Kazakstan - Demographic and Health Survey - 1995

Publication date: 1995

Kazakstan Demographic and Health Survey 1995 National Institute of Nutrition Academy of Preventive Medicine of Kazakstan ®DHS Demographic and Health Surveys Macro International Inc. World Summit for Children Indicators: Kazakstan 1995 Value BASIC INDICATORS Childhood mortality Maternal mortality Childhood undernutrition Clean water supply Sanitary excreta disposal Basic education Children in especially difficult situations Infant mortality rate Under-five mortality rate Maternal mortality ratio Percent stunted (of children under 3 years) Percent wasted (of children under 3 years) Percent underweight (of children under 3 years) Percent of households within 15 minutes of a safe water supply 2 Percent of households with flush toilets or VIP latrines Percent of women 15-49 with completed primary education Percent of men 15-49 with completed primary education Percent of girls 6-12 attending school Percent of boys 6-12 attending school Percent of women 15-49 who are literate Percent of children who are orphans (both parents dead) Percent of children who do not live with their natural mother Percent of children who live in single adult households 40 per 1,000 46 per 1,000 77 per 100,000 ] 15.8 3.3 8.3 86.6 42.6 98.6 98.8 81.3 80.4 99.8 0.1 8.1 4.1 SUPPORTING INDICATORS Women's Health Birth spacing Safe motherhood Family planning Nutrition Maternal nutrition Low birth weight Breast feeding Iodine Child Health Diarrhea control Percent of births within 24 months of a previous birth 3 Percent of births with medical prenatal care Percent of births with prenatal care in first trimester Percent of births with medical assistance at delivery Percent of births in a medical facility Percent of births at high risk Contraceptive prevalence rate (any method, married women) Percent of currently married women with an unmet demand for family planning Percent of currently married women with an unmet need for family planning to avoid a high-risk birth Percent of mothers with low BM[ Percent of births at low birth weight (of those reporting numeric weight) Percent of children under 4 months who are exclusively breastfed Percent of households with iodised salt Percent of children with diarrhea in preceding 2 weeks who received oral rehydration therapy (sugar-salt-water solution) Acute respiratory infection Percent of children with acute respiratory infection in preceding 2 weeks who were seen by medical personnel i Data from the Ministry of Health 2 Piped. well, and bottled water 3 First births are excluded. 34.3 92.5 58.9 99.6 98.4 38.7 59.1 15.7 12.5 7.9 9.1 12.0 52.9 31.2 47.7 Kazakstan Demographic and Health Survey 1995 National Institute of Nutrition Almaty, Kazakstan Academy of Preventive Medicine of Kazakstan Almaty, Kazakstan Macro International Inc. Calverton, Maryland USA November 1996 This report summarizes the findings of the 1995 Kazakstan Demographic and Health Survey (KDHS) conducted by the National Institute of Nutrition [Kazakstan]. Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development. The KDHS 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 about the Kazakstan survey may be obtained from the National Institute of Nutrition, 66 Klotchkov St., Almaty, Kazakstan 480008 (Telephone: (73272) 429-111 ; Fax: (73272) 420-720). Additional information about the DHS program may be obtained by writing to: DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (Telephone: 301-572-0200; Fax: 301-572-0999). Recommended citation: National Institute of Nutrition [Kazakstan] and Macro International Inc. 1996. Kazakstan Demographic and Health Survey, 1995. Calverton, Maryland: National Institute of Nutrition and Macro International Inc. CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Map of Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvi CHAPTER 1 1.1 1.2 1.3 1.4 1.5 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Almaz Sharmanov Geography, History, and Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.1 Geography and Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.2 Pre-Soviet Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.3 Kazakstan During the Soviet Era . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.1.4 Social Programs and the Educational System . . . . . . . . . . . . . . . . . . . . . . 2 1.1.5 Kazakstan During the Socioeconomic Transition . . . . . . . . . . . . . . . . . . . 3 Health Care Sytem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.1 Socialistic Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.2 Health Care Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.3 Health Care Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Maternal and Child Health and Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . 6 Demographic and Health Data Collection System in Kazakstan . . . . . . . . . . . . . . 7 Objectives and Organization of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.1 Sample Design and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.2 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.5.3 Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.5.4 Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.5.5 Response Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 CHAPTER 2 2.1 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . 13 Shamshiddin A. Balgimbekov and Raimbek Sissemaliev Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.1.1 Sex and Age Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.1.2 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.1.3 Educational Level of Household Members . . . . . . . . . . . . . . . . . . . . . . 16 iii 2.2 2.3 Page Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.2.1 Household Durable Goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 2.3.1 Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 2.3.2 Educational Level of the Respondents . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.3.3 School Attendance and Reasons for Leaving School . . . . . . . . . . . . . . . 24 2.3.4 Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 2.3.5 Women's Employment Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.3.6 Employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.3.7 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 2.3.8 Decisions on Use of Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2.3.9 Child Care While Working . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 CHAPTER 3.1 3.2 3.3 3.4 3.5 3.6 3 FERTIL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Vassily N. Devyatko and Kia L Weinstein Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Children Ever Bom and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Pregnancy and Motherhood Among Women Age 15-19 . . . . . . . . . . . . . . . . . . . 42 CHAPTER 4 CONTRACEPT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Nina A. Kayupova, Nailya M. Karsybekova, and Khazina M. Biktasheva 4.1 Knowledge of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 4.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 4.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.4 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . 53 4.5 Knowledge of Fertile Period and Contraceptive Effects of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 4.6 Source of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 4.7 Intention to Use Family Planning Among Nonusers . . . . . . . . . . . . . . . . . . . . . 59 4.8 Reasons for Nonuse of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.9 Preferred Method of Contraception for Future Use . . . . . . . . . . . . . . . . . . . . . . 60 4.10 Exposure to Family Planning Messages in the Electronic Media . . . . . . . . . . . . . 61 4.11 Acceptability of Use of Electronic Media to Disseminate Family Planning Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.12 Exposure to Family Planning Messages in Print Media . . . . . . . . . . . . . . . . . . . 63 4.13 Attitudes of Couples toward Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 65 iv CHAPTER 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Page 5 INDUCED ABORTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Jeremiah M. Sullivan, Nailya M. Karsybekova, and Kia L Weinstein Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Lifetime Experience with Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Rates of Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Time Trends in Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Abortion Rates from the Ministry of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Impact of Contraception on Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Contraceptive Use Before Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Service Providers and Procedures Used for Abortion . . . . . . . . . . . . . . . . . . . . . 76 Complications of Abortion and Medical Treatment . . . . . . . . . . . . . . . . . . . . . . 76 CHAPTER 6.1 6.2 6.3 6.4 6.5 6.6 6 OTHER PROXIMATE DETERMINANTS OF FERTIL ITY . . . . . . . . . . . . . . . 77 Kia L Weinstein Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Age at First Sexual Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Postpartum Amenorrhea, Abstinence and Insusceptibility . . . . . . . . . . . . . . . . . . 84 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 CHAPTER 7.1 7.2 7.3 7.4 7 FERTIL ITY PREFERENCES Kia L Weinstein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Wanted and Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAt t ieR 8.1 8.2 8.3 8.4 8.5 8.6 8 INFANT AND CHILD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Jeremiah M. Sullivan Background and Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Levels and Trends in Early Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . 100 Mortality Rates from the Ministry of Health . . . . . . . . . . . . . . . . . . . . . . . . . 101 Socioeconomic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . 102 Demographic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . 103 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 CHAPTER 9 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Page MATERNAL AND CHILD HEALTH Amangeldy D. Duisekeev and Temirkhan K. Bekbosynov . . . . . . . . . . . . . . . 107 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Assistance and Medical Care at Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Characteristics of Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 CHAPTER 10 10,1 10.2 10.3 NUTRITION OF WOMEN AND CHILDREN Toregeldy S. Sharmanov and Temirkhan K. Bekbosynov . . . . . . . . . . . . . . . . 121 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 10.1.1 Initiation of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 10.1.2 Age Pattern of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 10.1.3 Types of Supplemental Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 10.1.4 Frequency of Food Supplementation . . . . . . . . . . . . . . . . . . . . . . . 126 10.1.5 Differentials in Food Supplementation . . . . . . . . . . . . . . . . . . . . . . 126 Nutritional Status of Children under Age Three . . . . . . . . . . . . . . . . . . . . . . 128 10.2.1 Measures of Nutritional Status in Childhood . . . . . . . . . . . . . . . . . 128 10.2.2 Levels of Child Undemutrition in Kazakstan . . . . . . . . . . . . . . . . . 129 Women's Anthropometric Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 CHAPTER 11 11.1 11.2 11.3 11.4 11.5 ANEMIA Almaz Sharmanov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Anemia Measurement Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Anemia Prevalence Among Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Anemia Prevalence Among Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 APPENDIX A SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Thanh L~ A. 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 vi Page A.2 Characteristics of the KDHS Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 A.3 Sample Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 A.4 Stratification and Systematic Selection of Clusters . . . . . . . . . . . . . . . . . . . . . 154 A.5 A.4.1 Almaty City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 A.4.2 Other urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 A.4.3 Rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Sampling Probabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 A.5.1 Almaty City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 A.5.2 Other urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 A.5.3 Rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 APPENDIX B ESTIMATES OF SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Thanh L~ APPENDIX C DATA QUALITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 APPENDIX D PERSONS INVOLVED IN THE 1995 KAZAKSTAN DEMOGRAPHIC AND HEALTH SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 APPENDIX E QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 vii Table 1.1 TaMe 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 ~I able 2.6 tab le 2.7 Table 2.8 Table 2.9 TaMe 2.10 Table 2.11 Table 2.12 TaMe 2.13 Table 2.14 Table 2.15 Table 2.16 TaMe 2.17 Table 2.18 TaMe 2.19 Table 3.1 TaMe 3.2 Table 3.3 Table 3.4 TaMe 3.5 Table 3.6 Table 3.7 TaMe 3.8 Table 3.9 TaMe 3.10 TaMe 3.11 TABLES Page Results of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . 12 Household population by age, le.,idence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Fosterhood and orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Educational level of the female household population . . . . . . . . . . . . . . . . . . . . . . 17 Educational level of the male household population . . . . . . . . . . . . . . . . . . . . . . . . 18 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Ethnicity, religion and residence by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 School attendance and reasons for leaving school . . . . . . . . . . . . . . . . . . . . . . . . . 25 Access to m~ss media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Decision on use of earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Child care while working . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Trends in fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . .~ . . . . . . . . . 38 Trends in fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Pregnancy and motherhood among women age 15-19 . . . . . . . . . . . . . . . . . . . . . . 42 Children born to women age 15-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 ix Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 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 4.19 Table 4.20 Table 5.1 Table 5.2 Table 53 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 6.1 Table 6.2 Table 63 Page Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Knowledge of contraceptive methods by background characteristics . . . . . . . . . . . . 47 Ever u~e of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . . . 51 Pill use and possession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Use of pill brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Number of children ~t first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Perceived contraceptive effect of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Source of supply for modern contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . 57 Satisfaction with current sources of supply for contraceptive methods . . . . . . . . . . . 58 Future u,,e of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Heard about family planning on radio and television . . . . . . . . . . . . . . . . . . . . . . . 62 Acceptability ( f media messages on family planning . . . . . . . . . . . . . . . . . . . . . . . 63 Family planning messages in print . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Discussion of family planning by couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Wives ' perceptions of their husbands' attitude toward family planning . . . . . . . . . . . 66 Pregnancy outcomes by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . 68 Lifetime experience with induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Induced abortion rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Induced abortion rates by background characteristics . . . . . . . . . . . . . . . . . . . . . . . 72 Trends in age-specific induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Comparison of abortion lates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Time trends in contraception and abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Use of contraception prior to pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Source cf services, type cf provider, and procedure used for abortion . . . . . . . . . . . 76 Health problems following abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Sexual relationships of nonmarried women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table 6A Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 6.9 Table 6.10 Table 7.1 Table 7.2 Table 7.3 Table 7.4.1 Table 7.4.2 Table 7.4.3 Table 7.5 Table 7.6 Tat le 7.7 Table 7.8 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 9.9 Table 9.10 Page Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Age at first ~exual intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Median age at first intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Recent sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Postpartum amenorrhea, abstinence and insusceptibility . . . . . . . . . . . . . . . . . . . . . 84 Median duration of postpartum amenorrhea, abstinence and insusceptibility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 86 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . 87 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Need for family planning services: currently married women . . . . . . . . . . . . . . . . . 91 Need for family planning services: unmarried women . . . . . . . . . . . . . . . . . . . . . . 92 Need for family planning services: all women . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Mean ideal number cf children by background characteristics . . . . . . . . . . . . . . . . . 96 Fertility planning ~,tatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Comparison of infant mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . . 102 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . 104 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Number cf antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . 109 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Delivery characteristics: caesarean ,,ection, birth weight and size . . . . . . . . . . . . . 112 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Prevalence of acute respiratory infection and fewr . . . . . . . . . . . . . . . . . . . . . . . 116 Knowledge of diarrhea care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 xi Table 9.11 Table 9.12 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 10.6 Table 10.7 Table 10.8 Page Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Feeding practices during diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . 124 Types of foods received by children in preceding 24 hours . . . . . . . . . . . . . . . . . . 125 Types of food received by children in preceding week . . . . . . . . . . . . . . . . . . . . . 126 Types of food received by children by background characteristics . . . . . . . . . . . . . 127 Nutritional status of children by demographic characteristics . . . . . . . . . . . . . . . . . 129 Nutritional status of children by background characteristics . . . . . . . . . . . . . . . . . 131 Table 10.9 Anthropometric indicators of female nutritional status . . . . . . . . . . . . . . . . . . . . . 132 Table 10.10 Nutritional status of women by background characteristics . . . . . . . . . . . . . . . . . . 133 Table 11.1 Table 11.2 Table 11.3 Table 11.4 Table A. 1 Table A.2 Table A.3 Table A.4 Table A.5 Table A.6 Table B.1 Table B.2 Table B.3 Table B.4 Table B.5 Table B.6 Table B.7 Table B.8 Table B.9 Table B.10 Table B. 11 Anemia among women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Anemia among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Anemia among children by demographic characteristics . . . . . . . . . . . . . . . . . . . . 141 Anemia among children born to anemic mothers . . . . . . . . . . . . . . . . . . . . . . . . . 142 Population distribution (1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Percent distribution of population (1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Proportional sample allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Proposed sample allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Number of sample points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Proposed number of sample points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 List of selected variables for sampling errors . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Sampling errors - National sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Urban sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Rural sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Almaty City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 South Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 West Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Central Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 North and East Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Kazak ethnic group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Russian ethnic group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 xii Table B.12 Sampling errors - Other ethnic groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Table C. 1 Table C.2 Table C.3 Table CA Table C.5 Table C.6 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . 180 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Births by calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 xiii FIGURES Figure 1.1 Figure 2.1 Figure2.2 Figure2.3 Figure 3.1 Figure 3.2 Figure 3.3 Figure 4.1 Figure 4.2 Figure 4.3 Figure 5.1 Figure 5.2 Figure5.3 Figure 6.1 Figure 7.1 Figure 7.2 Figure 7.3 Figure 8.1 Figure 8.2 Figure 9.1 Figure 9.2 Figure 9.3 Figure 10.1 Figure 10.2 Figure 11.1 Figure 11.2 Figure 11.3 Page Oblast Composition of Regions in Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Population Pyramid of Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 School Enrollment by Age and Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Housing Characteristics by Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Age-specific Fertility Rates by Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Total Fertility Rate by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . 36 Trends in Age-Specific Fertility Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Use of Specific Contraceptive Methods among Currently Married Women . . . . . . . . 50 Current Use of Family Planning by Background Characteristics . . . . . . . . . . . . . . . 52 Distribution of Current Contraceptive Users by Source of Supply . . . . . . . . . . . . . . 57 Age-specific Rates of Fertility and Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . 71 Total Induced Abortion Rate by Background Characteristics . . . . . . . . . . . . . . . . . . 71 Age-specific Abortion Rates by Time Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Marital Status of Women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Fertility Preferences among Currently Married Women 15-49 . . . . . . . . . . . . . . . . . 88 Fertility Preferences among Currently Married Women by Number of Living Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Percentage of Currently Married Women with Unmet Need and Met Need for Family Planning Services by Background Characteristics . . . . . . . . . . . . . 94 Trends in Infant Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Under-five Mortality by Selected Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 103 Percent Distribution of Births by Antenatal Care and Delivery Characteristics . . . . 109 Percentage of Children Age 12-23 Months with Specific Vaccinations . . . . . . . . . . 114 Prevalence of Respiratory Illness and Diarrhea in the Last Two Weeks by Age of the Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Prevalence of Stunting by Age of Child and Length of Birth Interval . . . . . . . . . . 130 Prevalence of Stunting by Background Characteristics . . . . . . . . . . . . . . . . . . . . . 131 Prevalence of Moderate Anemia among Women Age 15-49 by Pregnancy Status and Breastfeeding Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Percent Distribution of Hemoglobin Levels among Women Age 15-49 . . . . . . . . . 138 Percentage of Women with Moderate or Severe Anemia among Those Who are Currently Using or Not Using the IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 XV LIST OF CONTRIBUTORS Toregeldy S. Sharmanov, M.D., Ph.D. Director, National Institute of Nutrition President, Academy of Preventive Medicine 66 Klotchkov Street Almaty, Kazakstan 480008 Jeremiah M. Sullivan, Ph.D. Deputy Director, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA Vassily N. Devyatko Minister of Health, Republic of Kazakstan Ministry of Health 63 Abylaikhan Street Almaty, Kazakstan 480004 Amangeldy D. Duisekeev, M.D., Ph.D. First Deputy Minister of Health, Republic of Kazakstan Ministry of Health 63 Abylaildaan Street Almaty, Kazakstan 480004 Nina A. Kayupova, M.D., Ph.D. Director, National Research Center of Maternal and Child Health 125 Dostyk Street Almaty, Kazakstan 480020 Almaz T. Sharmanov, M.D., Ph.D. Health Specialist, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA Kia I. Weinstein, Ph.D. Consultant, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA Thanh L~ Sampling Statistician, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA xvii Nailya M. Karsybekova, M.D. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 Temirkhan K. Bekbossynov, M.D. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 Khazina M. Biktasheva, M.D. Senior Researcher, National Research Center of Maternal and Child Health 125 Dostyk Street Almaty, Kazakstan 480020 Shamshiddin A. Balgimbekov, M.D. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 Raimbek Sissemaliev, D.D.S. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 xviii PREFACE The 1995 Kazakstan Demographic and Health Survey (KDHS) was the first national level population and health survey in Kazakstan. The purpose of the survey was to provide the Ministry of Health of Kazakstan with information on fertility, reproductive practices of women, maternal care, child health and mortality, child nutrition practices, breastfeeding, nutritional status and anemia. This information is important for understanding the factors that influence the reproductive health of women and the health and survival of infants and young children. It can be used in planning effective policies and programs regarding the health and nutrition of women and their children. This is especially important now during this the time of economic transition which involves virtually all aspects of life for the people of Kazakstan. The survey provides data important to the assessment of the overall demographic situation in the country. It is expected that the findings of the KDHS will become a useful source of information necessary for the ongoing health care reform in Kazakstan. The successful completion of the KDHS and publication of this volume is due to the contribution of many people. I would like to express appreciation to the KDHS senior technical staff: Drs. Nailya Karsybekova and Temirkhan Bekbosynov; KDHS field coordinators: Drs. Igor Tsoy, Yuri Sinyavskyi, Shamshuddin Balgimbekov, and Ms. Nagima Esenalinova; and to all interviewing teams and data entry groups for their devotion and sincere efforts in accomplishing the survey activities. The survey fieldwork was completed smoothly and successfully with the support of the Ministry of Health, and also with the help of government officials and public health workers at the levels ofoblasts, raions and villages of Kazakstan. Our thanks are also due to the members of the National Survey Advisory Committee and to all specialists who were involved in the survey and contributed to its success. The KDHS is part of an international program that has executed more than 60 national-level surveys around the world. Kazakstan is the first country among the republics of the former Soviet Union to participate in this international program. The KDHS would not have been feasible without financial support of the U.S. Agency for International Development and technical assistance which was provided by the Demographic and Health Surveys (DHS) program of Macro International Inc. First, I would like to thank Dr. Jeremiah M. Sullivan, DHS Deputy Director, for assisting with overall project design, analyses of the survey results, and report production. I would also like to thank the following Macro staff: Drs. Almaz Sharmanov and Kia Weinstein for assisting with questionnaire development, fieldstaff training, analysis of the survey results, and writing chapters of this report; Mr. Trevor Croft for writing the computer programs, setting up the data processing operation, and producing the tabulations; and Ms. Thanh L8 for the sampling design. Special thanks are also due to Ms. Anne Cross and Dr. Elisabeth Sommerfelt for their valuable reviewing of various chapters of the report. Many others we have not mentioned have also put long hours into ensuring the successful completion of this task; their names are listed in Appendix D. Dr. Toregeldy S. Sharmanov KDHS National Director Director of the National Institute of Nutrition President of the Academy of Preventive Medicine xix SUMMARY OF FINDINGS Toregeldy S. Sharmanov The 1995 Kazakstan Demographic and Health Survey (KDHS) is a nationally representative survey of 3,771 women age 15-49. Fieldwork for the KDHS was conducted from May to September 1995. The KDHS was sponsored by the Ministry of Health (MOH), Republic of Kazakstan and was funded by the United States Agency for International Development. The National Institute of Nutrition implemented the survey with technical assistance from the Demographic and Health Surveys program. The Kazakstan Academy of Preventive Medicine participated in analysis and report writing. The purpose of the KDHS was to develop an information base to be used by the MOH in developing policies pertaining to the health and nutrition of women and children. The KDHS provides information on many factors which determine the health status of women and children such as fertility, contraception, induced abortion, maternal care, infant mortality, and nutritional status. Some statistics presented in this report are currently available to the MOH from other sources. For example, the MOH collects and regularly publishes information on fertility, contraception, induced abortion and infant mortality. However, the survey presents information on these indices in a manner which is not currently available, i.e., by population subgroups such as those defined by age, marital duration, education, ethnicity, etc. Additionally, the survey provides statistics on some issues not previously available in Kazakstan: for example, breastfeeding practices and anemia status of women and children. Thus, existing data and the KDHS data are complementary; when considered together, they provide a more complete picture of the health conditions in Kazakstan than was previously available. Decreasing Fertility. Survey results indicate a total fertility rate (TFR) for all of Kazakstan of 2.5 children per woman. Fertility levels differ for different population groups. The TFI, t is lowest