve utilization of nets by the most vulnerable groups at high risk of malaria. Use of nets varies inversely with altitude, with large differences in mosquito net use between children living at altitudes less than 1,000 metres (19 percent) and those living at altitudes above 1,000 metres (4 percent and less). 168 | Malaria Table 12.2 Use of mosquito nets by children Percentage of children under five years of age who slept under a mosquito net (treated or untreated), an ever-treated mosquito net, or an insecticide-treated net (ITN) the night before the interview, by background characteristics, Ethiopia 2005 Background characteristic Percentage of children who slept under any net the preceding night Percentage of children who slept under an ever-treated net the preceding night1 Percentage of children who slept under an ITN the preceding night Number of children Age in months < 12 2.9 2.0 1.8 2,284 12-23 2.5 2.0 1.7 1,955 24-35 2.1 1.5 0.8 1,969 36-47 1.7 1.5 1.4 2,243 48-59 2.4 2.1 1.6 2,239 Sex Male 2.3 1.8 1.6 5,426 Female 2.4 1.8 1.4 5,266 Residence Urban 9.3 6.7 3.6 780 Rural 1.8 1.5 1.3 9,911 Region Tigray 2.1 2.0 1.6 686 Affar 13.8 5.4 3.1 101 Amhara 2.1 1.2 0.9 2,440 Oromiya 1.0 0.8 0.4 4,220 Somali 5.5 4.0 3.7 453 Benishangul-Gumuz 3.7 2.1 1.4 102 SNNP 3.6 3.4 3.2 2,449 Gambela 12.2 4.7 2.2 30 Harari 2.0 1.2 1.0 22 Addis Ababa 0.6 0.1 0.1 151 Dire Dawa 20.4 19.6 19.0 38 Wealth quintile Lowest 1.8 1.6 1.4 2,352 Second 1.1 0.8 0.8 2,256 Middle 1.8 1.1 1.1 2,337 Fourth 2.1 1.8 1.7 2,150 Highest 6.0 4.7 2.8 1,596 Altitude 0 - 999 19.3 11.5 8.4 213 1000 - 1499 2.8 2.5 2.1 777 1500 - 1999 3.8 3.1 2.6 4,080 2000+ 0.5 0.4 0.3 5,498 Total 2.3 1.8 1.5 10,691 Note: Total includes 115 children missing information on altitude who are not shown separately. 1 An ever-treated net is a pretreated net or a non-pretreated net that has been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pretreated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide in the past 12 months. Use of Mosquito Nets by Women As in the case of children under five years of age, pregnant women are also one of the target groups of high priority for ITNs, with households in targeted areas where pregnant women reside having a greater chance of getting free ITNs through the public distribution system. The 2004-05 health and health-related indicators of the Federal Ministry of Health identify malaria as the primary cause of health problems among female patients attending health facilities, and accounts for 15 Malaria | 169 percent of out-patient consultations, 19 percent of admissions, and 29 percent of in-patients deaths (MOH, 2005a). Given that the level of fertility in the population is high, the burden of malaria on women, especially pregnant women, is high. Despite this, the level of utilization of ITNs by all women and by pregnant women is not sufficient for what the problem calls for. Table 12.3 shows the percentage of all women and pregnant women who slept under any mosquito net and the proportion who slept under an ITN the night prior to the interview, by background characteristics. Generally, a very small proportion of women slept under a mosquito net (2 percent), and only 1 percent of pregnant women slept under an ITN. Thus, the data show little difference in the use of nets between pregnant and non-pregnant women (both 2 percent). Women in urban areas are more than twice as likely as women in rural areas to sleep under a mosquito net. Urban pregnant women are more than ten times as likely to sleep under a net as rural pregnant women. Table 12.3 Use of mosquito nets by women Percentage of all women age 15-49 and pregnant women age 15-49 who slept under a mosquito net (treated or untreated), an ever- treated mosquito net, or an insecticide-treated net (ITN) the night before the interview, by background characteristics, Ethiopia 2005 Percentage of all women age 15-49 who: Percentage of pregnant women age 15-49 who: Background characteristic Slept under any net the preceding night Slept under an ever- treated net the preceding night1 Slept under an ITN2 the preceding night Number of women Slept under any net the preceding night Slept under an ever- treated net the preceding night1 Slept under an ITN2 the preceding night Number of pregnant women Residence Urban 4.4 3.4 2.3 2,569 11.0 9.5 6.4 60 Rural 1.9 1.5 1.3 11,915 1.1 0.8 0.8 1,121 Region Tigray 2.1 2.1 1.6 946 3.1 3.1 2.8 80 Affar 12.3 6.6 3.8 150 13.3 8.0 5.9 12 Amhara 1.7 1.0 0.7 3,582 1.5 0.3 0.3 253 Oromiya 1.2 0.9 0.6 5,154 0.0 0.0 0.0 450 Somali 4.8 3.2 2.9 504 2.2 1.5 1.5 46 Benishangul-Gumuz 5.5 2.8 2.0 129 1.2 0.0 0.0 13 SNNP 4.2 4.0 3.5 3,085 2.9 2.9 2.4 308 Gambela 12.0 6.4 4.1 45 6.7 5.6 2.7 3 Harari 1.1 0.9 0.5 40 0.0 0.0 0.0 2 Addis Ababa 0.1 0.0 0.0 776 (0.0) (0.0) (0.0) 11 Dire Dawa 8.9 8.4 7.9 71 * * * 3 Education No education 1.9 1.5 1.2 9,416 1.1 0.7 0.7 868 Primary 3.0 2.5 2.1 3,469 2.6 2.6 2.2 257 Secondary and higher 3.4 2.2 1.5 1,599 4.1 3.0 1.5 55 Wealth quintile Lowest 1.7 1.3 1.2 2,526 1.1 1.0 0.9 246 Second 1.3 0.9 0.8 2,732 1.1 0.3 0.3 292 Middle 1.6 1.1 1.1 2,789 0.2 0.0 0.0 287 Fourth 2.0 1.8 1.6 2,721 1.4 1.2 1.2 221 Highest 4.3 3.4 2.2 3,716 7.0 6.1 4.7 135 Altitude 0 - 999 17.5 10.8 7.7 280 13.2 9.5 7.8 19 1000 - 1499 3.3 2.7 2.1 861 5.1 4.4 4.0 73 1500 - 1999 4.2 3.4 2.8 5,391 1.7 1.2 1.0 473 2000+ 0.4 0.3 0.2 7,821 0.8 0.7 0.5 599 Total 2.3 1.8 1.4 14,484 1.6 1.2 1.1 1,181 Note: Total includes 137 women and 17 pregnant women for whom information on altitude is not known. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 An ever-treated net is a pretreated net or a non-pretreated net that has been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pretreated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide in the past 12 months. 170 | Malaria The use of mosquito nets among all women is highest in the Affar and Gambela regions (12 percent each) and lowest in Addis Ababa (negligible use). The highest percentage of women sleeping under an ever-treated net or ITN the night before the survey was reported in Dire Dawa (8 percent). Among pregnant women, use of mosquito nets is highest in Affar (13 percent slept under any net, 8 percent slept under an ever-treated net, and 6 percent slept under an ITN). In general, the use of mosquito nets (treated and untreated) increases among women and pregnant women as the level of wealth increases. A higher proportion of women in low altitude areas use mosquito nets than those in higher altitudes, and the highest coverage (18 percent) is reported in areas of less than 1,000 metres. Eight percent of pregnant women living in areas less than 1,000 metres slept under an ITN the night before the interview. Use of Mosquito Nets by Population age Five and Older The malaria transmission pattern in Ethiopia is highly seasonal and unstable. Because of this unstable transmission and infrequent exposure to infection, immunity is generally underdeveloped and all age groups are at risk of malarial disease. Although pregnant mothers and children under five years of age are the most vulnerable, the population age five and older is also at high risk, and adult deaths from malaria during epidemics are relatively high. Table 12.4 shows the percentage of the population age five and older who slept under a mosquito net whether treated or untreated, and the proportion who slept under an ITN the night prior to the interview, by background characteristics. Generally, a very low percentage of this population slept under any net (2 percent), an ever-treated-net (1 percent), or an ITN (1 percent). The pattern of use of mosquito nets in this population is similar to that for pregnant women and children under age five. Persons age five and older in urban areas are more likely to sleep under a mosquito net than those in the rural areas. Use of mosquito nets among this group is highest in Gambela (9 percent use any net, 5 percent use an ever-treated net, and 3 percent use an ITN), followed by Affar (8 percent use any net, 4 percent use an ever-treated net, and 2 percent use an ITN). The population age five and older sleeping under an ITN the night before the interview was highest in Dire Dawa (6 percent), followed by Gambela (3 percent) and SNNP (3 percent). In general, the use of mosquito nets (treated and untreated) among this group increases slightly as the level of wealth increases. Use of mosquito nets is higher in areas at altitudes below 1,000 metres, with 12 percent using any net, 7 using an ever-treated net, and 5 percent using an ITN. Malaria | 171 Table 12.4 Use of mosquito nets by population age five and older Percentage of population age five and older who slept under a mosquito net (treated and untreated), under an ever-treated mosquito net, or an insecticide-treated net (ITN) the night before the interview, by background characteristics, Ethiopia 2005 Background characteristic Percentage who slept under any net the preceding night Percentage who slept under an ever- treated net the preceding night1 Percentage who slept under an ITN2 the preceding night Number of persons age 5 and older Sex Male 1.5 1.2 1.0 28,219 Female 1.7 1.4 1.0 28,626 Residence Urban 3.4 2.7 1.8 7,395 Rural 1.3 1.1 0.9 49,450 Region Tigray 1.6 1.5 1.2 3,587 Affar 7.8 3.7 2.3 606 Amhara 0.9 0.5 0.3 14,356 Oromiya 0.8 0.6 0.5 20,546 Somali 3.2 2.3 2.0 2,292 Benishangul-Gumuz 3.1 1.6 1.1 485 SNNP 3.1 2.9 2.5 12,299 Gambela 9.1 5.1 3.4 169 Harari 0.6 0.4 0.2 135 Addis Ababa 0.1 0.0 0.0 2,127 Dire Dawa 6.2 6.0 5.6 241 Wealth quintile Lowest 1.2 1.0 0.9 11,064 Second 0.9 0.7 0.6 11,175 Middle 1.2 0.9 0.9 11,243 Fourth 1.3 1.2 1.1 11,347 Highest 3.1 2.5 1.7 12,016 Altitude 0 - 999 11.6 7.1 5.2 1,124 1000 - 1499 2.7 2.4 1.8 3,443 1500 - 1999 2.8 2.4 2.0 21,122 2000+ 0.2 0.2 0.1 30,554 Total 1.6 1.3 1.0 56,845 Note: Total includes 611 persons missing information on altitude who are not shown separately. 1 An ever-treated net is 1) a pretreated net or a non-pretreated net that has been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pretreated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide in the past 12 months. Indoor Residual Spraying of Insecticide The malaria vector control programme in Ethiopia employs an integrated application of vector control interventions that augment each other for maximum reduction in vector longevity and hence transmission. The selection and application of vector control interventions is based on the principles of integrated vector management whereby the judicious use of insecticides is ensured in an economi- cally and environmentally agreeable manner. The service is fully funded by the government and the public receives services at no cost. Indoor residual spraying with DDT or Malathion, as per WHO recommendations, is one of the major malaria vector control interventions applied to preempt malaria epidemics in selected epidemic-prone localities. The intervention annually is estimated to cover 20-30 percent of the malaria 172 | Malaria epidemic-prone localities (MOH, unpublished sources). The operation demands substantial financial input and coordinated logistics. The amount of insecticide utilized each year costs an estimated US$2.5 million and the operational cost is much higher. This intervention has been applied in the country since the 1950s. The level of coverage is usually reported in activity reports. However, efforts to collect data on the percentage of unit structures that received spraying and where the sprayed walls remained intact without being re- plastered (mud, white wash, reconstructed) have not been implemented. For the first time, population- based data on the coverage and status of sprayed unit structures have been collected through the household questionnaire of the 2005 EDHS. Table 12.5 shows the percentage of houses sprayed within the past six months and the percentage of houses with white insecticide powder visible on the sprayed walls. Table 12.5 Coverage of spraying programs Percentage of households occupying a dwelling in which the inner walls were ever sprayed with insecticide to prevent malaria, percentage of households occupying a dwelling whose inner walls were sprayed with insecticide 0-6 months preceding the survey, and percentage of households occupying a dwelling with white insecticide powder visible on the inner walls, by background characteristics, Ethiopia 2005 Background characteristic Percentage of households occupying a dwelling ever sprayed with insecticide to prevent malaria Percentage of households occupying a dwelling sprayed with insecticide to prevent malaria 0-6 months preceding the survey Percentage of households occupying a dwelling with white insecticide powder visible on the inner walls Number of households Residence Urban 7.0 3.2 2.5 1,974 Rural 11.1 2.1 2.8 11,747 Region Tigray 22.4 2.5 4.1 940 Affar 11.0 3.5 1.4 138 Amhara 13.1 2.8 3.7 3,709 Oromiya 8.5 2.1 2.3 4,790 Somali 0.6 0.4 0.1 540 Benishangul-Gumuz 25.6 0.4 0.6 128 SNNP 9.1 2.1 2.8 2,802 Gambela 25.7 1.9 2.5 47 Harari 5.5 2.3 0.3 39 Addis Ababa 0.5 0.2 0.0 525 Dire Dawa 23.3 17.0 12.7 64 Wealth quintile Lowest 10.4 2.2 3.1 2,757 Second 10.4 2.6 3.0 2,838 Middle 11.9 1.5 2.6 2,670 Fourth 11.2 2.1 2.6 2,531 Highest 8.8 2.8 2.5 2,925 Altitude 0 - 999 18.6 2.6 4.2 279 1000 - 1499 18.4 4.1 4.8 853 1500 - 1999 17.0 3.9 4.7 5,085 2000+ 4.9 0.9 1.1 7,376 Total 10.5 2.3 2.8 13,721 Note: Total includes 138 households missing information on altitude that are not shown separately. Malaria | 173 Eleven percent of households were reported as ever having been sprayed with insecticide to prevent malaria, with 2 percent having been sprayed in the past six months. Only 3 percent were reported to have white powder visible on the inner walls. The coverage of houses ever sprayed is highest in Gambela and Benshangul-Gumuz regions (26 percent each) followed by Dire Dawa (23 percent) and Tigray (22 percent). The percentage of houses sprayed in the six months preceding the survey is highest in Dire Dawa (17 percent), while it is below 4 percent in all other regions. The highest percentage of houses with visible insecticide powder on sprayed walls is in Dire Dawa (13 percent) followed by Tigray and Amhara (4 percent each) and SNNP (3 percent). Houses located at altitudes less than 2,000 metres are more likely to have ever been sprayed and more likely to have been sprayed within the past 6 months than houses located at or above 2,000 metres. For example, more than 17 percent of households located below 2,000 meters were sprayed at some time, compared with less than 5 percent of households at or above 2,000 metres. Malaria Prophylaxis in Pregnancy The malaria prevention and control guidelines in the country recommend the use of chemoprophylaxis as a preventive measure. The drug recommended for chemoprophylaxis starting July 2004 is mefloquine (MOH, 2004b). Chemoprophylaxis is recommended for visitors to malarious areas and pregnant mothers residing in malaria endemic areas. Intermittent preventive treatment (IPT) using sulfadoxine-pyrimethamine for the prevention of malaria during pregnancy has never been officially adopted and introduced by the Ministry of Health. This intervention is recommended for areas with stable transmission. Therefore, its application in Ethiopia where transmission is generally seasonal and unstable is not recommended. Even in some parts of the country like Gambela, where the malaria transmission season is relatively long (more than 6 months), the intervention has not been implemented because of the co-existence of P. vivax infections (approximately 40 percent), for which sulfadoxine-pyrimethamine is not effective. The high level of resistance to sulfadoxine- pyrimethamine (36 percent, range 20-54) that led to the change of the first-line, anti-malarial drug for the treatment of falciparum malaria to the ACT drug Artemether-Lumefantrine was the other reason for not applying the intervention (Jima et al., 2005) . Table 12.6 indicates summary findings on the preventive use of anti-malarial drugs and use of IPT. Four percent of pregnant women took an anti-malarial drug, 2 percent took SP/Fansidar, 1 percent received two or more doses of SP/Fansidar, less than 1 percent received any SP/Fansidar during an antenatal visit, and a negligible percent received two or more doses of SP/Fansidar at least once during an ANC visit (IPT). Since SP/Fansidar is not recommended as a prophylactic drug and has never been introduced for IPT, it is not surprising that the percentage who received it during an ANC visit is low and probably reflects individual practice by service providers and users. 174 | Malaria Table 12.6 Prophylactic use of antimalarial drugs and use of intermittent preventive treatment (IPT) by women during pregnancy Percentage of women who took any antimalarial drugs for prevention, who took SP/Fansidar, and who received intermittent preventive treatment (IPT), during the pregnancy for their last live birth in the two years preceding the survey, by background characteristics, Ethiopia 2005 Intermittent preventive treatment (IPT)1 SP/Fansidar Background characteristic Percentage who took any antimalarial drug Percentage who took any SP/Fansidar Percentage who took 2+ doses Percentage who received any SP/Fansidar during an ANC visit Percentage who received 2+ doses, at least once during an ANC visit Number of women Residence Urban 5.4 2.9 1.0 1.0 0.3 322 Rural 4.3 2.0 1.2 0.5 0.3 3,999 Region Tigray 4.5 2.5 1.8 0.5 0.3 256 Affar 11.6 5.1 2.3 0.9 0.7 41 Amhara 7.0 3.9 1.6 0.8 0.2 1,046 Oromiya 1.5 0.6 0.4 0.4 0.4 1,668 Somali 0.7 0.7 0.7 0.0 0.0 168 Benishangul-Gumuz 13.3 5.8 2.2 1.1 0.3 40 SNNP 6.6 2.8 2.0 0.5 0.5 1,005 Gambela 9.8 4.3 2.3 0.8 0.3 11 Harari 2.9 1.4 0.0 0.0 0.0 10 Addis Ababa 0.0 0.0 0.0 0.0 0.0 61 Dire Dawa 1.4 1.4 0.8 1.4 0.8 15 Education No education 4.1 2.1 1.2 0.5 0.3 3,363 Primary 5.5 2.2 1.7 0.8 0.7 768 Secondary and higher 3.6 1.6 0.2 0.2 0.2 190 Wealth quintile Lowest 2.4 1.6 1.2 0.3 0.2 918 Second 2.7 1.7 1.1 0.4 0.3 926 Middle 6.3 2.3 1.4 0.6 0.4 957 Fourth 4.7 2.9 1.6 0.6 0.4 859 Highest 6.2 2.0 0.6 0.8 0.4 660 Altitude 0 - 999 14.3 6.0 4.3 0.6 0.4 80 1000 - 1499 11.4 3.8 2.4 0.7 0.5 285 1500 - 1999 5.5 2.8 1.6 0.9 0.6 1,659 2000+ 2.2 1.2 0.6 0.2 0.1 2,262 Total 4.4 2.1 1.2 0.5 0.3 4,321 Note: Total includes 30 women missing information on altitude who are not shown separately. 1 IPT = Intermittent preventive treatment (received SP/Fansidar during an antenatal (ANC) visit). 12.1.2 Malaria Diagnosis and Treatment Treatment of Malaria in Children Child illness and death in Ethiopia are due primarily to five common childhood illnesses, namely, pneumonia (ARI), diarrhoea, malaria, measles and malnutrition, and often to a combination of these conditions (MOH 2005b). The level of childhood mortality in Ethiopia is one of the highest in the world. The 2004-05 health and health-related indicators of the Ministry of Health identified malaria as the primary cause of health problems in infants, accounting for 19 percent of out-patient visits, 18 percent of admissions, and 28 percent of in-patients deaths (MOH, 2005a). Thus, children under five are recognized as the most vulnerable group for whom diagnosis and treatment should be given priority. Malaria | 175 Table 12.7 presents data on the percentage of children under age five with fever who received treatment for malaria. Overall, of the 19 percent of children with fever in the two weeks preceding the survey, 3 percent took anti-malarial drugs but less than 1 percent took the anti-malarial drug the same day or the next day following the onset of fever. Table 12.7 Prevalence and prompt treatment of children with fever Percentage of children under age five with fever in the two weeks preceding the survey, and among children with fever, the percentage who received antimalarial drugs and the percentage who received the drugs the same or next day following the onset of fever, by background characteristics, Ethiopia 2005 Children under age five Children under age five with fever Background characteristic Percentage with fever in the two weeks preceding the survey Number of children Percentage who received antimalarial drugs Percentage who received antimalarial drugs same or next day Number of children Age in months < 6 16.8 1,152 0.6 0.0 194 6-11 27.6 1,071 4.4 0.0 295 12-23 23.3 1,877 2.7 0.8 438 24-35 21.6 1,892 1.9 1.2 408 36-47 15.1 2,105 3.5 0.1 317 48-59 11.6 2,013 4.9 1.9 233 Sex Male 18.2 5,129 2.7 0.8 935 Female 19.1 4,980 3.2 0.5 951 Residence Urban 16.0 752 4.2 1.6 121 Rural 18.9 9,357 2.9 0.6 1,765 Region Tigray 20.3 653 0.0 0.0 132 Affar 17.0 96 9.0 6.6 16 Amhara 14.2 2,312 2.4 0.6 329 Oromiya 19.0 4,017 1.5 0.6 764 Somali 14.0 432 0.0 0.0 60 Benishangul-Gumuz 15.3 95 4.0 1.6 15 SNNP 23.5 2,273 6.3 0.8 534 Gambela 17.8 29 11.2 6.6 5 Harari 13.7 21 1.2 0.0 3 Addis Ababa 16.1 146 3.3 1.5 23 Dire Dawa 12.3 34 (0.0) (0.0) 4 Mother's education No education 18.3 7,951 2.5 0.7 1,457 Primary 21.3 1,709 4.9 0.4 364 Secondary and higher 14.4 450 4.1 1.5 65 Wealth quintile Lowest 19.1 2,218 0.5 0.0 422 Second 19.5 2,122 2.7 1.1 413 Middle 19.7 2,210 3.6 0.4 436 Fourth 17.7 2,015 3.5 0.5 357 Highest 16.7 1,544 5.7 1.8 258 Altitude 0 - 999 14.8 205 12.8 4.0 30 1000 - 1499 23.6 732 3.4 0.9 173 1500 - 1999 19.8 3,857 3.9 0.4 763 2000+ 17.0 5,205 1.9 0.7 886 Total 18.7 10,109 3.0 0.7 1,886 Note: Total includes 102 children under age five and 27 children under age five with fever missing information on altitude and not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 176 | Malaria Types of Anti-Malarial Drugs Used In Ethiopia, the first-line, anti-malarial drug for the treatment of malaria has been changing over the past decade. The main reason for change was the level of efficacy of the drugs. Chloroquine was the first-line, anti-malarial drug for the treatment of uncomplicated malaria until 1998. However, because of the high level of failure (65 percent) of chloroquine for the treatment of uncomplicated falciparum malaria that was detected through a nationwide study conducted at 18 sentinel sites in 1997-1998, the drug was replaced by SP/Fansidar (WHO 2001). At the time of the introduction of SP/Fansidar as the first-line drug, the level of treatment failure observed was about 7 percent (WHO, 2001). In subsequent years, however, unpublished reports from isolated studies indicated higher treatment failure rates. As a result, a nationwide study on the therapeutic efficacy of SP/Fansidar for the treatment of uncomplicated falciparum malaria was conducted at 10 sentinel sites from October to December 2003. A mean treatment failure rate of 36 percent (ranging from 20-54 percent) was reported. Cognizant of the high treatment failure rates of SP/Fansidar and the need to shift to more effective anti-malarial drugs, the Ministry of Health—after a series of consultative meetings with experts in the field and based on WHO recommendations—decided to introduce the Artemisinin- based combination therapy (ACT) drug Artemether-Lumefantrine in July 2004 (MOH, 2004b). The introduction of the new ACT drug and the phasing out of the old drug was estimated to take up to two years given the limited supply of the new drug and the size of the country. Since the introduction of the new ACT drug over 5.5 million treatment courses have been distributed with much of the ACT drug distributed from September to December 2005 (MOH, 2006). The new ACT drug is used in all health facilities. However, its distribution for home and community use has not yet been implemented, pending local evidence regarding the ease and economic feasibility of using the ACT drug at home and at the community level. Table 12.8 presents data on the percentage of children treated with specific anti-malarial drugs. The most common anti-malarial drugs used are SP/Fansidar and chloroquine (about 1 percent each) and quinine (less than 1 percent). Artemether-Lumefantrine use was reported in only one region, Harari, and the number of febrile cases treated with the drug in the region was about 1 percent. Malaria | 177 Table 12.8 Type and timing of antimalarial drugs received by children with fever Among children under five years of age with fever in the two weeks preceding the survey, the percentage who received specific antimalarial drugs and the percentage who received the drugs the same or next day following the onset of fever, by background characteristics, Ethiopia 2005 Percentage of children with fever who received drug Percentage of children with fever who received drug the same or next day Background characteristic SP/ Fansidar Chloroquine Artemether/ lumefantrine Quinine Other anti- malarial SP/ Fansidar Chloroquine Quinine Number of children with fever Age in months < 6 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 194 6-11 1.4 2.0 0.0 1.6 0.0 0.0 0.0 0.0 295 12-23 1.3 1.1 0.0 0.4 0.0 0.4 0.3 0.0 438 24-35 0.7 1.0 0.0 0.0 0.3 0.6 0.5 0.0 408 36-47 2.6 1.9 0.0 0.0 0.0 0.0 0.1 0.0 317 48-59 1.8 2.6 0.0 1.2 0.0 0.1 0.6 1.2 233 Sex Male 1.1 1.8 0.0 0.3 0.0 0.1 0.4 0.3 935 Female 1.7 1.0 0.0 0.7 0.1 0.4 0.1 0.0 951 Residence Urban 0.8 3.4 0.0 0.0 0.1 0.4 1.2 0.0 121 Rural 1.4 1.3 0.0 0.5 0.1 0.2 0.2 0.2 1,765 Region Tigray 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 132 Affar 4.9 4.1 0.0 0.0 0.0 4.9 1.7 0.0 16 Amhara 0.9 1.1 0.0 0.0 0.3 0.0 0.6 0.0 329 Oromiya 0.5 0.0 0.0 1.0 0.0 0.2 0.0 0.4 764 Somali 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 60 Benishangul-Gumuz 2.4 2.8 0.0 0.0 0.0 0.0 1.6 0.0 15 SNNP 3.1 4.0 0.0 0.3 0.0 0.3 0.5 0.0 534 Gambela 6.8 6.2 0.0 0.5 2.2 5.0 2.7 0.0 5 Harari 0.0 0.0 1.2 0.0 0.0 0.0 0.0 0.0 3 Addis Ababa 3.3 0.0 0.0 0.0 0.0 1.5 0.0 0.0 23 Dire Dawa (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 4 Mother's education No education 1.3 1.0 0.0 0.4 0.0 0.3 0.3 0.2 1,457 Primary 1.7 2.8 0.0 1.1 0.3 0.0 0.4 0.0 364 Secondary and higher 1.9 2.3 0.0 0.0 0.0 1.2 0.3 0.0 65 Wealth quintile Lowest 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 422 Second 0.8 1.2 0.0 0.7 0.0 0.4 0.0 0.7 413 Middle 2.3 1.1 0.0 0.5 0.0 0.4 0.0 0.0 436 Fourth 1.4 2.1 0.0 0.7 0.3 0.1 0.4 0.0 357 Highest 2.0 3.7 0.0 0.6 0.0 0.3 1.4 0.0 258 Altitude 0 - 999 7.1 2.6 0.0 0.1 3.7 3.5 0.8 0.0 30 1000 - 1499 2.5 1.8 0.0 0.0 0.0 0.0 0.9 0.0 173 1500 - 1999 2.1 2.2 0.0 0.2 0.0 0.4 0.0 0.0 763 2000+ 0.4 0.7 0.0 0.9 0.0 0.0 0.4 0.3 886 Total 1.4 1.4 0.0 0.5 0.1 0.2 0.3 0.1 1,886 Note: Total includes 27 children for whom information on altitude is not known. Figures in parentheses are based on 25-49 unweighted cases.   HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 179 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 The chapter presents current levels of HIV/AIDS knowledge, attitudes, and related behaviours for the general adult population. The chapter then focuses on HIV/AIDS knowledge and patterns of sexual activity among young people, as youth are the main target of many HIV prevention efforts. The findings in this chapter will assist the AIDS control program in Ethiopia to identify particular groups of people most in need of information and services and most vulnerable to the risk of HIV infection. 13.1 KNOWLEDGE OF HIV/AIDS AND OF TRANSMISSION AND PREVENTION METHODS 13.1.1 Awareness of AIDS In Ethiopia, knowledge of AIDS is widespread but not universal; 90 percent of women 15-49 and 97 percent of men 15-49 have heard of AIDS (Table 13.1).1 The level of awareness of AIDS is lowest in the Somali and Gambela regions. In the Somali Region, only half of women and 64 percent of men know about AIDS while, in Gambela, 63 percent of women and 88 percent of men have heard about AIDS. Knowledge of AIDS exceeds 90 percent among men in all other groups while among women, knowledge levels are more variable but exceed 80 percent among all other groups. 13.1.2 Knowledge of Ways to Reduce HIV/AIDS Transmission HIV/AIDS prevention programmes focus their messages and efforts on three important aspects of behaviour: delaying sexual debut in young persons (abstinence), limiting the number of sexual partners/ staying faithful to one partner, and use of condoms (the ABC message). To ascertain whether programmes have effectively communicated these messages, EDHS respondents were prompted with specific questions about whether it is possible to 1 For tables in this chapter that relate to the general adult population, the base population includes women and men age 15-49. For the male tables, an additional row has been added to provide information for all men ages 15-59. Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Ethiopia 2005 Women Men Background characteristic Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-24 90.2 5,813 95.3 2,399 15-19 89.2 3,266 94.0 1,335 20-24 91.5 2,547 97.1 1,064 25-29 89.1 2,517 96.9 741 30-39 89.4 3,410 98.2 1,405 40-49 90.4 2,330 96.6 919 Marital status Never married 91.1 3,516 95.0 2,417 Ever had sex 96.3 223 99.8 412 Never had sex 90.8 3,293 94.0 2,005 Married/living together 89.1 9,066 97.6 2,890 Divorced/separated/ widowed 91.4 1,488 99.4 157 Residence Urban 98.6 2,499 99.7 854 Rural 88.0 11,571 95.9 4,610 Region Tigray 97.0 919 99.7 315 Affar 85.4 146 96.4 59 Amhara 87.9 3,482 96.2 1,347 Oromiya 94.7 5,010 98.4 2,041 Somali 50.0 486 64.3 180 Benishangul-Gumuz 67.7 124 94.6 50 SNNP 87.3 2,995 97.2 1,143 Gambela 62.9 44 87.7 19 Harari 98.2 39 99.8 15 Addis Ababa 99.2 756 99.4 266 Dire Dawa 96.9 69 97.8 27 Education No education 86.1 9,271 92.5 2,164 Primary 95.6 3,123 98.8 2,140 Secondary and higher 99.8 1,675 99.9 1,160 Wealth quintile Lowest 80.4 2,428 91.2 980 Second 87.8 2,643 96.0 1,052 Middle 89.2 2,732 97.5 980 Fourth 91.5 2,647 97.6 1,088 Highest 97.0 3,621 99.1 1,364 Total 15-49 89.9 14,070 96.5 5,464 Total men 15-59 na na 96.6 6,033 na = Not applicable 180 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior reduce the chances of getting the AIDS virus by having just one faithful sexual partner, using a condom at every sexual encounter, and abstaining from sex. Table 13.2 presents levels of knowledge for the various HIV/AIDS prevention methods by background characteristics. Women and men are most aware that the chances of getting the AIDS virus can be reduced by limiting sex to one uninfected partner who has no other partners (63 percent and 79 percent, respectively) or by abstaining from sexual intercourse (62 percent and 80 percent, respectively). Knowledge of condoms and the role that they can play in preventing transmission of the AIDS virus is much less common, particularly among women. Around four in ten women and six in ten men are aware that using a condom during sexual encounters can reduce HIV/AIDS transmission. Even fewer women and men are aware that using condoms and limiting sex to one uninfected partner can reduce the risk of getting the AIDS virus (35 percent and 57 percent, respectively). As Table 13.2 shows, young women age 15-24 are generally somewhat more knowledgeable of the various modes of prevention than older women, while the opposite pattern is observed among men. Considering the relationship with marital status, among women, knowledge of HIV/AIDS prevention methods is highest among the never-married group and lowest among those who are currently in union. Never-married women who ever had sex are the most likely to report knowledge of the various modes of prevention. Among men, the differences in knowledge of various prevention modes by marital status are not as great as those among women. As is the case with women, however, never-married men who ever had sex are the most knowledgeable about ways to reduce the risk of getting the AIDS virus. Among both women and men, levels of knowledge of preventive methods are higher in urban than in rural areas. There is considerable variability across regions in knowledge of prevention methods. Among women, knowledge levels for the various methods are highest in Addis Ababa and lowest in the Somali Region. Among men, knowledge levels tend to be higher in Tigray, Harari, Addis Ababa, and Dire Dawa than in other regions and lowest in the Somali Region. Women and men with higher levels of schooling are more likely than those with less schooling to be aware of various preventive methods. Similarly, women and men in higher wealth quintiles are more likely than those in lower quintiles to be aware of ways to prevent the transmission of the HIV virus. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 181 Table 13.2 Knowledge of methods of HIV prevention Percentage of women and men age 15-49 who, in response to a prompted question, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is not infected and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Ethiopia 2005 Women Men Background characteristic Use condoms1 Limit sex to one uninfected partner2 Use condoms1 and limit sex to one uninfected partner2 Abstain from sexual intercourse Number of women Use condoms1 Limit sex to one uninfected partner2 Use condoms1 and limit sex to one uninfected partner2 Abstain from sexual intercourse Number of men Age 15-24 47.4 66.1 41.1 64.2 5,813 65.7 76.5 58.2 77.8 2,399 15-19 47.4 65.0 40.8 63.7 3,266 66.4 73.2 57.4 77.5 1,335 20-24 47.4 67.5 41.4 64.9 2,547 64.9 80.6 59.1 78.2 1,064 25-29 38.6 60.8 33.8 61.2 2,517 62.4 82.6 54.7 83.8 741 30-39 34.2 58.9 29.1 61.0 3,410 64.3 81.3 56.2 82.8 1,405 40-49 32.7 60.2 27.7 60.3 2,330 61.8 79.5 56.0 80.4 919 Marital status Never married 54.2 70.5 48.0 68.5 3,516 65.3 76.4 57.6 77.5 2,417 Ever had sex 70.2 78.8 64.7 71.9 223 74.2 85.1 65.9 83.1 412 Never had sex 53.1 69.9 46.9 68.3 3,293 63.5 74.6 55.9 76.3 2,005 Married/living together 34.5 59.5 29.2 59.8 9,066 63.2 81.1 55.9 82.6 2,890 Divorced/separated/ widowed 42.1 61.4 36.0 62.4 1,488 68.1 80.9 63.5 81.6 157 Residence Urban 72.2 81.8 65.5 75.9 2,499 82.5 89.0 75.5 89.5 854 Rural 33.3 58.3 28.0 59.3 11,571 60.9 77.2 53.4 78.6 4,610 Region Tigray 52.3 72.1 47.4 76.8 919 77.9 92.3 73.8 96.0 315 Affar 27.2 36.9 22.2 41.5 146 60.6 73.5 52.3 73.5 59 Amhara 35.9 56.8 29.5 54.5 3,482 74.9 79.7 65.7 86.3 1,347 Oromiya 41.0 68.3 35.6 69.4 5,010 61.8 81.5 54.1 78.1 2,041 Somali 10.6 26.2 9.3 22.8 486 15.8 32.0 14.6 36.3 180 Benishangul-Gumuz 29.0 43.3 23.2 41.9 124 58.2 72.1 51.7 80.6 50 SNNP 35.9 57.9 30.4 58.1 2,995 57.2 77.1 50.9 78.1 1,143 Gambela 25.3 34.0 18.2 39.1 44 54.2 60.9 46.7 60.3 19 Harari 60.7 77.5 54.8 73.9 39 74.0 95.9 72.9 96.2 15 Addis Ababa 78.5 87.4 72.6 82.3 756 77.8 83.1 68.2 89.9 266 Dire Dawa 56.7 69.3 49.8 70.1 69 70.9 85.6 67.1 83.1 27 Education No education 28.3 54.4 23.5 56.4 9,271 51.6 72.2 44.9 73.6 2,164 Primary 54.1 72.7 46.5 68.8 3,123 66.7 80.9 59.1 82.6 2,140 Secondary and higher 80.1 88.0 74.3 82.7 1,675 83.2 88.4 75.1 88.8 1,160 Wealth quintile Lowest 21.9 46.0 18.2 47.7 2,428 52.3 69.8 47.1 68.5 980 Second 29.7 55.5 25.1 57.2 2,643 59.8 75.9 51.2 79.1 1,052 Middle 33.6 61.1 28.8 61.4 2,732 62.3 77.6 54.1 79.0 980 Fourth 39.5 63.8 32.9 65.4 2,647 63.0 79.9 54.5 82.7 1,088 Highest 65.7 78.6 58.3 74.1 3,621 78.7 88.4 72.2 88.8 1,364 Total 15-49 40.2 62.5 34.6 62.3 14,070 64.3 79.0 56.9 80.3 5,464 Total men 15-59 na na na na na 62.9 78.6 55.7 80.0 6,033 na=Not applicable 1 Every time they have sexual intercourse 2 Who has no other partners 13.1.3 Knowledge about Transmission The 2005 EDHS included questions to assess the prevalence of common misconceptions about AIDS and HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have the AIDS virus. They were asked whether a person can get AIDS from mosquito bites, by supernatural means, or by eating from the same plate as a person who has AIDS. 182 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior The results in Tables 13.3.1 and 13.3.2 indicate that many Ethiopian adults lack accurate knowledge about the ways in which the AIDS virus can and cannot be transmitted. Particularly critical is the fact that only 51 percent of women and 69 percent of men know that a healthy-looking person can have (and thus transmit) the virus that causes AIDS. Many women and men also erroneously believe that AIDS can be transmitted by mosquito bites; only 47 percent of women and 57 percent of men reject this common misconception. Larger proportions of women and men are aware that the AIDS virus cannot be transmitted by supernatural means (70 percent and 84 percent, respectively) and by sharing food with a person who has AIDS (63 percent and 80 percent, respectively). Overall, only a minority of women (27 percent) and men (42 percent) both reject two of the more common misconceptions in Ethiopia—that AIDS can be transmitted by mosquito bites and that a person can become infected with the AIDS virus by sharing food or utensils with someone who is infected—and believe that a healthy-looking person can have the AIDS virus. Tables 13.3.1 and 13.3.2 provide an assessment of the level of comprehensive knowledge of HIV/AIDS prevention and transmission. Comprehensive knowledge is defined as: 1) knowing that both condom use and limiting sex partners to one uninfected person are HIV/AIDS prevention methods, 2) being aware that a healthy-looking person can have HIV, and 3) rejecting the two most common local misconceptions—that HIV/AIDS can be transmitted through mosquito bites and by sharing food. According to the EDHS results, 16 percent of women and 30 percent of men in Ethiopia have comprehensive knowledge of HIV/AIDS prevention and transmission. Finally, Tables 13.3.1 and 13.3.2 document considerable variation in HIV/AIDS knowledge. Although the patterns are not completely consistent, particularly among men, the proportions of women and men who reject the most common misconceptions, who know that a healthy-looking person can have the AIDS virus, or who have comprehensive knowledge about AIDS generally decrease with age. Sexually active, never-married women and men tend to be more knowledgeable than men and women in other marital status categories. For all indicators, the proportion of women and men with correct knowledge about HIV/AIDS prevention and transmission is higher in urban than rural areas. Variations in knowledge levels by region are marked among both women and men, with the highest levels observed among residents of Addis Ababa and the lowest levels found in the Somali Region (Figure 13.1). Education and wealth are directly related to both correct knowledge concerning common misconceptions and comprehensive knowledge of HIV/AIDS prevention and transmission. Among women, for example, 53 percent of women with a secondary or higher education have comprehensive knowledge about prevention and transmission modes compared with 7 percent of women with no education. Among men, the level of comprehensive knowledge varies from 18 percent among those with no education to 57 percent of those with a secondary or higher education. