Jordan - Demographic and Health Survey - 1992

Publication date: 1992

Jordan Jordan Population and Family Health Survey 1990 Department of Statistics Ministry of Health ®DHS Demographic and Health Surveys IRD/Macro International Inc. THE HASHEMITE KINGDOM OF JORDAN Jordan Population and Family Health Survey 1990 Abdallah Abdel Aziz Zou'bi Sri Poedjastoeti Mohamed Ayad Department of Statistics Amman, Jordan Ministry of Health Amman, Jordan IRD/Macro International Inc. Columbia, Maryland USA August 1992 Principal Editor: Dr. Abdnllmdi Alawin Editors: J. Ties Boerma Anne R. Cross Sidney H. Moore Jeremiah M. Sullivan This report summarizes the f'mdings of the 1990 Jordan Population and Family Health Survey (JPFHS) conducted by the Jordan Department of Statistics. IRD/Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development. The JPFHS is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information on the Jordan survey may be obtained from the Department of Staff sties, P.O. Box 2015, Jubhaiha Street, Amman, Jordan (Telephone 962-6-842171; Fax 962-6-833518). Additional information about the DHS program may be obtained by writing to: DHS, IRD/Macro International Inc., 8850 Stanford Boulevard, Suite 4000, Columbia MD 21045, US A (Telephone 410-290-2800; Telex 198116; Fax 410-290-2999). CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Summary and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Map of Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx CHAPTER 1. INTRODUCTION 1.1 1.2 1.3 1.4 1.5 History, geography and economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Health policy and programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Objectives of the survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Organization of the survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 CHAPTER 2. CHARACTERIST ICS OF HOUSEHOLDS AND RESPONDENTS 2.1 Population by age and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.2 Population by age from other sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.3 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.4 Level of educaton of the household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.5 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.6 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.7 Presence of durable goods in the household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.8 Age structure of respondents to the individual questionnaire . . . . . . . . . . . . . . . . . . . . . . 17 2.9 Respondent's level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2.10 Exposure to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 CHAPTER 3. FERT IL ITY 3.1 3.2 3.3 3.4 3.5 3.6 Levels and differentials in fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Fertility trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Children ever born and l iving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 BirLh intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Teenage fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 CHAPTER 4. FAMILY PLANNING 4.1 Knowledge of family planning methods and sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 4.2 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 4.3 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.4 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.5 Problems with current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 4.6 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 iii Page 4.7 Timing of sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 4.8 Source of supply of modem methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 4.9 Time to source of modem family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.10 Contraceptive discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.11 Future use of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 4.12 Acceptability of media messages on family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 CHAPTER 5. NUPTIALITY AND EXPOSURE TO THE RISK OF PREGNANCY 5.1 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.2 Marital exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 5.3 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.4 Postpartum amenorrbea, postpartum abstinence, and insusceptibility . . . . . . . . . . . . . . . 60 5.5 Termination of exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 CHAPTER 6. FERTILITY PREFERENCES 6.1 Desire for children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 6.2 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 6.3 Ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 6.4 Planning status of births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 CHAPTER 7. INFANT AND CHILDHOOD MORTALITY 7.1 Assessment of data quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 7.2 Levels, trends and differentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 7.3 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 CHAPTER 8. MATERNAL AND CHILD HEALTH 8.1 Antenatal care and delivery assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 8.2 Immunization of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 8.3 Child morbidity and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 CHAPTER 9. INFANT FEEDING AND CHILDHOOD NUTRITION 9.1 Breasffeeding and supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 9.2 Nutritional status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 APPENDICES Appendix A. Sample design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Appendix B. Estimates of sampling errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Appendix C. Data quality tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ; . . . . . . . . . . 133 Appendix D. Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 iv Table 1.1 Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 Table 3.11 Table 3.12 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 TABLES Page Results of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Educational level of the household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Current fertility according to selected surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Age specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Children ever bern according to selected surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Median age at first birth by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Teenage fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Children born to teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Knowledge of contraceptive methods and source for methods . . . . . . . . . . . . . . . . . . . . . . 34 Knowledge of modem contraceptive methods and sources for methods . . . . . . . . . . . . . . 35 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Trends in contraceptive use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . 42 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Problems with current method of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 V Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 5.1 Table 5.2 Table 5.3 Table 5A Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Page Timing of sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Time to source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . 48 First-year discontinuation rates for contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Reasons for discontinuation of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Acceptability of the use of mass media for disseminating family planning messages . . . . 54 Ever-married women according to selected surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Marital exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Postpartum amenorrhea, abstinence and insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Median duration of postpartum insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Fertility preferences by age . . . ; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Desire to stop having children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . . . . . . . . 72 Planning status of biahs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 81 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 vi Table 8.5 Table 8.6 Table 8.7 Table 8.8 Table 8.9 Table 8.10 Table 8.11 Table 8.12 Table 8.13 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table A. 1 Table A.2 Table B.1 Table B.2 Table B.3 Table B.4 Table B.5 Table C. 1 Table C.2 Table C.3 Table C.4 Table C.5 Page Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Delivery characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Vaccination by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Vaccinations in the first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Knowledge and use of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Breasffeeding practices during diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Breasffeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Breastfeeding and supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Median duration and frequency of breastfceding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Nutritional status by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Distribution of sample points by govemorate and stratum, Jordan 1990 . . . . . . . . . . . . . 118 Results of the household and individual interviews by residence and region . . . . . . . . . . 120 List of selected variables for sampling errors, Jordan 1990 . . . . . . . . . . . . . . . . . . . . . . . 125 Sampling errors - Entire sample, Jordan 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Sampling errors - Large city, Jordan 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Sampling errors - Other urban, Jordan 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Sampling errors - Rural, Jordan 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Births by calendar year since birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 vii FIGURES Figure 2.1 Figure 2.2 Figure 2.3 Figure 3.1 Figure 3.2 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 5.1 Figure 5.2 Figure 6.1 Figure 6.2 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 7.5 Figure 8.1 Figure 8.2 Figure 8.3 Figure 9.1 Male and female population by single years of age, Jordan, 1990 . . . . . . . . . . . . . . . . . . . 10 Population pyramid of Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Population by broad age groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Age-specific fertility rates, JFS 1976, Jl-,Pl-lS 1983, and JPFHS 1990 . . . . . . . . . . . . . . . . 22 Mean number of children ever born, Jordan, 1976, 1983, and 1990 . . . . . . . . . . . . . . . . . . 26 Current use of contraceptive methods, currently married women 15-49 . . . . . . . . . . . . . . 39 Current use of specific contraceptive methods, currently married women 15-49 . . . . . . . . 40 Contraceptive use by residence and education, currently married women 15-49 . . . . . . . . 41 Contraceptive use by number of living children, currently married women 15-49 . . . . . . . 43 Sources of family planning methods, current users of modem methods . . . . . . . . . . . . . . . 47 Never-married women 15-39 by age, Jordan, 1976, 1983, and 1990 . . . . . . . . . . . . . . . . . 56 Median duration of postpartum amennrrhea, abstinence, and insusceptibility . . . . . . . . . . 62 Fertility preferences, currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Deaths under age two by age at death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Trends in infant and child mortality by five-year periods . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Infant mortality by five-year periods, JFS 1976, JFFHS 1983, and JPFHS 1990 . . . . . . . . 78 Infant and under-five mortality by residence and education . . . . . . . . . . . . . . . . . . . . . . . . 80 Infant mortality by selected demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Maternal care indicators by residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Vaccination coverage among children 12-23 months by source of information . . . . . . . . . 94 Prevalence of diarrhea among children under five years . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Percentage of children under five years who are chronically undernourished (stunted) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 ix PREFACE The Department of Statistics takes pleasure in presenting the principal report for the Jordan Population and Family Health Survey, 1990. This survey was undertaken by the Department of Statistics in collaboration with the Ministry of Health and IRD/Macro International Inc. under the international Demographic and Health Surveys (DHS) program. IRD/Macro International provided funding as well as technical assistance. Additional funds were provided by the United States Agency for International Development (USAID)/Amman. The survey covered a national sample of about 16,300 households. This sample was used to collect information on households, including basic demographic characteristics, education, health insurance, and basic information to measure unemployment. Half of the sample (also nationally representative and covering all sample clusters) was used to identify ever-married women of childbearing age for the individual interview. Information collected from these women covered the areas of fertility and fertility preference, family planning, breastfeeding and nutrition, child health, immunization, morbidity and mortality. The Department of Statistics would like to thank all the agencies that participated in this survey, whose support brought this work to success, especially IRD/Macro International, USAID, the Ministry of Health, and all the households that cooperated with the DOS survey staff by providing the required information. I hope that the information in this report will be useful to those interested in policy formulation and decision making in the health and population areas. Dr. Abdulhadi Alawin Director General of Statistics xi ACKNOWLEDGMENTS The Jordan Population and Family Health Survey (JPFHS) was successfully conducted with fieldwork taking place September through December 1990. The success of the survey was made possible by the keen and dedicated participation of a large number of persons, and it is not possible to thank each and every one of them individually. The National Committee for the JPFHS under the directorship of Dr. Abdulhadi Alawin, Director General of the Department of Statistics, has given valuable suggestions to the survey design, particularly in the areas of maternal and child health. I would like to acknowledge the participation of Drs. AbdaUah Hamdan, Fuad EI-Ayed, Akef E1-Azab and Mr. Abdulrahim Ma'itah in the preparation of this report. The survey would not have materialized without the participation throughout the survey activities of the project team at the Department of Statistics, particularly Mr. Kamal Saleh, Mr. Abdelhadi Kharabsheh and Ms. Ekhlas Aranki. I would also like to thank the USAID/Amman for providing funds for the survey, and in particular Mr. P.E. Balakrishnan, Chief of the Office of Population, Health and Nutrition, for his keen interest and continued assistance. Thanks are also extended to the UNFPA for assisting the Department of Statistics in establishing the mapping unit, which bad an important role in the sampling work for the survey. The survey benefited from the assistance extended by the Demographic and Health Surveys (DHS) program, especially for providing funds for the survey and through a number of DHS staff who made visits to Jordan during the project. I would like to thank Mr. Martin Vaessen for his assistance and encouragement; Dr. Mohamed Ayad for his assistance at all stages of the survey, including the preparation of the survey reports; Dr. Ann Way for her involvement during the preparation of the project documents; and Dr. Alfredo Aliaga for designing the survey sample and supervising the sample selection. I would also like to thank Mr. GuiUermo Rojas, for providing assistance in data processing and the tabulation of survey results. Ms. Anne Cross, Dis. Ties Boerma, Jerry Sullivan and Sidney Moore made significant contributions in improving this report. Ms. Kaye Mitchell and Mr. Robert Wolf are acknowledged for their contribution to the production of the survey report. Special thanks go to Ms. Sri Poedjastoeti, DHS Country Monitor, for her invaluable contributions and helpful advice throughout the various stages of the survey. Last but not least, the field workers, field editors, supervisors and coordinators who were employed by this project should be commended for their tireless efforts to obtain data of notable quality. Dr. Abdallah Alxlel Aziz Zou'bi Survey Director xiii SUMMARY AND RECOMMENDATIONS The Jordan Population and Family Health Survey (JPFHS) was carried out by the Department of Statistics between September and December 1990. Financial and technical assistance were provided by IRD/Ivlaero International Inc. under a contract with the United States Agency for International Development (USA1D)/Washington. The USAID/Amman provided partial financial support for the survey. The JPFI-IS was designed to provide information on levels and trends of fertility, infant and child mortality, and family planning. The survey also gathered information on breastfeeding, matemal and child health cam, the nutritional status of children under five, as well as the characteristics of households and household members. The survey covered a nationally representative sample of 8,333 households and a total of 6,461 ever-married women between the ages of 15 and 49. A. CURRENT STATUS AND PROGRESS Fertility The JPFHS documents that significant progress has been made in relation to the fertility of women in Jordan. The total fertility rate for the five-year period prior to the survey indicates that on average, women have 5.6 children by the end of their reproductive years. This figure represents a reduction of 15 percent over the preceding seven-year period (from 1983 to 1990). The total fertility rate was 7.7 in the 1976 Jordan Fertility Survey (JFS) and 6.6 in the 1983 Fertility and Family Health Survey (JFFHS). There are large differences in fertility by educational attainment of the women. Women who have attended more than secondary schooling can expect to have 4 children in their lifetime, while women with no education have close to 7 children. Further decline in fertility can be expected in the future. Approximately 50 percent of currently married women in Jordan do not want any more children. If the desired family size were achieved, the fertility rate would be only 3.9 children per woman, or 30 percent less than the current rate. Family Planning A major portion of the decline in fertility can be attributed to the increasing use of family planning, especially modem methods. Results from the survey indicate that 40 percent of currently married women are using a method of family planning (including 5 percent of women who use prolonged breastfeeding as a method of contraception). This is an increase of 35 percent since 1983, when the contraceptive prevalence rate was 26 percent (which does not include users of prolonged breastfeeding). Two-thirds of women use modem methods, particularly the IUD (15 percent), female sterilization (6 percent), and pill (5 percent). Widespread knowledge of family planning is also supportive of further fertility decline. Virtually all currently married women know a method of contraception. Women generally feel it is acceptable to have family planning messages broadcast on radio and television. • Married women living in large cities are twice as likely to use modem contraception as women in rural areas. XV • Contraceptive use increases with parity; currently married women who have no living children have the lowest level of use; women with four or more children have the highest level of use. Other Fertility Determinants The JPFHS data show that women in Jordan are marrying at increasingly older ages. The differentials in age at first marriage by region and type of residence are small. However, women who have attended more than secondary education marry on average almost 6 years later than women with no education. In addition to marriage patterns, the risk of pregnancy is affected by postpartum amenorrhea, the period al~er childbirth when menstruation has not yet returned; postpartum abstinence, the period when sexual activity has not yet been resumed; and breasO~eeding. On average, women start menstruating again 7 months after childbirth; sexual relations are resumed a little over 2 months after childbirth; and women breastfeed their children for 13 months. • Taking into account the effects of postpartum amenorrhea and abstinence, a women is not at risk of pregnancy for an average of 7 months aher delivering a baby. The protection from pregnancy conferred by postpartum amenorrhea, abstinence, and breastfeeding is one month shorter for women living in large cities than for rural women. It is two months shorter for women who have attended more than secondary education than for women who have no education. Future Use of Family Planning • Four in ten married women who are not currently using contraception say that they intend to adopt a family planning method some time in the future. • Close to half of the women who expressed an intention to use contraception in the future said they would prefer to use the IUD. The next most popular method is the pill. Fertility Preferences On average, the ideal number of children for women is 4.4. There is little variation by residence, however, women 15-19 years want an average of more than one child less than women 45-49; women who have attended more than secondary school want one child less than women who have no education. • The JPFHS documents that seven in ten women who are using contraception do so to stop childbearing. Maternal and Child Health As indicated by the survey results, Jordan has made considerable progress in providing health care to pregnant women and their children. For 80 percent of births in the past five years, the mothers received at least one pregnancy checkup from medically trained personnel. • Four of five births in the past five years were delivered in a hospital. In the seven years between 1983 and 1990, hospitals have become popular as a place of delivery. xvi Forty percent of the binJas in the five years preceding the survey were to women who had a tetanus toxoid injection during pregnancy. This is a substantial improvement over coverage in 1983, when the injection was received for only 9 percent of births. The JPFHS found that 88 percent of children 12-23 months of age in Jordan have been vaccinated against DPT, polio and measles. However, less than one in five received a BCG vaccination. Nine percent of children under five had diarrhea in the two weeks preceding the survey. Of these children, four in ten were given oral rehydration therapy in the form of a solution prepared from ORS packets. In the JPFHS, all children born since January 1985 were weighed and measured. Nineteen percent of children under five are short for their age (stunted)--a measure of chronic undemutrition; 6 percent are underweight for their age. Infant and Child Mortality The infant and child mortality rates for the five-year period preceding the survey are 34 and 39 deaths per 1,000 births respectively. While there is no significant difference in infant mortality by urban-rural residence, children of mothers who have attended more than secondary education have a greater probability of surviving in the first year of life than children of mothers who have no education. CONTINUING CHALLENGES Despite the increase in the use of family planning methods and the apparent decline in fertility, the Jordan Population and Family Health Survey reveals a number of continuing challenges. The major concern is that, although fertility levels are declining, over 20 percent of births in the five years preceding the survey were not wanted when they occurred. If these unwanted births had been prevented, women would have had an average of 3.9 births, instead of 5.6 births. Almost one-quarter of currently married women reported that they wanted to delay the next birth or wanted to stop childbearing, but were not using a contraceptive method. This situation is defined as unmet need offamily planning. Eight percent of married women are in need of family planning to delay the next birth, while 15 percent are in need to limit further childbearing. To delay, and in many cases to prevent a birth is an important decision, which influences the health of children. Four of five births occurring in the five years preceding the survey were at high risk either because the mother was too young (under age 18), too old (age 35 and over), had many prior births (3 or more), or the interval since the previous birth was too short (less than two years). The JPFHS provides information on the reasons women give for discontinuing use of various family planning methods. Having become pregnant, wanting to become pregnant, and side effects of methods were the most frequently cited reasons for discontinuing the use of contraception. Pill and IUD users were most concemed about the side effects, while method failure was the major problem reported by users of traditional methods. xvii • The major (potential) barrier to use of family planning by married women who am not using contraception is the desire to have children and the difficulty in becoming pregnant. C. RECOMMENDATIONS The results of the 1990 JPFHS demonstrate that the maternal and child health (MCH) programs in Jordan have good coverage in providing antenatal and delivery care to women of reproductive age. The survey indicates that the utilization of MCH services has increased, along with knowledge and use of family planning. However, the survey data also suggest that there is room for improvement in a number of areas. Additional effort is needed in information and education on the benefits of adopting family planning for the purpose of delaying or limiting childbearing. These efforts should cover topics such as: sources of family planning services, the monthly reproductive cycle, and side effects associated with certain methods. • Potential users should be counseled on the most appropriate method for their age, fertility intentions, and personal situation. • Emphasis should be placed on the health benefits for mothers and children of practicing traditional methods such as prolonged breastfeeding. xviii JORDAN IRAQ SYRIA AMMAN ZARQA AND MAFRAQ DEAD SEA SOUTH SAUDI ARABIA 20 CHAPTER 1 INTRODUCTION 1.1 HISTORY, GEOGRAPHY, AND ECONOMY Jordan, one of the most modem countries in the Middle East, is almost entirely land-locked. The port of Aqaba in the far south is Jordan's only outlet to the sea. Palestine separates it from the Mediterranean, while Sandi Arabia lies to the south and east, Iraq to the northeast, and Syria to the north. The total area of the country is about 89,000 square kilometers. The country was part of the Ottoman Empire until 1921 when it gained its independence. It was declared a political entity known as "Transjordan" in 1923. In 1950, Transjordan and the West Bank were united, and assumed the current name of the Hasbemite Kingdom of Jordan. In 1967, the West Bank and Gaza Strip were occupied by Israeli forces, causing a massive influx of migrants to the East Bank. The West Bank was excluded from the Kingdom in 1988 upon the desires of the Arab states to facilitate the estab- lishment of the Palestinian state. The country is divided into 8 govemorates, which are organized into three regions: Irbid and Mafraq in the Northern region; Amman, Zarqa, and Balqa in the Central region; and Karak, Tafielah, and Ma'an in the Southern region. The major cities are Amman, Zarqa, and Irbid. There are three agricultural development regions that divide the country longitudinally from north to south. These are the Jordan Valley, the highlands, and the semidesert badia. The geographical distribution of the population is determined mainly by rainfall patXerns and methods of cultivation, in addition to business and manufacturing. More than 80 percent of the population are concentrated in one-eighth of the total land area, mainly in the uplands of the northwest. Ninety-six percent of Jordanians are Muslims; about 4 percent are Christians (Department of Statistics, 1984a). The most serious problem facing the government after the 1991 Gulf War was the return of large numbers of Jordanian nationals who had been working in the Gulf countries. By the end of 1990, their number was estimated to reach 300,000, most of whom came from Kuwait. In addition, some 90,000 refugees (primarily from Bangladesh, Egypt, Sri Lanka, and the Philippines) crossed into Jordan from neighboring countries. These people came mostly from Kuwait and Saudi Arabia. The sudden increase in the population has created problems regarding food, housing, employment, and education. 1.2 POPULATION Size, Growth, and Structure Prior to 1952, there was no organized attempt to study the population of the East Bank of Jordan, except for rough estimates based on registers compiled by the United Nations Relief and Welfare Agency (UNRWA). The 1952 Housing Census produced information about the population (then estimated at 586,000 persons), as well as about the housing situation. The first population census, which was carded out in 1961, found 900,000 persons living in the East Bank. As a result of the establishment of the state of Israel in 1948 and the 1967 Arab-Israeli War, which caused the occupation of the West Bank and Gaza Strip, alarge number of Palestinians moved to the East Bank. The population increased from 2.13 million in 1979 (Department of Statistics, 1982) to 3.45 million in 1990 (National Population Commission, 1991), an average increase of 4.3 percent annually. At this rate, the population can be expected to double in 16 years. The Jordanian population is highly urbanized. More than 70 percent of the population live in localities of more than 5,000 inhabitants. These localities are concentrated in the three largest, most urban govemorates, Amman, Zarqa and Irbid, which are named after the three largest cities. Twenty-five percent of the population live in the capital, Amman; while Zarqa and Irbid cities are inhabited by more than 10 and 5 percent of the country's population, respectively. Results of the Health, Nutrition, Manpower, and Poverty Survey conducted in 1987 (Department of Statistics, 1989a) indicate that the age structure of the population has changed considerably since 1979, primarily as a result of changes in fertility, mortality, and migration. The proportion of population under 15 years of age declined from 57 percent in 1979 to 46 percent in 1987, while the proportion age 65 or over increased from 2.8 percent in 1979 to 3 percent in 1987. Fertility Fertility has been declining in Jordan since the mid-1970s. Studies have found that the total fertility rate declined from 7.7 children per woman in 1976, to 7.1 in 1981, to 6.6 in 1983. The estimated crude birth rate, based on births registered with the DeparUnent of Civil Status and Passports, was 50 births per thousand population in the early 1970s, and 34 births per thousand population in 1990 (Department of Statistics, 1991). Mortality Mortality has been declining even faster than fertility. The crude death rate, estimated at 19 deaths per thousand population in the 1950s, had declined to 12 per thousand two decades later. In 1990, the crude death rate was estimated to be 7 deaths per thousand population (Department of Statistics, 1991). Another measure of mortality, the infant mortality rate, was estimated at 125 deaths per thousand live births for the period 1951-1955. After twenty years, it had declined by half to 67 per thousand (Abdel Aziz, 1983) and in 1980-1987 it was estimated to be 49 deaths per thousand live births (Zou'bi, 1989). Internal Migration and Urbanization The most recent information on internal migration is obtained from the 1986 Intemal Migration Survey (Department of Statistics, 1989b). According to this survey 6 percent of the population are lifetime migrants and 9 percent are current migrants. Lifetime migrants are calculated based on place of birth, while current migrants are calculated based on last place of residence. The study was limited to the East Bank, with the governorates as geographic units. Forced migration from the West Bank and Gaza Strip was not included. Intemal migration has generally taken place over short distances and occurs mainly in the Central region. The movement of people from rural to urban areas is an important factor in the rapidly increasing population density in urban areas. A typical migration pattem is for people to move from a village to an urban center in the same govemorate, then move to another urban center in another govemorate. International Migration International migration in Jordan flows in two directions. There has always been considerable population movement from Jordan to the Gulf States; at the same time, people are coming into Jordan from Egypt, Syria and Asia, mainly from Sri Lanka and the Philippines. The Gulf crisis brought back an estimated 300,000 Jordanians from the Gulf States, particularly from Kuwait. The large influx of people created problems of unemployment and poverty, and a general worsening of the standard of living. 1.3 HEALTH POLICY AND PROGRAMS Health Policy and Strategy The national health policy is based on the principle that all citizens have the right to health services. The Ministry of Health is committed to making health services available, accessible, and acceptable in all communities, and seeks to ensure equitable distribution of these services. The objective of the government is to achieve "Health for all by the year 2000," in accordance with the guidelines set forth by the World Health Organization. To meet this objective, the government has given priority to the health sector and developed a national health strategy. This strategy is aimed at creating a comprehensive health care system, utilizing both public and private service providers, and covering all levels of care from preventive care to tertiary and rehabilitative care. The health sector's goal in improving the health status and the quality of life is twofold: to reduce the probability of becoming ill, and to increase the probability of recovery. Health Plans and Programs Recognizing that investment in socioeconomic development is vital to improving the quality of life and the standard of living, the government of Jordan has, in its health.programs, focused on the following areas: . Coordination of primary, secondary, and tertiary health service delivery, in order to improve the efficiency of the health system and to avoid duplication among health providers and the waste of resources; . Health manpower development to raise standards in all health manpower categories and to maintain quality standards throughout the system; . Facility development by upgrading the existing health centers and hospitals, and building new facilities as needed; 4. Improve efficiency in expenditures without affecting the quality of services. Short-term and long-term plans have been developed to improve the health care system and the delivery of services to the population. 1.4 OBJECTIVES OF THE SURVEY The 1990 Jordan Population and Family Health Survey (JPFHS) was carried out as part of the Demographic and Health Survey (DHS) program. The Demographic and Health Surveys is assisting governments and private agencies in the implementation of household surveys in developing countries. The main objectives of the project include: a) providing decision makers with a data base and analyses useful for informed policy choices, b) expanding the international population and health data base, c) advancing survey methodology, and d) developing skills and resources necessary to conduct high quality demographic and health surveys in the participating countries. The JPFHS was specifically aimed at providing information on fertility, family planning, and infant and child mortality. The questionnaires also gathered information on breastfeeding, maternal and child health cam and nutritional status, as well as the characteristics of households and household members. The Jordan Population and Family Health Survey will provide policy makers and planners with important information for use in formulating programs and policies related to reproductive behavior and health. 1.5 ORGANIZAT ION OFTHESURVEY The JPFHS is a national sample survey designed to collect data on ever-married women of reproductive age. The areas covered include: demographic and socioeconomic characteristics, marriage and reproduction, antenatal care, breastfeeding and child care, fertility preferences, and nutritional status of children under five years of age. The survey was funded primarily by the United States Agency for Inter- national Development (USAID) as part of the worldwide DHS program. The Jordan DHS survey was conducted by the Department of Statistics (DOS) in collaboration with the Ministry of Health. The national director for the JPFHS was the Director General of Statistics; the survey director was the Chief of the National Household Survey Division (Department of Statistics). A national advisory committee was established to provide guidelines for the planning and implementation of the survey. The committee carried out its tasks by holding periodic meetings, particularly during the design stages of the survey. The committee consisted of representatives from various agencies associated with population and health issues. In addition to the Department of Statistics and the Ministry of Health, there were repre- sentatives from the Ministry of Planning, the University of Jordan, the Jordan University of Science and Technology, the National Population Committee, and the Jordan Family Planning and Protection Association. A representative from the USAID mission in Amman maintained close contact with the national advisory committee and the survey director. The survey was executed in three stages; the first was the preparatory stage, which involved mapping, the listing of housing units, and the design and implementation of sampling procedures. At the same time, the survey questionnaires were developed, pretested, and finalized. All of these activities were completed in September 1990. The second stage was the interviewing and collection of data. This was carried out by 11 teams, each consisting of one supervisor, one field editor, three interviewers, and one person to do the anthropometric measurements. Each team was provided with a vehicle and driver. Data collection took place from October through December 1990. The last stage involved data processing, evaluation, and analysis. Data entry started soon after the beginning of the fieldwork, and continued until May 1991. The Gulf crisis had an impact on the second phase of the data processing, delaying the publication of the preliminary report. Sample Design and Implementation The sample for the JPFHS survey was selected to be representative of the major geographical regions, as well as the nation as a whole. The survey adopted a stratified, multi-stage sampling design. In each govemorate, localities were classified into 9 strata according to the estimated population size in 1989. The sampling design also allowed for the survey results to be presented according to major cities (Amman, Irbid and Zarqa), other urban localities, and the rural areas. Localities with fewer than 5,000 people were con- sidered rural. For this survey, 349 sample units were drawn, containing 10,708 housing units for the individual interview. Since the survey used a separate household questionnaire, the Department of Statistics doubled the household sample size and added a few questions on labor force, while keeping the original individual sample intact. This yielded 21,172 housing units. During fieldwork for the household interview, it was found that 4,359 household units were ineligible either because the dwelling was vacant or destroyed, the household was absent during the team visit, or some other reason. There were 16,296 completed household interviews out of 16,813 eligible households, producing a response rate of 96.9 percent. The completed household interviews yielded 7,246 women eligible for the individual interview, of which 6,461 were successfully interviewed, producing a response rate of 89.2 percent. The sample design 4 is described in Appendix A, and a discussion of the sampling errors for selected variables is presented in Appendix B. Questionnaires The 1990 JPFI-IS utilized two questionnaires, one for the household interview and the other for individual women (see Appendix D). Both questionnaires were developed first in English and then translated into Arabic. The household questionnaire was used to list all members of the sample households, including usual residents as well as visitors. For each member of the household, basic demographic and socioeconomic characteristics were recorded and women eligible for the individual interview were identified. To be eligible for individual interview, a woman had to be a usual member of the household (part of the de jure population), ever-married, and between 15 and 49 years of age. The household questionnaire was expanded from the standard DHS-II model questionnaire to facilitate the estimation of adult mortality using the orphanhood and widowhood techniques. In addition, the questionnaire obtained information on polygamy, economic activity of persons 15 years of age and over, family type, type of insurance covering the household members, country of work in the summer of 1990 which coincided with the Gulf crisis, and basic data for the calculation of the crude birth rate and the crude death rate. Additional questions were asked about deceased women if they were ever-married and age 15-49, in order to obtain information for the calculation of materoal mortality indices. The individual questionnaire is a modified version of the standard DHS-II model "A" questionnaire. Experience gained from previous surveys, in particular the 1983 Jordan Fertility and Family Health Survey, and the questionnaire developed by the Pan Arab Project for Child Development (PAPCHILD), were useful in the discussions on the content of the JPFHS questionnaire. A major change from the DHS-II model questionnaire was the rearrangement of the sections so that the marriage section came before reproduction; this allowed the interview to flow more smoothly. Questions on children's cause of death based on verbal autopsy were added to the section on health, which, due to its size, was split into two parts. The first part focused on antenatal care and breastfeeding; the second part examined measures for prevention of childhood diseases and information on the morbidity and mortality of children loom since January 1985. As questions on sexual relations were considered too sensitive, they were replaced by questions about the husband's presence in the household during the specified time period; this served as a proxy for recent sexual activity. The JPFHS individual questionnaire consists of nine sections: Respondent's background and household characteristics Marriage Reproduction Contraception Breastfeeding and health Immunization, morbidity, and child mortality Fertility preferences Husband's background, residence, and woman's work Height and weight of children The questionnaires used in the JPFHS survey are reproduced in Appendix D. Pretest The household and individual questionnaires were pretested in July 1990 in a number of urban and rural clusters. All senior staff members of the survey organization participated in this activity. The field staff 5 for the pretest was made up of female university graduates hired through the government recruitment office. To assist in the survey activities, particularly in regard to obtaining health information, the Ministry of Health provided a number of staff nurses. Pretest training, which lasted three weeks, involved class discussion and field practice. Staff from the Ministry of Health and the Jordan Family Planning and Protection Agency were invited to give talks on their respective area of expertise. The pretest teams were also trained to carry out supervisory tasks, since they were expected to act as supervisors or field editors during the main fieldwork. Anthropometric measurements were not included in the pretest because the scales and boards were not available. The pretest revealed some minor problems in the questionnaire skip patterns, which were corrected. Fieldwork Activities Prior to the main survey fieldwork, mapping was carried out and the enumeration areas/blocks were selected. During this process, buildings and dwelling units in the areas were listed and numbered. The selected clusters were identified and marked with large signs on the buildings forming the comers of the clusters. In the same activity, housing units were documented, along with the name of the owner/tenant of the unit, or household and the name of the household head. A large proportion (almost 17 pereen0 of the housing units were vacant. These activities were completed in between September 26 and October 10, 1990. Fieldworkers for the main survey were hired through the government recruitment office. At the time of hiring, they were informed about the type of work they would be expected to do. All the interviewers had college degrees. Supervisors and field editors were selected from those who participated in the pretest. They were retained by the Department of Statistics after the pretest to assist in sampling activities. Training of field workers was done in two stages; the first was training for the household interview. More than one hundred people participated in this activity. The household survey was carried out in September (ahead of the individualinterview) to provide the government with much-needed data for planning purposes, particularly regarding employment and persons who returned from the Gulf countries. It should be noted that the fieldwork started after the crisis in the Gulf region began. The training of interviewers and supervisors for the individual questionnaire lasted three weeks and was carded out concurrently at two training centers. One site was the Statistical Training Center in Amman, part of the Department nf Statistics; the other was the regional statistical office in Irbid. The training was conducted by Dr. AbdaUah Zou'bi, the Survey Director, Mr. Kamal Saleh, a senior demographer, and Dr. Mohamed Ayad of IRD/Macro International. Much of the training consisted of lectures on how to conduct the interviews and how to fill out the questionnaires. Practice interviewing was done in the third week of training. Staff from the Ministry of Health and the Jordan Family Planning and Protection Agency were invited to speak on issues related to their activities. The main survey fleldwork was carried out from October to December 1990. Each of the 11 field teams was made up of one supervisor, one field editor, three interviewers, and one anthropometrist. The teams were equipped with scales and measuring boards to collect information on the height and weight of children. A vehicle was assigned to each team. All teams started working in Amman, Zarqa, Irbid, and Balqa and were stationed in the respective govemorates. In other govemorates teams were formed from the field staff who had worked in Amman, Irbid and Zarqa. Data collection in these governorates was carried out in the first week of November through the end of December 1990. 