among women in Almaty City (1.5 children per woman) and the North and East Region (2.8), intermediate in the West and Central Regions (2.7 each), and highest in the South Region (3.4). The TFR for ethnic Russian women (1.7 children per woman) is substantially lower than for Kazak women (3.1). The re suits of the 1989 Census and the 1995 KDHS show that fertility has declined in Kazakstan over the past five years from a TFR of 2.9 to 2.5 children per woman. Over the same period, the TFR among ethnic Kazaks has declined from 3.6 to 3.1 and among ethnic Russians from 2.2 to 1.7. The declining trend in fertility can also be seen by comparing the completed family size of women near the end of their childbearing years with the current TFR. Completed family size among women 45-49 is 3.4 children which is nearly one child more than the current TFR (2.5). Overall, one-third of non-first births (34 percent) in Kazakstan take place within 24 months of the previous birth. Birth intervals are significantly longer among births to Russian mothers (median interval length of 44 months) than among Kazak mothers (median interval length of 28 months). Births to urban women have a median interval length of 39 months, while births to rural women have a median interval length of 29 months. The age at which women in Kazakstan begin childbearing has not changed significantly over time. Overall, approximately 15 percent of women have their first birth at age 18 or 19, an additional 25-30 percent have their first birth at age 20 or 21, and 25-30 percent at age 22-24. xxi The majority of married women in Kazakstan (60 percent) don't want to have more children, and a large majority of women (79 percent) want to either delay their next birth (l 9 percent) or stop childbearing altogether. These are the women who are potentially in need of some method of family planning. Decreasing Childhood Mortality. In the KDHS, infant mortality data were collected based on the international definition of a live birth which, irrespective of the duration of pregnancy, is a birth that breathes or shows any sign of life (such as the beating of the heart or movement of voluntary muscles) after separation from the mother. Infant deaths are deaths of live-born infants under one year of age (United Nations, 1992). For the period 1990-94, infant mortality in Kazakstan is estimated at 40 infant deaths per 1,000 births. The estimates of neonatal and postneonatal mortality are about equal at 20 per 1,000. The estimate of child mortality (ages 1-5) is much lower at 6 deaths per 1,000 population. During the period between 1980-1984 and 1990-1994, the infant mortality rate in Kazakstan declined from 44 to 40 per 1,000 births (by about 10 percent). All of this decline occurred in the postneonatal period. The pace of mortality decline was more pronounced for children (ages 1-5 ), and over the l 0-year period, child mortality rates fell from 10 to 6 per 1,000 population (by about 38 percent). The MOH publishes infant mortality rates annually but the definition of a live birth used by the MOH differs from that used in the survey. As is the case in most of the republics of the former Soviet Union, a pregnancy that terminates at less than 28 weeks of gestation is considered premature and is classified as a late miscarriage even if signs of life are present at the time of delivery. Only if a premature birth survives for seven days is the child classified as a live birth. Thus, some events classified as late miscarriages in the MOH system would be classified as live births and infant deaths according to the definitions used in the KDHS. Because of this difference, the infant mortality estimates of the MOH are consistently about 30 percent lower than the KDHS estimates. Nevertheless, the 15 percent decline in the MOH estimates between 1980-84 (32 per 1,000) and 1990-94 (27) is of the same order of magnitude as the decline indicated by the KDHS estimates. Increasing Use of Contraception. Knowledge of contraceptive methods is very high among women in Kazakstan. Knowledge of at least one method is nearly universal (98 percent of respondents know of at least one method). High levels of knowledge are the norm for women of all ages, all regions of the country, all educational levels, and all ethnicities. Women have knowledge of, on average, five methods of contraception. Among currently married women, 84 percent report having used a method of contraception at some time. The women who are the most likely to have ever used a method of contraception are those in the broad age group 25-44 (83-90 percent of these women have used a method of contraception at some time). Overall, among currently married women, 59 percent report that they are currently using a contraceptive method. Forty-six percent are using a modem method of contraception and another 13 percent are using a traditional method. The IUD is by far the most commonly used method; two out of every three currently married women who are using contraception are using the IUD. One out of five currently married women who are using contraception are using either periodic abstinence, withdrawal, or douche. The level of modem contraceptive use is similar for women of various population subgroups. Most of the differentials observed in overall levels of use are due to differentials in use of traditional methods. For example, Kazak and Russian women are equally likely to be using a modem method of contraception (47 and 45 percent, respectively); however, Russian women are more likely than Kazak women to be using a xxii traditional method (20 and 7 percent, respectively), resulting in a higher overall level of use among Russian women. Statistics from the MOH show that, between 1988 and 1993, the percent of women of reproductive age who were IUD and pill users increased by approximately 48 percent from 20 to 29 percent. The vast majority of women obtain their contraceptives through the public sector (92 percent). Forty- four percent of users obtain their method from a hospital or polyclinic, 26 percent from a women's consulting center, and 19 percent from public pharmacies. The source where women obtain their methods depends on the method they are using. Most women using IUDs obtain them at hospitals (34 percent) or women's consulting centers (31 percent). Pharmacies supply 58 percent of pill users and 60 percent of condom users. Of the 41 percent of currently married women who are not using contraception, about half (48 percent) report that they intend to use contraception in the future; 28 percent within the next 12 months, 17 percent at some more distant time, while the remaining 3 percent are unsure when they will use a method. The majority (79 percent) of nonusers who intend to use in the future indicate that the IUD is their preferred method. Decreasing Levels of Induced Abortion. As in most of the republics of the former Soviet Union, induced abortion has been a primary means of fertility control in Kazakstan. In a manner analogous to the analysis of the fertility data, the total abortion rate (TAR)--the number of abortions a woman will have in her lifetime based on the currently prevailing abortion rates--was calculated at the national level and for various population subgroups. At current rates, a woman in Kazakstan will have an average of nearly two abortions (1.8) over her lifetime. The TAR is higher in urban areas (2.0 abortions per woman) than in rural areas (1.5). Additionally the TAR is substantially higher among ethnic Russian women (2.7) than among ethnic Kazak women (1.1). As expected, levels of abortion and fertility are inversely correlated. In the high-fertility South Region, the TAR is lowest (0.9 abortions per woman). In the West and Central Regions where fertility levels are intermediate, abortion rates are also intermediate (1.0 and 1.6, respectively), while in the relatively low fertility areas of the North and East Region and Almaty City, abortion rates are highest (2.5 and 3.0, respectively). The KDHS data indicate a 20 percent decline in the general abortion rate between the time periods 1986-90 and 1993-95. This is in agreement with the abortion statistics published by the MOH, which indicate a 17 percent decline in induced abortion over the same time periods. A finding of considerable interest which is based on both KDHS and MOH data concerns the link between the use of contraception and the level of abortion. The data indicate that over an interval of about five years, the pill and IUD prevalence rate in Kazakstan has increased by 32 percent, and over the same period the abortion rate has declined by 15 percent. This is clear and convincing evidence that contraceptive use has been a substitute for abortion. Maternal and Child Health. Kazakstan has a well-developed health system with an extensive infrastructure of facilities that provide maternal care services. This system includes special delivery hospitals, the obstetrics and gynecology departments of general hospitals, women's counseling centers, and doctor's assistant/midwife posts (FAPs). There is an extensive network of the latter mentioned facilities throughout the rural areas, xxiii Virtually all births in Kazakstan (98 percent) are delivered at health facilities: 96 percent in delivery hospitals and another 2 percent in either general hospitals or FAPs. Only 2 percent of births are delivered at home. Almost all births (99 percent) are delivered under the supervision of medically trained persons: 78 percent by a doctor and 21 percent by a nurse or midwife. As expected, the survey data indicate that a high proportion of respondents (93 percent) receive antenatal care from professional health providers: the majority from a doctor (69 percent) and a significant proportion from a nurse or midwife (23 percent). Only 7 percent of women report no antenatal care. The general pattern in Kazakstan is that women seek antenatal care early and continue to receive care throughout their pregnancies. The median number of antenatal care visits reported by respondents is 11. The practice in Kazakstan is to keep child health cards at the health facilities rather than in the possession of the child's mother so that most of the information on vaccination coverage in the KDHS is based on mother's recall. Among children 12-23 months of age, mothers report that a high proportion of children have received the BCG vaccine (97 percent), the first dose of DPT (98 percent), and polio (100 percent). However, approximately half of those who started the DPT and the polio series did not finish. In the case of the measles vaccine, 72 percent of children 12-23 months of age have been vaccinated. Nutrit ional Status. Breastfeeding is almost universal in Kazakstan; 96 percent of children born in the three years preceding the survey are breastfed. Overall, 10 percent of children are breastfed within an hour of delivery and 40 percent within 24 hours of delivery. The median duration of breastfeeding is lengthy (14 months). However, durations of exclusive breastfeeding, recommended by the World Health Organization, are short (0.4 months). Supplementary feeding starts early in Kazakstan. At age 0-3 months, a significant proportion of breastfeeding children are given infant formula (20 percent) and powdered or evaporated milk (17 percent). By 4-7 months of age, 25 percent of breastfeeding children are given foods high in protein (meat, poultry, fish, and eggs) and almost half are given cereals and fruits or vegetables. Among nonbreastfeeding children age 0-3 years, a high proportion are given powered or evaporated milk in the last 24 hours (about 80 percent), and after the first birthday, a high proportion receive high protein foods (about 80 percent of children). In the KDHS, the height and weight of children under three years of age was measured. These data, in conjunction with information on age, are used to determine the nutritional status of children, i.e., the proportion of children who are stunted (short for their age, a condition which may reflect chronic undernutrition) and the proportion who are wasted (underweight according to their height, a condition which may reflect an acute episode of undemutrition resulting from a recent illness). In a well-nourished population of children, it is expected that about 2.3 percent of children will be measured as moderately or severely stunted or wasted. For all of Kazakstan, the survey found that 16 percent of children are severely or moderately stunted and 3 percent are severely or moderately wasted. Particularly in terms of the stunting index, undernutrition differs between subgroups of children. Moderate or severe stunting is found to be high among children 12-23 months of age (23 percent) compared to infants under 6 months of age (4 percent) and age 6-11 months (10 percent), and among children born after a birth interval of less than 24 months (28 percent) compared to those born after longer birth intervals of 24- 47 months (20 percent) and 48 months or more (7 percent). Moderate or severe stunting is also particularly high among children in rural areas (22 percent), in the South and Central Regions (23 and 22 percent, respectively), and among the children of ethnic Kazak women (21 percent). xxiv Anemia Status. Testing of women and children for anemia was one of the major efforts of the 1995 KDHS. Anemia is recognized as a major public health problem throughout the world, and has been considered a major public health problem in Kazakstan for decades. Nevertheless, this was the first anemia study in Kazakstan done on a nationally representative sample. The study involved hemoglobin (Hb) testing for anemia using the Hemocue system. Approximately, half (49 percent) of the women in Kazakstan suffer from some degree of anemia. Thirty-seven percent of these women have mild anemia, 11 percent have moderate anemia, and 1 percent are severely anemic (Hb level less than 7.0 g/dl). The highest overall rate of anemia (59 percent) is found in the West Region while Almaty City has the lowest overall rate (38 percent). With respect to ethnicity, the rate of anemia is higher among ethnic Kazak women (57 percent) than among ethnic Russian women (42 percent) and women of other ethnic groups (43 percent). Sixty-nine percent of children under the age of three in Kazakstan suffer from some degree of anemia. About the same proportions of children have mild (30 percent) and moderate anemia (34 percent). A smaller, but substantial, proportion of children is severely anemic (6 percent). As is the case for women, the highest overall rate of anemia among children is found in the West Region (81 percent) and the lowest rate in Almaty City (48 percent). Ethnic Kazak children have higher overall rates of anemia (78 percent) than ethnic Russian children (59 percent) or children of other ethnic groups (55 percent). Perhaps the most significant finding of the study is the high rate of severe anemia among Kazak children (9 percent), while no ethnic Russian children are severely anemic, and the prevalence for other ethnic groups is 1 percent. There are some demographic predisposing factors which increase the likelihood of anemia in children. These factors include the age of 12-23 months, high birth order, and having an anemic mother. XXV ~< x _<. KAZAKSTAN West Kazakstanskaya Oblast Atyrauskaya Oblast Caspian Sea Mangistauskaya Oblast North Kazakstanskaya Oblast \ \ \ Oblas t I ~ r , u r ,~ , .==°uo , I _ Oblast Aktiubinskaya Oblast Tourgaiskaya Oblast / " Aral Sea KzyI-Ordins Oblast _s - - J h. Akmolinskaya Oblast Zhezkazganskaya Oblast Oblast • South • Kazakstanskay~ ~1 Oblast / RUSSIA Pavlodarsk Oblast aandinskaya Oblast Semipalatinskaya Oblast S Almatinskaya l Oblas~ Oblast CHINA UZBEKISTAN ~. ~ "" ALMATY CITY CHAPTERI INTRODUCTION A~az ~ ~armanov 1.1 Geography, History, and Economy I.I.I Geography and Population Kazakstan, the second largest republic after Russia in the former Soviet Union, has a territory of over 1 million square miles (2.7 million square kilometers). It borders Russia to the north and west, the Central Asian republics of Uzbekistan, Kyrgyzstan, and Turkmenistan to the south, and China to the east. The northern part of Kazakstan consists of grasslands, while most of the south and center consists of desert and steppe. Kazakstan has access to both the Caspian Sea and the Aral Sea and it is crossed by the Siberian river of Ertys, and the rivers of Esil, Oral, and Syr Darya (Goskomstat, 1996). Kazakstan is divided into 19 administrative regions (oblasts), which are further broken down into 220 smaller administrative areas called raions. The country has a population of 16.5 million (Goskomstat, 1996). With 16.4 persons per square mile (6.4 per square kilometer), Kazakstan has one of the lowest population densities in the world. The population is comprised of more than 100 nationalities and ethnic groups. Forty- five percent of the population is Kazak, 35 percent Russian, 4 percent German, and 4 percent Ukrainian in origin. Other significant subpopulations are Uzbeks, Tatars, Uighuers, and Koreans. Traditional Kazak culture is influenced by Islam. The Russian population has a loose affiliation with the Russian Orthodox Church. 1.1.2 Pre-Soviet Kazakstan Prior to the 20th century, the people of Kazakstan were mainly nomadic. For centuries, the Kazak people grazed their horses and sheep on the grasslands of the north and on the pastures of the south. In the 13th century, the Kazaks, who were originally Turkik speaking tribes, were invaded and influenced by the Mongols. The ethnic Kazak population is homogeneous in terms of its cultural traditions and language. It is common, however, to divide it into three major tribes or zhoozes: Uly (senior) Zhooz (southeastern Kazakstan), Orta (middle) Zhooz (central and northern Kazakstan), and Kishi (junior) Zhooz (western Kazakstan). The Kazak state was formally established in the 16th century during the rule of Qasym-khan. Later, the representatives of all three Zhoozes, facing the threat of Dzhungar's conquest, gathered in Ulu-Tau (currently Dzhezkazgan oblast), and declared the nation's unification (Baishev et al., 1979). In the 18th century, Ablai-khan, the most eminent person in Kazak history, was able to politically unify the Kazak state. He was, however, the last independent Kazak khan, deriving his power solely from the Kazak people (Olcott, 1995). Beginning in the 18th century, the territory of Kazakstan was subject to Russian conquest and was incorporated into the Russian Empire. At the end of the 19th and beginning of the 20th centuries, Kazakstan was a destination of intensive migrations of Russian, Ukrainian, and Polish peasants. 1.1.3 Kazakstan During the Soviet Era After the communist revolution of 1917, an autonomous republic was established in the territory of Kazakstan. In 1936, the territory became the Soviet Socialist Republic of Kazakhstan, member of the USSR. The Stalin era of collectivization of farmland in the 1920s and 1930s resulted in huge numbers of Kazaks starving due to losses of livestock and poor harvests. It has been estimated that 1,750,000 Kazaks (about 40 percent of Kazakstan's population) died as a result of famine and Stalin's repression (Abylgozhin et al., 1989). Prior to and during World War II, Stalin deported many Germans, Koreans, Chechens, and Crimean Tatars to Kazakstan from central Russia, the Far East, Caucasus, and Crimea. They now constitute a significant portion of Kazakstan's population. In the mid-1950s, Nikita Khmshchev announced the Virgin Lands campaign which was designed to bring the enormous acreage of pasture land in Kazakstan under plow. The next 10 years brought another wave of immigrants from Russia, Byelorussia, and Ukraine to settle the Kazak steppes. Some 64 million acres of pasture were plowed and hundreds of collective farms were established, mainly in the central and northern areas of Kazakstan, which became major producers of grain. The southern part of Kazakstan remained populated mainly by Kazaks who produced cotton, fruits, and vegetables. The industrial development of Kazakstan, initiated in the mid- 1950s, benefitted from the country's abundance of natural resources. Kazakstan is one of the most mineral rich countries in the world, with deposits of copper, chromium, magnesium, iron ore, gold, titanium, lead, zinc, bauxite, and other minerals (UNDP, 1995). During the last three decades, Kazakstan has developed national industries in iron and steel production, chemical fertilizers, copper, machinery and construction of coal and hydroelectric plants. The economic development of Kazakstan since the 1950s has been tremendously accelerated by the military industry and the space program. The Semipalatinsk region of Kazakstan was designated as the Soviet nuclear bomb testing zone. Baikonour, the area in the middle of Kazakstan's southern deserts, became a Soviet space harbor, similar to the United States' Cape Canaveral. The Soviet government considered Kazakstan's borders with China strategically important and stationed large numbers of troops along the border forming the Central Asian Military Zone. Thus, two major demographic trends characterize Kazakstan in the 20th century: rapid urbanization and a shift in ethno-national structure. Kazakstan's present ethnic spectrum is the result of an intensive migration process, initiated and influenced by industrialization and political changes throughout Kazakstan's history. The migration process brought millions of ethnic Slavs, mostly Russians, who settled predominantly in the northern territories of Kazakstan and now constitute a majority of the population. The central and southern regions remain populated primarily by ethnic Kazaks. 1.1.4 Social Programs and the Educational System During the Soviet era, Kazakstan developed advanced social and educational programs. In 1992, more than nine million people (about half of the population) were covered by some kind of social welfare and social security system, such as pensions, maternity leave, disability protection, etc. With a strong public commitment to education, which is free of charge, a high level of literacy is now nearly universal in Kazakstan. The 1989 Census reported a mean number of 9.7 years of schooling by the age of 25 (Goskomstat, 1990). The country's primary and secondary educational system has three levels: primary (classes 1-4, age 6/7 - 10/11 years); principal (classes 5-9, age 11-15 years); secondary (classes 10-11, age 16-17 years). In 1995, there were 8,801 schools operating in Kazakstan, more than two-thirds of which offered all three levels 2 of primary/secondary education. The national teacher/pupil ratio was estimated to be 1:11 (Goskomstat, 1996). The primary and principal education levels are compulsory. Those who leave after the principal level of education (9 classes) may continue in secondary-special (vocational) education. Those who finish all three levels of primary/secondary school can continue their education at a higher level--at universities or academic training institutes. The secondary-special (vocational) educational system in Kazakstan includes 251 schools providing a combination of general education and technical skills to students age 15-20 during 2-4 years of schooling. The number of years in the secondary-special schools depends on the curriculum profile and professional orientation of the student. In 1995, there were 65,200 students who were enrolled in these schools (Goskomstat, 1996). In 1995, there were 71 universities and academic training institutes in Kazakstan offering formal higher education, and there were 260,000 students enrolled in these institutions (Goskomstat, 1996). Currently, the secondary-special and higher education systems are undergoing changes to meet a growing demand for new types of professional skills, particularly for professionals with market management and business administration skills. 1.1.5 Kazakstan During the Socioeconomic Transition With the collapse of the former Soviet Union in 1991, Kazakstan was granted formal independence and became a sovereign republic. The country opened its doors to the world community and became a member of the United Nations and many other international organizations. The head of the newly independent state is the President, Mr. Nursultan Nazarbayev. Under transition from a centrally-planned economy to a market economy, Kazakstan is now experiencing rapid social and economic changes. The process to date has produced disruption in most sectors of the economy, causing economic decline, inflation, and instability of the new national currency. Almost all sectors of the economy experienced dramatic decreases in production from 1991 to 1995. Not until the beginning of 1995 was an increase in the production of ferrous and nonferrous metallurgy and the chemical industries noticeable (Goskomstat, 1996). The Government of Kazakstan liberalized consumer prices as part of an economic transition program. This induced tremendous inflation which was estimated at almost 50 percent per month in June 1994 for food and nonfood commodities. Despite the fact that the overall monthly inflation rate has fallen since 1994 to 2-5 percent in 1995-96, the increasing gap between personal income and the cost of living continues to affect most household budgets (Goskomstat, 1996). The country's declining economy and budget deficits place downward pressure on expenditures for social programs, education, and health care (see also section 1.2.2. on the health care crisis). The inability of the Government to collect and maintain sufficient pension funds has led to new legislation that raises the retirement age from 55 to 58 years for women and from 60 to 63 for men by the year 2001. The Government of Kazakstan, facing economic and social crisis, has initiated a number of activities to restructure the economy by attracting foreign investments and rebuilding economic relations with Russia and other former Soviet republics. In 1995, the Government of Kazakstan initiated the transfer of major enterprises, including Karaganda steel, Dzhezkazgan copper, and Donskoi chromium plants, to the management of foreign companies such as British Ispat Corporation and Korean Samsung. Such transfers are intended to assist in the move from a Soviet planned economic system to a market economy. Kazakstan has also urged other former Soviet republics to form a Euro-Asian Union comparable to the European Union. In 3 March 1996, Kazakstan signed an agreement with Russia, Byelorussia, and Kyrgyzstan to form a union intended to eliminate trade barriers and restore economic and financial relationships. 1.2 Health Care Sytem 1.2.1 Socialistic Health Care System In 1978 the historic International Conference on Primary Health Care was held in Kazakstan under the aegis of the World Health Organization (WHO) and UNICEF. The Alma-Ata Declaration was drawn up and the "Health for All" strategy was developed, calling for primary care driven health systems that would guarantee equal access for all citizens (WHO, 1978). During the 1970s and early 1980s, Kazakstan became an example of how a multiethnic state in a developing and industrialized setting could achieve this goal. The system of comprehensive and planned health care that was developed in Kazakstan provided adequate access to health services and maintained a focus on prevention. With six medical schools and 10 medical colleges, Kazakstan has been successful in training medical doctors, nurses, and other medical professionals. The country has reached one of the world's highest per capita rates of physicians and hospital beds. In 1995 there were 365 doctors per 100,000 population. Figures for the U.S., Japan, and China were 288, 225, and 154, respectively. The number of hospital beds was 1,169 per 100,000 population, which was also one of the world's highest rates (Ministry of Health, 1996). The planned system, developed under the Soviet health care system, maintains a network of primary health care institutions. The network includes doctor' s assistant/midwife post (FAP), district polyclinics, and rural hospitals at the primary level; district hospitals and dispensaries at the secondary level; and central hospitals and clinical research institutes at the highest level. It has proven efficient and successful in providing adequate health services for the majority of the population, including those residing in the most remote areas of Kazakstan. However, maintaining such a system depends entirely on substantial and continuous budgetary support, and requires enormous resources of manpower and managerial skill. 1.2.2 Health Care Crisis Unfortunately, Kazakstan's declining economy has reduced health care expenditures. The country is currently experiencing a health care crisis and the system is continually threatened with severe financial cutbacks. The health care budget has declined to 1.1 percent of the Gross National Product (GNP) (Goskomstat, 1996). This compares with average health care expenditures of 6-10 percent of the GNP in most developed countries. Meanwhile, Kazakstan's GNP has also decreased tremendously in the past few years producing an even greater tightening of the budget (UNDP, 1995). Since 1990, Kazakstan's health care system has become highly decentralized and less manageable. Due to lack of funding, some regions reduced the number of hospital beds and supplies of essential drugs and medical equipment. Physicians in Kazakstan are now paid less on average than factory workers. Hospitals and other health facilities are in poor condition; many are lacking in sanitary conditions, running water, and electricity (Barr and Field, 1996; Sharmanov et al., 1996). The crude death rate in Kazakstan has increased from 7.7 deaths per 1,000 population in 1990 to 10.1 in 1995 (Goskomstat, 1996). Average life expectancy at birth decreased from 68.6 years (63.8 for men and 73.1 for women) in 1990 to 66.8 (60.7 for men and 71.1 for women) in 1994 (Ministry of Health, 1996). The major causes of death in Kazakstan are cardiovascular diseases, cancer, and respiratory diseases (in 1995 there were 484, 134, and 93 deaths per 100,000 population, respectively). While the incidence rate of infectious diseases such as diarrhea has declined, morbidity from noncommunicable diseases has risen in the 4 past decade. In 1995, 26 percent of people in Kazakstan had respiratory diseases and 4 percent had infectious diseases or parasite infestation. Pulmonary tuberculosis is one of the most serious health problems in Kazakstan. The highest levels are observed in the northern and western regions. The number of new cases of tuberculosis increased from 59.7 per 100,000 population in 1994 to 67.1 in 1995. The overall morbidity rate from tuberculosis in Kazakstan in 1995 was 271.1 per 100,000 population, which was the highest in Central Asia, and one of the highest in the world (Ministry of Health, 1996). Drug-resistant forms of tuberculosis have become more prevalent in the past decade, resulting in high rates of mortality and disability. Many of the health problems in Kazakstan have arisen from deteriorating environmental conditions. Radioactive contamination around the Semipalatinsk nuclear bomb testing zone, and agro-chemical pollution in the area of ecological crisis of the Aral Sea have provoked international attention over the last several years. There is great concern in the health community that malignant neoplasms and genetic and mental disorders in these geographic areas have increased significantly. In addition to environmental factors, behaviors such as heavy smoking, excessive alcohol consumption, and a high-fat diet contribute significantly to the deteriorating health condition of the general population of Kazakstan. Nutrition-related diseases, particularly those caused by malnutrition and micronutrient deficiencies, are a major public health concern in Kazakstan, since they appear to be important predisposing factors for infectious diseases and underlying causes of many noncommunicable diseases. Among nutrition-related diseases, iron deficiency anemia has been considered a major health problem in Kazakstan for decades. 