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 183 Table 13.3.1 Misconceptions and comprehensive knowledge about AIDS: women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Ethiopia 2005 Percentage of women who say that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by super- natural means A person cannot become infected by sharing food with a person who has AIDS Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of women Age 15-24 55.5 53.1 72.6 68.9 32.7 20.5 5,813 15-19 55.8 54.8 72.7 68.8 34.1 21.1 3,266 20-24 55.1 51.0 72.5 69.0 30.9 19.7 2,547 25-29 49.0 44.6 72.0 64.0 24.8 14.4 2,517 30-39 44.4 43.6 66.9 57.0 21.4 11.5 3,410 40-49 48.9 39.6 66.5 58.5 21.9 11.8 2,330 Marital status Never married 60.2 60.4 76.5 74.4 39.7 26.5 3,516 Ever had sex 72.1 66.8 87.5 85.3 51.0 40.8 223 Never had sex 59.4 60.0 75.7 73.7 39.0 25.6 3,293 Married/living together 46.4 42.1 67.6 58.8 21.5 11.5 9,066 Divorced/separated/ widowed 53.4 46.0 70.8 65.9 28.1 16.2 1,488 Residence Urban 78.8 71.2 91.0 90.4 56.8 42.4 2,499 Rural 44.5 41.9 65.6 57.6 20.3 10.0 11,571 Region Tigray 36.7 35.6 65.6 60.4 16.6 13.1 919 Affar 40.9 41.2 48.3 46.5 21.6 12.8 146 Amhara 53.5 48.2 75.0 67.4 31.0 15.2 3,482 Oromiya 58.6 44.2 67.9 60.5 25.4 15.3 5,010 Somali 10.6 17.4 22.3 22.4 6.2 3.9 486 Benishangul-Gumuz 33.9 38.9 52.2 51.3 20.8 11.1 124 SNNP 36.2 52.8 72.5 64.2 21.4 11.5 2,995 Gambela 32.2 37.5 50.4 48.3 21.1 8.9 44 Harari 50.1 64.3 76.8 81.9 35.1 28.3 39 Addis Ababa 88.8 71.7 96.0 95.1 64.5 50.1 756 Dire Dawa 50.3 65.7 83.9 79.9 36.8 27.2 69 Education No education 41.2 36.8 62.2 53.3 16.6 7.3 9,271 Primary 60.3 58.5 79.9 76.0 34.8 20.9 3,123 Secondary and higher 84.4 82.6 95.6 96.3 68.3 53.0 1,675 Wealth quintile Lowest 31.3 30.4 53.0 43.0 12.6 6.2 2,428 Second 42.7 39.4 61.7 52.4 18.0 8.1 2,643 Middle 46.5 43.9 67.9 58.5 20.6 9.7 2,732 Fourth 51.3 46.2 73.2 67.3 24.4 11.8 2,647 Highest 71.7 66.8 87.3 86.0 49.2 35.3 3,621 Total 15-49 50.6 47.1 70.1 63.4 26.8 15.8 14,070 1 AIDS can be transmitted through mosquito bites and by sharing food. 2 Respondent knows that using a condom at every sexual intercourse and having just one uninfected and faithful partner can reduce the risk of getting the AIDS virus, knows that a healthy-looking person can have the AIDS virus, and rejects the two most common local misconceptions about AIDS transmission. 184 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.3.2 Misconceptions and comprehensive knowledge about AIDS: men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Ethiopia 2005 Percentage of men who say that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by super-natural means A person cannot become infected by sharing food with a person who has AIDS Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of men Age 15-24 70.1 60.4 82.6 81.0 45.7 33.3 2,399 15-19 68.0 59.0 82.2 78.0 44.1 32.1 1,335 20-24 72.9 62.0 83.2 84.7 47.7 34.8 1,064 25-29 69.5 55.1 84.3 82.9 39.7 25.9 741 30-39 69.3 53.1 85.2 80.0 37.3 26.7 1,405 40-49 65.7 56.4 82.8 74.5 39.6 29.6 919 Marital status Never married 70.4 61.1 82.6 80.8 46.1 33.4 2,417 Ever had sex 80.9 67.4 88.4 91.5 54.7 42.4 412 Never had sex 68.2 59.8 81.5 78.6 44.3 31.5 2,005 Married/living together 67.9 54.1 84.1 79.2 38.3 27.0 2,890 Divorced/separated/ widowed 72.1 51.9 86.9 78.0 37.5 31.1 157 Residence Urban 90.2 79.6 93.3 93.6 71.5 56.7 854 Rural 65.2 53.0 81.7 77.4 36.2 25.0 4,610 Region Tigray 77.3 55.1 87.0 81.3 44.6 36.5 315 Affar 66.3 45.9 63.9 71.3 30.9 20.2 59 Amhara 76.1 64.1 91.1 82.0 51.8 41.6 1,347 Oromiya 69.6 46.8 76.3 77.7 33.4 22.2 2,041 Somali 31.7 34.8 37.9 36.1 16.2 8.5 180 Benishangul-Gumuz 57.0 59.7 85.5 80.4 40.0 31.7 50 SNNP 58.8 66.2 91.4 84.1 40.4 26.1 1,143 Gambela 50.2 56.1 76.9 73.1 34.2 22.0 19 Harari 78.4 76.4 91.1 92.1 62.1 53.0 15 Addis Ababa 92.3 80.2 97.5 96.4 74.6 53.8 266 Dire Dawa 76.1 64.5 89.4 89.8 51.0 40.6 27 Education No education 55.7 42.6 76.5 67.1 26.1 17.5 2,164 Primary 71.6 58.8 85.5 84.6 40.8 28.2 2,140 Secondary and higher 89.5 81.3 93.1 95.2 72.4 56.5 1,160 Wealth quintile Lowest 53.7 40.8 69.8 63.8 24.6 17.7 980 Second 63.6 52.4 81.1 76.7 34.0 23.7 1,052 Middle 70.1 53.0 82.7 79.8 37.9 24.3 980 Fourth 66.8 59.5 88.4 82.7 40.5 26.7 1,088 Highest 85.4 73.7 92.0 91.8 63.7 50.4 1,364 Total 15-49 69.1 57.1 83.5 79.9 41.7 30.0 5,464 Total men 15-59 68.4 55.9 83.5 78.7 40.2 28.7 6,033 1 AIDS can be transmitted through mosquito bites and by sharing food. 2 Respondent knows that using a condom at every sexual intercourse and having just one uninfected and faithful partner can reduce the risk of getting the AIDS virus, knows that a healthy-looking person can have the AIDS virus, and rejects the two most common local misconceptions about AIDS transmission. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 185 13.1.4 Knowledge about Mother-to-Child Transmission Increasing knowledge of ways in which HIV can be transmitted from mother to child and the fact that the risk of transmission can be reduced by using antiretroviral drugs is critical to reducing mother-to-child transmission (MTCT). To obtain information on these issues, respondents in the 2005 EDHS were asked if the virus that causes AIDS can be transmitted from a mother to a child during breastfeeding and whether a mother with HIV can reduce the risk of transmission to the baby by taking certain drugs (antiretrovirals) during pregnancy (see Table 13.4). Although 69 percent of women and 75 percent of men know that HIV can be transmitted by breastfeeding, only slightly more than around one-fifth of women and one-fourth of men know that the risk of MTCT can be reduced through the use of certain drugs during pregnancy. Twenty percent of women and 26 percent of men are aware of both aspects of MTCT transmission. There are marked differences in MTCT knowledge among women and men by age, marital status, residence, education, and wealth. Knowledge about mother-to-child transmission is highest among men and women living in urban areas, especially among those in Addis Ababa. Knowledge levels are lowest among women and men who have no education, who are in the lowest wealth quintile, and who live in the Somali Region. Particularly notable is the comparatively low level of knowledge among pregnant women; just 10 percent of pregnant women are aware that HIV can be transmitted from mother to child during breastfeeding and that mother-to-child transmission can be reduced by taking certain drugs during pregnancy. 13 13 15 15 4 11 12 9 28 50 27 37 20 42 22 9 32 26 22 53 54 41 Tigray Affar Amhara Oromiya Somali Benishangul-Gumuz SNNP Gambela Harari Addis Ababa Dire Dawa 0 10 20 30 40 50 60 Women Men Figure 13.1 Percentage of Women and Men Age 15-49 with Comprehensive Knowledge about AIDS EDHS 2005 Note: Comprehensive knowledge 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 most common local misconceptions--that HIV/AIDS can be transmitted through mosquito bites and by sharing food. Percent 186 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.4 Knowledge of prevention of mother to child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Ethiopia 2005 Women1 Men Background characteristic HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 70.8 26.0 23.7 2,872 73.4 31.4 27.9 2,399 15-19 70.2 27.2 25.3 1,645 71.8 28.7 25.6 1,335 20-24 71.6 24.3 21.6 1,228 75.4 34.8 30.9 1,064 25-29 70.4 20.0 18.5 1,167 74.4 30.8 26.6 741 30-39 69.1 17.3 16.5 1,622 76.1 28.2 25.0 1,405 40-49 64.6 15.5 14.3 1,090 75.2 21.7 20.3 919 Marital status Never married 74.0 33.9 31.2 1,703 72.6 33.7 29.9 2,417 Ever had sex 78.8 49.7 44.9 104 77.8 47.4 40.6 412 Never had sex 73.7 32.8 30.3 1,599 71.6 30.9 27.7 2,005 Married/living together 67.8 16.2 14.9 4,317 76.0 24.6 22.0 2,890 Divorced/separated/ widowed 67.1 20.7 19.7 731 77.5 33.1 29.7 157 Pregnancy status Pregnant 62.2 11.7 10.0 566 na na na na Not pregnant 70.0 22.0 20.4 6,185 na na na na Residence Urban 85.4 55.6 51.5 1,173 79.9 62.0 53.1 854 Rural 65.9 13.9 12.8 5,579 73.6 22.7 20.7 4,610 Region Tigray 77.0 20.5 18.8 448 83.7 36.2 33.2 315 Affar 36.0 13.3 12.1 72 62.2 32.9 28.0 59 Amhara 62.5 20.7 18.7 1,640 75.2 29.4 26.2 1,347 Oromiya 78.4 18.4 17.5 2,368 76.8 28.8 26.1 2,041 Somali 12.9 6.2 6.1 243 36.2 6.2 5.5 180 Benishangul-Gumuz 43.2 15.5 15.1 62 72.9 27.7 25.4 50 SNNP 68.9 15.7 14.6 1,504 74.3 19.2 17.4 1,143 Gambela 44.8 12.0 11.4 23 65.7 34.7 30.9 19 Harari 78.5 52.4 47.7 20 75.2 60.7 49.9 15 Addis Ababa 83.9 77.6 69.4 339 73.0 69.6 56.9 266 Dire Dawa 72.4 41.8 40.5 33 78.5 54.1 46.3 27 Education No education 61.4 12.4 11.5 4,419 65.4 14.8 13.9 2,164 Primary 81.5 25.0 22.9 1,552 78.5 27.5 24.5 2,140 Secondary and higher 90.0 62.8 58.0 781 84.3 57.7 50.2 1,160 Wealth quintile Lowest 52.1 8.6 8.0 1,251 65.5 16.3 15.3 980 Second 64.7 13.1 12.3 1,321 73.0 19.0 17.2 1,052 Middle 68.3 14.0 12.5 1,273 75.0 25.9 23.2 980 Fourth 71.7 15.0 13.9 1,234 77.5 24.5 21.4 1,088 Highest 84.9 46.9 43.4 1,672 79.5 51.2 45.0 1,364 Total 15-49 69.3 21.2 19.5 6,751 74.5 28.9 25.7 5,464 Total men 15-59 na na na na 74.4 27.9 24.9 6,033 Note: Only women in households selected for the male subsample were administered questions on MTCT. na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 187 13.2 STIGMA ASSOCIATED WITH AIDS AND ATTITUDES RELATED TO HIV/AIDS Knowledge and beliefs about AIDS affect how people treat those they know to be living with HIV. In the 2005 EDHS, a number of questions were posed to respondents to measure their attitudes towards HIV-infected people including questions about their willingness to buy vegetables from an infected vegetable seller, to let others know the HIV status of family members, and to take care of relatives who have the AIDS virus in their own household. They were also asked whether an HIV- positive female who is not sick should be allowed to continue teaching. Tables 13.5.1 and 13.5.2 show the percentages who express positive attitudes towards people with HIV among women and men who have heard about HIV/AIDS by background characteristics. Both women and men tend to express more positive attitudes in response to the questions concerning behaviour towards HIV-infected relatives than to the questions about shopkeepers or teachers. Sixty-five percent of women and 77 percent of men say that they would not want to keep secret that a family member was infected with the AIDS virus and 59 percent of women and 72 percent of men say they would be willing to care for a family member with the AIDS virus in their home. In contrast, only 42 percent of women and 52 percent of men say that an HIV-positive teacher should be allowed to continue teaching and only 20 percent of women and 26 percent of men would buy fresh food from a shopkeeper with AIDS. The percentage expressing accepting attitudes on all four measures is low, 11 percent among women and 17 percent among men. Higher education, wealth, and urban residence are related to more accepting attitudes towards those who are HIV positive. Among men, for example, the percentage expressing accepting attitudes towards those living with AIDS on all four measures exceeds 40 percent among urban residents, those with a secondary or higher education, and those living in Addis Ababa, Dire Dawa or Harari. Among women, the percentage expressing accepting attitudes on all four measures exceeds 40 percent among those with a secondary or higher education and those living in Addis Ababa and Harari. 188 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.5.1 Accepting attitudes toward those living with HIV: women Among women who have heard of HIV/AIDS, percentage expressing specific accepting attitudes toward people with HIV, by background characteristics, Ethiopia 2005 Percentage of women who: Background characteristic Are willing to care for family member with the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Percentage expressing accepting attitudes on all four indicators Number of women who have heard of HIV/AIDS Age 15-24 64.0 25.7 48.6 64.8 14.5 5,244 15-19 64.7 27.1 51.4 65.9 15.2 2,913 20-24 63.2 23.9 45.1 63.4 13.5 2,331 25-29 55.5 18.1 39.3 66.1 10.1 2,243 30-39 55.5 14.8 34.8 64.3 7.2 3,049 40-49 55.4 15.0 35.9 66.3 7.1 2,107 Marital status Never married 69.2 35.3 58.5 64.9 20.4 3,204 Ever had sex 81.1 59.3 76.6 66.6 38.4 214 Never had sex 68.4 33.6 57.2 64.8 19.2 2,990 Married/living together 54.3 13.8 34.5 65.1 6.8 8,078 Divorced/separated/ widowed 63.1 20.3 42.8 66.4 11.2 1,361 Residence Urban 86.0 58.4 78.9 71.1 37.3 2,463 Rural 52.5 10.6 32.4 63.7 4.3 10,180 Region Tigray 84.9 29.5 39.0 60.3 14.2 892 Affar 60.9 14.4 36.8 53.9 5.1 125 Amhara 71.0 16.5 43.9 68.5 8.6 3,061 Oromiya 44.9 15.3 34.8 68.6 8.0 4,742 Somali 68.5 22.4 24.4 47.0 8.6 243 Benishangul-Gumuz 73.8 17.2 45.8 55.0 10.7 84 SNNP 49.4 12.3 37.8 57.7 5.7 2,613 Gambela 69.5 27.9 55.2 52.2 15.1 28 Harari 69.4 50.6 66.8 85.5 42.4 38 Addis Ababa 94.3 73.9 91.9 68.5 46.9 750 Dire Dawa 76.9 49.8 64.8 78.7 37.1 67 Education No education 51.6 9.0 29.3 63.2 3.4 7,986 Primary 62.0 22.9 49.0 67.6 11.7 2,985 Secondary and higher 88.8 66.7 86.4 70.2 44.1 1,672 Wealth quintile Lowest 51.8 7.6 22.6 59.6 2.5 1,952 Second 50.2 9.0 27.8 61.5 3.4 2,321 Middle 48.8 9.8 31.8 65.6 3.0 2,437 Fourth 55.4 11.7 38.4 65.6 5.3 2,421 Highest 78.3 46.7 70.0 70.0 29.2 3,513 Total 15-49 59.0 19.9 41.5 65.2 10.7 12,643 HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 189 Table 13.5.2 Accepting attitudes toward those living with HIV: men Among men who have heard of HIV/AIDS, percentage expressing specific accepting attitudes toward people with HIV, by background characteristics, Ethiopia 2005 Percentage of men who: Background characteristic Are willing to care for family member with the AIDS virus in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Percentage expressing accepting attitudes on all four indicators Number of men who have heard of HIV/AIDS Age 15-24 72.4 30.7 54.6 76.2 18.9 2,287 15-19 70.0 30.5 53.4 75.6 19.1 1,255 20-24 75.3 30.9 56.2 76.9 18.8 1,033 25-29 70.5 27.0 54.2 76.0 17.6 718 30-39 71.8 21.1 49.0 79.2 13.9 1,380 40-49 70.4 21.7 47.1 77.1 14.4 888 Marital status Never married 73.2 33.1 56.0 76.7 20.9 2,297 Ever had sex 82.3 48.5 68.3 80.9 33.3 411 Never had sex 71.2 29.7 53.3 75.8 18.2 1,885 Married/living together 69.8 20.3 47.7 77.2 13.0 2,820 Divorced/separated/ widowed 80.7 30.5 65.4 81.2 21.2 157 Residence Urban 90.8 64.5 82.8 79.2 45.3 851 Rural 67.9 18.8 45.9 76.7 11.2 4,422 Region Tigray 86.6 38.0 59.2 86.1 27.5 314 Affar 84.6 32.6 48.6 68.3 15.0 57 Amhara 82.7 25.9 62.9 75.3 19.7 1,295 Oromiya 58.8 22.5 42.6 82.0 13.6 2,009 Somali 79.9 24.2 68.5 51.7 13.0 116 Benishangul-Gumuz 72.4 23.4 59.8 71.0 14.6 47 SNNP 70.2 17.5 43.3 71.4 8.3 1,111 Gambela 77.3 51.0 67.6 80.8 32.5 17 Harari 85.1 54.7 76.4 83.5 43.0 15 Addis Ababa 94.2 71.4 82.8 74.9 44.0 265 Dire Dawa 78.1 52.0 66.6 84.8 43.3 27 Education No education 63.3 12.2 39.4 75.8 7.2 2,002 Primary 69.0 22.9 48.4 76.0 12.5 2,114 Secondary and higher 90.7 56.2 79.5 81.3 40.6 1,158 Wealth quintile Lowest 59.7 13.3 35.9 76.5 6.7 893 Second 64.6 15.6 41.1 75.7 8.2 1,011 Middle 69.3 17.0 46.9 77.0 10.5 955 Fourth 71.8 22.1 50.8 76.3 13.4 1,062 Highest 86.2 52.1 74.6 79.3 36.5 1,353 Total 15-49 71.6 26.1 51.8 77.1 16.7 5,273 Total men 15-59 71.2 25.4 50.8 77.4 15.9 5,826 13.3 ATTITUDES TOWARDS NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent it are of little use if people feel powerless to negotiate safer sex practices with their partner. In an effort to assess the ability of women to negotiate safer sex with a spouse who has an STI, EDHS respondents were asked two attitudinal questions: is a wife justified in refusing to have sex with her husband when she knows he has a disease that can be transmitted through sexual contact, and is a woman in the same circumstances justified in asking her husband to use a condom? 190 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.6 shows that 85 percent of women and 89 percent of men believe that, if she knows her husband has an STI, a woman is justified in either refusing to have sex with him or asking him to wear a condom. Considering the two actions separately, the majority of both women (81 percent) and men (85 percent) say that a woman can refuse to have sex. Far fewer women (42 percent) and somewhat fewer men (65 percent) agree that a woman would be justified in asking the man to use a condom. Table 13.6 Attitudes toward negotiating safer sex with husband Percentage of women and men age 15-49 who believe that if a husband has a sexually transmitted disease his wife is justified in either refusing to have sexual relations with him or asking that he use a condom, by background characteristics, Ethiopia 2005 Women who believe that wife is justified in: Men who believe that wife is justified in: Background characteristic Refusing to have sexual relations Asking that they use a condom Either refusing sexual relations or asking to use a condom Number of women Refusing to have sexual relations Asking that they use a condom Either refusing sexual relations or asking to use a condom Number of men Age 15-24 82.1 48.3 85.4 5,813 83.5 63.8 87.5 2,399 15-19 80.3 48.3 83.5 3,266 81.3 60.7 85.3 1,335 20-24 84.4 48.2 87.8 2,547 86.4 67.8 90.2 1,064 25-29 82.3 40.8 85.9 2,517 87.1 68.2 91.0 741 30-39 79.5 36.2 82.6 3,410 86.3 67.6 91.1 1,405 40-49 80.9 34.0 83.7 2,330 86.1 59.2 88.4 919 Marital status Never married 82.0 54.7 85.5 3,516 82.5 63.6 86.9 2,417 Ever had sex 90.9 76.8 94.9 223 90.0 82.0 94.2 412 Never had sex 81.4 53.2 84.8 3,293 80.9 59.9 85.4 2,005 Married/living together 80.5 36.2 83.8 9,066 87.2 64.9 90.7 2,890 Divorced/separated/ widowed 84.2 44.0 86.5 1,488 89.2 73.9 91.8 157 Residence Urban 90.4 74.7 95.0 2,499 92.7 84.0 97.0 854 Rural 79.3 34.5 82.3 11,571 83.8 61.0 87.6 4,610 Region Tigray 81.9 41.8 84.3 919 95.1 68.3 98.3 315 Affar 60.1 21.7 64.4 146 79.5 67.2 84.4 59 Amhara 86.7 42.6 89.3 3,482 93.4 74.8 95.4 1,347 Oromiya 82.6 43.1 85.9 5,010 79.1 67.8 84.8 2,041 Somali 59.4 7.9 59.9 486 85.7 22.9 86.5 180 Benishangul-Gumuz 67.1 33.1 70.6 124 78.4 53.2 81.8 50 SNNP 74.6 33.0 79.1 2,995 81.9 47.0 85.7 1,143 Gambela 54.7 21.8 58.7 44 65.0 63.0 78.2 19 Harari 85.1 62.0 90.2 39 94.3 81.5 98.2 15 Addis Ababa 94.3 87.4 98.0 756 94.5 88.3 97.3 266 Dire Dawa 85.5 56.4 87.7 69 94.1 70.2 95.4 27 Education No education 77.9 29.7 80.5 9,271 83.4 54.4 86.1 2,164 Primary 84.6 54.7 89.2 3,123 83.6 64.2 88.2 2,140 Secondary and higher 94.0 83.2 98.2 1,675 91.3 84.4 96.0 1,160 Wealth quintile Lowest 74.2 24.8 76.2 2,428 79.1 49.0 82.0 980 Second 79.3 29.9 81.6 2,643 83.5 58.6 87.0 1,052 Middle 79.3 35.4 82.6 2,732 85.5 64.7 89.9 980 Fourth 82.4 40.1 85.7 2,647 85.1 64.8 89.1 1,088 Highest 88.1 67.3 92.9 3,621 90.6 80.3 95.0 1,364 Total 15-49 81.3 41.6 84.5 14,070 85.2 64.6 89.1 5,464 Total men 15-59 na na na na 85.3 63.9 89.0 6,033 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 191 The majority of respondents in all groups support a woman’s right to negotiate safer sex. However, there are differences by background characteristics in the percentages of respondents holding this opinion. For example, the higher a respondent’s educational attainment, the more likely he or she is to say that a woman can refuse sex or propose using a condom. Support for women’s negotiating rights also increases across wealth quintiles among both women and men. The proportions supporting a woman’s right to negotiate safer sex vary considerably across regions. Among women, the percentage saying that a woman is justified in refusing sex and asking that a condom be used ranges from a low of 59 percent in Gambela to 98 percent in Addis Ababa. Among men, support for women’s negotiating rights is also lowest in Gambela (78 percent) and highest in Tigray, Harari (98 percent each) and Addis Ababa (97 percent). 13.4 HIGHER-RISK SEX Given that most HIV infections in Ethiopia are contracted through heterosexual contact, information on sexual behaviour is important in designing and monitoring intervention programmes to control the spread of the epidemic. In the context of HIV/AIDS prevention, limiting the number of sexual partners and having protected sex are crucial to combating the epidemic. The 2005 EDHS included questions on respondents’ sexual partners during the 12 months preceding the survey. For male respondents, an additional question was asked on whether they paid for sex during the 12 months preceding the interview. Information on the use of condoms at the last sexual encounter with each type of partner was collected from both women and men. Finally, sexually active women and men were asked about the total number of partners they had during their lifetime. These questions are of course sensitive, and in interpreting the results in this section it is important to remember that respondents’ answers are likely subject to at least some reporting bias. 13.4.1 Multiple Sexual Partners and Higher-Risk Sex Tables 13.7.1 and 13.7.2 present several indicators based on information collected from women and men who had ever had intercourse about their sexual partners during the 12-month period before the survey and over their lifetime. The first two indicators in the tables assess the prevalence of multiple partners and of higher-risk sexual intercourse among women and men who reported having intercourse during the 12 months prior to the survey. Higher-risk sex involves sexual intercourse with a partner who is neither a spouse nor a cohabiting partner. The third indicator relates to condom use during the last higher-risk sexual encounter. The fourth indicator, the mean number of sexual partners that a woman or man has had during their lifetime, provides an assessment of lifetime exposure to one of the elements of higher-risk sex, multiple partners. The tables show that, among those who had sex in the previous 12 months, less than 1 percent of women age 15-49 and only 4 percent of men age 15-49 report having had two or more sexual partners during the period. Somewhat larger proportions—3 percent of women and 9 percent of men—report having had higher-risk sexual intercourse in the past 12 months (i.e., sexual intercourse with someone other than their spouse or cohabiting partner). The differentials presented in the tables suggest that higher-risk sex, particularly among women, is concentrated in a limited number of population subgroups. First the prevalence of higher- risk sex is virtually universal among never-married women and men who reported having sexual intercourse during the 12-month period prior to the EDHS.2 Looking at the other marital status categories, very few women and men who were currently in union (less than 1 percent) reported higher-risk sexual encounters during the 12 months prior to the survey,, while 25 percent of women and 33 percent of men who were widowed, divorced or separated said they had engaged in higher-risk sex during the period. 2 To determine marital status, the EDHS asked respondents whether or not they were currently or had ever been married or lived together with a partner. Thus, by definition, most sexual intercourse among respondents classified as never-married is high risk, i.e., it involves a nonmarital, noncohabiting partner. 192 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.7.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: women Among women age 15-49 who had sexual intercourse in the past 12 months, the percentage who had intercourse with more than one partner and the percentage who had higher-risk sexual intercourse, and among those having higher-risk intercourse in the past 12 months, the percentage reporting that a condom was used at last higher-risk intercourse, and among women who ever had sexual intercourse, the mean number of sexual partners during lifetime, by background characteristics, Ethiopia 2005 Women who had sexual intercourse in past 12 months Women who had higher- risk intercourse1 in past 12 months Women who ever had sexual intercourse Background characteristic Percentage who had 2+ partners in past 12 months Percentage who had higher-risk intercourse1 in past 12 months Number of women Percentage who reported using a condom at last higher-risk intercourse1 Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 0.5 5.8 1,212 28.4 71 1.2 1,360 15-19 0.4 7.2 411 27.1 29 1.2 469 20-24 0.6 5.1 800 29.3 41 1.3 891 25-29 0.1 1.7 977 (32.7) 17 1.3 1,075 30-39 0.2 1.6 1,360 * 21 1.6 1,585 40-49 0.0 1.3 805 * 10 1.6 1,086 Marital status Never married and ever had sex 1.0 99.7 63 28.7 63 2.4 104 Married/living together 0.2 0.5 4,142 (7.8) 20 1.4 4,291 Divorced/separated/ widowed 1.0 24.5 148 (23.2) 36 1.8 711 Residence Urban 0.4 13.5 492 39.9 66 1.7 709 Rural 0.2 1.4 3,862 3.0 53 1.4 4,396 Region Tigray 0.0 5.2 290 * 15 1.5 347 Affar 0.7 2.0 55 * 1 1.3 63 Amhara 0.1 2.9 1,140 * 33 1.8 1,374 Oromiya 0.2 2.8 1,558 * 43 1.2 1,764 Somali 0.0 0.0 161 * 0 1.1 196 Benishangul-Gumuz 0.7 2.0 47 * 1 1.6 52 SNNP 0.4 0.5 942 * 5 1.2 1,070 Gambela 0.6 5.0 14 * 1 1.5 19 Harari 0.4 3.7 12 * 0 1.3 14 Addis Ababa 0.3 15.7 117 (34.9) 18 2.3 182 Dire Dawa 1.5 9.2 18 * 2 1.5 24 Education No education 0.3 1.4 3,318 (9.0) 47 1.5 3,876 Primary 0.0 4.0 740 (30.2) 30 1.3 853 Secondary and higher 0.1 14.4 296 34.9 43 1.5 376 Wealth quintile Lowest 0.2 1.3 888 * 12 1.4 1,047 Second 0.3 1.8 936 * 16 1.4 1,064 Middle 0.3 1.1 877 * 10 1.4 988 Fourth 0.2 1.5 827 * 13 1.4 939 Highest 0.3 8.3 826 40.8 68 1.6 1,067 Total 0.2 2.7 4,354 23.6 119 1.4 5,106 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a nonmarital, noncohabiting partner HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 193 Table 13.7.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: men Among men age 15-49 who had sexual intercourse in the past 12 months, the percentage who had intercourse with more than one partner and the percentage who had higher-risk sexual intercourse, and among those having higher-risk intercourse in the past 12 months, the percentage reporting that a condom was used at last higher-risk intercourse, and among men who ever had sexual intercourse, the mean number of sexual partners during lifetime, by background characteristics, Ethiopia 2005 Men who had sexual intercourse in past 12 months Men who had higher-risk intercourse1 in past 12 months Men who ever had sexual intercourse Background characteristic Percentage who had 2+ partners in past 12 months Percentage who had higher-risk intercourse1 in past 12 months Number of men Percentage who reported using a condom at last higher-risk intercourse1 Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 4.8 37.4 446 50.2 167 2.0 561 15-19 3.9 68.0 78 44.0 53 2.0 96 20-24 5.0 31.0 368 53.1 114 2.0 465 25-29 3.2 9.1 531 47.1 48 2.2 600 30-39 4.0 3.1 1,291 57.2 39 2.6 1,355 40-49 4.6 1.1 853 * 9 4.0 902 Marital status Never married and ever had sex 9.7 98.0 227 53.0 222 3.0 407 Married/living together 3.7 0.8 2,840 (28.3) 24 2.7 2,861 Divorced/separated/ widowed 3.3 33.2 53 (70.0) 18 3.7 150 Residence Urban 3.2 29.9 393 79.9 118 4.4 490 Rural 4.3 5.4 2,728 29.4 146 2.5 2,928 Region Tigray 4.5 15.9 187 (53.7) 30 2.7 194 Affar 7.1 15.9 45 (38.7) 7 3.5 47 Amhara 2.0 3.5 775 * 27 3.3 845 Oromiya 3.5 8.8 1,147 (46.0) 101 2.5 1,255 Somali 3.2 2.6 116 * 3 1.8 124 Benishangul-Gumuz 12.7 5.0 34 * 2 2.8 35 SNNP 6.5 4.6 657 * 31 2.2 705 Gambela 12.4 28.2 12 45.3 4 5.7 15 Harari 2.2 20.8 10 (76.9) 2 3.5 11 Addis Ababa 6.1 44.4 123 70.9 55 4.8 170 Dire Dawa 7.6 22.3 15 (70.9) 3 3.1 17 Education No education 4.0 2.7 1,532 9.8 41 2.5 1,642 Primary 4.6 7.8 1,077 46.1 84 2.5 1,156 Secondary and higher 3.5 27.1 512 67.9 139 4.1 620 Wealth quintile Lowest 3.4 4.8 566 15.2 27 2.1 615 Second 4.6 5.3 645 (32.7) 34 2.6 686 Middle 4.9 4.8 648 (34.8) 31 2.2 676 Fourth 4.7 6.9 604 (29.0) 42 2.8 648 Highest 3.0 19.7 658 76.2 129 3.9 794 Total 15-49 4.1 8.5 3,121 51.9 264 2.8 3,418 Total men 15-59 4.1 7.3 3,630 51.7 266 3.0 3,974 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a nonmarital, noncohabiting partner 194 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Because many respondents in the 15-24 age group are likely to be never-married, it is expected that higher-risk sex would be more prevalent in these cohorts than among older women and men. What is somewhat surprising is the size of the gender differential in the reporting of these sexual behaviours among respondents in this age range. For example, 37 percent of men age 15-24 who had sexual intercourse during the 12-month period prior to the survey reported that they had engaged in higher-risk sex compared with 6 percent of women in the same cohort. The size of the differential suggests that there may be significant underreporting of recent sexual activity among never-married women in this age cohort. As noted in Chapter 6, only 6 percent of never-married women reported that they had ever had sex. Considering the other variables in Tables 13.7.1 and 13.7.2, higher-risk sex among both women and men is most prevalent among those living in urban areas, in Addis Ababa, those with a secondary or higher education, and those in the highest wealth quintile. Among men, the prevalence of higher-risk sex is also notably high among men living in Gambela, Dire Dawa, Harari, Tigray and Affar (Figure 13.2). As mentioned above, condom use is an important tool in the fight to curtail the spread of HIV/AIDS. Although truly effective protection would require condom use at every sexual encounter, the most important sexual encounters to cover are those considered to be “higher risk.”, i.e., sex with a nonmarital, noncohabitating partner in the 12 months preceding the survey. Tables 13.7.1 and 13.7.2 show that, among women reporting they engaged in higher-risk sex during the 12-month period prior to the survey, 24 percent reported a condom was used the last time they had higher-risk intercourse. Men who engaged in higher-risk sex during the year before the survey were much more likely to report condom use; around half said that a condom was used during their last higher-risk sexual encounter. The numbers of respondents, particularly women, reporting higher-risk sex are frequently quite small, making it difficult to assess differences in the prevalence of condom use across subgroups. However, the results sugge st that, among men who engaged in higher-risk sex, condom use is highest among urban residents, those with a secondary or higher education, and those in the highest wealth quintile. 5 7 2 4 3 13 7 12 2 6 8 16 16 4 9 3 5 5 28 21 44 22 Tig ray Af far Am ha ra Or om iya So ma li Be nis ha ng ul- Gu mu z SN NP Ga mb ela Ha rar i Ad dis Ab ab a Di re Da wa 0 10 20 30 40 50 2+ partners in past 12 months Higher-risk intercourse in past 12 months Figure 13.2 Multiple Sexual Partners and Higher-Risk Sexual Intercourse in the Past 12 Months among Men Age 15-49 EDHS 2005 Region Note: Higher-risk sexual intercourse refers to intercourse with a nonmarital, noncohabiting partner. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 195 Finally, Tables 13.7.1 and 13.7.2 show that men who have ever been sexually active report having an average (mean number) of 2.8 lifetime sexual partners, more than twice the average reported by women who have ever been sexually active (1.4 partners). The mean number of sexual partners for both women and men increases with age and is higher among urban than rural residents. Regions in which the mean number of lifetime partners among women is comparatively higher include Addis Ababa (2.3) and Amhara (1.8). Among men, the highest mean numbers of lifetime sexual partners were reported in Gambela (5.7 partners) and Addis Ababa (4.8 partners). 13.4.2 Paid Sex Paid sex is considered a special category of higher-risk sex. Male respondents in the 2005 EDHS were asked whether they had paid money in exchange for sex in the past 12 months or if any of their last three partners in the past 12 months was a commercial sex worker. Less than 1 percent of men had engaged in paid sex in the year before the survey (Table 13.8). The highest percentages of men reporting that they had engaged in paid sex are observed among men in Gambela (5 percent), Affar (2 percent), and Tigray (2 percent) and men who were divorced, separated or widowed (3 percent). Finally, about one-third of the small num- ber of men reporting they engaged in higher-risk sex used a condom at last sex with a prostitute (data not shown). 13.5 TESTING FOR HIV Knowledge of HIV status helps HIV- negative individuals make specific decisions to reduce risk and increase safer sex practices so they can remain disease free. For those who are HIV infected, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. Testing of pregnant women is especially important so action can be taken to prevent mother-to-child trans- mission. To obtain information on the prevalence of HIV testing, all respondents were asked whether they had ever been tested for HIV. If they said that they had, respondents were asked whether they had received the results of their last test. Women giving birth in the two-year period before the survey were asked additional questions regarding testing that may have occurred as part of any antenatal care they received prior to the birth. Table 13.8 Payment by men for sexual intercourse Percentage of men age 15-49 reporting payment for sexual intercourse in the past 12 months, by background characteristics, Ethiopia 2005 Background characteristic Percentage reporting sex with commercial sex worker in past 12 months1 Number of men Age 15-24 0.8 2,399 15-19 0.5 1,335 20-24 1.2 1,064 25-29 0.8 741 30-39 1.2 1,405 40-49 0.5 919 Marital status Never married 0.9 2,417 Married or living together 0.7 2,890 Divorced/separated/ widowed 2.9 157 Residence Urban 1.1 854 Rural 0.8 4,610 Region Tigray 2.0 315 Affar 2.4 59 Amhara 0.6 1,347 Oromiya 1.1 2,041 Somali 0.0 180 Benishangul-Gumuz 1.9 50 SNNP 0.2 1,143 Gambela 4.8 19 Harari 1.3 15 Addis Ababa 1.6 266 Dire Dawa 1.5 27 Education No education 0.9 2,164 Primary 0.8 2,140 Secondary and higher 0.9 1,160 Wealth quintile Lowest 0.3 980 Second 1.3 1,052 Middle 1.1 980 Fourth 0.6 1,088 Highest 1.0 1,364 Total 15-49 0.9 5,464 Total men 15-59 0.8 6,033 1 Includes men who reported that at least one of their last three sexual partners in the past 12 months was a commercial sex worker. 196 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Tables 13.9.1 and 13.9.2 show that, among the adult population age 15-49, 4 percent of women and 6 percent of men have been tested for HIV at some time. The majority of women and men who were tested indicated that that they had received the results of their test. Around half of the women who had ever been tested and received the test results said that they had received results from an HIV test taken during the 12 months prior to the survey. Among both women and men, the proportions ever tested are higher among those under age 30 than among those age 30 and older. Considering marital status, testing rates are highest among never-married women and men who have ever had sex and widowed, divorced and separated men. Considering the other characteristics for which results are presented in the tables, the highest testing rates are observed among urban residents, residents of Addis Ababa, Harari, and Dire Dawa, those with a secondary or higher education, and those in the highest wealth quintile. Table 13.9.1 Coverage of prior HIV testing: women Percent distribution of women by whether tested for HIV and by whether received the results of the test, and the percentage of women who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Ethiopia 2005 Ever tested Background characteristic Received results Did not receive results Don’t know/ missing whether received results Never tested/ don’t know/ missing Total Percentage who received results from HIV test taken in past 12 months Number of women Age 15-24 4.9 0.2 0.3 94.6 100.0 2.9 2,872 15-19 3.6 0.4 0.3 95.7 100.0 2.4 1,645 20-24 6.7 0.0 0.2 93.1 100.0 3.6 1,228 25-29 4.5 0.1 0.0 95.4 100.0 1.7 1,167 30-39 2.5 0.1 0.0 97.3 100.0 1.0 1,622 40-49 1.8 0.0 0.0 98.2 100.0 0.6 1,090 Marital status Never married 6.6 0.3 0.3 92.8 100.0 3.8 1,703 Ever had sex 29.0 0.0 0.0 70.9 100.0 12.2 104 Never had sex 5.1 0.3 0.3 94.2 100.0 3.2 1,599 Married/living together 2.3 0.1 0.1 97.5 100.0 0.9 4,317 Divorced/separated/ widowed 5.7 0.0 0.0 94.3 100.0 3.1 731 Residence Urban 16.6 0.5 0.5 82.4 100.0 7.8 1,173 Rural 1.0 0.1 0.0 98.8 100.0 0.6 5,579 Region Tigray 3.0 0.2 0.0 96.8 100.0 1.9 448 Affar 2.7 0.0 0.0 97.3 100.0 1.8 72 Amhara 1.8 0.0 0.1 98.1 100.0 1.0 1,640 Oromiya 2.9 0.1 0.2 96.7 100.0 1.4 2,368 Somali 1.9 0.1 0.0 98.0 100.0 1.3 243 Benishangul-Gumuz 3.0 0.1 0.0 96.9 100.0 0.8 62 SNNP 2.4 0.3 0.0 97.3 100.0 1.4 1,504 Gambela 0.8 0.2 0.0 99.0 100.0 0.6 23 Harari 13.9 0.8 2.2 83.1 100.0 7.8 20 Addis Ababa 26.5 0.6 0.1 72.9 100.0 10.9 339 Dire Dawa 12.5 0.4 0.0 87.1 100.0 5.2 33 Education No education 0.6 0.0 0.0 99.3 100.0 0.3 4,419 Primary 4.0 0.3 0.2 95.5 100.0 2.2 1,552 Secondary and higher 20.8 0.6 0.7 77.9 100.0 10.0 781 Wealth quintile Lowest 0.0 0.1 0.0 99.9 100.0 0.1 1,251 Second 0.7 0.0 0.0 99.3 100.0 0.2 1,321 Middle 0.9 0.1 0.2 98.9 100.0 0.8 1,273 Fourth 2.0 0.3 0.0 97.7 100.0 1.2 1,234 Highest 12.5 0.2 0.3 86.9 100.0 5.7 1,672 Total 3.8 0.2 0.1 96.0 100.0 1.9 6,751 Note: Only women in households selected for the male subsample were administered questions on prior testing. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 197 Table 13.9.2 Coverage of prior HIV testing: men Percent distribution of men by whether tested for HIV and by whether received the results of the test, and the percentage of women who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Ethiopia 2005 Ever tested Background characteristic Received results Did not receive results Don’t know/ missing whether received results Never tested/ don’t know/ missing Total Percentage who received results from HIV test taken in past 12 months Number of men Age 15-24 4.7 0.3 0.1 94.8 100.0 2.6 2,399 15-19 2.0 0.0 0.2 97.7 100.0 1.5 1,335 20-24 8.1 0.7 0.0 91.2 100.0 4.0 1,064 25-29 8.7 0.5 0.0 90.8 100.0 4.1 741 30-39 4.5 0.8 0.1 94.6 100.0 1.6 1,405 40-49 3.1 0.6 0.0 96.4 100.0 1.0 919 Marital status Never married 5.4 0.3 0.1 94.2 100.0 3.0 2,417 Ever had sex 17.6 0.0 0.0 82.3 100.0 8.5 412 Never had sex 2.9 0.3 0.2 96.6 100.0 1.8 2,005 Married/living together 4.2 0.7 0.0 95.0 100.0 1.6 2,890 Divorced/separated/ widowed 10.6 0.3 0.0 89.0 100.0 3.4 157 Residence Urban 17.4 1.7 0.5 80.4 100.0 7.8 854 Rural 2.6 0.3 0.0 97.1 100.0 1.2 4,610 Region Tigray 4.8 0.6 0.9 93.7 100.0 2.5 315 Affar 3.0 0.6 0.0 96.4 100.0 1.2 59 Amhara 4.0 0.6 0.0 95.4 100.0 2.5 1,347 Oromiya 3.9 0.5 0.0 95.5 100.0 1.7 2,041 Somali 0.0 0.0 0.0 100.0 100.0 0.0 180 Benishangul-Gumuz 2.7 0.2 0.0 97.1 100.0 1.5 50 SNNP 3.5 0.4 0.0 96.1 100.0 1.3 1,143 Gambela 2.4 0.8 0.0 96.8 100.0 0.6 19 Harari 17.1 0.7 1.4 80.8 100.0 7.4 15 Addis Ababa 26.4 0.8 0.5 72.4 100.0 11.0 266 Dire Dawa 13.9 1.2 0.0 84.9 100.0 7.3 27 Education No education 1.6 0.1 0.0 98.3 100.0 0.9 2,164 Primary 3.7 0.6 0.0 95.8 100.0 1.3 2,140 Secondary and higher 13.6 1.1 0.3 85.0 100.0 6.7 1,160 Wealth quintile Lowest 1.1 0.3 0.0 98.6 100.0 0.3 980 Second 1.0 0.2 0.0 98.8 100.0 0.6 1,052 Middle 2.5 0.4 0.0 97.1 100.0 1.4 980 Fourth 4.2 0.3 0.0 95.5 100.0 1.6 1,088 Highest 13.1 1.1 0.3 85.5 100.0 6.1 1,364 Total 15-49 4.9 0.5 0.1 94.5 100.0 2.3 5,464 Total men 15-59 4.6 0.5 0.1 94.9 100.0 2.1 6,033 Table 13.10 presents data on HIV/AIDS information and counselling during antenatal care. Among women who gave birth in the past two years, 3 percent received information and counselling about HIV/AIDS during antenatal care for their most recent birth. Less than 1 percent of the women reported that they were offered and accepted an HIV test during antenatal care. Taking both these elements into account, the EDHS results indicate that less than 1 percent of women giving birth during the two-year period prior to the survey were counselled about HIV, voluntarily accepted an offer of an HIV test, and received the test results. Women who gave birth during the two-year period before the survey were most likely to have received HIV/AIDS counselling and/or testing services during antenatal care if they lived in an urban area, especially in Addis Ababa, had a secondary or higher education, or were in the highest wealth quintile. 