6 Data Processing Activities Data processing started almost immediately aRer the field work began. Field editors checked the questionnaires for completeness and consistency. Supervisors also checked completed questionnaires on a sample basis with more emphasis in the first few days of the fieldwork. Questionnaires were then sent to the central office in Amman, where they were again hand edited and the open-ended questions were ceded. Data entry started one week after the beginning of fieldwork, using eight microcomputers. The process of data entry, editing and cleaning was done with ISSA (Integrated System for Survey Analysis) programs specially designed for DHS surveys. These activities took place through the first week of March 1991. Under normal circumstances, the DHS data processing specialist would have made a trip to Jordan toward the end of the fieldwork, to identify problems associated with data entry and editing, and to work on tabulations for the preliminary report. However, due to the Gulf crisis in early 1991, this trip was delayed. Instead, the survey data were sent to the DHS office in Columbia, Maryland, and it was not until May 1991 that preparations for the preliminary report were begun. Results of the Household and Individual Interviews Table 1.1 is a summary of the results from the household and individual interviews by type of residence. In the JPFI-IS, there are three residential categories: large cities, other urban areas, and rural areas. The table shows the number of households sampled, the number that were found, and the number that were successfully interviewed. For the individual interview, the number of eligible women found in the selected households and the number of women successfully interviewed are presented. The data indicate a high response rate for the household interview (96.9 percent), and a lower rate for the individual interview (89.2 percent). Women in large cities have a slightly lower response rate (88.6 percent) than those in other areas. Most of the nonresponse for the individual interview was due to the absence of respondents and the postponement of interviews which were incomplete. Table 1,1 Results of the household and individual interviews Number of households, number of individual Interviews and response rates, by urban-rural residence, Jordan 1990 Residence Large Other Result city urban Rural Total Household Interviews Number of housing anits sampled 8034 Number of households found 6580 Number of households interviewed 6391 Household response rate 97.1 Individual Interviews Number of eligible women 2756 Number of eligible women interviewed Individual response rate 7043 6095 21172 5505 4728 16813 5318 4587 16296 96.6 97.0 96.9 2407 2083 7246 2441 2143 1877 6461 88.6 89.0 90.1 89.2 7 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS This chapter describes the general characteristics of the sample population, including age and sex composition, residence, education, housing facilities, and exposure to mass media. The data are presented for various subgroups of the population. When combined with data from other sources, the information can be used to monitor changes over time. Another purpose of the chapter is to describe the environment in which the respondents and their children live. The characteristics which are highlighted are those that particularly influence nuptiality, fertility, contraceptive behavior, maternal care and child morbidity and mortality. The questionnaire for the Jordan Population and Family Health Survey (JPFHS) included two questions distinguishing between the de jure population (persons who usually live in the selected household) and the de facto population (persons who spent the night before the interview in the household). It was found, however, that the difference between them was small, and since sample selection for the JPFHS was based on the de jure population, and past demographic surveys were based on de jure populations, tabulations for the JPFHS household data were carried out based on the de jure population only. 2.1 POPULAT ION BY AGE AND SEX In many developing countries, data on age are affected by errors such as misstatement and preference for or avoidance of certain digits. In order to improve age reporting in cases where age is not given, the interviewers were instructed to ask for legal documents, such as an identity card, birth certificate, or health card for pre-school children. The survey results indicated that not only age, but month and year of birth are widely recognized. Of the total population covered in the survey (more than 111,000), only 7 cases did not have age recorded. Also, the distribution of the population by single years of age (see Figure 2.1) indicates that although there is some preference for ages ending in 0 or 5, the problem is limited in extent. Table 2.1 shows the percent distribution of the population by age and sex, according to urban-rural residence. The table serves two purposes. The first is to show the effects of past demographic trends on the population and to give an indication of their future trends. The second is to describe the context in which a variety of demographic processes are operating. Experience indicates that age reporting in some populations suffers from problems of age heaping or age preference, which means that respondents tend to report ages with a particular terminal digit. The extent of age heaping or digit preference is usually investigated using the Myers' Index (Shryock and Siegel, 1973) which provides a summary measure and identifies the digits which are preferred or avoided by the respondents. Results from the 1990 JPFI-IS survey indicate that the quality of age reporting in Jordan is very good. On a scale of 0 to 180, males scored 5 and females 7. These figures show that age reporting in the 1990 survey is better than that in previous surveys. In the 1983 Jordan Fertility and Family Health Survey (JFFHS), the indices were 12 for males and 15 for females, and in the 1976 Jordan Fertility Survey (JFS) the indices were 42 for males and 49 for females (Abdel Aziz et al., 1983). Analysis of the JPFHS data indicated a preference for reporting ages ending with "0" and "5", at the expense of ages with terminal digits of "1" and "9" (see Figure 2.1). 9 Figure 2.1 Male and Female Population by Single Years of Age Jordan, 1990 Number of persons 1000 800 600 400 200 0 0 5 10 15 20 25 30 35 40 45 50 55 Age . . . . Male I Female / J PFHS 1990 Table 2.1 Household population by age) residence and sex Percent distribution of the de jure household population by five-year age group, according to sex and urban-rural residence, Jordea 1990 Large dry Other urban Rural Total Age group Male Female Total Male Female Total Male Female Total Male Female Total 0-4 13.4 13,8 13.6 14.8 15.4 15.1 16,5 16.7 16.6 14.7 15.1 14,9 5-9 13,3 13,4 13.3 14.8 15.3 15.1 16.1 15.8 15.9 14.5 14.7 14.6 10-14 13.7 13,8 13.7 15.1 14.3 14.7 15.8 15.1 15.5 14.7 14.3 14.5 15-19 13.3 13.1 13.2 13.0 13,4 13.2 12.9 12.9 12.9 13.1 13.2 13.1 20-24 12.1 11.2 11.6 11.2 10.6 10.9 9.9 9.4 9.7 11.2 10.5 10.9 25-29 8.7 7.8 8.3 7.7 7.2 7.4 6.6 6.5 6,6 7.8 7.3 7.5 30-34 4.9 5.5 5.2 5.0 5.1 5.1 4.4 4.8 4.6 4.8 5.2 5.0 35-39 3.7 3.9 3.8 3.4 4.0 3.7 3.5 3.9 3.7 3.6 3.9 3.7 40-44 3.4 3.9 3.7 3.1 3,6 3.3 2.8 3.4 3,1 3.1 3.7 3.4 4549 3.6 3.7 3.6 3.3 3,0 3.2 2.8 3.0 2.9 3,3 3.3 3.3 50-54 3.1 3.1 3.1 2.7 2.6 2.7 2.5 2.8 2.6 2,8 2.8 2.8 55-59 2.3 7,3 2.3 1.9 1.7 1.8 1.7 1.5 1.6 2.0 1.9 1.9 60454 1.9 1.7 1.8 1.5 1.5 1.5 1.5 1.4 1.5 1.7 1.6 1.6 65-69 1.2 1.1 1.1 0.8 0.9 0.9 1.0 0.8 0.9 1.0 0.9 1.0 70-74 0.7 0.7 0.7 0.6 0.7 0.7 0.9 0.8 0.8 0.7 0.7 0.7 75-79 0.3 0,4 0.4 0.4 0.3 0.3 0.4 0.4 0.4 0.4 0.4 0.4 80 + 0.5 0.6 0.5 0.6 0.5 0.6 0.8 0.6 0.7 0.6 0.6 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 23022 21359 44381 19333 17901 37234 15709 14135 29844 58065 53394 111459 10 Figure 2.2 Population Pyramid of Jordan 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 10 5 0 5 10 Percent JPF H-q 1990 In Jordan, there are more males than females. The overall ratio of males to females is 109, or 109 males for every 100 females. This is a slightly higher ratio than that reported for the 1983 JFI-'HS survey (108). The large percentage of children under 15 years of age is an indicator of high fertility. The proportion under age 15 is consistently higher for rural populations and for males. The population pyramid for Jordan (see Figure 2.2) shows the wide-base pattern typical of countries in which fertility is high. 2.2 POPULAT ION BY AGE FROM OTHER SOURCES Table 2.2 and Figure 2.3 present a comparison of broad age groups for three surveys: the 1976 JFS, the 1983 JFFHS, and the 1990 JPFHS. The percentage of the population under 15 years of age declined sub- stantially between 1983 and 1990. As a result, the per- centage in the 15-59 shows an increase. This pattern is typical of populations that are experiencing a fertility decline. The change in the age structure is favorable in economic terms, assuming that those who are in the pro- duaive ages are economically active. The dependency ratio, calculated as the ratio of persons in the "depend- ent" ages (under 15 and 60 and over) to those in the "economic, ally active" ages (15-59) based on these figures, decreases from 130 in 1976, to 123 in 1983, and 94in 1990. Table 2.2 Population by ago from selected sources Percent distzibution of the de jure population by broad age groups, selected sources, Jordan 1976-1990 JFS JFFHS JPFHS Age group 1976 1983 1990 Less than 15 52.0 51.2 44.0 15-60 43.4 44.8 51.6 60+ 4.5 4.0 4.3 Total 100.0 100.0 100.0 11 60 50 40 30 20 10 0 Percent Figure 2.3 Population by Broad Age Groups JFS 1976 JFFHS 1983 JPFHS 1990 BIB 0-14 ~ 15-59 ~ 60+ "~ I 2.3 HOUSEHOLD COMPOSIT ION Table 2.3 provides information on the size and composition of the sampled households. Household characteristics affect the social and economic well-being of the members of the household. Large household size may be associated with crowding, which can lead to unfavorable health conditions. Single-parent families, especially if they are headed by females, usually have limited financial resources. Information on household composition can also be examined in terms of the number of generations present, since multi- generation households are distinct from single-generation households in a number of ways. In the JPFHS, instead of asking the relationship of each household member to the head-of-household, relationship among members was recorded. This information is used to construct family classifications which am comparable to other data sources. Large households are common in Jordan. The average number of members (usual residents) in a household is nearly 7. Households in major cities are smaller than those in other urban areas, which are in turn, smaller than rural households. The difference in household size between the large cities and rural areas is almost one person. Thirty-two percent of households are comprised of 9 or more persons. The figure is higher (39 percent) in rural areas, and lower in large cities (25 percent). The majority of households in Jordan (71 percent) are nuclear families (parents and children) (see Table 2.3). With slight variation, households in large cities are more likely to be nuclear, or nuclear with unmarried relatives, while in the mral areas the households tend to be either nuclear or consist of ever-married relatives. One in eight families in large cities is a nuclear family with unmarried relatives, which may indicate difficulty in finding separate housing for relatives. 12 Table 2.3 Household composition Pereem distribution of households by size of household and family type, according to urben.rural residence, Jordan 1990 Residence Large Other Characteristic city urban Rural Total Number of usual members 0 0.0 0.0 0.l 0.0 l 2.9 2.7 3.0 2.9 2 8.4 7.9 8.1 8.2 3 8.4 8.1 6.2 7.7 4 10,3 9.1 7.5 9.2 5 11.9 9.3 9.0 10.4 6 13,1 9.5 8.9 10.9 7 10.9 9.8 10.5 10.5 8 9.2 9.2 8.1 8.9 9+ 24.9 34.3 38.7 31.5 Total 100.0 100.0 100.0 100.0 Mean size of household 6.4 7.1 7.3 6.9 Family type Single person 2.8 2.7 3.0 2.8 Single parent with child(ten) 6.3 4.8 4.8 5.4 Parents with children 69,6 71.0 73.3 71.0 Parents with children end unmarried relatives 12.0 5.9 5.9 8.5 Two ever-married siblings with or without children 1.7 1.5 1.1 1.5 Two ever-married relatives with or without children 3.3 6.4 7.3 5,3 Three or more ever-married relatives with or without childre~ 3.0 5.7 3.2 3.9 Unrelated 1.3 2.1 1.3 1.5 Not classifiable 0.0 0.0 0.l 0.0 Total 100.0 100.0 100.0 100.0 2.4 LEVEL OF EDUCATION OF THE HOUSEHOLD POPULATION Education is an important variable affecting demographic behavior. Higher education is usually associated with greater knowledge and use of health practices and family planning methods. The education system in Jordan has been in place for a long time. Basic education is free and compulsory, starting at age six and lasting for 10 years. A further two-year period, known as the secondary cycle, is virtually free (Battelle Human Affairs Research Canters, 1980). In the JPFHS, questions on education were asked for persons five years of age and older. They included literacy, highest level of education attended and highest grade completed at that level, and whether the person was still in school at the time of the survey. These data can be used to generate school enrollment rates. Table 2.4 presents data on the educational composition of the population reported in the household questionnaire. Animportant observationisthatwomenhavelesseducationthanmen. More than 90 percent 13 Table 2.4 Educationallevel of the household populalion l~w, ent di~ailmtion of the de jam male and female hou~hold populations ago five and over by highest level of education a:tmdr~ e.~otff~n 8 to se~ backsround characteristics, Jordan 1990 I~vel of education Numb~ Median Backgmund No Morethan of numbm" c~___~_'lti¢ education Primary Secondary secondary Missing Total persons ofyears MALE Age 5-9 1.6 56.7 0.0 0.0 41.7 100.0 8436 2,8 10-14 0.9 72.2 26.4 0.0 0.5 100.0 8553 5.9 15-19 1.5 7.8 87.4 3.3 0.1 100.0 7616 9,6 20-24 2,7 7.4 60.2 29.6 0,I I00,0 6486 12,1 25-29 4.2 9.2 50.5 36.1 0.1 190.0 4533 12,4 30-34 5.6 13.7 49.1 31.6 0.0 190.0 2778 11,5 35-39 9.1 17,9 49.0 23.8 0.1 190.0 2067 9.6 40-44 11.0 24.6 44.4 19.8 0.1 190.0 1822 9.1 45-49 16.3 29.2 38.1 16.4 0.0 100.0 1901 7.7 50-54 31.6 33.3 25.4 9.7 0.0 190.0 1633 5,7 55-59 41.2 36.9 16.2 5.7 0.0 190.0 1153 4.3 60-64 50.9 35.4 10.6 3.1 0,0 190.0 971 1.0 65+ 71,8 20.7 5.7 1,8 0.0 190.0 1571 0.7 Miuing/Don't know 65.5 34.5 0.0 0.0 0.0 1~.0 3 0.8 Residence Large city 6.3 30,3 40.8 16.2 6.5 190.0 19931 8.4 Othe~ urban 8.0 32.7 40.0 12.1 7.1 190.0 16477 7.6 Rural 12.0 33.7 38.9 6.9 8,5 190.0 13115 6.7 Region Amman 7.5 30.9 39.8 15.0 6.8 190.0 19394 8.1 Zaxqa + Mefiaq 8.2 32.5 41,4 10.8 7.2 100.0 9926 7.6 Irbid 8,6 31,9 40.4 11,7 7.4 190.0 12237 7.6 Balqa 10.1 33.0 38.8 10.6 7.6 190.0 3312 7.2 South 10.6 35.2 37.7 7.7 8.7 190.0 4654 6.7 Total 8.4 32.0 40.0 12.4 7.2 190.0 49523 7.7 FEMALE Age 5-9 1.7 56.7 0.0 0.0 41.6 190.0 7852 2.8 10-14 1.6 70.9 27.0 0.0 0.5 100.0 7647 5.9 15-19 3,0 9.3 82.4 5.3 0.0 190.0 7030 9.8 20-24 5.3 9.3 54.6 30.7 0.1 190.0 5607 12.2 25-29 9.6 13.7 50.3 26.4 0.1 190.0 3877 11,2 30-34 18.1 22,6 41.5 17,8 0.0 190.0 2766 8.4 35-39 33.4 25.1 31.8 9.7 0.0 190.0 2106 6.2 40-44 48.6 25.4 19.9 6.0 0.1 100.0 1966 2.5 45-49 65.0 19.5 12.9 2.5 0.0 100.0 1747 0.8 50-54 81.5 11.2 5.9 1.4 0.0 100.0 1504 0.6 55-59 85.2 9.6 4.0 1.2 0.0 1~.0 994 0.6 60-64 88.7 6.7 3.9 0.7 0.0 190.0 832 0.6 65+ 93.4 4.2 1.8 0.5 0.I 190.0 1385 0.5 Miuing/Do~'t Imow I00.0 0.0 0.0 0.0 0.0 190.0 8 0.5 Res/denee Larse city 15.2 29.6 37.7 11.3 6.2 100.0 18416 7.1 Oth= ud~n 17.9 30.9 34.0 9.3 7.9 100.0 15137 6.4 Rural 25.7 32.4 28.9 4.6 8.5 190.0 11770 4.9 Region Amnum 16.2 29.8 36.7 10.6 6.8 I00.0 18157 6.9 Zm-qa + Mafreq 18.6 33.0 33.4 7.5 7.5 190.0 8832 6.1 kbld 20.3 30.6 33.8 7.8 7.5 190.0 11143 6.1 Balqa 22.6 31.4 30.0 8.2 7.9 I00.0 3064 5.6 South 24.6 30.5 29.0 7,8 8.2 190.0 4127 5.3 Total 18.8 30.8 34.2 8.9 7.3 190.0 45322 6,3 14 of the males in Jordan have had some schooling, while just over 80 percent of the females have attended school. Furthermore, men are likely to stay in school longer than women. The figures for median number of years of schooling (see Table 2.4) indicate that public education has a long history in Jordan. Men age 50-54 have a median of 6 years of education (equivalent to completing primary school), while women in the same age cohort have less than one year. Among persons age 35-39 years, the median duration of schooling for men is close to 10 years, whereas women have a little more than 6 years. For persons 25-34 the gap has narrowed, and finally disappears for those under 25 years of age. The level of education is closely associated with residence. In the large cities, a greater proportion of the population have attended higher education than in the restofthe country. The govemorates of Amman, Zarqa and Mafraq, and Irbid lead in terms of overall educational attainment. 2.5 SCHOOLENROLLMENT Table 2.5 shows the proportion of the household population age 6-24 years enrolled in school, by age, sex and residence. Although the differentials are small, the data support the association of educational enrollment with residence. Large cities have the highest level of educationai enrollment, followed by other urban areas, and rural areas. School enrollment differentials by gender vary according to age. For boys and gifts age 6-10 years there is virtually no difference in enrollment. However, as age increases, the gap between males and females widens, and by age 21-24 the enrollment rate for femaies is only half that for males. Table 2.5 School enroUmeaat Percentage of the de jt~e household population age 6-24 yews er~olled in school by age group, sex, and urban-rural residence, Jordan 1990 Male Female Total Large Other Large Other Large Other Age group city urban Rural Total city urban Rural Total city urbcm Rural. Total 6-10 97.2 97.5 96.6 97.1 97.7 97.5 95.6 97.0 97.5 97.5 96.1 97.1 11-15 93.2 93.7 93.5 93.4 93.5 92.1 87.1 91.2 93.3 92.9 90.5 92.4 6-15 95.2 95.6 95.1 95.3 95.6 94.9 91.5 94.2 95.4 95.3 93.4 94.8 16-20 54.2 51.7 44.8 50.9 54.3 50.3 41.9 49.8 54.2 51.0 43,4 50.4 21-24 15.5 11.5 8.3 12.5 8.0 6.2 3.6 6.4 12.1 9.1 6.2 9.7 2.6 HOUSING CHARACTERISTICS In the JPFHS, information on housing characteristics was collected in the individual questionnaire rather than in the household questionnaire. Thus, a sampled household is represented by the number of eligible women interviewed in the household. Households for which no individual interview was completed are, therefore, not included in the analysis. 15 Table 2.6 presents the distribution of households by housing characteristics. Elec- tricity is widely available; only 3 percent of households do not have electricity. The per- centage varies from 10 percent in rural areas to less than 1 percentin the large cities. Virtually all households in Jordan have piped water; this is particularly true in large cities and urban areas where water is piped into the houses. In rural areas, although 80 percent of the house- holds have water piped into the house, 8 per- cent have water piped into the yard only. Almost all houses in Jordan are built of permanent materials such as stone, brick, and concrete. Brick is used in more than 50 percent of the houses; another third of the houses are built with concrete. This pattern is the same in cities and rural areas, although, cut stone is more popular in urban areas. In large cities, one in five dwellings is made of cut stone alone or cut stone combined with con- crete. The large size of households in Jordan can be seen in Table 2.6. The mean number of persons per sleeping room is 4 for the country as a whole; this number varies from 3.7 in large cities to 4.5 in rural areas. Almost half of the households have 3 to 4 persons per sleep- ing room, 29 percent have 1 or 2 persons, and one in six households has 5 to 6 persons per sleeping room. These figures indicate the ex- tent of crowdedness in the household. 2.7 PRESENCE OF DURABLE GOODS IN THE HOUSEHOLD Jordan is a modemized society, and most of the population enjoy the convenience of electrical appliances (see Table 2.7). About Table 2.6 Housing characteristics Percent distribution of households by housing eharaeteristles, according to urban-rural residence, Jordma 1990 Residence Housing Large Other characteristics city urban Rural Total Electricity Yes 99.5 98.9 90.0 96.8 No 0.5 1.1 10.0 3.2 Total 100.0 100.0 100.0 100.0 Source of drinking water Piped into residence 97.6 92.9 80.1 91.5 Piped into yard, plot 0.7 2.3 8.0 3.1 Public tap 1.1 2.2 3.1 2.0 River, spring, dam 0.0 0.0 1.1 0.3 Tanker truck, vendor 0,4 1.5 2.9 1.4 Well 0.l 1.0 4.1 1.5 Other 0.0 0.1 0.5 0.2 Total 100.0 100.0 100.0 100.0 Building type Cut stone 6.5 3.7 1.0 4.1 Cut stone+concrete 14.0 8.2 2.0 9.0 Concrete 33.6 29.9 36.2 33.1 Brick 44.7 55.9 55.9 51.3 Mud brick 1.0 1.4 3.8 1.9 Zinc/metal 0.1 0.3 0.6 0.3 Other 0.1 0.7 0.5 0.4 Total 100.0 100.0 100.0 100.0 Persons per sleeping room 1-2 34.1 29.8 21.6 29.4 34 47.2 45.8 44.0 45.9 5-6 12.6 14.8 21.7 15.7 7 + 6.2 9.6 12.7 9.0 Total 100.0 100.0 100.0 100.0 Mean 3.7 4.0 4.5 4.0 Number 2465 1953 1573 5990 82 percent of the households have a refrigerator, 88 percent have a radio, and television sets are present in 91 percent of households. There are some differences between the large cities and rural areas, particularly regarding the presence of a refrigerator. Ninety-one percent of households in the large cities had a refrig- erator, whereas, only 66 percent of rural households had a refrigerator. A telephone is available in 34 percent of the households; this figure ranges from 43 in the large cities to 21 percent in rural areas. 