1.2.3 Health Care Reform It has become clear that success in health care will not be solely determined by the number of physicians or hospital beds. Even if the medical care system is efficient and affordable, the health of the society will depend on its ability to cope with non-medical issues. The challenge for the Kazakstan Government is to reform the health system in such a way that it will be both financially viable and provide comprehensive service to the population at large, including the most vulnerable groups. In April 1996, a national compulsory health insurance system was introduced in Kazakstan. The system has been developed to attract private funds to expand the health care sector and to move it away from govemment control. Under the new system, physicians are to operate within a group of private practitioners financed by the national insurance fund. Funds are meant to be employment-based, providing government funding for the elderly, students, the unemployed, and the disabled. Kazakstan is currently in the initial stages of transition from the former government-owned health care system, which fell into financial crisis, to the new system that is expected to be competitive and market-oriented. Meanwhile, the Ministry of Health of Kazakstan is in the process of developing programs to restructure the primary health care system, and improve maternal, child, environmental, and occupational health. As part of an intersectoral approach in health care reform, the National Nutrition Policy has been developed by the National Institute of Nutrition with technical assistance from UNDP, UNICEF, and WHO (National Institute of Nutrition, 1996). The Policy outlines emerging nutrition and health issues in Kazakstan during economic transition and stresses the needs in such areas as maternal and child nutrition, development of iron and iodine fortification programs, promotion of breastfeeding, improvement of the national food control and nutrition surveillance systems, coordination of food production and marketing, food provision for socially deprived population groups, etc. 1.3 Maternal and Child Health and Family Planning For many years, the Government of Kazakstan promoted policies to encourage women to have more children. Women in Kazakstan who had seven or more children were traditionally glorified and recognized as a "mother-hero" and provided with a number of benefits, including bonuses, housing assistance, extensive paid maternity leave, child benefits, support for day care, etc. Kazaks have historically been in favor of large families. A long history of pronatalist policies and traditions provides the backdrop within which all fertility policies must be designed. First, a fertility program must be supported by adequate maternal and child health services. Second, any introduction of family planning approaches must address fears, voiced by national political groups, regarding the reduction of the proportion of ethnic Kazaks within the overall ethnic structure of Kazakstan. Therefore, the Ministry of Health of Kazakstan incorporates family planning within a more comprehensive program of maternal and child health services, without specifying any demographic targets. To promote maternal and child health services, the Government of Kazakstan has built a nationwide multilevel network of health care facilities. The main health facility in this network that provides delivery assistance is the delivery hospital. Some births are delivered in the obstetrics/gynecology department of regular hospitals. In remote areas of Kazakstan, pre-doctoral delivery assistance is provided by the staff of doctor's assistant/midwife posts (FAPs). The major facilities responsible for antenatal care and family planning in urban areas are women's consulting centers and polyclinics. In rural areas, family planning services and antenatal care are the responsibility of the staff of rural hospitals and the FAPs. This system makes antenatal and delivery care available to women in virtually all regions, both urban and rural, including the remote areas of Kazakstan. Obstetricians and gynecologists in the facilities also provide family planning services; their main objectives are to reduce complications due to inadequately spaced pregnancies and to reduce the number of induced abortions. Despite initial successes in improving maternal and child health and overall reductions in maternal and child mortality during the last two decades, Kazakstan maintains morbidity and mortality patterns typical of developing countries. For instance, almost 80 percent of children in Kazakstan reportedly had some illness in 1995, mainly respiratory or diarrheal disease (Ministry of Health, 1996). Many children suffer from various forms of malnutrition and micronutrient deficiency. The infant mortality rate, which has remained relatively static since 1980, was 26.8 per 1,000 live births in 1995, according to the data of the Kazakstan State Committee on Statistics (Goskomstat, 1996). Data from the Kazakstan National Research Center on Maternal and Child Health show the 1994 and 1995 maternal mortality rates in Kazakstan to be 69.3 and 77.3 deaths per 100,000 live births, respectively. Most industrialized countries report rates of 3 to 10 deaths per 100,000 live births. The major causes of maternal death in Kazakstan are hemorrhage, induced abortion, extragenital diseases, and late gestosis, each accounting for 15 to 23 percent of the total deaths (Ministry of Health, 1996). Predisposing factors of maternal death are infection, extragenital diseases, malnutrition, iron-deficiency anemia, and other micronutrient deficiencies. Most of these maternal deaths could be prevented if steps were taken to identify high-risk pregnancies and implement preventive measures. Induced abortion is a significant cause of maternal mortality in Kazakstan. It accounts for 19 percent (41 cases) of maternal deaths in 1995 (Ministry of Health, 1996). Almost half of the maternal deaths caused by induced abortion were related to cases of illegal abortions. The rate of induced abortion in Kazakstan is reported by the Ministry of Health Statistical Office at 54.7 per 1,000 women of reproductive age in 1995, similar to the high levels observed in most Eastern European countries. 6 Since the legalization of induced abortion in 1955, it has been a primary method of birth control in Kazakstan. High prevalence of abortion is the result of both wide availability of providers who can perform the procedure free of charge, and public tolerance of the practice. Another contributing factor is an insufficient supply of alternative methods of birth control, such as oral contraceptives. In 1974, the Ministry of Health of the former Soviet Union published On the side effects and complications of oral contraceptives, a document which practically banned the distribution and use of oral contraceptives. In addition, in 1987, the former Soviet Government introduced and legalized vacuum aspiration for mini-abortions. These two regulations enabled unlimited use of various methods of inducing abortions and restricted women's choices of other safe methods of birth control. Only intrauterine devices were widely available. Despite some indications that the number of induced abortions has declined in the last several years, the abortion issue remains a great public health concern due to the prevalence of complications and overall adverse effects on women's health. Thus, while Kazakstan has indeed developed an advanced system of maternal and child health services, several health indicators have declined in the last several years as a result of deteriorating socioeconomic conditions, environmental problems, and cutbacks in health expenditures during the transition to a market economy. The challenge for the Government of Kazakstan is to develop appropriate long-term health strategies and to define priorities, particularly in the area of maternal and child health. Policy planning requires population-based data on reproductive health, fertility, infant mortality, and the nutritional status of women and children. Such data were collected in the Kazakstan Demographic and Health Survey. 1.4 Demographic and Health Data Collection System in Kazakstan The demographic and health data collection system in Kazakstan is based on the registration of events and periodic censuses. The data on births, deaths, marriages, and divorces are registered at the local admini- strative level of an internal passport control system. These data are then forwarded to the State Committee on Statistics ("Goskomstat") through the raion and oblast level statistical offices. Goskomstat is responsible for conducting censuses and maintaining this registration system. The last census in Kazakstan was conducted in 1989, and the data were made available in the 1990 publication of census results (Goskomstat, 1990). In addition, Goskomstat is responsible for tabulating and publishing an annual report of information on major economic and demographic categories generated by the registration system. Collection of health data in Kazakstan is a primary responsibility of the Statistical Department of the Ministry of Health. The original health information is generated under the responsibility of staff at the local health care facility and then sent to the Statistical Department through the raion and oblast level health de- partments. The Statistical Department of the Ministry of Health compiles and analyzes these data and issues annual reports entitled Health of the Population of the Republic of Kazakstan and Health Services. The re- ports are distributed on the national and oblast levels for use by health administrators, health professionals, etc. The health data collected and published by the Statistical Department of the Ministry of Health consists of the following major categories: 1) morbidity specified by type of disease (infectious and non- infectious); 2) mortality specified by causes of death; 3) infant deaths, including data on antenatal, perinatal, and early neonatal deaths; 4) maternal mortality specified by causes of maternal death; 5) data on maternal and child health, including antenatal care and delivery assistance, 'contraceptive clients, induced abortion rates, pediatric services, vaccination coverage, etc; 6) number of health facilities, medical personnel, hospital beds, and length of average stay in the hospital; and 7) health data specified by type of medical services including medical care for patients with cancer, tuberculosis, mental disorders, drug abuse, and sexually transmitted diseases. These data are usually tabulated at the national and oblast levels, and for some categories, by the age groups 0-14 and 15 or more years. 1.5 Objectives and Organization of the Survey The purpose of the 1995 Kazakstan Demographic and Health Survey (KDHS) was to provide an information base to the Ministry of Health for the planning of policies and programs regarding the health and nutrition of women and their children. The 1995 KDHS collected data on women's reproductive histories, knowledge and use of methods of contraception, breastfeeding practices, nutrition indicators, vaccination coverage, and episodes of diseases among children under age three. The survey also included measurement of hemoglobin levels in the blood to assess the prevalence of anemia, and measurements of height and weight to assess nutritional status. A secondary objective of the survey was to enhance the capabilities of institutions in Kazakstan to collect, process, and analyze population and health data so as to facilitate the implementation of future surveys of this type. The 1995 KDHS was the first national level population and health survey in Kazakstan. It was implemented by the National Institute of Nutrition, Republic of Kazakstan. The Kazakstan Academy of Preventive Medicine contributed significantly to the analysis of the KDHS results. The 1995 KDHS was funded by the United States Agency for International Development (USAID) and technical assistance was provided by Macro International Inc. (Calverton, Maryland USA) through its contract with USAID. 1.5.1 Sample Design and ImpLementation The 1995 KDHS employed a nationally representative probability sample of women age 15-49. The country was divided into five survey regions (Figure IA). Four survey regions consisted of groups of contiguous oblasts (except the East Kazakstanskaya oblast which is not contiguous). Almaty City constituted a survey region by itself although it is part of the Almatinskaya oblast. The five survey regions were defined as follows: I) Almaty City 2) South Region: Taldy-Korganskaya, Almatinskaya (except Almaty city), Dzhambylskaya, South Kazakstanskaya, and Kzyl-Ordinskaya 3) West Region: Aktiubinskaya, Mangistauskaya, Atyrauskaya, and West Kazakstanskaya 4) Central Region: Semipalatinskaya, Zhezkazganskaya, and Tourgaiskaya 5) North and East Region: East Kazakstanskaya, Pavlodarskaya, Karagandinskaya, Akmolinskaya, Kokchetauskaya, North Kazakstanskaya, and Koustanaiskaya It is important to note that the oblast composition of regions outside of Almaty City was determined on the basis of geographic proximity, and in order to achieve similarity with respect to reproductive practices within regions. The South and West Regions are comprised of oblasts which traditionally have a high proportion of Kazak population and high fertility levels. The Central Region contains three oblasts in which the fertility level is similar to the national average. The North and East Region contains seven oblasts situated in northern Kazakstan in which a relatively high proportion of the population is of Russian origin, and the fertility level is lower than the national average. Figure 1.1 OBLAST COMPOSITION OF REGIONS IN KAZAKSTAN, 1995 KDHS RUSSIA '~ ULD=I~IO i ,~1~ ~ ALMA1Pt CITy ALMATY CiTY SOUTH WEST CENTRAL NORTH and EAST CITY OF ALMATY SOUTH 1. KzyI-Ordinskaya 2. South Kazakstanskaya 3. Zhambylskaya 4. Almatinskaya 5. Taldy-Korganskaya WEST 6. Aktiubinskaya 7. Atyrauskaya 8. Mangistauskaya 9. West Kazakstanskaya CENTRAL 10. Tourgaiskaya 11. Zhezkazganskaya 12. Semipalatinskaya NORTH and EAST 13. Koustanaiskaya 14. North Kazakstanskaya 15. Kokchetauskaya 16. PavIodarskaya 17. Akmolinskaya 18. Karagandinskaya 19. East Kazakstanskaya 9 In Almaty City, the sample for the 1995 KDHS was selected in two stages. In the first stage, 40 census counting blocks were selected with equal probability from the 1989 list of census counting blocks. A complete listing of the households in the selected counting blocks was carried out. The lists of households served as the frame for second-stage sampling; i.e., the selection of the households to be visited by the KDHS interviewing teams. In each selected household, women age 15-49 were eligible to be interviewed. In the rural areas, the primary sampling units (PSUs) were the raions which were selected with probability proportional to size, the size being the 1993 population published by Goskomstat (1993). At the second stage, one village was selected in each selected raion, from the 1989 Registry of Villages. This resulted in 50 rural clusters being selected. At the third stage, households were selected in each cluster following the household listing operation as in Almaty City. In the urban areas other than Almaty City, the PSUs were the cities and towns themselves. In the second stage, one health block was selected from each town except in self-representing cities (large cities that were selected with certainty) where more than one health block was selected. The selected health blocks were segmented prior to the household listing operation which provided the household lists for the third stage selection of households. In total, 86 health blocks were selected. On average, 22 households were selected in each urban cluster, and 33 households were selected in each rural cluster. It was expected that the sample would yield interviews with approximately 4,000 women between the ages of 15 and 49. Because of the nonproportional distribution of the sample to the different survey regions, sampling weights have been applied to the data in this report. Details concerning the KDHS sample design are provided in Appendix A and the estinaation of sampling errors are included in Appendix B. 1.5.2 Questionnaires Two questionnaires were used for the 1995 KDHS: the Household Questionnaire and the Individual Questionnaire. The questionnaires were based on the model survey instruments developed in the DHS program. They were adapted to the data needs of Kazakstan during consultations with specialists in the areas of reproductive health, child health and nutrition in Kazakstan. The Household Questionnaire was used to enumerate all usual members and visitors in tile sample households and to collect information relating to the socioeconomic position of a household. In the: first part of the Household Questionnaire, information was collected on age, sex, educational attainment, marital status, and relationship to the head of household of each person listed as a household member or visitor. A primary objective of the first part of the Household Questionnaire was to identify women who were eligible for the individual interview. In the second part of the Household Questionnaire, questions were included on the dwelling unit, such as the number of rooms, the flooring material, the source of water, the type. of toilet facilities, and on the availability of a variety of consumer goods. The Individual Questionnaire was used to collect information from women age 15-49. These women were asked questions on the following major topics: Background characteristics Pregnancy history Outcome of pregnancies and antenatal care Child health and nutrition practices Child immunization and episodes of diarrhea and respiratory illness 10 Knowledge and use of contraception Marriage and fertility preferences Husband's background and woman's work Anthropometry of children and mothers Hemoglobin measurement of women and children One of the major efforts of the 1995 KDHS was testing women and children for iron-deficiency anemia. Testing was done by measuring hemoglobin levels in the blood using the Hemocue technique. Before collecting the blood sample, each woman was asked to sign a consent form giving permission for the collection of a finger-stick blood droplet from herself and her children. Results of anemia testing were kept confidential (as are all KDHS data); however, strictly with the consent of respondents, local health care facilities were informed of women and children who had severely low levels of hemoglobin (less than 7 g/dl). 1.5.3 Training and Fieldwork The 1995 KDHS questionnaires were pretested in December 1994. Six female interviewers were trained over a two-week period at the Institute of Nutrition. The pretest included one week of interviewing in an urban area (AImaty City) and one week in a rural area. A total of 124 women were interviewed. Based on the pretest experience, the questionnaires were modified. Pretest interviewers were retained to serve as supervisors and field editors for the main survey. Female nursing students of the National Medical College were recruited as interviewers and male students were recruited as medical technicians for the main survey. A total of 40 students were trained at the Medical College for four weeks from mid-April to mid-May 1995. Training consisted of in-class lectures and practice, as well as interviewing in the field. Interviewers were selected based on their performance during the training period. The data collection was carried out by four teams. Each team consisted of eight members: the team supervisor, one editor, one household interviewer, four individual women interviewers, and one medical technician (responsible for height and weight measurement and anemia testing). All team members other than the medical technician were female. Fieldwork for the KDHS was conducted from May to September 1995. 1.5.4 Data Processing Questionnaires were returned to the Institute of Nutrition in Almaty for data processing. The office editing staff checked that the questionnaires for all selected households and eligible respondents were retumed from the field. The few questions which had not been precoded (e.g., occupation, type of chronic disease) were coded at this time. Data were then entered and edited on microcomputers using the ISSA (Integrated System for Survey Analysis) package, with the data entry software translated into Russian. Office editing and data entry activities began in May 1995 (i.e., the same time that fieldwork started) and were completed in September 1995. 1.5.5 Response Rates Table 1.1 presents information on the coverage of the 1995 KDHS sample including household and individual response rates. A total of 4,480 households were selected in the sample, of which 4,241 were occupied at the time of fieldwork. The main reason for the difference was that some dwelling units which were occupied at the time of the household listing operation were either vacant or the household members were away for an extended period at the time of interviewing. Of the 4,241 occupied households, 4,178 were interviewed, yielding a household response rate of 99 percent. 11 In the interviewed households, 3,899 women were eligible for the individual interview (i.e., all women 15-49 years of age who were either usual residents or visitors who had spent the previous night in the household). Interviews were successfully completed with 3,771 of these women, yielding a response rate of 97 percent. The principal reason for nonresponse was the failure to find an eligible woman at home after repeated visits to the household. The overall response rate for the survey--the product of the household and the individual response rates- -was 95 percent. Table 1.1 Results of the household and individual interviews Number of households, number of interviews and response rates, Kazakstan 1995 Residence Result Urban Rural Total Household interviews Households sampled 2,808 1,672 4,480 Households found 2,627 1,614 4,241 Households interviewed 2,570 1,608 4,178 Household response rate 97.8 Individual interviews Number o f eligible women 2,131 Number of eligible women interviewed 2,056 Eligible woman response rate 96.5 99.6 98.5 1,768 3,899 1,715 3,771 97.0 96.7 12 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Shamshiddin A. Balgimbekov and Raimbek Sissemaliev Data about the background characteristics of the households and respondents are presented in this chapter. Since demographic and health parameters are largely determined by sociobiological factors, this information is important in interpreting results. Moreover, data on characteristics of households and respondents can serve as an indicator of the representativeness of the sample and of the quality of the data obtained. This chapter includes three sections: characteristics of the household population (household structure, age-sex characteristics, level of education of the household members); housing characteristics (presence of electricity, source of drinking water, sanitation, etc.) and background characteristics of survey respondents (residence, age, ethnicity, marital status, occupation, etc.). 2.1 Household Population The KDHS Household Questionnaire was intended to elicit data on the sociodemographic characteristics of the members and visitors in each identified household. A household was defined as a person or group of persons usually living and eating together and jointly running the household's economy (de jure population). Visitors were persons who were not household members but had spent the night before the interview in the selected household. All female household members and visitors 15-49 years of age were eligible as respondents for the individual interview. The total de facto population in the selected households was 15,635 people. 2.1.1 Sex and Age Composition Table 2.1 presents the distribution of the de facto household population by five-year age groups according to sex and residence. Almost one-third of the population consists of children under 14 years of age (32 percent), with the proportion of children in mral areas higher than in urban areas (37 and 26 percent, respectively). Starting from age group 35-39, there is a gradual decrease in the proportion of subsequent age groups. In general, the number of women exceeds the number of men. This difference is more notable in urban areas. One-fourth of the de facto household population consists of women 15-49 years of age who are the main KDHS respondents. As seen in Figure 2.1, the age-sex structure of the Kazakstan population has the form of a pyramid with a wide base, gradually tapering to a sharp peak. The relatively small size of the male and female population in the age interval 50-54 is a reflection of the low birth rates during World War II (i.e., 50 to 55 years prior to the KDHS). It is interesting to compare 1995 KDHS data with the 1989 Census (Table 2.2). Correspondence of the percent distribution of the population in broad age groups between the 1995 KDHS and the 1989 Census confirms the representativeness of the KDHS sample. 13 Table 2.1 Household population by age~ residence and sex Percent distribution of the de facto household population by age, according to sex and residence, Kazakstan 1995 Age Urban Rural Total Male Female Total Male Female Total Male Female Total 0-4 7.8 6.7 7.2 12.3 I 1.5 11.9 10.3 9.2 9.7 5-9 9.4 9,0 9.2 13.4 12.2 12.8 11.6 10.7 11.1 10-14 10.4 9.6 10.0 11.8 I 1.7 11.8 11.2 10.7 10.9 15-19 9.3 8.4 8.9 9.8 8.9 9.4 9.6 8.7 9.1 20-24 7.8 6.1 6.9 9.0 8.4 8.7 8.4 7.3 7.9 25-29 7.2 7,1 7.1 8.5 6.3 7.4 7.9 6.7 7.3 30-34 8.6 6.7 7,6 7.5 7.5 7.5 8.0 7.1 7.5 35-39 8.2 8.2 8.2 6.6 6.2 6.4 7.3 7.2 7.2 40-~ 8.6 8.1 8.3 4.4 4.7 4.6 6.3 6,3 6.3 45-49 5.6 5.4 5.5 4.6 3.8 4.2 5.0 4.5 4.8 50-54 3.7 4.4 4.1 2.5 3.4 2.9 3.0 3.9 3.5 55-59 5.2 6.0 5.6 4.2 4.6 4.4 4.6 5.3 4.9 60-64 2.9 3.4 3.2 2.0 3.1 2.5 2.4 3.2 2.8 65-69 3.3 4.3 3.8 1.4 2.8 2.1 2.3 3.5 2.9 70-74 1.2 2.8 2.1 1.3 2.0 1,7 1.3 2.4 1.9 75-79 0.5 1.7 1.2 0.5 1.3 0,9 0,5 1.5 1.0 80+ 0.5 2.0 1.3 0.3 1.5 0.9 0.4 1.7 1.1 Missin~Don't know 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,358 3,864 7,222 4,137 4,277 8,413 7,495 8,141 15,635 Ago 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 Figure 2.1 Population Pyramid of Kazakstan 6 5 4 3 2 1 0 1 2 3 Percent KDHS1995 14 2.1.2 Household Composition Table 2.3 presents information on the size and composition of households according to urban-rural residence. The head of house- hold (as recognized by other members) and the relationship of each household member to the head was determined in each household. In general, heads of households mainly were males (68 percent), and in urban areas the proportion of households headed by men (61 percent) was less than in rural areas (77 percent). About 70 percent of households consist of 1-4 members, with the average size of a household in Kazakstan being 3.8 mem- bers. There are significant differences in the household size between urban and rural areas, with the average urban household consisting of 3.1 members compared to 4.7 in rural households. Only 3 percent of households include a child under 15 neither of whose parents were household members. Table 2.2 Population by age from selected sources Percent distribution of the de jure popu- lation by age group, selected sources, Kazakstan 1989 and 1995 1995 1989 Age KDHS Census <15 31,0 31.8 15-64 62.1 62.5 65+ 6.9 5.7 Total 100.0 100.0 Median age 26.5 26.9 Dependency ratio 61.0 60.0 Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, and percentage of households with foster children, according to residence, Kazakstan 1995 Characteristic Residence Urban Rural Total Household headship Male 61.3 76.6 68.0 Female 38.7 23.4 32.0 Total 100.0 100.0 100.0 Number of members 1 16.2 5.6 11.6 2 23.6 11.4 18.3 3 20.8 14.l 17.9 4 21.5 19.9 20.8 5 10,0 16.7 12.9 6 4.6 13.5 8.4 7 1.5 8.8 4.7 8 0.6 4.8 2.4 9+ 0.9 5.2 2.8 Total 100.0 100.0 100.0 Mean size 3.1 4.7 3.8 Percent with foster children 2.2 4.4 3,1 Note: Table is based on de jure members; i.e., usual residents. Table 2.4 presents information on children under age 15 by survival status of the parents according to selected sociobiological factors. Seventy-nine percent of children under age 15 live with both parents. As children get older, fewer of them live with both parents; 86 percent of children in age group 0-2 live with both parents, compared to 75 percent in the age group 12 years or more. Rural chil- dren are more likely than urban children to live with both parents. It is notable that a greater percent of chil- dren live with both parents in the Soutbern and Western Regions (83 percent in each region). Twelve percent of children under 15 are living with only their mother; of these, 3 percent have lost their fathers and 9 percent have fathers who are still alive. There are distinctions in this parameter depending on age of children, sex, and place of residence. It is notable that a significant number of children (6 percent) are not living with their parents though both parents are alive. Regarding orphanhood, about 4 percent of chil- dren under 15 have fathers who have died and less than 1 percent have mothers who have died, while only a tiny fraction have lost both parents. 15 Table 2.4 Fosterhood and orphanhood Percent distribution of de facto children under age fifteen by their living arrangement and survival status of parents, according to child's age, sex, residence, and region, Kazakstan 1995 Living Living with mother with father Not living with but not father but not mother either parent Living Missing with Father Mother info. on Number Background both Father Father Mother Mother Both only only Both father/ of characteristic parents alive dead alive dead alive alive alive dead mother Total children Age 0-2 85.9 10.1 0.8 0.0 0.0 2.9 0.0 0.0 0.0 0.4 100.0 870 3-5 81.6 10.7 1.2 0.7 0.2 5.0 0.1 0.3 0.0 0.2 1130.0 981 6-8 78.1 10.2 2.6 0.2 1.0 7.3 0.0 0.1 0.0 0.3 100.0 1,056 %11 76.7 6.5 4.6 1.0 0.9 9.4 0.0 0.2 0.0 0.6 100.0 1,033 12+ 74.6 7.4 6.1 1.6 1.4 6.9 0.3 0.3 0.3 1.0 100.0 1,034 Sex Male 80.2 7.9 3.6 1.0 1.1 5,5 0.1 0.1 0.1 0.4 100.0 2,478 Female 78.2 9.9 2.8 0.4 0.3 7.3 0.1 0.2 0.1 0.6 100.0 2,496 Residence Urban 75.7 12.3 2.8 0.8 0.5 6.6 0.2 0.2 0.0 0.8 100.0 1,907 Rural 81.3 6.8 3.4 0.6 0.8 6.3 01 0.2 0.1 0.4 100.0 3,067 Region Almaty City 68.6 18.7 6.0 1.0 0.0 3.7 0.6 0.6 0.0 0.8 100.0 188 South 82.7 5.6 3.1 0.7 0.9 6.5 0.1 0.0 0.1 0.4 100.0 2,286 West 82.7 7.5 3.4 0.4 1.5 3.9 0.1 0.3 00 0.4 100.0 718 Central 75.2 9.7 4.6 0.1 0.8 8.1 0.4 0.1 0.1 0.8 100.0 447 North and East 74.1 13.7 2.4 1.1 0.1 7.4 0.0 0.4 0.0 0.7 100.0 1,335 Total 79.2 8.9 3.2 0.7 0.7 6.4 0.1 0.2 0.1 0.5 100.0 4,974 Note: By convention, foster children are those who are not living with either parent. This includes orphans, i.e., children both of whose parents are dead. 2.1.3 Educational Level of Household Members One of the most important background characteristics is the level of education of the household members. The parameters of reproductive health of women and the health status of children in many respects depend on educational level. According to the Constitution of the former Soviet Union, every person has a guarantee in getting secondary, secondary-special or higher education. In Kazakstan, most children begin to attend school at seven years of age (see chapter 1.1.4 on the educational system in Kazakstan). 