198 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior In interpreting the findings in Table 13.10, it is important to recognize that the very low coverage of HIV counselling and testing among women giving birth during the two-year period before the survey is in part due to the fact that only a minority of pregnant women obtain antenatal care. Table 13.10 Pregnant women counselled and tested for HIV Among women who gave birth in the two years preceding the survey, the percentage who received HIV counselling during antenatal care for their most recent birth, and among those who accepted an offer of HIV testing, percentage who received and did not receive their test results, by background characteristics, Ethiopia Among those who accepted an offer of an HIV test during antenatal care, percentage who:2 Background characteristic Percentage who received HIV counselling during antenatal care1 Received results Did not receive results Percentage who were counselled, were offered and accepted an HIV test, and received results2 Number of women who gave birth in the past 2 years3 Age 15-24 3.3 0.9 0.0 0.5 672 15-19 1.8 0.3 0.2 0.0 176 20-24 3.8 1.1 0.0 0.6 496 25-29 2.3 1.0 0.1 0.5 592 30-39 3.3 0.7 0.3 0.7 679 40-49 3.9 0.7 0.0 0.5 176 Marital status Never married and ever had sex 0.9 0.9 0.0 * 9 Married/living together 3.0 0.8 0.1 0.6 2,015 Divorced/separated/ widowed 4.0 2.2 0.3 0.0 95 Residence Urban 20.0 6.7 1.8 5.5 156 Rural 1.7 0.4 0.0 0.2 1,963 Region Tigray 4.7 0.0 0.0 0.0 134 Affar 2.6 0.0 1.3 0.0 25 Amhara 2.0 0.4 0.0 0.0 491 Oromiya 0.9 0.3 0.0 0.0 799 Somali 0.0 0.0 0.0 0.0 90 Benishangul-Gumuz 0.9 0.4 0.0 0.0 21 SNNP 4.8 0.6 0.2 0.6 512 Gambela 6.9 0.7 0.0 0.7 6 Harari 8.6 7.1 0.0 6.0 5 Addis Ababa 50.0 33.1 4.2 26.8 29 Dire Dawa 9.8 6.2 0.0 6.2 7 Education No education 1.5 0.4 0.0 0.1 1,630 Primary 4.5 1.1 0.4 1.0 395 Secondary and higher 24.1 8.0 0.7 7.4 93 Wealth quintile Lowest 0.3 0.0 0.0 0.0 460 Second 1.8 0.3 0.0 0.3 466 Middle 0.8 0.9 0.0 0.0 470 Fourth 3.4 0.4 0.3 0.4 426 Highest 12.3 3.6 0.5 2.9 297 Total 3.1 0.8 0.1 0.6 2,119 Note: Only women in households selected for the male subsample were administered questions on MTCT. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 In this context, "counselled" means that someone talked with the respondent about all three of the following topics: 1) babies getting the AIDS virus from their mother, 2) preventing the virus, and 3) getting tested for the virus. 2 Only women who were offered the test are included here; women who were either required or asked for the test are excluded from the numerator of this measure. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 199 13.6 REPORTS OF RECENT SEXUALLY TRANSMITTED INFECTIONS Information about the incidence of sexually transmitted infections (STIs) is not only useful as a marker of unprotected sexual intercourse but also as a cofactor for HIV transmission. The 2005 EDHS asked respondents who had ever had sex whether they had had an STI in the past 12 months. They were also asked whether, in the past year, they had experienced a genital sore or ulcer, and whether they had any genital discharge. These symptoms have been shown useful in identifying STIs in men. They are less easily interpreted in women because women are likely to experience more non- STI conditions of the reproductive tract that produce a discharge. Table 13.11 shows that about 2 percent each of women and men who have ever been sexually active had an STI and/or STI symptoms in the 12 months prior to the survey. Those reporting STI symptoms were somewhat more likely to say they had had an abnormal genital discharge than to report a genital ulcer. It is likely that these figures, which are quite low, underestimate the actual prevalence of STIs among the sexually active population in Ethiopia. Table 13.11 Self-reported prevalence of sexually-transmitted infections (STI) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having had an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Ethiopia 2005 Women Men Background characteristic STI Abnormal genital discharge Genital sore or ulcer STI, genital discharge, sore or ulcer Number of women who ever had sexual intercourse STI Abnormal genital discharge Genital sore or ulcer STI, genital discharge, sore or ulcer Number of men who ever had sexual intercourse Age 15-19 0.3 1.0 0.2 1.4 904 0.4 0.1 0.1 0.5 97 20-24 0.4 1.1 0.4 1.5 1,850 0.4 0.7 0.5 1.2 469 25-29 0.6 1.6 0.5 2.4 2,314 0.9 0.8 0.2 1.4 601 30-39 0.4 1.3 1.1 1.9 3,357 0.4 0.8 0.3 1.2 1,367 40-49 0.6 1.5 1.2 2.3 2,323 1.0 1.8 0.7 2.3 916 Marital status Never married 0.5 2.6 0.2 3.1 223 0.6 0.6 0.3 1.2 412 Married or living together 0.5 1.2 0.8 1.9 9,058 0.4 0.9 0.3 1.3 2,886 Divorced/separated/ widowed 0.2 1.8 1.0 2.5 1,467 5.1 3.7 3.3 6.1 152 Residence Urban 0.7 1.6 1.1 2.5 1,518 1.0 1.4 0.8 1.6 506 Rural 0.5 1.3 0.7 1.9 9,230 0.6 0.9 0.4 1.5 2,943 Region Tigray 0.1 1.1 0.4 1.3 721 0.5 0.4 0.5 1.3 198 Affar 0.0 1.0 1.0 1.5 126 0.5 0.4 0.4 0.5 49 Amhara 0.4 1.1 0.4 1.6 2,917 0.0 0.5 0.4 0.7 848 Oromiya 0.8 1.4 1.0 2.2 3,770 1.1 0.5 0.6 1.5 1,270 Somali 0.2 0.8 1.2 1.7 399 2.5 8.3 0.6 8.8 126 Benishangul-Gumuz 0.1 0.6 1.0 1.6 105 0.0 0.0 0.0 0.0 35 SNNP 0.3 1.6 0.9 2.2 2,179 0.2 1.3 0.2 1.3 706 Gambela 0.6 1.6 1.7 2.7 38 0.7 2.1 1.3 2.8 15 Harari 0.4 0.3 0.4 0.6 27 0.4 0.4 0.4 0.4 12 Addis Ababa 1.1 2.3 1.4 3.5 415 1.1 0.9 0.4 1.6 173 Dire Dawa 0.3 0.2 0.1 0.4 50 0.8 0.0 0.8 0.8 18 Education No education 0.5 1.4 0.8 2.0 8,242 0.7 1.3 0.3 1.9 1,653 Primary 0.3 1.3 0.8 1.9 1,695 0.5 0.8 0.8 1.2 1,163 Secondary and higher 0.5 1.4 0.8 1.9 810 0.7 0.5 0.2 1.1 635 Wealth quintile Lowest 0.5 1.5 1.0 2.2 2,055 1.0 1.8 0.5 2.4 617 Second 0.4 1.4 0.9 2.1 2,189 0.3 1.2 0.5 1.7 689 Middle 0.3 1.0 0.5 1.4 2,137 0.0 0.2 0.2 0.2 683 Fourth 0.8 1.3 0.7 2.0 2,052 1.0 0.6 0.3 1.5 651 Highest 0.5 1.5 0.8 2.2 2,315 1.1 1.2 0.6 1.8 810 Total 15-49 0.5 1.4 0.8 2.0 10,748 0.7 1.0 0.4 1.5 3,450 Total men 15-59 na na na na na 0.8 1.0 0.4 1.5 4,019 na = Not applicable 200 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior 13.7 MALE CIRCUMCISION Circumcision of men is widely practiced in Ethiopia and often serves as a rite of passage to adulthood. Some studies have shown that absence of circumcision may be a contributory factor to the risk of contracting STIs, including HIV. To investigate this relationship the EDHS asked all men if they had been circumcised. Table 13.12 shows that 93 percent of Ethiopian men age 15-59 are circumcised. Cir- cumcision is highest among men age 40-44 and low- est among those age 15-19. Currently married men are slightly more likely to be circumcised than formerly married men. Men who have never married are least likely to be circumcised. Circumcision is highest among Ortho- dox Christians and lowest among men of other un- specified religions. With the exception of men in Gambela and SNNP, circumcision is nearly universal among men in the other regions. Less than one in two men living in Gambela is circumcised, while three in four men living in SNNP are circumcised. There is no clear relationship between edu- cation and male circumcision. However, men with at least secondary education are most likely to be cir- cumcised. 13.8 INJECTIONS Injection overuse in a health care setting can contribute to the transmission of blood-borne patho- gens because it amplifies the effect of unsafe practices such as reuse of injection equipment. As a consequence, the proportion of injections given with reused injection equipment is an important pre- vention indicator in an initiative to control the spread of HIV/AIDS. Table 13.13 presents data on the prevalence of injections among respondents. Respondents were asked if they had had any injections given by a health worker in the 12 months preceding the sur- vey, and if so, the number of injections they had received and whether their last injection was given with a syringe from a new, unopened package. It should be noted that medical injections can be self-administered (e.g., insulin for diabetes). These injections were not included in the calculation. Women are more likely than men to report receiving at least one injection (26 percent and 19 percent, respectively). These may in part reflect the fact that a substantial proportion of women are currently using injectable contraceptives. The average number of injections received from a health provider was 1.1 among women and 1.0 among men. Table 13.12 Prevalence of male circumcision Percentage of men circumcised, according to selected background characteristics, Ethiopia 2005 Background characteristic Percentage of men who are circumcised Number of men Age 15-19 86.7 1,335 20-24 93.3 1,064 25-29 93.2 741 30-34 94.5 754 35-39 92.5 651 40-44 97.8 497 45-49 93.8 422 50-54 96.7 335 55-59 94.4 235 Marital status Never married 90.3 2,419 Married or living together 94.1 3,424 Divorced/separated/widowed 92.7 190 Residence Urban 97.9 916 Rural 91.6 5,117 Region Tigray 98.0 366 Affar 98.5 65 Amhara 97.3 1,521 Oromiya 94.2 2,222 Somali 99.2 202 Benishangul-Gumuz 97.6 54 SNNP 79.6 1,244 Gambela 46.8 21 Harari 99.5 16 Addis Ababa 98.5 292 Dire Dawa 99.7 30 Education No education 93.0 2,589 Primary 90.1 2,252 Secondary and higher 96.1 1,192 Wealth quintile Lowest 88.9 1,100 Second 90.8 1,184 Middle 91.8 1,081 Fourth 93.2 1,200 Highest 96.6 1,469 Religion Orthodox 97.3 2,974 Catholic 78.4 61 Protestant 80.1 1,038 Moslem 94.3 1,788 Other 74.5 55 Total 92.5 6,033 HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 201 Table 13.13 shows that the largest variations in the injection prevalence indicator are across regions. Among women, for example, the percentage reporting they had received at least one injection from a health worker during the 12 months prior to the survey varies from 6 percent in the Somali Region to 32 percent among women in SNNP and Addis Ababa. Among men, the likelihood of having received an injection is lowest in the Somali Region (4 percent) and highest in Benishangul- Gumuz (29 percent). Urban residents are more likely than rural residents to have received at least one injection from a health provider, although the differential is greater for women than for men. The percentage receiving at least one injection from a health provider varies directly with education among both women and men. Among women, there is also a direct association between wealth quintile and the likelihood of receiving at least one injection. Among men, however, the association between wealth and receipt of an injection is not consistent. Table 13.13 Prevalence of injections Percent of women and men age 15-49 who received at least one injection from a health worker1 in the past 12 months, the average number of medical injections1 per person, and among those who received an injection, the percentage for whom the health worker took the syringe and needle from a new and unopened package for the last injection, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage who received an injection from a health worker in the past 12 months Average number of medical injections per year Number of women Last injection, syringe and needle taken from newly opened package Number receiving injections from a health worker in the past 12 months Percentage who received an injection from a health worker in the past 12 months Average number of medical injections per year Number of men Last injection, syringe and needle taken from newly opened package Number receiving injections from a health worker in the past 12 months Age 15-19 22.7 0.8 3,266 92.8 741 18.1 0.7 1,335 96.6 242 20-24 26.1 1.1 2,547 93.1 665 21.2 1.1 1,064 94.6 226 25-29 28.7 1.2 2,517 89.9 722 18.2 1.1 741 97.3 135 30-39 25.9 1.3 3,410 89.1 882 19.5 1.0 1,405 93.1 274 40-49 25.6 1.2 2,330 88.9 596 17.1 1.1 919 94.5 157 Residence Urban 30.4 1.8 2,499 98.6 759 20.3 1.1 854 98.4 173 Rural 24.6 1.0 11,571 88.6 2,847 18.7 0.9 4,610 94.4 860 Region Tigray 16.5 0.7 919 93.4 152 16.2 0.8 315 95.9 51 Affar 15.3 1.2 146 88.9 22 14.7 0.9 59 (99.2) 9 Amhara 23.4 1.0 3,482 82.0 815 15.5 0.6 1,347 91.2 208 Oromiya 26.6 1.1 5,010 91.9 1,333 22.4 1.4 2,041 96.2 458 Somali 5.7 0.4 486 80.9 28 3.8 0.2 180 * 7 Benishangul-Gumuz 25.3 1.2 124 94.4 31 28.5 1.5 50 97.6 14 SNNP 31.6 1.2 2,995 94.6 945 17.7 0.7 1,143 94.7 203 Gambela 25.2 1.9 44 96.8 11 25.0 1.5 19 96.4 5 Harari 26.2 1.2 39 98.8 10 19.5 0.8 15 100.0 3 Addis Ababa 31.9 2.2 756 96.5 241 26.5 1.4 266 97.6 71 Dire Dawa 24.9 1.9 69 96.7 17 17.6 1.4 27 94.5 5 Education No education 23.1 1.0 9,271 86.7 2,139 13.9 0.7 2,164 93.4 300 Primary 29.6 1.2 3,123 95.5 924 21.8 1.1 2,140 95.0 466 Secondary and higher 32.4 1.7 1,675 98.4 542 23.0 1.2 1,160 97.0 267 Wealth quintile Lowest 17.0 0.7 2,428 81.8 412 16.6 1.1 980 97.1 162 Second 21.3 0.8 2,643 90.6 563 20.6 1.1 1,052 90.3 217 Middle 25.1 1.0 2,732 85.1 687 16.6 0.8 980 96.5 163 Fourth 29.3 1.1 2,647 91.0 776 20.3 0.9 1,088 94.3 221 Highest 32.2 1.7 3,621 97.1 1,167 19.8 1.0 1,364 97.3 270 Total 15-49 25.6 1.1 14,070 90.7 3,606 18.9 1.0 5,464 95.0 1,033 Total men 15-59 na na na na na 19.1 1.0 6,033 94.3 1,155 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Includes injections given by a doctor, nurse, pharmacist, dentist or other health worker 202 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior The majority of recent injections (91 percent among women and 95 percent among men) were given with a needle and syringe taken from a newly opened package. Women living in Somali (81 percent) and Amhara (82 percent) and women in the lowest wealth quintile (82 percent) are the least likely to report that the injection was given using a needle and syringe from a previously unopened package. 13.9 HIV/AIDS-RELATED KNOWLEDGE AND BEHAVIOUR AMONG YOUTH Knowledge of HIV/AIDS issues and related sexual behaviour among youth age 15-24 is of particular interest because the period between sexual initiation and marriage is for many young people a time of sexual experimentation that may involve high-risk behaviours. This section considers a number of issues that relate to both transmission and prevention of HIV/AIDS among youth, including the extent to which youth have comprehensive knowledge of HIV/AIDS transmission and prevention modes and knowledge of a source where they can obtain condoms. Issues such as abstinence, age at sexual debut, age differences between partners, and condom use are also covered in this section. 13.9.1 Knowledge about HIV/AIDS and Source for Condoms Knowledge of how HIV is transmitted is crucial to enabling young people to avoid AIDS. Young people are often at greater risk because they may have shorter relationships with more partners or engage in other risky behaviours. As discussed earlier, comprehensive knowledge is defined as knowing that: 1) people can reduce their chances of getting the AIDS virus by having sex with only one uninfected, faithful partner and by using condoms consistently; 2) a healthy-looking person can have the AIDS virus; and 3) HIV cannot be transmitted by mosquito bites or by sharing food with a person who has AIDS. Table 13.14 shows that only around one-fifth of women and one-third of men age 15-24 know all of these facts about HIV/AIDS. The level of comprehensive knowledge about HIV/AIDS does not vary greatly by age within the youth population. Among young women, comprehensive knowledge is highest among the never-married, especially those who have ever had sex. Among young men, comprehensive knowledge is most common among the small numbers who were divorced, separated or widowed. As expected, comprehensive HIV/AIDS knowledge is much more common among urban than rural youth. Among young women, the level of comprehensive knowledge ranges from a low of 1 percent in the Somali Region to a high of 50 percent in Addis Ababa. Among young men, comprehensive knowledge is lowest in the Somali Region (7 percent) and highest in Harari (54 percent) and Addis Ababa (53 percent). Young women with a secondary education or higher are more than six times as likely as those with no schooling to have comprehensive knowledge of HIV/AIDS while highly educated young men are more than three times as likely as those with no education to have comprehensive knowledge. Youth in the highest wealth quintile are much more likely to have comprehensive knowledge than other youth. Because of the important role that condoms play in combating the transmission of HIV, respondents were asked whether they knew where condoms could be obtained. Only responses about “formal” sources were counted, so that friends and family and other similar sources were not in- cluded. As shown in Table 13.14, young men are more likely than young women to know where to obtain a condom (56 and 34 percent, respectively). Among either sex, knowledge of a condom source does not vary consistently with age. Never-married young women, particularly those who have had sex, are much more likely to know about a source for condoms than those who have ever married. Among young men, the variations in knowledge by marital status are comparatively minor. Among both young women and men, those in urban areas are more likely than those in rural areas to know of HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 203 a condom source. Knowledge of a condom source is lowest in the Somali Region (7 percent of women and 20 percent of men) and highest in Addis Ababa (87 percent of women and 82 percent of men). Consistent with the patterns observed for other indicators, youth who are better educated and live in wealthier households are more likely than other youth to know a source of condoms. Finally, to gauge the extent of support for programmes to increase condom knowledge among youth, all EDHS respondents (youth and adults) were asked whether they thought that children age 12-14 should be taught about using condoms to avoid AIDS. Table 13.14 Comprehensive knowledge about AIDS and a source for condoms among youth Percentage of young women and men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of women Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of men Age 15-19 21.1 34.4 3,266 32.1 51.8 1,335 15-17 21.3 34.2 1,952 31.5 50.6 822 18-19 20.7 34.7 1,313 33.0 53.7 513 20-24 19.7 34.4 2,547 34.8 60.3 1,064 20-22 19.6 32.5 1,797 34.4 61.3 740 23-24 19.9 38.9 751 35.8 58.1 324 Marital status Never married 26.1 42.2 3,165 32.9 55.5 2,081 Ever had sex 40.3 66.6 136 38.0 53.2 257 Never had sex 25.5 41.1 3,030 32.2 55.8 1,824 Married/living together 13.4 23.8 2,284 34.2 56.8 284 Divorced/separated/ widowed 15.7 32.9 363 (47.3) (51.3) 35 Residence Urban 44.4 81.4 1,242 54.4 81.5 431 Rural 14.0 21.6 4,571 28.6 49.9 1,968 Region Tigray 17.5 45.8 387 46.8 60.4 145 Affar 17.4 34.7 54 20.3 39.9 18 Amhara 19.9 35.6 1,392 44.8 58.7 614 Oromiya 20.2 27.3 2,131 25.2 53.5 907 Somali 1.4 6.7 155 7.4 19.6 60 Benishangul-Gumuz 15.1 28.9 51 42.8 52.0 18 SNNP 15.9 27.6 1,197 28.2 52.2 491 Gambela 10.6 29.7 17 21.4 53.4 8 Harari 30.1 66.7 17 53.7 63.5 6 Addis Ababa 49.8 87.3 382 52.6 82.2 120 Dire Dawa 29.7 63.2 29 43.8 68.4 12 Education No education 8.0 12.8 2,841 14.1 30.7 630 Primary 22.9 39.0 1,996 31.3 53.8 1,135 Secondary and higher 51.7 87.8 975 55.8 83.4 634 Wealth quintile Lowest 8.2 10.6 836 20.4 37.0 425 Second 11.5 17.0 1,045 29.0 46.2 421 Middle 13.5 20.0 1,135 29.4 49.8 391 Fourth 16.5 26.5 1,043 28.3 58.3 493 Highest 38.5 70.0 1,753 50.1 74.6 669 Total 15-24 20.5 34.4 5,813 33.3 55.6 2,399 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Respondent knows that using a condom at every sexual intercourse and having just one uninfected and faithful partner can reduce the risk of getting the AIDS virus, knows that a healthy-looking person can have the AIDS virus, and rejects the two most common local misconceptions about AIDS transmission. 2 Friends, family members, and home are not considered sources for condoms. 204 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.15 shows that 54 percent of women and 77 percent of men age 18-49 agree that children age 12-14 should be taught about using a condom to avoid AIDS. Women and men age 18- 29 appear to be slightly more supportive of condom education for children age 12-14 than older adults. Among adult women, support for condom education is higher among urban than rural residents and increases as expected with education and wealth. There is also considerable regional variability in the level of support for condom education among women, from a low of 4 percent in the Somali Region to a high of 73 percent in Addis Ababa. Among adult men, support for condom education does not vary consistently with education and wealth, and rural residents are almost as likely as urban residents to express support. The Somali Region again stands out as having the lowest level of support from men (19 percent). In the other regions, support for condom education varies from 71 percent in Harari to 90 percent in Tigray. Table 13.15 Adult support for education about condom use to prevent AIDS Percentage of women and men 18-49 who agree that children 12-14 years should be taught about using a condom to avoid AIDS, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage Number Percentage Number Age 18-19 57.4 689 73.9 513 20-24 59.6 1,228 79.9 1,064 25-29 56.4 1,167 78.6 741 30-39 51.8 1,622 77.6 1,405 40-49 47.2 1,090 71.9 919 Marital status Never married 63.8 914 76.1 1,600 Ever had sex 73.7 95 81.9 390 Never had sex 62.6 819 74.2 1,210 Married/living together 52.2 4,186 76.7 2,886 Divorced/separated/ widowed 53.3 696 83.9 156 Residence Urban 71.0 984 78.5 721 Rural 50.7 4,811 76.4 3,920 Region Tigray 67.9 371 90.3 270 Affar 30.2 64 77.1 54 Amhara 54.1 1,409 82.6 1,127 Oromiya 56.0 2,060 75.0 1,733 Somali 4.4 215 18.9 156 Benishangul-Gumuz 36.8 55 71.8 43 SNNP 53.8 1,272 78.8 972 Gambela 39.2 21 75.5 17 Harari 49.4 17 70.5 13 Addis Ababa 72.7 283 76.9 235 Dire Dawa 55.2 29 77.3 23 Education No education 46.9 4,090 70.4 2,008 Primary 70.3 1,074 83.1 1,655 Secondary and higher 73.7 631 78.9 979 Wealth quintile Lowest 38.8 1,098 66.7 825 Second 49.2 1,156 79.3 918 Middle 52.6 1,099 77.2 845 Fourth 57.3 1,045 80.2 906 Highest 69.2 1,398 78.9 1,148 Total 18-49 54.2 5,795 76.7 4,641 Total 18-59 na na 76.1 5,211 Note: Only women in households selected for the male subsample were administered questions on MTCT. na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 205 13.9.2 Age at First Sex and Condom Use at First Sexual Intercourse Information from the EDHS can be used to look at several important issues relating to the initiation of sexual activity among youth including age at first sex and condom use at first sexual intercourse. Table 13.16 shows the proportions of women and men in the 15-24 age cohort who had sex before age 15 and before age 18. Sixteen percent of young women and 2 percent of young men had sex by age 15 while 35 percent of young women and 9 percent of young men had sex by age 18. Table 13.16 Age at first sex among youth Percentage of young women and men age 15-24 who have had sexual intercourse before exact ages 15 and 18, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage who have had sexual intercourse before exact age 15 Percentage who have had sexual intercourse before exact age 18 Number of women 15-24 Percentage who have had sexual intercourse before exact age 15 Percentage who have had sexual intercourse before exact age 18 Number of men 15-24 Age 15-19 11.1 na 3,266 1.7 na 1,335 15-17 9.0 na 1,952 1.4 na 822 18-19 14.2 36.6 1,313 2.1 10.0 513 20-24 21.9 48.6 2,547 1.7 14.1 1,064 20-22 22.0 48.9 1,797 1.5 14.8 740 23-24 21.5 47.9 751 2.2 12.4 324 Marital status Never married 0.2 1.8 3,165 1.6 6.5 2,081 Married or living together 33.2 74.6 2,284 2.0 30.2 284 Divorced/separated/ widowed 42.5 78.1 363 4.4 (11.9) 35 Knows a condom source1 Yes 9.8 25.3 1,998 2.2 11.6 1,411 No 19.0 40.3 3,815 0.9 6.3 988 Residence Urban 7.4 20.1 1,242 1.5 9.6 431 Rural 18.1 39.3 4,571 1.7 9.3 1,968 Region Tigray 20.0 39.7 387 0.0 8.5 145 Affar 13.5 47.4 54 5.5 26.6 18 Amhara 32.0 54.5 1,392 1.4 6.3 614 Oromiya 11.5 31.6 2,131 1.4 9.8 907 Somali 10.6 34.7 155 3.8 10.9 60 Benishangul-Gumuz 22.0 51.2 51 0.9 14.8 18 SNNP 7.1 22.4 1,197 2.2 9.8 491 Gambela 23.5 55.5 17 19.0 51.7 8 Harari 6.2 29.9 17 1.5 15.4 6 Addis Ababa 6.1 16.3 382 2.3 14.0 120 Dire Dawa 7.4 28.2 29 1.6 16.1 12 Education No education 25.4 52.6 2,841 1.0 9.2 630 Primary 8.3 22.0 1,996 1.9 8.8 1,135 Secondary and higher 3.5 11.5 975 2.0 10.6 634 Wealth quintile Lowest 20.0 45.2 836 1.3 8.9 425 Second 20.4 44.3 1,045 1.3 8.6 421 Middle 21.2 40.5 1,135 1.8 9.9 391 Fourth 16.3 35.4 1,043 2.9 10.3 493 Highest 7.4 21.4 1,753 1.2 9.2 669 Total 15-24 15.8 35.2 5,813 1.7 9.4 2,399 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Friends, family members, and home are not considered sources for condoms. na = Not applicable 206 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Looking at the age patterns for young women, the proportions of young women reporting that they had sex before age 15 are markedly lower among those under age 18 than among older girls. Young women age 18-19 were less likely than those age 20-24 to say they had initiated sex before age 18. This likely reflects the effect of rising age at marriage because only very small proportions of never-married young women report that they had sex by age 15 (0.2 percent) or by age 18 (2 percent). Other differentials in the indicators for young women reflect the influence of factors that predict delayed marriage, e.g., young women in urban areas are much less likely to have had sex by age 15 or by age 18 than young women in rural areas. Differentials in these indicators for young men tend to be minor. This is at least in part because the proportions initiating sexual activity at an early age are not large in most subgroups with the exception of Gambela and to a lesser extent Affar. More than half of young men in Gambela and more than one-quarter of young men in Affar report that they had sex for the first time before age 18. To assess the extent of condom use from the beginning of sexual exposure, respondents age 15-24 were asked whether they had used condoms the first time they had sex. Table 13.17 shows that only 1 percent of young women and 17 percent of young men used condoms during their first sexual encounter. Never-married women and men were much more likely than ever-married youth to have used a condom. Higher educational attainment, greater wealth, and urban residence are related to a greater likelihood that condoms were used the first time a young woman and, particularly, a young man had sex. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 207 Table 13.17 Condom use at first sexual intercourse among youth Percentage of young women and young men age 15-24 who used a condom the first time they had sexual intercourse, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage who used a condom at first sexual intercourse Number who have ever had sexual intercourse Percentage who used a condom at first sexual intercourse Number who have ever had sexual intercourse Age 15-19 0.8 904 23.3 97 15-17 0.0 332 (26.0) 25 18-19 1.2 572 22.4 72 20-24 1.1 1,850 15.6 469 20-22 0.5 1,285 17.8 269 23-24 2.4 565 12.8 201 Marital status Never married 10.0 136 31.9 257 Married or living together 0.6 2,276 4.9 280 Divorced/separated/ widowed 0.1 342 (0.5) 29 Knows a condom source1 Yes 3.2 744 22.0 385 No 0.2 2,009 6.2 182 Residence Urban 5.7 393 48.0 117 Rural 0.2 2,361 8.8 449 Region Tigray 0.6 196 (30.0) 34 Affar 3.7 34 (10.3) 9 Amhara 0.2 864 12.0 142 Oromiya 1.2 967 17.5 215 Somali 0.0 77 * 11 Benishangul-Gumuz 0.6 34 (14.0) 5 SNNP 1.0 441 9.8 98 Gambela 0.5 12 13.8 5 Harari 8.5 8 20.2 2 Addis Ababa 6.0 108 41.3 41 Dire Dawa 4.0 12 (49.5) 3 Education No education 0.2 1,916 4.6 193 Primary 1.4 602 16.1 218 Secondary and higher 7.0 235 33.4 156 Wealth quintile Lowest 0.2 484 8.8 93 Second 0.3 604 5.1 87 Middle 0.0 587 8.9 117 Fourth 0.3 483 6.8 98 Highest 4.0 595 38.7 171 Total 15-24 1.0 2,754 16.9 566 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Friends, family members, and home are not considered sources for condoms. 13.9.3 Recent Sexual Activity The period between age at first sex and age at marriage is often a time of sexual experimentation. Unfortunately, in the era of HIV/AIDS, it can also be a risky time. Table 13.18 presents data on the percentage of never-married young women and men age 15-24 who have not yet engaged in sex, the percentage who had sex in the 12 months preceding the survey, and the percentage who used condoms during most recent sex. 208 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.18 Premarital sexual intercourse and condom use among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who have had sexual intercourse in the past 12 months, and, among those who have had sexual intercourse in the past 12 months, the percentage who used a condom at last sexual intercourse, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage who never had sexual intercourse Percentage who have had sexual intercourse in the past 12 months Number of never- married women 15-24 Percentage who never had sexual intercourse Percentage who have had sexual intercourse in the past 12 months Number of never- married men 15-24 Percentage who used a condom at last sexual intercourse Number of men Age 15-19 97.5 1.0 2,394 94.6 3.9 1,304 44.8 51 15-17 98.7 0.5 1,622 97.2 2.0 817 (28.7) 16 18-19 94.8 2.2 773 90.2 7.2 487 52.2 35 20-24 90.3 3.1 771 75.9 13.4 777 51.8 104 20-22 91.9 2.6 555 80.3 11.5 584 54.2 67 23-24 86.1 4.3 216 62.9 19.0 194 47.5 37 Knows a condom source1 Yes 93.2 2.6 1,335 82.6 10.8 1,231 57.8 133 No 97.5 0.8 1,831 94.9 2.6 850 (0.0) 22 Residence Urban 90.5 3.3 938 76.5 15.2 410 84.5 62 Rural 97.9 0.8 2,228 90.4 5.6 1,672 26.1 93 Region Tigray 95.5 1.3 200 84.3 11.8 132 * 16 Affar 94.4 2.6 21 65.3 30.1 15 * 5 Amhara 95.9 0.9 523 93.2 3.4 497 * 17 Oromiya 96.0 2.1 1,210 85.7 9.0 807 (38.9) 73 Somali 100.0 0.0 77 92.8 5.4 52 * 3 Benishangul-Gumuz 95.6 1.1 19 91.3 7.3 14 * 1 SNNP 98.7 0.5 765 92.4 3.6 425 36.1 15 Gambela 84.5 7.3 7 49.9 37.1 6 (43.8) 2 Harari 91.8 3.2 10 76.2 17.1 4 * 1 Addis Ababa 87.0 3.0 314 67.3 18.3 116 75.9 21 Dire Dawa 89.1 2.9 19 75.8 16.6 11 * 2 Education No education 96.9 1.0 939 91.8 4.2 472 (17.1) 20 Primary 96.3 1.2 1,434 90.7 5.4 1,007 42.1 54 Secondary and higher 93.2 2.8 792 79.3 13.5 602 62.4 81 Wealth quintile Lowest 98.3 1.3 354 93.3 3.5 354 (22.6) 12 Second 98.5 1.2 443 91.4 5.3 363 * 19 Middle 98.2 0.6 552 88.5 7.2 310 * 22 Fourth 97.6 0.4 562 89.9 6.3 437 * 28 Highest 92.1 2.6 1,254 80.1 11.9 617 77.2 74 Total 15-24 95.7 1.5 3,165 87.6 7.5 2,081 49.5 155 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Friends, family members, and home are not considered sources for condoms. The great majority of never-married young women (96 percent) and men (88 percent) reported that they had never had sex, and, as a result, the proportions reporting recent sexual activity (i.e., within the 12-month period before the survey) are low (2 percent among young women and 8 percent among young men). Half of never-married young men reporting recent sexual activity used a condom the last time they had sex compared with around one-third of young women (data not shown). Given the comparatively small proportion of never-married young women reporting premarital sexual intercourse, differentials in this indicator are generally minimal. Among never- married young men, the proportion reporting premarital sexual activity tends to increase with age, education, and wealth, and is higher among urban than rural residents. Looking at regional variations, Gambela and Affar have the highest proportions of never-married young men reporting premarital sex. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 209 13.9.4 Higher-Risk Sex The most common mode of transmission of HIV in Ethiopia is through unprotected sex with an infected person. To prevent HIV/AIDS transmission, it is important that young people practice safe sex through the much-advocated ABC method (abstinence, being faithful to one uninfected partner, and condom use). Table 13.19 presents data on the percentage of young people engaging in higher- risk sex (sex with a nonmarital, noncohabiting partner) in the 12-month period preceding the survey, and the rate of condom use in these higher-risk sexual encounters. Among sexually active youth age 15-24, 6 percent of women and 37 percent of men engaged in higher-risk sexual activity in the past 12 months. One-quarter of these women and just under half of these men reported condom use in their last higher-risk encounter (data not shown). Table 13.19 Higher-risk sexual intercourse among youth Among young women and men age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse, and among those who had higher-risk sexual intercourse in the past 12 months, the percentage who used a condom at last higher- risk sexual intercourse, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage who had higher-risk sex in past 12 months Number of women sexually active in past 12 months Percentage who had higher-risk sex in past 12 months Number of women sexually active in past 12 months Age 15-19 7.2 411 68.0 78 15-17 5.6 145 96.6 18 18-19 8.0 267 59.2 59 20-24 5.1 800 31.0 368 20-22 5.1 518 33.4 214 23-24 5.2 282 27.7 155 Marital status Never married 99.6 48 98.7 155 Married or living together 1.1 1,099 3.8 278 Divorced/separated/ widowed 16.5 65 24.8 13 Knows a condom source1 Yes 12.8 378 47.7 295 No 2.7 834 17.3 151 Residence Urban 26.4 154 76.8 83 Rural 2.9 1,058 28.5 363 Region Tigray 7.7 94 61.3 28 Affar 4.5 14 60.3 8 Amhara 4.0 375 15.3 113 Oromiya 6.9 430 42.6 170 Somali 0.0 32 29.1 10 Benishangul-Gumuz 3.4 16 21.5 5 SNNP 2.4 209 29.3 80 Gambela 8.0 4 68.0 4 Harari 7.5 4 39.1 2 Addis Ababa 39.8 28 92.0 24 Dire Dawa 15.1 4 76.2 2 Education No education 2.7 823 14.9 160 Primary 7.2 280 34.6 175 Secondary and higher 25.7 109 73.9 112 Wealth quintile Lowest 2.2 234 22.3 77 Second 4.1 269 28.1 73 Middle 2.3 265 24.1 102 Fourth 3.9 200 38.3 78 Highest 16.7 243 64.5 116 Total 15-24 5.8 1,212 37.4 446 1 Friends, family members, and home are not considered sources for condoms. 210 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Among young women and men, there are significant differences in the prevalence of higher- risk sex by background characteristics. Youth with a secondary or higher education are much more likely than those with less schooling to have engaged in higher-risk sex, and higher-risk sexual activity, particularly among young women, is concentrated among those in the highest wealth quintile. Urban youth are considerably more likely than rural youth to have engaged in risky sexual behaviour. Addis Ababa and Dire Dawa stand out as regions with the highest proportions of youth reporting that they have engaged in higher-risk sex. 13.9.5 Age-Mixing in Sexual Relationships In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the wider spread of HIV and other STIs because if a younger, uninfected partner has sex with an older, infected partner, the younger, uninfected partner can contract the virus. To investigate this practice, in the 2005 EDHS women age 15-24 who had sex with a nonmarital, noncohabiting partner in the 12 months preceding the survey were asked whether the man was younger, about the same age, or older than they were. If older, they were asked if they thought he was less than ten years older or ten or more years older. Less than 1 percent of the small number of young women who had engaged in higher-risk sex in the 12-month period prior to the survey reported that they had had intercourse with a man who was ten or more years older (not shown in table). 13.9.6 Drunkenness during Sexual Intercourse Sexual intercourse when one or both partners are under the influence of alcohol is more likely to be unplanned than otherwise, and the partners are less likely to use condoms. Respondents who had had sex during the preceding 12 months were asked if they or their partner drank alcohol the last time they had sex, and if so, whether they or their partner were drunk. Table 13.20 shows the prevalence of sexual intercourse while drunk. The overall prevalence of sex when the respondent or partner is drunk is low, especially for young women (3 percent for women and 2 percent for men). Given the rarity of the phenomenon, differences across groups are minimal. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 211 Table 13.20 Drunkenness during sexual intercourse among youth Percentage of young women and men age 15-24 who had sexual intercourse in the past 12 months while being drunk, by background characteristics, Ethiopia 2005 Women Men Background characteristic Respondent and/or partner drunk Number who had sexual intercourse in past 12 months Respondent and/or partner drunk Number who had sexual intercourse in past 12 months Age 15-19 2.9 411 1.9 78 15-17 0.1 145 0.6 18 18-19 4.5 267 2.3 59 20-24 3.3 800 2.3 368 20-22 4.5 518 3.1 214 23-24 1.1 282 1.3 155 Marital status Never married 7.6 48 4.8 155 Married or living together 2.9 1,099 0.9 278 Divorced/separated/ widowed 5.6 65 0.0 13 Knows a condom source1 Yes 4.3 378 2.6 295 No 2.7 834 1.6 151 Residence Urban 6.3 154 2.5 83 Rural 2.7 1,058 2.2 363 Region Tigray 0.0 94 2.8 28 Affar 2.3 14 4.6 8 Amhara 1.6 375 1.1 113 Oromiya 5.1 430 2.0 170 Somali 0.0 32 0.0 10 Benishangul-Gumuz 0.9 16 0.0 5 SNNP 3.9 209 3.0 80 Gambela 6.4 4 1.5 4 Harari 0.0 4 0.0 2 Addis Ababa 6.2 28 6.6 24 Dire Dawa 4.1 4 7.1 2 Education No education 2.7 823 1.6 160 Primary 4.5 280 2.2 175 Secondary and higher 3.4 109 3.3 112 Wealth quintile Lowest 1.6 234 1.8 77 Second 4.5 269 0.0 73 Middle 1.3 265 3.5 102 Fourth 3.0 200 2.4 78 Highest 5.5 243 2.8 116 Total 15-24 3.2 1,212 2.3 446 1 Friends, family members, and home are not considered sources for condoms. 