16 Table 2.7 Household durable goods Percentage of households possessing various durable consumer goods, by urban-rural residence, Jordan 1990 Residence Large Other Item city urban Rural Total Radio 92.2 88.2 81.4 88.1 Television 94.4 92.7 84.3 91.2 Refrigerator 90.9 82.3 66.2 81.6 Video player 27.2 15.6 6.9 18.1 Telephone 42.7 33.3 20.8 33.9 Air conditioner 2.3 4.2 1.7 2.7 Bicycle 0.5 0.8 0.8 0.7 Motorcycle 0.3 0.2 0.9 0.4 Private car 29.2 24.0 13.9 23.5 Commercial e~ 3.7 2.8 1.5 2.8 Pick-up truck 4.3 7.0 11.0 6.9 Other transport 1.5 2.2 2.4 2.0 Number of households 2465 1953 1573 5990 2.8 AGE STRUCTURE OF RESPONDENTS TO THE INDIVIDUAL QUESTIONNAIRE Table 2.8 presents the distribution of respondents to the individual questionnaire by selected background characteristics, including age, marital status, and residence. Knowledge of date of birth among respondents is widespread. Among women who completed the individual interview, 73 percent gave the month and year of birth, and another 26 percent were able to report their age. Age information was missing for less than one percent of the respondents. The distribution of ever-married women by age group is shown in Table 2.8. Less than 6 percent of women are under 20 years of age, about 37 percent are age 20 to 29, 32 percent are age 30 to 39, and the rest (25 percent) are 40 or over. Except for the youngest age group, the age structure for ever-married women in 1990 is similar to that in 1976. Compared with data from the 1983 JFFHS, however, the age structure in 1990 is younger. The proportion of women under 35 years of age is larger in the 1990 survey than in the 1983 survey. Likewise, the proportion in the older age cohorts is smaller in the 1990 survey than in the 1983 survey. Among ever-married women, the percent distribution by marital status has remained constant since 1976 (Depamnent of Statistics, 1979); more than 95 percent are currently married, while the rest are either separated, divorced or widowed. However, comparison of the data from the 1990 JPFHS with data from previous surveys (not shown) regarding the proportion of ever-married women, indicates that the percentage of women in the population who are married is decreasing gradually in almost all age groups. Among women in the 15-19 age group, for example, more than 30 percent were married according to the 1972 National Fertility Survey (Department of Statistics, 1976). This percentage declined to 20 percent in 1976, 13 percent in 1983, and 11 percent in 1990. By age 30, when almost all women would have been married, the percentage was 96 in 1972, 90 in 1983, and 89 in 1990. 17 The population of Jordan is highly urbanized (see Table 2.8). Forty-one percent of the sample popu- lation reside in the major cities of Amman, Zarqa and Irbid, and another 33 percent live in other urban areas; only one in four Jordanians resides in the rural areas. The distribution of the population by governorate emphasizes the degree of urbanization. The three south- ern governorates (Karak, Ma'an and Tafielah), have small populations and are largely rural. Due to their small size, the three govemoratcs were grouped together under the category "South" to obtain reliable estimates. Mafraq, another small largely rural govemorate, was combined with Zarqa for the same reason. Overall, 84 percent of the population live in the governorates with the largest populations~Amman, Irbid, and Zarqa and Mafraq. The weighted and unweighted numbers of women in the sample are presented in Table 2.8. The unweighted numbers of women in the major govemor- ates (Amman, Irbid, and Zarqa and Mafraq) are smaller than the weighted numbers; the opposite is true in rural areas (Balqa and the South). This is because of over- sampling in the five smaller govemorates (Balqa, Karak, Ma'an, Mafraq, and Tafielah). The difference between the weighted and unweighted numbers can be seen in the distribution by govemorate. For example, in Balqa, although the weighted number of women is 433, in reality the data were collected from 762 women. Oversampling was done in order to provide a sufficient number of women upon which to base estimates. 2.9 RESPONDENT'S LEVEL OF EDUCATION Table 2.8 Background characteristics of respondents Percent distribution of ev~-man'ied women by selected background characteristics, Jorden 1990 Number of women Background Wdghted Un- characteristic percent Weighted weighted Age 15-19 5.6 359 353 20-24 16.6 1073 1082 25-29 20.3 1313 1329 30-34 17.6 1138 1128 35-39 14.8 959 946 40~4 13.4 866 878 4549 11.7 755 745 Marital status Married 95.5 6168 6181 Divorced 1.6 102 101 Widowed 2.8 180 172 Separated 0.2 11 7 Education No education 23.5 1516 1645 Primary 22.5 1456 1400 Secondary 43.5 2811 2741 More than secondary 10.5 677 675 Residence Large city 40.8 2635 2441 Other urban 33.0 2133 2143 Rural 26.2 1693 1877 Region Amman 39.2 2530 2166 Zarqa + Mafraq 20.6 1334 1277 Irbid 24.0 1549 1307 Balqa 6.7 433 762 South 9.5 615 949 Total 100.0 6461 6461 Table 2.9 presents an overview of the rela- tionship between level of education and selected background characteristics of the respondents. About 24 percent of women have never been enrolled in formal education, 23 percent have some primary education, 44 percent have some preparatory or secondary education, and 11 percent have more than secondary education. The distribution of women by level of education and age shows the expected pattern: the percentage of women who have no education and those who have only primary education increases with age, while the percentage who have secondary education decreases with age. More than half of women under age 30 have completed secondary school, and up to 17 percent have higher education. Women in large cities and other urban areas are more likely to have higher education than their rural counterparts. There is a pronounced difference in women's educational attainment by govemorate. In the govemorate of Amman, 18 percent of women have no education, whereas, in the South, the proportion is 37 percent. The gap is narrower for primary and secondary education. The larger percentage of women with higher education in certain govemorates may be due in part to the greater availability of higher education facilities there. 18 Table 2.9 Level of education pro'cent distribution of area-married women by highest level of education attended, according to sdected back~ound characteristics, Jordan 1990 Level of education Number Background No More them of ch~acterlstlc education Primary Secondezy secondary Total women Age 15-19 3.7 15.2 78.2 2.9 Ico.O 359 20-24 6.1 11.7 67.9 14.2 1{30.0 1073 25-29 9.2 18.0 55.4 17.4 100.0 1313 30-34 15.4 26.0 44.8 13.7 100.0 1138 35-39 28.5 32.3 31.1 8.1 100.0 959 40-44 45.2 29.9 21.0 3.9 I00.0 866 45-49 63.2 23.2 11.3 2.4 100.0 755 ResMence Large city 14.2 21.7 51.4 12.7 100.0 2635 Other urben 22.3 23.9 42.7 II.I I00.0 2133 Rural 39.4 22.2 32.2 6.3 100.0 1693 ReOou Ammem 17.7 23.6 47.9 10.8 I00.0 2530 Zarqa + Me.~aq 24.1 23.6 43.3 9.0 I00.0 1334 Irbid 24.2 22.3 42.5 11.0 I00.0 1549 Balqa 33.9 22.1 34.9 9.0 100.0 433 South 36.6 16.9 34.8 11.8 100.0 615 Total 23.5 22.5 43.5 10.5 100.0 6461 In the JPFI-IS, women who had never gone to school and women whose highest level of education was primary school were asked if they could read. About 7 percent of women who had never been to school and 83 percent of women who had some primary school education declared that they could read written materials (data not shown). 19 2.10 EXPOSURE TO MASS MEDIA The exposure of women to television, radio, and newspapers is shown in Table 2.10. Half of the women in the sample watch television frequently, and 39 percent listen to the radio; only 11 percent read newspapers frequently. Although exposure to mass media varies little across age groups, younger women are slightly more likely to be exposed to mass media than older women. As expected, there is a positive association between newspaper reading and education; a greater proportion of the women with secondary or higher education read newspapers than those with less education. The same pattern is present for television viewing and listening to the radio, although women with higher schooling seem to do these activities to a lesser extent than women in other education groups. The relationship between residence and exposure to mass media varies depending on the type of media. Women in the large cities are more likely to read the newspaper (15 percent) than women in rural areas (5 percent); however, rural women are more likely to watch television (52 percent) than women in large cities (46 percent). The extent to which women listen to the radio does not vary substantially by residence. The same is true for differentials by govemorate. Table 2.10 Access to mass media Percentage of women who frequently read a newspaper, watch television, or listen to the radio, by selected background cbhractevistics, Jordan 1990 Read Watch Listen to Number Background newspaper television radio of characteristic f~quenfly frequently frequently women Age 15-19 13.4 55.8 45.6 359 20-24 10.3 56.2 45.8 1073 25-29 13.2 50.8 41.9 1313 30-34 11.6 50.6 38.6 1138 35-39 10.6 45.8 36.9 959 40-44 10.0 42.6 31.4 866 45-49 7.4 41.3 30.7 755 Education No education 0.3 37.8 25.0 1516 Primary 7.0 49.4 36.8 1456 Secondary 16.1 55.0 46.8 2811 More than secondary 21.9 48.2 40.3 677 Residence Large city 14.7 46,4 38.1 2635 Other Urban 11,1 50.0 40,3 2133 Rural 4.9 51.7 37.7 1693 Region Amman 13.6 44.2 38.2 2530 Zurqa + Mafraq 11.3 45,6 36.9 1334 Irbid 8.2 61.4 41.5 1549 Balqa 6.9 43.3 40.5 433 South 9.3 48.8 36.6 615 Total 10.9 49.0 38.7 6461 20 CHAPTER 3 FERTILITY The Jordan Population and Family Health Survey (JPFHS) collected information on past, current and cumulative fertility. In this survey, a series of questions about live births was asked to obtain data pertaining to fertility. Based on the experience gained from past surveys, the wording and sequence of the questions were designed so as to reduce errors commonly found in such surveys. Basically, data were collected in two sections. First, each woman was asked a series of questions on the number of her sons and daughters living with her, the number living elsewhere, and the number who may have died. Next, for each live birth, the sex, age, whether the birth was single or multiple, whether the child was living in the household or away, and survival status were asked. For dead children, the age at death was recorded. As an indicator of future fertility, information was collected on whether currently married women were pregnant at the time of the interview. Experience in using birth histories to estimate fertility levels and trends has found that underreporting of children ever born and displacement of children's dates of birth are common in many countries. Underreporting of children affects estimates of fertility levels, while misreporting of children's date of birth distorts fertility trends over time. With regard to the latter, one of the characteristics of the 1990 JPFHS is the high quality of age and date reporting. As noted earlier, virtually all women knew their age. The same is true for age at marriage and date of marriage. With regard to the children's age and date of birth reporting, both month and year of birth are documented for 98 percent of all births recorded in the birth history; for the rest, either age or year of birth is given. This information lends confidence in the quality of the basic data used in the estimation of fertility measures. Because the fertility rates presented in this chapter are all based on direct measures derived from the binah history section of the JPFHS, two potential drawbacks require some attention. First, only surviving women were interviewed in the survey. This would only bias the rates if mortality of women of childbearing age were high and if fertility of surviving and nonsurviving women differed significantly, neither of which is the case in Jordan. The limitation of the survey respondents to ever-married women presents another potential bias. However, since births in Jordan occur within marriage, the number of births to single women is negligible. Although information on fertility was obtained only from ever-married women, estimates can be made for all women (regardless of marital status) using information in the household questionnaire; these estimates assume that women who have never been married have had no children. 3.1 LEVELS AND DIFFERENTIALS IN FERT IL ITY Fertility Levels Table 3.1 presents the age-specific fertility rates and total fertility rates (TFR) for three Jordanian surveys---the 1976 Jordan Fertility Survey (JFS), the 1983 Jordan Fertility and Family Health Survey (JFFHS), and the Jordan Population and Family Health Survey (JPFHS). The tt~l< is the sum of the age- specific fertility rates and represents the average number of children a Jordanian woman would have at the end of her reproductive years if she were subject to the observed age-specific rates. Comparison of the fmdings from the three survey shows the trends in fertility levels over a fourteen-year period. Data for the 1976 survey are calculated based on the two years preceding the survey (1975-1976), while those for 1983 and 1990 refer to the three years preceding the survey (1981-1983 and 1988-1990 respectively). There is a consistent decline in fertility from the mid-1970s to the late 1980s: thetl~Rs for women age 15-49 declined from 7.4 children in 1976 to 6.6 in 1983, and 5.6 in 1990. The decline in fertility between the mid- 1970s and 21 the early 1980s is 11 percent; the decline between the mid-1970s and late 1980s is 24 percent. A similar pattern is seen for women 15-44 years. The curve for age-specific fertility rates has re- mained about the same for each survey since 1976 (see Figure 3.1). It starts low in the youngest age group, in- creases rapidly in the next group, and peaks in ages 20- 34, after which it declines sharply in the 40-44 age group. Very few births occur to women over 45 years of age. The findings from the three surveys indicate that fertility has declined in all age groups. In the 14 years between the JFS and the JPFHS, the largest declines appear to have taken place among women 15-24 years of age. This sug- gests that much of the decline between 1976 and 1983 can be attributed to an increase in the age at marriage, while decline between 1983 and 1990 is due to greater use of contraception. Table 3.1 Curreaat ferlili~ according to selected SUl~e~$ Age-specific fertility rates and total fertility rates from selected stnveys, Jordan, 1976, 1983 md 1990 .ITS jt+t~HS JPFHS Age group 19761 19832 19902 15-19 71 49 49 20-24 300 228 219 25-29 367 335 296 30-34 332 305 264 35-39 240 233 188 40-44 112 127 79 45-49 47 40 19 TFR 15-49 7.4 6.6 5.6 TFR 15-44 7.1 6.4 5.5 TITR: Total fertility rates, expressed per woman ]Based on two years preceding survey 2Based on three years preceding survey Table 3.2 presents the age-specific fertility rates and cumulative fertility for the three-year period pre- ceding the survey by urban-rural residence. The general fertility rate (GFR) is the annual number of live births per 1,000 women age 15-44 years in the three years preceding the survey. The crude birth rate (CBR) is the annual number of live births per 1,000 population for the same period. All of these measures show a similar Figure 3.1 Age-specific Fertility Rates JFS 1976, JFFHS 1983, and JPFHS 1990 Births per 1,000 women 40O 300 200 100 0 15-19 I i i i + 20-24 25-29 30-34 35-59 40-44 Age I . . . . JFS 1976 ~JFFHS 1983 ~ JPFHS 1990 45-49 22 pattern: women living in urban areas have a much lower fertifity rate than those living in rural areas. Women in large cities bear an average of 4.7 children, compared to 5.6 for women in other urban areas and 6.8 for rural women. The data show that regardless of residence, about half of all births are to women age 25-34, and another 20 percent are to women age 20-24. Table 3.2 Current fertility Age-specific fertility rates (per thousand women), cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-rural residence, Jordan 1990 Large Other Age group city urban Rural Total 15-19 55 40 51 49 20-24 194 228 251 219 25-29 265 293 346 296 30-34 214 267 339 264 35-39 159 188 232 188 40-44 58 82 111 79 45-49 [5] [23i a [39] a [19] TFR 15-49 4.75 5.60 6.85 5.57 TFR 15-44 4.72 5.49 6.65 5.48 GFR 148.8 165.4 203.1 168.3 CBR 33.9 35.8 39.0 36.1 Note: Figures in brackets are partially truncated rates. TFR: Total fertility rate, expressed per woman GFR: General fertility rate (bhlks divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population aBased on fewer than 500 person-months of exposure Fertility Differentials Table 3.3 presents the total fertility rate (TFR) and the mean number of children ever born (CEB) per woman according to background characteristics of the women. Column one shows the total fertility rates for the three years preceding the survey (1988-1990); column two presents the mean number of children ever born to women 4049 years. The average number of children ever born is an indicator of cumulative fertility and reflects the fertility of older women who are nearing the end of their reproductive period; it is a measure that represents completed fertility. When fertility remains constant over time, the two measures, TPR and CEB will be the same or almost the same. In the JPFHS, however, completed fertility (8.1 children per woman) is much higher than the total fertility rate (5.6 children per woman), indicating a considerable decline in fertility. Fertility is much lower in urban areas than in rural areas (see Table 3.3). The total fertifity rate for women in large cities (4.8) is almost one child lower than for women in other urban areas (5.6) and more than two children lower than for rural women (6.9). The differentials in the number of children ever bom to women 4049 are not as large, however, suggesting that the large differences in fertility by residence are a recent phenomenon. 23 Women in Amman Govemorate have the lowest fertility rate when comparing fertility levels across gov- ernorates. They have, on average, 0.7 child less than women in Zarqa and Mafraq, and Balqa, 1.8 children less than women in the South, and 1.3 children less than women in Irbid. The largest fertility differentials are by educa- tional attainment. Education is negatively associated with fertility as measured by the total fertility rate and children ever born. Women who have attended higher education (more than secondary) have the lowest level of fertility (4.1), while those with no education have the highest (6.9). The difference between the two groups of women is close to 3 children in terms of the TPR, and almost 5 children according to the mean number of chil- dren ever born. These figures suggest that as educa- tional opportunities for women improve, and fertility declines, the differentials in fertility among women ac- cording to education will narrow. 3.2 FERT IL ITY TRENDS In addition to comparing data from previous surveys (see Section 3.1), fertility trends can also be in- vestigated using retrospective data from a single survey. The birth history information collected in the JPFHS is used for this purpose. Table 3.4 presents age-specific fertility rates over time, while Table 3.5 presents marital Table 3.3 Fertility by background characteristics Total fertility rate for the three years preceding the stawey and mean number of children evex born to women age 40-49. by selected background ebarac- teristies. Jordan 1990 Mean number of children Total ever born Background fertility to women characteristic rate I age 40-49 Residence Large city 4.75 7.50 Other urban 5.60 8.38 Rural 6.85 8.83 Region Amman 4.88 7.65 Zarqa + Mafraq 5.58 8.32 Irbid 6.20 8.85 Balqa 5.55 7.29 South 6.64 8.59 Education level attended No edueatlon 6.92 8.84 Primary 6.00 8.38 Secondary 5.39 6.31 More than secondary 4.10 4.03 Total 5.57 8.12 IRate for women age 15-49 years duration fertility rates over time. Data in the tables are not comprehensive; they are progressively truncated as time before the survey increases. The bottom diagonal of estimates (enclosed in brackets) is also tmnca~l. Due to the mmcation, changes taking place over the 20 years preceding the survey are observed only for women up to age 29, and for women who have been married for up to 19 years. Information in these tables should be treated with caution due to the possible omission of or incorrect dating of events, especially by older women, and for distant time periods. The data in Table 3.4 indicate that the fertility decline at ages 15-29 in the 20 years preceding the survey is quite substantial (37 percent). The data also indicate that while the decline was slow at first (6 percent from 15-19 to 10-14 years preceding the survey), it accelerated to 15 percent from 10-14 to 5-9 years preceding the survey, reaching 22 percent in the most recent period (from 5-9 to 0-4 years preceding the survey). Table 3.5 presents a similar pattern: for the same marriage duration, fertility rates are lowest for the five-years immediately preceding the survey, indicating a decline in fertility over time. 24 Table 3.4 Age-specific fertility rates Age-specific fertility rates for five-yeer periods preceding the su~ey, by mother's age at the time of birth, Jordan 1990 Number of years preceding the survey Mother's age 0-4 5-9 10-14 15-19 15-19 52 85 131 146 20-24 230 307 345 377 25-29 307 363 410 417 30-34 277 326 349 [374] 35-39 198 243 [300] U 40-44 86 [149] U U 45-49 [23] U U U Note: Age-specific feilility rates are per 1,000 ever-marrled women. Figures in brackets are partially truncated rates. U = Unknown; no information Table 3.5 Fertility by marital duration Fertility rates for five-year periods preceding the survey, by number of years since first marriage, Jordan 1990 Number of years preceding the survey Years since flrst merriage 0-4 5-9 10-14 15-19 0-4 460 476 492 474 5-9 371 422 448 454 10-14 310 364 385 412 15-19 229 278 334 [349] 20-24 137 203 [310] 25-29 46 [123] Note: Duration-specific fertility rates ere per 1,000 women. Figures in brackets are partially mmcated rates. 3.3 CHILDREN EVER BORN AND LIVING In the survey questionnaire, the total number of children ever born to women age 15-49 was ascertained by a series of questions designed to maximize recall. Past experience indicates that, even among illiterate, high fertility populations, omission of births can be kept to a low level, except perhaps for the oldest women in the sample. 