16 The KDHS results confirm the high educational level of the Kazakstan population. As can be seen in Table 2.5, 95 percent of women have had at least some education. A high percentage of the women have secondary-special and higher education, especially those in the 20-49 age group. The educational level of urban women is higher than for rural women. There are educational differences between women in Almaty city and other regions. The median number of years of schooling is 10 for women. Table 2.5 Educational level of the female household population Percent distribution of the de facto female household population age seven and over by highest level of education attended, and median number of years of schooling, according to selected background characteristics, Kazakstan 1995 Level of education Median Background No Primary/ Secondary- years of characteristic education Secondary Special Higher Missing Total Number schooling Age 7-9 12,0 88.0 0,0 0.0 0.0 100,0 520 2.2 10-14 0.1 99.9 0.1 0.0 0.0 100.0 873 6,6 15-19 02 66.9 25.9 7.1 0.0 100.0 709 10,5 20-24 06 35.6 494 14.4 0.0 1000 597 11 0 25-29 0,0 25.6 49.7 24.7 0.0 100.0 543 110 30-34 0.0 30.4 49.9 19.7 0.0 100.0 580 10,9 35-39 0.4 36.8 43.8 18.3 0.7 100.0 583 10,8 40-44 04 34.8 46.8 17.3 06 100.0 515 109 45-49 13 42.2 36,7 18.3 1.5 100,0 370 10,9 50-54 0,2 63.2 21,7 14.4 0,5 100,0 316 102 55-59 3,6 61.9 23,6 9.8 1,2 100.0 428 9,1 60-64 15.5 63.1 12.3 9.1 0.0 100.0 263 70 65+ 23.0 62.7 10.5 3.5 0.3 100.0 741 4.8 Residence Urban 3.6 473 32.4 16,2 05 100.0 3,471 104 Rural 5.0 655 23.1 6,2 01 100.0 3,567 95 Region Ahnaty City 2.1 40.7 26.2 30.7 0.3 100.0 435 10,9 South 52 62.4 23.7 84 0.2 100.0 2,638 9.9 West 4.2 57.2 28.4 10.2 0.0 100.0 963 10.0 Central 3.2 52.9 31.8 12 0 0.1 100.0 628 10.1 North and East 4.0 53.6 31.0 10,8 0.6 100,0 2,374 10.1 Total 43 56.5 277 I 1.2 0.3 100.0 7,038 10 1 17 Data in Table 2.6 show that men in Kazakstan also have a high educational level. Thirty-eight percent of men have secondary-special and higher education, and in certain age groups, the proportion is about 60 percent. The proportion of men with higher education is greater in urban areas than rural (18 and 7 percent, respectively). The median duration of studying is higher in Almaty(10.8 years), than in the other four regions, where this parameter is almost identical (10.1-10.3 years). Table 2.6 Educational level of the male household population Percent distribution of the de facto male household population age seven and over by highest level of education attended, and median number of years of schooling, according to selected background characteristics. Kazakstan 1995 Level of education Median Background No Primary/ Secondary- years of characteristic education Secondary Special Higher Missing Total Number schooling Age 7-9 13.8 86.2 0.0 0.0 0.0 100.0 520 2.1 10-14 0.2 99.8 0.0 0.0 0.0 100.0 837 6.5 15-19 1.0 75.1 18.5 5.4 0.0 100.0 718 10.1 20-24 0.1 50.0 37.6 12.2 0.1 100.0 631 11.0 25-29 0.1 39.3 43.9 16.2 0.6 100.0 593 11.0 30-34 0.7 39.3 40.9 18.1 1.0 100.0 599 11.0 35-39 0.0 38.5 44.3 16.6 0.6 100.0 547 109 40-44 0.3 39.5 41.0 18.7 0.5 100.0 470 10.8 45-49 0.0 45.5 35.7 17.3 1.5 100.0 375 11.0 50-54 0.7 53.7 24.7 19.3 1.7 100.0 225 10.7 55-59 1.7 54.0 26.5 17.3 0.6 100.0 346 10.2 60-64 8.8 58.9 18.3 13.7 0.2 100.0 180 7.6 65+ 8.3 58.6 17.9 14.4 0.8 100.0 330 7.5 Residence Urban 1.7 49.2 30.9 17.5 0.6 100.0 2,957 10.5 Rural 2.6 68.1 22.6 6.5 0.4 100.0 3,417 10.0 Region Almaty City 1.6 455 23.0 29.6 03 100.0 329 10.8 South 2.7 63.4 22.1 11.5 0.4 100.0 2,550 10.3 West 2.0 63.4 23.8 10.7 0.0 1000 865 10.2 Central 1.6 56.9 29.4 I 1.6 0 5 1000 546 10.1 North and East 1.8 55.5 32.6 9.3 0.8 100.0 2,084 10.1 Total 2.2 59.3 26.4 11.6 0.5 100.0 6,374 10.2 To predict a general educational level of the population of the country, it is important to have information about school enrollment of the children and young people under age 24. As can be seen in Table 2.7 and Figure 2.2, 85 percent of children age 7-17 were enrolled in school, with only slight differences by residence and sex. Not everyone continues studying in secondary-special and higher educational institutions after high school. Only one in four of those age 18-20 and only one in ten of those age 21-24 are enrolled in school. As age increases, the urban-rural gap widens such that the proportion enrolled in school is more than twice in urban than in rural areas. Although women generally have slightly higher enrollment rates than men, this advantage reverses among those age 21-24. 18 Table 2.7 School enrollment Percentage of the de facto household population age 7-24 years enrolled in school, by age, sex, and residence, Kazakstan 1995 Male Female Total Age Urban Rural Total Urban Rural Total Urban Rural Total 7-17 86.4 81.4 83.4 87.2 87.1 87.1 86.8 84.2 85.2 18-20 35.5 13.3 23.4 36.7 19,9 28.1 36.1 16.5 25.8 21-24 17.2 8.5 12.1 16.0 4.1 8.8 16.6 6.3 10.4 Figure 2.2 School Enrollment by Age and Sex 100 80 60 40 20 0 Percent , . . . . . . . . . . . T . . . . . . . . . . . . . . . . . . . . . ] - 7-17 19-20 21-24 Age Group [-~ M--aie~ F--em-ffie i KDHS 1995 2.2 Housing Characteristics In order to assess the socioeconomic conditions of respondents, appropriate information on housing was collected. Table 2.8 presents the data on source of drinking water, sanitation, quality of the floor and crowding, which are important determinants of the health status of household members, particularly of children. 19 As can be seen from Table 2.8 and Figure 2.3, all households in Kazakstan are supplied with electrici- ty. That is the result of the successful policy of universal electrification that took place in the former Soviet Union. The source of drinking water usually determines its quality. Eighty-five percent of households in Kazak- stan have piped water, mostly piped into the residence. Most other households use well water. Almost all urban households use piped water (97 percent), almost all of which have the pipes inside. In rural areas, 70 percent of households have piped water, while more than one-fifth of the population uses water from wells. It is rare for people to use drinking water from tanker trucks, rivers, and other open water sources. Almost 90 percent of households in Kazakstan are within 15 minutes of the source of their water. One indicator of sanitary conditions is the type of toilet in a household. In Kazakstan, a majority of households (57 percent) have pit toilets (latrines) and 42 percent have flush toilets. In urban areas, 73 percent of households have flush toilets, while in rural areas, 96 percent have traditional pit toilets. During the interview, interviewers noted the type of material from which the floor in each household was made. As can be seen from the data, 75 percent of households have a wooden floor and 22 percent of households use linoleum. In rural areas, floors are main- ly made from wood (94 percent) and in cities, along with wood, people use linoleum (37 percent). An important indicator of housing conditions is the level of crowding, which was estimated by the num- ber of persons sleeping in one room and the average number of persons per sleeping room. Both in cities and in villages, more than 90 percent of households have between one and two persons sleeping in a room. The average number of persons per room is a little bit higher in rural areas than in urban areas (1.6 and 1.3 percent, respectively). 2.2.1 Household Durable Goods One criterion of the socioeconomic well-being of a household is ownership of various durable goods Table 2.8 Housing characteristics Percent distribution of households by housing characteristics, according to residence, Kazakstan 1995 Residence Characteristic Urban Rural Total Electricity Yes 99.9 99.9 99.9 No 0.1 0.1 0.1 Total I00.0 100.0 100.0 Source of drinking water Piped into residence 90.5 32.5 65.4 Public tap 6.4 37.0 19.6 Well in residence 1.7 11.2 5.8 Public well 0.5 I 1.8 5.4 Spring 0.0 1.0 0.4 River/stream 0.1 3.2 1.4 Pond/lake 0.0 0.3 0.1 Tanker truck 0.8 2.9 1.7 Other 0.0 0.2 0.1 Total 100.0 100.0 100.0 Time to water source (in minutes) <15 minutes 96.7 75.9 87.7 Median time to source 0.5 4.1 0.7 Sanitation facility Own flush toilet 72.8 2.4 42.3 Shared flush toilet 0.3 0.0 0.2 Traditional pit toilet 26.6 95.9 56.6 Ventilated improved pit latrine 0.2 0.0 0.1 No facility/bush 0.1 1.7 0.8 Total 100.0 100.0 100.0 Floor material Wood planks 60.5 93.9 75.0 Linoleum 36.9 3.1 22.3 Parquet/polished wood 2.0 0.6 1.4 Earth/sand 0.0 1.9 0,8 Cement 0.0 0.3 0.1 Other 0.4 O. 1 0.3 Total 100.0 100.0 100.0 Personspersleepingroom 1-2 95.2 92.4 94.0 3-4 4.3 7.0 5.5 5-6 0.5 0.3 0.4 7+ 0.0 0.3 0.1 Total 100.0 100.0 100.0 Mean persons per sleeping room Number of households 1.3 1.6 1.4 2,368 1,810 4,178 (radio, television, telephone, and refrigerator), and means of transport (bicycle, motorcycle, and private car). Presence of a radio and television set in a household is also an indicator of availability of information. 20 Figure 2.3 Housing Characteristics by Residence 100 80 60 40 20 0 Percent of Households Electricity Piped Water Flush Toilet (in residence) TOTALj KDHS 1995 Table 2.9 shows that urban households are more likely than rural households to have these durable goods, especially radios, telephones, television sets, and refrigerators. An approximately equal proportion of urban and rural households own bicycles and private vehicles. The higher proportion of rural than urban households owning a motorcycle is due to the greater need for transport in rural areas. Overall, 90 percent of households in Kazakstan have television, 82 percent have refrigerators, but only half have radios and only 38 percent have telephones. Less than one in four households owns a car. 2.3 Characteristics of Survey Respondents 2.3.1 Background Characteristics The information in this section is important for interpretation of the main results of the study. Table 2.10 presents the percent distribution of women 15-49 by age, marital status, residence, region, educational level, religion, and ethnicity. Table 2.9 Household durable goods Percentage of households possessing various durable consumer goods, by residence, Kazakstan 1995 Residence Durable goods Urban Rural Total Radio 62.0 36.9 51.1 Television 92.7 85.6 89.6 Telephone 48.9 22.6 37.5 Refrigerator 92.4 69.3 82.4 Bicycle 17.7 16.7 17.3 Motorcycle 7.0 15.9 10.9 Private car 24.0 21.3 22.9 None of the above 1.7 6.2 3.7 Number of households 2,368 1,810 4,178 To obtain the exact age of the women, the KDHS questionnaire included two questions: "In what month and year were you born?" and "How old are you?" To these questions special attention was given during the training of the interviewers. Interviewers learned how to use probing techniques for situations in which respondents did not know their date of birth. 21 Table 2.10 Background characteristics of respondents Percent distribution of women 15-49 by selected background characteristics, Kazakstan 1995 Number of women Background Weighted Un- characteristic percent Weighted weighted Age 15-19 17.7 669 660 20-24 15.0 567 586 25-29 13.8 521 530 30-34 14.8 557 558 35-39 14.9 564 562 40-44 14.3 537 505 45-49 9.4 355 370 Marital status Never married 23.5 885 912 Married 64.0 2,413 2,371 Living together 2.5 94 86 Widowed 2.9 108 115 Divorced 5.4 204 221 Not living together 1.8 67 66 Residence Urban 56.6 2,133 2,056 Rural 43.4 1,638 1,715 Region Almaty City 7.2 271 615 South 32.0 1,206 920 West 12.7 477 830 Central 9.5 358 726 North and East 38.7 1,458 680 Education Primary/secondary 36.6 1,380 1,397 Secondary-special 45.6 1,721 1,630 Higher 17.8 670 744 Respondent still in school Yes 11.9 449 455 No 88.1 3,322 3,316 Religion Muslim 50.8 1,914 2,106 Christian 32.8 1,238 1,110 Other 1.3 51 41 Not religious 13.2 499 455 Don't know 1.8 69 59 Ethnicity Kazak 45.0 1,696 1.937 Russian 34.7 1.309 1.178 Ukrainian 3.8 141 120 German 3.8 142 116 Byelorussian 0.9 35 28 Tatar 1.6 61 68 Uzbek 1.1 42 28 Other 9.1 344 296 Total 100.0 3,771 3,771 As shown in Table 2.10, female respondents are rather equally distributed by age groups, except for a smaller proportion at age 45-49. The majority of the women are married or l iving with a man (67 percent), but there is also a significant proportion of never-married women (24 percent), and widowed, divorced, or separated women (10 percent). More than half of women 15-49 live in urban areas (57 percent). More than 70 percent of the respondents live in the South and the North and East Regions. All women 15-49 have at least some education and 63 percent have secondary-special or higher education. Twelve percent are still in school. 22 More than half of the female respondents are Muslim, while one-third are Christian. There are a significant number of women (13 percent) who are not religious. The ethnic structure of the respondents basically represents two large ethnic groups: Kazaks (45 percent) and Russians (35 percent). Table 2.11 shows the distribution of women 15-49 by ethnicity, religion, and residence according to region. It shows that the South, West and Central Regions have a higher than average concentration of Kazaks, while Russians make up a majority of the respondents in Almaty city and the North and East Region. Similarly, Muslims tend to be concentrated in the South, West and Central Regions, while Christians are concentrated in Almaty City and the North and East Region. Table 2.11 Ethnicity, religion and residence by region Percent distribution of women 15-49 by ethnicity, religion and residence, according to region, Kazakstan 1995 Region North Background Almaty and characteristic City South West Central East Total Ethnicity Kazak 25.7 67.5 69.0 53.5 20.0 45,0 Russian 55.6 12.2 21.0 30.9 54.9 34.7 Ukrainian 3.9 0.3 2.9 2.9 7.1 3.8 German 1.6 0.6 1.3 5.2 7.2 3.8 Byelorussian 0.3 0.1 0.7 1.0 1.8 0.9 Tatar 2.3 0.8 1.4 3.8 1.7 1.6 Uzbek 0.5 3.1 0.0 0.0 0.3 1.1 Other 10.1 15.4 3.7 2.7 7.1 9.1 Religion Muslim 30.7 83.0 69.6 51.7 21,4 50.8 Christian 49.1 12.1 24.0 26.0 51.5 32.8 Other 1.5 0.9 0.2 1.3 2.1 1.3 Not religious 16.9 3.7 5.6 18.7 21,6 13.2 Don't know 1,8 0.4 0.6 2.3 3.3 1.8 Residence Urban 100,0 41.6 55.7 55.9 61.3 56.6 Rural 0.0 58.4 44.3 44.1 38.7 43.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 271 1,206 477 358 1,458 3,771 2.3.2 Educational Level of the Respondents Table 2.12 shows the percent distribution of women by the highest level of education attended, according to background characteristics. As will be seen later in the report, differences in the reproductive health of the women in many respects are related to differences in the level of education. Thirty-seven percent of respondents have attended primary/secondary schools, 46 percent have attended secondary-special schools, and 18 percent have reached higher education schools. Women age 25- 44 tend to have more education than younger or older women. There are significant differences in education between urban and rural areas and between regions. The proportion of respondents with higher education in 23 Table 2.12 Level of education Percent distribution of women by the highest level of education attended, according to selected background characteristics, Kazakstan 1995 Highest level of education Number Background Primary/ Secondary- of characteristic Secondary special Higher Total women Age 15-19 63.5 28.6 7.9 100.0 669 20-24 35.5 49.5 15.0 100.0 567 25-29 22.3 50.9 26.7 100.0 521 30-34 27.2 52.0 20.8 1 (30.0 557 35-39 32.2 48.4 19.3 100.0 564 40-44 30.5 50.6 18.9 100.0 537 45-49 39.5 41.7 18.7 100.0 355 Residence Urban 27.9 48.3 23.8 100.0 2,133 Rural 48.0 42.1 9.9 100.0 1,638 Region Almaty City 25.9 33.3 40.8 100.0 271 South 45.7 40.1 14.2 100.0 1,206 West 41.5 42.4 16.1 l (30.0 477 Central 31.2 50.0 18.7 100.0 358 North and East 30.8 52.5 16.7 100.0 1,458 Ethnicity Kazak 39. I 40.2 20.6 100.0 1,696 Russian 27.4 54.4 18.2 100.0 1,309 Other 46.8 42.5 10.7 100.0 766 Total 36.6 45.6 17.8 100.0 3,771 urban areas is twice that in rural areas, and almost three times more in Almaty city than in the other regions. Russian women are more educated on average than Kazak women, with the latter more likely to have only primary/secondary education; on the other hand, Kazak women are slightly more likely than Russian women to have reached higher education. 2.3.3 School Attendance and Reasons for Leaving School Because of the apparent effect of women's education on so many demographic and health itldicators, it is interesting to analyze the reasons why women leave school. As shown in Table 2.13, 35 percent of women age 15-24 currently attend school. The main reasons for leaving school are marriage and the sufficiency of obtained education. Ten percent of the women declare that they left school in order to earn money. Women who leave school early in their education are more likely to leave to get married or to earn money or because they did not like school, compared to those who leave at a higher level of education. 24 Table 2.13 School attendance and reasons for leaving school Percent distribution of women 15 to 24 by whether attending school and reason for leaving school, according to highest level of education attended and residence, Kazakstan 1995 Educational attainment Reason for Incomplete Complete leaving school secondary secondary Higher Total TOTAL Currently attending 44.1 23.9 72.0 35.1 Got pregnant 0.7 1.0 1.1 0.9 Got married 10.2 17.6 0.8 13.6 Take care of younger children 1.2 0.8 0.3 0.9 Family need help 5.4 7.2 1.4 6.0 Need to earn money 9.2 11.1 2.2 9.5 Graduated/Enough school 6.2 16.8 20.2 14.1 Did not pass exams 2.5 7.0 0.0 4.9 Did not like school 12.4 6.0 1.9 7.4 School not accessible 3.3 0.7 0.0 1.4 Applying for school 1.1 6.2 0.0 4.0 Other 3.6 1.4 0.0 1.9 Don't know/missing 0.0 0.4 0.0 0.3 Total 100.0 100.0 100.0 100.0 Number 358 739 138 1,235 URBAN Currently attending 54.1 27.8 75.6 42.3 Got pregnant 0.0 1.4 0.4 0.9 Got married 8.1 13.5 0.0 9.9 Take care of younger children 1.5 1.7 0.0 1.4 Family need help 4.9 3.0 0.0 3.0 Need to earn money 6.3 11.4 1.9 8.5 Graduated/Enough school 7.0 18.3 19.6 15.7 Did not pass exams 2.5 7.0 0.0 4.7 Did not like school 9.8 6.1 2.5 6.4 School not accessible 0.8 0.6 0.0 0.6 Applying for school 2.3 7.0 0.0 4.7 Other 2.6 1.6 0.0 1.5 Don't know/missing 0.0 0.6 0.0 0.4 Total 100.0 100.0 100.0 100.0 Number 154 363 103 620 RURAL Currently attending 36.5 20.1 61.2 27.9 Got pregnant 1.2 0.6 3.3 0.9 Got married 11.7 21.6 3.3 17.3 Take care of younger children 1.0 0.0 1.3 0.4 Family need help 5.8 11.2 5.6 9.1 Need to earn money 11.4 10.7 3.3 10.5 Graduated/Enough school 5.6 15.3 22.2 12.5 Did not pass exams 2.5 7.1 0.0 5.2 Did not like school 14.4 5.9 0.0 8.4 School not accessible 5.3 0.8 0.0 2.2 Applying for school 0.2 5.4 0.0 3.4 Other 4.4 1.2 0.0 2.2 Don't know/missing 0.0 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 Number 204 376 35 615 25 2.3.4 Access to Mass Media During the KDHS interviews, women were questioned about the availability of mass media, which are important potential sources of disseminating awareness of certain issues, including family planning. These data facilitate the development of recommendations for drawing up programs on radio and TV, publications in the newspapers, and magazines on reproductive health, family planning, and other topics. Table 2.14 shows that 94 percent of women watch TV weekly, while 78 percent read a newspaper at least once a week. Daily radio listening is less widespread at only 40 percent. While there is little difference by age in newspaper reading and TV watching, older women listen to the radio more than younger women. Women in Almaty City have more access to all three types of mass media (63 percent) than women in the South Region (24 percent). It is notable that there is a connection between the availability of mass media and respondents' educational level; the higher the educational level, the more often women watch TV, read newspapers, and listen to the radio. Russian women are more likely than Kazak women to avail themselves of all three of these media. Table 2,14 Access to mass media Percentage of women who usually read a newspaper once a week, watch television once a week, or listen to radio daily, by selected background characteristics, Kazakstan 1995 Mass media No Read Watch Listen to All Number Background mass newspaper television radio three of characteristic media weekly weekly daily media women Age 15-19 1.1 76.8 94.7 29.7 23.5 669 20-24 1.5 79.2 93.1 32.5 25.8 567 25-29 4.0 79.5 92.8 38.5 34.4 521 30-34 2.0 77.8 94.9 41.6 33.1 557 35-39 1.8 79.9 93.3 43.7 36.6 564 40-44 2.1 77.1 93.7 46.9 38.4 537 45-49 3.9 75.0 91.1 54.0 44.4 355 Residence Urban 0.8 82.6 96.3 48.3 41.6 2,133 Rural 4.0 72.0 89.9 29.0 21.3 1,638 Region Almaty City 0.5 94.1 98.2 66.7 63.4 271 South 3.9 65.8 91.7 32.3 24.0 1,206 West 2.6 84.6 90.0 38.7 32.3 477 Central 1.6 81.4 94.0 39.8 33.5 358 North and East 1.1 82.1 95.2 41.7 34.4 1,458 Education Primary/Secondary 3.8 69.2 90.6 32.7 23.7 1,380 Secondary-special 1.4 79.9 94.9 39.9 33.4 1,721 Higher 0.9 91.3 96.1 54.8 49.9 670 Ethnicity Kazak 3.1 75.6 91.0 35.8 28.3 1,696 Russian 1.4 83.6 95.4 46.5 40.0 1,309 Other 1.7 73.9 95.9 37.8 30.4 766 Total 2.2 78.0 93.5 39.9 32.8 3,771 26 2.3.5 Women's Employment Status The reproductive health of women depends to some extent on their economic status, especially their employment. The economic crisis in Kazakstan is characterized by a recession in manufacturing, the closing of a majority of enterprises, and an increase in the number of unemployed people, especially women. Table 2.15 presents information on women's employment status according to age, residence, region, educational level, and ethnicity. Overall, 47 percent of women are not currently employed and 40 percent have not been employed for the last 12 months. Unemployment is more common among younger women, those living in rural areas, those in the South, West and Central Regions, those with lower educational level, and Kazak women. Almost one-fifth of the employed women work for less than five days a week and 5 percent of the women are employed only seasonally or occasionally. Table 2.15 Employment Percent distribution of women by whether currently employed and distribution of employed women by continuity of employment, according to background characteristics, Kazakstan 1995 Not currently employed Currently employed Did not work Worked All year in last in Background 12 last 12 5+ days <5 days Season- Occasion- characteristic months months per week per week ally ally Total Number Age 15-19 75.6 6.9 8.4 2.6 4.7 1.7 100.0 669 20-24 53.2 6.1 30.6 4.2 3.7 2. l 100.0 567 25-29 46.7 5.5 37.5 5.9 3.5 0.9 100.0 521 30-34 33.1 6.2 43.3 11.9 4.1 1.4 100.0 557 35-39 25.8 41 55.5 9.1 4.3 1.2 100.0 564 40 44 15.0 6.8 60.6 11.2 4.9 1.4 100.0 537 45-49 16.7 8.5 60.5 12.3 1.7 0.3 100.0 355 Residence Urban 34.5 6.1 45.5 10.5 1.7 1.8 100.0 2,133 Rural 47.9 6.4 33.6 4.3 7.0 0.8 100.0 1,638 Region AImaty City 30.1 8.0 46.7 8.9 3.9 2.4 100.0 271 South 51.0 5.2 31.6 5.7 6.2 0.2 100.0 1,206 West 40.5 6.0 44.7 6.3 1.7 0.8 100.0 477 Central 40.9 6.5 40.7 8.2 2.7 1.0 100.0 358 North and East 33.2 6.7 44.8 9.7 3.2 2.4 100.0 1,458 Education Primary/Secondary 52.0 5.7 27.6 6.4 7.0 1.3 100.0 1,380 Secondary-special 35.0 7.1 43.9 9.8 2.8 1.4 100.0 1,721 Higher 29.9 5.2 57.3 5.5 0.8 1.3 100.0 670 Ethnicity Kazak 47.1 5.4 37.3 5.3 4.0 0.8 100.0 1,696 Russian 32.7 6.9 45.2 11.2 2.2 1.8 100.0 1,309 Other 38.4 6.8 38.5 7.4 7.0 1.9 100.0 766 Total 40.3 6.2 40.3 7.8 4.0 1.4 100.0 3,771 27 2.3.6 Employer Table 2.16 shows the percent distribution of currently employed women by type of employer, according to background characteristics. Eighty-three percent of employed women work in state enterprises. Eleven percent of women work for themselves or in enterprises owned by their relatives. This type of employment is highest for younger women, women who live in urban areas, and those who live in Almaty City. Women in Almaty City are also more likely to work in a private finn. Kazak women are more likely to work in a government enterprise, while Russian women are slightly more likely than Kazak women to work for a private finn. Table 2.16 Employer Percent distribution of currently employed women by employer, according to background characteristics, Kazakstan 1995 Employer Govern- ment or State Family, Private Background enter- own firm, Self- characteristic prise business person employed Total Number Age 15-19 69.6 7.7 4.6 18.0 100.0 117 20-24 75.3 3.2 8.0 13.5 100.0 231 25-29 82.0 2.5 6.8 8.7 100.0 250 30-34 81.2 4.0 6.0 8.9 100.0 338 35-39 80.0 3.1 8. I 8.9 100.0 395 40-44 90.4 1.0 5.3 3.3 100.0 420 45-49 88.2 2.5 6.4 2.9 100.0 265 Residence Urban 77.1 2.9 10.0 10.0 100.0 1,268 Rural 91.7 3.0 0.7 4.5 100.0 748 Region Almaty City 64.8 3.7 20.2 11.3 100.0 168 South 84.6 5.5 2.7 7.3 100.0 528 West 89.6 1.5 3.4 5.5 100.0 255 Central 88.1 1.2 5.1 5.7 100.0 188 North and East 81.5 2.0 7.5 8.9 100.0 877 Education Primary/Secondary 82.1 4.0 3.6 10.4 100.0 585 Secondary-special 82.3 2.6 7.5 7.7 I IJ0.0 996 Higher 83.8 2.3 8.4 5.4 100.0 435 Ethnicity Kazak 87.7 2.6 3.3 63 100.0 805 Russian 79.2 2.7 10.0 8.1 100.0 791 Other 78.9 3.9 6.4 10.8 100.0 420 Total 82.5 2.9 6.6 8.0 100.0 2,016 Note: Private firm/person includes 9 women who do not earn cash. 28 2.3.7 Occupation Kazakstan is mainly an agrarian country. However, only 10 percent of employed women work in agriculture (Table 2.17) and the majority of them work on state land. Women in the South Region are more likely to be working in agriculture, either on state land, or on their own or rented land. A higher proportion of less educated women work in agriculture, compared to better educated women. Ninety percent of employed women are not engaged in agriculture. Almost half work in professional, technical, and managerial occupations; 20 percent in sales and trade; and 21 percent in manual labor. These parameters differ by age, residence, region, and respondent's ethnicity. Significant differences are also seen by educational level--women with higher education are engaged mainly in professional and technical fields, with few employed in manual labor. Table 2.17 Occupation Percent distribution of currently employed women by occupation and type of agricultural land worked or type of nonagricultural employment, according to background characteristics, Kazakstan 1995 Agricultural Nonagricultural Prof./ Background Own Family Rented State tech./ Sales/ Skilled Unskilled Other/ characteristic land land land land manag, services manual manual Missing Total Number Age 15-19 0.0 1.0 3.3 11.6 25.8 34.6 10.7 12.6 0.4 100.0 117 20-24 0.0 0.0 2.0 5.5 47.1 22.7 9.6 12.8 0.2 100.0 231 25-29 0.0 0.0 3.2 5.0 55.0 20.3 8.1 8.4 0.0 100.0 250 30-34 1.1 0.0 0.8 7.5 52.2 20,3 9.2 8.8 0.0 100.0 338 35-39 0.4 0.1 1.4 8.9 45.0 19.1 11.3 13.7 0.0 100.0 395 40-44 0.0 0.0 0.4 I1.1 49.9 18.5 9.8 10.3 0.0 100.0 420 45-49 0.2 0.0 0.4 6.7 52.6 14,9 I 1.4 13.9 0.0 100.0 265 Residence Urban 0.2 0.0 0,2 0.3 53.0 23.5 13.1 9.6 0.0 100.0 1,268 Rural 0.5 0.2 3.4 21.3 41.1 14.3 4.8 14.5 0.0 100.0 748 Region Almaty City 0.3 0.3 0.3 0.3 51.4 28.6 10.5 8.1 0.3 100.0 168 South 1.0 0.2 5.0 12.1 49.3 15,4 6.7 10.4 0.0 100.0 528 West 0.2 0.0 0.2 4.9 50.8 15.7 12.2 16.0 0.0 100.0 255 Central 0.0 0.0 0.0 3.5 53.8 16.3 12.1 14.0 0.3 100.0 188 North and East 0.0 0.0 0,0 9.2 45.9 23.3 10.9 10.7 0.0 100.0 877 Education Primary/Secondary 1.0 0.2 3.2 16.4 20.2 22.6 12.5 23.9 0.0 1130.0 585 Secondary-special 0.0 0.0 0.9 6.6 50.3 22.2 11.4 8.5 0.1 100.0 996 Higher 0.0 0.0 0.0 0.5 82.9 11.9 3.5 1.1 0.1 100.0 435 Ethnlelty Kazak 0.1 0.1 1.5 9.6 55.8 14.3 7.0 11.5 0.2 100.0 805 Russian 0.0 0.0 0.2 3.8 49.5 21.6 13.5 11.4 0.0 100.0 791 Other 1.3 0.1 3.4 13.4 33.1 28.5 9.3 11.0 0.0 100.0 420 Total 0.3 0.1 1.4 8.1 48.6 20.1 10.0 11.4 0.0 100.0 2,016 Note: Professional, technical, managerial includes professional, technical, clerical and managerial occupations. 29 2.3.8 Decisions on Use of Earnings When the socioeconomic status of women is being assessed, their independence in making decisions on the use of their earnings is a valuable indicator. Table 2.18 shows that almost 45 percent of employed women make their own decisions on the use of their earnings, while 42 percent decide together with their husband or partner, and 9 percent make decisions jointly with someone other than a husband. Only 2 percent of women report that their husbands alone decide how to spend their wives' earnings. Independent decision making on use of earnings tends to be higher among women in urban areas, especially Almaty City, and among women who are not married. Table 2.18 Decision on use of earnings Percent distribution of women receiving cash earnings by person who decides on use of earnings, according to background characteristics, Kazakstan 1995 Person who decides how earnings are used Jointly with Jointly Background Self Husband/ husband/ Someone with characteristic only partner partner else someone Total Number Age 15-19 36.7 0.0 13.5 15.0 34.8 100.0 115 20-24 46.3 0.9 23.1 5.5 24.2 100.0 230 25-29 36.9 3.5 44.0 1.7 13.8 100.0 250 30-34 45.3 2.7 44.8 1.5 5.7 100.0 336 35-39 46.9 1.7 47.6 0.2 3.6 100.0 393 40-44 44.3 1.8 50.3 0.1 3.5 100.0 420 45-49 50.2 1.6 43.6 0.4 4.1 100.0 264 Residence Urban 48.3 2.1 40.4 1.0 8.2 100.0 1,263 Rural 38.4 1.6 44.6 3.8 11.6 100.0 744 Region Almaty City 50.4 2.9 35.7 2.4 8.7 100.0 168 South 37.6 2.2 47.6 4.4 8.3 100.0 525 West 45.6 2.0 38.0 2.7 I 1.7 100.0 251 Central 50.1 1.1 40.6 0.5 7.7 100.0 186 North and East 46.3 1.7 41.2 0.7 10.0 100.0 877 Education Primary/Secondary 42.0 1.8 39.1 3.6 13.5 100.0 580 Secondary-special 48.3 2.1 42.3 1.3 6.0 100.0 992 Higher 39.8 1.8 44.8 1.7 11.9 100.0 435 Ethnicity Kazak 43.2 2.1 42.5 2.6 9.7 100.0 799 Russian 45.5 1.5 44.5 1.0 7.4 100.0 789 Other 45.7 2.4 36.1 3.0 12.8 100.0 420 Marital status Not married 67.2 0.0 03 4.8 27.8 100.0 592 Currently married 35.2 2.7 59.4 0.9 1.7 100.0 1,414 2,007 Total 44.6 1.9 41.9 2.1 9.4 100.0 2.3.9 Child Care While Working Preschool age children in the family pose employment obstacles, since child care requires significant time and appropriate conditions. When child care is provided completely by the mother, her work possibilities are limited. 