212 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior 13.9.7 HIV Testing Young people may believe there are barriers to accessing and using many health services and facilities, particularly for sensitive concerns relating to sexual health, such as sexually transmitted infections like HIV/AIDS. Table 13.21 presents data on the percentage of sexually active youth being tested and receiving the results within the past year. Young men are about three times as likely as young women to have been tested for HIV (6 percent and 2 percent, respectively). Given the generally low level of testing, differences across groups should be interpreted cautiously. However, there is a clear tendency for testing rates to be higher among urban youth, youth with a secondary or higher education, youth in the highest wealth quintile, and youth living in Addis Ababa. Table 13.21 Recent HIV tests among youth Among young women and men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who have had an HIV test in the past 12 months and received the results of the test, by background characteristics, Ethiopia 2005 Women Men Background characteristic Percentage who have been tested for HIV and received results in past 12 months Number of women Percentage who have been tested for HIV and received results in past 12 months Number of men Age 15-19 1.8 411 8.3 78 15-17 1.1 145 (0.3) 18 18-19 2.2 267 10.8 59 20-24 1.9 800 5.6 368 20-22 2.3 518 5.7 214 23-24 1.1 282 5.5 155 Knows a condom source1 Yes 4.2 378 6.6 295 No 0.8 834 5.2 151 Residence Urban 8.1 154 15.2 83 Rural 1.0 1,058 4.0 363 Region Tigray 1.2 94 (6.6) 28 Affar 0.0 14 (3.7) 8 Amhara 1.6 375 7.6 113 Oromiya 0.6 430 3.2 170 Somali 0.0 32 * 10 Benishangul-Gumuz 1.0 16 (2.9) 5 SNNP 3.2 209 (5.1) 80 Gambela 1.4 4 3.2 4 Harari 7.0 4 5.3 2 Addis Ababa 18.9 28 25.4 24 Dire Dawa 7.4 4 (13.9) 2 Education No education 0.4 823 6.6 160 Primary 3.0 280 1.2 175 Secondary and higher 9.8 109 13.0 112 Wealth quintile Lowest 0.0 234 0.1 77 Second 0.6 269 2.0 73 Middle 0.9 265 3.6 102 Fourth 1.7 200 4.7 78 Highest 6.3 243 15.8 116 Total 1.9 1,212 6.1 446 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Friends, family members, and home are not considered sources for condoms. HIV Prevalence and Associated Factors | 213 HIV PREVALENCE AND ASSOCIATED FACTORS 14 The 2005 EDHS is the first national survey in Ethiopia to include HIV testing. In Ethiopia, as in most of sub-Saharan Africa, national HIV prevalence estimates have been derived primarily from sentinel surveillance regarding pregnant women attending antenatal care facilities. Although the information from the ANC surveillance system has been very useful for assessing HIV levels, and especially for monitoring trends in HIV prevalence, the inclusion of HIV testing in the 2005 EDHS offers the opportunity to obtain information on the magnitude and patterns of HIV infection in the general reproductive age population in Ethiopia. Thus, the HIV prevalence data from the EDHS are expected to provide important information to plan the national response to the AIDS epidemic in Ethiopia. This chapter first presents information on the coverage of HIV testing among eligible survey respondents and then discusses levels and differentials in HIV prevalence among those tested. The chapter also considers the similarities and differences between the 2005 EDHS HIV findings and HIV estimates from other data sources, specifically the HIV results from the 2005 round of antenatal sentinel surveillance. Lastly, it discusses the effect of nonresponse on HIV rates. 14.1 COVERAGE OF HIV TESTING IN THE EDHS All women age 15-49 and all men age 15-59 living in the households that were chosen for the male survey (i.e., half of all households sampled for the 2005 EDHS) were eligible for the HIV testing component of the EDHS.1 Table 14.1 shows the coverage rates for HIV testing among eligible respondents by reason for not being tested, according to gender and residence. HIV tests were conducted for 83 percent of the 7,142 eligible women and 76 percent of the 6,778 eligible men. For both sexes combined, coverage was 80 percent. Refusals were the most important reason for non- response on the HIV testing component of the survey for both women (13 percent) and men (17 percent). Rural residents were more likely to be tested than their urban counterparts (85 percent and 67 percent, respectively). Differences in HIV testing coverage rates are also evident by region. Among both sexes, SNNP had the highest rate of testing (90 percent), followed by Tigray and Oromiya (87 percent), while the rates were lowest in Dire Dawa (60 percent) and the Somali Region (65 percent). Table 14.2 shows coverage rates for HIV testing by age group, education, and wealth. If HIV status influenced participation in the testing, coverage would be expected to decline with age since HIV levels typically increase sharply with age before levelling off or declining at the older ages. In fact, coverage rates for testing in the EDHS tend to rise with age, although not consistently, among women and men. Considering the relationship with education, those with little or no education are more likely to have been tested, while men and women with at least some secondary education were least likely to be tested. Similarly, those in the highest quintile of the wealth index were the least likely to be tested. In order to further explore whether nonresponse might have an impact on the HIV seroprevalence results, tables describing the relationship between participation in the HIV testing and a number of other characteristics related to HIV risk were also examined (see Tables A.3-A.6 in Appendix A). These tables show that nonresponse levels tend to increase, although often not 1 For additional information on the HIV testing component of the 2005 EDHS, see Chapter 1. 214 | HIV Prevalence and Associated Factors markedly, with a number of characteristics associated with a higher risk for HIV. For example, coverage rates among women and, especially, men are lower among those who have ever been sexually active than among those who have never had sex, and lower among those reporting that they had higher-risk sexual intercourse in the 12-month period before the survey than those who did not engage in higher-risk sex. Table 14.1 HIV testing coverage by residence and region Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to residence and region (unweighted), Ethiopia 2005 Tested Refused Absent/other/missing Background characteristic Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Total Unweighted number WOMEN 15-49 Residence Urban 72.7 0.1 18.8 3.7 1.3 3.3 100.0 2,239 Rural 88.0 0.2 7.8 1.6 0.8 1.8 100.0 4,903 Region Tigray 90.2 0.0 6.1 0.2 1.3 2.2 100.0 625 Affar 72.8 0.7 20.5 3.0 1.5 1.5 100.0 405 Amhara 87.7 0.1 9.4 0.7 0.7 1.3 100.0 937 Oromiya 87.6 0.3 7.4 1.8 0.5 2.4 100.0 1,101 Somali 71.3 0.3 20.2 5.2 0.6 2.5 100.0 362 Benishangul-Gumuz 89.2 0.0 6.4 1.6 1.4 1.4 100.0 436 SNNP 93.2 0.1 3.9 0.8 0.9 1.0 100.0 1,070 Gambela 82.8 0.2 8.0 4.6 1.5 2.9 100.0 413 Harari 73.6 0.0 17.9 4.5 1.3 2.8 100.0 469 Addis Ababa 73.8 0.1 17.4 3.6 0.9 4.2 100.0 912 Dire Dawa 70.9 0.0 22.6 2.4 0.7 3.4 100.0 412 Total 83.2 0.2 11.2 2.2 1.0 2.3 100.0 7,142 MEN 15-59 Residence Urban 59.5 0.1 22.6 6.7 1.4 9.7 100.0 1,948 Rural 81.8 0.2 8.6 3.6 0.8 5.0 100.0 4,830 Region Tigray 84.2 0.0 5.5 2.7 1.2 6.4 100.0 563 Affar 60.2 0.3 20.2 8.0 0.8 10.6 100.0 387 Amhara 84.9 0.2 7.8 2.8 0.8 3.4 100.0 959 Oromiya 85.2 0.1 6.7 3.2 0.6 4.3 100.0 1,126 Somali 57.4 0.6 26.2 8.3 0.0 7.4 100.0 336 Benishangul-Gumuz 82.4 0.0 11.7 2.5 0.7 2.7 100.0 403 SNNP 86.0 0.2 5.1 3.5 0.9 4.3 100.0 956 Gambela 74.4 0.3 9.5 6.3 1.3 8.3 100.0 398 Harari 66.2 0.2 17.0 5.9 1.7 9.0 100.0 423 Addis Ababa 62.2 0.0 20.0 6.2 1.4 10.1 100.0 834 Dire Dawa 47.3 0.3 34.6 6.1 2.0 9.7 100.0 393 Total 75.4 0.2 12.6 4.5 1.0 6.3 100.0 6,778 TOTAL 15-49 Residence Urban 66.9 0.1 20.4 5.0 1.4 6.2 100.0 4,054 Rural 84.9 0.2 8.2 2.6 0.8 3.4 100.0 9,263 Region Tigray 87.4 0.0 5.8 1.4 1.3 4.2 100.0 1,107 Affar 66.9 0.5 19.8 5.7 1.1 6.1 100.0 758 Amhara 86.1 0.2 8.7 1.8 0.8 2.5 100.0 1,791 Oromiya 86.3 0.2 7.0 2.4 0.6 3.5 100.0 2,134 Somali 64.4 0.5 23.3 6.8 0.3 4.8 100.0 665 Benishangul-Gumuz 86.3 0.0 8.8 2.0 0.9 2.0 100.0 804 SNNP 89.8 0.2 4.5 2.1 0.9 2.6 100.0 1,952 Gambela 79.2 0.3 8.7 5.4 1.4 5.1 100.0 783 Harari 70.3 0.1 17.8 5.1 1.3 5.4 100.0 864 Addis Ababa 68.3 0.1 18.4 4.9 1.2 7.1 100.0 1,681 Dire Dawa 59.8 0.1 28.1 4.1 1.3 6.6 100.0 778 Total 79.4 0.2 11.9 3.3 1.0 4.3 100.0 13,317 HIV Prevalence and Associated Factors | 215 Table 14.2 HIV testing coverage by background characteristics Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to background characteristics (unweighted), Ethiopia 2005 Tested Refused Absent/other/missing Background characteristic Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Total Unweighted number WOMEN 15-49 Age 15-19 81.8 0.5 10.4 2.8 1.2 3.3 100.0 1,718 20-24 81.5 0.1 12.6 2.8 1.0 2.1 100.0 1,329 25-29 84.1 0.1 10.8 1.8 0.7 2.5 100.0 1,311 30-34 85.2 0.0 10.8 1.4 1.1 1.5 100.0 853 35-39 82.7 0.0 12.2 2.2 0.7 2.2 100.0 821 40-44 85.7 0.0 10.3 2.2 0.5 1.3 100.0 602 45-49 84.4 0.2 12.0 1.2 1.4 0.8 100.0 508 Education No education 85.4 0.2 9.6 2.0 0.9 1.9 100.0 4,251 Primary 84.6 0.2 9.7 2.0 1.0 2.6 100.0 1,563 Secondary and higher 74.5 0.0 18.1 3.2 1.1 3.0 100.0 1,328 Wealth quintile Lowest 83.1 0.2 10.7 2.9 1.0 2.2 100.0 1,473 Second 88.0 0.2 8.2 1.1 0.5 2.0 100.0 1,070 Middle 92.1 0.1 4.6 0.6 1.2 1.4 100.0 1,006 Fourth 90.8 0.3 5.5 1.3 0.8 1.2 100.0 968 Highest 75.0 0.1 17.4 3.2 1.1 3.1 100.0 2,625 Total 83.2 0.2 11.2 2.2 1.0 2.3 100.0 7,142 MEN 15-59 Age 15-19 74.1 0.1 12.5 4.9 1.1 7.2 100.0 1,457 20-24 75.1 0.0 11.6 5.2 0.9 7.1 100.0 1,185 25-29 73.7 0.4 12.4 4.7 1.0 7.8 100.0 953 30-34 75.6 0.1 13.7 3.7 1.0 5.9 100.0 841 35-39 74.9 0.3 14.1 4.4 0.7 5.7 100.0 725 40-44 75.3 0.0 13.8 4.9 0.9 5.1 100.0 551 45-49 78.8 0.4 11.0 3.9 0.9 5.0 100.0 463 50-54 78.6 0.0 12.3 3.3 1.9 3.8 100.0 365 55-59 79.8 0.0 12.2 2.9 1.3 3.8 100.0 238 Education No education 77.0 0.3 10.6 5.2 1.1 5.9 100.0 2,745 Primary 81.6 0.1 9.9 2.8 0.7 4.9 100.0 2,111 Secondary and higher 66.3 0.1 18.6 5.4 1.3 8.4 100.0 1,919 Wealth quintile Lowest 75.1 0.2 12.1 4.9 0.9 6.7 100.0 1,377 Second 84.5 0.1 6.8 3.3 1.1 4.1 100.0 1,016 Middle 85.5 0.3 5.4 3.6 0.9 4.3 100.0 957 Fourth 82.7 0.2 8.7 3.1 0.7 4.6 100.0 994 Highest 64.7 0.1 19.8 5.7 1.2 8.5 100.0 2,434 Total 75.4 0.2 12.6 4.5 1.0 6.3 100.0 6,778 Note: Total for men includes 3 cases with missing information on education, who are not shown separately 216 | HIV Prevalence and Associated Factors 14.2 HIV PREVALENCE Results from the 2005 EDHS indicate that 1.4 percent of Ethiopian adults age 15-49 are infected with HIV (Figure 14.1). HIV prevalence in women is nearly 2 percent, while for men 15-49, it is just under 1 percent. The female-to-male infection ratio of 2.1 is higher than what has been previously assumed in the Ethiopian situation. However, it is consistent with female-to-male HIV infection ratios observed in a number of other countries in sub-Saharan Africa: Senegal – ratio of 2.3 (Ministry of Health, 2005), Guinea – ratio of 2.1 (National Directorate of Statistics, 2005), and Kenya - ratio of 1.9 (Central Bureau of Statistics, 2004). Gender differences in infection levels reflect the fact that biological factors make women more susceptible to the risk of infection. They also relate to the fact that women both initiate sexual activity and marry at a much younger age than men (see Chapter 6). Also, their husbands (partners) tend to be older than them. 14.2.1 HIV Prevalence by Age Table 14.3 shows for both men and women that HIV prevalence levels rise with age, peaking among women in their late 30s and among men in their early 40s. The age patterns suggest that young women are particularly vulnerable to HIV infection compared with young men. Among women age 15-19, for example, 0.7 percent are HIV infected, compared with 0.1 percent of men age 15-19. HIV prevalence among women 20-24 is over three times that of men in the same age group (1.7 percent and 0.4 percent, respectively). Figure 14.1 HIV Prevalence among Women and Men Age 15-49 1.9 0.9 1.4 Women Men Total 0 0.5 1 1.5 2 2.5 EDHS 2005 Percentage HIV positive HIV Prevalence and Associated Factors | 217 Table 14.3 HIV prevalence by age Percentage HIV positive among women age 15-49 and men age 15-59 who were tested, by age, Ethiopia 2005 Women 15-49 Men 15-59 Total 15-49 Age Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 0.7 1,397 0.1 1,175 0.4 2,572 20-24 1.7 1,025 0.4 929 1.1 1,954 25-29 2.1 1,004 0.7 640 1.6 1,645 30-34 1.5 734 1.9 664 1.7 1,398 35-39 4.4 650 1.8 581 3.2 1,231 40-44 3.1 487 2.8 438 3.0 925 45-49 0.8 439 0.0 376 0.5 815 50-54 na na 0.9 293 na na 55-59 na na 0.3 208 na na Total age 15-49 1.9 5,736 0.9 4,804 1.4 10,540 Total age 15-59 na na 0.9 5,306 na na na = Not applicable 14.2.2 HIV Prevalence by Socioeconomic Characteristics As Table 14.4 shows, urban residents have a significantly higher risk of HIV infection (6 percent) than rural residents (0.7 percent). The risk of HIV infection among rural women and men is almost identical, while urban women are more than three times as likely as urban men to be infected. Regional variations in HIV prevalence are also presented in Table 14.4. Prevalence levels are highest in Gambela (6 percent) and Addis Ababa (5 percent). Other regions in which HIV prevalence exceeds the national average include Harari, Dire Dawa, Afar, Tigray, and Amhara. Somewhat surprisingly, SNNP Region has the lowest overall prevalence (0.2 percent). The regional variations are discussed further below when the 2005 EDHS results are compared with the results of the ANC surveillance system. In addition, the regional patterns, particularly the unexpectedly low prevalence rate in the SNNP Region, merit further investigation, including additional future surveys taking into account both information on regional differences in patterns of risk behaviour available in the 2005 EDHS and data from other sources. HIV infection levels increase directly with education among both women and men and are markedly higher among those who have a secondary or higher education compared with those with less education. Employment (in the past 12 months) is also related to HIV levels among both women and men, with those who are employed being more likely than the unemployed to be infected. Particularly among men, those who were unemployed during the 12-month period prior to the survey are heavily concentrated in the younger age groups where HIV levels are quite low. This helps to explain why none of the men in this category were HIV positive. Both women and men in the highest quintile of the wealth index have substantially higher rates of HIV infection than those in other wealth quintiles. 218 | HIV Prevalence and Associated Factors Table 14.4 HIV prevalence by socioeconomic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by socioeconomic characteristics, Ethiopia 2005 Women Men Background characteristic Percentage HIV positive Number Percentage HIV positive Number Total Number Residence Urban 7.7 980 2.4 684 5.5 1,664 Rural 0.6 4,756 0.7 4,120 0.7 8,875 Region Tigray 2.6 387 1.6 274 2.1 661 Affar 3.3 61 2.4 46 2.9 107 Amhara 1.8 1,411 1.6 1,212 1.7 2,623 Oromiya 2.2 2,000 0.4 1,812 1.4 3,812 Somali 1.3 189 0.0 140 0.7 328 Benishangul-Gumuz 0.9 55 0.0 45 0.5 100 SNNP 0.1 1,290 0.4 1,010 0.2 2,300 Gambela 5.5 19 6.7 16 6.0 35 Harari 4.6 16 2.2 13 3.5 29 Addis Ababa 6.1 280 3.0 214 4.7 495 Dire Dawa 4.4 28 1.9 22 3.2 50 Education No education 1.0 3,745 0.8 1,920 0.9 5,665 Primary 2.5 1,349 0.5 1,912 1.3 3,260 Secondary and higher 5.5 642 2.0 972 3.4 1,614 Employment1 Not currently working 1.5 3,423 0.0 609 1.3 4,032 Currently working 2.3 1,981 1.1 4,187 1.5 6,168 Wealth quintile Lowest 0.3 1,053 0.7 863 0.5 1,916 Second 1.0 1,108 0.3 949 0.7 2,057 Middle 0.4 1,107 0.9 898 0.6 2,006 Fourth 0.2 1,073 0.4 951 0.3 2,023 Highest 6.1 1,395 2.2 1,143 4.3 2,538 Total 1.9 5,736 0.9 4,804 1.4 10,540 Note: Total excludes numbers missing information on employment status and not shown separately. 1 Employed at any time in the 12 months preceding the survey 14.2.3 HIV Prevalence by Other Sociodemographic Characteristics Table 14.5 presents the relationships between HIV prevalence and a number of other socio- demographic variables. As expected, marital status is closely related to HIV prevalence. Women and men who are widowed, divorced, or separated have significantly higher rates than those who are married or living together. HIV rates are lowest for respondents who have never been in union. However, within the latter group, the small number of women who are sexually active but have never been in a marital union, have an HIV prevalence rate of 9 percent, higher than the levels found among widowed or divorced and separated women. Among never-married men who have ever had sex, the HIV rate approaches but is lower than the level among men who are currently married or living with a partner. Finally, a small proportion of individuals who say they have never had sex are HIV positive. This suggests either reporting errors in sexual behaviour or non-sexual transmission of HIV. Considering the type of current union, HIV rates do not differ between those in a polygynous union and those who are not. HIV Prevalence and Associated Factors | 219 Table 14.5 looks at how HIV rates relate to two measures of male mobility. The results indicate that the number of times a man slept away from home is more closely associated with HIV prevalence than is the total amount of time that a man spent away. The HIV rate is 3 percent among men who slept away six or more times in the 12-month period prior to the survey compared with less than 1 percent among men who never slept away and men who slept away fewer than six times. Table 14.5 HIV prevalence by demographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by demographic characteristics, Ethiopia 2005 Women Men Total Demographic characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Never married 0.7 1,449 0.3 2,084 0.5 3,532 Ever had sexual intercourse 9.3 92 1.0 330 2.8 422 Never had sexual intercourse 0.1 1,356 0.2 1,754 0.1 3,110 Married/living together 1.6 3,685 1.3 2,583 1.5 6,268 Divorced or separated 8.1 206 * 16 8.4 222 Widowed 5.6 396 1.9 121 4.7 517 Type of union In polygynous union (1.5) 455 1.3 152 1.4 607 Not in polygynous union 1.5 3,194 1.3 2,431 1.4 5,624 Missing polygyny, don’t know (7.6) 36 na 0 (7.6) 36 Not currently in union 2.4 2,051 0.5 2,221 1.4 4,272 Times slept away from home in past 12 months 0 na na 0.8 3,389 na na 1-2 na na 0.9 821 na na 3-5 na na 0.4 332 na na 6+ na na 3.1 259 na na Time away in past 12 months More than 1 month na na 0.8 289 na na Less than 1 month na na 1.3 1,110 na na Never away na na 0.8 3,389 na na Missing na na * 16 na na Currently pregnant Yes 1.1 480 na na na na Not pregnant/not sure 1.9 5,256 na na na na Antenatal care for births in past 3 years No birth 2.0 3,308 na na na na Birth and ANC by health professional 3.5 702 na na na na Birth and no ANC by health professional 1.0 1,726 na na na na Delivery care for births in past 3 years No birth 2.0 3,308 na na na na Birth and delivery care by health professional 9.9 143 na na na na Birth and no delivery care by health professional 1.2 2,285 na na na na Total 1.9 5,736 0.9 4,804 1.4 10,540 Note: Figures in parentheses are based on 25-49 unwei ghted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 220 | HIV Prevalence and Associated Factors HIV prevalence among women who are currently pregnant is 1 percent, roughly half the level found among nonpregnant women. This is a somewhat unexpected pattern since, as discussed in the introduction to this chapter, pregnant women are generally assumed to have a higher risk of HIV infection than nonpregnant women. It may be related to the fact that fertility is much lower among urban women than rural women and, thus, the currently pregnant population is likely to be disproportionately rural and, thus, less exposed to the risk of infection. Finally, HIV rates are markedly higher among women who received antenatal care at a health facility and especially among the comparatively few women who received delivery care from a health professional for births that occurred in the three-year period prior to the survey (4 percent and 10 percent, respectively). Again these relationships are likely related to the fact that women who receive antenatal and delivery care are much more likely than other women to live in urban areas, be highly educated, and fall into the highest wealth quintile. All of these latter factors are associated with much higher than average risk of HIV infection. 14.2.4 HIV Prevalence by Sexual Risk Behaviour Table 14.6 presents HIV prevalence rates by sexual behaviour indicators among respondents who have ever had sexual intercourse. In reviewing these results, it is important to remember that responses about sexual risk behaviours may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk. For women, there is a clear pattern of higher HIV prevalence with sexual debut at ages 16-19 while the age at which men initiated sex appears to be unrelated to their HIV status. The pattern among women is somewhat unexpected in view of the assumption that early sexual debut would be associated with a longer average period of sexual activity and thus, greater exposure to the transmission of the HIV virus. It may reflect the fact that individuals initiating sex at very young ages are concentrated in groups with lower HIV prevalence (e.g., they live in rural areas or are less educated). EDHS respondents are considered to have had a higher-risk sexual encounter if they had intercourse with a nonmarital, noncohabiting partner. Table 14.6 shows that both women and men who had a higher-risk sexual partner in the 12-month period before the survey are more likely to be HIV-infected than those who were sexually active but did not have sex with a higher-risk partner. The differential is especially large for women, with the small number of women who report having a higher-risk sexual encounter being seven times as likely to be HIV positive as women who had sex but not with a higher-risk partner, and more than two times as likely to be HIV positive as women who did not have sex during the 12-month period. In turn, the comparatively high prevalence among the latter group of women is probably because many are widowed or divorced or separated women who, as was shown earlier, have much higher than average risk of HIV infection. HIV risk is also assumed to increase with the number of lifetime sexual partners that an individual has. The results in Table 14.6 suggest that HIV risk does not rise directly with the number of sexual partners but that having a large number of partners (five or more for women and ten or more for men) is associated with significantly higher rates of HIV infection. HIV Prevalence and Associated Factors | 221 Table 14.6 HIV prevalence by sexual behaviour Percentage HIV positive among women and men age 15-49 who ever had sexual intercourse and were tested, by sexual behaviour characteristics, Ethiopia 2005 Women Men Total Sexual behaviour characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sexual intercourse 15 or less 2.2 2,146 0.5 234 2.0 2,379 16-17 3.5 840 2.2 399 3.1 1,238 18-19 2.7 609 1.3 704 2.0 1,313 20+ 2.2 542 1.3 1,661 1.5 2,202 Non-numeric 0.0 228 4.3 46 0.7 274 Higher-risk intercourse in past 12 months1 Had higher risk sexual intercourse 12.3 106 1.8 218 5.2 324 Had sexual intercourse, not higher risk 1.6 3,618 1.3 2,557 1.5 6,175 No sexual intercourse in past 12 months 5.4 640 2.0 268 4.4 908 Number of sexual partners in past 12 months 0 5.4 636 2.1 259 4.5 895 1 1.9 3,719 1.2 2,665 1.6 6,385 2 * 5 4.2 106 4.6 111 3+ * 1 * 7 * 8 Number of higher-risk partners2 in past 12 months 0 2.2 4,228 1.4 2,811 1.8 7,039 1 9.4 132 1.9 206 4.8 338 2+ * 2 (0.3) 19 5.7 21 Don’t know/missing * 2 * 6 * 9 Condom use Ever used condom 20.0 88 2.1 322 5.9 410 Never used condom 2.0 4,276 1.3 2,721 1.8 6,998 Condom use at last sexual intercourse in past 12 months Used condom 22.4 40 1.6 117 7.0 157 Did not use condom 1.7 3,681 1.3 2,659 1.5 6,340 Condom use at last higher-risk intercourse1 in past 12 months Used condom (30.8) 28 1.8 97 8.2 125 Did not use condom 5.8 79 1.7 121 3.3 199 Number of lifetime partners 1 1.4 3,148 0.6 1,419 1.2 4,567 2 4.7 863 1.8 679 3.4 1,542 3-4 4.1 280 1.3 576 2.3 857 5-9 (10.5) 54 1.4 210 3.3 265 10+ * 4 6.1 134 7.1 137 Paid for sexual intercourse in past 12 months3 Used condom na na (1.6) 15 na 0 Did not use condom na na (2.7) 28 na 0 No paid sexual intercourse na na 1.3 2,722 na 0 Total 2.4 4,364 1.4 3,043 2.0 7,407 Note: Total includes men women and men missin g information on whether paid for sexual intercourse in the past 12 months, not shown separately. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a nonmarital, noncohabiting partner 2 Nonmarital, noncohabiting partners among the last two partners for women and the last three partners for men in the past 12 months 3 Includes men who report having a prostitute as at least one of their last three partners in the past 12 months na = Not applicable 222 | HIV Prevalence and Associated Factors Table 14.6 examines the relationship between condom use (ever use and recent use). When used properly, condoms are an effective way of preventing the transmission of HIV and other STIs. Although this would suggest that HIV rates should be lower among condom users, there are a number of factors that may influence the direction of the relationship. For example, condom use rates may be higher among individuals who are infected because they are seeking to protect an uninfected partner. Also, reported condom use cannot be assumed to be “correct condom use.” Thus, it is not surprising that the association between condom use and infection levels is not uniform in Table14.6. Among women, condom use is associated with markedly higher levels of HIV infection, while among men, it is associated with only slightly elevated risk of infection. Finally, among men, the small number who said that they paid for sex in the 12 months preceding the survey have higher HIV prevalence than those who reported no paid sex. In summary, the results presented in Table 14.6 do not demonstrate a consistent relationship between sexual risk behaviour and HIV prevalence. More detailed analysis is clearly necessary to understand these relationships because they are often confounded by factors such as age, residence, and educational status that are associated with both the behavioural measures and HIV prevalence. 14.2.5 HIV Prevalence by Other Characteristics Related to HIV Risk Table 14.7 presents HIV prevalence by other characteristics related to HIV risk among women and men who have ever had sex. The table shows that women and men with a history of a sexually transmitted infection (STI) or STI symptoms have slightly higher rates of HIV infection than those with no history or symptoms. Table 14.7 HIV prevalence by STI status and prior HIV testing status Percentage HIV positive among women and men age 15-49 who have ever had sexual intercourse and were tested for HIV, by whether they had an STI in the past 12 months and by prior HIV testing status, Ethiopia 2005 Women Men Total STI in past 12 months/ Prior HIV testing Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number STI in past 12 months Had STI or STI symptoms 3.4 96 2.2 41 3.0 137 No STI, no symptoms 2.4 4,196 1.4 2,984 2.0 7,181 Prior HIV testing Previously tested 7.1 196 2.2 97 5.5 293 Previously tested, received results of last test 7.5 179 2.2 95 5.7 273 Previously tested, did not receive results of last test * 17 * 2 (2.4) 19 Not tested previously 2.2 3,870 1.5 2,668 1.9 6,538 Total 2.4 4,364 1.4 3,043 2.0 7,407 Note: Total includes numbers missing information on sexually transmitted infections in past 12 months and HIV testing status not shown separately. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. The table also shows that the small number of women and men who have been tested for HIV have higher rates of HIV infection than those who have never been tested. The differential is especially large among women; 7 percent of women who had been tested for HIV prior to the survey were HIV positive compared with 2 percent who had not been tested previously. HIV Prevalence and Associated Factors | 223 14.3 HIV PREVALENCE AND MALE CIRCUMCISION Although studies have not always found a uniform relationship, lack of circumcision is considered a risk factor for HIV infection, in part because of physiological differences that increase the susceptibility to HIV infection among uncircumcised men. The 2005 EDHS obtained information on male circumcision status, and these results can be used to examine the relationship between HIV prevalence and male circumcision status. Table 14.8 shows that the relationship be- tween male circumcision and HIV levels in Ethiopia conforms to the expected pattern of higher rates among uncircumcised men than circumcised men (0.9 percent and 1.1 percent, re- spectively). However, the difference in HIV prevalence is very small and not significant. 14.4 HIV PREVALENCE AMONG COUPLES Over 2,674 cohabiting couples were tested for HIV in the 2005 EDHS. Results shown in Table 14.9 indicate that, for 98 percent of cohabit- ing couples, both partners tested nega- tive for HIV. The majority of the re- maining couples (1.8 percent out of a total of 2.1 percent) are discordant, that is, one partner is infected and the other is not. There is clearly an unmet need for VCT services oriented towards couples, because most of these couples do not mutually know their HIV status. Table 14.8 HIV prevalence by male circumcision Among men age 15-59 who were tested for HIV, percentage HIV positive by whether circumcised and background characteristics, Ethiopia 2005 Circumcised Uncircumcised Background characteristic Percentage HIV positive Number Percentage HIV positive Number Age 15-19 0.0 1,015 0.9 159 20-24 0.4 862 0.1 67 25-29 0.7 599 1.3 41 30-34 2.0 625 (0.5) 39 35-39 1.6 537 (4.6) 45 40-44 2.9 429 * 9 45-49 0.0 353 (0.0) 23 50-54 0.9 284 * 9 55-59 0.4 196 * 12 Residence Urban 2.4 713 (10.7) 20 Rural 0.6 4,187 0.6 386 Region Tigray 2.0 312 * 6 Affar 2.2 50 * 0 Amhara 1.5 1,332 * 38 Oromiya 0.3 1,845 1.7 125 Somali 0.0 158 * 2 Benishangul-Gumuz 0.0 47 * 1 SNNP 0.3 879 0.7 219 Gambela 2.3 8 9.8 9 Harari 2.1 13 * 0 Addis Ababa 3.4 231 * 4 Dire Dawa 1.7 24 * 0 Education No education 0.8 2,129 0.9 165 Primary 0.6 1,816 0.2 197 Secondary and higher 1.9 955 6.0 43 Wealth quintile Lowest 0.7 858 0.2 110 Second 0.3 965 0.2 97 Middle 0.7 911 2.2 80 Fourth 0.4 981 0.2 72 Highest 2.1 1,184 (4.5) 47 Total 0.9 4,900 1.1 406 Note: Figures in parentheses are ba sed on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 224 | HIV Prevalence and Associated Factors Table 14.9 HIV prevalence among couples Among cohabiting couples both of whom were tested, percent distribution by HIV test results, according to background characteristics, Ethiopia 2005 Background characteristic Both partners HIV positive Male partner positive, female negative Female partner positive, male partner negative Both partners HIV negative Total Number Woman's age 15-19 0.0 0.4 1.1 98.5 100.0 235 20-29 0.1 1.2 0.9 97.9 100.0 1,151 30-39 0.6 0.3 1.2 97.9 100.0 838 40-49 0.5 1.0 0.9 97.6 100.0 450 Man's age 15-19 * * * * * 18 20-29 0.1 0.3 1.5 98.1 100.0 555 30-39 0.5 1.2 0.9 97.3 100.0 1,029 40-49 0.3 0.5 0.9 98.2 100.0 699 50-59 0.0 0.8 0.8 98.4 100.0 373 Age difference between partners Man older by 15+ years 0.3 0.8 1.0 97.9 100.0 2,674 Marital status Married 0.3 0.8 0.9 98.0 100.0 2,640 Living together (0.1) (1.0) (8.0) (90.9) (100.0) 34 Type of union Monogamous 0.3 0.9 0.9 97.9 100.0 2,463 Polygynous 0.0 0.0 1.2 98.8 100.0 195 Residence Urban 3.1 2.2 5.6 89.1 100.0 202 Rural 0.1 0.7 0.6 98.6 100.0 2,472 Region Tigray 0.0 3.3 1.6 95.1 100.0 155 Affar 3.8 0.0 0.0 96.2 100.0 26 Amhara 0.2 1.4 0.7 97.6 100.0 730 Oromiya 0.4 0.2 1.5 97.9 100.0 995 Somali 0.0 0.0 1.3 98.7 100.0 76 Benishangul-Gumuz 0.0 0.0 0.0 100.0 100.0 27 SNNP 0.0 0.2 0.1 99.6 100.0 595 Gambela 2.6 3.1 5.6 88.7 100.0 8 Harari 0.8 1.8 1.6 95.8 100.0 5 Addis Ababa 2.7 3.7 3.7 89.9 100.0 51 Dire Dawa 0.0 0.0 1.6 98.4 100.0 6 Woman’s education No education 0.1 0.8 0.5 98.6 100.0 2,068 Primary 0.6 0.8 1.8 96.9 100.0 487 Secondary and higher 3.5 0.4 6.8 89.3 100.0 119 Man's education No education 0.0 0.8 0.4 98.8 100.0 1,487 Primary 0.0 0.5 1.0 98.5 100.0 898 Secondary and higher 2.6 1.8 4.3 91.2 100.0 289 Wealth quintile Lowest 0.0 1.1 0.0 98.9 100.0 502 Second 0.0 0.0 1.2 98.8 100.0 594 Middle 0.1 0.7 0.6 98.6 100.0 608 Fourth 0.0 0.3 0.0 99.6 100.0 530 Highest 1.7 2.2 3.6 92.6 100.0 440 Total 0.3 0.8 1.0 97.9 100.0 2,674 Note: Total includes number missing information on type of union not shown separately. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. HIV Prevalence and Associated Factors | 225 14.5 EDHS AND ANC SURVEILLANCE RESULTS As noted above, prior to the 2005 EDHS, national prevalence estimates for the general adult population in Ethiopia were derived from information obtained through the national ANC surveillance system. The most recent round of ANC surveillance conducted in 2005 included 79 sites in government health facilities from all 11 regions of the country. While the rate of HIV infection in pregnant women has been shown to be a reasonable proxy for the level in the combined male and female adult population in a number of settings (WHO and UNAIDS, 2000), there are several limitations in estimating the HIV rate in the general adult population from data derived exclusively from pregnant women attending antenatal clinics. First, it is recognized that ANC data may overstate the risk of HIV infection in the general population for several reasons. Most obviously is the fact that the rates among pregnant women are not a good proxy for male HIV rates, which are typically lower than the rates for women. In addition, ANC data do not reflect HIV prevalence levels in non-pregnant women, many of whom are at lower risk of HIV infection either because they are not sexually active or because they use condoms to prevent pregnancy or to avoid sexually transmitted infections including HIV. The ANC results also do not represent women who either do not attend a clinic for pregnancy care or receive antenatal care at facilities not represented in the surveillance system. These women tend to be concentrated in more rural localities and, thus, are likely to be at lower risk of HIV infection. Although most of the potential biases in ANC surveillance are related to lower risks of infection, ANC data also potentially exclude some women who have contracted HIV because HIV infection reduces fertility and because knowledge of HIV status may influence fertility choices among infected women. Table 14.10 compares HIV prevalence results from the 2005 EDHS with estimates derived from the 2005 round of ANC surveillance. The national estimate based on the ANC surveillance results is 3.5 percent. This compares to the level of 1.4 percent found in the EDHS. Additional analysis will be needed to understand both the differences and similarities between the ANC and DHS results. However, initial comparisons of the EDHS and ANC findings suggest that the differences are owed principally to: (1) the relatively limited coverage of antenatal care services in Ethiopia and (2) differences in geographic coverage of the EDHS and the ANC surveillance systems. With respect to the first point, the EDHS results suggest that only around one in four pregnant women in Ethiopia goes for antenatal care, with coverage levels much higher among urban than rural women (see Chapter 9). Thus, at least part of the difference between the ANC-based HIV rate and the EDHS figure may rest in the selective nature of the population attending antenatal care. Some confirmation for this hypothesis is seen in Figure 14.2. The first two bars in the figure show the HIV rates for two groups of EDHS respondents: (1) respondents who gave birth during the three-year period before the survey and received antenatal care and (2) EDHS respondents who either gave birth but did not receive antenatal care during pregnancy or did not give birth (see also Table 14.5). The HIV rate for the EDHS respondents is identical to that found in the 2005 ANC surveillance round (3.5 percent) and higher than the rate observed among EDHS respondents who were not ANC clients or did not give birth (1.6 percent). 226 | HIV Prevalence and Associated Factors Table 14.10 HIV prevalence results from the EDHS and the National Antenatal Care Surveillance System Percentage HIV positive among the adult population age 15-49 reported in the 2005 EDHS and estimated in the 2005 round of the national antenatal care 2005 EDHS 2005 ANC Round Region HIV prevalence Number of sample points Unweighted number of adults tested HIV prevalence Number of sites Number of pregnant women tested Tigray 2.1 50 1,038 4.2 9 3,111 Affar 2.9 35 528 3.1 2 763 Amhara 1.7 80 1,636 4.5 17 6,961 Oromiya 1.4 83 1,924 2.4 20 7,185 Somali 0.7 34 451 1.2 2 607 Benishangul-Gumuz 0.5 30 721 2.8 5 1,615 SNNP 0.2 84 1,819 2.3 12 4,119 Gambela 6.0 29 638 4.0 2 506 Harari 3.5 30 625 5.2 2 569 Addis Ababa 4.7 50 1,192 11.7 3 1,939 Dire Dawa 3.2 30 478 6.8 5 872 Total 1.4 534 11,050 3.5 79 28.247 Note: ANC estimates are from the national HIV/AIDS Prevention and Control Office (HAPCO), HIV/AIDS/STIs Monitoring and Evaluation Unit. Figure 14.2 HIV Prevalence among EDHS Respondents by Antenatal Care Status and HIV Rate from ANC Surveillance Data 3.5 1.6 3.5 Had ANC at heatlh facility No ANC/no birth HIV rate from ANC Surveillance Data 0 0.5 1 1.5 2 2.5 3 3.5 4 EDHS 2005 HIV rates among women age 15-49 from 2005 EDHS survey 1 1 Women giving birth in the three-year period before the survey HIV Prevalence and Associated Factors | 227 Differences in geographic coverage between the 2005 EDHS survey and the ANC surveil- lance system are another important factor in explaining the differences in HIV estimates derived from the two data sources. Figure 14.3 shows the location of both the health facilities included in the ANC surveillance system and the census enumeration areas from which the 2005 EDHS sample was drawn.2 The map shows that the facilities included in the ANC surveillance system are mainly clustered in or near urban areas and along the main transport corridors in Ethiopia (well-known routes along which the HIV virus is transmitted) while the EDHS clusters are more geographically dispersed. Confirmation that the geographic concentration of ANC surveillance sites in high transmission areas is responsible for a large part of the difference between the EDHS HIV rate and the HIV rate derived from ANC surveillance results is seen in Figure 14.4. EDHS respondents living within 15 kilometres of the ANC surveillance sites have markedly higher HIV levels than populations living 15 kilometres or more from the sites. The HIV rate for the adult population living within 15 kilometres is also similar to that observed in the ANC results. This confirms that the ANC results are a reasonable proxy for adult prevalence, once they are adjusted for geographic coverage issues, and lends confidence to the use of the ANC results in assessing trends in the course of the AIDS epidemic. Population-based surveys like the EDHS are not conducted at frequent enough intervals to effectively monitor trends. This initial review indicates that the EDHS seroprevalence results are comparable at the national level with the ANC-based HIV data once differences in the geographic and population coverage between the two surveys are addressed. However, there are a number of questions that the comparisons of the EDHS and ANC data raise that will require additional analysis. In particular, there are questions regarding differences in regional patterns. For example, in Gambela the EDHS found higher prevalence than would be expected in view of the ANC findings. The very low prevalence rate in SNNP also deserves additional consideration. 