25 Table 3.6 and Figure 3.2 show the mean num- ber of children ever born to all women age 15-49 for the years 1976, 1983 and 1990. The data support the previ- ous fmding that there has been a substantial decline in fertility during the 14 years preceding the survey. In 1976, a woman had on average 3.6 children; seven years later tiffs had declined to 3.1, and in 1990 the average number of children ever born was 2.9, reflecting a de- cline of almost one (0.7) child from 1976. The decline appears to have occurred at all ages, although it is great- er for younger women, probably due to later age at first marriage and later age at first birth (see Section 3.5). Women age 20-24 in 1990 have had on average 0.8 child less than women in the same age group 14 years preceding the survey. The decline is greatest among women age 25-29, an average of more than one (1.2) child. The Inconsistency of figures for women 40 years of age and older, which is also present in Table 3.1 for 1983, indicates errors either in the reporting of ages of older women or in the reporting of date of birth of their children, or both. Table 3.6 Children ever born according to selected surveys Mean number of children ever born for all woman by age group, Jordan, 1976, 1983 and 1990 JFS JFFHS JPFHS Age group 1976 1983 1990 15-19 0.2 0.1 0.1 20-24 1.6 0.9 0.8 25-29 3.7 3.0 2.5 30-34 5.6 5.0 4.8 35-39 7.1 6.6 6.6 40-44 8.4 7.5 7.9 45-49 8.6 7.8 8.3 Total 3.6 3.1 2.9 Figure 3.2 Mean Number of Children Ever Born Jordan, 1976, 1983, and 1990 Mean number of children 1o 8 9 4 2 0: 13-19 I I I I I 20-24 25-29 30-34 35-39 40-44 Age I . . . . JFS 1976 I JFFHS 1933 ~JPFH8 1990 / I 45-49 26 Table 3.7 presents the distribution of all women and currently married women by the number of children they have had. In the JPFHS, since the respondents are ever-married women, information on the reproductive history of never-married women is not available. However, since virtually all births in Jordan take place within marriage, it can be assumed that never-married women have had no births. The data represent the accumulation of births over time. The difference in fertility between all women and currently married women is due to the proportion of women who were not married at the time of the survey (i.e., single, divorced, or widowed); the difference is most pronounced in the younger age groups. The average number of children increases with age, reflecting the natural family building process. Table 3.7 Children ever born and living Percent distribution of all women and of currently married women by number of children ever born (CEB) and mean number of children ever born and living, according to age groups, Jordan 1990 Number of children ever born (CEB) Age SrOt~ 0 I 2 3 4 5 6 7 8 9 ALL WOMEN Number Mean no. Mean no, of of of living I0+ Total women CEB c.hild nm 15-19 94.7 3.8 1.4 0.1 . . . . . . . . . . 100.0 3394 0.1 0.1 20-24 64.8 11 .4 10.7 8.0 3.4 1.3 0.3 - 0.1 -- 100.0 2374 0.8 0.8 25-29 32.1 7,3 11 .8 13 .5 13.1 10.5 6.3 3.7 1.1 0.6 -- 100.0 1781 2.5 2.4 30-34 13,6 2.8 5.5 7,8 12.0 15.8 13 .5 12.3 8.7 4.1 3.7 100.0 1277 4.8 4.6 35-39 8.3 2.3 2.2 5.2 6.9 8.2 11.4 12.3 12,8 12.6 17.7 100.0 1014 6.6 6.2 40-44 3.9 1.9 2.1 3.4 5.7 7.5 6.5 10.1 12 .4 10.4 36.2 100.0 890 7,9 7.4 45-49 4.0 1.0 1.8 2.4 4.6 7,3 7.4 8.7 9.3 14.7 38.8 100.0 770 8.3 7.7 Total 49.1 5,3 5.5 5.5 5,4 5.4 4.5 4.4 3.9 3.5 7.4 100.0 11499 2.9 2.7 CURRENTLY MARRIED WOMEN 15-19 50.2 35.8 12.5 1.1 0.1 0,3 . . . . . . . 100.0 353 0.7 0,6 20-24 22.0 24.9 23.7 17.9 7.7 2.9 0.7 -- 0.1 -- 100.0 1057 1.8 1.7 25-29 6.9 9.4 16.3 18.3 18.2 14.4 8.8 5.2 1.6 0.9 --- I00.0 1268 3.5 3.4 30-34 2.6 2.6 5.7 8.5 13.6 18.0 15.6 14.1 10.2 4.8 4.3 I00.0 1098 5.5 5.2 35-39 2.5 1,8 1.8 5.1 7.6 8.9 11 .4 13.6 13.6 13.6 19.9 100.0 905 7.1 6.7 40-44 I.I I.I 1.8 3.1 5.5 7.1 6.6 10.5 13.0 II.0 39.1 I00.0 807 8.4 7.8 45-49 2.3 0.7 1.8 1.5 3.8 6.8 7.3 9.1 9.1 15.3 42,4 100.0 680 8.7 8.1 Total 9.3 9.2 9.9 9.7 9.7 9.7 8.1 8.0 6.9 6,1 13.5 100.0 6168 5.1 4.8 -- Leu than 0.1]6 percent Thelevelof fertility among teenagers islow. Only5 percentofwomenage 15-19 havehad achild. The past high fertility of Jordanlan women can be seen from the large proportion of women age 45-49 who have had 10 or more children (39 percent). Since voluntary childlessness is virtually nonexistent, child- lessness at age 40 or above can be taken as evidence of primary infertility. Data from the JPFHS indicate that 4 pereent of women over age 40 have never given birth. The last two columns in Table 3.7 show the average number of children ever bom and the average number of children still living according to mother's age. Differences in the mean number of children born and living are notable only after age 30. Caution should be used in interpreting the data for women in the oldest age groups due to the problem of memory lapse; older women are more likely to omit some of their children, particularly if the children died at a young age or are living away from their mother. 27 3.4 BIRTH INTERVALS A birth interval is the period of time between two successive live births. Information on the length of bixl_h intervals in Jordan is presented in Table 3.8. The data are based on births in the five years preceding to the survey. Table 3.8 Birth intervals Percent distribution of births in the five years preceding the survey by number of months since previous birth, according to selected background characteristics. Jordan 1990 Median no. Number of months since previous birth of months Number Background since previous of chm'act~ris~ie 7-17 18-23 24-35 36-47 48+ Total birth births Age 15-19 61.7 18.5 18.2 1.7 0.0 100.0 16.5 57 20-29 37.0 26.8 26.7 6.4 3.1 100.0 20.9 3020 30-39 20.5 21.0 34.8 11.0 12.7 100.0 26.0 3025 40+ 10.3 17.1 36.7 14.1 21.7 100.0 30.5 830 Birth order 2-3 39.3 25.0 23.6 7.3 4.8 100.0 20.5 2192 4-6 23.6 23.3 32.2 9.5 11.5 100.0 24.7 2420 7+ 18.4 20.9 37.7 11.1 11.9 1(30.0 26.2 2320 Sex of prior birth Male 25.4 22.1 31.8 9.5 11.3 I(30.0 24.7 3555 Female 28.4 24.0 30.8 9.1 7.6 100.0 23.5 3377 Survival of prior birth Living 26.0 23.2 31.6 9.5 9.7 100.0 24.2 6655 Dead 46.0 19.6 24.2 5.9 4.3 100.0 18.8 278 Residence Large city 27.0 20.9 28.3 11.1 12.7 100.0 24.6 2465 Other urban 27.4 23.3 31.4 9.3 8.7 100.0 23.8 2264 Rural 26.1 25.1 34.6 7.4 6.8 100.0 23.8 2202 Region Amman 26.6 22.3 28.8 10.2 12.1 100.0 24.3 2402 Zarqa + Mafraq 2,*.8 22.5 31.7 10.6 10.4 1(30.0 24.6 1403 Irbid 30.7 24.3 31.1 7.0 6.9 100.0 23.0 1874 Balqa 23.8 21.4 36.6 10.1 8.1 100.0 24.7 512 South 23.7 24.5 35.7 9.4 6.7 100.0 24.4 741 Education level attended No education 17.7 21.6 40.9 10.6 9.3 100.0 26.1 1550 Primary 23.5 23.9 31.7 8.9 11.9 100.0 24.6 1606 Secondly 30.8 23.4 28.2 8.8 8.8 100.0 23.1 3111 More then secondary 37.6 22.3 22.8 9.8 7.5 1(30.0 21.5 664 Total 26.8 23.0 31.3 9.3 9.5 100.0 24.0 6932 Note: First-ordea births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 28 Women in Jordan favor relatively long birth intervals: half of all children are born at least 2 years after their siblings, and one in five is born after an interval of 3 years or longer. As expected, children born to younger and lower parity women have shorter birth intervals than those born to older, higher parity women. Birth intervals following a child who died are also shorter than those following surviving children (19 months versus 24 months). This is consistent with results of an earlier survey (Abdel Aziz, 1988). The length of birth intervals does not vary by urban-rural residence or govemorate. However, intervals are shorter between births to more highly educated women, presumably in part because they marry later. Since these women are starting their families later, they are more likely to have shorter birth intervals in order to "catch up" with women who started childbearing earlier. Another reason may be the length ofbreastfeeding; educated women breastfeed their children for shorter duration than uneducated women. 3.5 AGE AT FIRST BIRTH The onset of childbearing is an important indicator of fertility. In Jordan, the postponement of first births, reflecting later age at first marriage, has made a large contribution to tile overall fertility decline. Table 3.9 shows the distribution of women by age at first birth. Women under age 25 were not included in the calculation of median age at first birth because most had not given birth. The trend in the median age at first birth across age cohorts suggests an increase in the youngest cohorts: 23 years for women age 25-29, and 21.2 years for women age 30-34. Change has been negligible for women 35 years and over (median age at first birth 20.4 to 20.6 years). Table 3.9 Age at first birth Percent distribution of women by age at first birth, according to current age, Jordan 1990 Ctmem age Women Median with Age at first birth Number age at no of first births <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 94.7 -- 3.4 1.9 - -- 100.0 3394 a 20-24 64.8 0.3 7.6 12.9 9.3 5.1 -- 100.0 2374 a 25-29 32.1 0.6 13.8 15.5 14.0 16.7 7.3 100.0 1781 23.0 30-34 13.6 1.8 19.3 19.2 15.8 17.3 13.0 100.0 1277 21.2 35-39 8.3 1.3 21.5 22.7 16.7 16.1 13.3 100.0 1014 20.4 40-44 3.9 2.7 19.3 22.1 19.3 20.7 12.0 100.0 890 20.5 45-49 4.0 3.7 16.6 21.7 23.6 18.4 11.9 100.0 770 20.6 -- Less than 0.05 percent aLess than 50 pea~ent of the women have had a biRh by the beginlfing of the age group. Table 3.10 presents the differentials in age at first birth among women 25-49 years by background characteristics. The median age at first birth for women residing in large cities (21.6 years) is slightly higher than that for women living in other urban or rural areas (21.0 years). There are no significant differences in the age at first birth by region. Differentials by education are more marked and show an unusual pattem. Women with secondary education have the highest median age at first birth (21.2 years), followed by women with no education. The lowest median age at first birth is for women who have attended primary school (19.6 years). 29 Table 3.10 Median age at first birth by background eharecteristies Median age at first birth among women 25-49, by current age mad selected background characteristics, Io~an 1990 Current age Woman Beck~ound age che~aetea'istic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Large city 24.1 21.7 20.5 20.6 20.2 2L6 Other urban 23.2 20.6 20.1 20.4 20.7 2L0 Rmal 21.5 21.1 20.8 20.7 21.0 2t.0 Region Amman 23.4 21.6 20.1 20.1 20.2 21-:2 Zarqa + Mafraq 22.7 20.6 20.7 20.4 20.7 21.1 Irbid 22.9 21.4 20.3 21.1 21.1 2L4 Balqa 23.0 21.5 21.9 21.7 21.3 21.8 South 22.7 20.9 20.3 20.3 20.0 2L0 Education level attended No education 20.7 20.6 20,3 20.3 20.6 20.5 Prhnezy 20.6 19.0 19.3 19.8 19.9 19.6 Secondmy 21.7 20.7 20.5 22.2 21.4 21.2 More than secondary a 25.9 25.6 24.2 26.2 a Total 23.0 21.2 20.4 20,5 20.6 21.2 Note: The medians for cohorts 15-19 and 20-24 could not be determined because some women may still have a birth before reaching age 20 or 25, respectively. aLess than 50 percent of the women in these age groups have had a birth. 3.6 TEENAGE FERT IL ITY Table 3.11 examines the extent of fertility among women age 15-19. This issue is of major social and health concern because teenage mothers and their children usually have higher risk of morbidity and mortality. At the same time, women who become mothers in their teens are more likely to curtail their education. The level of teenage childbearing in Jordan is low; only 7 percent of 3,394 women age 15-19 in the sample have given birth (5 percent) or are pregnant with their first child (2 percent). This is consistent with information on the age at marriage (see Chapter 5). Since half of Jordanian women marry when they are nearing age 20, very few have given birth before age 18. Among women 18 years of age, only one in seven (14 percent) is pregnant with her first child or has become a mother, this increases to 18 percent for women 19 years of age. 30 Table 3.11 Teenage fertility Percentage of women 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Jordan 1990 Percentage who are: Percentage who have Pregnant begtm Number Background with first child- of characteristic Mothers child bearing women Age 15 0.2 0.3 0.6 738 16 1.2 1.6 2.8 863 17 4.3 2.1 6.3 616 18 9.2 4.2 13.5 639 19 15.3 2.7 18.0 537 r r , Residence Large city 5.6 1.8 7.5 1351 Other urban 5.1 1.9 7.1 1252 Rural 5.0 2.7 7.7 788 Region Amman 5.3 1.6 6.9 1522 Zarqa + Mafraq 4.7 1.9 6.6 683 Irbid 5.3 2.4 7.7 860 Balqa 3.6 4.2 7.8 145 South 9.9 3.3 13.2 169 Education level aRended No education 8.3 2.3 10.6 74 Primary 8.g 4.2 13.0 310 Secondary 4.8 1.7 6.5 3000 More than secondary 0.8 2.1 3.0 239 Total 5.3 2.1 7.4 3394 Urhan-mral residence is not strongly associated with teenage motherhood. With respect to education, the proportion of teenagers who are mothers or pregnant declines as education level increases. The data indicate that the impact of education in reducing teenage pregnancy appears to begin with secondary schooling. There is also a reverse relationship between education and childbearing in that young women who are pregnant often drop out of school. The regional distribution shows that the South has the highest level of teenage childbearing, followed by Balqa and Irhid, while Amman, Zarqa and Mafraq have the lowest levels. 31 Tab le 3 .12 presents the distr ibut ion o f women age 15-19 by number o f ch i ldren ever 10om. The average number o f ch i ldren ever born for this age group is less than 0.1 chi ld, ind icat ing that the leve l o f teenage fert i l i ty in Jordan is very low. Table 3.12 Children bern to teenagers Percent distribution of women 15-19 by number of children ever bern (CEB), according to single year of age, Jordan 1990 Age 0 1 2+ Number of Mean children ever room number Number of of Total CEB women 15 99.8 0.2 -- 100.0 -- 738 ' " 16 98.8 1.1 0.1 100.0 -- 863 17 95.7 3.6 0.6 100.0 -- 616 18 90.8 6.4 2.8 100.0 0.1 639 19 84.7 10.1 5.3 100.0 0.2 537 Total 94.7 3.8 1.5 100.0 0,1 3394 -- Less than 0.05 percent, or mean less than 0.05 children 32 CHAPTER 4 FAMILY PLANNING The Government of Jordan has no explicit population policy intended to influence fertility levels, but it acknowledges the right of parents to decide the number and spacing of their children. In recent years, family planning activities have increased substantially. Through the Ministry of Health, the Jordan Family Planning and Protection Association and rural development projects, women are receiving information about family health, breasffeeding, and childspacing. The 1990 JPFHS was designed to collect information on topics related to the spacing and limiting of births. This chapter presents the major findings on current, past, and intended future use of contraception. Whenever possible, comparison is made with the results of three DHS surveys carried out in North Africa (Egypt, Morocco, and Tunisia); time trends are examined by comparing the JPFHS findings with those of two earlier surveys: the 1976 Jordan Feilility Survey (JFS) (Department of Statistics, 1979) and the 1983 Jordan Fertility and Family Health Survey (JFFHS) (Department of Statistics, 1984b). 4.1 KNOWLEDGE OF FAMILY PLANNING METHODS AND SOURCES One of the major objectives of the JPFHS is to determine the level of knowledge of contraceptive methods. In the survey, the level of awareness of family planning methods was measured in two ways: . Respondents were first asked an open-ended question about which contraceptive methods they had heard of. All methods named in response to this question were recorded as unprompted (sponta- neous) knowledge. . When a respondent failed to mention any of the listed methods, the interviewer would describe the method and ask if the respondent had heard about it. All methods recognized by the respondent after description were recorded as prompted (probed) knowledge. Information on knowledge was collected for seven modem methods (the pill, IUD, injection, vaginal methods (foam, jelly, sponge or diaphragm), the condom, female sterilization and male sterilization), and three traditional methods (periodic abstinence, withdrawal and prolonged breastfeeding~). In addition, provision was made in the questionnaire to record any other methods named spontaneously by respondents. In this analysis, only the overall levels of knowledge are presented, i.e., respondents are classified as knowing a method regardless of whether they recognized it spontaneously or after hearing it described. It should be noted that knowledge of a family planning method in the JPFHS and all DHS surveys is defined simply as having heard of a method. No questions were asked to elicit depth of knowledge, such as how a specific method is used. t Jordan and Egypt were the only two DHS countries that included prolonged breastfeeding in the list of family planning methods on which respondents were prompted. 33 Virtually all currently married women in Jordan know at least one method of family planning (see Table 4.1). Among modem methods, the pill and IUD are the best known (98 percent), followed by female sterilization (95 percent). Knowledge of the condom, vaginal methods and injection varies from 51 to 58 percent. The least recognized method, male sterilization, is known by only 26 percent of married women. Among traditional methods, as expected, prolonged breasffeeding is known by nearly all currently married women. Periodic abstinence and withdrawal am also well known (78 and 70 percent, respectively). Most currently married women (95 percent) know a source for family planning methods (see Table 4.1). Knowledge of a source is highest for the pill (89 percent) and the IUD (88 percent), and lowest for injec- tion (40 percent) and male sterilization (21 percent). Generally, eight or nine of every ten women who know a specific method are familiar with a source for that method. Table 4.1 Knowledge of contraceptive methods and source for methods Percentage of currently married women who know specific contraceptive methods and who know a source (for information or services), by specific methods, Jordan 1990 Contraceptive Know Know a method method source Any method 99.8 94.8 Any modern method 99.0 94.2 Pill 98.3 88.6 IUD 97.9 87.7 Injection 50.7 39.8 Vaginal methods 58.1 49.7 Condom 55.2 46.8 Female sterilization 94.5 85.3 Male sterilization 26.3 20.9 Any traditional method 99.7 64.7 Periodic abstinence 78.0 64.7 Withdrawal 70.2 NA Prolonged breasffceding 99.7 NA Otimr 6.8 NA Number of women 6168 6168 NA = Not applicable Table 4.2 presents the percentage of currently married women who know any method of contraception, who know any modem method, and the percentage who know a source for a modem method by selected background characteristics. Since knowledge of any family planning method or any modem method is almost universal, there is little variation among subgroups. With respect to knowledge of a source for modem methods, at least 90 percent of women in all subgroups know a source for a modem method except women living in rural areas (89 percent), those with no education (87 percent), and those residing in Balqa Govemorate (69 percent). 34 Table 4.2 Knowledge of urodem contraceptive methods and source for methods Percentage of cm'renfly married women who know at le.~st one modem contraceptive method and who lmow a source (for information or services) for a modem method, by selected background characteristics, Jordan 1990 Know a Know Know source for Number Background any a modern modern of characteristic method method I method women Age 15-19 99.3 97.8 91.0 353 20.24 99.9 99.1 94.2 1057 25-29 100.0 99.8 96.2 1268 30-34 99.9 99.4 95.2 1098 35-39 99.8 98.9 95.1 905 40-44 99.8 98.5 92.7 807 45-49 99.8 97.8 91.5 680 Residence Large city 99,9 99.5 97.2 2513 Other urban 100.0 99.3 94.6 2034 Rural 99.7 97.8 89.2 1622 Region Amman 99.9 99.5 96.5 2420 Zerqa + Mafraq 100.0 99.3 94.8 1265 Irbid 100.0 99.5 98.1 1470 Bakla 98.7 93.6 69.3 416 South 100.0 98.6 92.0 597 Education level attended No education 99.7 97.1 87.3 1422 lXthnary 99.8 99.1 95.1 1365 Secondscy 99.9 99.7 96.6 2723 More than secondary 100.0 99.8 97.8 658 Total 99.8 99.0 94.2 6168 1Includes pill, IUD, injection• vaginal methods (diaphr agm/foam/j ally), condom, female sterilization, male sterilization and Norplant 4.2 EVER USE OF CONTRACEPTION Table 4.3 shows the percentage of women who have ever used a contraceptive method. Two-thirds (64 percent) of ever-married women report that they have used a contraceptive method at sonte time, including 18 percent who have used prolonged breasffeeding. Ever-use among currently married women (65 percent) is almost the same as for ever-married women. Modem methods are used by the majority of c~t ly married ever-users (52 percent). The pill is the most popular method (33 percent), followed by the IUD (31 percent). The percentage reporting ever-use of any other modem method is less than 8 percent. 35 Table 4.3 Eve~ use of contraception Perecmage of aver-married women and of cu~ently married women who have ever used a contraceptive method, by specific method end age, Jordan 1990 Contraceptive method Age of woman 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total EVER-MARRIED WOMEN Any method 21.2 45.8 65.5 76.0 73.9 73.0 64.0 63.7 Any modern method 9.0 30.3 49.4 62.8 63.7 63.2 53.5 50.8 Pill 6.1 16.0 29.4 39.4 41.9 45.4 39.5 32.8 IUD 2.7 19.8 32.2 42.5 38.8 30.6 20.7 29.7 Injection . . . . 0.4 1.1 1.8 3.3 4.5 1.5 Vaginal metheds 2.2 2.3 5.5 8.3 10.1 10.6 8.8 7.0 Condom 1,3 3.1 6.2 12.4 6.8 7.8 5.7 6.7 Fumale stexillzation . . . . 0.3 1.9 I0.I 15.4 13.2 5.5 Male stezilization . . . . . . . . 0.I . . . . . . Any traditional method 16.0 28.2 41.4 47.5 42.2 40.3 34.8 38.1 Periedic abstlnenc¢ 4.8 11.2 16.6 23.1 18.6 18.0 14.6 16.5 Withdrawal 6.3 9,4 17,3 23.1 18.9 20.9 15.7 16.9 Prolonged bre~tfending 8.3 13.0 20.1 22.5 21.3 19.6 16.7 18.4 Other -- 0.I 0.8 0.8 1.4 2.3 2.1 1.1 Number of women 359 1073 1313 1138 959 866 755 6461 CURRENTLY MARRIED WOMEN Any method 20.9 46.0 66.9 77.3 75.9 74.7 67.1 64.9 Any modern method 8.9 30,3 50.4 63.7 65,5 64,7 55.9 51,7 Pill 6.2 16.2 30.0 40.0 42.6 45.9 41.2 33.2 IUD 2.4 20.1 33.2 43.6 40.7 32.1 22.3 30.8 Injection . . . . 0.2 1.0 i .8 3, I 4.8 1,4 Vaginal metho& 2.2 2.3 5.5 8.6 10.4 10.7 9.2 7. I Condom 1,4 2,9 6.2 12.6 6.9 7.7 6.0 6,8 Female smrillzation . . . . 0.3 1.8 10.7 16,2 14.0 5.6 Male steail'tzation . . . . . . . . 0.I . . . . . . Any traditional method 15.6 28.3 42.2 48,6 43.7 41.9 36,8 39.0 PeTindic abstinence 4.9 11.3 17.1 23.8 19.6 18.6 15.8 17.0 Withdrawal 6.1 9.4 17.8 23.5 19.6 21.8 17.1 17.4 Prolonged breastfceding 8.1 13,1 20,3 23.2 21.9 20.5 17.3 18.8 Other -- 0.1 0.8 0.8 1.5 2.4 2.4 1.1 Number of women 353 1057 1268 1098 905 807 680 6168 -- Less than 0.05 pcrcem 36 The level of ever-use of traditional contraceptive methods is fairiy high in Jordan. Prolonged brcastfeeding, the most frequently adopted traditional method, has been used by 19 percent of currently married women, followed by withdrawal (17 percent) and periodic abstinence (17 percent). Ever use of contraceptive methods increases with age, from 21 percent among currently married women age 15-19 to 77 percent among women age 30-34, and declines thereafter. This pattern is particularly true for the IUD. While the IUD has been used by less than 3 percent of currently married women age 15-19, ever use of the IUD increases rapidly to 44 percent among women age 30-34. Ever use of the pill peaks at age 40-44. Among traditional methods, prolonged breastfeeding is used most frequently by women age 25- 44, while withdrawal and periodic abstinence arc most popular among women age 30-34. Compared with the findings of the 1976 JFS, the level of ever-use among ever-married women has increased by 36 percent, from 47 percent in 1976 to 64 percent in 1990. The overall increase in ever use of modem methods between the two surveys is slightly lower (31 percent) than the increase for all methods. 