30 As Table 2.19 shows, less than one-fourth of employed women have a child under age six at home. It is notable that the likelihood of a working woman having a child under six years is greater in rural areas (32 percent), the South Region (30 percent) and among Kazaks (31 percent). Among employed women with young children, only 7 percent care for the children themselves, 7 percent are cared for by the husband or partner, and 28 percent are cared for by relatives. One-third of employed women with young children use preschool child care institutions despite the mass shutdown during recent years. Use of institutional child care is greatest in urban areas (47 percent), the North and East Region (43 percent), and among Russian women (48 percent). When other children are used as child care providers, the caretaker is much more likely to be a sister (10 percent) than a brother (4 percent). The role of other people (neighbors, servants) in providing child care is insignificant. Table 2.19 Child care while working Percent distribution o f currently employed women by whether they have a child under six years of age, and the percent distribution of employed mothers who have a child under six at home by person who cares for child while mother is at work, according to background characteristics, Kazakstan 1995 Background characteristic Employed women with: Child's caretaker while mother is at work One or more No chil- child dren Hus* Serv- Child Not Number under under Re- band/ Other ants/ Institu- Other Other lives worked of six at six at spond- part- rela- Neigh- Hired tional female male else- since employed home home ent aer tire bor help care child child where birth I Other Total women Residence Urban 80.8 19.2 4.7 8.2 22.7 1.9 I1 46.8 4.6 2.7 1.2 5.9 0.2 100.0 1,268 Rural 68.3 31.7 10.2 5.8 32,4 0.2 00 18.6 16.3 4.6 0.7 8.7 2.6 100.0 748 Education No education 75.4 24.6 13,6 6.9 25.0 1.6 0.0 24.5 15.4 5,9 0.0 5.8 1.3 10~.0 585 Primary 76,9 23.1 5.1 5.4 28,7 1.2 1.0 35.1 9.4 2.7 1.6 8.8 I,I 10~.0 996 Secondary+ 75.6 24.4 4.0 10.8 28,3 0.0 0,4 39.3 5.7 2.5 0.8 6.0 2.3 10~.0 435 Work status For family member 74,5 25.5 0.0 13.0 36.8 0.0 0.0 14.3 22.5 7.5 5.9 0.0 0.0 100,0 59 For someone else 87.9 12.1 0.0 13.4 21.4 0.0 2.8 56.2 0.0 3.5 2.8 0.0 0.0 100.0 132 Self-employed 66,7 33.3 21.2 10.1 32.6 0.0 0.0 26.4 2.5 0.8 0.0 6.4 0.0 100,0 160 Region Almaty City 84.3 15.7 0.0 6.7 41.7 0.0 1.7 36.7 1.7 3.3 8.3 0.0 0.0 100.0 168 South 69.7 30.3 10,2 5.3 29.6 0.0 0.0 18.8 13.1 3,9 0.7 18.4 0.0 100.0 528 West 72.7 27.3 4,2 5.5 28.7 0.0 0.0 37.6 10.4 3,7 17 3.3 4.9 100.0 255 Central 75.4 24.6 8.3 10.7 28,7 09 00 31.7 11.3 3.3 0,0 2.1 3.1 100.0 188 North and East 79.7 20.3 7.0 8.2 227 2.6 1,3 43.4 9.0 3.5 0.0 1.3 I I 100.0 877 Ethnicity Kazak 69,2 30.8 4.9 7.7 28.7 0.2 1.1 26.1 I 1.2 4.1 1.5 12.0 2.5 100.0 805 Russian 81.0 19.0 6.2 6.9 21.5 30 00 48.0 7.9 3.1 0.3 2.7 0,4 100.0 791 Other 80.4 19.6 17.1 5.3 34.8 00 0,0 25.4 12.3 3.2 0.5 1,4 0.0 100.0 420 Occupation Agricuhural 65.5 34.5 13.7 7.0 31.6 0.0 0.0 5.3 25.7 4.5 1.6 9,9 0.6 100.0 199 Nonagricultural 77.3 22.7 6,3 7.0 26.8 1.2 0.7 37.5 7.8 3.5 0.8 6.8 1.5 100.0 1,817 Employment status All year, full week 77.0 23.0 4.9 6.4 27.9 1.4 0,1 36.0 10.2 3.0 0.9 7,6 1.5 100.0 1,520 All year, part week 77.1 22.9 6.8 13.3 21.4 0,0 3.4 31.4 10.7 6.6 0.7 5.1 0.7 100.0 294 Seasonal 67.7 32.3 12.6 4.1 34.8 0.0 0.0 17,1 12.5 5.0 1.8 10.3 1.8 100,0 150 Occasional 72.4 27,6 53.6 3.1 22.4 0.0 0.0 16.1 4.8 0.0 0.0 0.0 0.0 100.0 521 Total 76.2 23.8 7.4 7.0 27.5 1.0 0.6 32.9 10.4 3.6 0.9 7.3 1.4 100.0 2,016 Note: Totals include 1 woman with occupation missing. Figures may not add to 100.0 due to rounding. I Respondent was employed but had not actually worked since the birth; therefore, current caretaker status is not applicable. 31 CHAPTER 3 FERTILITY Vassily N. Devyatko and Kia I. Weinstein A complete pregnancy history was collected from each woman interviewed in the 1995 KDHS. To encourage complete reporting of all pregnancies, respondents were asked separate questions about pregnancies that resulted in live births, induced abortions (including mini-abortions), miscarriages, and stillbirths. Accounting of live births was achieved by asking separately about the number of sons and daughters living with the respondent, the number living elsewhere, and the number who had died. To encourage complete reporting of all pregnancies, all pregnancy intervals of four or more years in duration were additionally probed for intervening pregnancies. The pregnancy history was collected in reverse chronological order from the most recent to the first pregnancy. Pregnancy outcome (live birth, abortion, miscarriage, or stillbirth) and date (month and year) of termination was recorded for each pregnancy. For each live birth, sex of child, survival status, and age (for living children) or age at death (for dead children) were also collected. This chapter presents the findings pertaining to live births. Because ethnicity is a major determinant of fertility in Kazakstan, fertility data are shown separately for ethnic Kazaks and ethnic Russians, in addition to overall rates for all of Kazakstan. Chapter 5 presents the findings pertaining to pregnancy loss. 3.1 Current Fertility Table 3.1 and Figure 3.1 present age-specific fertility rates for the three-year period preceding the survey (mid- 1992 to mid- 1995).~ Rates are expressed per 1,000 women. The sum of the age-specific rates, known as the total fertility rate (TFR), is used to summarize the current level of fertility. The TFR is interpreted as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed age-specific rates. Two other summary measures are presented in Table 3.1, the general fertility rate (GFR), and the crude birth rate (CBR). The GFR represents the annual number of births in the population per 1,000 women age 15-44. The crude birth rate (CBR) is the annual number of births in the population per 1,000 population. The latter two measures are calculated from the birth history data for the three-year period preceding the survey, and the age and sex distribution of the household population. Fertility among urban women is lower than among rural women throughout all the childbearing years, resulting in a TFR among urban women that is one child lower than among rural women. If fertility were to remain constant at current levels, a Kazakstan woman would give birth to an average of 2.5 children; urban women would have 2.0 children, while rural women would have 3.1 children. The peak childbearing years for both urban and rural women are during the early twenties (age 20-24). Numerators for age-specific fertility rates are calculated by summing the number of live births which occurred in the 1-36 months preceding the survey (determined from the date of interview and birth date of the child), and classifying them by age (in five-year groups) of the mother at the time of birth (determined from the birth date of the mother). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. 33 Table 3.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by residence and ethnicity, Kazakstan 1995 Residence Ethnicity Age Urban Rural Kazak Russian Other Total 15-19 51 78 37 97 79 64 20-24 145 235 229 125 174 190 25-29 132 140 180 73 131 136 30-34 46 92 100 27 55 67 35-39 22 56 60 15 26 35 40-44 4 11 14 1 5 7 45-49 0 0 0 0 (0) 0 TFR 15-49 2.00 3.06 3.11 1.69 (2.35) 2.49 TFR 15-44 2.00 3.06 3.11 1.69 2.35 2.49 GFR 62 109 109 52 76 83 CBR 15 24 19 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. TFR: Total fertility rate, expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Figure 31 Age-specific Fertility Rates by Ethnicity Births per l,OOO Women 250 200 150 100 sot/ i 0 ! . . . . • 15-19 20-24 i l 25-29 30-34 Age Group I÷Totai ~Kazak ÷RussianJ 351_39 40~14 KDHS 1995 34 Ethnic Kazaks and ethnic Russians both experience their peak childbearing years during their early twenties. However, ethnic Kazaks achieve a TFR that is higher (3.1 children per woman) than the overall TFR, and ethnic Russians a TFR that is lower (1.7 children per woman). No respondents age 45-49 report having a live birth in the previous three years. Table 3.2 and Figure 3.2 present TFRs for the three years preceding the sur- vey by background characteristics. It can be seen that regional variation in fertility is substantial, varying by as much as two chil- dren. The TFR is lowest among women in Almaty city (1.5 children per woman) and the North and East Region (1.8), interme- diate in the West and Central Regions (both 2.7) and highest in the South Region (3.4). Women in Kazakstan exhibit a childbearing pattern, observed in many societies, of decreasing fertility with in- creasing education. The TFR declines from 2.9 children per woman among women with primary or secondary schooling to 2.4 among women with secondary-special schooling and then down to 2.0 children per woman among those with higher education. Trends in fertility can be inferred by comparing the TFR (a measure of cur- rent fertility) with the mean number of chil- dren ever born (CEB) to women age 40-49 (a measure of completed fertility). If there had been no change in fertility for three or more decades prior to the survey, the TFR Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage currently pregnant and mean number of children ever born to women age 40-49, by selected background characteristics, Kazakstan 1995 Mean number of children Total Percentage ever born Background fertility currently, to women characteristic rate I pregnant I age 40-49 Residence Urban 2.00 2.21 2.46 Rural 3.06 5.81 4.36 Region Almaty City ( 1.45) 1.46 1.94 South (3.44) 5.47 4.27 West (2.69) 4.40 3.42 Central (2.69) 3.24 3.17 North and East (1.76) 2.73 2.54 Education Primary/Secondary 2.93 3.69 4.09 Secondary-special 2.38 3.75 2.77 Higher (1.99) 4.01 2.21 Ethnicity Kazak 3.11 4.82 4.21 Russian 1.69 2.42 2.25 Other (2.35) 3.77 2.95 Total 2.49 3.77 3.11 Note: Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. 1 Women age 15-49 years and CEB would be nearly the same. The fact that the "I'I~R (2.5 children per woman) is lower than the CEB (3.1) indicates that fertility has declined in Kazakstan over the past three decades. The TFR is lower than the CEB among both urban and rural women, and in every region, education level, and ethnicity. Table 3.2 also presents the percent of women who report themselves to be currently pregnant. Because women at early stages of pregnancy may not yet know they are pregnant, this proportion may be underestimated. Percentages are generally low, commensurate with fertility that is overall relatively low. The percent of women pregnant generally exhibits the same patterns by background characteristics as the TFR. Women with higher education are the one exception; unlike their fertility level, they exhibit the highest percentage pregnant. 35 Figure 3.2 Total Fertility Rate by Background Characteristics KAZAKSTAN RESIDENCE Urban Rural EDUCATION Pnma~ISeconda~ Secondanj-special Higher ETHNICITY Kazak Russian Other REGION Almaty City South West Central 2.5 "i//////////////////////IJded/~/////I/////ll///////~ 20 " i l l / l l l l l l l l l l l l l l / l l l l l~) ' / / I / - i l l / / l l / / l l~/ l l l l~// l l l / / l l l l l l l l l l l l l~ 31 2 ~\ \ \ \ \ \~ ,~\ \ \ \ \ \ \ \ \ '~ 3.1 ~\ \ \ \ \ \ \ \ \ \ \ \ \ \~ \ \~ 23 34 .~,~, 2.7 ~ ' ~ 2.7 North and East ~ 18 O0 10 2.0 30 40 50 Births per Woman 60 KDHS 1995 3.2 Fertil ity Trends The most direct way of observing fertility trends is to examine changes in age-specific rates over time. Table 3.3 compares age-specific fertility rates (ASFRs) from the KDHS (which were shown in Table 3.1) with ASFRs reported in the 1989 Census. The data provide evidence of declines in fertility among women of all age groups, with the exception of 15-19 year olds, and among both ethnic Kazaks and ethnic Russians. The decline in ASFRs results in an overall decline of the TFR from 3.6 to 3.1 among ethnic Kazaks, and 2.2 to 1.7 among ethnic Russians. The TFR for all of Kazakstan declines from 2.9 to 2.5. Figure 3.3 shows the decline in ASFRs for all Kazakstan. 36 Table 3.3 Trends in fertility Age-specific fertility rates and total fertility rates, 1989 Census and 1995 KDHS Kazak Russian Total I Age of Census KDHS Census KDHS Census KDHS woman 1989 1995 1989 1995 1989 1995 15-19 31 37 59 97 45 64 20-24 232 229 182 125 215 190 25-29 208 180 110 73 159 136 30-34 140 1(30 63 27 96 67 35-39 76 60 27 15 45 35 40-44 27 14 7 1 14 7 45-49 3 0 0 0 1 0 Total fertility rate 3.58 3.11 2.24 1,69 2.88 2.49 Note: Single-year period rates are used for the Census; three-year period rates are used for the KDHS. I Includes Kazak, Russian, and other ethnic groups. Figure 3.3 Trends in Age-specific Fertility Rates 1989 Census and 1995 KDHS 250 Births per 1,O0O Women 200 150 100 50 15-19 20-24 25-29 35-34 35-39 40-44 Age group [ !1989 Census ,.~-1995 KDHS 1 45-49 37 Evidence of a recent decline in fertility is also supported by the ASFRs calculated over time from the KDHS data. Table 3.4 presents age-specific fertility rates for five-year periods preceding the survey using data on live births from respondents' pregnancy histories. 2 The decline is steadily greater with increasing age, a pattern indicative of increasing fertility control. The decline from 5-9 to 0-4 years prior to the survey steadily increases from a 5 percent decline among 20-24 year-olds to a 41 percent decline among 35.-39 year- olds. Unlike women of other ages, 15-19 year-olds actually show an increase in fertility over time. Table 3.5 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. The decline in fertility has occurred at all marital durations; however, the decline is greatest among women of longer marital durations. Fertility within the first several years of marriage typically remains less resistant to change, even when fertility is declining, because fertility decline usually begins among older women who want to stop their childbearing and not by young couples postponing births. Table 3.5 shows dramatic declines in fertility for all marital durations of five or more years. Table 3.4 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of birth, Kazakstan 1995 Number of years preceding the survey Mother's age 0-4 5-9 10-14 15-19 15-19 65 45 40 38 20-24 202 212 197 226 25-29 141 173 178 180 30-34 74 97 123 [151] 35-39 33 56 [60] 40-44 7 [16] 45-49 [0] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 3.3 Children Ever Born and Living Table 3.5 Trends in fertility by marital duration Fertility rates for ever-married women by duration (years) since first marriage for five-year periods preceding the survey, Kazakstan 1995 Marriage duration at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 0-4 312 320 313 336 5-9 113 156 160 179 10-14 59 86 102 142 15-19 20 52 94 * 20-24 7 35 * 25-29 3 * Note: Duration-specific fertility rates are per 1,000 women. An asterisk indicates that a rate is based on fewer than 125 unweighted years of exposure and has been suppressed. Table 3.6 presents the distribution of all women and currently married women by number of children ever born. Fifty-six percent of 20-24 year-olds have had one or more children. The modal number of children among all women age 25 and above is two. Thirty-five percent of women age 45-49 have had four or more children. The greatest difference between the data for currently married women and the total sample occurs among young women, due to the large number of unmarried young women with minimal fertility. Differences at older ages reflect the generally fertility-reducing impact of marital dissolution (divorce or widowhood). The table also shows the mean number of children ever born and the mean number surviving by five- year age group of the mother. On average, women in their early twenties have had 0.8 children, women in their early thirties have had 2 children, and women in their early forties have had 3 children. 2 The rates for the older age groups (shown in brackets in Table 3.4) represent partial fertility rates due to truncation. Women 50 years of age and older were not included in the survey, and the further back into time that the rates are calculated, the more severe is the truncation. For example, rates cannot be calculated for women age 40-44 for the period 10-14 years before the survey because these women would have been over age 50 years at the t ime of the survey and thus were not interviewed. 38 Table 3.6 Children ever born and l iv ing Percent distribution of all women and of currently married women age 15-49 by number of children ever born (CEB) and mean number ever born and l iving, according to five-year age groups, Kazakstan 1995 Number of children ever born (CEB) Number Mean no. Mean no. Age of of of living group 0 I 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN 15-19 93.2 6.1 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 669 0.07 0.07 20-24 44.2 3%9 14.5 2.9 0.6 0.0 0.0 0.0 0.0 0.0 0.0 100.0 567 0.78 0.75 25-29 17.1 28.7 37.3 11.6 4.4 0.5 0.3 0.0 0.0 0.0 0.0 100.0 521 1.60 1.52 30-34 7.4 18.2 41.1 18.3 8.6 4.8 1.1 0.4 0.0 00 0.0 100.0 557 2.23 2.14 35-39 6.8 13.2 36.1 18.2 12.6 6.5 4.0 2.1 0.4 0.1 0.0 100.0 564 2.65 2.50 40-44 5.0 9.9 378 18.4 9.4 9.5 4.6 2.6 1.7 04 0.7 100.0 537 2.96 2.79 45-49 4.6 12.5 32.2 16.2 9.5 5.8 7.1 5.1 4.1 0.4 2.5 100.0 355 3.35 3.07 Total 28.8 18.0 27.3 11.6 6.1 3.7 2.1 1.2 0.7 0.1 0.3 100.0 3,771 1.82 1.71 CURRENTLY MARRIED WOMEN 15-19 50.1 44.6 5.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 80 0.55 0.54 20-24 18.8 54.8 21.9 3.6 1.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 347 1.13 1.09 25-29 6.3 30.5 42.6 14.1 5.4 0.6 0.4 0.0 0.0 0.0 0.0 100.0 425 1.85 1.76 30-34 2.1 14.9 44.9 20.8 10.1 5.3 1.4 0.5 0.0 0.0 0.0 1130.0 458 2.46 2.36 35-39 3.2 9.5 39.1 20.4 135 7.0 4.4 2.3 0.4 0.1 0.0 100.0 482 2.85 2.70 40-44 1.6 7.6 404 19.1 10.3 11.0 4.9 2.6 1.6 0.5 0.5 100.0 447 3.11 2.91 45-49 1.0 11.0 30.4 17.1 11.0 7.3 7.9 6.3 44 0.4 3.3 100.0 268 3.70 3.40 Total 6.7 21.3 36.6 15.8 8.5 5.1 2.9 1.7 0.8 0.1 0.4 100.0 2,507 2.43 2.30 A cursory view of the survival status of children can be made by comparing the mean number of children ever born to the mean number surviving. Eight percent of children born to women age 45-49 at the time of the survey had not survived. The proportion of children surviving gradually increases among younger women. This may not only be due to shorter exposure to risk among children of younger women, but also due to improved mortality conditions. Overall, of all children born, 94 percent had survived to the time of the survey. 3.4 Birth Intervals The length of birth intervals is an important component of childbearing. Research has shown that children born too close to a previous birth have an increased risk of dying, especially when the interval between births is less than 24 months. Table 3.7 presents the percent distribution of second- and higher-order births in the five years prior to the survey by the number of months since the previous birth. Overall, one- third of births (34 percent) were born within 24 months of the previous birth. The median birth interval length is 32 months or about 2.6 years. The length of birth intervals by region mimics the pattern of fertility; regions with the highest fertility have the shortest birth intervals. In the lowest fertility regions of Almaty city and the North and East Region, birth intervals are the longest, with median lengths of 40 and 41 months, respectively. The West and Central Regions, which have intermediate levels of fertility, both have median birth intervals of 34 months. Women in the South, who have the highest level of fertility, also have the shortest birth intervals. The median length is 27 months; 39 percent of non-first births in the South were born within 24 months of the previous birth. Birth intervals are significantly longer among births to Russian mothers (median interval length of 44 months) than among births to Kazak mothers (median interval length of 28 months). Thirty-nine percent 39 Table 3.7 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Kazakstan 1995 Number of months since previous birth Characteristic 7 17 [ 8-23 24-35 36-47 48+ Total Median number of Number months since of previous birth births Age of mother 15 19 * * * * * 100.0 * 4 20 29 230 23.6 27.9 13.0 12.5 100.0 24.8 414 30-39 11.5 I 1.6 19.6 155 41.7 100.0 40.6 391 40 + 0.0 8.6 14.8 6.3 703 100.0 i 45 Birth order 2 3 18.1 18.6 22.0 13.9 27.5 100.0 30.7 611 4-6 13.8 15.5 24.8 13.2 32.6 100.0 33.2 220 7+ (0.0) (11.1) (43.2) 115.7) (30.0) 100.0 (336) 22 Sex of prior birth Male 17,6 18.2 22.2 13.3 28.7 100.0 31.0 447 Female 15.4 16.9 24.5 14.2 29.0 100.0 32.2 406 Survival of prior birth Living 154 17.6 22.9 14.2 29.9 100.0 32.1 800 Dead 33.1 17.6 29.4 68 13 I 10031 23.9 53 Residence Urban 12.4 13 3 23.1 12.6 38.7 100.0 38.6 322 Rural 19.0 20.2 23.4 14.4 22.9 100.0 28.7 532 Region Almaty City 86 20.0 18.6 8.6 44.3 100.0 40.0 31 South 18.9 20.1 28.1 11.7 21.1 100.0 26.6 423 West 12.4 19.0 22.2 16.9 29.5 100.0 34.4 119 Central 15.1 17.3 20.3 122 35.1 100.0 33.9 79 Norlh and East 15.7 I 1.2 15.6 17.5 40.1 100.0 41.4 201 Education Primary/Secondary [ 6 7 20.4 25.9 11.6 25.3 100.1/ 29.6 339 Secondary-special 179 159 20.9 16.4 291) 100.0 32.5 391 Higher 118 15.2 238 111.9 38.3 100.0 34.6 123 Ethnicity Kazak 17.7 20.9 23.8 13.5 24.1 100.0 28.0 556 Russian 16.3 5.3 16.5 233 38.7 100.0 43.8 146 Other 12.3 17.3 27.8 5.5 37.1 100.0 33.3 151 Total 16.5 17.6 23.3 13.7 28.9 100.0 31.6 853 Note: First births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in ~arentheses are based on 25-49 unweighted cases. Median number is more than 48 months. of births to Kazak mothers were born within 24 months of the previous birth while 22 percent of births to Russian women were born within 24 months of the previous birth. Urban and rural women also exhibit significant differentials in birth intervals. Births to urban women have a median interval length of 39 months while births to rural women have a median interval length of 29 months. 3.5 Age at First Birth The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. Early initiation into childbearing is generally associated with large family size and rapid population growth when family planning is not widely practiced. 40 Table 3.8 presents the percent distribution of women by age at first birth according to current age. Initiation into childbearing has a relatively narrow age range in Kazakstan, and the age at which women begin childbearing has not changed significantly over time. One exception seems to be that 20-24 year-olds are beginning childbearing at younger ages than women have in the past. Nearly one-third of the 20-24 year-olds have had a birth by age 20. Table 3.8 Age at first birth Percent distribution of women 15-49 by age at first birth, according to current age, Kazakstan 1995 Current 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 93.2 0.0 3.5 3.3 NA NA NA 100.0 669 a 20-24 44.2 0.0 6.5 22.8 18.0 8.5 NA 100.0 567 a 25-29 17.1 0.1 3.3 14.4 25.5 30.4 9.1 I00.0 521 22.5 30-34 7.4 0.0 4.1 14.1 27.3 30.4 16.8 100.0 557 22.4 35-39 6.8 0.0 2.2 15.1 29.8 25.7 20.4 100.0 564 22.2 40-44 5.0 0.0 3.4 12.7 33.5 27.6 17.8 100.0 537 22.0 45-49 4.6 0.0 7.9 16.4 23.8 28.9 18.4 100.0 355 22.1 NA = Not applicable a Omitted because less than 50 percent of the women in the age group x to x+4 have had a birth by age x Table 3.9 presents the median age at first birth for cohorts age 25 and above across background characteristics. The median age at first birth hovers around age 22 for all age cohorts. The greatest differentials are by education; the median age increases by two to three years with increasing education. Table 3.9 Median age at first birth Median age at first birth among women age 25-49 years, by current age and selected background characteristics, Kazakstan 1995 Current age Background Ages characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 22.3 22.7 22.4 22.6 22.5 22.4 Rural 22.8 22.3 21.9 21.5 21.6 22.1 Region Almaty City 22.8 23.2 23.4 23.1 23.3 23.1 South 22.7 23.0 22.1 2L9 22.2 22.4 West 23.2 23.2 22.6 22.0 21.8 22.7 Central 23.1 22.4 22.7 22.1 22.0 22.4 North and East 21.8 21.7 21.9 22.0 22.0 21.9 Education Primary/Secondary 21.0 21.7 21.9 21.6 20.5 21.5 Secondary-special 22.3 22.2 22.0 21.9 22.6 22.1 Higher 24.0 23.8 23.4 23.9 24.6 23.9 Ethnieity Kazak 23.3 22.9 23.0 22.4 22.7 22.9 Russian 21.6 21.7 21.6 21.7 21.8 21.7 Other 22.0 22.6 22.1 22.2 21.7 22.2 Total 22.5 22.4 22.2 22.0 22.1 22.3 Note: The medians for cohorts 15-19 and 20-24 could not be determined because half the women have not yet had a birth. 41 3.6 Pregnancy and Motherhood Among Women Age 15-19 Fertility among women age 15-19 warrants special attention because young mothers at this age as well as their children are at high risk of encountering social and health problems. There has been much research on this topic, and the causality of the problems has proven difficult to identify. Children born to young mothers are associated with higher levels of illness and mortality during childhood than are children born to older mothers. Table 3.10 presents the percentage of women age 15-19 who are mothers or are pregnant with their first child. Overall, 9 percent of women age 15-19 have begun childbearing (have already given birth, or are pregnant with their first child at the time of the survey). However, the percentage of women who become mothers increases during the teenage years, so that one-quarter (26 percent) of 19 year-olds have begun childbearing. Table 3.10 Pregnancy and motherhood among women age 15-19 Percentage of women 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Kazakstan 1995 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of characteristic Mothers child bearing women Age 15 0.0 0.0 0.0 144 16 0.0 0.0 0.0 136 17 3.3 1.7 5.0 140 18 10.4 5.1 15.5 125 19 22.5 3.3 25.8 123 Residence Urban 7.1 1.0 8.1 356 Rural 6.5 2.9 9.4 313 Region Almaty City 5.3 0.0 5.3 34 South 6.7 2.7 9.3 255 West 8.4 1.6 10.0 85 Central 7.9 0.7 8.6 65 North and East 6.2 1.8 8.1 230 Education Primary/Secondary 4.8 1.8 6.6 425 Secondary-special 12.8 2.1 14.9 191 Higher (1.1) (2.1) (3.2) 53 Ethnicity Kazak 5.0 2.1 7.0 327 Russian 9.9 2.3 12.2 212 Other 6.3 0.9 7.1 130 Total 6.8 1.9 8.7 669 Note: Figures in parentheses are based on 25-49 unweighted cases. 42 The percent of women age 15-19 who have begun childbearing varies from 5 to 10 percent across the regions of Kazakstan. Women age 15-19 with secondary-special education are the most likely to become mothers (13 percent have already given birth). Women age 15-19 of Russian ethnicity are more likely than women of Kazak ethnicity to have begun childbearing (12 versus 7 percent). Table 3.11 indicates that 20 percent of women age 19 have one child, and that 3 percent have two or more children. The percentage of women age 15-19 with one or more children increases with age from 3 percent among women age 17 to 23 percent among those age 19. Table 3.11 Children born to women age 15-19 Percent distribution of women 15-19 by number of children ever born (CEB), according to single year of age, Kazakstan 1995 Age 0 1 2+ Number of Mean children ever born number Number of of Total CEB women 15 100.0 0.0 0.0 100.0 0.00 144 16 100.0 0.0 0,0 100.0 0.00 136 17 96.7 3.3 0.0 100.0 0.03 140 18 89.6 9.9 0.5 100.0 0.11 125 19 77.5 19.6 3.0 100,0 0.25 123 Total 93.2 6.1 0.6 100.0 0.07 669 43 CHAPTER 4 CONTRACEPTION Nina A. Kayupova, Nailya M. Karsybekova, and Khazina M. Biktasheva The primary function of family planning programs is to advocate conscious entry into parenthood for both men and women, i.e., to grant families the right to define their desired number of children and provide them the means to achieve that goal. Family planning involves the control of reproductive behavior, including conception, preservation of the fetus, and childbearing, as well as prevention of conception and interruption of pregnancy. Family planning not only helps couples to avoid undesired pregnancies, but also allows them to control the timing of their childbearing. By controlling the time they enter into parenthood, the time they stop childbearing, and the intervals between births, couples can achieve their ultimate desired family size. Family planning has positive effects on the overall health of both mother and child, and is also a contributing factor in the reduction of maternal and infant mortality, and secondary sterility. The efficacy of family planning depends on people's knowledge of methods and on the availability of methods to meet the varying needs of a wide spectrum of potential users. Availability of methods, in turn, depends on the quality and quantity of service providers and on available financial and technical resources. In the republics of the former Soviet Union, family planning primarily consisted of the use of traditional contraceptive methods through the 1960s. Low levels of infrastructure and technology, as well as knowledge and attitudes towards family planning, limited use of modern methods. Historically, the status of a Kazak woman in the family was such that the number of children she was to bear was determined not only by the husband and wife as a couple, but also by the husband's family. These factors, as well as many others, have resulted in high levels of reliance on induced abortion as a means of fertility control. Only recently has the Ministry of Health actively engaged in efforts to reduce the heavy reliance upon abortion by providing safe and effective modern contraceptive methods (Foreit and McCombie, 1995). Family planning offices have been opened in most oblasts and regional centers, in both large cities and villages. These offices, spanning most of the Republic, offer women professional advice and a supply of family planning methods. With the transition of the Republic to a market economy and the accompanying general reduction in living standards, desires to limit family size seem to be on the rise. Statistics on the number of IUD and pill users obtaining supplies from government facilities have been maintained by the Ministry of Health since 1988. These statistics indicate a substantial increase in contraceptive use between 1988 and 1993: the prevalence rate for these two methods increased by 48 percent, from 20 to 29 percent of all women age 15-49 (Church and Koutanev, 1995). Family planning topics addressed in this chapter include knowledge of contraceptive methods, sources of supply, use of methods in the past and present, reasons for nonuse, desire to use in the future, and attitudes and exposure to family planning messages. These data can serve as an information base for the Ministry of Health and family planning organizations to better define the need for contraceptives and better define the allocation of resources. 4.1 Knowledge of Contraceptive Methods Determining levels of knowledge and use of contraceptive methods was one of the major objectives of the KDHS. Data on knowledge were collected by asking the respondent to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method 45 spontaneously, the interviewer described the method and asked if she recognized it. The respondent was also asked whether she had ever used each method. Current use of contraception was determined by asking whether the respondent (or her partner) was currently using any method, and if so, which one. Contraceptive methods include both modem and traditional methods. Modem methods include the pill, IUD, injectables, female sterilization, and the barrier methods (diaphragm, foam, jelly, and condom). Traditional methods include periodic abstinence (rhythm method), withdrawal, and vaginal douching. Information on knowledge of contraceptive methods is presented in Table 4.1 for all women interviewed, and separately for currently married women, ~ sexually active unmarried women, and women who have never had sexual intercourse. The knowledge of at least one method of contraception is nearly universal (98 percent). Also, 98 percent of respondents know at least one modem method and 75 percent know at least one traditional method. Women know, on average, five methods of contraception. The average number of methods known varies by marital status of the respondents. Currently married women know an average of 5.8 methods, while unmarried women who are sexually active know of 6.7 methods, and women who have never had sex know on average 3.7 methods (71 percent of women who have never had sex are women age 15-19). Table 4.1 Knowledge of contraceptive methods Percentage of all women, of currently married women, of sexually active unmarried women, and of women who have never had sex, who know specific contraceptive methods, by specific methods. Kazakstan 1995 Sexually Women Currently active who Contraceptive All married unmarried never method women women women had sex Any method 97.6 99.3 99.2 91.7 Any modern method 97.6 99.3 99.2 91.7 Pill 78.8 81.8 97.2 62.7 IUD 95.9 99.0 98.8 84.8 Injectables 33.3 35.2 54.0 21.9 Diaphragm/Foam/Jelly 43.2 48.7 63.4 19.4 Condom 87.6 89.2 99.2 78.8 Female sterilization 59.2 64.5 68.3 36.2 Any traditional method 75.2 82.8 93.8 42.8 Periodic abstinence 68.3 75.1 87.5 37.8 Withdrawal 55.3 61.3 81.2 25.8 Douche 18.8 22.0 15.0 6.0 Other 3.3 3.4 6.3 1.2 Any traditional/folk method 75.3 82.8 93.8 42.9 Number of women 3,771 2,507 136 751 Mean number of methods 5.4 5.8 6.7 3.7 1 The currently married category includes women in both formal unions (civil or religious) and informal unions (living together). 