2 The map was created using GIS coordinates for the ANC surveillance sites and for the EDHS clusters. 228 | HIV Prevalence and Associated Factors HIV Prevalence and Associated Factors | 229 14.6 EFFECT OF NONRESPONSE ON THE EDHS HIV PREVALENCE RESULTS As was seen earlier in this chapter, not all eligible EDHS respondents participated in the HIV testing component. The potential for bias associated with this nonparticipation is a concern since respondents who refused to be tested or were absent at the time of testing may bias the results in ways that are different in their characteristics or behaviour from those who consented to provide a blood sample To address these concerns, it has become standard procedure in DHS surveys with an HIV testing component to conduct an analysis of those who are not tested in order to look for potential biases. Table 14.11 summarizes the results of the nonresponse analysis that was conducted for the 2005 EDHS. The table shows the observed HIV rates for women, men, and the total sample and the rates for these groups following an adjustment for nonresponse. Overall, the adjustment for nonresponse raises the HIV prevalence by about 0.2 percentage points above the observed level (from 1.4 percent to 1.6 percent). For women, the adjusted prevalence is 2.1 percent compared with the observed level of 1.9 percent. For men, the effect of the adjustment is slightly smaller, adding about 0.1 percentage points to the observed rate of 0.9 percent. The differences between the observed and adjusted rates were not found to be statistically significant. Additional details regarding the non- response analysis are found in Appendix A. Table 14.11 Observed and adjusted HIV prevalence among women and men Percentage HIV positive among women and men age 15-49 who were tested for HIV, by observed and adjusted prevalence and 95% co nfidence intervals, Ethiopia 2005 Observed HIV prevalence Adjusted HIV prevalence 95% confidence interval 95% confidence interval Sex Prevalence (R) R-2SE R+2SE Prevalence (R) R-2SE R+2SE Women 1.86 1.52 2.21 2.06 1.77 2.37 Men 0.94 0.66 1.22 1.01 0.79 1.24 Total 1.44 1.214 1.67 1.57 1.38 1.76 Figure 14.4 HIV Prevalence by Distance from 2005 ANC Sentinel Sites, EDHS Respondents Age 15-49 3.2 1.0 <15 km 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 EDHS 2005 >15 km 230 | HIV Prevalence and Associated Factors Table 14.12 compares observed and adjusted HIV prevalence for women and men according to various respondent and household characteristics. For the most part, the differences between the observed and adjusted figures are relatively small. Table 14.12 Observed and adjusted HIV prevalence among women and men by background characteristics Percentage HIV positive among women and mean age 15-49 who were tested for HIV, by observed and adjusted prevalence and background characteristics, Ethiopia 2005 Women Men Total Background characteristic Observed Adjusted Observed Adjusted Observed Adjusted Age 15-19 0.7 0.7 0.1 0.1 0.4 0.4 20-24 1.7 1.9 0.4 0.4 1.1 1.2 25-29 2.1 2.4 0.7 0.8 1.6 1.7 30-34 1.5 1.6 1.9 2.2 1.7 1.8 35-39 4.4 5.1 1.8 2.2 3.2 3.7 40-44 3.1 3.1 2.8 2.9 3.0 3.0 45-49 0.8 1.1 0.0 0.0 0.5 0.6 Residence Urban 7.7 7.9 2.4 2.6 5.5 5.6 Rural 0.7 0.7 0.7 0.7 0.7 0.7 Region Tigray 2.6 2.9 1.6 1.6 2.1 2.4 Afar/Somali 1.8 2.0 0.6 0.6 1.3 1.3 Amhara 1.8 2.0 1.6 1.7 1.7 1.8 Oromiya 2.2 2.4 0.4 0.4 1.4 1.5 SNNP 0.1 0.1 0.4 0.4 0.2 0.2 Gambela/ Benishangul-Gumuz 2.1 2.4 1.8 1.9 1.9 2.1 Harari 4.6 4.5 2.2 2.3 3.5 3.6 Addis Ababa 6.1 6.2 3.0 3.6 4.7 5.0 Dire Dawa 4.4 4.5 1.9 1.9 3.2 3.4 Education No education 1.0 1.1 0.8 0.7 0.9 1.0 Primary 2.5 2.7 0.5 0.5 1.3 1.4 Secondary and higher 5.5 5.9 2.0 2.3 3.4 3.8 Wealth quintile Lowest 0.3 0.3 0.7 0.6 0.5 0.5 Second 1.0 1.0 0.3 0.3 0.7 0.7 Middle 0.4 0.4 0.9 0.8 0.6 0.6 Fourth 0.2 0.2 0.4 0.4 0.3 0.3 Highest 6.1 6.4 2.2 2.3 4.3 4.5 Total 1.9 2.1 0.9 1.0 1.4 1.6 Minimizing nonresponse is a major challenge to all population-based surveys. The main reasons are refusal and absence. The analysis of nonresponse in Ethiopia is consistent with results from other DHS countries with linked HIV data (Kenya, Ghana, Burkina Faso, Tanzania, Cameroon, Malawi, and Lesotho) and indicates that nonresponse does not bias the national HIV estimates from population-based surveys significantly (Mishra et al., 2006a, draft manuscript). The overall effect of nonresponse on the observed national HIV prevalence estimates tends to be small. It is important to recognize that the adjustments only partially address the nonresponse bias. The estimates can only be adjusted to the extent that the sociodemographic and behavioural characteristics included in the analysis are correlated with the risk of HIV infection in each country. Another limitation is that the adjustments for the “not-interviewed, not-tested” respondents (mostly absentees) are based on somewhat limited information although variables strongly associated with HIV infection such as age, residence, education, and wealth are included. Adult and Maternal Mortality | 231 ADULT AND MATERNAL MORTALITY 15 Since the launch of the Safe Motherhood Initiative in 1987, attention to reproductive health has increased worldwide, as has the need for reliable countrywide estimates of maternal deaths. In response to this increased interest, DHS surveys began collecting maternal mortality data through a series of questions designed to obtain a direct measure of maternal mortality. These questions were included in the 2005 EDHS, the second time such information was collected in Ethiopia, the first time was in the 2000 EDHS. In addition to information on maternal mortality, data gathered from the maternal mortality module also allow for the estimation of adult mortality. Maternal mortality estimates need a comprehensive and accurate reporting of maternal deaths. Such estimates can be obtained through vital registration, longitudinal studies of pregnant women, and household surveys. However, there is no vital registration system in Ethiopia, nor has there been any national household survey carried out for the sole purpose of estimating maternal mortality. For these reasons questions on maternal mortality were added to the 2000 EDHS and later to the 2005 EDHS. The estimates presented in this chapter will play a vital role in filling the need for a reliable national estimate of maternal mortality. Nevertheless, it is important for users of this information to understand the inherent problems associated with measuring maternal mortality to avoid misinterpretation of the survey results. Direct estimates of maternal mortality use data on the age of surviving sisters of survey respondents, the age at death of sisters who have died, and the number of years since the death of sisters. Interviewers in the 2005 EDHS were asked to list all the brothers and sisters born to the natural mother of female respondents in chronological order starting with the first. Information was then obtained on the survivorship of each of the siblings, the ages of surviving siblings, the year of death or years since death of deceased siblings, and the age at death of deceased siblings. For each sister who died at age 12 or over, the respondent was asked additional questions to determine whether the death was maternity related; that is, whether the sister was pregnant when she died, and if not, whether the sister died during childbirth, and if not, whether the sister died within two months of the termination of a pregnancy or childbirth. Listing all siblings in chronological order of their birth is believed to result in better reporting of events than would be the case if only information on sisters were sought. Moreover, the information collected also allows direct estimates of adult male and female mortality. 15.1 DATA QUALITY ISSUES A brief discussion of data quality is warranted here. This discussion refers to tables in Appendix C. One measure of the quality of the data collected is the completeness of information on siblings. Overall, the data on siblings are nearly complete, with only 2 percent of siblings missing information on age at death and years since death, with little difference between brothers and sisters (Table C.7). Rather than exclude siblings with missing information from the analysis, the information on the birth order of siblings in conjunction with other information is used to impute the missing data.1 The distribution of year of birth of respondents in relation to their siblings is another crude measure of the quality of data. If there is no bias in reporting, the year of birth of siblings should be 1 The imputation procedure is based on the assumption that the reported birth order of the siblings in the birth history is correct. The first step is to calculate birth dates. For each living sibling with a reported age and for each dead sibling with complete information on both age at death and year of death, the birth date is calculated. For a sibling missing these data, a birth date is imputed within the range defined by the birth dates of the bracketing siblings. In the case of living siblings, an age is calculated from the imputed birth date. In the case of dead siblings, if either age at death or year of death is reported, that information is combined with the birth date to produce missing information. If both pieces of information are missing, the age at death is imputed. This imputation is based on the distribution of the ages at death for those whose year of death is unreported, but age at death is reported. 232 | Adult and Maternal Mortality roughly equivalent to the year of birth of respondents overall. The distribution of respondents and their siblings by year of birth is close, with the median year of birth of respondents identical to that of siblings (1971 for both), indicating that there is no serious underreporting of siblings (Table C.8). Yet another crude measure of data quality is the mean number of siblings, or the mean sibship size (Table C.9). Sibship size is expected to decline as fertility declines over time. The absence of a monotonic decline in sibship size, even though fertility has declined in Ethiopia, is an indication that there may be some omission in the reporting of older siblings. However, since adult mortality rates are reported here for the seven years preceding the survey, this omission is unlikely to affect the calculation of mortality rates. Moreover, if the omission occurred mostly among sisters who did not survive to adulthood (which is most likely the case), it may not even bias the estimation of maternal mortality. This is also confirmed by the sex ratios that are larger than the internationally accepted sex ratio of 103-105, indicating that either sisters are underreported or brothers are overreported. Nevertheless, it should be borne in mind that any information that relies on recall of events will suffer from some degree of misreporting, especially if it pertains to deceased persons and occurred a long time before the survey. 15.2 ADULT MORTALITY It is advisable to begin by estimating overall adult mortality. If the overall mortality estimates display a general, stable, and plausible pattern, it lends credence to the maternal mortality estimates derived thereafter. This is simply because maternal mortality is a subset of adult mortality. Direct estimates of male and female adult mortality are obtained from information collected in the sibling history. Age-specific death rates are computed by dividing the number of deaths in each age group by the total person-months of exposure in that age group during a specified reference period. In total, female respondents to the Ethiopia DHS survey reported 80,530 siblings, of whom 38,392 were sisters and 42,138 were brothers (Table C.7). Direct estimates of age-specific mortality rates for females and males are shown in Table 15.1. To minimize the impact of possible heaping on years since death ending in zero and five, direct estimates are presented for the period 0-6 years before the survey, which roughly corresponds to 1998-2004. Although the number of sibling deaths is relatively high, because of the large sampling variability, it is preferable to aggregate the data over the age range 15-49. There are more female than male deaths in the seven years preceding the survey (925 compared with 903). The female mortality rate is 6.4 deaths per 1,000 population and is 8 percent higher than the male mortality rate of 5.9 deaths per 1,000 population. The trend in adult mortality can be gauged by comparing similarly collected data from the 2000 EDHS with data from the 2005 EDHS. The data show that adult mortality has declined over the past five years with the decline in male mortality much more significant than the decline in female mortality. Male mortality declined by 26 percent while female mortality declined by just 4 percent over the past five years. 15.3 MATERNAL MORTALITY Information on maternal mortality for the period 0-6 years before the survey is shown in Table 15.2. As previously mentioned, this period was chosen to reduce any possible heaping of reported Table 15.1 Adult mortality rates Direct estimates of female and male mortality for the period 0-6 years prior to the survey, Ethiopia 2005 Age Deaths Exposure years Mortality rates1 FEMALE 15-19 125 32,168 3.89 20-24 172 32,171 5.33 25-29 183 28,305 6.46 30-34 184 22,881 8.03 35-39 132 16,170 8.15 40-44 73 9,742 7.54 45-49 57 5,997 9.52 15-49 925 147,433 6.39a MALE 15-19 135 33,999 3.96 20-24 164 35,574 4.61 25-29 170 30,503 5.58 30-34 167 23,459 7.10 35-39 116 16,852 6.90 40-44 84 10,527 8.01 45-49 67 6,699 10.07 15-49 903 157,613 5.94a 1 Expressed per 1,000 population a Age-adjusted rate Adult and Maternal Mortality | 233 years since death on five-year intervals. Age-specific mortality rates are calculated by dividing the number of maternal deaths by years of exposure. To remove the effect of truncation bias (the upper boundary for eligibility in the Ethiopia DHS survey is 49 years), the overall rate for women age 15-49 is standardized by the age distribution of the survey respondents. Maternal deaths are defined as any death that occurred during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy.2 Maternal mortality in Ethiopia is high relative to developed countries. However, for each age group, maternal deaths are a relatively rare occurrence. As such, the age-specific pattern should be interpreted with caution. There were 197 maternal deaths in the seven years preceding the survey. The maternal mortality rate, which is the annual number of maternal deaths per 1,000 women age 15-49, for the period 1994-2000 is 1.34. Maternal deaths accounted for 21 percent of all deaths to women age 15-49; in other words, more than one in five Ethiopian women who died in the seven years preceding the survey died from pregnancy or pregnancy-related causes. The maternal mortality ratio, which is obtained by dividing the age-standardized maternal mortality rate by the age-standardized general fertility rate, is often considered a more useful measure of maternal mortality since it measures the obstetric risk associated with each live birth. Table 15.2 shows that the maternal mortality ratio for Ethiopia for the period 1998-2004 is 673 deaths per 100,000 live births (or alternatively 7 deaths per 1,000 live births). Similarly collected data from the 2000 EDHS show the maternal mortality ratio for Ethiopia for the period 1994-2000 to be 871 deaths per 100,000 live births or 9 deaths per 1,000 live births. Although it appears that maternal mortality may be declining in Ethiopia, the rates are both subject to a high degree of sampling error. Because 95 percent confidence intervals around the two estimates overlap, it is not possible to conclude that there has been a decline.3 Table 15.2 Direct estimates of maternal mortality Direct estimates of maternal mortality for the period 0-6 years prior to the survey, Ethiopia 2000 Age Maternal deaths Exposure years Mortality rates1 Proportion of maternal deaths to female deaths 15-19 15 32,168 0.470 12.1 20-24 44 32,171 1.353 25.4 25-29 53 28,305 1.870 29.0 30-34 45 22,881 1.960 24.4 35-39 35 16,170 2.170 26.6 40-44 4 9,742 0.433 5.7 45-49 1 5,997 0.202 2.1 Total 197 147,433 1.336a 21.3 General fertility rate (GFR) 0.193a Maternal mortality ratio (MMR)2 673 1 Expressed per 1,000 woman-years of exposure 2 Expressed per 100,000 live births; calculated as the maternal mortality rate divided by the general fertility rate a Age-adjusted rate 2 This time-specific definition includes all deaths that occurred during the specified period even if the death is due to nonpregnancy-related causes. However, this definition is unlikely to result in overreporting of maternal deaths because most deaths to women in the specified period are due to maternal causes, and maternal deaths in general are more likely to be underreported than overreported. 3 The maternal mortality ratio obtained from the 2000 EDHS is 871 deaths per 100,000 live births. The true ratio of the 95 percent confidence intervals ranges between 703 and 1,039. The true MMR for 2005 ranges from 548 and 799.   Women’s Empowerment and Demographic and Health Outcome | 235 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOME 16 Earlier discussions in this report have shown that Ethiopian women are less educated than men and have a lower level of literacy and exposure to mass media than their male counterparts. In addition, the EDHS data have shown that women are predominantly engaged in agricultural occupations, have little manual skills, and are less likely than men to be engaged in the professional, technical and managerial fields. Educational attainment, literacy, exposure to mass media, and employment are critical contributors to women’s empowerment and exert considerable influence on the development of their personality and on solidifying their position in the household and in society in general. In this chapter we explore women’s empowerment in terms of type of earnings, women’s control over cash earnings, and the magnitude of their earnings relative to their partner’s. In addition, specific questions were posed to determine women’s role in household decisionmaking, on acceptance of wife beating, and on opinions about when a wife should be able to refuse sex with her husband. These questions are used to define three different indicators of women’s empowerment, namely women’s participation in decisionmaking, the degree of acceptance of wife beating, and the degree of acceptance of a wife’s right to refuse sex with her husband. The extent to which women’s empowerment influences maternal and child health and contraceptive decisionmaking is also examined. Finally, this chapter discusses the proportion of women who have ever been widowed and dispossessed of property belonging to their late husband. Additional insight into women’s empowerment in Ethiopia comes from information collected with a series of questions on harmful traditional practices, namely female genital cutting, the practice of uvulectomy or tonsillectomy, and marriage by abduction. The survey also collected information on the prevalence of obstetric fistula, a condition that may develop following childbirth, and which causes women to be socially ostracized. 16.1 EMPLOYMENT AND FORM OF EARNINGS Table 16.1 shows the percent distribution of currently married women who were employed in the 12 months preceding the survey by type of earnings they received (cash, in-kind, or both). Em- ployment is assumed to go hand in hand with payment for work. Not all women receive earnings for the work they do, and among women those who do receive earnings not all receive earnings in cash. Table 16.1 Employment and cash earnings of currently married women Percentage of currently married women who were employed at any time in the last 12 months and the percent distribution of currently married women employed in the past 12 months by type of earnings, according to age, Ethiopia 2005 Currently married women Percent distribution of currently married women employed in past 12 months by type of earnings Age Percentage employed Number of women Cash only Cash and in- kind In-kind only Not paid Missing/ don't know Total Number of women 15-19 24.0 711 12.9 5.0 16.6 65.5 0.0 100.0 171 20-24 29.8 1,574 24.6 4.0 9.6 61.3 0.6 100.0 468 25-29 31.9 2,066 30.5 2.6 7.4 59.4 0.1 100.0 659 30-34 31.8 1,551 32.2 2.4 8.9 56.1 0.4 100.0 493 35-39 31.9 1,343 25.2 3.0 11.9 59.8 0.0 100.0 428 40-44 36.3 960 25.3 3.6 12.6 57.8 0.7 100.0 348 45-49 33.2 862 22.4 4.7 11.6 61.2 0.0 100.0 286 Total 31.5 9,066 26.5 3.4 10.3 59.5 0.3 100.0 2,854 236 | Women’s Empowerment and Demographic and Health Outcome Thirty-two percent of currently married women reported being employed. Slightly more than one-fourth (27 percent) of employed women receive payment in cash only and 3 percent receive both cash and payment in-kind. Ten percent receive payment in-kind alone. Three in five employed women do not receive any form of payment for their work. The percentage of currently married women who were employed increases with age up to age 44 and then declines slightly for the oldest age group. 16.2 CONTROL OVER AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS As a means of assessing women’s autonomy, currently married women who earned cash for their work in the 12 months preceding the survey were asked who the main decisionmaker is with regard to the use of their earnings. This information allows the assessment of women’s control over their own earnings. It is expected that employment and earnings are more likely to empower women if women themselves control their own earnings and perceive them as significant relative to those of their husband or partner. Women who earned cash for their work were asked the relative magnitude of their earnings compared with those of their husband or partner. Table 16.2 shows the degree of control women have over the use of their earnings, and their perception of the magnitude of their earnings relative to those of their husband or partner by background characteristics. Almost two-fifths of currently married women who receive cash earnings report that they alone decide how their earnings are used, while more than half of currently married women say that they decide jointly with their husband or partner. Only 5 percent of women report that their husband or partner alone decides how their earnings will be used. The proportion of currently married women who say that they decide by themselves how their earnings are used declined from 62 percent in 2000 to 39 percent in 2005. On the other hand, the percentage of currently married women who say that they jointly decide with their husband or partner, increased from 32 percent to 51 percent over the same period. Younger women age 15-19 and older women age 45-49 are somewhat more likely to make independent decisions on their earnings than women in the middle age groups. Women with five or more children are more likely to decide on their own how to use their earnings than women with fewer children or no children at all. Sixty percent of currently married women with one or two children make joint decisions with their husbands or partners. Rural women are more independent in making their own decisions than urban women (41 and 35 percent, respectively). On the other hand, urban women are more likely than rural women to report that they make decisions about how the money they earn will be used jointly with their husband or partner. There are regional variations in the way decisions are made on how women’s earnings are used. The percentage of women who make independent decisions on their earnings ranges from 64 percent in the Somali Region to about 19 percent in Affar and Benishangul-Gumuz. Among the regions, women in Amhara (69 percent) are most likely to decide jointly with their husband or partner on how to spend the money they earn. More than two-thirds of women with a secondary or higher education say that they decide jointly with their husband or partner. Surprisingly, women with no education are more likely than those who have at least secondary education to decide on their own how to use the money they earn. Women’s Empowerment and Demographic and Health Outcome | 237 Table 16.2 Control over women's earnings and relative magnitude of women's earnings Percent distribution of currently married women who received cash earnings for employment in the 12 months preceding the survey by person who decides how earnings are to be used and by whether she earned more or less than her husband/partner, according to background characteristics, Ethiopia 2005 Person who decides how woman's earnings are used Woman's earnings compared with husband/partner's earnings Background characteristic Respond- ent only Respond- ent and husband/ partner jointly Husband/ partner only Other Missing Total More Less Same Husband/ partner has no earnings Don't know/ missing Total Number of women Age 15-19 46.9 32.5 11.9 0.2 8.5 100.0 9.5 58.4 19.5 1.4 11.2 100.0 31 20-24 40.3 51.3 5.4 0.0 3.1 100.0 7.8 69.5 14.7 4.3 3.7 100.0 134 25-29 27.7 60.3 6.2 0.0 5.8 100.0 14.5 68.0 9.8 0.9 6.8 100.0 218 30-34 37.7 52.3 4.2 0.0 5.9 100.0 11.4 69.3 10.7 2.4 6.2 100.0 171 35-39 37.2 53.0 4.7 0.0 5.1 100.0 15.2 51.4 20.2 7.3 5.8 100.0 121 40-44 50.8 41.4 2.4 0.0 5.5 100.0 17.4 57.4 13.1 6.0 6.1 100.0 101 45-49 55.7 39.4 4.9 0.0 0.0 100.0 12.9 63.5 16.0 7.1 0.5 100.0 78 Number of living children 0 43.1 46.1 7.0 0.0 3.8 100.0 6.2 66.3 20.7 0.4 6.4 100.0 88 1-2 30.7 60.2 3.7 0.0 5.4 100.0 12.6 62.6 15.3 3.3 6.1 100.0 282 3-4 35.7 50.7 7.3 0.0 6.3 100.0 12.8 68.2 8.0 4.3 6.7 100.0 265 5+ 52.0 41.9 3.4 0.0 2.7 100.0 16.3 60.4 15.0 5.3 3.1 100.0 217 Residence Urban 35.1 57.8 1.6 0.0 5.4 100.0 15.8 64.4 8.8 4.8 6.2 100.0 326 Rural 41.3 47.0 7.2 0.0 4.4 100.0 11.2 64.0 16.5 3.2 5.1 100.0 528 Region Tigray 26.5 47.6 5.0 0.0 20.9 100.0 2.4 38.8 33.9 1.8 23.0 100.0 94 Affar (19.2) (31.8) (42.0) (0.0) (7.0) 100.0 (8.6) (50.9) (33.5) (0.0) (7.0) 100.0 5 Amhara 23.6 68.5 2.8 0.0 5.0 100.0 11.4 61.3 19.0 1.9 6.4 100.0 141 Oromiya 43.6 50.8 3.9 0.0 1.7 100.0 13.7 69.0 7.9 7.8 1.7 100.0 237 Somali 63.5 30.7 3.0 0.0 2.9 100.0 19.4 62.7 6.3 8.7 2.9 100.0 24 Benishangul-Gumuz 19.5 47.0 27.1 0.0 6.4 100.0 3.9 75.5 19.1 1.6 0.0 100.0 9 SNNP 47.9 42.2 6.8 0.0 3.2 100.0 14.3 70.0 9.0 2.6 4.1 100.0 229 Gambela 31.2 47.3 19.1 0.0 2.3 100.0 10.3 61.7 22.3 2.5 3.2 100.0 5 Harari 54.1 39.3 5.3 0.7 0.5 100.0 27.6 62.2 5.4 1.7 3.1 100.0 8 Addis Ababa 35.7 60.6 2.5 0.0 1.2 100.0 17.9 68.4 10.5 1.6 1.6 100.0 90 Dire Dawa 47.9 40.4 9.8 0.0 1.9 100.0 23.4 59.0 15.0 0.8 1.9 100.0 10 Education No education 45.9 44.3 5.0 0.0 4.9 100.0 11.2 63.3 15.3 4.5 5.7 100.0 461 Primary 37.0 46.5 11.4 0.0 5.1 100.0 18.0 64.9 8.6 2.5 6.1 100.0 165 Secondary and higher 26.5 68.3 0.7 0.0 4.5 100.0 12.8 65.4 13.5 3.5 4.8 100.0 228 Wealth quintile Lowest 46.5 37.9 8.4 0.0 7.2 100.0 11.0 62.0 14.0 3.7 9.4 100.0 96 Second 35.3 51.7 10.1 0.0 2.9 100.0 10.6 68.1 15.8 2.5 2.9 100.0 124 Middle 52.0 38.7 6.6 0.0 2.7 100.0 13.1 60.7 14.2 7.5 4.4 100.0 118 Fourth 39.4 47.5 4.8 0.0 8.3 100.0 5.5 67.9 16.9 1.8 7.8 100.0 122 Highest 34.3 59.0 2.3 0.0 4.4 100.0 16.4 63.3 11.4 3.8 5.1 100.0 393 Total 39.0 51.1 5.1 0.0 4.8 100.0 12.9 64.1 13.5 3.8 5.6 100.0 853 Note: Figures in parentheses are based on 25-49 unweighted cases. Regarding relative magnitude of their earnings compared with those of their husband or partner, 64 percent of women believe that they earn less than their husband or partner, 14 percent believe that they earn as much as their husband or partner and 13 percent believe that they earn more. Women age 40-44, women with primary education, women with five or more children, women in the highest wealth quintile, urban women, and women who live in Harari are more likely than their counterparts to believe that they earn more than their husband or partner. Three-fourths of women in Benishangul-Gumuz believe that they earn less than their husband or partner. Table 16.2 shows that 4 percent of women reported that their husband or partner did not bring in any money, and almost 6 percent of women did not know if their husband or partner earned more or less than they did. 238 | Women’s Empowerment and Demographic and Health Outcome A cross tabulation by the person in the household who decides how women’s cash earnings are used and how their husband or partner’s cash earnings are used, by the women’s earnings relative to her husband or partner, may provide some insight into women’s empowerment in the family and the extent of their control over decisionmaking in the household. Table 16.3 shows that currently married women who believe they earn more than their husband are much more likely to decide how their husband or partner’s earnings are used (21 percent). Women who believe that they earn the same amount as their husband are most likely to make joint decisions with their husband or partner on how their earnings and their partner’s earnings are used (about 84 percent). Husbands or partners are much more likely to make sole decisions on the use of their earnings in the case of women who believe that they earn less than their partner (26 percent), women who have no cash earnings of their own (27 percent), and women who did not work in the past 12 months (41 percent). Table 16.3 Women's control over her own earnings and over those of her husband/partner 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/partner's earnings are used, according to the relation between women's and husband's earnings in last 12 months, if any Ethiopia 2005 Person who decides how women's earnings are used Person who decides how husband/partner's earnings are used Women's earnings relative to husband/ partner's earnings Respond -dent only Respond- ent and husband/ partner jointly Husband/ partner only Other Missing Total Respond- ent only Respond- ent and husband/ partner jointly Husband/ partner only Other Missing Total Number of women More than husband/partner 48.1 46.0 5.8 0.0 0.0 100.0 20.5 61.1 13.1 0.1 5.2 100.0 110 Less than husband/partner 43.3 50.8 5.8 0.0 0.1 100.0 9.6 64.4 25.8 0.0 0.2 100.0 547 Same as husband/partner 11.1 84.6 4.3 0.0 0.0 100.0 6.8 84.0 9.1 0.0 0.0 100.0 115 Husband/partner has no cash earnings/did not work (76.4) (23.5) (0.0) (0.1) (0.0) 100.0 na na na na na na 33 Woman has no cash earnings na na na na na na 5.7 66.7 26.5 0.4 0.6 100.0 1,993 Woman did not work in past 12 months na na na na na na 6.9 51.1 41.2 0.3 0.5 100.0 6,212 Note: Figures in parentheses are based on 25-49 unweighted cases. Excludes cases where women or her husband/partner have no earnings and includes cases where women do not know whether they earned more or less than their husband/partner. na = Not applicable 16.3 WOMAN’S PARTICIPATION IN DECISIONMAKING Decisionmaking can be a complex process and the ability of women to make decisions that affect the circumstances of their own lives is essential for their empowerment. In order to assess women’s decisionmaking autonomy, the 2005 EDHS sought information on women’s participation in four types of household decisions: respondent’s own health care, making large household purchases; making household purchases for daily needs; and visits to family or relatives. Table 16.4 shows the percent distribution of currently married women according to the person in the household who usually makes decisions concerning these matters. Women are considered to participate in decisionmaking if they make decisions alone or jointly with their husband or someone else. Women’s Empowerment and Demographic and Health Outcome | 239 The strength of the role of women in decisionmaking varies with the type of decision. Almost 53 percent of currently married women reported that they alone made the final decision about daily household purchases. Although 15 percent of currently married woman make sole decisions on their own health care, one-third say that their husband makes such decisions without consulting them. Decisions on large household purchases are most likely to be made by the husband or partner alone (42 percent) or jointly with the wife or partner (45 percent). More than two-thirds of women say that decisions to visit family or relatives are made jointly with their husband or partner. Table 16.4 Women's participation in decisionmaking Percent distribution of currently married women by person who usually makes decisions on four specific issues in the household, Ethiopia 2005 Decision Respondent only Respondent and husband/ partner jointly Husband/ partner only Someone else Other Missing Total Own health care 14.6 51.2 33.3 0.6 0.1 0.2 100.0 Large household purchases 12.4 44.7 41.9 0.6 0.2 0.2 100.0 Daily household purchases 52.8 30.1 16.0 0.7 0.2 0.2 100.0 Visits to family or relatives 10.4 68.0 20.8 0.4 0.2 0.2 100.0 Table 16.5 shows the percentage of women who report that they alone or jointly have the final say in specific household decisions, according to background characteristics. The results indicate that 44 percent of currently married women participate in all of the four specified decisions. Only 8 percent of women report that they do not participate in any of the decisions. The majority of currently married women participate in making decisions on daily purchases (83 percent) and visits to family or relatives (78 percent), but less so in making decisions about large purchases (57 percent) and on their own health (66 percent). Older women are more likely than younger women to have a say in all the specified decisions as are women who have at least a secondary education compared with women with lower levels of education. Participation in decisionmaking is also higher among women who are in the highest wealth quintile, urban women, and women who reside in Addis Ababa, compared with their counterparts. Participation in decisionmaking is lower among women who reside in the Somali and Gambela regions. Employed women, especially those employed for cash, are much more likely to have a say in all the specified decisions than women who are not employed. Women may have a say in some but not other decisions. To assess a woman’s overall decisionmaking autonomy, the decisions in which she participates—that is, in which she alone has the final say or does so jointly with her husband or partner—are added together. The total number of decisions in which a woman participates is one simple measure of her empowerment. The number of decisions in which a woman jointly with her husband or partner has the final say is positively related to women’s empowerment and reflects the degree of decisionmaking control women are able to exercise in areas that affect their lives and environments. Figure 16.1 shows the distribution of cur- rently married women according to the number of decisions in which they participate. Forty-four percent of currently married women participate in all four household decisions, 22 percent participate in three decisions and 18 percent participate in two decisions. Less than 10 percent of women participate in one decision or no decision at all. 240 | Women’s Empowerment and Demographic and Health Outcome Table 16.5 Women's participation in decisionmaking by background characteristics Percentage of currently married women who usually make decisions on four specific issues in the household either by themselves or jointly with their husband/partner, by background characteristics, Ethiopia 2005 Background characteristic Own health care Making large purchases Making daily purchases Visits to family or relatives All specified decisions None of the specified decisions Number of women Age 15-19 63.6 52.7 78.1 72.8 40.3 12.5 711 20-24 62.5 54.1 80.7 75.8 40.0 9.4 1,574 25-29 65.0 57.0 83.5 77.8 42.7 8.0 2,066 30-34 64.1 55.6 83.0 78.7 42.4 8.4 1,551 35-39 67.9 57.0 82.3 79.0 43.9 8.6 1,343 40-44 67.0 62.8 85.3 80.5 47.6 6.3 960 45-49 74.1 63.2 88.0 85.3 51.6 4.8 862 Number of living children 0 66.0 56.4 76.2 70.0 40.5 12.9 801 1-2 66.3 57.0 83.0 79.0 44.2 7.9 2,628 3-4 65.7 57.0 83.5 79.0 44.4 8.7 2,631 5+ 65.4 57.5 84.1 79.6 43.0 7.0 3,007 Residence Urban 83.5 74.0 91.6 91.6 64.8 3.5 959 Rural 63.7 55.1 81.9 76.8 41.0 8.8 8,107 Region Tigray 65.4 65.1 80.7 89.4 53.8 7.6 570 Affar 67.2 57.0 67.3 74.9 41.0 13.7 109 Amhara 77.4 65.9 84.9 85.4 55.8 7.7 2,330 Oromiya 62.3 56.5 82.8 77.5 41.7 8.4 3,300 Somali 54.0 41.7 72.6 52.5 25.1 20.2 363 Benishangul-Gumuz 57.1 49.9 67.6 68.2 37.8 19.1 92 SNNP 57.9 45.0 83.4 72.1 28.6 6.7 1,988 Gambela 56.1 42.1 71.2 71.8 27.5 11.6 31 Harari 75.0 71.1 95.3 82.9 56.8 1.9 22 Addis Ababa 90.5 86.8 95.4 94.9 81.3 2.2 224 Dire Dawa 72.1 79.0 93.3 79.5 59.1 5.0 37 Education No education 63.9 54.9 82.0 77.5 41.1 8.7 7,094 Primary 65.8 58.4 83.5 77.0 43.7 8.3 1,402 Secondary and higher 89.3 82.1 92.8 93.0 73.7 2.8 570 Employment Not employed 62.6 54.0 80.4 75.9 39.4 9.7 6,821 Employed for cash 83.9 71.3 92.0 88.6 60.9 2.7 680 Employed not for cash 71.8 64.3 89.9 84.9 53.8 4.5 1,562 Missing 96.3 100.0 100.0 96.3 96.3 0.0 3 Wealth quintile Lowest 59.6 47.5 76.9 72.8 35.2 13.1 1,759 Second 61.3 53.9 82.2 76.1 38.9 8.6 1,892 Middle 62.5 56.9 82.5 77.8 41.1 8.4 1,903 Fourth 68.5 60.5 85.6 79.7 45.6 6.0 1,823 Highest 78.2 67.3 87.6 86.1 58.0 5.2 1,689 Total 65.8 57.1 82.9 78.4 43.5 8.3 9,066 Women’s Empowerment and Demographic and Health Outcome | 241 16.4 ATTITUDE TOWARDS REFUSING SEX WITH