4.3 CURRENT USE OF CONTRACEPT ION The level of current use of contraception is one of the indicators most frequently used to assess the success of family planning activities. It is also widely used as a measure in the analysis of the determinants of fertility. The JPFHS findings indicate that 40 percent of currently married women are using a contraceptive method, including 5 percent of women who are using prolonged breastfeeding (see Table 4.4 and Figure 4.1 ). Two-thirds of current users rely on modem methods, while the remaining women use traditional methods. The IUD is the most widely adopted modem method ( 15 percent), followed by female sterilization (6 percent) and the pill (5 percent). Less than 2 percent rely on other modem methods, such as the condom and vaginal methods. Thirteen percent of currently married women are using a traditional method, principally prolonged breastfeeding (5 percent); withdrawal and periodic abstinence arc each practiced by 4 percent of currently married women. Overall, the level of contraceptive use has increased substantially in recent years, from 23 percent in the 1976 JFS survey to 26 percent in the 1983 JFFI-IS survey, and to 35 percent in the 1990 JPFHS survey 2 (see Table 4.5). The relative increase in the seven years preceding the JPFHS is more than 29 percent for modem methods, and 35 percent for all methods. Comparing specific methods, there has been considerable change in the use of specific contraceptive methods in the period between 1976 and 1990 (see Table 4.5 and Figure 4.2). Most noticeable is the shift from the pill to the IUD and female sterilization. While 12 and 8 percent of married women were using the pill in 1976 and 1983 respectively, only 5 percent were using it in 1990. On the other hand, IUD use increased from 2 percent in 1976 to 8 percent in 1983, and to 15 percent in 1990. Use of female sterilization also increased substantially. The JPFHS findings on use of contraception arc similar to those for other Arab countries in which DHS surveys have been conducted (Egypt, Morocco and Tunisia), and which have long-established family planning programs. The Jordan findings are most similar to those from Egypt and Momceo (see below). 2 To maintain comparability with data from previous surveys, prolonged breasffeeding is not included as a family planning method. 37 Table 4.4 Current use of conffacepfion Percent dislribufion of evca-mm'ried women end of currently married women by current use of contraceptive methods, acen'tding to nge, J ~ 1990 method Age of woman 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total EVER-MARRIED WOMEN Any methad 12.1 27.7 36.0 47.0 49.3 48.5 31.0 38.3 Any modern method 3.8 16.1 22.7 32.3 35.6 34.9 22.5 25.8 Pill 1.1 3.7 4.2 5.2 6.1 5.6 2,5 4.4 IUD 1.9 11.6 16.7 23.3 18.1 12.6 5.9 14.6 Injection 0.0 0,0 0.0 0.1 0.0 0.1 0,0 0.0 Vaginal methods 0.3 0.3 0.8 0.5 0.6 0.6 0.4 0.5 Condom 0.5 0.5 0.7 1.4 0.7 0.5 0.4 0.7 Female slc~izafion 0.0 0.0 0.3 1.9 I0. I 15.4 13.2 5.5 Male sterilization 0.0 0.0 0.0 0.0 0.I 0.0 0.0 0.0 Any traditional method 8.3 I 1.6 13.3 14.6 13.7 13.6 8.5 12.5 Periodic abstinence 1.4 2,9 3.2 3.6 5.0 5.5 3.3 3.7 Withdrawal 2.3 2,9 3.2 4.5 3.9 5.4 4,1 3.8 Prolonged brcesffceding 4,5 5.7 6.9 6.3 4.7 2.2 0,8 4.8 Oth~ 0.0 0,I 0,0 0.3 0.I 0.4 0.3 0.2 Not using 87.9 72.3 64.0 53.0 50.7 51.5 69.0 61.7 Total I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 Number 359 1073 1313 1138 959 866 755 6461 CURRENTLY MARRIED WOMEN Any method 12.3 28.1 37.2 48.5 52.3 51.6 33.7 40.0 Any madern malhod 3.9 16.4 23.5 33.3 37.8 37.1 24.2 26.9 Pill 1.1 3.7 4.4 5.4 6,5 6.0 2.8 4.6 IUD 2.0 11.8 17.3 24.1 19.2 13.5 6.5 15.3 Injoctlon 0.0 0.0 0.0 0. I 0.0 0. I 0.0 0.0 Vaginal methods 0.3 0.3 0.8 0.6 0.6 0.6 0.5 0.6 Condom 0.5 0.5 0.7 1.4 0.7 0.6 0.5 0.8 Feanal¢ sUn'ffizalion 0.0 0.0 0.3 1.8 10.7 16.2 14.0 5.6 Male sterilization 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Any tradlflonal method 8.4 11.7 13.7 15.1 14.5 14.5 9.5 13.1 Periodic abstinence 1.5 2.9 3,3 3.7 5.3 5.9 3.7 3.9 Withdrawal 2,4 2.9 3.3 4.7 4.1 5.8 4.5 4.0 Prolonged b~ffeeding 4.6 5.8 7.2 6.5 5.0 2.3 0.9 5.0 Other 0.0 0.l 0,0 0.3 0.I 0.5 0.4 0.2 Not using 87.7 71,9 62.8 51.5 47.7 48.4 66,3 60.0 Total I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 Number 353 1057 1268 1098 905 807 680 6168 38 Figure 4.1 Current Use of Contraceptive Methods Currently Married Women 15-49 Other Modern Methods 1% Female Sterilization 6% 15% Pill 5% Not Using 60% Traditional ~ethod9 13% JPFH8 1990 Table 4.5 Trends in contraceptive usa Percentage of currently married women who are using specific contraceptive methods, Iordan, 1976 IFS, 1983 JFFHS, and 1990 JPFHS Contraceptive 1976 1983 1990 method JFS JFFHS .IPFHS Any method 22.8 26.0 35.0 Any modern method 17.3 20,8 26.9 Pill 11.9 7.8 4,6 IUD 2.0 8.3 15.3 Injection NA 0.2 0.0 Vaginal methods 0.1 0.1 0.6 Condom 1.4 0.6 0.8 Female sterilization 1.9 3.8 5.6 Any traditional method a 5.4 5.3 8.1 b Periodic abstinence 2.1 2,9 3.9 Withdrawal 3,3 2,4 4.0 Number of women 3455 3735 6184 aother methods are excluded because of ~rn-curaparability among the three surveys. olonged breasffeeding is exchded as a con~aceptive method because no question was asked about this method in the two e~liar surveys, Source: Deparunent of Statistics (1979; 19847o) 39 Figure 4.2 Current Use of Specific Contraceptive Methods, Currently Married Women 15-49 Any method Pill IUD Female ator. Other ~ 8 ~!i!i~ii~!!i!i~i~!~!i~i~!~i!i~!~i~i!i~i~!i~i~i~i!i~i~!i~i~ii~i~i~i~i~i~!i:i~i~!~i~i~i~!~ii~i~i~i!~i~i!i~i~ii:~ ta 36 10 20 30 40 Percent using contraception k L I Use of contraception among currently married women, selected DHS surveys, 1987-1990 ~ Any Modern Traditional method method method Egypt, 19884 36.7 35.4 1.3 Jordan, 19904 35.0 26.9 g.1 Morocco, 1987 35.9 28.9 6.9 Tunisia, 1988 49.8 40.4 9.4 Use of contraceptive methods differs by demographic and socioeconomic characteristics. With regard to age patterns, the proportion of women using contraception increases with age and then declines (see Table 4.4); current use among currently married women is lowest among women age 15-19 (12 percent), increases to the highest level among women 35-39 (52 percent), then declines sharply among those 45-49 years of age (34 percent). Most women in the younger cohorts use contraception for spacing births, relying on the pill, IUD, and traditional methods. Women age 40-49 are more likely to use female sterilization in order to limit (stop) childbearing. 3 Source: Sayed, et al., 1989 (Egypt); Azelmat, Ayad and Belhachmi, 1989 (Morocco); Aloui, Ayad and Fourati, 1989 (Tunisia). 4 Prolonged breasffeeding is excluded from the data for Egypt and Jordan. 40 Contraceptive use is highest among women living in large cities (48 percent), followed by women in other urban areas (39 percent) and rural areas (29 percent) (see Table 4.6) The percentage using modem methods among women in large cities is twice that of rural women (34 percent and 17 percent respectively) (see Figure 4.3). There is considerable regional variation in current use of family planning (see Table 4.6). The govemorate of Amman has the highest level of contraceptive use (48 percent) followed by the govemorates of Zarqa and Mafraq (40 percent). The lowest levels are in the South (32 percent) and Balqa (26 percent). Differentials in use of modem methods are similar to those for use of any method. With regard to education, current use of contraception varies primarily between women who have received formal education and those with no education (see Table 4.6). Differences between the three edncation levels are small This pattern is also true for current use of modem methods. It should be noted, however, that use of the IUD increases with level of education, while use of female sterilization is negatively correlated with level of educational attainment. This could be due in part to the fact that women with no education tend to be older and have more children than women who have received formal education, and thus are more likely to want to stop childbearing altogether. Use of traditional methods also increases with level of education; this is particularly true for periodic abstinence. 60 50 40 SO 20 10 0 Figure 4.3 Contraceptive Use by Residence and Education, Currently Married Women 15-49 Percent 48 Large clty Other Rural urban RESIDENCE I mModern Methods No Prl. Sec. eduo. EDUCATION m Traditional Methods Higher JPFHS 1990 41 Current use of contraception increases with the number of living children, ranging from less than 1 percent among currently married women with no children to 48 percent among those with four or more children (see Table 4.6 and Figure 4.4). Table 4.6 C"un'e~t use of contraception by background characteristics Percent distributiun of currently married women by contracop~ve method currently used, according to selected background chm'acteristics, Jcyrdan 1990 Any Any Backsrotmd meth- modem characteris~ od method I Pill Modem methods Traditional methods Not Vaginal Female Periodic prolong, usin 8 Number meth- Con- slefili- Any absri- With-breast- any of IUD ods dora zation method nence drawal feeding Other method Total women Realden~ Large city 48.3 33.5 6.2 19.4 0.8 1.1 5.9 14.8 5.4 4.7 4.6 0.1 51.7 100.0 2513 Other url~m 38.7 26.5 3.9 14.8 0.5 0.6 6.6 12.2 3.1 4.3 4.6 0.2 61.3 I00.0 2034 Rural 28.5 16.9 3.0 9.5 0.2 0.3 3.8 11.6 2.5 2.6 6.2 0.3 71.5 I00.0 1622 Reslon Amman 48.3 33.8 5.7 19.3 1.0 1.1 6.7 14.5 4.6 4.8 5.0 0.1 51.7 I00.0 2420 Zarqa + Mafraq 39.9 25.6 5.2 15.8 0.5 4.0 14.3 3.6 5.3 5.2 0.2 60.1 I00.0 1265 Irbid 33.7 20.9 2.8 11.2 0.5 0.7 5.9 12.7 3.8 3.1 5.6 0.3 66.3 100.0 1470 Balqa 25.5 20.1 4.7 10.4 0.1 0.1 4.8 5.5 2.6 0.9 1.7 0.2 74.5 I00.0 416 South 31.8 20.7 3.2 11.4 0.3 0.8 4.8 II.I 2.4 2.6 5.9 0.2 68.2 I00.0 597 Educatlon levd attended No educaficnl 31.6 20.7 3.0 8.1 0.2 0.I 9.3 10.9 2.1 3.0 5.6 0.2 68.4 I00.0 1422 Primary 42.6 30.5 4.9 15.2 0.5 0.7 9.2 12.0 3.1 4.4 4.3 0.2 57.4 I00.0 1365 Secondmy 42.2 27.8 5.3 17.9 0.6 1.0 2.9 14.4 4.4 4.6 5.3 0.I 57.8 100.0 2723 More than secc~dmy 43.2 28.6 4.9 19.9 1.4 1.0 1.6 14.6 7.1 3.1 4.2 0.2 56.8 I00.0 658 Number of llvlns dllldlrea 0 0.9 0.3 0.2 0.2 -* -- 0.5 0.I 0.4 99.1 I00.0 583 I 22.9 7.6 3.4 2.8 0.6 0.6 0.2 15.3 5.2 3.3 6.8 -- 77.1 I00.0 582 2 37.5 24.3 4.4 17.6 0.3 1.6 0.5 13.2 4.3 4.2 4.6 -- 62.5 I00.0 652 3 45.9 30.6 5.3 21.5 0.5 0.9 2.4 15.3 4.2 3.0 8.0 0.I 54.1 I00.0 628 4+ 48.2 33.8 5.4 18.1 0.7 0.7 8.8 14.3 4.1 4.8 5.1 0.3 51.8 I00.0 3724 Total 40.0 26.9 4.6 15.3 0.6 0.8 5.6 13.1 3.9 4.0 5.0 0.2 60.0 I(30.0 6168 -- Less then 0.{~ percent *Includes usen of injection and mile sterilizarion. 42 60 60 40 80 20 10 o _/ Figure 4.4 Contraceptive Use by Number of Living Children, Currently Married Women 15-49 Percent /• ~A 48 1 2 6 4* m Modern Methods m Traditional Methods / I JPFH6 1990 4.4 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION Table 4.7 shows the number of children women had when they first used contraception. With increasing adoption of family planning, particularly among younger women, the average parity of women at first use of contraception has been declining. Less than one-third of women age 40-49 used any family planning method before having 4 or more children, compared to over hail of women age 25-29. Women are adopting family planning fairly early in the family building process. The proportion who started using contraception after marriage to delay the first birth has increased from less than 1 percent among women age 45-49 to almost 4 percem among those age 15-19. Overall, 19 percent of ever-married women (30 percent of ever-users), began using a contraceptive method when they had one child, and an additional 12 percent when they had two children. When the Jordan findings were compared with those from the three North African countries in which DHS survey has been conducted (Egypt, Morocco, and Tunisia), it was found that parity at first use of contraception in Jordan was about the same as in Egypt, but higher than in Tunisia and Morocco. 43 Table 4.7 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at the time of first use of eonu'aeeption, according to eurreaat age, Jordan 1990 Never Number of children at time used of first use of conUraception Number Current contra- of age ceptinn 0 1 2 3 4+ Total women 15-19 78.8 3.6 14.9 2.6 0.0 0.0 100.0 359 20-24 54.2 2.7 24.0 13.0 4.2 2.0 100.0 1073 25-29 34.5 2.1 27.6 16.3 8.8 10.7 100.0 1313 30-34 24.0 2.0 21.0 17.2 11.4 24.4 100.0 1138 35-39 26.1 0.8 14.4 11.3 9.8 37.5 100.0 959 40-44 27.0 0.6 13.5 7.9 10.1 40.8 100.0 866 45-49 36.0 0.2 11.1 6.1 6.7 39.8 100.0 755 Total 36.3 1.7 19.4 12.1 8.1 22.5 I00.0 6461 4.5 PROBLEMS WITH CURRENT USE OF CONTRACEPT ION Table 4.8 presents the problems identified by women as associated with the use of specific contraceptive methods. Overall, the majority of current users (71 to 98 percent) have had no problems with their methods. However, a minority of users report that they have had problems, mainly with the pill and IUD. Side effects and health concerns are the main problems reported by pill and IUD users (27 percent and 20 perecm, respectively). Table 4.8 Problems with current method o f contraception Percent distribution of contraceptive users by the main problem with current method, according to specLfic methods, Jordma 1990 Female Periodic Prolonged Vaginal Con- sterili- absti- With breast- Main problem Pill IUD methods dom zat lon nenee drawal feeding No proble~n 70.5 76.9 88.5 90.6 81.1 95.0 89.3 97.5 Husband disapproves 0.0 0.0 0.0 0.7 0.0 1.2 2.6 0.0 Side effects 17.0 13.6 5.0 0.0 7.5 0.7 1.3 0.0 Health concerns 9,7 6.7 3.7 5.1 9.6 0.0 3.3 0.7 Inconvenient to use 0,5 0.2 2.9 3.7 0.0 I.I 2.1 0.4 Sterilized, want childrcrt 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 Other 2.4 2.4 0.0 0.0 1.8 2.1 1.0 0.7 Missing 0.0 0.3 0.0 0.0 0.0 0.0 0.5 0.3 Total I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 Numbe~ 285 942 34 47 356 238 248 310 Note: Users of injection, male sterilization and other traditionel methods are excluded because of their small numb=s. 44 4.6 KNOWLEDGE OF THE FERTILE PERIOD Periodic abstinence is regarded as an important family planning method for health reasons as well as psychological, religious, and social reasons. A basic knowledge of the ovulatory cycle and an awareness of the fertile period is important for practicing periodic abstinence or the safe period method. As noted earlier, this method has been used by 17 percent of currently married women at some time, and it is currently being used by 4 percent of women. Since the failure rate for using the safe period method is high, it is important to find out if women who are practicing the method know when in the ovulatory cycle they should avoid having sexual intercourse. Table 4.9 presents the distribution of all ever- married women and of women who have ever used peri- odic abstinence by the time in the ovulatory cycle when they think a woman is most likely to get pregnant (per- ceived fertile period). To obtain these data, the respond- ent was asked when in the monthly cycle a woman has the greatest chance of becoming pregnant. The response was recorded in one of the preceded categories. The results indicate that the ovulatory cycle is well known to ever-married women, as well as to women who have used the safe period method. Half of ever-married wom- en can identify the correct safe period. This proportion is more than twice that for ever-married women in Egypt, Tunisia, Morocco and Sudan (DHS surveys). Among women who have used periodic abstinence, 69 percent answered correctly, while 21 percent gave the response "after the period ended." Again, these rates are higher than in all the above-mentioned countries except Sudan (72 percent). Table 4.9 Knowledge of fer tile period Percent distribution of ever-married women and of women who have ever used periodic abstinence by knowledge of the fertile period during the ovulatory cycle, Jorden 1990 Ever- Evor users Perceived married of periodic fertile period women abstinence During her period 1.1 0.6 After period ended 24.1 21.4 Middle of her cycle 50.3 68.6 Before period begins 1.7 1.6 Any time 0.7 0.3 Other 0.3 0.4 Don't know 21.8 7.1 Total 100.0 100.0 Number 6461 1064 Despite the relatively large proportion of wom- en who can correctly identify the fertile period, it should be noted that more than one in five ever-married women say they do not know when the fertile period occurs. As periodic abstinence is being used by a substantial number of women, family planning workers need to provide more information on the physiology of reproduction, with emphasis on the ovulatory cycle. 4.7 T IMING OF STERIL IZAT ION With the increasing use of sterilization among women, the age at which the operation takes place is of particular interest to family planning officials (see Table 4.10). Overall, age at sterilization has remained about the same in Jordan; the median age for women under 40 years of age is 35 years, s Women who were sterilized when they were less than 30 years of age are more likely to have had the operation performed in the distant past; older women (40 years and over) tend to have had the operation more recently. The median is calculated for women under 40 years of age in order to minimize problems of censoring. 45 Table 4.10 Timing of sterilization Percent distribution of sterilized woman by age at the time of sterilization, according to the number of years since the operation, Jordan 1990 Age at time of operation Number Years since of Median ~eratinn <25 25-29 30-34 35-39 40.44 .45.49 Total women age: <2 1.4 6.8 10.6 46.2 27.7 7.3 100.0 74 36,4 2-3 0.7 6.2 26.6 41.8 21.6 3.1 100.0 76 35.5 4-5 0.0 4.7 21.3 44.6 29.4 1(30.0 56 36.0 6-7 1.8 12.3 15.5 53.0 17.4 100.0 53 36.1 8-9 5.5 10.0 36.9 43.4 4.2 100.0 40 34.8 10+ 2.2 20.9 59.4 17.5 100.0 57 32.0 Total 1.7 9.8 27.3 41.1 18.0 2,2 100.0 356 35,1 -- Less than 0.05 percent tMedian age was calculated only for women less than 40 ye&s of age to avoid problems of censoring. 4.8 SOURCE OF SUPPLY FOR MODERN METHODS In addition to information about the level of contraceptive use, program officials need to know where users obtain their methods. The JPFI-IS included a question for current users of modem methods about the source of their method. Family planning clinics and private doctors predominate as the sources of supply for modem contraceptive methods (see Table 4.11 and Figure 4.5). Together, they serve half of current users. This contrasts with 1983, when private doctors served 35 percent of current users (Department of Statistics, 1984b). Over the same period, family planning clinics gained in popularity, increasing fivefold from 6 percent in 1983 to 30 percent in 1990. Pharmacies are the primary source for users of methods which require resupply, including the pill (64 percent), vaginal methods (71 percent), and condoms (61 percent). Family planning clinics provide services for half of IUD users (49 percent). Government hospitals are the source for most female sterilizations (73 percent). 46 Table 4.11 Source o f supply for modem contraceptive methods Percent distribution of current users of modern contraceptive methods by most recent source of supply or information, according to specific methods, Jordan 1990 Female Atl Somr.e of supply Vaginal Con- sterili- modern or information Pill IUD methods dom zation methods t Government hospital 4.8 2.6 8.4 -- 73,0 18.2 MCH/Heal~h canter 3.7 8.9 -- 13.0 0.5 6.1 Fandly planning clinic 9.4 48,9 3.4 24.3 30.1 Private doctor 13.8 30.6 17.5 2.3 1,6 20.4 Private hospital 2.2 5.9 . . . . 24.9 9.0 Pharmacy 64.0 L1 70,6 60.5 14.7 Friends/~lafives 0.4 . . . . . . 0.I Other 0.8 2.0 . . . . 1,2 Don't know 1.0 . . . . . . 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 285 942 (34) (47) 356 1666 Note: Figtw~s in pazcntheses ~ based on fewer than 50 cases. -- Less than 0.0510¢rcent tlncindea users of injection and male stecilizatlo~ Figure 4.5 Sources of Family Planning Methods Current Users of Modern Methods FP Clinic 3( MCH/Health Canter 6% 3overnment Iospital 18% 3harmacy 15% Pri~ Docto . . . . r ' rwaze Hospital 10% JPFH8 1990 47 4.9 TIME TO SOURCE FOR MODERN FAMILY PLANNING METHODS Current users of modem contraceptive methods were asked how much time (minutes) was required to get from their home to the place where they obtained their method. The same question was asked of women who were not using a modem method, and of all women who knew a contraceptive method (with reference to the place they would go if they wanted to obtain a modem method). The median time to a source for modem methods was 16 minutes; this was the same for all three subgroups (see Table 4.12). Rural women live 15 minutes fatxher from a source than women in large cities. Among users of modem methods, 56 percent live less than 30 minutes from their source of supply, and another 25 percent are 30 to 59 minutes from a source. For women who are not using a modem method and women who know a method, the proportion in each time category is slightly smaller. Table 4.12 Time to source of supply for modem contraceptive methods Percent distribution of women who are currently using a modem contraceptive method, of women who are not using a modem contraceptive method, and of women who know a method, by time to reach a source of supply, according to urban- rural residence, Jordan 1990 Women who ale cun~ntly using a modern method Women who ate not using a modern method Women who know a contraceptive method Minutes Large Other Large Other Large Other to source city urban Rural Total city urban Rural Total city urban Rural Total 0-14 31.2 22.7 13.9 25.6 10.1 10.2 9.1 9.8 16.9 13.4 9.9 13.9 15-29 36.4 27.5 16.2 30.2 15.7 11.5 10.0 12.6 22.4 15.6 11.1 17.2 30-59 21.0 27.2 32.0 24.9 8.5 10.7 9.8 9.6 12.6 14.9 13.4 13.6 60+ 7.5 16.6 28.9 14.0 2.9 4.2 7.4 4.7 4.4 7.3 11.0 7.1 Don't know time 3.9 5.9 9.0 5.4 1.4 2.0 3.2 2.2 2.2 3.0 4.2 3.0 Don't know source . . . . . . . . 13.8 19.1 23.8 18.5 9.2 14.2 19.6 13.6 Not stated . . . . . . . . 2.4 2.8 1.8 2.4 1.6 2.1 1.5 1.8 Users of ~aditional methods NA NA NA NA 45.2 39.5 34.7 40.2 30.7 29.4 29.2 29.9 Total percentage 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 847 544 275 1666 1788 1589 1418 4795 2631 2132 1687 6451 Median 15.6 20.7 30.8 16.0 15.6 15.9 30.3 15.9 15.6 20.1 30.4 15.9 -- Less than 0.05 percent NA = Not applicable 4.10 CONTRACEPTIVE DISCONTINUATION A key concern of family planning officials is the extent to which women discontinue use of contraceptive methods, and their reasons for doing so. Life table discontinuation rates based on information collected in the calendar are presented in Table 4.13. Discontinuation rates were calculated for each method based on use during the first twelve months after beginning the method. The reasons for discontinuation were examined, and classified into three main categories: method failure, desire to become pregnant, and other reasons including problems related to the use of a particular method, husband's disapproval, and absence of need to use a family planning method. 