46 The most commonly known method is the IUD (known by 96 percent of all women). The condom and the pill are the next most commonly known methods, known by 88 and 79 percent of women, respectively. The lesser known modem methods are still known by a significant proportion of women--59 percent have knowledge of female sterilization (although historically this method was carried out only for medical reasons), 43 percent know vaginal barrier methods such as the diaphragm, foam or jelly, and 33 percent know injectables. The data in Table 4. I show that sexually active unmarried women are generally more informed about modem methods than are currently married women. Knowledge of the IUD, condom, and pill is universal among sexually active unmarried women (99, 99 and 97 percent, respectively), and they are also more likely to know of the lesser known modem methods as well. While women who have never had sex are less likely to know of methods than are married or sexually active unmarried women, more than three-quarters of such women do know of the IUD (85 percent) and the condom (79 percent). For purposes of communicating family planning information, women of reproductive age who have not yet engaged in sexual intercourse are an equally important audience as are sexually active women because these women are certain to engage in sexual activity in the near future. Periodic abstinence and withdrawal are commonly known traditional methods among currently married and sexually active unmarried women. Periodic abstinence is known by 75 per- cent of currently married women and 88 percent of sexually active unmarried women; withdrawal is known to 61 percent and 81 percent, respec- tively. Traditional methods are not as commonly known among women who have never had sex (38 percent have heard of periodic abstinence and 26 percent have heard of withdrawal). Vagi- nal douche is known to 22 percent of married women and 15 percent of sexually active unmar- ried women. Folk methods mentioned by re- spondents include herbs, segment of a lemon, aspirin, iodine, vinegar, wine and others. Table 4.2 presents the percent of cur- rently married women who know of at least one method of contraception (modem or traditional) and the percent who know of at least one modem method, by background characteristics of the re- spondents. Virtually all currently married wom- en know of at least one modem method of con- traception. This level of knowledge includes women of all ages, all regions of the country, all educational levels, and all ethnicities. 4.2 Ever Use of Contraception All respondents who had heard of a Table 4.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women who reported having heard of at least one method and at least one modern method by selected background characteristics, Kazakstan 1995 Knowledge of contraception Knows Knows Number Background any modem of characteristic method method women Age 15-19 95.8 95.8 80 20-24 99.7 99.6 347 25-29 99.6 99.6 425 30-34 99.8 99.8 458 35-39 99.1 99.1 482 40-44 99.1 99.1 447 45-49 99.0 99.0 268 Residence Urban 99.6 99.6 1,398 Rural 98.9 98.9 1,109 Region Almaty City 1(30.0 100.0 164 South 98.4 98.4 811 West 99.4 99.4 298 Central 99.5 99.3 235 North and East 99.8 99.8 1,000 Education Primary/Secondary 98.4 98.3 797 Secondary-special 99.7 99.7 1,259 Higher 99.7 99.7 450 Ethnicity Kazak 98.7 98.6 1,064 Russian 100.0 100.0 930 Other 99.2 99.2 513 Total 99.3 99.3 2,507 method of contraception were asked whether they (or a partner with them) had ever used the method; each method was inquired about separately. An additional probe for use was made for women who reported no contraceptive use. Results are presented in Table 4.3 for all women by five-year age groups, for currently married women by five-year age groups, and for sexually active unmarried women. 47 Overall, 84 percent of currently married women and 78 percent of sexually active unmarried women have used a method of contraception at some time in their life. Sixty-five percent of all women age 15-49 have used a method at some time. Levels of ever-use among all women are somewhat lower than among currently married women because the former includes women who are not sexually active; the most significant differential is among 15-19 year-old women. While 51 percent of currently married 15-19 year- olds have ever used a method, only 12 percent of all 15-19 year-olds have done so; however, only 20 percent of all 15-19 year-olds have ever had sex. The women who are the most likely to have ever used a method of contraception are those age 25-44 among the currently married and age 30-44 among all women (83-90 percent of these women have used a method of contraception). These women are also the most likely to have used a modem method of contraception. The method that is by far the most widely ever used is the IUD. Overall, 46 percent of all women of reproductive age have used an IUD at some time. Three out of four currently married women in their thirties have used an IUD at some time in their life (and two out of three women age 25-29 and 40-44 have done so). Condoms are the next most commonly tried method; approximately one of ew:ry three currently married women has used a condom at some time. Condoms are the most likely method to have been tried among sexually active unmarried women. Pills are the third most commonly tried modem method; Table 4.3 Ever use of contraception Percentage of all women, of currently married women, and of sexually active unmarried women who have ever used any contraceptive method, by specific method and age, Kazakstan 1995 Modem method Traditional method Any Any Any Periodic trad./ Number Any modern Other trad. absti- With- Other folk of Age method method Pill IUD Condom modern j method hence drawal Douche methods method women ALL WOMEN 15-19 11.9 82 2.1 1.2 6.4 0,2 9.7 44 5.6 2.8 01 9,7 669 20 24 55.7 472 8.7 268 272 1,2 354 18.3 21.1 I 1.9 0.9 35,5 567 25-29 74.7 712 20,5 587 34.5 3.8 356 20.0 19.4 9.2 0.3 35.7 521 30-34 84.2 79.5 19.9 68.3 33.3 7.6 448 26.6 20.5 14.6 08 44.8 557 35-39 82.8 77.1 20.9 68.0 33.4 5.6 47.8 30.6 22.3 15.8 14 48.0 564 40-44 85.9 78,7 17.5 648 39.0 6.9 49.4 30.7 25.6 17.0 18 50.0 537 45-49 74.5 63.1 11.7 44.8 316 7.8 452 28,3 21.5 17.5 1,8 463 355 Total 64.9 58.8 14.2 46,1 28.4 44 37.0 21.9 189 122 0.9 37.3 3,771 CURRENTLY MARRIED WOMEN 15-19 50.9 31.5 6.9 7.6 18.4 0.5 423 15.9 18.6 17.3 0.8 42.3 80 20-24 71.7 61.9 11.0 38.6 33.6 1.6 419 19.0 25.7 140 0.7 42.0 347 25-29 83.3 80.3 22.8 670 38.9 4.3 382 21.6 21.1 102 01 38.2 425 30-34 89.6 86.0 21.5 73.7 35.6 7.6 46.6 269 225 152 0.8 46.6 458 35-39 88.3 83.1 21.6 74,3 35.6 6.2 51.1 327 239 16.8 0.9 51.4 482 40-44 89.6 82,6 18.4 691 41.6 8.1 53.3 330 28.7 173 1.9 540 447 45-49 79.1 67.1 128 49.5 33.4 76 470 300 226 174 1.3 47,6 268 Total 83.5 76.8 18.3 62.3 36.2 58 46 5 27 I 24.0 15 2 09 46.7 2,507 SEXUALLY ACTIVE UNMARRIED WOMEN Total 784 68.9 25.0 31.1 49.0 3.9 59,7 39.4 34.5 119 19 60.0 136 t Includes injectables and diaphragm 48 nearly one in five currently married women has used them at some time in their life. Other modem methods (injectables and diaphragm) have been used at some time by only 6 percent of married women. While more women have used modem than traditional methods, many women have in fact used a traditional method at some time. Overall, nearly half of all currently married women have used a traditional method at some time in their life, while 37 percent of all women have done so. The sexually active unmarried women are the most likely to have ever used a traditional method (60 percent). Periodic abstinence and withdrawal are the traditional methods most likely to have been tried by women at some time in their life. Twenty-seven percent of married women have used periodic abstinence at some time, and 24 percent have used withdrawal at some time. Sexually active unmarried women are more likely to have used both of these methods at some time in their life (39 percent have used periodic abstinence and 35 percent have used withdrawal at some time). Fifteen percent of married women and 12 percent of sexually active unmarried women have used vaginal douching as a method of contraception at some time in their life. 4.3 Current Use of Contracept ion Table 4.4 presents levels of current use of contraception for all women by five-year age groups, for currently married women by five-year age groups, and for sexually active unmarried women. Figure 4.1 shows the distribution of currently married women by method currently used. Table 4.4 Current use of contraception Percent distribution of all women, of currently married women, and of sexually active unmarried women who are currently using a contraceptive method by specific method, according to age, Kazakstan 1995 Modem method Traditional method Any Any Periodic Not Number Any modern Other trad, absti- With- currently of Age method method Pill IUD Condom modern I method nence drawal Douche using Total women ALL WOMEN 15-19 7,1 47 0.8 1.0 2.8 0.0 2.4 0.4 1.0 1.0 92.9 100.0 669 20-24 35,1 250 2.0 18.0 4.8 0.3 10A 4.9 2.6 2.6 64.9 100.0 567 25-29 53.3 445 2,5 38,1 3.0 1.0 8.8 3.7 3.1 2.0 46.7 100.0 521 30-34 64.9 53.7 1.5 4%5 3.3 1.4 11.2 6.1 3.0 2.1 35.1 100.0 557 35-39 61.8 48.4 1,7 41.7 4.6 0.5 13.3 8.8 2.1 2.4 38.2 100.0 564 40-44 54.8 409 1.4 35.3 2.5 1.7 14.0 7.6 3.3 3.1 45,2 100.0 537 45-49 28.5 19.6 0.0 16,0 2.6 1.0 8.7 4,7 0.3 3.7 71.5 100.0 355 Total 43.3 33,6 15 27.9 34 0.8 9,6 5.0 2.3 2.3 56.7 1 t~9,0 3,771 CURRENTLY MARRIED WOMEN 15-19 31.5 14.4 6.1 6.5 1,8 0.0 17.1 3.2 6.2 77 68.5 100.0 80 20-24 47.0 34.1 2.5 27,2 4.1 0.3 12.9 5,2 3.8 40 53.0 100.0 347 25-29 61.0 51.0 2.3 44.1 3.4 1.2 10.0 4,2 3.4 2.4 39.0 100,0 425 30-34 71.7 60.6 1,1 54.0 3.9 1.5 11.1 5.5 3.5 2.1 28.3 100,0 458 35-39 69.5 54.6 1.9 47.4 4.9 0,5 14.9 9.6 2.5 2,8 30.5 100.0 482 40-44 63,3 470 1.7 404 2,8 2.0 16.4 8.7 4,0 3.8 36.7 100.0 447 45-49 32.6 21,7 0.0 18.1 3.3 0.3 107 5.4 0.4 49 67,4 100.0 268 Total 59.1 46.1 1.8 39.6 3,7 1,0 13.0 6.5 3.2 3.3 40.9 100.0 2,507 SEXUALLY ACTIVE UNMARRIED WOMEN Total 57,9 39.1 50 13.7 19.3 1.1 18,8 14.0 4.5 0.3 42.1 100,0 136 Note: Totals may not add to 100.0 due to rounding. i Includes injectables and diaphragm 49 Figure 4.1 Use of Specific Contraceptive Methods among Currently Married Women IUD 40% Condom 4% Other modem methods 1% Traditional methods 13% Pill 2% Not currently using 41% KDHS 1995 One out of every three women of reproductive age is currently using a modem method of contraception (34 percent); one out of every 10 is using a traditional method (10 percent). Nearly one out of every two currently married women is currently using a modem method of contraception (46 percent), and 13 percent are using a traditional method] The IUD is by far the most commonly used method---two out of every three currently married women who are using some method of contraception are using the IUD. The collection of traditional methods represents the second most commonly used method; one out of five currently married women who are using some method of contraception are using either periodic abstinence, withdrawal, or douche. Prevalence among sexually active unmarried women (58 percent) is the same as among currently married women; however, the former exhibit a greater method mix than the latter. There is much less reliance upon the IUD among sexually active unmarried women and greater use of all other methods (both modem and traditional) compared to married women. Condoms are the most commonly used method (19 percent) and sexually active unmarried women are as equally likely to be using periodic abstinence (14 percent) as they are to be using the IUD (14 percent). Five percent of these women are using pills, and 5 percent are using withdrawal. 2 It is worth comparing the contraceptive prevalence statistics which are published by the Ministry of Health (MOH) with those computed from KDHS data. The MOH collects data and publishes statistics on IUD and pill users relative to all women of reproductive age (i.e., all women 15-49). According to the MOH data, the percentage of IUD and pill users among women age 15-49 for 1993 were 27.8 and 1.4, respectively (Church and Koutanev, 1995). These are virtually identical to the KI)HS rates of 27.9 and 1.5 for 1995 (Table 4.4). In spite of the two-year time difference in the date to which these statistics apply, the results are remarkably similar, substantiating the reliability of the data collected by the MOH and the KDHS survey. 50 Use of contraception increases steadily by age, peaking at age 30-34 (61 percent of currently married women are using a modem method), and then declines. Use of traditional methods remains relatively constant over all ages. Of course, the desire to avoid pregnancy varies greatly over the course of one's reproductive life; use of contraception in relation to the age and fertility preferences of women is discussed in Chapter 7. Levels of contraceptive use by background characteristics of respondents are presented in Table 4.5 and Figure 4.2 for currently married women. Perhaps the most significant finding of Table 4.5 and Figure 4.2 is that the level of modem contraceptive use observed for the population as a whole is maintained across background characteristics of respondents. Most of the differentials observed in overall levels of use can be attributed to differential levels of use of traditional methods. For example, urban women are slightly more likely than rural women to be using a method of contraception (62 and 56 percent, respectively), but most of the differential can be attributed to higher use of traditional methods among urban women. Table 4.5 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to selected background characteristics, Kazakstan 1995 Modem method Traditional method Any Any Periodic Not Number Any modern Other trad. absti- With- currently of Characteristic method method Pill IUD Condom modern I method nence drawal Douche using Total women Residence Urban 61.9 47.0 2.3 39.2 4.4 1.0 14.8 7.9 2.1 4.8 38.1 100.0 1,398 Rural 55.6 44.9 1.1 40.0 2.8 0.9 10.7 4.7 4.5 1.5 44.4 100.0 1,109 Region Almaty City 64.4 47.2 5.1 29.9 9.2 3.0 17.3 11.3 1.9 4.0 35.6 100.0 164 South 50.2 44.3 0.6 41.5 1.6 0.6 5.9 3.3 0.8 1.8 49.8 100.0 811 West 51.9 41.6 0.8 37.5 3.0 0.2 10.1 6.2 1.5 2.4 48.1 100.0 298 Central 66.2 52.5 1.5 44.8 4.6 1.5 13.5 5.3 2.7 5.5 33.8 100.0 235 North and East 66.0 47.2 2.6 39.0 4.5 1.1 18.8 8.6 5.9 4.2 34.0 100.0 1,000 Education Primary/Secondary 51.9 41.8 0.7 36.6 3.5 0.9 10.0 3.4 4.1 2.5 48.1 100.0 797 Secondary-special 62.0 48.2 1.9 42.3 3.0 I.I 13.7 7.2 3.1 3.4 38.0 100.0 1,259 Higher 64.0 47.6 3.4 37.2 6.2 0.8 16.3 9.9 1.8 4.7 36.0 100.0 450 Ethnicity Kazak 53.5 46.8 0.5 43.6 2.0 0.6 6.7 4.0 0.7 2.1 46.5 100.0 1,064 Russian 65.1 45.3 3.9 35.3 4.5 1.6 19.7 9.6 5.1 5.1 34.9 100.0 930 Other 59.9 46.0 0.5 38.9 6.0 0.7 13.9 6.0 5.0 2.9 40.1 100.0 513 Number of living children 0 13.8 5.5 1.8 1.4 2.1 0.2 8.3 4.5 0.6 3.2 86.2 100.0 181 I 51.1 36.2 2.9 29.3 3.5 0.6 14.9 6.9 4.0 4.0 48.9 100.0 562 2 68.6 54.4 1.8 46.9 4.4 1.3 14.1 7.6 3.2 3.3 31.4 100.0 938 3 71.0 56.8 0.7 50.4 4.9 0.9 14.1 7.1 3.9 3.1 29.0 100.0 396 4+ 57.0 47.8 1.3 43.2 2.1 1.3 9.1 3.8 2.4 2.9 43.0 100.0 431 Total 59.l 46.1 1.8 39.6 3.7 1.0 13.0 6.5 3.2 3.3 40.9 100.0 2,507 Includes injectables and diaphragm 51 Figure 4.2 Current Use of Family Planning by Background Characteristics KAZAKSTAN RESIDENCE Urban Rural REGION West Central North and East EDUCATION Primary/Secondary Secondary-Special Higher NO. LIVING CHILDREN ~///////////////////////////i//////////////////////////////////////////////////////////////~ h ~ i7~!~] 59 ~//////~/////j/////~//////////////////~////////////////////////jy/~///////~y////////~:~;~ ~.W> i; ~ 55 <<.: >: : :I 52 ~B~'Z~'~W2~/2x / /~/~/2x~/~/~/~ ,~;,~ ,: ,: ~ ~ 7~ ~ 7~ ~ 7~ 7~ : I 66 r / ~ i x ~ i ~ ~ i ~ x ;Q~3 ~ ~- ~ 54 ~//~/~/~/~/~//~/~//~/~/~/~/////~//~//~//~/~/~/7~p'~'~ :. ) !" )" i : i i ~:T: !~ 65 2 ~//[//////////,¢/i//7////////////,¢///~¢7/,e~'# /~ ' : : ~ ;G{; : ;~] 69 3 V/~~/2~/y~'~7~/ j~2y/~7"~e~J / J /~ ;~;~; ;~ ~C~L] 71 4+ V///////////////////////////////////////////////////////////////////////////////////////////////~` ~S~:~ I 57 0 20 40 60 80 J~M~lern Methods ~Traditional/Folk Method-- Note: Currently married women age 1549 KDHS 1995 Contraceptive use by region does not vary to the degree that might be expected from the fertility differentials by region. Approximately one out of every two women is using a method of contraception in both the South and West Regions, while two in three are using a method in the Central, the North and East, and the Almaty City Regions. The correlation of contraceptive use with fertility levels is not very clear by region; for example, the West has an intermediate level of fertility and a relatively lower level of use (one in two women is using a method), while the Central Region, which also has an intermediate level of fertility, has a relatively higher level of use (two in three women is using a method). A more complete investigation of regional fertility differentials would have to consider factors such as age at marriage, breastfeeding practices, and induced abortion, in addition to the use of contraception. Women with primary or secondary education have lower levels of contraceptive use (52 percent) than do women with more education. However, women with secondary-special and higher education have similar levels of use (62 and 64 percent). Kazak and Russian women are equally likely to be using a modem method of contraception (47 and 45 percent, respectively). However, Russian women are more likely than Kazak women to be using a traditional method (20 percent and 7 percent, respectively) resulting in a higher overall level of use among Russian women. The level of contraceptive use increases with increasing numbers of living children, but then declines among women with four or more children. Use of contraception among married women with no children is quite low (6 percent are using a modem method and 8 percent are using a traditional method). Any differentials in method mix are overshadowed by the heavy reliance on the IUD among women of all background characteristics (the only exception being women with no children). However, the broadest method mix is observed among women in Almaty City. While use of the IUD still predominates (30 percent), use of modem methods other than the IUD is higher in Almaty City than any other region: condoms (9 percent), the pill (5 percent), and other modem methods (3 percent). Nevertheless, even with this broader 52 mix of modem methods, periodic absti- nence still ranks as the second most com- monly used method (11 percent) among women in Almaty City, as it does for Kazakstan as a whole. Users of the pill were asked to pre- sent their pill package to the interviewer, who then proceeded to record the brand name of the pills. Respondents who were unable to present the package were asked to report the brand name of their pills. Table 4.6 presents the percentage of women who are using the pill and the percentage of pill users who presented their pill packages to interviewers, by background characteristics of respondents. Table 4.7 presents the dis- tribution of pill users by their brand of pills. Both tables present data for all pill users, regardless of marital status. Pill use is highest among women age 25-29 years (3 percent), urban women (2 percent), women living in Almaty (5 per- cent), women with higher education (3 per- cent), and Russian women (3 percent). Overall, 70 percent of pill users were able to present their packets to the interviewer; however, there was variability in the ability to do so by background characteristics of the respondents. Urban women were twice as likely (80 percent) as rural women (40 Table 4.6 Pill use and possession Percentage of all women using the pill and the percentage of pill users who have a packet at home, by background characteristics, Kazakstan 1995 Percentage of users who Background Percent Number could show characteristic using pill of women package Age 15-19 0.8 669 57.1 20-24 2.0 567 84.3 25-29 2.5 521 73.7 30-34 1.5 557 78.5 35-39 1.7 564 74.5 40-44 1.4 537 38.3 45-49 0.0 355 Residence Urban 2.0 2,133 79.5 Rural 0.8 1,638 39.7 Region Almaty City 5.0 271 58.1 South 0.4 1,206 62.4 West 1.0 477 74.5 Central 1.1 358 54.4 North and East 1.9 1,458 79.1 Education Primary/Secondary 0.6 1,376 59.6 Secondary-special 1.4 1,721 61.0 Higher 3.3 670 84.2 Ethnicity Kazak 0.5 1,696 54.8 Russian 3.3 1,309 72.4 Other 0.4 766 84.6 Total 1.5 3,771 70.3 percent) to present a packet to the interviewer. Women with higher education were more likely to show a packet (84 percent) than women with less education (60 percent). And Table 4.7 Use of pill brands Percent distribution of pill users by the brand of pills used, Kazakstan 1995 Pill brand Total Diane-35 8.1 Lo-femenal 1.6 Marvelon 2.4 Microgynon 5.0 Non-ovlon 8.5 Ovidon 7.0 Postinor 5.0 Rigevidon 8.7 Triquilar 21.0 Triquilar ED Fe 14.5 Anteovin 2.4 Don't know/missing 15.8 Total 100.0 Number 55 finally, 72 percent of Russian women presented a packet, while 55 percent of Kazak women did so. Table 4.7 reveals that there are 11 brands of pills being used, with the most common being Triquilar (36 percent). 4.4 Number of Children at First Use of Contraception To make some assessment of the motivations behind using family planning methods, women were asked how many living children they had at the time they first used a method of family planning. Women who use a method before ever having a child presumably want to delay their childbearing to some time in the future. Women who first employ a method after they have had one or two children may either want to delay the next child or limit their childbearing to one or two children. Women who use a method for the first time after having several children 53 are more likely to be using family planning to stop childbearing, rather than simply spacing their childbearing. Table 4.8 presents the percent distribution of all ever-married women by the number of living children they had at the time they first used a method of family planning. Use of family planning to delay the first pregnancy is uncommon in Kazakstan (11 percent of women have done so). However, the steady increase in percent of first-time users with no children at younger ages indicates that the number of women who wish to delay their first child has been increasing over time. Twenty-four percent of ever-married 20-24 year-olds and 31 percent of 15-19 year-olds have used a method before ever having a child. The decreasing median number of living children at time of first use at younger ages also indicates that more women are now acting to delay their first pregnancy than they have in the past. Older women (over the age of 35) had a median of 2.0 children before they first used contraception; younger women have a median of approximately 1.5 children at their first use of contraception. Thirty-seven percent of ever-married women had one living child at the time they first used a method of contraception; this percent does not change greatly with age, with the exception of 15-19 year-olds, among whom 17 percent first used a method after having one living child. Table 4.8 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 contraception, and median number of children at first use, according to current age, Kazakstan 1995 Never Number of living children at time used of first use of contraception Number contra- of Current age ception 0 1 2 3 4+ Total women Median 15-19 48.8 30.5 17.4 3.3 0.0 0.0 100.0 90 0.8 20-24 27.5 24.2 38.9 9.2 0.3 0.0 100.0 387 1.3 25-29 18.5 17.3 37.0 22.9 2.6 1.6 100.0 468 1.6 30-34 12.4 9.9 40.5 26.4 6.9 4.0 100.0 531 1.8 35-39 14.4 6.0 38.2 24.2 7.1 10.1 100.0 540 2.0 40-44 12.4 4.3 38.9 22.4 9.3 12.7 100,0 525 2.0 45-49 24.5 4.5 33.1 18.0 6.5 13.4 100.0 345 2.0 Total 18.3 11.3 37.4 20.7 5.5 6.8 100.0 2,886 1.8 4.5 Knowledge of Fertile Period and Contraceptive Effects of Breastfeeding Knowledge of reproductive physiology is an important prerequisite for effective use of traditional contraceptive methods. To success- fully practice periodic sexual abstinence, a woman must know at which point during the ovulation cycle she is most likely to become pregnant. All women were asked whether they thought there was a time during their monthly cycle that they were more likely to become pregnant, and if so, to identify when that was. Table 4.9 presents the percent distribution of all women, women who have ever used periodic abstinence, and women who have ever used the calendar rhythm method by their knowledge of the fertile period. Table 4.9 Knowledge of fertile period Percent distribution of all women and of those who currently use periodic abstinence or the calendar rhythm method, by knowledge of the fertile period during the ovulatory cycle, Kazakstan 1995 Current users of: Perceived All Periodic Calendar fertile period women abstinence rhythm During menstrual period 0.7 0.7 0.7 Right after period has ended 4.1 4.5 4.0 In the middle of the cycle 29.3 87.3 88.0 Just before period begins 1.0 1.5 1.4 At any time 28.6 2.6 2.7 Other 0.1 0.0 0.0 Don't know 36.2 3.3 3.2 Total 100.0 100.0 100.0 Number 3,771 190 185 Note: Five respondents reported using the symptothermal method. 54 Only 29 percent of all respondents properly identify the middle of the cycle as the most likely time to become pregnant. Most of the remaining respondents said either that there is no time which is more likely than another (29 percent of all women), or simply did not know (36 percent of all women). On the other hand, most women who are using either periodic abstinence or the calendar rhythm method know about the varying likelihood to become pregnant. Eighty-seven percent of women who are using periodic abstinence and 88 percent of women who are using the calendar method could properly identify the time during which they are most fertile. Exclusive and frequent breastfeeding can prolong the period of time following a birth during which a woman is amenorrheic (not menstruating) and anovulatory (not ovulating). It has also been shown that even after the resumption of menstruation the probability of pregnancy is lower among women who continue to breastfeed than among women who have stopped (Hobcraft and Guz, 1991; Potts et al., 1985). Women were asked what, if any, they perceive the effects of breastfeeding to be on the risk of pregnancy. Women were also asked whether they have ever relied on breastfeeding as a method of contraception and whether they are currently doing so. These data are presented in Table 4.10 for currently married women. Table 4.10 Perceived contraceptive effect of breastfeeding Percent distribution of currently married women by perceived risk of pregnancy associated with breastfeeding and percentage who previously relied on breastfeeding to avoid pregnancy, who currently rely on breastfeeding to avoid pregnancy and who meet lactational amenorrheic method (LAM) criteria, according to selected background characteristics, Kazakstan 1995 Perceived risk of pregnancy associated with breastfeeding Reliance on breastfeeding to avoid pregnancy Meet Number Background Un- In- De- Don't Previ- Cur- LAM of characteristic changed creased creased Depends know Total ously rently criteria I women Age 15-19 58.3 10.2 22.2 5.5 3.8 100.0 15.1 6.7 1.4 80 20-24 58.2 6.2 27.6 6.5 1.4 100.0 15.0 10.8 2.4 347 25-29 57.2 6.6 28.2 5.7 2.4 100.0 14.9 9.9 2.1 425 30-34 57.1 5.8 28.3 8.5 0.3 100.0 17.3 11.7 0.9 458 35-39 57.9 6.5 28.1 6.5 0.9 100.0 l&5 10.9 0.4 482 40-44 48.4 4.4 38.4 8.0 0.8 100.0 22.1 10.2 0.2 447 45-49 43.6 7.8 37.0 10.5 1.1 100.0 20.1 7.5 0.0 268 Residence Urban 56.6 5.1 29.9 7.3 1.1 100.0 15.6 8.6 1.0 1,398 Rural 51.8 7.7 31.7 7.5 1.3 100.0 20.8 12.3 1.1 1,109 Region Almaty City 55.8 7.3 31.3 3.5 2.2 100.0 13.2 6.2 0.8 164 South 49.5 7.3 37.6 4.9 0.6 100.0 22.4 15.5 1.5 811 West 47.4 13.1 19.9 19.5 0.0 100.0 15.1 10.1 2.3 298 Central 60.9 6.1 28.9 2.9 1.3 100.0 14.4 4.5 1.2 235 Noah and East 58.9 3.2 28.6 7.4 1.9 100.0 16.7 8.1 0.2 1,000 Education Primary/Secondary 56.0 7.8 27.1 7.8 1.4 100.0 18.1 12.1 1.0 797 Secondary-special 52.9 6.6 32.2 7.1 1.2 100.0 18.6 9.1 1.2 1,259 Higher 56.3 2.5 32.9 7.4 1.0 100.0 15.4 10.1 0.6 450 Ethnieity Kazak 49.0 8.5 34.5 6.9 1.1 100.0 21.3 14.2 1.9 1,064 Russian 58.3 4.2 28.8 6.9 1.8 100.0 15.6 7.4 0.4 930 Other 58.8 5.2 26.2 9.3 0.5 100.0 14.9 7.2 0.4 513 Total 54.5 6.2 30.7 7.4 1.2 100.0 17.9 10.2 1.0 2,507 J Currently fully breastfeeding, child is less than 6 months old, and mother is postpartum amenorrheic 55 One-third of women (31 percent) report that breastfeeding reduces the risk of becoming pregnant, and the percent of women who report a decreasing effect of breastfeeding increases with age. While urban and rural women are equally likely to report a decreasing effect, women in the West are the least likely to do so (20 percent). Women in the West are more likely than women in other regions to report that breastfeeding increases the risk of pregnancy (13 percent), as well as to report that it depends on other factors (20 percent). Approximately half (55 percent) of currently married women believe that breastfeeding has no effect on the risk of becoming pregnant; this level is maintained across most background characteristics. Eighteen percent of currently married women have used breastfeeding as a means of contraception at some time in their lives, and 10 percent of women report they are currently doing so. Women in the South are the most likely to have used breastfeeding for family planning purposes (22 percent) and are also the most likely to be current users (16 percent). Women in the South are also the most likely to report the decreasing effect of breastfeeding on fecundity (38 percent). Kazak women are more likely than Russian women to report themselves as currently using breastfeeding as a method of contraception (14 and 7 percent, respectively). Table 4.10 also presents the proportion of currently married women who meet the lactational amenorrheic method (LAM) criteria. In order to meet these criteria, a woman must be fully breastfeeding a child whose is less than six months old, and she must also be amenorrheic. One percent of women meet the LAM criteria, and this percent varies by background characteristics between 0 and 2 percent of women. 4.6 Source of Family Planning Methods In Kazakstan, modern methods of contraception, such as the IUD, the pill, condoms, and injectables, are distributed through the public medical sector free of charge. Public sector sources include womens' consulting centers and womens' consulting offices of polyclinics. Modern contraceptives are also available for a fee at commercial facilities. All women currently using a modern method were asked where they most recently obtained their method. 