HUSBAND The extent of control women have over when and with whom they have sex has important implications for demographic and health outcomes such as transmission of HIV and other sexually transmitted infections. It is also an indicator of women’s empowerment because it measures women’s level of acceptance of norms in certain societies that socialize them to believe that women do not have the right to refuse sexual intercourse with their husband for any reason. The number of reasons a wife can refuse to have sexual intercourse with her husband reflects perceptions of sexual roles and women’s rights over their bodies, and relates positively to women’s sense of self-empowerment. To measure beliefs about sexual empowerment of women, the 2005 EDHS included questions on whether the respondent thinks that a wife is justified in refusing to have sexual intercourse with her husband under three circumstances: she knows her husband has a sexually transmitted disease (STD); she knows her husband has sexual intercourse with other women; and when she is tired or not in the mood. These three circumstances for which women’s opinions are sought have been chosen because they are effective in combining issues of women’s rights and consequences for women’s health. Tables 16.6.1 and 16.6.2 show the responses of all women and all men, respectively. Overall, the majority of women agree with each specified reason for refusing to have sex. Slightly more than three-fifths (62 percent) of women and 72 percent of men agree that all of the above reasons are justification for a woman to refuse to have sexual relations with her husband. Only one in ten women and men agree with none of the reasons. The most accepted reasons for refusing to have sex, among women and men, are if the wife knows her husband has a sexually transmitted disease and if the wife knows her husband has sex with other women. For both women and men, the least acceptable reason for a wife to refuse sex is being tired or not in the mood. Women in the middle age groups, those with no education, unemployed women, women who have married, those who have five children or more, and poorer women are the least likely to agree with all of the reasons for refusing sex. Among men, those age 15-19, those who have primary education, those who are employed but not for cash, those who have never married, and those who have no children are the least likely to agree with all of the reasons for refusing sex. 8 8 18 22 44 0 1 2 3 4 Number of household decisions 0 10 20 30 40 50 Percent Figure 16.1 Number of Household Decisions in Which Currently Married Women Participate EDHS 2005 242 | Women’s Empowerment and Demographic and Health Outcome Table 16.6.1 Attitude toward refusing sexual intercourse with husband: women Percentage of women 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Ethiopia 2005 Wife is justified in refusing sexual intercourse with husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has sex with other women Is tired or not in the mood Agrees with all of the specified reasons Agrees with none of the specified reasons Number of women Age 15-19 80.3 82.8 71.1 64.5 11.8 3,266 20-24 84.4 84.9 72.6 66.0 8.5 2,547 25-29 82.3 82.3 68.6 61.1 10.0 2,517 30-34 78.6 80.3 67.1 59.0 11.6 1,808 35-39 80.4 81.0 68.5 60.1 10.7 1,602 40-44 80.1 81.0 67.1 59.8 10.9 1,187 45-49 81.7 79.4 67.8 59.2 9.6 1,143 Marital status Never married 82.0 83.6 72.5 66.9 11.3 3,516 Married or living together 80.5 81.3 68.3 60.2 10.4 9,066 Divorced/separated/ widowed 84.2 83.9 69.8 62.8 8.5 1,488 Number of living children 0 82.4 84.0 72.8 66.8 10.6 4,554 1-2 81.6 82.5 68.6 60.6 9.7 3,226 3-4 80.8 80.7 67.4 60.2 11.5 2,981 5+ 79.8 80.5 67.7 58.9 10.1 3,309 Residence Urban 90.4 92.4 80.4 75.9 4.3 2,499 Rural 79.3 79.9 67.2 59.2 11.8 11,571 Region Tigray 81.9 81.3 71.0 63.4 9.7 919 Affar 60.1 58.0 48.3 37.2 29.1 146 Amhara 86.7 87.9 68.2 62.2 6.9 3,482 Oromiya 82.6 84.1 74.8 67.0 8.9 5,010 Somali 59.4 48.3 48.8 33.9 27.5 486 Benishangul-Gumuz 67.1 65.9 51.1 43.4 22.9 124 SNNP 74.6 76.4 63.6 55.8 15.1 2,995 Gambela 54.7 48.6 35.3 27.5 34.3 44 Harari 85.1 89.9 81.5 76.0 6.8 39 Addis Ababa 94.3 96.4 83.1 79.8 1.9 756 Dire Dawa 85.5 86.9 76.9 73.1 10.0 69 Education No education 77.9 78.2 65.2 56.9 12.8 9,271 Primary 84.6 86.6 75.9 69.3 8.2 3,123 Secondary and higher 94.0 95.4 81.6 77.9 1.9 1,675 Employment Not employed 79.8 80.7 67.8 60.2 11.6 10,085 Employed for cash 87.0 87.9 74.5 68.6 6.4 1,632 Employed not for cash 83.5 84.3 73.6 66.1 8.5 2,339 Missing 88.9 75.7 50.7 50.7 10.7 14 Wealth quintile Lowest 74.2 72.6 60.5 51.8 15.5 2,428 Second 79.3 79.0 65.0 57.9 12.4 2,643 Middle 79.3 81.1 68.9 60.1 11.1 2,732 Fourth 82.4 83.3 69.6 62.0 9.7 2,647 Highest 88.1 90.7 79.3 73.8 5.7 3,621 Total 81.3 82.1 69.5 62.1 10.5 14,070 Women’s Empowerment and Demographic and Health Outcome | 243 Table 16.6.2 Attitude toward refusing sexual intercourse with husband: men Percentage of men age 15-59 believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances by background characteristics, Ethiopia 2005 Wife is justified in refusing sexual intercourse with husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has sex with other women Is tired or not in the mood Agrees with all of the specified reasons Agrees with none of the specified reasons Number of men Age 15-19 81.3 79.5 72.3 67.3 14.6 1,335 20-24 86.4 83.7 77.8 73.3 10.1 1,064 25-29 87.1 81.7 78.3 72.3 10.4 741 30-34 86.7 85.0 80.0 72.9 8.3 754 35-39 85.9 81.9 77.9 71.4 10.5 651 40-44 87.1 87.0 78.1 74.2 7.2 497 45-49 84.8 85.1 83.1 77.2 10.4 422 50-54 85.3 83.3 79.4 73.3 9.7 335 55-59 89.7 85.8 81.3 75.8 7.1 235 Marital status Never married 82.5 80.3 74.0 68.7 13.2 2,419 Married or living together 87.2 84.8 79.5 74.1 9.0 3,424 Divorced/separated/ widowed 87.5 83.3 86.8 76.5 6.3 190 Number of living children 0 83.4 81.3 74.6 69.5 12.5 2,766 1-2 88.5 84.5 81.2 75.0 8.6 993 3-4 86.8 82.7 77.4 72.7 10.4 967 5+ 86.0 85.3 81.1 74.7 8.2 1,307 Residence Urban 92.4 91.2 90.8 85.2 4.0 918 Rural 84.1 81.5 75.2 69.7 11.8 5,115 Region Tigray 94.5 90.3 85.5 81.7 4.1 366 Affar 78.9 77.4 76.0 69.1 15.2 65 Amhara 93.7 92.6 83.8 81.3 4.3 1,521 Oromiya 79.3 75.5 70.7 63.5 15.8 2,222 Somali 85.3 82.5 88.9 77.3 6.9 202 Benishangul-Gumuz 78.8 79.0 76.7 63.8 10.6 54 SNNP 81.8 80.0 74.4 68.7 13.0 1,244 Gambela 64.0 63.2 64.6 52.3 26.4 21 Harari 94.4 96.1 94.2 91.4 2.7 16 Addis Ababa 94.4 93.5 92.9 88.7 2.9 292 Dire Dawa 94.5 92.4 81.7 77.1 2.0 30 Education No education 83.8 81.2 75.1 70.1 11.7 2,589 Primary 83.8 81.9 74.9 69.2 12.0 2,252 Secondary and higher 91.4 88.6 87.9 81.7 5.4 1,192 Employment Not employed 89.2 85.1 81.9 75.5 7.8 867 Employed for cash 82.1 81.5 78.9 73.4 13.0 1,440 Employed not for cash 85.7 83.0 76.0 70.7 10.3 3,723 Missing 98.3 98.3 98.3 98.3 1.7 3 Wealth quintile Lowest 79.3 76.8 71.8 66.0 16.1 1,100 Second 83.6 81.1 73.9 68.4 12.1 1,184 Middle 85.7 82.2 76.0 69.4 9.8 1,081 Fourth 85.5 83.7 77.0 72.2 10.4 1,200 Highest 90.9 88.9 86.5 81.3 6.0 1,469 Total 85.3 82.9 77.5 72.0 10.6 6,033 244 | Women’s Empowerment and Demographic and Health Outcome Differences are also notable by urban-rural residence. More than three-fourths of women and men in urban areas agree with all of the specified reasons for refusing sex and 4 percent agree with none of the specified reasons. There are substantial variations by region. Women and men residing in Gambela are the least likely to agree with all of the reasons for refusing sex (28 percent and 52 percent, respectively). Men in Harari and woman in Addis Ababa are the most likely to believe that a wife is justified in refusing to have sex with her husband for any of the specified reasons. 16.5 ATTITUDES TOWARDS WIFE BEATING The critical problems that women face are many and diverse. One of these, and essentially the most serious, is the issue of violence against women. It can be described as the most serious because it concerns the personal security of women, and right of personal security is fundamental to all other rights. Domestic violence is a common phenomenon in Ethiopia, in both urban and rural families. If violence against women is tolerated and accepted in a society, its eradication is made more difficult. Women who believe that a husband is justified in hitting or beating his wife for any of the five specified reasons may believe themselves to be low in status both absolutely and relative to men. Such a perception could act as a barrier to accessing health care for themselves and their children, affect their attitude towards contraceptive use, and impact their general well being. To assess women’s and men attitudes towards wife beating, women and men were asked whether a husband is justified in hitting or beating his wife in each of the following five situations: if she burns the food; if she argues with him; if she goes out without telling him; if she neglects the children; and if she refuses to have sexual relations with him. A lower score on the “number of reasons wife beating is justified” indicates a woman’s greater sense of entitlement, self-esteem and status, and therefore, has a negative association with women’s empowerment. The results are summarized on Tables 16.7.1 and 16.7.2. A sizeable majority of women (81 percent) believe that a husband is justified in beating his wife for at least one of the specified reasons. This is not unexpected because many traditional customs in Ethiopia as in many other countries teach and expect women to accept, tolerate and even rationalize wife beating. This impedes women’s empowerment and has serious health consequences. A high proportion of respondents agree that wife beating is acceptable, which indicates that respondents generally accept violence as part of the male-family relationship. The most widely accepted reasons for wife-beating are going out without telling the partner and neglecting the children (about 64 percent). Three-fifths of women believe that a husband is justified in beating his wife if she burns the food or argues with him. Forty-four percent of women feel that denying sex is a justifiable reason for a man to beat his wife. Compared with women, men are less likely to report that they find violence against women justifiable (Table 16.7.2) Overall, slightly more than half of Ethiopian men agree with at least one of the reasons for why a man is justified in beating his wife. Men are most likely to justify beating a wife if she goes out without telling him (36 percent) or neglects the children (31 percent). Like women, men are least likely to say that burning food (24 percent) or arguing with him (31 percent) are grounds for wife beating. Only about one-quarter of men feel that denying sex is a justifiable reason for wife beating. The tables also show attitudes towards wife beating by background characteristics. The percentage of women who agree with at least one of the reasons justifying wife beating is higher among older women, married women, and those with five or more children. Women who are employed for cash are less likely to agree with at least one of the reasons for wife beating than those who are either not employed or are employed but not for cash. Differences are also notable by level of education; slightly more than half of women with secondary or higher education agree with at least one specified reason for wife beating, compared with 87 percent of women with no education. Women’s Empowerment and Demographic and Health Outcome | 245 Table 16.7.1 Attitude toward wife beating: women Percentage of women 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Ethiopia 2005 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sex with him Agrees with at least one specified reason Number of women Age 15-19 57.4 55.6 59.9 59.9 36.3 77.3 3,266 20-24 59.3 56.4 61.9 63.5 42.0 78.4 2,547 25-29 61.2 58.8 66.3 66.5 45.4 81.8 2,517 30-34 64.4 61.7 66.0 66.8 49.2 83.9 1,808 35-39 62.7 62.3 68.1 67.3 49.1 83.5 1,602 40-44 62.9 59.8 66.4 66.9 47.0 83.5 1,187 45-49 65.3 61.5 66.0 66.2 52.7 84.9 1,143 Marital status Never married 49.7 48.2 52.0 54.0 31.4 70.0 3,516 Married or living together 65.6 63.0 68.6 68.2 49.4 84.9 9,066 Divorced/separated/ widowed 59.7 57.3 65.7 67.5 43.3 83.4 1,488 Number of living children 0 53.5 51.9 56.6 58.1 34.2 74.0 4,554 1-2 61.9 58.9 65.3 65.8 46.1 82.3 3,226 3-4 65.3 62.6 67.9 68.7 49.2 84.0 2,981 5+ 66.6 64.3 70.2 68.5 51.9 86.6 3,309 Residence Urban 30.8 34.6 41.5 44.2 19.8 59.0 2,499 Rural 67.5 63.9 69.1 69.0 49.6 85.8 11,571 Region Tigray 52.0 52.6 61.0 60.0 28.2 73.7 919 Affar 37.0 53.5 62.2 61.7 42.2 80.4 146 Amhara 68.1 66.5 74.9 75.8 45.1 91.3 3,482 Oromiya 65.1 60.6 65.0 63.0 48.2 80.9 5,010 Somali 53.0 55.9 70.5 70.0 54.8 87.7 486 Benishangul-Gumuz 57.3 56.1 61.4 60.8 47.9 83.9 124 SNNP 64.8 60.2 61.5 64.5 49.8 81.1 2,995 Gambela 53.8 51.6 52.3 55.8 45.3 78.4 44 Harari 31.5 37.9 48.2 57.0 24.0 67.0 39 Addis Ababa 13.4 19.2 24.3 30.4 8.4 41.7 756 Dire Dawa 23.5 32.1 36.1 37.1 22.4 47.5 69 Education No education 67.9 64.3 70.4 69.5 51.0 86.7 9,271 Primary 60.5 59.0 62.2 64.0 40.4 80.1 3,123 Secondary and higher 24.0 27.1 33.5 38.2 14.5 51.0 1,675 Employment Not employed 62.3 59.8 66.0 65.9 46.2 82.7 10,085 Employed for cash 45.1 45.9 52.2 53.4 32.7 68.3 1,632 Employed not for cash 66.7 63.1 64.6 66.4 44.2 82.8 2,339 Missing 52.0 46.0 43.6 57.9 41.4 58.4 14 Wealth quintile Lowest 64.4 60.3 71.0 68.9 51.3 87.0 2,428 Second 70.1 66.2 71.5 69.6 53.0 87.1 2,643 Middle 69.5 67.1 69.0 70.0 50.5 86.1 2,732 Fourth 69.6 64.5 69.5 69.1 46.9 85.2 2,647 Highest 39.5 41.6 46.7 50.5 26.7 65.6 3,621 Total 61.0 58.7 64.2 64.6 44.3 81.0 14,070 Eighty-six percent of rural women agree with at least one of the reasons justifying wife beating, compared with 59 percent among urban woman. There is large variation by region. Nine in ten women in Amhara agree with at least one specified reason for wife beating compared with slightly more than two-fifths of women in Addis Ababa (42 percent). 246 | Women’s Empowerment and Demographic and Health Outcome Men who are married, those who have no education, and those who are employed but do not earn cash are more likely to agree with at least one specified reason for wife beating. Acceptance of wife beating declines as the level of education increases. For all reasons, poorer women and men are more likely than their wealthier counterparts to believe that wife beating is justified. Acceptance of wife beating for at least one of the specified reasons is generally lower among urban men than rural men (28 percent and 56 percent, respectively). Similar to women, men’s beliefs vary greatly by region. Men in Benishangul-Gumuz and Affar are the most likely to agree that wife beating is justified for at least one specified reason. Table 16.7.2 Attitude toward wife beating: men Percentage of men age 15-59 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Ethiopia 2005 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sex with him Agrees with at least one specified reason Number of men Age 15-19 27.5 32.4 36.6 32.6 26.6 53.3 1,335 20-24 24.3 29.9 36.5 29.9 23.2 50.6 1,064 25-29 23.0 29.3 36.3 29.4 21.6 50.0 741 30-34 22.6 31.2 35.2 30.8 20.9 50.9 754 35-39 21.2 26.4 32.7 26.6 21.5 48.9 651 40-44 24.6 32.0 37.9 35.6 26.3 53.2 497 45-49 22.6 27.8 36.2 27.4 20.7 50.2 422 50-54 21.7 32.0 37.1 36.0 19.7 53.0 335 55-59 24.7 34.9 39.7 34.4 27.5 55.6 235 Marital status Never married 24.0 28.9 34.4 28.2 23.7 49.5 2,419 Married or living together 24.1 31.4 37.4 32.5 23.2 53.1 3,424 Divorced/separated/ widowed 25.2 33.2 37.6 39.6 20.9 48.7 190 Number of living children 0 24.1 30.0 35.5 29.5 24.3 50.7 2,766 1-2 23.3 29.5 32.5 30.4 20.2 47.5 993 3-4 24.6 30.7 37.6 33.1 23.3 52.2 967 5+ 24.2 32.2 39.5 33.1 23.9 55.5 1,307 Residence Urban 7.8 11.8 17.5 13.0 8.8 27.8 918 Rural 27.0 33.8 39.5 34.2 26.0 55.7 5,115 Region Tigray 15.1 23.9 20.9 23.0 14.2 35.4 366 Affar 36.1 45.4 51.5 47.0 44.9 61.4 65 Amhara 22.9 27.8 36.4 32.4 19.0 52.9 1,521 Oromiya 27.9 36.3 42.0 29.0 27.1 56.0 2,222 Somali 7.9 18.0 22.0 36.1 18.0 38.0 202 Benishangul-Gumuz 32.1 37.9 40.5 43.3 22.6 62.0 54 SNNP 28.5 32.7 38.1 38.6 29.1 56.5 1,244 Gambela 22.0 27.1 37.1 26.0 23.2 54.4 21 Harari 11.3 24.5 25.3 16.0 24.0 38.8 16 Addis Ababa 2.5 4.7 8.6 8.9 3.7 15.2 292 Dire Dawa 9.8 19.1 28.3 28.1 14.9 41.0 30 Education No education 28.3 36.2 41.3 37.4 27.5 58.3 2,589 Primary 26.8 32.9 39.9 32.5 25.9 55.0 2,252 Secondary and higher 9.6 13.5 18.1 14.3 9.6 29.9 1,192 Employment Not employed 19.1 23.0 29.4 22.5 19.0 41.4 867 Employed for cash 19.4 24.0 30.3 27.6 17.4 43.6 1,440 Employed not for cash 26.9 34.7 40.1 34.3 26.7 56.8 3,723 Missing 93.8 89.9 55.0 91.9 4.8 95.8 3 Wealth quintile Lowest 27.1 37.4 39.9 38.6 27.7 56.0 1,100 Second 31.9 37.6 44.3 39.6 31.8 61.4 1,184 Middle 27.6 33.3 38.7 33.5 25.2 56.0 1,081 Fourth 23.7 31.1 39.7 29.6 22.9 53.4 1,200 Highest 13.2 16.9 22.2 17.8 12.2 35.3 1,469 Total 24.1 30.5 36.2 31.0 23.3 51.5 6,033 Women’s Empowerment and Demographic and Health Outcome | 247 16.6 CURRENT USE OF CONTRACEPTION BY WOMEN’S STATUS A woman’s desire and ability to control her fertility and her choice of contraceptive method are in part affected by her status in the household and her own sense of empowerment. A woman who feels that she is unable to control her life may be less likely to feel she can make and carry out decisions about her fertility. She may also feel the need to choose methods that are less obvious or which do not depend on her husband’s cooperation. Table16.8 shows the distribution of currently married women by contraceptive method use, according to the three empowerment indicators. The data indicate that there is a positive relationship between women’s status and use of contraception. Contraceptive use is highest among women who participate in most (3-4) household decisions, who agree that a woman can refuse sexual intercourse with her partner for all three specified reasons, and who believe that wife beating is not justified for all of the five specified reasons. This pattern is consistent for both any method and modern methods. For example, current use of modern contraceptive methods rises from 7 percent among women who believe there is no justifiable reason for a woman to refuse sexual intercourse with a husband to 16 percent among women with three reasons for refusing to have sexual intercourse with a husband. Table 16.8 Current use of contraception by women's status Percent distribution of currently married women by contraceptive method currently used, according to women's status indicators, Ethiopia 2005 Modern method Women's status indicators Any method Any modern method Injectables Temporary methods,1 female sterilization and male condom Any tradi- tional method Not currently using Total Number of women Number of decisions in which woman participates 0 8.0 7.5 4.8 2.7 0.5 92.0 100.0 736 1-2 10.0 9.5 6.8 2.6 0.6 90.0 100.0 2,376 3-4 17.4 16.5 11.8 4.7 0.9 82.6 100.0 5,954 Number of reasons given for refusing to have sexual inter- course with husband/partner 0 7.4 7.1 5.2 2.0 0.2 92.6 100.0 946 1-2 13.4 12.6 9.2 3.4 0.8 86.6 100.0 2,663 3 16.6 15.7 11.1 4.7 0.9 83.4 100.0 5,457 Number of reasons given that justify wife beating 0 24.1 22.0 14.9 7.1 2.2 75.9 100.0 1,371 1-2 16.3 15.2 10.2 5.0 1.2 83.7 100.0 1,585 3-4 13.2 12.7 9.3 3.4 0.4 86.8 100.0 3,130 5 11.1 10.8 8.1 2.7 0.4 88.9 100.0 2,980 Total 14.7 13.9 9.9 4.0 0.8 85.3 100.0 9,066 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly and lactational amenorrhoea method. 16.7 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS The ability of women to effectively make decisions has important implications for their fertility preferences and the practice of family planning. An increase in women’s status and empowerment is recognized as important for efforts to reduce fertility through at least two main pathways: its negative association with desired family size and its positive association with women’s ability to meet their own family-size goals through the effective use of contraception. 248 | Women’s Empowerment and Demographic and Health Outcome Table 16.9 shows how women’s ideal family size and their unmet need for family planning vary by women’s status indicators. The data indicate that mean ideal family size decreases with increasing number of decisions in which a woman has a final say and number of reasons to refuse sex with her husband or partner, and increases with the number of reasons women believe wife beating is justified. Thus, the data suggests that the more empowered the woman, the fewer children she desires. Although there is no clear relationship between women’s decisionmaking power and belief that refusing sexual intercourse is acceptable for any reason, unmet need increases with the number of reasons women belief that wife beating is justified, indicating that less empowered women as measured by this indicator are also less able to meet their contraceptive needs. Table 16.9 Ideal number of children and unmet need for family planning by women’s status Mean ideal number of children and the percentage of women with an unmet need for family planning, by women’s status indicators, Ethiopia 2005 Unmet need for family planning2 Women's status indicator Mean ideal number of children1 Number of women For spacing For limiting Total Number of women Number of decisions in which woman participates3 0 5.3 632 23.3 10.9 34.2 736 1-2 5.2 2,045 23.7 13.9 37.6 2,376 3-4 5.0 5,251 18.2 14.1 32.3 5,954 Number of reasons given for refusing to have sexual intercourse with husband/partner 0 5.0 1,263 12.1 7.2 19.2 1,471 1-2 5.0 3,496 14.9 9.0 24.0 3,856 3 4.2 7,843 12.3 9.1 21.4 8,743 Number of reasons given that justify wife beating 0 3.9 2,449 9.3 6.0 15.3 2,673 1-2 4.4 2,368 11.4 8.3 19.7 2,638 3-4 4.7 4,188 13.6 9.4 23.0 4,667 5 4.8 3,597 15.7 10.6 26.3 4,092 Total 4.5 12,602 13.0 8.9 21.9 14,070 1 Excludes respondents who gave non-numeric responses. 2 See Table 7.3 for definition of unmet need for family planning 3 Currently married women 16.8 REPRODUCTIVE HEALTH CARE BY WOMEN’S STATUS Table 16.10 shows women’s use of antenatal, delivery and postnatal care services by the three indicators of women’s empowerment. In societies where health care is widespread, women’s empowerment may not affect their access to reproductive health services; in other societies, however, increased empowerment of women is likely to increase their ability to seek out and use health services to better meet their own reproductive health goals, including the goal of safe motherhood. The data indicate that there is a correlation between women’s status and utilization of health services. The more empowered a woman, the more likely she is to receive antenatal care, postnatal care, and delivery assistance from a health professional. For example, nearly one-third of women who participate in making three or four decisions received antenatal care from health professionals, compared with 18 percent of women who are not involved in any decisionmaking. Almost one in ten women who participate in three or four decisions utilized postnatal and delivery care, compared with 2 percent of women who had no say in any decisionmaking. Women’s Empowerment and Demographic and Health Outcome | 249 Table 16.10 Reproductive health care by women's status Percentage of women with a live birth in the five years preceding the survey who received antenatal care, delivery assistance, and postnatal care from a health worker for the most recent birth, by women’s status indicators, Ethiopia 2005 Women's status indicator Received antenatal care from a health professional Received delivery assistance from a health professional Received postnatal care from a health professional within two days of delivery1 Number of births Number of decisions in which woman participates2 0 18.1 2.2 2.1 552 1-2 22.4 3.6 4.1 1,878 3-4 30.7 8.5 8.9 4,342 Number of reasons given for refusing to have sexual intercourse with husband/partner 0 17.2 3.7 4.1 752 1-2 25.2 4.6 5.8 2,156 3 30.6 8.6 8.8 4,399 Number of reasons given that justify wife beating 0 38.1 17.2 17.9 1,069 1-2 28.8 9.4 9.3 1,263 3-4 25.4 4.3 4.6 2,498 5 24.9 4.0 4.8 2,477 Total 27.6 7.0 7.4 7,307 1 Includes mothers who delivered in a health facility 2 Currently married women The number of reasons for which women feel that a wife is justified in refusing to have sexual intercourse with her husband has a stronger positive relationship with all three variables. For example, the proportion of women who receive antenatal care increases from 17 percent among women who think a wife is not justified in refusing to have sex with her husband for any of the specified reasons to 31 percent among those who said that all three reasons cited were justifiable. A similar relationship is observed between the number of reasons given for refusing sexual intercourse with husband/partner and receiving postnatal and delivery care. The data also show a steady increase in utilization of health services as the number of reasons wife beating is believed to be justified decreases. For example, 17 percent of women who say wife beating is not justified in any of the situations described were attended by medical professionals compared with only 4 percent of women who say that wife beating is justified in all five of the specified circumstances. 16.9 EARLY CHILDHOOD MORTALITY RATES BY WOMEN’S STATUS An outcome of empowerment is women’s ability to access information, make decisions, and act effectively in their own interest or in the interest of those who depend on them. It follows that if women, who are the primary caretakers of children, are empowered, the health and survival of their children will be enhanced. Table 16.11 shows information on the impact of women’s empowerment on infant and child mortality. Surprisingly, the data show that women who have no final say in any decision in the household have lower childhood mortality rates than those who have a say in three or four decisions. 250 | Women’s Empowerment and Demographic and Health Outcome For example, the infant mortality rate for children whose mothers have no final say in any decision is 69 deaths per 1,000 live births, compared with about 79 deaths per 1,000 live births for children of mothers who participate in three or four decisions in the household. With the exception of infant mortality, there is no clear association between a woman’s belief that it is acceptable to refuse sexual intercourse with her husband and childhood mortality. The infant mortality rate of children whose mothers think a wife is justified in refusing to have sexual intercourse with her husband for any of the specified reasons is 75 deaths per 1,000 live births, compared with 84 deaths per 1,000 live births for children of those who say that a woman is justified for all three reasons cited. Table 16.11 Early childhood mortality rates by women's status Infant, child, and under-five mortality rates for the 10-year period preceding the survey, by women's status indicators, Ethiopia 2005 Women's status indicators Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which woman participates1 0 34 35 69 61 126 1-2 39 43 82 53 131 3-4 41 38 79 54 128 Number of reasons given for refusing to have sexual intercourse with husband/partner 0 36 40 75 61 132 1-2 35 39 74 59 129 3 44 40 84 54 133 Number of reasons given that justify wife beating 0 38 37 75 45 116 1-2 41 43 85 58 137 3-4 37 43 80 63 138 5 45 36 81 53 130 1 Currently married women Attitudes towards wife beating are reflections of women’s status. Women who do not approve of any form of wife beating are assumed to enjoy a higher status in the household and in society. In turn, this translates into a more favourable mortality profile for their children. The rates of childhood mortality are generally lower among children whose mothers believe that wife beating is not justified for any reason. For example, the infant mortality rate for children of mothers who consider wife beating unjustified for any reason is 75 deaths per 1,000 live births compared with 81 deaths per 1,000 live births for children whose mothers agree with all of the specified reasons for wife beating. A similar relationship is observed between women’s status and levels of child mortality and under-five mortality. 16.10 PROPERTY DISPOSSESSION Property dispossession can make widowed women and their children especially vulnerable. In many countries, widows are often denied an inheritance either because of common law or religious laws. Also, in many cases, even where such laws provide for the transfer of property to widows and their children, enforcement of inheritance laws may be weak, leaving them at the mercy of relatives. Women’s Empowerment and Demographic and Health Outcome | 251 Table 16.12 shows that 6 percent of women age 15-49 interviewed in the EDHS have been widowed at some time and of these, one in five has been dispossessed of property belonging to their late husband. Dispossession of property is most common among younger women (less than 30 years) who have been widowed than older women. Previously widowed women who are currently married are somewhat more likely to be dispossessed of property as are the small numbers of women who have no children. Women with children under 18 years of age are also somewhat more likely to have property taken away from them than women with children 18 years and older. Table 16.12 Widows dispossessed of property Percentage of de facto women age 15-49 who have been widowed, and the percentage of widowed women who have been dispossessed of property, by selected background characteristics, Ethiopia 2005 Ever-widowed women Background characteristics Percentage of ever- widowed women Number of women Percentage who were dispossessed of property Number of women Age 15-19 0.3 3,266 * 10 20-29 2.6 5,064 34.6 132 30-39 8.8 3,410 20.4 301 40-49 19.5 2,330 14.3 454 Marital status Married 3.4 8,914 34.4 302 Living together 12.0 152 * 18 Divorced/separated 2.2 932 (28.5) 21 Widowed 100.0 556 12.0 556 Age of youngest child No children 0.6 4,357 (42.7) 24 <18 years 8.6 9,535 19.5 820 18 + years 30.0 178 14.2 53 Residence Urban 6.8 2,499 22.6 171 Rural 6.3 11,571 19.1 726 Region Tigray 7.5 919 24.9 69 Affar 6.2 146 (16.2) 9 Amhara 6.6 3,482 13.8 231 Oromiya 6.7 5,010 21.0 336 Somali 5.2 486 (9.0) 25 Benishangul-Gumuz 6.7 124 7.1 8 SNNP 5.5 2,995 25.9 164 Gambela 12.6 44 44.3 6 Harari 4.7 39 (22.4) 2 Addis Ababa 5.3 756 17.3 40 Dire Dawa 8.6 69 15.3 6 Education No education 8.0 9,271 19.0 741 Primary 3.0 3,123 27.7 92 Secondary and higher 3.7 1,481 18.6 54 Wealth quintile Lowest 8.7 2,428 15.7 210 Second 7.5 2,643 19.8 199 Middle 5.0 2,732 17.3 137 Fourth 5.8 2,647 27.2 155 Highest 5.4 3,621 20.1 196 Total 6.4 14,070 19.8 897 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 252 | Women’s Empowerment and Demographic and Health Outcome Urban women are slightly more likely to be dispossessed of property than rural women. Women living in Gambela are most likely to be dispossessed compared with women living in the other regions. Surprisingly, women with primary education are more vulnerable to having property dispossessed than women with no education or women with at least some secondary education. Also, women in the lowest wealth quintile are least likely to be denied their late husband’s property compared with women in the other wealth quintiles. 16.11 HARMFUL TRADITIONAL PRACTICES The 2005 EDHS included a series of questions in the Women’s Questionnaire to gather information on women’s knowledge and attitude about three specific harmful traditional practices and their experience with each of them. All women were first asked if they had ever heard of female circumcision or uvulectomy/tonsillectomy. In addition, ever-married women were asked about the practice of marriage by abduction. If women had heard of any of these practices, they were further asked if they themselves had been subject to any of them. Circumcised women were also asked for the type of circumcision they had had. Women who had children were asked if any of their daughters had been circumcised or married by abduction, and if any of their children had had a uvulectomy. Finally, women were also asked for their opinion about whether the specific harmful traditional practice that they had knowledge of should be continued. 16.11.1 Female Circumcision Female circumcision, also known as female genital cutting (FGC) or female genital mutilation, is a common practice in many societies in sub-Saharan Africa. In Ethiopia, the age at which FGC is performed varies among the different ethnic groups. In Northern Amhara and Tigray, for example, FGC is performed at infancy and usually on the eighth day after birth (NCTPE, 1998). Data collected in the 2005 EDHS show that most women age 15-49 have heard of female circumcision (Table 16.13). With the exception of differences by region, differences by other background characteristics in the percentage of women who have heard of female circumcision are small. Less than one in two women in Gambela have heard of female circumcision (45 percent), compared with nearly all women in Harari, Dire Dawa, Addis Ababa, Affar, Somali and Oromiya and at least 80 percent of women in Amhara, SNNP, Tigray and Benishangul-Gumuz. Table 16.13 shows that three in four Ethiopian women have been circumcised. Six percent of circumcised women reported that their vagina was sewn closed (infibulation) during circumcision, which is the most severe form of FGC. Infibulation is most common among women age 25-39, women with no education, and women in the lowest wealth quintile. Rural women are also more likely than urban women to have experienced infibulation. More than four in five circumcised women residing in the Somali Region and three in five in Affar have experienced the most severe form of FGC. Less than one in three women who have heard of FGC believes that the practice should continue (Table 16.13). Support for female circumcision varies with background characteristics and is similar to that discussed under knowledge of female circumcision. Women’s Empowerment and Demographic and Health Outcome | 253 Table 16.13 Knowledge, prevalence, and support of female circumcision Percentage of women who have heard of female circumcision and who are circumcised, and among circumcised women the percentage who have their vagina sewn closed and among women who have heard of female circumcision the percentage who support the practice, by selected background characteristics, Ethiopia 2005 Among women who have heard of female circumcision Among circumcised women Background characteristic Percentage of women who have heard of female circumcision Percentage of women circumcised Number of women Percentage with vagina sewn closed Number of women Percentage who believe practice should be continued Number of women Age 15-19 90.0 62.1 3,266 4.7 2,029 22.9 2,939 20-24 92.5 73.0 2,547 5.8 1,860 27.2 2,356 25-29 91.9 77.6 2,517 6.8 1,954 34.5 2,314 30-34 91.1 78.0 1,808 7.7 1,410 36.5 1,647 35-39 93.1 81.2 1,602 7.1 1,302 37.7 1,491 40-44 94.3 81.6 1,187 6.1 969 33.7 1,120 45-49 92.1 80.8 1,143 4.7 924 38.0 1,052 Residence Urban 97.8 68.5 2,499 5.1 1,713 10.4 2,445 Rural 90.5 75.5 11,571 6.3 8,735 36.3 10,475 Region Tigray 82.9 29.3 919 1.1 269 21.5 762 Affar 98.4 91.6 146 63.2 134 65.6 144 Amhara 88.9 68.5 3,482 0.6 2,386 39.0 3,095 Oromiya 97.1 87.2 5,010 2.5 4,369 29.8 4,866 Somali 98.1 97.3 486 83.8 473 74.3 477 Benishangul-Gumuz 79.5 67.6 124 3.2 84 40.1 99 SNNP 86.7 71.0 2,995 0.6 2,127 26.0 2,597 Gambela 44.6 27.1 44 1.0 12 21.0 20 Harari 99.8 85.1 39 12.5 33 21.6 39 Addis Ababa 99.5 65.7 756 0.8 497 5.6 753 Dire Dawa 99.8 92.3 69 13.2 64 13.8 69 Education No education 89.8 77.3 9,271 7.9 7,165 40.6 8,328 Primary 93.8 70.8 3,123 1.9 2,211 20.2 2,928 Secondary and higher 99.3 64.0 1,675 3.0 1,072 4.7 1,663 Wealth quintile Lowest 87.9 73.0 2,428 21.1 1,773 48.3 2,135 Second 89.7 75.9 2,643 4.1 2,006 39.2 2,370 Middle 90.4 75.4 2,732 3.1 2,059 34.3 2,469 Fourth 92.2 77.6 2,647 1.8 2,055 30.7 2,441 Highest 96.8 70.6 3,621 3.2 2,556 14.1 3,505 Total 91.8 74.3 14,070 6.1 10,448 31.4 12,920 Women who had at least one daughter were asked if any of their daughters had been circumcised. Thirty-eight percent of women with a daughter reported having at least one of their daughters circumcised (Table 16.14). The probability that a respondent’s daughter is circumcised varies directly with her age, rising from 15 percent among women age 15-19 to 67 percent among women age 45-49, indicating that there may have been a decline in the practice of circumcision in recent years. Rural women are more likely than urban women to have a daughter circumcised. Circumcision of daughters is highest in Affar, where 85 percent of women have a circumcised daughter, and lowest in Gambela where 11 percent of women have a daughter circumcised. Women with no education are more than twice as likely as women with secondary education or higher to have a daughter circumcised. There is no uniform relationship between wealth and having a daughter circumcised. Nevertheless, women in the highest wealth quintile are least likely to have a daughter circumcised. Table 16.14 shows that 4 percent of circumcised daughters have experienced the most severe form of FGC. Infibulation is most prevalent among daughters of women age 30-34, rural women, women residing in Affar and Somali, women with no education, and women in the poorest wealth quintile. 254 | Women’s Empowerment and Demographic and Health Outcome Table 16.14 Daughter's circumcision experience and type of circumcision Among women with at least one living daughter, percentage with at least one circumcised daughter, and percent distribution by type of circumcision among most recently circumcised daughters, according to selected background characteristics, Ethiopia 2005 Mother's background characteristic Percentage of women with at least one daughter circumcised Number of women with at least one daughter Daughters with vagina sewn closed Number of most recently circumcised daughters Age 15-19 14.6 222 (3.5) 32 20-24 14.3 918 4.0 131 25-29 21.2 1,735 3.3 367 30-34 32.0 1,516 6.1 484 35-39 45.4 1,422 4.6 645 40-44 58.9 1,069 4.7 630 45-49 66.6 1,039 2.2 692 Residence Urban 30.0 914 2.9 274 Rural 38.7 7,007 4.2 2,708 Region Tigray 30.2 524 0.5 158 Affar 85.1 82 74.1 69 Amhara 56.8 2,014 0.0 1,144 Oromiya 34.9 2,873 0.9 1,003 Somali 28.1 323 62.3 91 Benishangul-Gumuz 49.3 74 1.1 37 SNNP 23.5 1,733 0.7 406 Gambela 11.0 25 0.0 3 Harari 27.1 17 7.8 5 Addis Ababa 25.1 223 0.0 56 Dire Dawa 34.3 32 6.2 11 Education No education 41.3 6,343 4.5 2,620 Primary 24.7 1,131 0.5 279 Secondary and higher 18.7 446 3.2 83 Wealth quintile Lowest 38.2 1,613 14.7 617 Second 37.2 1,607 2.6 598 Middle 37.7 1,578 0.8 594 Fourth 41.2 1,603 0.7 661 Highest 33.7 1,518 1.4 512 Total 37.7 7,920 4.1 2,982 Note: Figures in parentheses are based on 25-49 unweighted cases. Female circumcision has declined over the past five years from 80 percent in 2000 to 74 percent in 2005. Support for the practice has also declined from 60 percent to 31 percent over the same period. In addition, circumcising daughters has declined. Fifty-two percent of mothers with at least one daughter had a daughter circumcised in 2000 compared with 38 percent in 2005. 