48 Table 4.13 First-yeer discontinuation rates for contraception Proportion of contraceptive users who discontinued use of a method by 12 months after beginning the method, due to method failure, desire to become pregnant, or other reason, by specific methods, Jordan 1990 Reason for discontinuing use of contraceptive method Side Desire effects and Contraceptive Method to become health Other method failure pregnant concerns reason Total Pill 8.1 10.5 30.0 14.6 63.2 IUD 2.4 4.3 11.0 3.1 20.7 Vaginal methods 31.6 5.4 16.5 21.8 75.3 Condom 12.2 8.9 12.0 30.5 63.6 Periodic abstinence 29.9 11.3 1.9 12.4 55.6 Withdrawal 19.4 9.4 2.5 23.0 54.3 Prolonged breasffee~mg 19.4 4.3 0.7 18.0 42.4 Total 13.3 7.0 10.7 13.0 44.0 Note: Figures are based on llfe-table calculations. Thirteen percent of users stopped using before the end of the first year because the method failed to protect them from pregnancy; 7 percent said they stopped because they wanted to become pregnant; and 11 percent stopped because of side effects and health concerns. 6 First-year discontinuation rates due to method failure are highest for vaginal methods and traditional methods. Three in ten women who used a diaphragm, foam or jeUy and 30 percent of women who used periodic abstinence got pregnant while using the method. Table 4.14 provides information about women's reasons for discontinuing contraceptive use. The table includes all discontinuatons in the five years before the survey regardless of whether they occurred during the first twelve months of use or later. Method failure is the reason given most frequently for discontinuation (27 percent), followed by desire to get pregnant (22 percent), and side effects (17 percent). It should be noted that 16 percent of women did not give a definite answer to this question. Discontinuation due to method failure is particularly high for traditional methods: periodic abstinence (52 percent), prolonged breastfeeding (40 percent) and withdrawal (37 percent). For modem methods, method failure was the main reason given for discontinuation of vaginal methods (38 percent) and condoms (28 percent), both coitus- dependent methods. 6 Discontinuation rates presented in Table 4.13 refer to all episodes of contraceptive use in the period of time covered by the calendar, not just those episodes that began during this period. These are cumulative one-year discontinuation rates and represent the proportion of users discontinuing a method by 12 months after the start of use. The rates are calculated by dividing the number of discontinuations for each reason at each duration of use in single months by the number of months of exposure at that duration. The single-month rates are then cumulated to produce a one-year rate. The reasons for discontinuation are treated as competing risks (net rates). 49 Table 4.14 Reasons for discontinuation of contraception Poreont distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason for discontinuation, soeording to specific methods, Jordan 1990 Modem method discontinued Traditional method discontinued Periodic Prolonged Reason for Vaginal absti- With- breast- All discontinuation Pill iUD methods Condom nanee drawal feeding methods I Becmae Ixegnant 13.1 11.3 37.5 27.5 51.5 36.7 40.1 27.0 To become i~egnant 22.0 29.0 11.3 15.7 23.2 20.1 15.8 21.6 Husband diset,t,ioved 0.9 0.7 2.5 11.4 4.4 8.3 0.5 2.3 Side effects 35.5 30.3 17.3 7.7 1.1 2.5 0.7 17.2 Health concerns 7.1 6.8 4.1 5.8 3.1 2.8 1.0 4.6 Access/availability 0.5 -- 0.9 . . . . . . 0.3 0.7 More effective method 1.6 1.3 3.2 6.9 5.6 9.0 11.4 5.2 lnconvanient to use 1.9 2.0 4.0 8.2 1.4 3.5 0.6 2.0 Irffrequant sex 4.8 1.5 2.7 1.6 1.4 2.5 0.1 2.1 Fatalistic 0.I . . . . . . . . . . 0.4 0.I Manopauso 0.7 0.5 1.7 -- 0.6 0.8 0.5 0.7 Mmital dissolution 0.7 0.5 -- 0.9 0.1 0.2 0.1 0.3 Other 10.7 16.1 14.0 14.3 7.3 12.0 28.1 15.6 Don't know -- 0.1 0.8 -- 0.2 0.5 0.2 0.1 Missing 0.4 0.2 . . . . 0.2 1.0 0.2 0.3 Total 1(30.0 100.0 100.0 100.0 100.0 100.0 1(30.0 100.0 Number 1211 1160 162 124 615 522 1067 4923 -- Less than 0.05 percent tTotal includes I0 dlscontlnuatlons of injection and other traditional methods. 4.11 FUTURE USE OF FAMILY PLANNING To obtain information about potential demand for family planning services, all currently married women who were not using contraception at the time of the survey were asked about their interest in adopting family planning in the future. Those who responded in the affirmative were also asked which method they would prefer to use, and whether they intended to use this method in the next 12 months. Table 4.15 presents the distribution of currently married women who were not using contraception, by intention to use in the future, according to number of living children. Forty-one percent of nonusers say that they intend to use family planning in the future, most of them within the next 12 months. About the same proportion of nonusers say they do not intend to use in the future (43 percent). Those who intend to use a method in the future are more likely to have used in the past than to have never used a method. Those who had never used contraception are more likely to be unsure about their intentions. Among women who had no experience in using family planning, one in five was unsure about using a family planning method in the fumre. 50 Table 4.15 Futureuseofcontraception Percent distribution of eurrontiy married women who are not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living childron, Jordan 1990 Past experience with contraception and future inteations Number of living children I 0 1 2 3 4+ Total Never used contraception Intend to use in next 12 months 1.7 19.2 16.3 12.5 6.3 9.4 Intend to use later 24.4 20.7 10.9 4.7 3.0 8,5 Uust~e as to intontion 24.5 21.2 9.1 10.5 6.3 10.9 Does not intend use 47.1 28.2 28,9 21,8 28,5 29.6 Missing/Not in union 0.5 0.0 0.0 0.0 0.0 0.1 Previously used contraception Intend to use in next 12 months 0.3 2.2 14.1 23.5 22.2 16.6 Intend to use later 0.3 4.6 11.5 9.9 6.2 6.4 Unst~e as to intention 0.3 1.9 4.1 8.7 6.4 5.2 Does not intond use 0.9 1.9 5.1 8.3 20.8 13.2 Missing/Not in union 0.0 0.0 0.0 0.0 0.2 0.1 Total I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 Currently married nonusers Intend to use in next 12 months 2.0 21.4 30.3 36.0 28.6 26,0 Intend to use later 24.7 25.3 22.4 14.6 9.2 14,9 Uustre as to intention 24,8 23.1 13.2 19.3 12.7 16.1 Does not intend use 48.0 30.1 34.1 30.2 49.3 42.8 Missing/Not in union 0.5 0.0 0.0 0.0 0.2 0.2 Total 100.0 100.0 1(30.0 100.0 100.0 100.0 Number 363 503 407 396 2035 3704 1includes current pregnancy Intention to use contraception in the future has a strong positive association with the number of living children the woman has (see Table 4.15); women with more children are more likely to want to use contraception in the future than those with fewer children. More than half of women with two or three children say they intend to use a method of family planning, compared to 27 percent of childless women. The masons women do not use family planning are of particular interest to family planning program officials. Table 4.16 gives the distribution of women who are not using contraception by their reason for not using. The primary reason given has to do with infecundity: 28 percent of women say it is difficult to get pregnant. The next most common reason for not using is the desire to get pregnant: 21 percent of nonusers say they are not using because they want to have children. Other reasons mentioned are husband's disapproval (7 percent), health concern (7 percent), religion (7 percent), and a fatalistic view (6 percent). An additional 8 percent mention menopause, hysterectomy and infrequent sex. 51 Table 4.16 Reasons for not using contraception Percent distribution of women who are not using a contracopdve method and who do not intend to use in the future by main reason for not using, according to age, Jordan 1990 Age Reason for not using contraeeptlon 15-29 30-49 Total Wmats children 39.2 12.2 20.8 Lack of knowledge 0.8 1.7 1.4 Husband opposed 12.1 4.4 6.9 Cost too much 0,0 0.1 0.1 Side effects 4.5 4.3 4.3 Health concerns 7.7 6.3 6.7 Religion 8.0 5.7 6.5 Opposed to family planning 0.4 0.8 0.7 Fatalistic 6.3 6.4 6.4 Other people opposed 0.2 0.0 0.1 InfTequont sex 0.7 2.3 1.8 Difficult to be pregnant 12.4 35.5 28.2 Menopausal, had hysterectomy 0.2 9.4 6.5 Inoonveniont 0.3 0.9 0.7 Other 2.4 6.5 5.2 Don't know 4.9 3.5 3.9 Total 100.0 100.0 100.0 Number of women 508 1087 1595 Women under 30 are more likely than older women to mention the desire to have children, while difficulty in becoming pregnant is more often reported by older women. Husband's disapproval is mentioned more often by younger women than women 30 and over. As expected, hysterectomy and menopause are cited exclusively by older women+ Method preferences among women not using a contraceptive method at the time of the survey but who intend to use a family planning method in the future are shown in Table 4.17. The majority of women (74 percent) say they want to use a modem method of contraception; only 14 percent want to use a traditional method. Haifofthe women who intend to use contraception say they want to use the IUD. (Among currently married women, use of the IUD has increased from 8 percent in 1983 to 15 percent in 1990). After the IUD, the most popular methods are the pill (17 percent) and female sterilization (7 percent). Method preferences are almost identical for women who intend to use contraception in the next 12 months and for those who intend to use after 12 months. Some programmatic implications can be drawn from the data in Table 4.17. Because of the popularity of the IUD, pill, and female sterilization, a number of issues need to be considered in anticipation of women carrying out their intentions to use these methods. First, the pill supply must be adequate to meet the needs of women who want to use this method; second, for women who want to use the IUD or femaie sterilization, trained personnel must be available to provide these services. 52 Table 4.17 Preferred method of contraception for future use Percent distribution of currently married women who are not using a contraceptive method but who intend to use in the future by preferred method, according to whether they intend to use in the next 12 months or later, Jordan 1990 Intend to use • In next After Prefen'ed method 12 12 of contraception months months Total Pill 17.4 16.4 17.0 IUD 47.9 46.7 47.4 Injection 0.7 1.0 0.8 Vaginal methods 1.3 1.0 1.2 Condom 1.1 0.3 0,8 Female sterilization 7.9 4.0 6.5 Periodic absdrtonce 6.0 5.7 5.9 Withdrawal 2.7 3.6 3.0 Other 0.4 0.7 0.5 Prolonged breasffeeding 4.2 4.7 4.4 Missing 10•4 16.0 12.4 Total 100.0 100.0 100.0 Number 963 553 1516 4.12 ACCEPTABILITY OF MEDIA MESSAGES ON FAMILY PLANNING All ever-married women were asked if it was acceptable t O them to have family planning messages on radio or television. The objective of the question was to examine the level of popular support for family planning education and advertising on mass media. The results indicate that overall, 84 percent of ever- married women consider it acceptable for mass media to carry programs on family planning issues (see Table 4.18). Although acceptance is generally greater among younger than older women, when urban-rural differentials are considered, age differences are minimal. Younger women in urban areas are only slightly more likely than younger women in rural areas to favor family planning messages on mass media. The popularity of family planning information on radio and television varies across regions. It is highest in Balqa and Amman, and lowest in the South. Education is closely associated with acceptance of family planning messages. The popularity of family planning messages is uniformly high among women who have attended secondary or higher education (more than 88 percent). 7 Among women who have no schooling and those who have attended only primary school, older women are more likely to consider family planning messages acceptable than younger women• 7 The small proportion of women in the oldest age group who have attended higher education and are favorable toward family planning messages (76 percent) is probably due to the small number of women in that category. 53 Table 4,18 Acceptability of the use of mass media for dissem'mating fmnily planning messages Percentage of women who believe that it is acceptable to have messages about family planning on radio or television, by age e~l selected background characteristics, Jordaft 1990 Age of woman BackSronnd cheaeete~tic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Resldonce Large cities 84.3 86.4 88.5 85.4 87.4 84.6 86.3 86.4 Other Urban 92.9 86.7 86.5 85.9 83.5 80.7 78.3 84.7 Rural 82.8 84.1 85.4 83.2 78.5 74.8 72.3 80.7 Region Ammlm 92.2 90.8 90.7 88.8 87.4 87.8 86.4 89.0 Zarqa + Ma/raq 75.8 83.1 83.8 83.2 75.1 74.9 78.3 80.1 Irbid 87.9 83.4 86.0 80.8 83.3 74.3 70.7 81.1 Balqe 93.5 89.3 92.7 92.9 93,8 92.8 92.9 92.6 South 83.8 78.1 78.9 79.3 76.1 71.7 69.2 76.9 Education level attended No education 58.0 74.5 68.6 76.2 73,7 74.4 77.1 74.7 Primary 77.0 77.9 90.0 85.5 83.2 81.5 84.1 83.9 Secondm'y 90.1 87.7 88.6 86.5 91.4 92.8 91.3 88.8 More than seenndexy 89.1 88.9 88.3 89.0 90.3 86.1 75.9 88.4 Total 86.9 85.9 87.0 85.0 83.6 80.8 80.3 84.4 54 CHAPTER 5 NUPTIALITY AND EXPOSURE TO THE RISK OF PREGNANCY This chapter addresses the principal factors, other than contraception, which affect a woman's risk of becoming pregnant, namely nuptiality, postpartum amenordaea, and secondary infertility. The Jordan Population and Family Health Survey (JPFHS) questionnaire differs from the standard DHS questionnaire in that direct questions on recent sexual activity were not included due to the difficulty in addressing these questions to women. Information on sexual activity was replaced with proxy questions involving information on whether the respondent's husband lives in the same household and the amount of time he spent in the household during the month preceding the survey. The subject of nuptiality is of particular interest because marriage is a primary indicator of the exposure of women to the risk of pregnancy. Information about marriage patterns is important for an understanding of fertility. Early age at first marriage is associated with early childbearing and high fertility. In this survey and in all data collection in Jordan, the term marriage refers to a legal or formal union. 5.1 CURRENT MARITAL STATUS Table 5.1 compares the data for ever-married women from the 1976 Jordan Fertility Survey (JFS), 1983 Jordan Fertility and Family Health Survey (JFFHS), and the 1990 Jordan Population and Family Health Survey (JPFI-IS). In the 14 years between 1976 and 1990, the percentage of women ever married decreased from 66 to 56 percent, a drop of 15 percent. However, the decline appears to have occurred in the first 7 years, since the percentages are the same for 1983 and 1990. In Jordan, marriage is almost universal. By the end of the reproductive years, only 2 percent of women have never entered into marriage (see Figure 5.1). In 1976, less than 5 percent of women age 30-34 had never been married, while in 1990 11 percent of women in that age group were still single. Likewise, for women in younger age groups, the percentage who have never been married is lower in 1976 than in 1990. These figures indicate that women are marrying at older ages than in the past. The dam indicate that the decline is not smooth, suggesting that most of the increase in age at marriage took place between 1976 and 1983. Table 5.1 Eve~-marrled women according to selected surveys Percentage of women 15-49 who have ever married by age, Jordan, 1976, 1983 and 1990 JFS JFFHS JPFHS Age group 1976 1983 1990 15-19 19.5 9.4 10.6 20-24 64.1 42.0 45.2 25-29 87.4 76.3 73.7 30-34 95.3 90.1 89.1 35-39 92.4 94.9 94.6 40-44 98.0 96.8 97.3 45-49 98.3 97.1 98.0 Total 65.7 56.0 56.2 55 Figure 5.1 Never-Married Women 15-39 by Age Jordan, 1976, 1983, and 1990 Percent 18-19 20-24 25-29 30-34 r " J F8 1970 ~JFFH8 1988 ~JPFHS 1990 i 05-$9 Table 5.2 presents the distribution of women by current marital status. Of the 11,499 women age 15- 49 listed in the household schedule, 44 percent had never married, 54 percent were currently married, and the remaining 3 percent were either divorced, widowed or separated. The percentage of women 15-49 who were married in 1976 and 1983 was 63 percent and 53 percent respectively. Table 5.2 Cunent marital status Percent distribution of women by current marital status, according to age, Jord~at 1990 Age Marital status Number Never Not living of married Married Divorced Widowed together Total women 15-19 89.4 10,4 0.2 0.0 0.0 100.0 3394 20-24 54.8 44.5 0.4 0.2 0,I I00.0 2374 25-29 26.3 71.2 1.9 0.4 0.2 100.0 1781 30-34 10.9 86.0 1,5 1.4 0.2 I00.0 1277 35-39 5.4 89.3 1.6 3.5 0.2 100,0 I014 40-44 2.7 90.8 1.3 5.2 0.0 100.0 890 45-49 2.0 88.3 0.8 8.7 0.2 I00.0 770 Total 43.8 53.6 0.9 1.6 0.1 I00.0 11499 56 The proportion currently married increases steadily from 10 percent among women 15-19 to 91 percent among those 40-44, then declines slightly to 88 percent for women in the oldest age group. As expecw.xl, the proportion widowed increases with age, reaching 9 percent for women age 45-49. The percentage of divorced women is extremely low, less than 2 percent of women in all age groups. 5.2 MARITAL EXPOSURE Table 5.3 presents marital exposure to the risk of pregnancy, as measured by the pereemage of time the woman has been in marital union. Since the table is based on information colieeted in the calendar, exposure time is limited to the five years preceding the survey. Table 5.3 Marital exposure Percentage of time spent in marital union in the five years preceding the surTey, by age and selected background ¢harecteristics, Jordan 1990 Age at time of survey Background ¢harec~risae 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Large cities 3.7 29.3 60.1 81.5 88.2 91,9 89.8 47.0 Other Urban 3.3 27.2 63.7 86.6 91.5 88.6 89.8 45.3 Rural 3.6 30.9 74.7 87.7 88.9 95.5 88.9 51.4 Region Amman 3.2 28.9 61.4 81.4 89.5 92.3 91.5 45.3 Zavqa + Mafraq 3.8 29.9 67.1 88.5 89.5 90.8 87.6 47.9 Irbld 3.4 28.0 66.4 81.0 88.2 91.8 87.9 46.1 Balqa 3.9 26.1 65.1 86.8 85.5 89.8 88.3 53.8 South 6.7 32.7 69.8 93.5 96.1 92.4 91,4 57,7 Education levd attended No Education 6.2 50.3 76.0 85.5 89.3 94.0 90.1 82.9 Ptimar/ 6.2 42.8 74.1 87.6 91.0 91.8 87.4 68.4 Secondary 3.1 35.0 70.8 88.9 90.9 92.1 91.9 35.1 Morn thaa secondary 1.0 8.5 43.4 71.1 82.1 69.8 88.6 30.2 Total 3.5 29.1 65.2 84.9 89.6 91.7 89.5 47.6 Overall, women in Jordan spent 48 percent of the five years prec, eding the survey in marital union. This figure varies by age; younger women spent less time in marriage than older women, because a large proportion have not yet married. Women age 30-49 spent almost the entire live-year period in marital union, indicating that divorce is uncommon in Jordan. The lower percentage of exposure for women age 45-49 is due to widowhood. Data in the same table show that there is little variation between women living in urban and rural areas, and by govemorato. However, wide variationis found by educational attainment. Until age 30, women who have higher education spend much less time in marital union than women with less schooling or no schooling. The difference is sharpest for women 20-24, the age at which many women are recently married. 57 While women who had no formal schooling spent 50 percent of the five years preceding the survey in marital union, the proportion is 9 percent for women with higher education. The difference due to the fact that women with higher education marry later than women with no education. As a result, educated women are exposed to the risk of pregnancy for a shorter length of time than women with no education. 5.3 AGE AT F IRST MARRIAGE In Jordan, almost all births occur within marriage; thus, age at first marriage is an important indicator of exposure to the risk of pregnancy and childbirth. The Jordan Family Rights Law of 1976 sets the minimum age at marriage for males at 18 years, and for females 16 years. Table 5.4 shows the percentage of women who have ever married by specified ages and the median age at first marriage according to their age at the time of the survey. Comparing percentages across age groups, the data indicate increasing age at first marriage. For example, among women 20-24 years, 2 percent were married by age 15, 16 percent by age 18, and 30 percent by their twentieth birthday. For women 25-29, the percentages at each specific age are all higher than those for the younger women. Older women married at even younger ages, as demonstrated by the higher proportion of women married by each specific age. Table 5.4 Age at first marriage Percentage of women who were first married by exact age 15, t8, 20, 22, and 25, and median age at In-st marriage. according to current age, Jordan 1990 Current age 15 Percentage of women who were Percentage Median first married by exact age: who were Number age at never of first 18 20 22 25 married women marriage 15-19 1.1 NA NA NA NA 89.4 3394.0 a 20-24 2.1 16.4 29.7 NA NA 54.8 2374.0 a 25-29 4.9 26.3 42.2 54.8 69.0 26.3 1781.0 21.2 30-34 8.4 36.8 52.0 67.8 80.2 10.9 1277.0 19.7 35-39 9.3 42.8 61.1 72.6 85.1 5.4 1014.0 18,8 40-44 10.4 39.8 62.1 77.4 89.5 2.7 890.0 18.9 45-49 11.4 36.9 62.6 76.4 89.4 2.0 770.0 18.9 20-49 6.4 29.6 46.6 59.4 70.0 24.7 8105.0 a 25-49 8.2 35.1 53.6 67.3 80.3 12.2 5731.0 19.6 NA = Not applicable ~niued because less than 50 percent of women in the age group have been married. The last column in Table 5.4 provides further indication of later marriage among younger women. While the median age at first marriage---i.e., the age by which half of the women have married--is similar for women age 35 and over, younger women are marrying at older ages. Half of women age 25-29 marry after age 21, and overall, the median age at first marriage has increased from about 19 to 21 years. 58 There is little variation in age at first marriage by residence and region (see Table 5.5). Women marry at about the same age in all groups, although urban women and women in Balqa marry at slightly older ages than rural women and women in other govemorates. While there are only minor differentials in median age at first marriage by residence and region, education plays an important role in determining women's entry into marriage. The improvement of educational opportunities, particularly for girls, has resulted in their staying in school longer, and sub- sequentiy pushed the age at first marriage upward. Women who have attended more than secondary education tend to marry almost 6 years later than those with no education or primary education. Women who have attended primary education marry younger than women who have no formal schooling because they are more favored by potential husbands than illiterate women. Table 5.5 Median age at first marriage Median age at first marriage among woman age 25-49 years, by current age and selected background characteristics, Jordan 1990 Current age Woman Background age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Large cities 21.5 20.0 18.8 19.2 18.6 19.8 Otber Urban 21.4 19.5 18.5 18.6 19.1 19.5 Rural 20.7 19.3 19.0 18.9 19.3 19.5 Reglon Amman 21.4 19.9 18,5 18.8 18.6 19.5 Zarqa + Mafraq 21.1 19.1 19.0 18.8 19.3 19.6 Irbid 21,2 19.6 18.7 19.2 19.5 19.6 Balqa 20.4 20.3 20.1 19.4 19.5 19.9 South 21.7 19,8 17,9 18.6 18,0 19.5 Education level attended No education 19.1 18.6 18.0 18.4 18.8 18.6 Primary 19.4 17,5 17.9 18.3 18.4 18.2 Secondary 20.6 19.5 19.2 20.8 20.3 20,0 More than secondary 24.1 24.0 24.4 22.0 24.1 24.1 Total 21.2 19.7 18.8 18,9 18.9 19.6 Note: The medians for cohorts 15-19 and 20-24 could not be determined because less than 50 percent of the woman in each cohort have been married. 