3 Table 4.11 shows the percent distribution of all current users of modern contraceptives by the source from which they most recently obtained their method. The vast majority of women obtain their contraceptives through the public sector (92 percent). Thirty percent of users obtain their method from a hospital, while 26 percent obtained their method from a womens' consulting center. The source of supply of the method depends on the method being used. For example, most women using IUDs obtain them at hospitals (34 percent) or womens' consulting centers (31 percent). Pharmacies supply 58 percent of pill users and 60 percent of condom users. Pill users also use womens' consulting centers or polyclinics to obtain their pills ( 15 percent), and some obtain their pills from friends or relatives (9 percent). Other sources for condom users include shops (13 percent) and friends or relatives (9 percent). Figure 4.3 summarizes the distribution of current users of modern methods by source of method. All current users of modern methods were asked whether they know a source for family planning other than the source from which they most recently obtained their method. Women who do know an alternative source were asked to explain the main reason they went to their most recent source instead of the alternative source. Results are presented in Table 4.12 by background characteristics of respondents. More than half of women (56 percent) went to their current source of supply because they do not know any other source. Among users who do know more than one place to obtain methods, 39 percent 3 Data collection included recording of the name of the source so that team supervisors and editors could verify the sources. 56 Table 4.11 Source of supply for modem contraceptive methods Percent distribution of current users of modern contraceptive methods by most recent source of supply, according to specific methods, Kazakstan 1995 Method Other Source of supply Pill IUD Condom modern I Total Public 77.0 96.4 64.6 (98.5) 92.4 Hospital 0.0 34.2 0.0 (75,2) 30.2 Polyclinic 4.5 16.2 0.0 (8.9) 13.9 Women's consulting center 10.1 30.8 0.9 (7,2) 26.3 Pharmacy 58.0 12.1 60.3 (3.3) 18.7 Other 4.4 2.6 3.4 (3.8) 2.8 Public - Fee for service 6.2 0.4 0.3 (0.0) 0.6 Other 16.8 3.2 35.1 (I.5) 6.9 Shop 0.8 0.2 12.6 (0.0) 1.4 Friends/relatives 8.8 2.4 8,5 (1.5) 3.2 Other 7.2 0.7 14.0 (0.0) 2.3 Total 100.0 100.0 100.0 100.0 100.0 Number 55 1,054 128 30 1,266 Note: Figures in parentheses are based on 25-49 unweighted cases. i Other modem includes injectables and diaphragm Figure 4.3 Distribution of Current Contraceptive Users by Source of Supply Pharmacy 19% Vomen's consulting center 26% clinic 14% KDHS 1995 57 went to the place they did because it was closer to home (reason given by 17 percent of all users). Nine percent of users chose their source because it had a more competent and friendly staff. Other reasons were given by 3 percent or less of respondents. The primary finding of Table 4.12 is the variability by background characteristics of respondents in whether or not users of modem methods know more than one place to obtain methods. Rural women are much more likely than urban women to know only one source of supply (67 and 47 percent, respectively). The greatest differentials are seen across the regions of Kazakstan. In Almaty City, only 23 percent of users know only one source to obtain a method, while in the South, as many as 79 percent of women know only one source. The percent of women who know only one source for modem methods decreases steadily with increasing education. Sixty-eight percent of women with primary/secondary education know of only one place for methods; this percent declines to 53 percent among women with secondary-special education, and then declines further to 44 percent among women with higher education. The majority of Kazak women know only one source of supply (69 percent), while among Russian women, 41 percent know only one source. Women are about equally likely to know a second source of family planning whether they are using contraceptives to space or to limit their childbearing (53 and 57 percent know only one source, respectively). Table 4.12 Satisfaction with current sources of supply for contraceptive methods Percent distribution of current users of modem contraceptive methods by satisfaction with most recent source of supply, according to selected background characteristics and reason for using a method, Kazakstan 1995 Main reason for using current source of supply Staff Longer Use Know Trans- compe- hours other no Closer Closer port tent, Offers Shorter of serv- Low Don't Number Background other to to avail- friend- Cleaner more waiting opera- ices cost, know/ of characteristic source home work able ly facility privacy time tion there cheaper Other Missing Total users Residence Urban 47.3 18.0 4.2 2.4 10.6 2.0 2.3 0.4 1.5 4.1 3.1 0.5 0.6 100.0 742 Rural 67.4 15.5 1.4 2.5 6.1 0.2 0.8 0.2 0.4 2.1 1.4 0.2 0.8 100.0 524 Region Almaty City 22.8 32.6 4.9 2.2 10.7 0.9 4.5 1.3 1.8 5.4 2.2 1.3 0.9 100.0 99 South 78.8 8.9 0.8 0.3 2.3 2.2 0.0 0.0 0.9 4.0 0.8 0.5 0.3 100.0 367 West 57.5 16.3 3.9 5.0 5.1 0.0 2.0 0.8 1.5 3.2 0.0 0.8 0.0 100.0 137 Central 56.4 16.7 1.2 4.0 9.5 0.0 0.7 1.2 1.3 2.8 1.2 0.3 1.5 It)0.0 133 North and East 45.0 19.9 4.5 2.9 13.6 1.3 2.5 0.0 0.8 2.5 4.5 0.0 0.8 100.0 531 Education Primary/Secondary 68.2 11.6 0.6 2.5 7.0 1.8 0.5 0.3 0.7 4.2 0.5 0.5 0.7 100.0 365 Secondary-special 53.0 18.1 4.9 2.1 8.8 1.0 2.1 0.1 1.1 2.7 3.0 0.1 0.3 100.0 655 Higher 43.6 22.1 1.9 3.3 11.1 0.9 2.3 1.0 1.4 3.4 3.6 0.8 1.6 100.0 245 Ethnicity Kazak 69.4 12.2 1.9 1.6 5,0 0.9 1.1 0.3 0.8 3.3 1.1 0.4 0.3 100.0 531 Russian 41.0 20.5 4.4 3.5 12.6 1.4 2.3 0.4 1.1 3.9 3.6 0.4 1.4 100.0 488 Other 54.7 20.3 2.9 2.0 9.2 1.6 1.6 0.2 '1.5 1.9 2.9 0.2 0.0 100.0 247 Reason for using To space 52.8 20.7 1.6 2.5 6.9 1.6 2,1 0.4 0.5 3.5 2.9 0.6 0.7 100,0 455 To limit 57.2 14.9 3.9 2.4 9.8 1.0 1.5 0.3 1.4 3.1 2.2 0.2 0.6 100.0 811 Total 55.6 17.0 3.1 2.4 8.7 1.2 1.7 0.3 1.0 3.3 2.4 0.4 0.6 100.0 1,266 58 4.7 Intention to Use Family Planning Among Nonusers Intentions of women to use family planning methods in the future provide a basis for forecasting potential requirements of family planning services. The KDHS asked nonusers of contraception whether they intend to use a method of contraception at some time in the future, and more specifically, whether they intend to do so within the next 12 months. Table 4.13 presents the results for currently married women according to their past experience with contraception and by the number of living children they have. Overall, 48 percent of currently married nonusers do intend to use a method of family planning at some time in the future; 28 percent intend to use within the next 12 months, 17 percent at some more distant time in the future, and the remaining 3 percent are unsure as to when they would use a method. The majority (60 percent) of nonusers who intend to use a method at some time in the future are women who have used a method at some time in the past. Nonusers who intend to use a method later in the future tend to be women with fewer children. While most nonusers with no children say they intend to use a method at some time beyond the coming 12 months (46 percent), most nonusers with children who intend to use a method say they intend to do so within the next 12 months. Table 4.13 Future use of contraception Percent distribution of currently 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 children, Kazakstan 1995 Past experience with contraception and future intentions Number of living children I 0 1 2 3 4+ Total Never used contraception Intend to use in next 12 months 8.8 14.0 Intend to use later 25.7 7.6 Unsure as to timing 0.4 2.1 Unsure as to intention 4.8 2.6 Do not intend to use 25.1 15.3 Previously used contraception Intend to use in next 12 months 1.9 17.4 22.8 Intend to use later 20.6 14.2 10.6 Unsure as to timing 3.4 0.4 1.3 Unsure as to intention 1.0 2.1 3.1 Do not intend to use 8.1 24.2 29.8 10.9 10.2 9.1 11.1 4.3 2.2 1.2 6.6 1.3 1.8 0.5 1.3 5.5 4.4 1.3 3.7 10.4 13.3 32.4 17.7 19.6 13.3 17.0 4.4 3.6 10.5 1.6 1.5 1.4 5.2 3.6 3.0 37.3 33.6 27.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 All currently married nonusers Intend to use in next 12 months 10.7 31.4 33.7 29.9 22.4 28.0 Intend to use later 46.3 21.8 14.9 6.6 4.8 17.1 Unsure as to timing 3.8 2.5 2.6 3.4 1.9 2.7 Unsure as to intention 5.9 4.7 8.6 9.6 4.9 6.7 Do not intend to use 33.2 39.5 40.2 50.6 66.0 45.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 109 268 327 128 193 1,025 i Includes current pregnancy 59 Forty-five percent of all currently married nonusers of contraception do not intend to use a method of family planning at any time in the future. The percent who do not intend to use increases as number of children increases; 33 percent of nonusers with no children say they do not intend to use, while 66 percent among nonusers with four or more children say they do not intend to use. The KDHS results (data not shown) reveal that 43 percent of all nonusers of contraception 4 visited a health facility at some time in the 12 months prior to the survey but were not spoken to about family planning. This represents a significant lost opportunity on the part of the health community to impart knowledge about family planning to the population. In addition, 47 percent of the nonusers did not visit a health facility within the 12 months prior to the survey; this translates to 90 percent of all nonusers having had no contact with a health professional regarding family planning in the previous 12 months. 4.8 Reasons for Nonuse of Contraception The KDHS asked all nonusers who do not intend to use a method of family planning at any time in the future the reason they do not intend to use in the future. These results are presented for all women in Table 4.14, and for women below and above age 30. The most com- mon reason given for not using contraception is opposition to family planning on the part of the respondent (35 per- cent); this was the most common reason for both younger (43 percent) and older (34 percent) nonusers. The second most common reason given by younger women was want- ing more children (19 percent) and by older women being menopausal (24 percent). 4.9 Preferred Method of Contraception for Future Use Nonusers of contraception who intend to use at some time in the future were asked which method they would prefer to use. Data are presented for currently mar- ried women in Table 4.15 according to whether the non- users intend to use within the next 12 months or later. Three-quarters of nonusers who intend to use (79 Table 4.14 Reasons for not using contraception Percent distribution of women who are not cur- rently using a contraceptive method and who do not intend to use in the future, by main reason for not intending to use in the future, according to age, Kazakstan 1995 Age Reason for not using contraception <30 30-49 Total Infrequent sex 2.4 8.1 7.5 Menopausal/hysterectomy 1.9 23.6 21.4 Subfecund/int~cund 7.2 8.8 8.6 Want children 19.4 6.5 7.8 Gynecologic disease 2.4 6.6 6.2 Respondent opposed 42.5 33.7 34.6 Husband opposed 0.0 0.3 0.2 Religion 8.3 1.3 2.0 Knows no method 0.0 1.1 1.0 Knows no source 0.0 0.1 0.1 Health concerns 11.2 5.9 6.4 Side effects 0.0 0.5 0.4 Inconvenient 2.4 0.3 0.5 Interferes with body 0.0 0.5 0.4 Other 1.2 2.4 2.3 Don't know 1.2 0.4 0.5 Total 100.0 100.0 100.0 Number of women 47 418 466 ,ercent) report the IUD to be the method they would use. The pill is the second most commonly reported method (8 percent). Neither the rank order nor the magnitude of reporting varies greatly between nonusers who intend to use soon (within the next 12 months) and nonusers who intend to use at some later date. Other methods were mentioned by fewer than 4 percent of nonusers. 4 These data, which are not presented, refer to all nonusers regardless of marital status. 60 Table 4.15 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, Kazakstan 1995 Intend to use In next After Unsure Preferred method 12 12 as to of contraception months months timing Total Pill 5.8 9.9 (10.3) 7.5 IUD 81.4 75.8 (69.1) 78.7 lnjectables 1.3 0.0 (I.6) 0.8 Diaphragm/Foam/Jelly 0.0 0.6 (1.6) 0.3 Condom 3.8 3.0 (0.0) 3.3 Periodic abstinence 2.8 3.8 (0.0) 3.0 Withdrawal 0.4 0.0 (0.0) 0.2 Folk method 0.2 0.9 (1.6) 0.5 Douche 0.2 0.0 (0.0) 0.1 Missing 4.3 6.0 (15.8) 5.5 Total 100.0 100.0 100.0 100.0 Number of women 288 176 27 491 Note: Figures in parentheses are based on 25-49 unweighted cases. 4.10 Exposure to Family Planning Messages in the Electronic Media The mass media provide an opportunity to communicate family planning information to a broad spectrum of the population. Approximately half of the households in Kazakstan own a radio and nearly all (90 percent) own a television (see Table 2.9). All KDHS respondents were asked whether they had heard a family planning message on the radio or television in the few months prior to the interview. Results are presented in Table 4.16 by background characteristics of respondents. While 9 percent of respondents have recently heard or seen a family planning message on both radio and television, television is by far the most common source~3 percent of all respondents have seen a television message and 10 percent have heard a radio message. One-half of urban dwellers has seen a television message and 34 percent of rural dwellers have done so. As it was presented in Chapter 2.3.4, television is a more ready source to reach both urban and rural dwellers such that 94 percent of all respondents report watching television at least once a week. Ownership of radio and television in urban households is 62 and 93 percent, respectively, while only 37 percent of rural households own a radio and 86 percent own a television. Nearly everyone who hears a radio message has also seen a television message, and only 1 percent of respondents has heard only a radio message. Regional variation in exposure to television messages is greater than the urban/rural differential. Nearly three-quarters (71 percent) of women in Almaty City has recently seen a television family planning message, while only one-third (31 percent) of women in the South have seen such a message. Women in Almaty City are also the most likely to have both seen a television message and heard a radio message (25 percent). Nearly one-half of respondents in the other regions of Kazakstan has recently seen a television message. While television messages can be aimed at viewers of all educational levels, the likelihood that a respondent has in fact recently seen a television message increases steadily with increasing education. Thirty- 61 Table 4.16 Heard about family planning on radio and television Percent distribution of women by whether they have heard a radio or television message about family planning in the last few months prior to the interview, according to selected background characteristics, Kazakstan 1995 Heard family planning message on radio or television Heard Tele- Heard Number Background on Radio vision on of characteristic neither only only both Total women Residence Urban 49.9 0.9 37.6 11.7 100.0 2,133 Rural 64.3 1.2 29.2 5,2 100.0 1,638 Region Almaty City 26.0 2.6 46.0 25.4 100.0 271 South 68.7 0.8 24.7 5.8 100.0 1,206 West 50.0 0.1 40.8 9.1 100.0 477 Central 53.4 1.3 39.4 6.0 100.0 358 North and East 54.1 l.I 35.8 9.0 100.0 1,458 Education Primary/Secondary 63.5 0.9 29.2 6.3 100.0 1,376 Secondary-special 54.9 0.9 34.9 9.3 100.0 1,721 Higher 44.0 1.5 41.4 13. I 100.0 670 Ethnicity Kazak 63.6 0.9 29.0 6.5 100.0 1,696 Russian 46.4 1.4 40.6 I 1.7 100.0 1,309 Other 56.4 0.7 33.6 9.3 100.0 766 Total 56.2 1.0 33.9 8.9 100.0 3,771 Note: Total includes four women with no education. Figures may not add to 100.0 due to rounding. six percent of respondents with primary or secondary education has recently seen a television message, while 44 and 55 percent of women with secondary-special and higher education has seen such a message. Russian women are more likely than Kazak women to have recently seen a television message (52 percent and 36 percent, respectively). 4.11 Acceptability of Use of Electronic Media to Disseminate Family Planning Messages The KDHS asked all respondents whether they find it acceptable or not acceptable for family planning messages to be broadcast over the radio or television. Results are presented in Table 4.17 by background characteristics of respondents. Most women (81 percent) find it acceptable for family planning messages to be broadcast over the radio and television. Virtually all respondents who find radio messages acceptable also find television messages acceptable (data not shown). The youngest women (age 15-19) are less likely than older women to say they find broadcast messages acceptable (69 percent) because they are more likely to report being unsure (17 percent). Women in rural areas, women with primary or secondary education, and Kazak women all have approval levels that are slightly lower than their counterparts, but the overall levels of approval are high (approximately three-quarters of women in these categories approve). Overall, 12 percent of women feel that broadcasting of family planning messages is not acceptable. This level of nonacceptance is generally maintained across background characteristics of respondents. 62 Table 4.17 Acceptability of media messages on family planning Percent distribution of women by acceptability of messages about family planning on the radio or television, according to selected background characteristics, Kazakstan 1995 Acceptability of family planning messages on radio or television Not Number Background Accept- accept- of characteristic able able Unsure Total women Age 15-19 68.8 14,6 16.6 100.0 669 20-24 82.8 9.2 8.0 100.0 567 25-29 86.1 10.1 3.8 100.0 521 30-34 87.4 8,2 4.4 100.0 557 35-39 83.6 13.0 3.3 100.0 564 40-44 82.6 13.1 4.3 100.0 537 45-49 77.3 17.1 5,6 100.0 355 Residence Urban 85.6 9.6 4.8 100.0 2,133 Rural 75.1 15.1 9.8 100.0 1,638 Region Almaty City 84.9 12.2 2.9 100.0 271 South 77,4 13.8 8.8 100.0 1,206 West 80.5 7.2 12.3 100.0 477 Central 79.4 13.0 7.7 100.0 358 North and East 83.9 11.8 4.3 100.0 1,458 Education Primary/Secondary 72.8 15.1 12.1 100.0 1,376 Secondary-special 85.2 I0.1 4.7 100.0 1,721 Higher 87.4 10.4 2.1 100.0 670 Ethnicity Kazak 77.7 12.1 10.2 100.0 1,696 Russian 86.7 9.9 3.4 100.0 1,309 Other 78.7 15.4 5.8 100.0 766 Total 81.0 12.0 7.0 100.0 3,771 Note: Total includes four women with no education. Figures may not add to 100.0 due to rounding. 4.12 Exposure to Family Planning Messages in Print Media The high level of literacy in Kazakstan makes the print media a viable mechanism for communicating family planning information. Seventy-eight percent of all respondents report that they read a newspaper at least once a week. The KDHS asked women whether they saw a message about family planning in a newspaper or magazine, a poster, or a leaflet or brochure in the few months preceding the interview. Results are presented in Table 4.18 by background characteristics of respondents. About one-half (48 percent) of all respondents have recently seen information about family planning in the print media. Levels of exposure through print are generally on par with levels of exposure through television. Fifty-six percent of urban women and 37 percent of rural women have recently seen a family planning message in print. Three-quarters of women in Almaty City have recently read a printed family 63 Table 4.18 Family planning messages in print Percentage of women who received a message about family planning through the print media in the last few months prior to the interview, according to selected background characteristics, Kazakstan 1995 Type of print media containing family planning message Number Background No Newspaper/ Leaflet/ of characteristic source magazine Poster brochure women Residence Urban 44.5 49.1 13.1 22.9 2,133 Rural 62.6 32.5 5.8 L 3.6 1,638 Region Almaty City 24.7 66.2 28.5 35.6 27 I South 63.9 32.5 5.8 12.2 1,206 West 37.8 59.1 16.5 19.9 477 Central 44.7 46.6 10.9 31.7 358 North and East 54.7 38.4 7.5 17.7 1,458 Education Primary/Secondary 64.6 32.2 7.1 10.6 1,376 Secondary-special 49.3 43.4 9.8 21.6 1,721 Higher 34.9 58.1 16.2 28.9 670 Ethnicity Kazak 56.4 38.8 8.7 15.6 1,696 Russian 47.4 45.8 I 1.5 22.0 1,309 Other 51.9 42.0 10.0 20.8 766 Total 52.4 41.9 9.9 18.9 3,771 Note: Total includes four women with no education. planning message, while only one-third (36 percent) of women in the South Region have read such a message. While printed messages can be aimed at readers of all educational levels, the likelihood that a respondent has in fact recently seen or read a message increases steadily with increasing education. Thirty- five percent of respondents with primary or secondary education have recently read a message, while 51 and 65 percent of women with secondary-special and higher education have seen such a message. In fact, women with secondary-special and higher education are more likely to have read printed information than to have seen a television message. Russian women are more likely than Kazak women to have recently seen printed information on family planning (53 percent and 44 percent, respectively). Newspapers and magazines are the most commonly printed source in which family planning messages are seen (42 percent), although respondents also get messages from leaflets and brochures (19 percent) and posters (10 percent). Each of the print media presented in the table (newspapers/magazines, posters, leaflets/brochures) replicate the same patterns by background characteristics of respondents as the overall patterns for all print material combined. 64 4.13 Attitudes of Couples toward Family Planning Married women were asked how often they had discussed contraception with their husbands or partners in the previous year. Data are presented in Table 4.19 for currently married women by age. Whether or not couples speak with each other about family planning greatly depends on the age of the woman. Overall, about one-half of married women (47 percent) have not discussed family planning with their husbands at all in the previous year, one-third have discussed the topic once or twice, and one-fifth have discussed the topic more often. However, the percent of married women who have discussed family planning at least once in the previous year increases from 19 percent among 45-49 year-olds to 79 percent of 15-19 year-olds. One-third of women under the age of 25 have discussed family planning with their husbands three or more times. Table 4.19 Discussion of family planning by couples Percent distribution of currently married women who know a contraceptive method by the number of times family planning was discussed with their husband in the year preceding the survey, according to current age, Kazakstan 1995 Age Number of times family planning discussed Number Once or More of Never twice often Total women 15-19 21.4 44.1 34.5 100.0 77 20-24 23.2 43.3 33.5 100.0 346 25-29 29.7 42.9 27.4 100.0 421 30-34 44.3 34.9 20.8 100.0 452 35-39 53.5 30.3 16.2 100.0 476 40-44 64.6 26.7 8.6 100.0 434 45-49 80.8 14.0 5.2 100.0 264 Total 47.4 33.2 19.4 100.0 2,471 Currently married women were asked what they perceive to be their husbands' attitude toward contraception in terms of their approval or disapproval. Table 4.20 presents the results of the wives' perceptions of their husbands' attitude by background characteristics of respondents. Perhaps the most interesting finding in Table 4.20 is the fact that women report a lower approval level for their husbands than for themselves across every single background characteristic of respondents. Overall, 88 percent of women report that they approve of contraception, but only 70 percent report that their husbands approve; this translates to 66 percent of all married couples in which both the husband and wife approve of contraception. If there exists a difference of opinion, it is usually that the woman reports she approves, and that her husband disapproves (although not exclusively). Only 4 percent of women report that both she and her husband disapprove of family planning. The percent of couples in which both husband and wife approve of family planning has a pattern by background characteristics which generally mimics the pattern observed in the percent of women currently using family planning. 65 Table 4.20 Wives' perceptions of their husbands' attitude toward family p lanning Percent distribution o f currently marr ied women who know of a contraceptive method by wife's attitude toward family p lanning and wi fe 's perception of her husband's attitude toward family planning, according to selected background characteristics, Kazakstan 1995 Wife approves of Wife disapproves of couples using couples using family planning family planning Hus- Hus- Husband band's Both band's Number Background Both disap- attitude disap- Husband attitude Wife Husband Wife of characteristic approve proves unknown prove approves unknown unsure Total approves t approves women Age 15-19 53.2 22.1 12.7 2.5 2.0 0.0 7.5 1000 57,5 88.0 77 20-24 72,3 12.7 7.1 1.2 13 1,8 3.6 100.0 75,0 92.1 346 25-29 70.9 12,8 59 3.2 2.6 0.7 4.0 100.0 73,7 89.5 421 30-34 71.0 8.3 9,4 4.4 26 0.8 3.5 100.0 75.6 88.6 452 35°39 64.8 16.0 7.5 4,9 23 0.9 3.6 100.0 68.3 88.3 476 40-44 67.4 13.5 7.8 4.1 3.4 1.1 2.6 100.0 71.8 88.8 434 45-49 45.4 18.5 13.0 10.0 2.0 6.6 4,6 100,0 49.3 76.9 264 Residence Urban 68.6 14.1 7.1 3.4 2.7 1.1 3.0 100.0 72.5 89.8 1,381 Rural 62.8 12.9 9.9 5.5 2.1 2.2 4.6 100.0 66.3 85.6 1,090 Region Almaty City 73.2 9.3 74 4.1 2~7 11 2.2 100.0 77.0 89.9 161 South 58.2 14,0 8.4 6.3 3.4 2.6 71 100.0 64.3 80.6 796 West 65.7 9.8 175 2.1 116 1.2 32 1000 66.4 92.9 296 Central 72.5 116 59 43 2.3 2.0 14 1000 75,6 900 231 North and East 69.8 15.5 63 3,4 2.2 09 19 1000 72.6 91,6 987 Education Primary/Secondary 57.1 14~5 10.3 7.1 1.9 2~5 6.5 100.0 61.1 819 779 Secondary-special 68.8 13.9 8.0 3.3 2,6 1.2 2.2 1000 72.1 90.7 1,244 Higher 74.0 11,2 5.8 23 2.8 1.0 30 100.0 78.2 91.0 448 Ethnicity Kazak 61,6 13.0 9.8 5.3 2.3 2.7 5.2 100.0 65.5 84,5 1,047 Russian 71.0 13.9 7.4 29 2,5 1.0 1.3 100.0 74.2 923 916 Other 66.2 14.1 6.9 4.9 2.7 0.3 4.9 100.0 70.5 87.2 508 Total 660 13.6 8.3 4.3 2.4 1.6 3.7 100.0 69.7 88.0 2,471 i Includes cases in which the wife is unsure about her own attitude but knows her husband's 66 CHAPTER 5 INDUCED ABORTION Jeremiah M. Sullivan, Nailya M. Karsybekova, and Kia I. Weinstein Induced abortion as a means of fertility control has a long history in the republics of the former Soviet Union. Induced abortion was first legalized in the Soviet Union in 1920 but was banned in 1936 as part of a pronatalist policy emphasizing population growth. This decision was reversed in 1955 when abortion for nonmedical reasons was again legalized throughout the former Soviet Union. The practice of induced abortions can adversely affect a woman's health, reduce her chances for further childbearing and contribute to maternal and perinatal mortality. In Kazakstan, approximately 20 percent of maternal deaths are associated with this practice (Ministry of Health, 1996). In an effort to curtail this practice, the Ministry of Health of Kazakstan is committed to making modem, safe, and effective contraceptive methods readily available to the population. International experience with the collection of abortion data in population surveys has been relatively unsuccessful due to respondent reluctance to report events which, in many societies, are associated with social stigmas. In Kazakstan, social stigmas are not associated with the practice of abortion, and questions on this topic have been included, with apparent success, in some surveys (Foreit and McCombie, 1995). Accordingly, questions on abortion were developed, pretested, and included in the final questionnaires for the 1995 KDHS. Information about induced abortion was collected in the reproductive section of the Woman's Questionnaire (Appendix E). The section starts by asking respondents separate questions about the number of live births, induced abortions, miscarriages, and stillbirths they have bad. When asked about the number of induced abortions, respondents were told to include pregnancies terminated by vacuum aspiration (i.e., mini-abortions). After obtaining this aggregate data, an event-by-event pregnancy history was collected. The date of termination (month and year) and type of outcome were recorded for each reported pregnancy. ~ Information was first collected about the most recent (or last) pregnancy and then about the next-to-last, etc. 5.1 P regnancy Outcomes Table 5.1 shows the percent distribution by outcome of pregnancies terminating in the three years preceding the survey from mid- 1992 to mid- 1995. For all of Kazakstan, 54 percent of pregnancies terminate in a live birth and 46 percent in fetal wastage (i.e., an induced abortion, miscarriage, or stillbirth). Induced abortion is the most commonly reported type of fetal wastage and accounts for 38 percent of all pregnancy outcomes. A number of procedures were employed to obtain complete reporting of events in the pregnancy history. First, the event history was recorded in reverse chronological order (i.e., information was first collected about the last event, and then about the next-to-last, and so forth). It was felt that this procedure would result in more complete reporting of events for the period immediately prior to the survey than a procedure which proceeded in chronological order. Second, at the end of the section, interviewers were required to check that there was agreement between the aggregate data collected at the outset of the section and the number of events reported in the pregnancy history. Finally, interviewers were required to probe pregnancy intervals of four or more years in an effort to detect unreported events. 67 Table 5.1 Pregnancy outcomes by background characteristics Percent distribution of pregnancies terminating in the three years preceding the survey, by type of outcome, according to selected background characteristics, Kazakstan 1995 Pregnancy outcome Number Background Live Induced Mis- Still- of characteristics births abortion carriage births Total pregnancies Residence Urban 46.0 46.7 6.7 0.6 100.0 747 Rural 62.0 28.8 8.1 1.1 100.0 753 Region Almaty City 29.1 59.0 11.2 0.7 100.0 123 South 73.2 18.1 7.4 1.3 100.0 510 West 66.5 24.2 9.2 0.0 100.0 160 Central 57.2 33,4 8.2 1.3 100.0 148 Noah and East 37.5 55.9 5.8 0.7 100.0 559 Education Primary/Secondary 60.8 31.2 6.5 1.4 100.0 482 Secondary-special 5 I. I 40.2 7.9 0.8 100.0 754 Higher 49.7 42.5 7.6 0.2 100.0 264 Ethnicity Kazak 69.2 23.4 6.5 0.8 100.0 704 Russian 35.1 57.8 6.5 0.5 100.0 497 Other 49.5 37.8 10.9 1.7 100.0 298 Total 54.0 37.7 7.4 0.9 100.0 1,499 Table 5.1 also shows the distribution of terminated pregnancies by background characteristics of respondents. Women in all groups use induced abortion as a means of fertility control but the extent to which they do so varies substantially. For example, urban women abort 47 percent of their pregnancies while rural women abort 29 percent. Recourse to induced abortion also varies substantially by region. As expected, levels of abortion and fertility are inversely correlated. In the relatively low fertility areas of Almaty City and the North and East Region, women abort more than half of their pregnancies (59 and 56 percent, respectively). In the West and Central Regions where fertility levels are intermediate, women abort fewer pregnancies (24 and 33 percent, respectively). Finally, in the high-fertility South Region, women abort the lowest percentage of pregnancies (18 percent). Education and ethnicity are also associated with pregnancy outcome. For example, women of Russian ethnicity are twice as likely to abort a pregnancy (58 percent) as Kazak women (23 percent). 5.2 Lifetime Experience with Induced Abortion Table 5.2 presents the percentage of respondents who have had an abortion and the distribution of these women by the number of abortions by background characteristics. It should be noted that these statistics pertain to all women age 15-49 and, except for the statistics by age and number of live births, are not controlled for the stage of the family building process. 