16.11.2 Uvulectomy or Tonsillectomy Uvulectomy is commonly practiced in Ethiopia and involves the removal of the uvula with horse tail hair or thread looped through a bamboo stick. Often, a special knife-like, sharpened iron is used to cut the uvula before it is taken out. Tonsillectomy refers to the removal of the tonsils, often using just the index finger, to treat sore throats and swallowing difficulties (Jeppsson et al., 2003). These harmful traditional practices may pose a health hazard particularly if carried out with Women’s Empowerment and Demographic and Health Outcome | 255 unsterilised instruments or in an unhygienic setting. Questions in the EDHS did not distinguish between the two practices and hence the data discussed in this section refers to knowledge of uvulectomy and/or tonsillectomy, the prevalence of both, and attitude towards the continuation of both practices. Table 16.15 shows that a large majority of women (84 percent) have heard of uvulectomy or tonsillectomy. Knowledge of the practice is much higher among women in urban than in rural areas and ranges from a low of 52 percent among women in Gambela to universal knowledge among women in Tigray. Highly educated women and women from the highest wealth quintile are much more likely to have heard of the practice than less educated women and women in the other wealth quintiles. Differences by age are small. Table 16.15 Knowledge, prevalence, and support of uvulectomy or tonsillectomy Percentage of women who have heard of uvulectomy/tonsillectomy, percentage of women who have ever had an uvulectomy/tonsillectomy, and among those who have heard of uvulectomy/tonsillectomy, the percentage who support the practice, by selected background characteristics, Ethiopia 2005 Among women who have heard of uvulectomy/ tonsillectomy Background characteristic Percentage of women who heard of uvulectomy/ tonsillectomy Percentage of women who ever had an uvulectomy/ tonsillectomy Number of women Percentage who believe practice should be continued Number of women Age 15-19 83.5 37.3 3,266 23.0 2,727 20-24 84.5 37.9 2,547 27.1 2,153 25-29 82.4 42.2 2,517 30.6 2,074 30-34 84.2 46.0 1,808 33.6 1,523 35-39 85.4 44.1 1,602 32.2 1,369 40-44 83.6 45.5 1,187 30.9 993 45-49 85.9 48.5 1,143 33.6 981 Residence Urban 95.4 46.2 2,499 13.0 2,385 Rural 81.5 40.8 11,571 33.1 9,434 Region Tigray 99.5 89.2 919 68.3 915 Afar 93.3 76.9 146 69.5 136 Amhara 77.4 42.5 3,482 44.1 2,694 Oromiya 81.6 28.9 5,010 19.8 4,089 Somali 60.9 36.4 486 47.8 296 Benishangul-Gumuz 68.1 29.1 124 34.5 85 SNNP 91.2 46.8 2,995 17.3 2,732 Gambela 51.9 25.2 44 32.7 23 Harari 97.7 58.4 39 19.9 38 Addis Ababa 98.1 42.7 756 7.0 742 Dire Dawa 98.9 69.0 69 13.1 68 Education No education 81.4 43.5 9,271 37.6 7,548 Primary 84.7 36.8 3,123 18.0 2,647 Secondary and higher 96.9 41.4 1,675 7.4 1,624 Wealth quintile Lowest 80.6 47.3 2,428 45.9 1,958 Second 82.2 40.3 2,643 37.2 2,174 Middle 82.1 41.7 2,732 30.4 2,243 Fourth 80.5 37.4 2,647 26.6 2,130 Highest 91.5 42.5 3,621 14.4 3,314 Total 84.0 41.8 14,070 29.1 11,819 256 | Women’s Empowerment and Demographic and Health Outcome More than two in five Ethiopian women have had an uvulectomy or tonsillectomy. The prevalence of uvulectomy or tonsillectomy increases with woman’s age rising from 37 percent among women age 15-19 to 49 percent among women age 45-49, indicating a declining trend in the practice. The practice is most prevalent among urban women, women residing in Tigray, women with no education, and women in the lowest wealth quintile. Table 16.15 shows that 29 percent of women support the continuation of this harmful traditional prac- tice. There is no uniform pattern of support for the practice by age. One in three rural women supports the practice compared with just over one in ten urban women. More than two-thirds of women residing in Affar and Tigray support the continuation of this prac- tice compared with less than one in ten women residing in Addis Ababa. Support for uvulectomy or tonsil- lectomy is highest among women with no education and women in the lowest wealth quintile. Forty-two percent of women with at least one daughter have a daughter who has had an uvulectomy or tonsillectomy (Table 16.16). The percentage of daugh- ters who have had a uvulectomy or tonsillectomy in- creases monotonically with age. The percentage of daughters exposed to this harmful traditional practice varies widely by region, ranging from a low of 23 percent in Somali to a high of 93 percent in Tigray. Women with no education are much more likely to have a daughter exposed to this practice than women with some education. Differences by urban-rural residence and wealth quintile are relatively small. 16.11.3 Marriage by Abduction Marriage by abduction is another harmful tradi- tional practice that is known to exist in Ethiopia. In general, the would-be abductor forms a group of intimate friends and relatives to carry out the abduction (NCTPE, 1998). An unmarried young girl is forcefully dragged or carried over the shoulder of the abductor who may beat her to subdue her. The girl is then taken to a hideaway. This tactic is often used as a short cut to marriage. Abduction may be followed by rape. Eighty-three percent of women have heard of marriage by abduction (Table 16.17). Urban women are much more likely than rural women to have heard of the practice. Regional variations in knowledge of the practice is marked, with all or nearly all women in Dire Dawa, Addis Ababa, Harari, Oromiya and SNNP having heard of the practice, compared with about half of women residing in Somali, Gambela and Amhara. Educated women are much more likely to be aware of this practice than women with no education, as are women in the highest wealth quintile compared with women in the lowest. Table 16.16 Daughter's uvulectomy/tonsillectomy Among women with at least one living daughter, percentage with at least one daughter who ever had an uvulectomy/tonsillectomy, according to selected background characteristics, Ethiopia 2005 Mother's background characteristic Percentage of women with at least one daughter who had an uvulectomy/ tonsillectomy Number of women with at least one daughter Age 15-19 30.6 222 20-24 32.1 918 25-29 38.5 1,735 30-34 45.0 1,516 35-39 45.0 1,422 40-44 43.4 1,069 45-49 49.6 1,039 Residence Urban 44.5 914 Rural 41.8 7,007 Region Tigray 93.2 524 Affar 79.7 82 Amhara 43.3 2,014 Oromiya 29.3 2,873 Somali 22.7 323 Benishangul-Gumuz 32.2 74 SNNP 49.1 1,733 Gambela 26.2 25 Harari 53.6 17 Addis Ababa 38.9 223 Dire Dawa 46.8 32 Education No education 43.4 6,343 Primary 37.9 1,131 Secondary and higher 34.4 446 Wealth quintile Lowest 45.3 1,613 Second 41.2 1,607 Middle 42.6 1,578 Fourth 38.9 1,603 Highest 42.4 1,518 Total 42.1 7,920 Women’s Empowerment and Demographic and Health Outcome | 257 Table 16.17 Knowledge, prevalence, and support of marriage by abduction Percentage of women who have heard of marriage by abduction percentage of women who ever had a marriage by abduction and among those who have heard of marriage by abduction, the percentage who support the practice, by selected background characteristics, Ethiopia 2005 Among women who have heard of marriage by abduction Background characteristic Percentage of women who have heard of marriage by abduction Percentage of women married by abduction Number of women Percentage who believe practice should be continued Number of women Age 15-19 83.2 2.5 3,266 2.0 2,717 20-24 84.7 7.3 2,547 2.8 2,158 25-29 83.1 9.5 2,517 3.7 2,092 30-34 82.6 11.4 1,808 3.5 1,493 35-39 81.8 9.6 1,602 3.0 1,310 40-44 83.9 9.9 1,187 2.2 997 45-49 82.1 10.4 1,143 3.3 938 Residence Urban 93.7 4.7 2,499 1.1 2,342 Rural 80.9 8.5 11,571 3.3 9,363 Region Tigray 80.6 1.4 919 1.1 741 Affar 79.1 6.1 146 17.9 116 Amhara 53.8 2.4 3,482 3.2 1,872 Oromiya 98.0 10.8 5,010 2.8 4,909 Somali 48.0 4.6 486 17.4 233 Benishangul-Gumuz 58.9 3.5 124 5.1 73 SNNP 96.2 12.9 2,995 2.0 2,882 Gambela 53.6 9.2 44 4.2 24 Harari 99.0 6.9 39 1.8 38 Addis Ababa 99.0 4.3 756 0.6 749 Dire Dawa 99.8 6.6 69 0.7 69 Education No education 78.0 9.0 9,271 3.7 7,227 Primary 91.2 7.1 3,123 2.1 2,847 Secondary and higher 97.4 2.5 1,675 0.5 1,631 Wealth quintile Lowest 75.3 7.7 2,428 6.0 1,827 Second 80.1 10.1 2,643 3.2 2,118 Middle 81.6 8.6 2,732 3.1 2,229 Fourth 82.1 7.7 2,647 2.5 2,172 Highest 92.8 5.7 3,621 1.1 3,359 Total 83.2 7.8 14,070 2.9 11,705 Eight percent of women reported that they had been married by abduction. This is most commonly reported by women age 30-34, rural women, women residing in SNNP and Oromiya and women with no education. This practice is least common among the wealthiest group of women. As seen in Table 16.17, there is very little support among Ethiopian women for the continuation of this harmful traditional practice. Women age 25-29, women residing in rural areas, women from Affar and Somali, women with no education and women in the lowest wealth quintile are more likely than their counterparts to support the continuation of this practice. About 1 percent of daughters of women with at least one daughter was reported to have been married by abduction, with the practice more common among daughters of older women age 45-49 and daughters of women with no education (Table 16.18). Differences by other background characteristics are small. 258 | Women’s Empowerment and Demographic and Health Outcome Table 16.18 Daughter's marriage by abduction Among women with at least one living daughter, percentage with at least one daughter who ever had a marriage by abduction, according to selected background characteristics, Ethiopia 2005 Mother's background characteristic Percentage of women with at least one daughter who was married by abduction Number of women with at least one daughter Age 15-19 0.0 222 20-24 0.0 918 25-29 0.0 1,735 30-34 0.6 1,516 35-39 0.8 1,422 40-44 4.0 1,069 45-49 4.9 1,039 Residence Urban 1.5 914 Rural 1.4 7,007 Region Tigray 0.2 524 Affar 1.8 82 Amhara 0.3 2,014 Oromiya 2.0 2,873 Somali 0.5 323 Benishangul-Gumuz 0.7 74 SNNP 2.3 1,733 Gambela 1.5 25 Harari 2.2 17 Addis Ababa 1.9 223 Dire Dawa 1.2 32 Wealth quintile Lowest 1.2 1,613 Second 2.3 1,607 Middle 0.9 1,578 Fourth 1.1 1,603 Highest 1.7 1,518 Education No education 1.7 6,343 Primary 0.2 1,131 Secondary and higher 0.5 446 Total 1.4 7,920 16.11.4 Obstetric Fistula The 2005 EDHS included a series of questions on obstetric fistula, a condition that develops when the blood supply to the tissues of the vagina, bladder, and/or rectum is cut off during prolonged obstructed labour, resulting in the formation of an opening through which urine and/or faeces pass uncontrollably. Women who develop fistulas are often socially rejected. All women were asked if they had heard of obstetric fistula, and if they had, whether they themselves had experienced the condition. Those who reported suffering from obstetric fistula were asked if they had ever been treated for it. These women were also asked if there were any other women in the household who suffered from it and if so how many. Women’s Empowerment and Demographic and Health Outcome | 259 One in four women interviewed in the survey had heard of obstetric fistula. Knowledge of obstetric fistula is higher among urban women, women residing in Addis Ababa, highly educated women, and women in the highest wealth quintile (Table 16.19). There is no uniform pattern of knowledge by age. Table 16.19 shows that 1 percent of women who have ever had a birth reported experiencing obstetric fistula. Older women (age 40 and above) and very young women (age 15-19) are slightly more likely to report the condition, as are women residing in urban areas. Women in the Tigray and SNNP regions are relatively more likely to have experienced obstetric fistula. A very small number of women (less than 1 percent) reported ever being treated for obstetric fistula. According to information gathered from women who had heard of the condition, 4 percent of other women resident in the households also suffered from obstetric fistula. Table 16.19 Prevalence of obstetric fistula Percentage of women who have heard of obstetric fistula, among women who have ever given birth the percentage who experienced obstetric fistula and percentage who have been treated for obstetric fistula, and among women who have heard of obstetric fistula the percentage who live in a household where someone else experienced obstetric fistula, according to selected background characteristics, Ethiopia 2005 Among women who have ever given birth Among women who have heard of obstetric fistula Background characteristic Percentage of women who have heard of obstetric fistula Number Percentage who have experienced obstetric fistula Percentage ever treated for obstetric fistula Number Percentage of other women in household with obstetric fistula Number Age 15-19 19.7 3,266 2.0 0.6 443 4.1 642 20-24 24.5 2,547 0.9 0.2 1,535 3.2 625 25-29 24.0 2,517 0.6 0.1 2,194 3.5 604 30-34 21.8 1,808 0.6 0.1 1,701 4.2 395 35-39 24.8 1,602 1.1 0.3 1,559 4.2 398 40-44 26.1 1,187 1.6 0.9 1,155 4.0 310 45-49 25.8 1,143 1.9 0.8 1,125 4.0 295 Education No education 16.3 9,271 1.0 0.3 7,644 4.5 1,508 Primary 24.3 3,123 1.3 0.4 1,454 4.4 758 Secondary and higher 59.8 1,675 1.0 0.3 615 2.3 1,003 Residence Urban 50.1 2,499 1.4 0.7 1,232 2.2 1,251 Rural 17.4 11,571 1.0 0.3 8,480 4.8 2,018 Region Tigray 37.8 919 1.6 0.4 635 13.4 347 Afar 11.7 146 1.0 0.6 106 3.8 17 Amhara 16.0 3,482 0.5 0.5 2,566 1.6 557 Oromiya 23.0 5,010 1.2 0.2 3,467 2.1 1,153 Somali 7.2 486 0.0 0.0 382 5.9 35 Benishangul-Gumuz 14.3 124 0.6 0.0 94 2.3 18 SNNP 19.9 2,995 1.5 0.4 2,056 5.0 597 Gambela 10.9 44 1.1 1.0 34 3.9 5 Harari 46.4 39 0.1 0.0 23 2.1 18 Addis Ababa 66.1 756 1.0 0.5 308 2.3 500 Dire Dawa 31.8 69 1.0 0.2 42 1.5 22 Wealth quintile Lowest 15.1 2,428 1.3 0.3 1,920 5.0 367 Second 16.9 2,643 0.9 0.2 1,997 3.1 446 Middle 16.2 2,732 0.6 0.1 1,946 6.8 442 Fourth 19.5 2,647 1.6 0.4 1,902 5.6 515 Highest 41.4 3,621 1.0 0.6 1,948 2.3 1,498 Total 23.2 14,070 1.0 0.3 9,713 3.8 3,269   References | 261 REFERENCES Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. 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Geneva: World Health Organization.   Appendix A | 265 SAMPLE IMPLEMENTATION Appendix A Table A.1 Sample implementation: women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall response rates, according to urban-rural residence and region, Ethiopia 2005 Residence Region Result Urban Rural Tigray Affar Amhara Oromiya Somali Beni- shangul- Gumuz SNNP Gambela Harari Addis Ababa Dire Dawa Total Selected households Completed (C) 91.9 94.4 95.0 86.2 95.7 96.2 88.3 91.1 96.1 88.6 94.2 95.2 93.5 93.7 Household present but no competent respondent at home (HP) 1.4 0.6 1.0 0.7 0.8 0.2 1.6 1.4 0.4 1.0 2.0 0.6 1.4 0.9 Postponed (P) 0.1 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 Refused (R) 0.5 0.2 0.2 1.2 0.1 0.1 0.3 0.2 0.3 0.2 0.4 0.4 0.4 0.3 Dwelling not found (DNF) 0.4 0.2 0.0 0.4 0.1 0.0 0.9 0.1 0.1 0.2 0.1 0.1 1.1 0.2 Household absent (HA) 1.5 1.5 1.0 1.6 1.2 1.0 4.1 1.5 1.2 3.6 0.8 0.9 1.1 1.5 Dwelling vacant/address not a dwelling (DV) 3.2 1.4 1.9 4.3 1.0 1.6 1.1 2.8 1.2 5.0 1.6 1.1 2.0 1.9 Dwelling destroy (DD) 0.5 1.3 0.3 4.2 0.7 0.8 2.0 2.9 0.3 1.2 0.4 0.8 0.1 1.1 Other (O) 0.5 0.4 0.4 1.4 0.3 0.1 1.7 0.0 0.2 0.2 0.4 0.7 0.5 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 3,989 10,656 1,349 935 2,158 2,241 901 954 2,012 925 960 1,400 810 14,645 Household response rate (HRR) 97.4 98.9 98.7 97.3 98.9 99.6 97.0 98.2 99.1 98.4 97.3 98.7 97.1 98.5 Eligible women Completed (EWC) 94.4 96.2 97.6 91.9 97.3 96.5 91.4 97.5 97.8 92.4 92.5 94.5 95.2 95.6 Not at home (EWNH) 3.2 1.9 1.2 4.7 1.5 1.8 4.5 0.5 1.4 3.5 3.5 3.3 2.8 2.3 Postponed (EWP) 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.0 Refused (EWR) 1.4 0.8 0.1 2.2 0.3 0.6 2.3 0.9 0.2 2.7 2.2 1.2 1.3 1.0 Partly completed (EWPC) 0.2 0.3 0.2 0.3 0.1 0.2 1.1 0.5 0.2 0.6 0.2 0.2 0.1 0.3 Incapacitated (EWI) 0.5 0.7 0.9 0.7 0.7 0.7 0.3 0.7 0.4 0.4 0.9 0.6 0.2 0.6 Other (EWO) 0.3 0.2 0.1 0.1 0.2 0.2 0.4 0.0 0.0 0.4 0.7 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 4,686 10,031 1,288 859 1,996 2,312 732 868 2,135 789 912 1,978 848 14,717 Eligible women response rate (EWRR) 94.4 96.2 97.6 91.9 97.3 96.5 91.4 97.5 97.8 92.4 92.5 94.5 95.2 95.6 Overall response rate (ORR) 92.0 95.1 96.3 89.4 96.3 96.1 88.6 95.7 96.8 91.0 90.1 93.3 92.4 94.2 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 women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * EWC ___________________________________________________________________________ EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 266 | Appendix A Table A.2 Sample implementation: men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men and overall response rates, according to urban-rural residence and region, Ethiopia 2005 Residence Region Result Urban Rural Tigray Affar Amhara Oromiya Somali Beni- shangul- Gumuz SNNP Gambela Harari Addis Ababa Dire Dawa Total Selected households Completed (C) 91.7 94.1 94.9 87.6 95.0 95.4 89.0 90.3 95.4 89.2 93.5 94.8 94.1 93.4 Household present but no competent respondent at home (HP) 1.2 0.6 1.4 0.9 0.7 0.2 1.1 1.3 0.3 1.3 1.5 0.4 1.3 0.8 Postponed (P) 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Refused (R) 0.6 0.3 0.3 1.5 0.2 0.2 0.2 0.4 0.2 0.2 0.4 0.6 0.0 0.3 Dwelling not found (DNF) 0.4 0.1 0.0 0.2 0.2 0.0 0.9 0.0 0.2 0.2 0.0 0.3 0.8 0.2 Household absent (HA) 2.1 1.6 0.9 1.7 1.3 1.1 5.3 1.7 1.7 4.1 1.0 0.9 1.8 1.7 Dwelling vacant/address not a dwelling (DV) 3.1 1.5 1.8 2.8 1.3 2.0 0.7 2.9 1.5 4.3 2.5 1.5 1.3 1.9 Dwelling destroy (DD) 0.5 1.3 0.3 3.7 0.9 1.0 1.6 3.4 0.4 0.6 0.4 0.9 0.3 1.1 Other (O) 0.5 0.4 0.3 1.5 0.5 0.0 1.1 0.0 0.3 0.0 0.6 0.6 0.5 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 1,947 5,213 651 458 1,040 1,081 436 476 1,010 462 480 675 391 7,160 Household response rate (HRR) 97.6 98.9 98.3 97.1 98.9 99.5 97.5 98.2 99.3 98.1 98.0 98.6 97.9 98.6 Eligible men Completed (EMC) 83.6 91.2 90.9 81.1 93.5 92.5 83.6 94.8 92.1 85.2 84.9 83.7 84.0 89.0 Not at home (EMNH) 11.2 6.4 6.6 16.3 4.8 5.4 10.7 2.7 6.0 9.8 10.9 9.7 13.2 7.8 Postponed (EMP) 0.2 0.1 0.0 0.0 0.0 0.2 0.3 0.0 0.1 0.8 0.2 0.1 0.0 0.1 Refused (EMR) 2.6 1.2 0.9 1.6 0.8 0.5 3.6 1.2 0.8 3.0 2.1 3.8 1.5 1.6 Partly completed (EMPC) 0.4 0.1 0.0 0.8 0.0 0.1 0.3 0.2 0.1 0.5 0.2 0.1 0.3 0.2 Incapacitated (EMI) 1.3 0.7 0.7 0.3 0.7 0.9 1.2 1.0 0.6 0.3 1.2 1.7 1.0 0.9 Other (EMO) 0.8 0.2 0.9 0.0 0.1 0.4 0.3 0.0 0.3 0.5 0.5 0.8 0.0 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,948 4,830 563 387 959 1,126 336 403 956 398 423 834 393 6,778 Eligible men response rate (EMRR) 83.6 91.2 90.9 81.1 93.5 92.5 83.6 94.8 92.1 85.2 84.9 83.7 84.0 89.0 Overall response rate (ORR) 81.6 90.2 89.4 78.8 92.5 92.0 81.5 93.1 91.4 83.6 83.2 82.5 82.2 87.7 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 men falling into specific response categories, the eligible man response rate (EWRR) is calculated as: 100 * EMC ___________________________________________________________________________ EMC + EMNH + EMP + EMR + EMPC + EMI + EMO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EMRR/100 Appendix A | 267 Table A.3 Coverage of HIV testing among eligible respondents by social and demographic characteristics: women Percent distribution of women age 15-49 by HIV testing status, according to social and demographic characteristics (unweighted), Ethiopia 2005 Characteristic Tested Refused Absent/ other/ missing Total Number Marital status Never married 84.9 13.8 1.3 100.0 1,834 Ever had sexual intercourse 85.3 13.3 1.4 100.0 1,651 Never had sexual intercourse 81.4 18.0 0.5 100.0 183 Married / living together 88.7 10.4 0.9 100.0 4,189 Divorced or separated 85.1 13.5 1.4 100.0 289 Widowed 84.6 14.8 0.6 100.0 500 Type of union In polygynous union 91.5 7.3 1.1 100.0 531 Not in polygynous union 88.4 10.8 0.8 100.0 3,606 Not currently in union 84.9 14.0 1.2 100.0 2,623 Ever had sexual intercourse Yes 87.8 11.3 0.9 100.0 5,150 No 85.3 13.3 1.4 100.0 1,662 Currently pregnant Yes 90.5 9.2 0.4 100.0 524 Not pregnant/not sure 87.0 12.0 1.0 100.0 6.288 Total 87.2 11.8 1.0 100.0 6,812 Note: Totals include a small number of cases missing data on a particular characteristic. Table is based only on respondents who were interviewed, since these characteristics are obtained from the individual interview. 268 | Appendix A Table A.4 Coverage of HIV testing among eligible respondents by social and demographic characteristics: men Percent distribution of men age 15-59 by testing status, according to social and demographic characteristics (unweighted), Ethiopia 2005 Characteristic Tested Refused Absent/ other/ missing Total Number Marital status Never married 82.7 16.0 1.3 100.0 2,460 Ever had sexual intercourse 84.6 14.1 1.3 100.0 1,838 Never had sexual intercourse 77.0 21.4 1.6 100.0 622 Married/living together 86.4 12.6 1.0 100.0 3,332 Divorced or separated 74.6 25.4 0.0 100.0 59 Widowed 83.5 15.4 1.1 100.0 182 Type of union In polygynous union 86.9 12.6 0.5 100.0 222 Not in polygynous union 86.3 12.6 1.1 100.0 3,110 Not currently in union 82.6 16.1 1.3 100.0 2,701 Ever had sexual intercourse Yes 84.7 14.2 1.1 100.0 4,189 No 84.6 14.2 1.2 100.0 1,844 Circumcision status Circumcised 84.2 14.7 1.1 100.0 5,575 Not circumcised 90.8 8.3 0.9 100.0 445 Times slept away from home in past 12 months 0 84.8 14.1 1.1 100.0 4,107 1-2 86.2 12.5 1.3 100.0 1,029 3-5 81.2 18.0 0.8 100.0 490 6+ 84.1 14.4 1.5 100.0 396 Time away in past 12 months More than 1 month 81.4 17.2 1.4 100.0 431 Less than 1 month 85.7 13.2 1.2 100.0 1,459 Never away 84.8 14.1 1.1 100.0 4,107 Total 75.5 17.1 7.3 100.0 6,778 Note: Totals include a small number of cases missing data on a particular characteristic. Table is based only on respondents who were interviewed, since these characteristics are obtained from the individual interview. Appendix A | 269 Table A.5 Coverage of HIV testing by sexual behaviour characteristics: women Percent distribution of women who ever had sexual intercourse by HIV test status, according to sexual behaviour characteristics (unweighted), Ethiopia 2005 Sexual behaviour characteristic Tested Refused Absent/ other/ missing Total Number Age at first sexual intercourse 15 or less 88.5 10.4 1.0 100.0 2,480 16-17 89.7 9.7 0.6 100.0 1,057 18-19 86.9 12.3 0.9 100.0 800 20+ 84.3 14.9 0.7 100.0 804 Non numeric 88.9 11.1 0.0 100.0 9 Higher-risk intercourse in past 12 months Had higher risk sex 84.8 14.5 0.6 100.0 165 Had sex, not higher risk 89.2 10.0 0.7 100.0 4,034 No sex in past 12 months 82.5 16.0 1.5 100.0 951 Number of actual partners in past 12 months 0 83.3 15.9 0.9 100.0 933 1 89.1 10.1 0.7 100.0 4,184 2+ 80.0 20.0 0.0 100.0 15 Number of higher-risk partners in past 12 months 0 88.1 11.1 0.8 100.0 4,926 1 86.4 13.1 0.5 100.0 199 2+ 85.7 14.3 0.0 100.0 7 Condom use Ever used condom 78.9 21.1 0.0 100.0 152 Never used condom 88.1 11.0 0.9 100.0 4,998 Condom used at first sexual intercourse1 Used at first sex 84.2 15.8 0.0 100.0 57 Did not use at first sex 87.7 11.4 1.0 100.0 1,239 Missing 81.6 15.8 2.6 100.0 76 Condom use at last sexual intercourse in past 12 months2 Used condom last sex 80.8 19.2 0.0 100.0 73 No condom at last sex 89.2 10.1 0.8 100.0 4,124 No sex past 12 months 82.6 15.9 1.5 100.0 953 Condom use at last higher-risk intercourse in past 12 months2 Used condom 80.4 19.6 0.0 100.0 46 Did not use condom 86.6 12.6 0.8 100.0 119 Number of lifetime partners 1 87.6 11.6 0.7 100.0 3,752 2 88.9 10.2 0.9 100.0 1,011 3-4 90.1 8.8 1.0 100.0 294 5-9 91.5 8.5 0.0 100.0 47 10+ 77.8 22.2 0.0 100.0 9 HIV testing status3 Previously tested 81.4 17.8 0.8 100.0 258 Previously tested, received result of last test 81.8 17.4 0.8 100.0 253 Previously tested, did not receive result of last test 60.0 40.0 0.0 100.0 5 Not tested previously 89.3 10.1 0.6 100.0 4,084 Total 87.8 11.3 0.9 100.0 5,150 Note: Totals include a small number of cases missing data on a particular characteristic. Table is based only on respondents who were interviewed, since these characteristics are obtained from the individual interview. 1 Based on those age 15-24 only 2 Based on respondents who had sexual intercourse in the past 12 months 3 Excludes women who have not heard of AIDS 270 | Appendix A Table A.6 Coverage of HIV testing by sexual behaviour characteristics: men Percent distribution of men who ever had sexual intercourse by HIV test status, according to sexual behaviour characteristics (unweighted), Ethiopia 2005 Sexual behaviour characteristic Tested Refused Absent/ other/ missing Total Number Age at first sexual intercourse 15 or less 88.2 11.0 0.8 100.0 382 16-17 81.4 17.6 1.0 100.0 598 18-19 82.2 16.6 1.1 100.0 963 20+ 86.1 12.7 1.2 100.0 2,173 Non numeric 83.6 15.1 1.4 100.0 73 Higher-risk intercourse in past 12 months Had higher risk sex 76.0 22.6 1.3 100.0 446 Had sex, not higher risk 86.7 12.2 1.1 100.0 3,237 No sex in past 12 months 79.6 19.4 1.0 100.0 506 Number of partners in past 12 months 0 78.6 20.1 1.2 100.0 1,236 1 87.3 11.7 1.1 100.0 2,941 2+ 90.0 10.0 0.0 100.0 10 Number of higher-risk partners in past 12 months 0 85.8 13.2 1.1 100.0 3,723 1 76.3 22.2 1.5 100.0 401 2+ 75.9 24.1 0.0 100.0 58 Condom used at first sexual intercourse2 Used at first sex 76.7 21.8 1.5 100.0 133 Did not use at first sex 86.9 12.5 0.6 100.0 489 Condom use at last sexual intercourse in past 12 months1 Used condom last sex 70.2 28.7 1.1 100.0 282 No condom at last sex 86.7 12.2 1.1 100.0 3,402 No sex past 12 months 79.6 19.4 1.0 100.0 505 Condom use at last higher-risk intercourse in past 12 months1 Used condom 69.8 28.9 1.2 100.0 242 Did not use condom 83.3 15.2 1.5 100.0 204 Paid for sexual intercourse in past 12 months Used condom 82.6 17.4 0.0 100.0 46 Did not use condom 90.3 6.5 3.2 100.0 31 No paid sex 84.7 14.2 1.1 100.0 4,111 Number of lifetime partners 1 85.0 13.9 1.1 100.0 1,728 2 85.6 13.7 0.7 100.0 890 3-4 84.6 14.2 1.2 100.0 830 5-9 84.0 14.0 2.0 100.0 406 10+ 82.9 16.0 1.1 100.0 263 HIV testing status Previously tested 79.2 19.5 1.4 100.0 370 Previously tested, received result of last test 77.9 20.6 1.4 100.0 349 Previously tested, did not receive result of last test 100.0 0.0 0.0 100.0 21 Not tested previously 85.5 13.5 1.0 100.0 3,677 Total 84.7 14.2 1.1 100.0 4,189 Note: Totals include a small number of cases missing data on a particular characteristic. Table is based only on respondents who were interviewed, since these characteristics are obtained from the individual interview. 1 Based on respondents who had sexual intercourse in the past 12 months 2 Based on those age 15-24 only Appendix B | 271 ESTIMATES OF SAMPLING ERRORS Appendix B The estimates from a sample survey are affected by two types of errors: (1) nonsampling er- rors, and (2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, mis- understanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2005 Ethiopia Demo- graphic and Health Survey (EDHS) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2005 EDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be as- sumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2005 EDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2005 EDHS is the ISSA Sampling Error Module. This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated repli- cation method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = = ⎥⎦ ⎤⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ −− −== H h h h m i hi h h m zz m m x frvarrSE h 1 2 1 2 2 2 1 1)()( in which hihihi rxyz −= , and hhh rxyz −= where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, 272 | Appendix B yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using sim- ple formulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2005 EDHS, there were 535 non-empty clus- ters. Hence, 535 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − −=∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 535 clusters, r(i) is the estimate computed from the reduced sample of 534 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, ISSA computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the stan- dard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indi- cates the increase in the sampling error due to the use of a more complex and less statistically efficient design. ISSA also computes the relative error and confidence limits for the estimates. Sampling errors for the 2005 EDHS are calculated for selected variables considered to be of primary interest for the woman’s survey and the man’s surveys, respectively. The results are pre- sented in this appendix for the country as a whole, for urban and rural areas, and for each of the 9 re- gions (Tigray, Affar, Amhara, Oromiya, Somali, Benishangul-Gumuz, SNNP, Gambela and Harari) and the two city administration areas (Addis Ababa and Dire Dawa). For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.14 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known un- weighted value for woman-years of exposure to childbearing. The confidence interval (e.g., as calculated for children ever born to women aged 40-49) can be interpreted as follows: the overall average from the national sample is 6.931 and its standard error is 0.071. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the stan- dard error to the sample estimate, i.e., 6.931±2×0.071. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 6.788 and 7.074. Sampling errors are analyzed for the national woman sample and for two separate groups of estimates: (1) means and proportions, and (2) complex demographic rates. The relative standard errors (SE/R) for the means and proportions range between 0.6 percent and 36.9 percent with an average of 6.3 percent; the highest relative standard errors are for estimates of very low values (e.g., currently using Appendix B | 273 female sterilization). If estimates of very low values (less than 10 percent) were removed, then the average drops to 3.6 percent. So in general, the relative standard error for most estimates for the coun- try as a whole is small, except for estimates of very small proportions. The relative standard error for the total fertility rate is small, 2.6 percent. However, for the mortality rates, the average relative stan- dard error is much higher, 6.0 percent. There are differentials in the relative standard error for the estimates of sub-populations. For example, for the variable want no more children, the relative standard errors as a percent of the esti- mated mean for the whole country, and for the urban areas are 1.9 percent and 5.3 percent, respec- tively. For the total sample, the value of the design effect (DEFT), averaged over all variables, is 1.67 which means that, due to multi-stage clustering of the sample, the average standard error is in- creased by a factor of 1.67 over that in an equivalent simple random sample. 274 | Appendix B Table B.1 List of selected variables for sampling errors, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Variable Estimate Base population ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion All women 15-49 Literate Proportion All women 15-49 No education Proportion All women 15-49 Secondary education or higher Proportion All women 15-49 Net attendance ratio for primary school Ratio Children 7-12 years Never married Proportion All women 15-49 Currently married/in union Proportion All women 15-49 Married before age 20 Proportion Women age 20-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women age 40-49 Mean Women age 40-49 Knows any contraceptive method Proportion All women 15-49 Ever using contraceptive method Proportion Currently married women 15-49 Currently using any contraceptive method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using IUD Proportion Currently married women 15-49 Currently using female sterilization Proportion Currently married women 15-49 Currently using rythm method Proportion Currently married women 15-49 Obtained method from public sector source Proportion Currently married women 15-49 Want no more children Proportion Currently married women 15-49 Want to delay birth at least 2 years Proportion Currently married women 15-49 Ideal family size Mean All women 15-49 Perinatal mortality (0-6 years) Rate Births in last 5 years Mothers received tetanus injection for last birth Proportion Women with at least 1 live birth in past 5 years Mothers received medical assistance at delivery Proportion Births in last 5 years Had diarrhoea in two weeks before survey Proportion Children under 5 years Treated with oral rehydration salts (ORS) Proportion Children under 5 years with diarrhoea in past two weeks Taken to a health provider Proportion Children with diarrhoea in past two weeks Vaccination card seen Proportion Children age 12-23 months Received BCG Proportion Children age 12-23 months Received DPT (3 doses) Proportion Children age 12-23 months Received polio (3 doses) Proportion Children age 12-23 months Received measles Proportion Children age 12-23 months Fully immunized Proportion Children age 12-23 months Height-for-age (below -2SD) Proportion Children under 5 years who were measured Weight-for-height (below -2SD) Proportion Children under 5 years who were measured Weight-for-age (below -2SD) Proportion Children under 5 years who were measured Anaemic (children) Proportion Children under 5 years Anaemic (women) Proportion All women 15-49 BMI <18.5 Proportion All women 15-49 Has heard of HIV/AIDS Proportion All women 15-49 Knows about condoms Proportion All women 15-49 Knows about limiting partners Proportion All women 15-49 Had 2+ sex partners in past 12 months Proportion All women 15-49 High-risk sex Proportion All women 15-49 with sexual intercourse in past 12 months Condom use at high-risk sex Proportion All women 15-49 with high-risk intercourse in past 12 months Abstinence among youth Proportion Women 15-24 Sexually active in past 12 months among youth Proportion Women 15-24 Had an injection in past 12 months Proportion Women 15-24 Had HIV test and received results in past 12 months Proportion All women 15-49 Accepting attitudes towards people with HIV Proportion All women 15-49 who have heard of HIV/AIDS HIV prevalence among tested for HIV 15-49 Proportion All women 15-49 with blood sample tested at lab Total Fetility Rate (3 years) Rate All women 15-49 Neonatal NN rate (0-4 years) Rate Children exposed to the risk of mortality Postneonatal PNN rate (0-4 years) Rate Children exposed to the risk of mortality Infant 1q0 rate (0-4 years) Rate Children exposed to the risk of mortality Infant 1q0rate (5-9 years_ Rate Children exposed to the risk of mortality Infant 1q0 rate (10-14 years) Rate Children exposed to the risk of mortality Child 4q1 rate (0-4 years) Rate Children exposed to the risk of mortality Under five 5q0 (0-4 years) Rate Children exposed to the risk of mortality Maternal mortality rate (0-6 years) Rate All women 15-49 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion All men 15-59 Literate Proportion All men 15-59 No education Proportion All men 15-59 Secondary education or higher Proportion All men 15-59 Never married Proportion All men 15-59 Currently married (in union) Proportion All men 15-59 Married before age 20 Proportion All men 20-54 Want no more children Proportion Currently married men 15-59 Want to delay birth at least 2 years Proportion Currently married men 15-59 Ideal family size Mean All men 15-59 Has heard of HIV/AIDS (15-49) Proportion All men 15-49 Knows about condoms (15-49) Proportion All men 15-49 Knows about limiting partners (15-49) Proportion All men 15-49 Had two+ sex partners in past 12 months (15-49) Proportion All men 15-49 High-risk sex (15-49) Proportion All men 15-49 with sexual intercourse in past 12 months High-risk sex (15-59) Proportion All men 15-59 with sexual intercourse in past 12 months Condom use at high-risk sex (age 15-49) Proportion All men 15-49 with sexual intercourse in past 12 months Condom use at high-risk sex (age 15-59) Proportion All men 15-59 with sexual intercourse in past 12 months Abstinence among youth Proportion All men 15-24 Sexually active in past 12 months among youth Proportion All men 15-24 Paid for sexual intercourse in past 12 months Proportion All men 15-49 Had an injection in past 12 months (age15-49) Proportion All men 15-49 Had an injection in past 12 months (age 15-59) Proportion All men 15-59 HIV test and received results past 12 months (15-49) Proportion All men 15-49 Accepting attitudes towards people with HIV (15-49) Proportion All men 15-49 who have heard of HIV/AIDS HIV prevalence among tested for HIV 15-49 Proportion All men 15-49 with blood sample tested at lab HIV prevalence among tested for HIV 15-59 Proportion All men 15-59 with blood sample tested at lab Appendix B | 275 Table B.2 Sampling errors for national sample, Ethiopia 2005 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.178 0.007 14070 14070 2.317 0.042 0.163 0.193 Literate 0.292 0.009 14070 14070 2.278 0.030 0.274 0.309 No education 0.659 0.010 14070 14070 2.465 0.015 0.639 0.679 Secondary education or higher 0.119 0.006 14070 14070 2.143 0.049 0.107 0.131 Net attendance ratio for primary school 0.423 0.010 12462 13485 2.128 0.024 0.403 0.443 Never married 0.250 0.006 14070 14070 1.759 0.026 0.237 0.263 Currently married/in union 0.644 0.007 14070 14070 1.692 0.011 0.631 0.658 Married before age 20 0.748 0.007 10818 10804 1.668 0.009 0.734 0.762 Currently pregnant 0.084 0.003 14070 14070 1.420 0.039 0.077 0.091 Children ever born 3.141 0.038 14070 14070 1.437 0.012 3.065 3.216 Children surviving 2.586 0.032 14070 14070 1.494 0.013 2.522 2.651 Children ever born to women age 40-49 6.931 0.071 2261 2330 1.180 0.010 6.788 7.074 Knows any contraceptive method 0.875 0.006 8644 9066 1.810 0.007 0.862 0.888 Ever using contraceptive method 0.241 0.009 8644 9066 1.881 0.036 0.224 0.258 Currently using any contraceptive method 0.147 0.007 8644 9066 1.716 0.044 0.134 0.160 Currently using pill 0.031 0.003 8644 9066 1.659 0.100 0.025 0.037 Currently using IUD 0.002 0.000 8644 9066 0.954 0.220 0.001 0.003 Currently using female sterilization 0.002 0.000 8644 9066 0.999 0.266 0.001 0.003 Currently using rhythm method 0.006 0.001 8644 9066 1.093 0.158 0.004 0.007 Obtained method from public sector source 0.795 0.020 1496 1324 1.960 0.026 0.754 0.836 Want no more children 0.421 0.008 8644 9066 1.539 0.019 0.404 0.437 Want to delay birth at least 2 years 0.354 0.008 8644 9066 1.588 0.023 0.337 0.370 Ideal family size 4.498 0.055 12728 12602 1.949 0.012 4.389 4.607 Perinatal mortality (0-6 years) 37.241 2.698 9955 11280 1.400 0.072 