59 5.4 POSTPARTUM AMENORRHEA, POSTPARTUM ABSTINENCE, AND INSUSCEPT IB IL ITY The risk of pregnancy is affected by several factors other than marriage patterns. Women have little risk of becoming preg- nant during the period after childbirth when menstruation has not yet returned (post- partum amenorrhea) and in the period when sexual activity has not been resumed (post- partum abstinence). The duration of amen- orrhea is directly related to breastfeeding; the longer the woman breastfeeds her child the longer she is likely to be amenorrheic. Since breastfeeding is an important issue in childhood nutrition (see Chapter 9), only postpartum amenorrhea and postpartum ab- stinence are considered in this section. Women are insusceptible when they are ei- ther amenorrheic or still abstaining fol- lowing birth, or both, and thus not exposed to the risk of pregnancy. The estimates for postpartum amenorrhea, postpartum absti- nence, and insusceptibility are based on cur- rent status measures, that is, the proportion of births occurring x months before the sur- vey for which the mothers are still amenor- rheic, abstaining, or insusceptible at the time of the survey. The medians are calculated on the basis of current status proportions at each time period, and the data are grouped by two-month intervals for greater stability. Table 5.6 presents the distribution of births in the 36 months preceding the survey by the postpartum status of the mothers. Seventeen percent of the mothers have not Table 5.6 Postpartum amenorrhea~ abstinence end insusceptibility Percentage of births for which the mothers are postpartum amenorrheic, abstaining, mad insusceptible, by ntanber of months since birth, and median and mean durations thereof, Jordan 1990 Number Months Amenor- Abstain- lmuscep- of since birth rheic ing tibia births < 2 94.7 84.7 97.2 225 2-3 62.9 11.9 64.2 254 4-5 44.3 1.2 45.1 265 6-7 28.3 1.7 29.5 270 8-9 32.7 3.9 34.5 283 10-11 17.3 0.0 17.3 282 12-13 17.4 0.0 17.4 296 14-15 4.9 0.5 5.4 224 16-17 3.3 1.1 4.0 300 18-19 3.2 0.0 3.2 267 20-21 2.4 0.4 2.7 264 22-23 1.6 0.0 1.6 301 24-25 1.3 0.0 1.3 294 26-27 0.6 0.8 1.4 284 28-29 0.7 0.0 0.7 256 30-31 0.0 0.9 0.9 267 32-33 0.4 0.0 0.4 278 34-35 0.0 0.0 0.0 295 Total 16.5 5.1 17.1 4905 Median 4.1 1.9 4.2 NA Mean 6.6 2.5 6.8 NA Prev./lncidenee rneen 5.8 1.8 6.1 NA Note: Medians and means are based on the current status proportions at each two-month duration since birth. NA = Not applicable resumed menstruating, and 5 percent have not resumed sexual relations. Combining the two conditions, 17 percent of births were to women who are still insusceptible to the risk of pregnancy. The average duration of amenorrhea is about 7 months; the average duration of abstinence is about 3 months. While 95 percent of births are to women who are still amenorrheic 2 months after childbirth, between 2 and 3 months after birth the percentage drops to 63, and in the following 2 months it is reduced to less than half (44 percent). In Jordan, as in other Islamic societies, women observe a period of sexual abstinence after childbirLh. Traditionally, the period of postpartum abstinence lasts 40 days. This practice appears to emerge in the JPFHS data. The mothers of 85 percent of the births occurring in the 2 months before the survey were still abstaining from sexual relations at the time of the survey. By the end of this period, 2-3 months following the birth, only 12 percent of mothers were still abstaining; the decline continues over the next 2- month period with only 1 percent of mothers abstaining. 60 Table 5.7 presents the median duration of postpartum amenorrhea (4 months), postpartum abstinence (2 months), and postpartum insusceptibility (4 months) by background characteristics. In regard to post- partum amenorrhea, younger women, women who live in urban areas, and those with the highest education levels have shorter durations than other women (see Figure 5.2). There is little variation in the median duration of postpartum abstinence by background characteristics. Insusceptibility, the combined effect of amenorrhea and abstinence, shows a pattern similar to that of amenorthea. Comparing regions, women in Irbid have the longest durations of amenorrhea and insusceptibility. The level of education attended has both a positive and a negative effect on fertility. Age at first marriage increases with education, which tends to reduce fertility. At the same time, however, the duration of insusceptibility, which protects women from pregnancy decreases with education. The duration of insusceptibility among Jordanian women who have attended more than secondary education is about half that of women with no education (3 months compared to 5.4 months). The relationship between education and fertility warrants further investigation. Table 5.7 Median duration of postp~tum insusceptibility Median numbcx of months of postpartum amanonhe.a, postpartum abstlnence~ aad postpertnm insusceptibility, by selected background characteristics, Jordan 1990 Postpartum Number Background Postpartum Postpartum insuscep- of chaxactexisr;c amenorrhea abstinence tibility births Age ~0 3.8 1.9 4.0 ~50 3~ 4.6 1.9 4.8 ~56 Residence Large cities 3.7 2.1 3.8 1824 Other Urban 4.0 1.8 4.2 1608 Rural 4.7 1.8 4.7 1474 Region Amman 4.1 2.0 4.2 1768 Zerqa + Mafi'aq 3.7 2.0 3.9 979 Irbid 4.9 1.7 4.9 1297 Balqa 3.2 2,1 3,4 329 South 4.2 1.6 4.3 533 Education level attended No education 5.3 1.9 5.4 S50 Primary 4.3 1.7 4.3 992 Secondary 4.1 1.9 4.3 2441 More than secondary 3.0 2.0 3.0 622 Total 4.1 1.9 4.2 4905 Note: Medians ~ae based on cm-rent status. 61 6 5 4 3 2 1 0 Figure 5.2 Median Duration of Postpartum Amenorrhea, Abstinence, and insusceptibility Median duration (months) <30 30* Large Other Rur&l No Prl. So©. Higher city urban educ. AGE RESIDENCE EDUCATION I m Amenorrhe. m Ab.,Inence m Insusceptibility J PFH8 1990 5.$ TERMINAT ION OF EXPOSURE The termination of women's exposure to the risk of childbearing is an important aspect of fertility. Two indicators of termination of exposure are menopause and terminal infertility (see Table 5.8). Menopause is defined as the absence of a menstrual period in the six months preceding the survey. A woman is considered to have terminal infertility if she did not give birth during the five years preceding the survey in the absence of contraceptive use. The percentage of women who am menopausal increases gradually from age 30. At age 40-41, only 3 percent of women have reached menopause; by age 44-45 the percentage increases to 7, and at the end of the reproductive years (age 48-49) 14 percent of women are menopausal and no longer exposed to the risk of pregnancy. Terminal infertility shows a similar pattern; infertility increases with age, starting at 17 percent for age 30-34, and reaching 84 percent for women at age 48-49. 62 Table 5.8 Termination of exposure to the risk of pregnancy Indicators of menopause,, terminal infertility and long-term abstinence among currently married women age 30-49, by age, Jordan 1990 Terminal Age Menopause I infertility 2 30-34 1.2 17.3 35-39 1.3 27.7 40-41 3.3 33.2 42-43 3.7 55.7 44-45 6.9 75.1 46-47 9.6 78.7 48-49 13.9 83.8 Total 4.1 46.7 Ipercentage of non-pregnant, non- amenorrhelc currently married women whose last menstrual period occurred six or more months preceding the survey or who report thal they are menopausal. 2Percentage of women continuously married and not using con~aceplion during the five years preceding the survey who did not have a birth during the period and who are not pregnant. 63 CHAPTER 6 FERTILITY PREFERENCES This chapter addresses questions which allow an assessment of the need for contraception, and the extent nf unwanted fertility. The information collected from the respondents includes whether they want more children; and if so, how long they would prefer to wait before the next child; and if they could start afresh, how many children in all they would want. Two other issues are also examined---the extent to which unwanted and mistimed births occur and the effect that the prevention of such births would have on fertility rates. Survey questions on fertility preferences have often been the subject of criticism. First, it is suggested that the answers respondents give are misleading because they reflect unformed, ephemeral views, which are held with little conviction. Critics also argue that the questions do not take into account the effects of sncial pressure or the attitudes of other family members, particularly the husband, who may exert considerable influence on the wife's reproductive decisions. The first objection is probably not relevant in Jordan, since family planning is widely used, presumably to realize fertility preferences. The second objection is correct in principle, although evidence from surveys in which both the husbands and wives are interviewed suggests that there are no significant differences between husbands and wives regarding fertility preferences. Women who were pregnant at the time of the survey were asked if they wanted to have another child al~r the one they were expecting. Taking into account the way in which the preference variable is defined for pregnant women, a currant pregnancy is treated as equivalent to a living child. Women who have been sterilized am classified as wanting no more children. 6.1 DESIRE FOR CHILDREN Women's preferences concerning future childbearing serve as indicators of future fertility. However, for sterilized women and women who state that they are infecund (declared infecund), the desire for children remains only desire. Because their potential contribution to fertility has been curtailed, sterilized and infecund women have no impact on future fertility. The data on fertility preferences serve another purpose by providing information on the potential need for contraceptive services for spacing and limiting births. About half (47 percent) of currently married women in Jordan do not want any more children, while two in five want to continue childbearing (see Table 6.1 and Figure 6.1). Large families are favored; more than half of women who have 3 children and a substantial proportion of those who have 4 or 5 children want to have more children (see Figure 6.2). About 11 percent of childless women declared themselves infecund, probably because they are nearing the end of their reproductive years. 65 Table 6.1 Fertility preferences by number of living children Perccm distribution of cutreatly married women by desire for moxe children, according t~ number of living children, Jordan 1990 Number of living children I Desire for more children 0 1 2 3 4 5 6+ Total Have anedmr soon 2 68.7 33.1 17.8 Have another late~ 14.0 55.9 52.8 Have another, undecided Mum 2.1 2.5 2.1 Undecided 2.1 0.8 1.5 Want no more 2.3 5.6 23.7 35.5 Sterilized -- 0.2 0.5 2.2 Declar~ infectmd 10.8 1.9 1.6 1.6 Missing -- 0.2 Total 100.0 100.0 100.0 100.0 Number 368 636 652 685 -- Less than 0.05 percent ZIncludes current pregnancy 2Want next birth within two years ~Vant to delay next birth two er more years 16.0 11.8 8.3 4.6 15.2 41.2 27.8 17.8 8.1 24.8 0.9 1.2 0.5 0.6 1.1 2.3 1.9 2.9 2,2 2.0 50.6 59.3 69.0 47.1 3.4 8.1 10.0 5.6 3.1 3.0 5.4 4.1 0.1 0.2 -- 0.1 100.0 100.0 100.0 I00.0 649 626 2553 6168 Figure 6.1 Fertility Preferences Currently Married Women 15-49 Want Later .)2 yre 25% rant Soon ! yre 15% Undecided 3% Infecund* 10% Want No More 4r'~ • Includes sterilized and missing JPFHS 1990 66 Percent 100 80 6O 40 20 0 0 Figure 6.2 Fertility Preferences by Number of Living Children 1 2 3 4 5 6+ m Want no more m Infecund. ~ Want later | I m Want soon ~ Undecided • includes sterilized and missing JPFHS 1990 Table 6.2 shows the distribution of women by desire for more children. The desire for more children decreases and the desire to stop childbearing increases as women increase in age. In the youngest age group, almost all women want to have more children, but by age 25-29 only 59 percent want more children. This proportion declines to 5 percent among women in the oldest age group. On the other hand, one in five women age 20-24 say that they do not want to have another child. The proportion increases to 60 percent among women 30-34, and is 61 percent among women in the oldest age group. In this age group (women 45-49), one in three women are potentially unable to bear children because they are sterilized or say that they are infecund. Differentials in the desire to stop having children are presented in Table 6.3. In general, women living in large cities and urban areas are slightly more likely to want to stop childbearing than rural women. This phenomenon is reflected by a high percentage of women in Amman who do not want another child (55 percent). An exception to this pattern is Balqa, which has the highest proportion of women in the country who do not want to continue childbearing (64 percent). The same pattern is seen when the data are analyzed by the number of living children a woman has; women in urban areas and Balqa are more likely to want to stop childbearing than women in other areas. Education is negatively associated with the desire to stop childbearing. The proportion of women who want no more children decreases as the level of education increases, from 66 percent of among uneducated women to 36 percent among women who have attended more than secondary education. However, when these women am analyzed by the number of living children, the effect of education diminishes, suggesting that the reason uneducated women are more likely to want to stop childbearing is that they already have more children than educated women. 67 Table 6.2 Fertility preferences by age Percent distribution of eurrantly married women by desire for more children, according to age, Jordan 1990 Age of woman Desire for more ehild~n 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Tom] Have another soon I 38.1 24.4 18.0 12,4 9.7 7.3 4.5 15.2 Have another later= 52.0 50.9 40.2 20.0 6.2 2.6 0.3 24.8 Have another° undecided when 3.6 1.5 1.0 1.4 1.1 0.1 0.3 1.1 Undecided 1.4 1.7 1.8 2.5 2.9 2.2 1.4 2.0 Want no more 3 4.4 20.9 37.9 59.9 66.2 63.6 61.2 47.1 Starilized -- 0.3 1.8 10.8 16.2 14.0 5.6 Declared infeeund 0~5 0.6 0.7 1.9 3,0 7.7 18.3 4.1 Missing -- 0.1 0.1 0.2 0.1 Tom] 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 353 1057 1268 1098 905 807 680 6168 -- Lass than 0.05 percent tWant next birth within two years 2Want to delay next birth two or more years ~omea who have been sterilized are considered to want no more children. Table 6.3 Desire to stop having children Percentage of currently married women who want no mote children, by number of living children and selected be~kgroand characteristics, Jordan 1990 Number of living children I Backgrotmd characteadstic 0 1 2 3 4 5 6+ Total Residence Large city 2,3 8.9 29.9 46.8 59.7 73.0 82.6 55.5 Other urban 2.9 2.9 21,0 32.5 50.4 71.9 80,7 52.3 Rural 1.2 4.1 16.9 27,6 46.7 54.2 72,8 49.0 Region Amman 1.7 6.4 28.3 43.0 60.4 75.3 81.5 54.8 Zarqa + Mal~aq 3.1 8.6 26.8 42.3 51.1 65.5 82.5 53.9 Irbid 1.8 1.1 13.0 25.6 43.5 58.8 73.2 47.7 Balqe 7.5 7.4 38.9 57.8 67.8 72.0 85.1 64,4 South 0.0 5.4 17.2 23.8 48.3 50.3 74.6 45.8 Education level attended No education 1.0 8.8 29.0 32.9 45.5 55.5 77.6 65.9 Primary 4,6 2.5 21.0 44.8 52,9 66.4 79.3 62,5 Secondary 1.8 5.2 22.5 36.1 57.7 72.1 80,9 45.0 More than secondary 3.2 8.4 29.5 39.5 50.1 68.2 79.1 36.0 Total 2.3 5.7 24.2 37.7 54.0 67.4 79.1 52.7 tlncludes current pregnancy 68 6.2 NEED FOR FAMILY PLANNING SERVICES Information on fertility desires alone is not sufficient to estimate the need for family planning services. Many women who do not want to have another child soon are using contraception or are not exposed to the risk of pregnancy for other reasons. Therefore, a more detailed analysis of unmet need for family planning is called for. In this analysis, unmet need for family planning is de f'med as including women who are pregnant or amenorrheic and whose last birth was mistimed, and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and say that they either want to delay having their next birth for at least two years or say that they want no more children. Women who are menopausal or infertile are not included in the analysis because while they may want to have another child and want to use contraception in the future, they are actually no longer exposed to the risk of pregnancy. Table 6.4 presents information on the need for family planning services by background characteristics. The distribution of women who have an unmet need for family planning is shown in columns 1-3. Columns 4-6 show the distribution of women with met need for family planning, i.e., women who are currently using a family planning method for spacing (want to walt 2 years or more for their next child) or for l'maiting births (want no more children). Pregnant and amenorrheic women who became pregnant while using a family planning method (method failure) are not classified as having unmet need but are included because they are in need of a more effective method. The total demand for family planning is shown in columns 7-9. Total demand includes women who are not using a contraceptive method, women who are using a method, and women who used a method that failed. The last column of the table shows the percentage of the total demand for family planning that is satisfied, i.e., the proportion of women using a method to total demand. The data in Table 6.4 indicate that about 23 percent of currently married women in Jordan are in need of a family planning method, either for spacing (8 percent) or for limiting (15 percent). Of the 40 percent of women using contraception (including 5 percent who are using prolonged breasffeeding), 12 percent use it to delay their next birth, while 28 percent want to stop childbearing. An additional 4 percent of women have need of a better method, since the one they were using failed to protect them from pregnancy. Thus, the total demand for family planning among currently married women in Jordan is 66 percent, and 66 percent of this demand has been satisfied by women who are currently using contraception and women who had used it but failed. Unmet need for family planning for purposes of spacing births declines with age, while the need for limiting births increases with age. The two complement each other, such that total unmet need varies little by age of the woman. Unmet need is related to place of residence and region. Women living in rural areas tend to have greater unmet need than their urban counterparts. This is reflected by the lower level of unmet need for Amman (17 percent). Urban women are more likely to use contraception, and hence, have a greater per- centage of total demand for family planning satisfied. Unmet need is also associated with education. Women with no education have a higher level of unmet need (28 percent) than women who have attended secondary or more than secondary education (20 and 19 percent respectively). Since educated women are more likely to use a contraceptive method than uneducated women, a higher proportion of the total demand for family planning is satisfied for these women. 69 Table 6.4 Need for family planning services Percentage of currently matrled women with unmet need for farnily planning, met need for family planning, and the total demand for fanfily planning services, by selected background characteristics, Jordan 1990 Met need for Unmet need for family planning Total demand for Percentage fat~ly planning I (ictn-rently using) 2 family planning 3 of demand Background For For For For For For satin- characteristic spacing litniting Total spacing limiting Total spacing fimi6ng Total fled Age 15-19 19.3 3.1 22.4 11.5 0.8 12.3 31.6 6.4 38.0 41.0 20-24 13.9 6.5 20.5 18.7 9.4 28.1 34.9 17.7 52.5 61.0 25-29 12.0 12.0 24.0 19.7 17.5 37.2 36.1 31.3 67.4 64.4 30-34 6.9 16.1 23.0 15.0 33.5 48.5 26.0 51.4 77.5 70.3 35-39 2.5 20.2 22.6 4.7 47.5 52.3 10.7 67.8 78.4 71.1 40-44 1.8 20.2 22.0 2.7 48.9 51.6 5.5 69.2 74.7 70.6 45-49 0.2 21.7 21.9 0.4 33.3 33.7 0.6 55.0 55.6 60.6 Residence Large city 6.5 12.6 19.1 14.2 34.1 48.3 23.1 47.5 70.6 72.9 Other orban 7.9 14.4 22.3 10.7 28.0 38.7 21.7 43.3 65.0 65.7 Rural 9.7 18.1 27.8 8.8 19.7 28.5 21.5 39.6 61.1 54.5 Region level attended Amman 5.2 11.7 16.9 13.8 34.5 48.3 21.7 46.7 68.4 75.3 Zaxqa + Mafraq 8.9 15.3 24.1 11.5 28.4 39.9 22.7 45.0 67.7 64.4 Irbid 10.2 16.3 26.5 10.8 22.9 33.7 24.2 41.5 65.7 59.7 Balqa 7.9 24.4 32.3 4.2 21.4 25.5 13.5 45.9 59.3 45.6 South 10.1 14.3 24.4 10.9 20.9 31.8 24.3 36.5 60.8 59.9 Education No Education 4.4 23.1 27.5 3.8 27.8 31.6 9.9 51.3 61.3 55.1 Primary 6.1 17.1 23.2 7.8 34.8 42.6 16.1 52.3 68.4 66.1 Secondary 9.6 10.6 20.2 15.8 26.5 42.2 28.7 38.6 67.3 70.0 More than secondary 11.3 8.0 19.3 19.7 23.5 43.2 34.4 33.9 68.2 71.8 Total 7.8 14.6 22.4 11.7 28.3 40.0 22.2 44.0 66.2 66.1 1Unreel need for spacing refers to pregnant women whose !m'egnaney was nfistimed, amenorrhnie women whose last birth was mistimed, and women who are neither pregnant nor amenorrheic and who are not using any method of fanfily planning and say they want to wait two or mcae years for their next birth. Unreel need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhei¢ women whose last child was unwanted, and to women who axe neither pregnant n~ araenorrhnic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are inegnant and amenorrheic women who became pregnant while wing a method (these women are in need of better contraception). Also excluded me menopausal and infertile women, defined in footnotes 1 and 2 in table 5.8; 2Using for spacing refers to women who are using some method of fanfily planning and who say they want to wait two or more years for their next child. Using for limiting refers to women who are using and who want no more ehil&en. Note that the specific methods used m'¢ not taken into accounL 3Total demand includes pregnant or amenorrheic women who became pregnant while using a method (method failme). 6.3 IDEAL NUMBER OF CHILDREN The focus of this chapter has been on the future reproductive intentions of women, implicitly taking into account the number of living children they have. To ascertain the ideal number of children, the respondent is required to perform the more difficult task of considering abstractly and independently of her actual family size, the number of children she would choose if she could start again. 70 There is usually a correlation between actual and ideal number of children. The reason is twofold. First, to the extent that women implement their preferences, those who want larger families tend to achieve larger families. Second, women may adjust upwards their ideal family size, as the actual number of children increases. It is also possible that women with large families, being on average older than women with small families, have larger ideal sizes, because of attitudes that they acquired 20

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