31.845 42.636 Mothers received tetanus injection for last birth 0.322 0.011 6589 7307 1.963 0.033 0.301 0.344 Mothers received medical assistance at delivery 0.057 0.004 9861 11163 1.608 0.070 0.049 0.065 Had diarrhoea in two weeks before survey 0.180 0.006 9002 10109 1.579 0.035 0.167 0.193 Treated with oral rehydration salts (ORS) 0.199 0.016 1545 1819 1.586 0.078 0.168 0.230 Taken to a health provider 0.222 0.016 1545 1819 1.509 0.070 0.191 0.254 Vaccination card seen 0.369 0.017 1697 1877 1.478 0.045 0.336 0.402 Received BCG 0.604 0.020 1697 1877 1.787 0.034 0.564 0.645 Received DPT (3 doses) 0.319 0.019 1697 1877 1.718 0.058 0.281 0.356 Received polio (3 doses) 0.447 0.020 1697 1877 1.734 0.045 0.407 0.487 Received measles 0.349 0.018 1697 1877 1.617 0.051 0.313 0.384 Fully immunized 0.204 0.015 1697 1877 1.615 0.074 0.173 0.234 Height-for-age (below -2SD) 0.465 0.011 4130 4586 1.433 0.024 0.443 0.487 Weight-for-height (below -2SD) 0.105 0.006 4130 4586 1.375 0.061 0.092 0.118 Weight-for-age (below -2SD) 0.384 0.011 4130 4586 1.476 0.029 0.362 0.406 Anaemic (children) 0.535 0.011 3580 4138 1.371 0.020 0.514 0.557 Anaemic (women) 0.266 0.009 5963 6141 1.576 0.033 0.248 0.283 BMI <18.5 0.265 0.009 5988 5901 1.512 0.033 0.247 0.282 Has heard of HIV/AIDS 0.899 0.006 14070 14070 2.249 0.006 0.887 0.910 Knows about condoms 0.402 0.009 14070 14070 2.235 0.023 0.383 0.420 Knows about limiting partners 0.625 0.009 14070 14070 2.308 0.015 0.606 0.643 Had 2+ sex partners in past 12 months 0.002 0.001 4203 4354 1.179 0.369 0.001 0.004 High-risk sex 0.027 0.004 4203 4354 1.424 0.131 0.020 0.034 Condom use at high-risk sex 0.236 0.052 165 119 1.577 0.222 0.131 0.340 Abstinence among youth 0.957 0.007 3283 3165 1.944 0.007 0.943 0.971 Sexually active in past 12 months among youth 0.015 0.003 3283 3165 1.494 0.210 0.009 0.022 Had an injection in past 12 months 0.256 0.008 14070 14070 2.247 0.032 0.240 0.273 Had HIV test and received results in past 12 months 0.019 0.002 6812 6751 1.055 0.093 0.015 0.022 Accepting attitudes towards people with HIV 0.107 0.006 12414 12643 2.059 0.053 0.096 0.119 HIV prevalence among tested for HIV 15-49 0.019 0.002 5942 5736 1.230 0.116 0.014 0.023 Total fertility rate (3 years) 5.409 0.141 na 38974 2.300 0.026 5.127 5.692 Neonatal mortality (0-4 years) 39.328 2.851 9900 11217 1.439 0.072 33.626 45.029 Postneonatal mortality (0-4 years) 37.681 2.726 9920 11242 1.430 0.072 32.228 43.133 Infant mortality (0-4 years) 77.008 3.852 9925 11248 1.431 0.050 69.304 84.712 Infant mortality (5-9 years) 83.389 4.042 10359 11557 1.366 0.048 75.304 91.473 Infant mortality (10-14 years) 94.619 5.085 8346 9105 1.475 0.054 84.449 104.789 Child mortality (0-4 years) 50.318 3.149 10115 11446 1.408 0.063 44.020 56.616 Under-five mortallity (0-4 years) 123.451 5.141 10145 11482 1.525 0.042 113.170 133.732 Maternal mortality (0-6 years) 673.386 62.900 na na na 0.093 547.586 799.187 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.152 0.006 6033 6033 1.306 0.040 0.140 0.164 Literate 0.589 0.010 6033 6033 1.586 0.017 0.569 0.609 No education 0.429 0.010 6033 6033 1.567 0.023 0.409 0.449 Secondary education or higher 0.198 0.007 6033 6033 1.365 0.035 0.184 0.212 Want no more children 0.341 0.013 3332 3424 1.552 0.037 0.316 0.367 Want to delay birth at least 2 years 0.415 0.012 3332 3424 1.464 0.030 0.390 0.440 Ideal family size 5.243 0.080 5632 5615 1.421 0.015 5.084 5.402 Has heard of HIV/AIDS (15-49) 0.965 0.004 5472 5464 1.730 0.004 0.957 0.974 Knows about condoms (15-49) 0.643 0.011 5472 5464 1.701 0.017 0.620 0.665 Knows about limiting partners (15-49) 0.790 0.010 5472 5464 1.830 0.013 0.770 0.811 Had 2+ sex partners in past 12 months (15-49) 0.041 0.005 3199 3121 1.356 0.115 0.032 0.051 High-risk sex (15-49) 0.085 0.006 3199 3121 1.256 0.073 0.072 0.097 High-risk sex (15-59) 0.073 0.005 3686 3630 1.274 0.075 0.062 0.084 Condom use at high-risk sex (age 15-49) 0.519 0.038 440 264 1.593 0.073 0.443 0.595 Condom use at high-risk sex (age 15-59) 0.517 0.038 446 266 1.591 0.073 0.442 0.593 Abstinence among youth 0.876 0.009 2014 2081 1.233 0.010 0.858 0.894 Sexually active in past 12 months among youth 0.075 0.007 2014 2081 1.143 0.090 0.061 0.088 Paid for sexual intercourse in past 12 months 0.008 0.001 6033 6033 1.301 0.188 0.005 0.011 Had an injection in past 12 months (age 15-49) 0.189 0.008 5472 5464 1.461 0.041 0.174 0.205 Had an injection in past 12 months (age 15-59) 0.191 0.007 6033 6033 1.473 0.039 0.177 0.206 HIV test and received results past 12 months (15-49) 0.023 0.003 5472 5464 1.421 0.126 0.017 0.028 Accepting attitudes towards people with HIV (15-49) 0.167 0.009 5245 5273 1.812 0.056 0.148 0.185 HIV prevalence among tested for HIV 15-49 0.009 0.002 4631 4804 1.240 0.187 0.006 0.013 HIV prevalence among tested for HIV 15-59 0.009 0.002 5108 5306 1.259 0.183 0.006 0.013 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 276 | Appendix B Table B.3 Sampling errors for urban sample, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 4423 2499 na 0.000 1.000 1.000 Literate 0.736 0.015 4423 2499 2.325 0.021 0.705 0.767 No education 0.247 0.016 4423 2499 2.470 0.065 0.215 0.279 Secondary education or higher 0.509 0.021 4423 2499 2.795 0.041 0.467 0.551 Net attendance ratio for primary school 0.788 0.017 2043 1186 1.773 0.022 0.754 0.822 Currently pregnant 0.025 0.004 4423 2499 1.640 0.155 0.017 0.032 Children ever born to women age 40-49 5.113 0.143 612 351 1.232 0.028 4.827 5.399 Currently using any contraceptive method 0.467 0.017 1708 959 1.418 0.037 0.432 0.501 Currently using pill 0.107 0.015 1708 959 1.945 0.136 0.078 0.136 Currently using IUD 0.018 0.004 1708 959 1.225 0.216 0.011 0.026 Currently using female sterilization 0.013 0.004 1708 959 1.298 0.272 0.006 0.020 Currently using rhythm method 0.037 0.005 1708 959 1.205 0.149 0.026 0.048 Want no more children 0.478 0.025 1708 959 2.100 0.053 0.427 0.528 Ideal family size 3.442 0.072 4188 2387 1.964 0.021 3.299 3.585 Perinatal mortality (0-6 years) 44.897 12.143 1368 822 2.158 0.270 20.611 69.182 Mothers received tetanus injection for last birth 0.605 0.023 1054 634 1.578 0.038 0.559 0.651 Mothers received medical assistance at delivery 0.446 0.042 1358 815 2.778 0.095 0.362 0.531 Had diarrhoea in two weeks before survey 0.121 0.015 1275 752 1.653 0.123 0.091 0.151 Treated with oral rehydration salts (ORS) 0.457 0.073 155 91 1.820 0.160 0.311 0.604 Taken to a health provider 0.350 0.044 155 91 1.156 0.126 0.262 0.438 Vaccination card seen 0.620 0.044 249 147 1.470 0.071 0.532 0.709 Received BCG 0.840 0.057 249 147 2.532 0.068 0.726 0.955 Received DPT (3 doses) 0.657 0.048 249 147 1.649 0.074 0.560 0.754 Received polio (3 doses) 0.693 0.048 249 147 1.689 0.070 0.597 0.790 Received measles 0.654 0.078 249 147 2.634 0.119 0.499 0.809 Fully immunized 0.493 0.062 249 147 1.997 0.125 0.369 0.616 Height-for-age (below -2SD) 0.298 0.037 605 362 1.984 0.125 0.224 0.372 Weight-for-height (below -2SD) 0.063 0.025 605 362 2.733 0.401 0.012 0.113 Weight-for-age (below -2SD) 0.229 0.031 605 362 1.770 0.134 0.168 0.291 Anaemic (children) 0.468 0.038 426 270 1.651 0.080 0.393 0.543 Anaemic (women) 0.178 0.018 1636 948 1.950 0.102 0.141 0.214 BMI <18.5 0.188 0.019 1955 1112 2.153 0.101 0.150 0.226 Has heard of HIV/AIDS 0.986 0.004 4423 2499 2.303 0.004 0.977 0.994 Knows about condoms 0.722 0.012 4423 2499 1.853 0.017 0.697 0.747 Knows about limiting partners 0.818 0.013 4423 2499 2.155 0.015 0.793 0.843 Had 2+ sex partners in past 12 months 0.004 0.002 875 492 0.944 0.481 0.000 0.009 High-risk sex 0.135 0.020 875 492 1.772 0.152 0.094 0.176 Condom use at high-risk sex 0.399 0.089 109 66 1.884 0.223 0.221 0.577 Abstinence among youth 0.905 0.021 1602 938 2.836 0.023 0.864 0.947 Sexually active in past 12 months among youth 0.033 0.009 1602 938 1.990 0.270 0.015 0.051 Had an injection in past 12 months 0.304 0.021 4423 2499 2.967 0.068 0.262 0.345 Had HIV test and received results in past 12 months 0.078 0.008 2079 1173 1.323 0.100 0.062 0.093 Accepting attitudes towards people with HIV 0.373 0.020 4341 2463 2.779 0.055 0.332 0.414 HIV prevalence among tested for HIV 15-49 0.077 0.011 1628 980 1.591 0.136 0.056 0.098 Total fertility rate (3 years) 2.375 0.205 na 6868 2.289 0.086 1.966 2.785 Neonatal mortality (0-9 years) 34.668 7.129 2818 1702 1.938 0.206 20.410 48.925 Postneonatal mortality (0-9 years) 31.703 5.645 2820 1702 1.619 0.178 20.412 42.993 Infant mortality (0-9 years) 66.370 8.006 2820 1702 1.655 0.121 50.357 82.383 Child mortality (0-9 years) 33.898 5.687 2846 1716 1.490 0.168 22.523 45.272 Under-five mortality (0-9 years) 98.018 9.184 2848 1716 1.513 0.094 79.651 116.385 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 1628 916 na 0.000 1.000 1.000 Literate 0.937 0.008 1628 916 1.364 0.009 0.920 0.953 No education 0.079 0.010 1628 916 1.488 0.126 0.059 0.099 Secondary education or higher 0.718 0.019 1628 916 1.682 0.026 0.680 0.755 Want no more children 0.456 0.044 614 344 2.201 0.097 0.367 0.545 Want to delay birth at least 2 years 0.288 0.042 614 344 2.278 0.145 0.205 0.371 Ideal family size 3.579 0.124 1573 895 1.560 0.035 3.330 3.828 Has heard of HIV/AIDS (15-49) 0.997 0.001 1511 854 0.970 0.001 0.994 1.000 Knows about condoms (15-49) 0.825 0.018 1511 854 1.797 0.021 0.789 0.860 Knows about limiting partners (15-49) 0.890 0.016 1511 854 2.014 0.018 0.857 0.922 Had 2+ sex partners in past 12 months (15-49) 0.032 0.007 751 393 1.086 0.218 0.018 0.046 High-risk sex (15-49) 0.299 0.021 751 393 1.239 0.069 0.258 0.341 Condom use at high-risk sex (age 15-49) 0.799 0.029 267 118 1.168 0.036 0.741 0.856 Abstinence among youth 0.765 0.018 654 410 1.070 0.023 0.730 0.801 Sexually active in past 12 months among youth 0.152 0.015 654 410 1.098 0.101 0.121 0.183 Paid for sexual intercourse in past 12 months 0.010 0.003 1628 916 1.187 0.287 0.004 0.016 Had an injection in past 12 months (age 15-49) 0.203 0.017 1511 854 1.690 0.086 0.168 0.238 HIV test and received results past 12 months (15-49) 0.078 0.013 1511 854 1.825 0.161 0.053 0.103 Accepting attitudes towards people with HIV (15-49) 0.453 0.035 1502 851 2.744 0.078 0.382 0.523 HIV prevalence among tested for HIV 15-49 0.024 0.007 1080 684 1.442 0.279 0.011 0.038 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 277 Table B.4 Sampling errors for rural sample, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 9647 11571 na na 0.000 0.000 Literate 0.196 0.009 9647 11571 2.199 0.045 0.178 0.213 No education 0.748 0.011 9647 11571 2.406 0.014 0.727 0.769 Secondary education or higher 0.035 0.004 9647 11571 1.881 0.101 0.028 0.042 Net attendance ratio for primary school 0.388 0.011 10419 12299 2.010 0.027 0.367 0.409 Currently pregnant 0.097 0.004 9647 11571 1.294 0.040 0.089 0.105 Children ever born to women age 40-49 7.253 0.078 1649 1980 1.155 0.011 7.097 7.409 Currently using any contraceptive method 0.109 0.007 6936 8107 1.843 0.063 0.096 0.123 Currently using pill 0.022 0.003 6936 8107 1.747 0.140 0.016 0.028 Currently using IUD 0.000 0.000 6936 8107 1.281 0.999 0.000 0.001 Currently using female sterilization 0.000 0.000 6936 8107 1.201 0.873 0.000 0.001 Currently using rhythm method 0.002 0.001 6936 8107 1.292 0.362 0.001 0.003 Want no more children 0.414 0.009 6936 8107 1.452 0.021 0.397 0.431 Ideal family size 4.745 0.063 8540 10215 1.775 0.013 4.619 4.870 Perinatal mortality (0-6 years) 36.639 2.752 8587 10458 1.260 0.075 31.136 42.143 Mothers received tetanus injection for last birth 0.295 0.011 5535 6674 1.856 0.038 0.272 0.318 Mothers received medical assistance at delivery 0.026 0.003 8503 10348 1.603 0.116 0.020 0.032 Had diarrhoea in two weeks before survey 0.185 0.007 7727 9357 1.455 0.037 0.171 0.198 Treated with oral rehydration salts (ORS) 0.186 0.016 1390 1727 1.482 0.086 0.154 0.217 Taken to a health provider 0.216 0.016 1390 1727 1.399 0.075 0.183 0.248 Vaccination card seen 0.347 0.018 1448 1729 1.385 0.050 0.312 0.382 Received BCG 0.584 0.021 1448 1729 1.626 0.036 0.542 0.626 Received DPT (3 doses) 0.290 0.020 1448 1729 1.620 0.067 0.251 0.329 Received polio (3 doses) 0.426 0.021 1448 1729 1.622 0.050 0.383 0.468 Received measles 0.322 0.018 1448 1729 1.432 0.055 0.287 0.358 Fully immunized 0.179 0.015 1448 1729 1.507 0.085 0.148 0.209 Height-for-age (below -2SD) 0.479 0.012 3525 4224 1.329 0.024 0.456 0.503 Weight-for-height (below -2SD) 0.109 0.007 3525 4224 1.234 0.060 0.095 0.122 Weight-for-age (below -2SD) 0.397 0.012 3525 4224 1.370 0.029 0.374 0.420 Anaemic (children) 0.540 0.011 3154 3868 1.276 0.021 0.518 0.563 Anaemic (women) 0.282 0.010 4327 5193 1.463 0.036 0.262 0.302 BMI <18.5 0.283 0.010 4033 4789 1.384 0.035 0.263 0.302 Has heard of HIV/AIDS 0.880 0.007 9647 11571 2.065 0.008 0.866 0.893 Knows about condoms 0.333 0.011 9647 11571 2.193 0.032 0.312 0.354 Knows about limiting partners 0.583 0.011 9647 11571 2.160 0.019 0.561 0.605 Had 2+ sex partners in past 12 months 0.002 0.001 3328 3862 1.204 0.447 0.000 0.004 High-risk sex 0.014 0.003 3328 3862 1.313 0.194 0.008 0.019 Condom use at high-risk sex 0.030 0.026 56 53 1.132 0.872 0.000 0.082 Abstinence among youth 0.979 0.004 1681 2228 1.183 0.004 0.971 0.987 Sexually active in past 12 months among youth 0.008 0.002 1681 2228 1.153 0.318 0.003 0.013 Had an injection in past 12 months 0.246 0.009 9647 11571 2.044 0.036 0.228 0.264 Had HIV test and received results in past 12 months 0.006 0.001 4733 5579 1.203 0.222 0.003 0.009 Accepting attitudes towards people with HIV 0.043 0.004 8073 10180 1.682 0.088 0.035 0.050 HIV prevalence among tested for HIV 15-49 0.006 0.002 4314 4756 1.278 0.241 0.003 0.010 Total fertility rate (3 years) 6.024 0.140 na 32106 1.901 0.023 5.743 6.304 Neonatal mortality (0-9 years) 41.038 2.194 17417 21045 1.264 0.053 36.651 45.425 Postneonatal mortality (0-9 years) 40.383 2.362 17434 21067 1.495 0.058 35.659 45.108 Infant mortality (0-9 years) 81.421 3.060 17439 21072 1.309 0.038 75.302 87.540 Child mortality (0-9 years) 58.084 3.018 17618 21294 1.445 0.052 52.049 64.120 Under-five mortality (0-9 years) 134.776 4.300 17645 21327 1.435 0.032 126.177 143.376 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 4405 5117 na na 0.000 0.000 Literate 0.527 0.011 4405 5117 1.521 0.022 0.504 0.550 No education 0.492 0.011 4405 5117 1.495 0.023 0.469 0.514 Secondary education or higher 0.104 0.006 4405 5117 1.292 0.057 0.092 0.116 Want no more children 0.329 0.013 2718 3080 1.474 0.040 0.302 0.355 Want to delay birth at least 2 years 0.429 0.013 2718 3080 1.371 0.030 0.403 0.455 Ideal family size 5.558 0.090 4059 4720 1.330 0.016 5.379 5.738 Has heard of HIV/AIDS (15-49) 0.959 0.005 3961 4610 1.609 0.005 0.949 0.969 Knows about condoms (15-49) 0.609 0.012 3961 4610 1.608 0.020 0.584 0.634 Knows about limiting partners (15-49) 0.772 0.011 3961 4610 1.715 0.015 0.749 0.795 Had 2+ sex partners in past 12 months (15-49) 0.043 0.005 2448 2728 1.313 0.126 0.032 0.053 High-risk sex (15-49) 0.054 0.006 2448 2728 1.416 0.120 0.041 0.067 Condom use at high-risk sex (age 15-49) 0.294 0.055 173 146 1.581 0.187 0.185 0.404 Abstinence among youth 0.904 0.010 1360 1672 1.309 0.012 0.883 0.925 Sexually active in past 12 months among youth 0.056 0.007 1360 1672 1.199 0.134 0.041 0.071 Paid for sexual intercourse in past 12 months 0.007 0.002 4405 5117 1.284 0.223 0.004 0.011 Had an injection in past 12 months (age 15-49) 0.187 0.009 3961 4610 1.384 0.046 0.169 0.204 HIV test and received results past 12 months (15-49) 0.012 0.002 3961 4610 1.388 0.197 0.008 0.017 Accepting attitudes towards people with HIV (15-49) 0.112 0.008 3743 4422 1.504 0.069 0.096 0.127 HIV prevalence among tested for HIV 15-49 0.007 0.002 3551 4120 1.232 0.247 0.004 0.010 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 278 | Appendix B Table B.5 Sampling errors for Tigray Region, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.207 0.023 1257 919 1.973 0.109 0.162 0.253 Literate 0.337 0.023 1257 919 1.696 0.067 0.292 0.382 No education 0.635 0.023 1257 919 1.712 0.037 0.588 0.681 Secondary education or higher 0.165 0.021 1257 919 2.030 0.129 0.122 0.207 Net attendance ratio for primary school 0.506 0.029 1167 833 1.760 0.057 0.448 0.564 Currently pregnant 0.086 0.007 1257 919 0.915 0.084 0.072 0.101 Children ever born to women age 40-49 6.768 0.191 225 156 1.142 0.028 6.385 7.150 Currently using any contraceptive method 0.165 0.015 798 570 1.176 0.094 0.134 0.196 Currently using pill 0.029 0.005 798 570 0.801 0.165 0.019 0.038 Currently using IUD 0.000 0.000 798 570 na na 0.000 0.000 Currently using female sterilization 0.000 0.000 798 570 na na 0.000 0.000 Currently using rhythm method 0.003 0.000 798 570 0.072 0.050 0.002 0.003 Want no more children 0.285 0.014 798 570 0.906 0.051 0.256 0.314 Ideal family size 4.700 0.107 1208 886 1.411 0.023 4.486 4.913 Perinatal mortality (0-6 years) 19.981 4.507 985 702 1.009 0.226 10.967 28.994 Mothers received tetanus injection for last birth 0.398 0.027 671 480 1.438 0.069 0.343 0.453 Mothers received medical assistance at delivery 0.060 0.012 980 698 1.491 0.200 0.036 0.084 Had diarrhoea in two weeks before survey 0.128 0.012 915 653 1.089 0.096 0.104 0.153 Treated with oral rehydration salts (ORS) 0.211 0.046 122 84 1.175 0.216 0.120 0.303 Taken to a health provider 0.188 0.043 122 84 1.156 0.230 0.101 0.274 Vaccination card seen 0.584 0.040 193 135 1.098 0.068 0.505 0.664 Received BCG 0.774 0.033 193 135 1.069 0.043 0.709 0.840 Received DPT (3 doses) 0.516 0.039 193 135 1.061 0.076 0.438 0.594 Received polio (3 doses) 0.566 0.039 193 135 1.071 0.069 0.488 0.644 Received measles 0.633 0.032 193 135 0.896 0.050 0.570 0.697 Fully immunized 0.329 0.041 193 135 1.181 0.124 0.248 0.411 Height-for-age (below -2SD) 0.410 0.030 442 316 1.220 0.072 0.351 0.469 Weight-for-height (below -2SD) 0.116 0.017 442 316 1.045 0.149 0.081 0.151 Weight-for-age (below -2SD) 0.419 0.034 442 316 1.351 0.081 0.351 0.486 Anaemic (children) 0.565 0.027 407 288 1.088 0.048 0.510 0.620 Anaemic (women) 0.293 0.021 566 411 1.073 0.070 0.252 0.334 BMI <18.5 0.375 0.021 524 390 0.987 0.055 0.334 0.417 Has heard of HIV/AIDS 0.970 0.008 1257 919 1.611 0.008 0.955 0.986 Knows about condoms 0.523 0.020 1257 919 1.442 0.039 0.482 0.564 Knows about limiting partners 0.721 0.028 1257 919 2.221 0.039 0.665 0.777 Had 2+ sex partners in past 12 months 0.000 0.000 405 290 na na 0.000 0.000 High-risk sex 0.052 0.013 405 290 1.163 0.248 0.026 0.077 Condom use at high-risk sex 0.000 0.000 21 15 na na 0.000 0.000 Abstinence among youth 0.955 0.015 261 200 1.186 0.016 0.925 0.986 Sexually active in past 12 months among youth 0.013 0.008 261 200 1.134 0.606 0.000 0.029 Had an injection in past 12 months 0.165 0.012 1257 919 1.155 0.073 0.141 0.190 Had HIV test and received results in past 12 months 0.019 0.004 610 448 0.655 0.192 0.011 0.026 Accepting attitudes towards people with HIV 0.142 0.022 1219 892 2.182 0.153 0.099 0.186 HIV prevalence among tested for HIV 15-49 0.026 0.013 564 387 2.005 0.522 0.000 0.052 Total fertility rate (3 years) 5.125 0.303 na 2514 1.353 0.059 4.519 5.731 Neonatal mortality (0-9 years) 40.362 4.716 1953 1384 0.959 0.117 30.930 49.794 Postneonatal mortality (0-9 years) 26.211 3.981 1955 1386 0.982 0.152 18.250 34.172 Infant mortality (0-9 years) 66.573 6.219 1955 1386 1.007 0.093 54.136 79.010 Child mortality (0-9 years) 42.492 5.661 1970 1396 1.121 0.133 31.169 53.815 Under-five mortality (0-9 years) 106.236 7.890 1972 1397 1.071 0.074 90.456 122.017 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.189 0.024 512 366 1.387 0.127 0.141 0.237 Literate 0.675 0.029 512 366 1.404 0.043 0.617 0.733 No education 0.469 0.036 512 366 1.611 0.076 0.398 0.540 Secondary education or higher 0.231 0.024 512 366 1.282 0.104 0.183 0.279 Want no more children 0.280 0.029 297 206 1.115 0.104 0.222 0.338 Want to delay birth at least 2 years 0.490 0.023 297 206 0.787 0.047 0.445 0.536 Ideal family size 4.771 0.135 482 346 1.181 0.028 4.501 5.040 Has heard of HIV/AIDS (15-49) 0.997 0.002 439 315 0.932 0.002 0.992 1.002 Knows about condoms (15-49) 0.779 0.027 439 315 1.356 0.035 0.725 0.833 Knows about limiting partners (15-49) 0.923 0.015 439 315 1.194 0.017 0.892 0.953 Had 2+ sex partners in past 12 months (15-49) 0.045 0.014 262 187 1.084 0.310 0.017 0.072 High-risk sex (15-49) 0.159 0.028 262 187 1.224 0.174 0.104 0.215 Condom use at high-risk sex (age 15-49) 0.537 0.077 36 30 0.915 0.144 0.382 0.691 Abstinence among youth 0.843 0.035 178 132 1.283 0.042 0.773 0.913 Sexually active in past 12 months among youth 0.118 0.027 178 132 1.103 0.227 0.064 0.171 Paid for sexual intercourse in past 12 months 0.017 0.008 512 366 1.312 0.440 0.002 0.032 Had an injection in past 12 months (age 15-49) 0.162 0.015 439 315 0.872 0.095 0.132 0.193 HIV test and received results i past 12 months (15-49) 0.025 0.007 439 315 0.911 0.270 0.012 0.039 Accepting attitudes towards people with HIV (15-49) 0.275 0.025 437 314 1.153 0.090 0.225 0.324 HIV prevalence among tested for HIV 15-49 0.016 0.007 407 274 1.156 0.455 0.001 0.030 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 279 Table B.6 Sampling errors for Affar Region, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.200 0.030 789 146 2.119 0.151 0.140 0.260 Literate 0.156 0.036 789 146 2.795 0.232 0.084 0.228 No education 0.848 0.037 789 146 2.898 0.044 0.774 0.922 Secondary education or higher 0.068 0.027 789 146 2.958 0.389 0.015 0.122 Net attendance ratio for primary school 0.153 0.023 958 159 1.619 0.149 0.108 0.199 Currently pregnant 0.089 0.016 789 146 1.545 0.176 0.058 0.120 Children ever born to women age 40-49 5.783 0.232 149 27 0.970 0.040 5.319 6.247 Currently using any contraceptive method 0.066 0.017 616 109 1.694 0.257 0.032 0.100 Currently using pill 0.013 0.006 616 109 1.188 0.411 0.002 0.024 Currently using IUD 0.000 0.000 616 109 na na 0.000 0.000 Currently using female sterilization 0.000 0.000 616 109 na na 0.000 0.000 Currently using rhythm method 0.006 0.004 616 109 1.368 0.725 0.000 0.014 Want no more children 0.198 0.030 616 109 1.867 0.152 0.138 0.258 Ideal family size 7.828 0.416 729 137 2.339 0.053 6.996 8.660 Perinatal mortality (0-6 years) 16.007 5.968 577 108 1.155 0.373 4.072 27.943 Mothers received tetanus injection for last birth 0.109 0.027 377 68 1.637 0.244 0.056 0.162 Mothers received medical assistance at delivery 0.045 0.017 574 107 1.687 0.369 0.012 0.078 Had diarrhoea in two weeks before survey 0.137 0.023 521 96 1.357 0.168 0.091 0.183 Treated with oral rehydration salts (ORS) 0.088 0.061 65 13 1.805 0.697 0.000 0.211 Taken to a health provider 0.092 0.043 65 13 1.222 0.460 0.007 0.177 Vaccination card seen 0.040 0.020 107 18 1.024 0.508 0.000 0.081 Received BCG 0.276 0.048 107 18 1.056 0.174 0.180 0.372 Received DPT (3 doses) 0.028 0.013 107 18 0.767 0.456 0.002 0.054 Received polio (3 doses) 0.199 0.043 107 18 1.053 0.214 0.114 0.284 Received measles 0.081 0.031 107 18 1.130 0.386 0.018 0.144 Fully immunized 0.006 0.006 107 18 0.788 1.015 0.000 0.019 Height-for-age (below -2SD) 0.408 0.046 251 46 1.518 0.112 0.317 0.499 Weight-for-height (below -2SD) 0.099 0.025 251 46 1.282 0.254 0.049 0.149 Weight-for-age (below -2SD) 0.341 0.061 251 46 1.994 0.180 0.218 0.463 Anaemic (children) 0.585 0.035 176 32 1.045 0.061 0.514 0.656 Anaemic (women) 0.404 0.038 283 55 1.324 0.093 0.329 0.480 BMI <18.5 0.330 0.036 329 61 1.407 0.110 0.257 0.402 Has heard of HIV/AIDS 0.854 0.022 789 146 1.730 0.025 0.810 0.898 Knows about condoms 0.272 0.032 789 146 2.031 0.118 0.208 0.337 Knows about limiting partners 0.369 0.037 789 146 2.160 0.101 0.295 0.444 Had 2+ sex partners in past 12 months 0.007 0.007 304 55 1.407 0.981 0.000 0.020 High-risk sex 0.020 0.009 304 55 1.138 0.458 0.002 0.038 Condom use at high-risk sex 0.584 0.214 6 1 0.971 0.366 0.156 1.012 Abstinence among youth 0.944 0.020 97 21 0.841 0.021 0.904 0.983 Sexually active in past 12 months among youth 0.026 0.012 97 21 0.721 0.451 0.003 0.049 Had an injection in past 12 months 0.153 0.021 789 146 1.644 0.138 0.111 0.195 Had HIV test and received results in past 12 months 0.018 0.011 384 72 1.598 0.609 0.000 0.039 Accepting attitudes towards people with HIV 0.051 0.015 661 125 1.768 0.298 0.021 0.081 HIV prevalence among tested for HIV 15-49 0.033 0.012 295 61 1.144 0.364 0.009 0.056 Total fertility rate (3 years) 4.934 0.383 na 407 1.495 0.078 4.167 5.700 Neonatal mortality (0-9 years) 33.117 5.913 1343 243 1.017 0.179 21.291 44.943 Postneonatal mortality (0-9 years) 28.016 6.016 1343 243 1.376 0.215 15.984 40.048 Infant mortality (0-9 years) 61.134 8.521 1343 243 1.151 0.139 44.091 78.176 Child mortality (0-9 years) 65.843 13.403 1348 243 1.446 0.204 39.037 92.649 Under-five mortality (0-9 years) 122.951 17.443 1348 243 1.485 0.142 88.066 157.837 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.197 0.042 314 65 1.855 0.212 0.113 0.280 Literate 0.270 0.054 314 65 2.160 0.200 0.162 0.379 No education 0.714 0.054 314 65 2.104 0.075 0.607 0.822 Secondary education or higher 0.115 0.036 314 65 1.971 0.309 0.044 0.186 Want no more children 0.151 0.029 205 42 1.145 0.190 0.094 0.209 Want to delay birth at least 2 years 0.257 0.021 205 42 0.701 0.084 0.214 0.300 Ideal family size 11.282 0.894 296 62 1.973 0.079 9.494 13.070 Has heard of HIV/AIDS (15-49) 0.964 0.014 281 59 1.286 0.015 0.935 0.992 Knows about condoms (15-49) 0.606 0.036 281 59 1.243 0.060 0.534 0.679 Knows about limiting partners (15-49) 0.735 0.060 281 59 2.259 0.081 0.616 0.854 Had 2+ sex partners in past 12 months (15-49) 0.071 0.018 216 45 1.008 0.248 0.036 0.107 High-risk sex (15-49) 0.159 0.027 216 45 1.074 0.168 0.106 0.213 Condom use at high-risk sex (age 15-49) 0.387 0.097 31 7 1.095 0.251 0.193 0.582 Abstinence among youth 0.653 0.083 67 15 1.409 0.127 0.487 0.818 Sexually active in past 12 months among youth 0.301 0.083 67 15 1.461 0.274 0.136 0.466 Paid for sexual intercourse in past 12 months 0.021 0.011 314 65 1.376 0.528 0.000 0.044 Had an injection in past 12 months (age 15-49) 0.147 0.032 281 59 1.491 0.215 0.084 0.210 HIV test and received results past 12 months (15-49) 0.012 0.008 281 59 1.151 0.623 0.000 0.027 Accepting attitudes towards people with HIV (15-49) 0.150 0.032 268 57 1.452 0.211 0.087 0.214 HIV prevalence among tested for HIV 15-49 0.024 0.005 212 46 0.503 0.221 0.013 0.035 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 280 | Appendix B Table B.7 Sampling errors for Amhara Region, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.112 0.009 1943 3482 1.260 0.080 0.094 0.130 Literate 0.251 0.015 1943 3482 1.570 0.062 0.220 0.282 No education 0.756 0.016 1943 3482 1.643 0.021 0.724 0.788 Secondary education or higher 0.085 0.013 1943 3482 2.032 0.151 0.059 0.111 Net attendance ratio for primary school 0.504 0.018 1817 3283 1.535 0.037 0.467 0.541 Currently pregnant 0.072 0.006 1943 3482 1.051 0.085 0.060 0.085 Children ever born to women age 40-49 6.971 0.141 363 657 1.033 0.020 6.688 7.253 Currently using any contraceptive method 0.161 0.013 1295 2330 1.268 0.081 0.135 0.186 Currently using pill 0.036 0.007 1295 2330 1.361 0.196 0.022 0.050 Currently using IUD 0.002 0.001 1295 2330 1.085 0.705 0.000 0.004 Currently using female sterilization 0.001 0.001 1295 2330 1.134 0.996 0.000 0.003 Currently using rhythm method 0.003 0.001 1295 2330 1.059 0.583 0.000 0.005 Want no more children 0.475 0.014 1295 2330 1.014 0.030 0.447 0.503 Ideal family size 4.123 0.088 1790 3206 1.389 0.021 3.946 4.299 Perinatal mortality (0-6 years) 55.744 6.458 1493 2685 1.005 0.116 42.829 68.660 Mothers received tetanus injection for last birth 0.298 0.023 1032 1856 1.625 0.078 0.252 0.344 Mothers received medical assistance at delivery 0.037 0.007 1458 2621 1.285 0.188 0.023 0.052 Had diarrhoea in two weeks before survey 0.146 0.008 1289 2312 0.787 0.053 0.130 0.161 Treated with oral rehydration salts (ORS) 0.199 0.031 191 337 1.070 0.156 0.137 0.261 Taken to a health provider 0.271 0.044 191 337 1.352 0.162 0.184 0.359 Vaccination card seen 0.333 0.030 267 482 1.045 0.091 0.272 0.393 Received BCG 0.623 0.041 267 482 1.369 0.065 0.541 0.704 Received DPT (3 doses) 0.315 0.036 267 482 1.269 0.115 0.243 0.388 Received polio (3 doses) 0.456 0.038 267 482 1.257 0.084 0.379 0.533 Received measles 0.348 0.032 267 482 1.096 0.092 0.283 0.412 Fully immunized 0.171 0.025 267 482 1.094 0.147 0.120 0.221 Height-for-age (below -2SD) 0.566 0.024 538 973 1.103 0.042 0.519 0.614 Weight-for-height (below -2SD) 0.142 0.017 538 973 1.124 0.123 0.107 0.177 Weight-for-age (below -2SD) 0.489 0.023 538 973 1.032 0.047 0.442 0.535 Anaemic (children) 0.520 0.025 472 858 1.076 0.048 0.471 0.570 Anaemic (women) 0.310 0.023 827 1486 1.412 0.073 0.265 0.355 BMI <18.5 0.270 0.018 821 1471 1.164 0.067 0.234 0.307 Has heard of HIV/AIDS 0.879 0.013 1943 3482 1.774 0.015 0.853 0.905 Knows about condoms 0.359 0.017 1943 3482 1.552 0.047 0.326 0.393 Knows about limiting partners 0.568 0.017 1943 3482 1.550 0.031 0.534 0.603 Had 2+ sex partners in past 12 months 0.001 0.001 635 1140 0.944 0.999 0.000 0.004 High-risk sex 0.029 0.008 635 1140 1.239 0.286 0.012 0.045 Condom use at high-risk sex 0.128 0.089 19 33 1.136 0.699 0.000 0.307 Abstinence among youth 0.959 0.010 295 523 0.881 0.011 0.938 0.979 Sexually active in past 12 months among youth 0.009 0.006 295 523 1.045 0.623 0.000 0.021 Had an injection in past 12 months 0.234 0.015 1943 3482 1.570 0.064 0.204 0.264 Had HIV test and received results in past 12 months 0.010 0.002 917 1640 0.716 0.232 0.005 0.015 Accepting attitudes towards people with HIV 0.086 0.011 1711 3061 1.609 0.126 0.065 0.108 HIV prevalence among tested for HIV 15-49 0.018 0.005 822 1411 0.978 0.250 0.009 0.027 Total fertility rate (3 years) 5.085 0.202 na 9828 1.242 0.040 4.680 5.490 Neonatal mortality (0-9 years) 50.103 4.308 2979 5376 0.948 0.086 41.487 58.720 Postneonatal mortality (0-9 years) 44.311 4.648 2981 5379 1.203 0.105 35.014 53.607 Infant mortality (0-9 years) 94.414 6.195 2982 5381 1.035 0.066 82.024 106.805 Child mortality (0-9 years) 66.162 5.726 3021 5454 1.052 0.087 54.711 77.613 Under-five mortality (0-9 years) 154.330 8.877 3025 5461 1.173 0.058 136.576 172.084 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.085 0.007 897 1521 0.757 0.083 0.071 0.099 Literate 0.540 0.019 897 1521 1.154 0.036 0.502 0.579 No education 0.605 0.022 897 1521 1.359 0.037 0.560 0.649 Secondary education or higher 0.126 0.016 897 1521 1.425 0.125 0.095 0.158 Want no more children 0.356 0.028 534 913 1.346 0.078 0.301 0.412 Want to delay birth at least 2 years 0.397 0.025 534 913 1.176 0.063 0.347 0.447 Ideal family size 4.898 0.121 868 1470 0.970 0.025 4.657 5.139 Has heard of HIV/AIDS (15-49) 0.962 0.007 795 1347 1.100 0.008 0.947 0.977 Knows about condoms (15-49) 0.749 0.025 795 1347 1.625 0.033 0.699 0.799 Knows about limiting partners (15-49) 0.797 0.020 795 1347 1.368 0.024 0.758 0.836 Had 2+ sex partners in past 12 months (15-49) 0.020 0.007 456 775 1.105 0.363 0.005 0.034 High-risk sex (15-49) 0.035 0.007 456 775 0.870 0.214 0.020 0.050 Condom use at high-risk sex (age 15-49) 0.563 0.123 17 27 0.992 0.218 0.317 0.809 Abstinence among youth 0.932 0.012 296 497 0.821 0.013 0.908 0.956 Sexually active in past 12 months among youth 0.034 0.009 296 497 0.822 0.254 0.017 0.052 Paid for sexual intercourse in past 12 months 0.006 0.003 897 1521 1.038 0.456 0.001 0.011 Had an injection in past 12 months (age 15-49) 0.155 0.015 795 1347 1.177 0.098 0.125 0.185 HIV test and received results past 12 months (15-49) 0.025 0.008 795 1347 1.395 0.312 0.009 0.040 Accepting attitudes towards people with HIV (15-49) 0.197 0.023 765 1295 1.601 0.117 0.151 0.243 HIV prevalence among tested for HIV 15-49 0.016 0.005 720 1212 1.113 0.324 0.006 0.027 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 281 Table B.8 Sampling errors for Oromiya Region, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.151 0.017 2230 5010 2.183 0.110 0.118 0.184 Literate 0.295 0.019 2230 5010 1.952 0.064 0.257 0.332 No education 0.644 0.022 2230 5010 2.130 0.034 0.601 0.687 Secondary education or higher 0.100 0.012 2230 5010 1.853 0.118 0.076 0.124 Net attendance ratio for primary school 0.427 0.020 2196 4940 1.691 0.046 0.388 0.466 Currently pregnant 0.090 0.007 2230 5010 1.087 0.073 0.077 0.103 Children ever born to women age 40-49 7.053 0.123 367 816 0.762 0.017 6.808 7.299 Currently using any contraceptive method 0.136 0.012 1468 3300 1.311 0.086 0.113 0.160 Currently using pill 0.034 0.006 1468 3300 1.289 0.179 0.022 0.046 Currently using IUD 0.002 0.001 1468 3300 0.527 0.318 0.001 0.003 Currently using female sterilization 0.002 0.001 1468 3300 0.650 0.343 0.001 0.004 Currently using rhythm method 0.004 0.002 1468 3300 1.062 0.462 0.000 0.007 Want no more children 0.471 0.016 1468 3300 1.227 0.034 0.439 0.503 Ideal family size 4.210 0.100 1932 4338 1.460 0.024 4.010 4.410 Perinatal mortality (0-6 years) 34.162 5.092 1948 4433 1.118 0.149 23.978 44.346 Mothers received tetanus injection for last birth 0.311 0.019 1211 2723 1.441 0.062 0.273 0.350 Mothers received medical assistance at delivery 0.048 0.007 1938 4411 1.226 0.140 0.035 0.062 Had diarrhoea in two weeks before survey 0.177 0.012 1769 4017 1.317 0.070 0.152 0.201 Treated with oral rehydration salts (ORS) 0.226 0.032 317 709 1.308 0.139 0.163 0.289 Taken to a health provider 0.235 0.030 317 709 1.184 0.128 0.175 0.295 Vaccination card seen 0.388 0.032 304 691 1.161 0.084 0.323 0.453 Received BCG 0.578 0.041 304 691 1.448 0.071 0.497 0.660 Received DPT (3 doses) 0.285 0.037 304 691 1.443 0.131 0.211 0.360 Received polio (3 doses) 0.411 0.041 304 691 1.458 0.100 0.329 0.493 Received measles 0.294 0.038 304 691 1.445 0.129 0.218 0.370 Fully immunized 0.202 0.033 304 691 1.433 0.163 0.136 0.268 Height-for-age (below -2SD) 0.410 0.021 831 1867 1.158 0.050 0.369 0.452 Weight-for-height (below -2SD) 0.096 0.010 831 1867 1.040 0.110 0.075 0.117 Weight-for-age (below -2SD) 0.344 0.021 831 1867 1.279 0.062 0.301 0.387 Anaemic (children) 0.560 0.019 768 1717 1.059 0.035 0.521 0.599 Anaemic (women) 0.249 0.015 971 2177 1.053 0.059 0.220 0.278 BMI <18.5 0.243 0.016 902 2036 1.114 0.065 0.211 0.275 Has heard of HIV/AIDS 0.947 0.007 2230 5010 1.435 0.007 0.933 0.960 Knows about condoms 0.410 0.018 2230 5010 1.746 0.044 0.374 0.446 Knows about limiting partners 0.683 0.015 2230 5010 1.559 0.022 0.653 0.714 Had 2+ sex partners in past 12 months 0.002 0.002 694 1558 0.912 0.723 0.000 0.006 High-risk sex 0.028 0.007 694 1558 1.132 0.255 0.014 0.042 Condom use at high-risk sex 0.307 0.118 19 43 1.087 0.385 0.071 0.544 Abstinence among youth 0.960 0.016 536 1210 1.923 0.017 0.927 0.993 Sexually active in past 12 months among youth 0.021 0.007 536 1210 1.173 0.346 0.007 0.036 Had an injection in past 12 months 0.266 0.018 2230 5010 1.896 0.067 0.230 0.301 Had HIV test and received results in past 12 months 0.014 0.003 1052 2368 0.871 0.224 0.008 0.021 Accepting attitudes towards people with HIV 0.080 0.011 2114 4742 1.914 0.141 0.058 0.103 HIV prevalence among tested for HIV 15-49 0.022 0.004 965 2000 0.881 0.188 0.014 0.031 Total fertility rate (3 years) 6.175 0.316 na 13861 1.959 0.051 5.544 6.806 Neonatal mortality (0-9 years) 39.681 3.940 3865 8769 1.101 0.099 31.800 47.562 Postneonatal mortality (0-9 years) 35.853 4.028 3871 8783 1.277 0.112 27.798 43.909 Infant mortality (0-9 years) 75.534 4.863 3872 8785 1.024 0.064 65.808 85.261 Child mortality (0-9 years) 50.596 5.179 3908 8860 1.260 0.102 40.238 60.954 Under-five mortality (0-9 years) 122.309 6.645 3916 8879 1.095 0.054 109.019 135.598 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.124 0.012 1041 2222 1.178 0.097 0.100 0.148 Literate 0.615 0.018 1041 2222 1.188 0.029 0.579 0.651 No education 0.367 0.016 1041 2222 1.054 0.043 0.336 0.399 Secondary education or higher 0.203 0.012 1041 2222 0.989 0.061 0.178 0.227 Want no more children 0.397 0.025 572 1228 1.204 0.062 0.348 0.446 Want to delay birth at least 2 years 0.409 0.025 572 1228 1.228 0.062 0.358 0.459 Ideal family size 4.755 0.135 971 2057 1.365 0.028 4.485 5.025 Has heard of HIV/AIDS (15-49) 0.984 0.005 953 2041 1.325 0.005 0.973 0.995 Knows about condoms (15-49) 0.618 0.017 953 2041 1.082 0.028 0.584 0.652 Knows about limiting partners (15-49) 0.815 0.017 953 2041 1.322 0.020 0.782 0.848 Had 2+ sex partners in past 12 months (15-49) 0.035 0.009 530 1147 1.159 0.263 0.017 0.054 High-risk sex (15-49) 0.088 0.013 530 1147 1.059 0.148 0.062 0.114 Condom use at high-risk sex (age 15-49) 0.460 0.073 46 101 0.982 0.158 0.315 0.606 Abstinence among youth 0.857 0.019 382 807 1.069 0.022 0.819 0.895 Sexually active in past 12 months among youth 0.090 0.014 382 807 0.985 0.160 0.061 0.119 Paid for sexual intercourse in past 12 months 0.010 0.003 1041 2222 1.052 0.329 0.003 0.016 Had an injection in past 12 months (age 15-49) 0.224 0.014 953 2041 1.068 0.064 0.195 0.253 HIV test and received results past 12 months (15-49) 0.017 0.005 953 2041 1.167 0.290 0.007 0.026 Accepting attitudes towards people with HIV (15-49) 0.136 0.017 938 2009 1.483 0.122 0.103 0.170 HIV prevalence among tested for HIV 15-49 0.004 0.002 878 1812 1.000 0.506 0.000 0.009 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 282 | Appendix B Table B.9 Sampling errors for Somali Region, Ethiopia 2005 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.177 0.070 669 486 4.770 0.398 0.036 0.317 Literate 0.098 0.044 669 486 3.855 0.452 0.009 0.187 No education 0.906 0.044 669 486 3.900 0.049 0.817 0.994 Secondary education or higher 0.052 0.031 669 486 3.601 0.598 0.000 0.113 Net attendance ratio for primary school 0.138 0.034 988 647 2.322 0.245 0.070 0.206 Currently pregnant 0.100 0.015 669 486 1.333 0.155 0.069 0.130 Children ever born to women age 40-49 6.690 0.196 113 73 0.769 0.029 6.299 7.082 Currently using any contraceptive method 0.031 0.028 508 363 3.634 0.897 0.000 0.088 Currently using pill 0.000 0.000 508 363 na na 0.000 0.000 Currently using IUD 0.000 0.000 508 363 na na 0.000 0.000 Currently using female sterilization 0.000 0.000 508 363 na na 0.000 0.000 Currently using rhythm method 0.004 0.004 508 363 1.397 0.954 0.000 0.012 Want no more children 0.103 0.020 508 363 1.458 0.191 0.064 0.143 Ideal family size 9.743 0.633 547 400 2.806 0.065 8.478 11.009 Perinatal mortality (0-6 years) 29.815 7.857 666 480 0.996 0.264 14.101 45.530 Mothers received tetanus injection for last birth 0.094 0.032 398 288 2.195 0.342 0.030 0.159 Mothers received medical assistance at delivery 0.052 0.031 663 477 2.977 0.601 0.000 0.115 Had diarrhoea in two weeks before survey 0.122 0.015 604 432 1.097 0.124 0.092 0.152 Treated with oral rehydration salts (ORS) 0.158 0.053 68 53 1.153 0.338 0.051 0.264 Taken to a health provider 0.085 0.041 68 53 1.099 0.481 0.003 0.166 Vaccination card seen 0.081 0.049 101 78 1.705 0.605 0.000 0.178 Received BCG 0.171 0.055 101 78 1.453 0.321 0.061 0.280 Received DPT (3 doses) 0.056 0.039 101 78 1.759 0.699 0.000 0.134 Received po