68 Table 5.2 Lifetime experience with induced abortion Percentage of women who have had at least one induced abortion and, among these women, the percent distribution by the number of induced abortions and the mean number of induced abortions according to selected background characteristics, Kazakstan 1995 Percentage of Number of induced abortions among women who had women who have had an induced abortion Number Background an induced of characteristics abortion 1 2-3 4-5 6+ Total Mean women Age <20 0.9 * * * * 100.0 * 669 20-24 20.6 63.6 30.1 6.2 0.0 100.0 1.6 657 25-34 46.0 37.1 43.2 14.6 5.1 100.0 2.3 989 35+ 65.9 21.7 43.8 20.5 14.1 100.0 3.6 1,456 No. of llve births None 4.1 74.6 20.1 3.2 2.2 100.0 1.5 1,103 I 45.0 39.6 39.4 15.7 5.3 100.0 2.4 713 2-3 65.8 24.1 46.0 17.9 11.9 100.0 3.3 1,488 4-5 48.1 31.4 35.1 21.1 12.4 100.0 3.1 345 6+ 36.7 44.1 29.6 20.0 6.3 100.0 2.7 122 Residence Urban 50.0 27.1 44.1 17.3 I 1.5 100.0 3.2 2,133 Rural 29.9 36.8 38.2 17.8 7.2 100.0 2.7 1,638 Region Almaty City 54.5 28.1 39.1 18.2 14.6 100.0 3.4 271 South 24.5 39.4 41.5 14.0 5.2 100.0 2.3 1,206 West 30.7 37.7 44.3 13.0 5.0 100.0 2.4 477 Central 43.7 30.7 39.2 17.5 12.7 100.0 3.1 358 North and East 55.6 25.7 43.4 19.4 11.6 100.0 3.3 1,458 Education Primary/Secondary 29.3 32.2 35.6 20.1 12.1 100.0 3.3 1,380 Secondary-special 49.3 27.4 45.1 17.1 10.3 100.0 3.0 1,721 Higher 45.4 35.0 43.2 14.7 7. l 100.0 2.5 670 Ethnicity Kazak 25.0 43.5 40.1 13.9 2.5 100.0 2.2 1,696 Russian 60.7 24.6 42.4 19.7 13.3 100.0 3.4 1,309 Other 44.1 26.3 44.7 16.6 12.4 100.0 3.2 766 Marital status Never married 2.1 * * * * 100.0 * 885 Currently married, living together 54.1 29.6 42.9 17.5 10.0 100.0 3.0 2,507 Ever married 48.3 29.6 39.4 18.8 12.2 100.0 3.2 379 Total 41.3 30.1 42.3 17.4 10.2 100.0 3.0 3,771 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Overall, 41 percent of women in Kazakstan have had at least one induced abortion. As expected, the percentage of women who have had an induced abortion increases rapidly with age, from 21 percent in the age group 20-24 to 66 percent in the age group 35 and over. Differences are also large by residence such that 50 percent of urban women report having had an induced abortion as compared to 30 percent of rural women. Regional differences with induced abortion are even greater; 56 percent of women in the North and East Region report experience with abortion as compared to 25 percent in the South Region. Only one-quarter of Kazak women have had an induced abortion compared to 61 percent of Russian women. Table 5.2 also presents information on repeat use of induced abortion. Overall, among the 41 percent of women having experience with induced abortion, 70 percent have had more than one abortion. Among 69 women age 35 years or more who have had an induced abortion, 78 percent have had multiple abortions. Among these women, the mean number of abortions is 3.6 and 14 percent have had six or more abortions. It is clear that repeat use of induced abortion is common in Kazakstan. 5.3 Rates of Induced Abortion In this section, rates of induced abortion are shown for the three-year period preceding the KDHS (from mid-1992 to mid- 1995). Three types of rates are presented: age-specific rates, the total abortion rate (TAR), and the general abortion rate (GAR). The age-specific rates are shown per 1,000 women. The TAR is a convenient summary measure of the age-specific rates and is expressed on a per woman basis. The TAR is interpreted as the number of abortions a woman will have in her lifetime if she experiences the current age- specific abortion rates during her reproductive years. As shown in Table 5.3 for all of Kazakstan, the age-specific rates of induced abortion increase for the younger age groups of women, peak among women 25-29 ( 104 per 1,000 women) and decline in the older age groups. The pattern is such that the age-specific rates of abortion are less than the fertility rates for younger women (i.e., through age group 25-29) but greater than the fertility rates for older women (Figure 5.1). Table 5.3 Induced abortion rates Age-specific induced abortion, total abortion, and general abortion rates for the three-year period prior to the survey, by residence and ethnicity, Kazakstan 1995 Residence Ethnicity Age Urban Rural Kazak Russian Other Total I 15-19 20 10 0 35 21 15 20.24 86 70 31 171 77 78 25-29 123 82 86 147 78 104 30-34 81 67 53 78 117 75 35-39 53 46 36 68 44 50 40-44 19 15 10 32 2 18 45-49 12 7 5 18 (4) 10 TAR 15-49 1.97 1.48 1.11 2.74 (1.72) 1.75 TAR 15-44 1.91 1.45 1.08 2.66 (I.69) 1.70 GAR 62 50 36 84 57 57 TAR: Total abortion rate expressed per woman GAR: General abortion rate (induced abortions divided by number of women 15-44) expressed per 1,000 women Includes Kazak, Russian, and other ethnic groups Note: Rates in parentheses indicate tht one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. The age-specific rates imply a lifetime total abortion rate (TAR) of 1.8 abortions per woman. It is interesting to compare this TAR with an estimate for the Russian Federation based on data pertaining to the same time period (i.e., 1994). The estimate for Kazakstan is at the high end of the estimated range (between 1.0 and 2.0 abortions per woman) for the Russian Federation (Mroz and Popkin, 1995). Table 5.3 also shows induced abortion rates by residence and ethnicity. Age-specific abortion rates in the urban areas exceed the rural rates. At every age, the urban rates are at least 15 percent greater than the rural rates and frequently they are 30 to 50 percent greater. The urban TAR (2.0 abortions pet' woman) exceeds the rural TAR (1.5) by 33 percent (Figure 5.2). The differentials by ethnicity are even greater than 70 200 Figure 5.1 Age-specific Rates of Fertility (ASFR) and Induced Abortion (ASAR) Rates per 1,000 Women 150 100 50 0 ~- ~ ~ . . . . . . . . . . . . . . . , , 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Group KDHS1995 Figure 5.2 Total Induced Abortion Rate by Background Characteristics KAZAKSTAN RESIDENCE Urban Rural REGION Almaty City South West Central North and East ETHNICITY Kazak Russian 1.8 2.0 ~ 1 , 5 ~Z~dil i i:i ~ :;:i i i~~~S ~i:i!i::::::::;:~ 3.0 : : : : : : : : : : : : : : : : : : : : : : : : : :S~ ~~~:::::: : : ! 2 5 ~ % ~ 2.7 0D 1.0 2.0 30 4.0 Abortions per Woman 5.0 6.0 KDHS1995 71 by residence; Russian women frequently have age-specific rates two or three times greater than Kazak women. The TAR for Russian women (2.7 abortions per woman) exceeds the TAR for Kazak women (1.1) by about 150 percent. 5.4 T ime Trends in Induced Abort ion An indication of time trends in induced abortion can be obtained by comparing values of the TAR for the three- year period preceding the survey with the mean number of abortions reported by women age 40-49, 2 Table 5.4 indi- cates that, for all of Kazakstan, the current TAR (1.8 abortions per woman) is substantially less than the number of abortions reported by women age 40-49 (2.6). Lesser values of the TAR compared to the number of abortions reported by older women are evident for all population groups. This implies that a movement away from induced abortion as a means of fertility control has occurred at the national level and among all segments of the population. The KDHS data allow a more direct assessment of t ime trends of induced abortion. Table 5.5 shows age-spe- cific rates of induced abortion for successive five-year time periods prior to the survey) Except for women age 15-19, age-specific rates have declined in every age group. Declines in abortion rates are as large as 50 percent over the past 20 years among women ranging in age from 20-39. Figure 5.3 shows a graphical representation of these declines. The age-specific rates can be summarized in terms of the TAR restricted to women age 15-44. As seen in Table 5.5, between the time periods 5-9 and 0-4 years before the survey, the TAR declined from 2.0 to 1.7 abortions per woman- -a decline of approximately 15 percent over a five- year period. Table 5.4 Induced abortion rates by background characteristics Total induced abortion rates for the three-year period prior to the survey and mean number of induced abortions ever done to women age 40-49, by selected background characteristics, Kazakstan 1995 Total Mean induced number of Background abortion abortions characteristic rate I 40-49 Residence Urban 1.97 2.91 Rural 1.48 1.98 Region Almaty City (3.04) 3.57 South (0.89) 1.26 West (I .03) 1.48 Central (I.57) 2.96 North and East (2.54) 3.45 Education Primary/Secondary 1.61 2.47 Secondary-special 1.89 2.85 Higher (1.62) 2.16 Ethnicity Kazak 1.11 1.24 Russian 2.74 3.67 Other (I .72) 2.76 Total 1.75 2.59 Note: Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 women-years of exposure. I Women age 15-49 2 The TAR discussed is a summary measure of current abortion rates, while the mean represents the actual, cumulative experience of older women. 3 A limitation of survey methodology for the investigation of time trends is evident in Table 5.5. In the KDHS survey, women 50 years of age and older were not interviewed. Thus, when calculating age-specific rates for earlier time periods, data are not available for older age groups of women. For example, rates cannot be calculated for women age 40-44 for the period 10-14 years before the survey, because those women were over age 50 at the time of the survey and were not interviewed. 72 Figure 5.3 Age-specific Abortion Rates by Time Period 250 Abortions per 1,000 Women 200 150 100 50 0 I • -r i - - • I 15-19 20-24 25-29 30-34 35-39 4044 4549 Age Group Years Prior to Survey [*04 *5-9 .l~:t,~ +ig-~ KDHS 1995 Table 5.5 Trends in age-specific induced abortion Age-specific induced abortion rates for five-year periods preceding the survey, by woman's age at the time of birth, Kazakstan 1995 Number of years preceding the survey Age 0-4 5-9 10-14 15-19 15-19 21 9 13 12 20-24 80 99 125 134 25-29 99 117 136 205 30-34 79 84 120 [181] 35-39 40 51 [89] 40-44 22 [32] 45 -49 [ 14] TAR 15-44 1.71 1.96 GAR 58 71 Note: Age-specific induced abortion rates are per 1,000 women. Estimates in brackets are truncated. TAR: Total abortion rate expressed per woman GAR: General abortion rate (induced abortions divided by number of women 15-44) expressed per 1,0(30 women 73 5.5 Abortion Rates from the Ministry of Health The Ministry of Health (MOH) has for many years collected abortion data through a registration system which operates in all of its facilities. The data from the MOH have recently been published in a compendi- um of health statistics for the republics of Central Asia (Church and Koutanev, 1995). The data on induced abortion are shown in terms of annual rates per 1,000 women of childbearing age. Comparison of the MOH data with that of the KDHS will be useful as a means of evaluating the reliability of the two data sets. Table 5.6 shows rates of abortion per 1,000 women of childbearing age for the time periods 1986-90 and 1993-95. For both time Table 5.6 Comparison of abortion rates General abortion rates (induced abortions per 1,000 women of childbearing age) by time period and percent decline, Ministry of Health and KDHS, 1986-95 Time period Percent Source 1986-90 1993-95 decline KDHS 71 57 20 Ministry of Health 75 62 17 Sources: Church and Koutanev (1995) and Ministry of Health (1996) Note: Rates for the KDHS are displaced six months from the dates shown. The KDHS rate for 1993-95 is calculated for the three years preceding the survey, from mid-1992 to mid-1995 (see Table 5.3). Similarly, the rate for 1986-90 is for mid-1985 to mid-1990 (see Table 5.5). periods, the MOH rates are somewhat greater than the KDHS rates so that the MOH data appear to be more complete. Nevertheless, given the poor quality typically associated with abortion data, the agreement between the two data sets is remarkably good. Both data sets indicate a decline of the same magnitude in induced abortion over the five-year period, with a 20 percent decline for the KDHS rates and a 17 percent decline for the MOH rates. 5.6 Impact of Contraception on Abortion The relationship between the availability and use of reliable contraceptive methods and reliance on abortion as a fertility control measure is of considerable interest to Kazakstan and to the family planning community throughout the world. Intuitively, an inverse relationship would be expected but empirical confirmation of such a relationship is scarce. Data on Kazakstan offer an opportunity to observe the impact which increases in contraceptive use can have on induced abortion. For the period from 1988 to 1995, there are credible annual statistics from the MOH on contraceptive prevalence (pill and IUD users per 100 women age 15-49) and induced abortion (abortions per 1,000 women age 15-49). 4 4 Very similar levels and trends in abortion are found in the data from the KDHS and the MOH, which tends to substantiate the accuracy of both sets of data. Since 1988, the MOH has collected annual statistics on active pill and IUD users at public facilities. The KDHS prevalence rate for pill and IUD users for mid-1995 is identical to the MOH rate for 1993 (both were 29 percent of women of childbearing age), which supports the reliability of the MOH statistics. 74 Table 5.7 shows average values of the annual statistics for the periods 1988-89 and 1993-95. Over the interval of about five years, the pill and IUD prevalence rate in- creased by 32 percent and the abortion rate declined by 15 percent. This is clear and con- vincing evidence that contraception has been substituted for abortion in recent years in Kazakstan. 5.7 Contraceptive Use Before Abortion For each pregnancy terminated by in- duced abortion in the three years preceding the survey, respondents were asked whether Table 5.7 Time trends in contraception and abortion Contraceptive use rate (pill and IUD) and induced abortion rates, by time period, Ministry of Health, 1988-95 Time period Percent Rate 1988-89 1993-95 change Pill and IUD users (per 100 women) 22 29 +32 Abortion rate (per 1,000 women) 73 62 - 15 Sources: Church and Koutanev (1995) and Ministry of Health (1996) they were using a method of contraception at the time they became pregnant, and if so, what method. Table 5.8 shows the relevant statistics. Twenty-three percent of induced abortions are preceded by a contraceptive failure. 5 Most method failures resulting in abortions occur while using the IUD, although failures associated with use of condoms and periodic abstinence are significant. It seems clear that the availability of more reliable methods and greater consistency of method use would reduce the incidence of induced abortion. Table 5.8 Use of contraception prior to pregnancy Percentage of live births, all pregnancies, and pregnancies terminated by induced abortion in the three years preceding the survey by the contraceptive method used, if any, at the time of becoming pregnant, Kazakstan 1995 Use of Live Induced All contraception births abortions pregnancies l No contraception 98.2 77.3 89.9 Any method 1,8 22.7 10.1 Any modern method 1.4 16.6 7.6 Pill 0.2 2.4 1.1 IUD 1.0 10.0 4.5 Condom 0.2 4.2 2.0 Any traditional method 0.5 6.1 2.5 Periodic abstinence 0.3 4.4 1.8 Withdrawal 0.0 0.6 0.2 Douche 0.1 1.1 0.5 Total 100.0 100.0 100.0 Number of pregnancies 810 565 1,499 L Includes stillbirths and miscarriages 5 Another study of the reproductive practices of urban women in Kazakstan found that 33 percent of recent induced abortions were preceded by contraceptive failure (Foreit and McCombie, 1995). 75 5.8 Service Providers and Procedures Used for Abortion All women who had an induced abortion in the three years prior to the survey were asked where the abortion was per- formed, who assisted or provided the service, and what method was used. Table 5.9 indicates that a substantial majority of abor- tions, 66 percent, are performed at a hospital and another 27 per- cent at a polyclinic. Only 7 percent of abortions are performed at a place other than a hospital or polyclinic. The vast majority of abortions, 96 percent, are performed by a doctor. Table 5.9 also shows the distribution of abortions by pro- cedure used. Dilation and curettage is the procedure used for almost two-thirds of abortions (62 percent) while vacuum aspira- tion is employed for about one-third of the cases (35 percent). A small proportion of abortions are performed by Caesarean section (2 percent). Of the events occurring in hospitals (figures not shown), dilation and curettage is the procedure of choice (72 per- cent), while almost all other abortions are by vacuum aspiration (25 percent) and a small proportion are by Caesarean section (3 percent). Alternatively, abortions performed at polyclinics are about equally likely to be performed by dilation and curettage (48 percent) and vacuum aspiration (52 percent). Table 5.9 Source of services T type of provideq and procedure used for abortion Percent distribution of induced abortions in the three years peceding the survey by source of services, type of provider, and procedure used, Kazakstan 1995 Characteristic Percent Source of services Hospital 66.0 Polyclinic 26.7 Other 3.6 Public fee for service 2.9 Other 0.8 Type of provider Doctor 96.0 Nurse, midwife 3.3 Other 0.7 Procedure Dilation and curettage 62.3 Vacuum aspiration 35.2 Caesarean section 2.3 Total 100.0 Number of induced abortions 565 Table 5.10 Health problems following abortion Percentage of induced abortions in the three years preceding the survey in which women had selected specific health problems, and complications requiring hospitalization, Kazakstan 1995 Type of health problem Percent Specific health problems Infection 6.6 Lack of menstruation 6.9 Excessive bleeding 9.0 Complications requiring hospitalization Number of induced abortions 6.6 565 5.9 Complications of Abortion and Medical Treatment Respondents who reported having an induced abortion in the three years preceding the survey were also asked if they experienced any health problems following the abortion and, if so, the type of problem and if they were hospitalized as a result of their problem. Approximately 20 percent of respondents have had health problems following the abortion. The most commonly reported problems are infection, lack of menstruation, and exces- sive bleeding (Table 5.10). Seven percent of women report that they had been hos- pitalized as a result of problems relating to their abortion (Table 5.10). The mean length of hospital stay for these women is 14 days. Hospitalization is reported at about the same rate for abor- tions performed by dilation and curettage as for those performed by vacuum aspiration. The hospitalization rate for health prob- lems following an abortion seems high. However, it should be kept in mind that the number of cases of abortion in the survey is small so that the variance of the estimated statistic is large. Additionally, recourse to hospitalization is a common treatment pattem for reproductive health problems in Kazakstan, as in most of the republics of the former Soviet Union, so that the severity of a health problem can not be readily inferred from the fact of hospitalization. 76 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Kia L Weinstein This chapter addresses the principal factors, other than contraception and abortion, that affect a woman's risk of becoming pregnant. These include nuptiality, sexual activity, postpartum amenorrhea and abstinence from sexual relations. Marriage is an overall indicator of exposure to the risk of pregnancy. More direct measures of exposure relate directly to sexual activity: age at first sexual intercourse and the frequency of intercourse. Postpartum amenorrhea and abstinence affect the interval between births. These factors determine the length and pace of reproductive activity and are, therefore, important in understanding fertility. 6.1 Marital Status Table 6.1 and Figure 6.1 show the distribution of all women by marital status at the time of the survey. The term "married" refers to legal or formal marriage (civil or religious), while "living together" refers to informal unions. In subsequent tables, these two categories are combined and referred to collectively as "currently married" or "currently in union." Women who are widowed, divorced, and not living together (separated) make up the remainder of the "ever-married" or "ever in union" category. Two-thirds of women are currently in a union (67 percent are married or living together). While the majority of women are in a union, a fair proportion enter their twenties having never been married (32 percent of women age 20-24 are never-married). Eighty-two percent of women age 30 and older are in a union; 9 percent are divorced or separated. As expected, the proportion of women who are widowed increases with age, reaching 11 percent among those 45-49 years. Table 6.1 Current marital status Percent distribution of women by current marital status, according to age, Kazakstan 1995 Marital status Never Living Not living Age married Married together Widowed Divorced together Total Number 15-19 86.6 10.8 1.2 0.0 0.5 0.9 100.0 669 20-24 31.8 57.1 4.1 0.3 2.7 3.9 100.0 567 25-29 10.2 79.6 1.9 0.4 5.2 2.6 100.0 521 30-34 4.8 79.1 3.0 3.3 8.7 1.2 100.0 557 35-39 4.2 82.6 2.8 3.5 5.7 1.1 100.0 564 40-44 2.3 80.3 2.8 5.1 8,3 1.2 100.0 537 45-49 2.7 74.2 1.3 10.9 9.5 1.4 100.0 355 Total 23.5 64.0 2.5 2.9 5,4 1.8 100.0 3,771 Note: Figures may not add to I00.0 due to rounding. 77 Figure 6.1 Marital Status of Women 15-49 Currently manied 67% Widowed 3% ~)ivorced/seperated 7% Never married 24% KDHS 1995 Because marriage is not an exact measure of exposure to the risk of pregnancy, the 1995 KDHS also asked the one-third of women who are not currently in a union whether they have a regular sexual partner, an occasional sexual partner, or no sexual partner at all. Table 6.2 shows the distribution of women who are not currently in a union (whether never married or previously married) by type of current sexual relationship. Most women who are not currently married (never married or previously married) report that they have no sexual partner (84 percent). However, there are significant differences in sexual activity by background characteristics. While only 5 to 20 percent of unmarried women in all regions other than Almaty City have a sexual partner, 35 percent of unmarried women in Almaty City have a regular or occasional sexual partner. The likelihood of having a sexual partner increases with increasing education. While only 9 percent of women with primary or secondary schooling have a sexual partner, one-quarter of women with higher education have a sexual partner. A large differential also exists between ethnic Kazak and ethnic Russian women: 9 percent of ethnic Kazak women report having a partner, while 30 percent of ethnic Russian women have a sexual partner. Women who have previously been in a union (30 percent of those who are not married) are much more likely to have a sexual partner than women who have never been married. Twenty-seven percent of women who have previously been in a union report themselves as having a regular or occasional sexual partner; only 11 percent of never married women have a regular or occasional sexual partner. Adolescent sexual activity is relatively low in Kazakstan; 7 percent of teens report having a regular or occasional sexual partner. Unmarried women in their early thirties are the most likely to have a sexual partner (36 percent of 30-34 year-olds). 78 Table 6,2 Sexual relationships of nonmartied women Percent distribution of women currently not in a union by type of current sexual relationship, by selected background characteristics, Kazakstan 1995 Never married Widowed, divorced, not living together Regular Occasional No Regular Occasional No Number Background sexual sexual sexual sexual sexual sexual of characteristic partner partner partner partner partner partner Total women Age 15-19 4.4 2.1 92.0 0.7 0.2 0.7 100.0 588 20-24 9.6 5.1 67.4 3.6 2.0 12.3 100.0 220 25-29 7.8 4.0 43.5 13.0 3.2 28.5 100.0 96 30-34 3.6 0.5 22,5 24.1 7.3 42.0 1130.0 100 35-39 1.3 5.7 21.8 19.7 2.6 48.8 1130.0 82 40-44 0.0 1.9 11.5 7.9 1.5 77.2 100.0 91 45-49 3.1 0.0 7.7 3.7 7.4 78.0 100.0 87 Residence Urban 7.1 3.7 54.2 8.0 2.7 24.3 100.0 735 Rural 1.8 1.4 73.8 3.2 1.1 18.8 100,0 529 Region Almaty City 8.2 5.7 41.4 14.3 6.6 23.8 100,0 108 South 0.4 1.7 75.1 2.6 0.0 20.2 100.0 395 West 5.7 1.3 64.4 4.3 2.1 22.3 100.0 179 Central 6.8 1.2 62.8 7.5 3.4 18.3 100.0 124 North and East 7.2 3.8 55.5 7.1 2.3 24.1 100.0 458 Education Primary/Secondary 1.9 1.8 74.0 5.0 0.3 16.9 100.0 583 Secondary-special 6.8 2.5 52.5 5.7 3,8 28.7 100.0 461 Higher 8.7 5.6 52.5 8.9 2.9 21,4 100.0 220 Ethnlcity Kazak 2.0 2.0 73.6 3.7 0.8 17.9 100.0 632 Russian 10,6 3.9 46.1 10.6 5.1 23.6 100.0 378 Other 3.6 2.7 58.7 4.7 0.4 29.9 100.0 254 Total 4.9 2.7 62.4 6,0 2.0 22.0 100.0 1,264 6.2 Age at First Marriage Marriage is an important demographic and social indicator; it generally marks the point in a woman' s life when childbearing becomes welcome. Information on age at first marriage was obtained by asking all ever-married respondents the month and year they started living together with their first spouse. Virtually all women were able to report this date. The data in Table 6.3 show that the median age at marriage has been hovering at about 21 years for some time. This means that half the women in Kazakstan marry before age 21. Cohort trends in age at marriage can also be described by comparing the cumulative distribution for successive age groups, as shown in Table 6.3.~ While the KDHS did not find a marked change in the median For each cohort, the accumulated percentages stop at the lower age boundary of the cohort to avoid censor ing problems. For instance, for the cohort currently age 20-24, accumulation stops with the percentage marr ied by exact age 20. 79 Table 6.3 Age at first marriage Percentage of women who were first married by specific exact age and median age at first marriage, according to current age, Kazakstan 1995 Current age 15 Percentage who were Percentage Median first married by exact age: who had Number age at never of first 18 20 22 25 married women marriage 15-19 0.2 NA NA NA NA 86.6 669 a 20-24 0.4 18.5 44.5 NA NA 31.8 567 a 25-29 0.2 7.2 30.6 60.6 84.8 10.2 521 21.2 30-34 0.4 8.9 33.0 61.1 86.1 4.8 557 21.3 35-39 0.4 9,1 34,9 65.1 81.8 4.2 564 20.9 40-44 0.5 10.0 34.8 63.2 84.7 2.3 537 20.9 45-49 1.3 16.0 40.0 64.1 86.6 2.7 355 20.8 25-49 0.5 9.8 34.3 62.7 84.6 4.9 2,535 21.0 NA = Not applicable a Omitted because less than 50 percent of the women in the age group x to x+4 were first married by age x. age at marriage over time, it did find that the proportion marrying at the youngest ages has declined. The median is a summary measure, indicating the age by which half the population has married, but there can be a shift in the age at marriage which would not be reflected in the median. For example, there has been a gradual yet steady decline in the proportions marrying by age 18, from 16 percent of 45-49 year-olds down to 7 percent of 25-29 year-olds. However, women currently age 20-24 seem to be an exception to the trend. Young women would presumably have the most accurate reporting of dates of marriage because they married most recently. The data show that 20-24 year-olds are in fact marrying earlier than their predecessors. Overall, the majority of women in Kazakstan marry within a relatively narrow age range. One-third of women are married by age 20, and nearly an additional third by age 22. Table 6.4 presents the median ages at marriage for women age 25-49 by selected background characteristics. The most pronounced differential in median age at marriage is one that is observed in many societies--age at marriage increases with increasing education. A differential of two years in the median from least to most educated occurs within every age group; women with higher education have a median age at marriage (22.6) which is more than two years later than women with a primary or secondary education (20.1). The other significant differential is that ethnic Kazaks have a median age at marriage (21.7) that is one year later than ethnic Russians (20.5); this differential has been holding steady for over 20 years. Overall, while some differentials exist in age at marriage within the population, these data indicate that there has been no major change in age at marriage in Kazakstan over the past 20 years. 80 Table 6.4 Median age at first marriage Median age at first marriage among women age 25-49 years, by current age and selected background characteristics, Kazakstan 1995 Current age Women Background age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 20.9 21.3 21.1 21.4 21.0 21.2 Rural 21.6 21.2 20.7 20.3 20.4 20.9 Region Almaty City 21.4 21.3 21.7 21.8 21.8 21.6 South 21.2 21.5 20.7 20.4 20.9 21.0 West 22.0 21.9 21.4 21.0 20.5 21.5 Central 21.8 21.0 21.8 20.8 20.9 21.2 North and East 20.7 20.8 20.7 21.1 20.6 20.8 Education Primary/Secondary 20.1 20.2 20.7 20.3 19.2 20.1 Secondary-special 21.0 21.2 20.7 20.8 21.4 21.0 Higher 22.5 22.4 22.2 22.8 23.3 22.6 Ethnicity Kazak 22.1 21.8 21.9 21.2 21.5 21.7 Russian 20.5 20.6 20.4 20.7 20.5 20.5 Other 20.5 20.8 20.6 21.0 20.0 20.7 Total 21.2 21.3 20.9 20.9 20.8 21.0 Note: The medians for women 15-19 and 20-24 could not be determined because less than 50 percent were married by age 15 and 20 in all subgroups shown in the table. 6.3 Age at First Sexual Intercourse Whi le age at f i rst marr iage is commonly used as a proxy for exposure to in tercourse , the two events do not a lways co inc ide exact ly . Some women may engage in sexua l re lat ions pr io r to marr iage , in wh ich case, the propor t ion o f marr ied women wou ld underest imate the percent o f women who are sexua l ly act ive. The KDHS asked women to state the age at wh ich they f irst had sexua l in tercourse. The resu l ts are presented in Tab les 6.5 and 6.6. Table 6.5 Age at first sexual intercourse Percentage of women who had first sexual intercourse by exact age 15, 18, 20, 22, and 25, and median age at first intercourse, according to current age, Kazakstan 1995 Current age 15 Percentage who had Percentage Median first intercourse by exact age: who Number age at never had of first 18 20 22 25 intercourse women intercourse 15-19 1.4 NA NA NA NA 79.5 669 a 20-24 1.1 23.9 52.5 NA NA 23.6 567 a 25-29 0.3 10.4 38.8 65.9 85.8 7.7 521 20.7 30-34 0.5 11.5 38.2 64.3 86.4 3.2 557 20.9 35-39 0.5 10.6 38.1 66.9 82.1 2.9 564 20.7 40-44 0.5 11.2 38.5 64.1 86.0 1.2 537 20.8 45-49 1.3 17.1 42.0 66.2 89.7 1.2 355 20.6 25-49 0.6 11.8 38.9 65.4 85.7 3.4 2,535 20.8 NA = Not applicable a Omitted because less than 50 percent in the age group x to x+4 had had intercourse by age x. 81 As observed for marriage, there has been no great change over time in the median age at first intercourse. However, by comparing Table 6.5 with Table 6.3, it can be seen that the proportion of women having first intercourse by specific ages is slightly higher than the proportions married at that age. For example, 34 percent of women are married by age 20 while 39 percent have had sexual intercourse by age 20. Table 6.6 presents the median age at first intercourse by age and selected background characteristics. By comparing Tables 6.4 and 6.6, it can be seen that most of the differential between age at marriage and age at first intercourse is attributable to younger women. These women tend to have higher education, and live in urban areas. Ethnic Russian women age 25-29 have a median age at first intercourse that is one year earlier than their median age at first marriage. Table 6.6 Median age at first intercourse Median age at first sexual intercourse among women age 25-49 years, by current age and selected background characteristics, Kazakstan 1995 Current age Women Background age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 20.2 20.7 20.7 21.2 20.9 20.7 Rural 21,5 21.1 20.8 20.1 20.0 20.8 Region Almaty City 20.7 20.5 21.1 21.5 21.1 20.9 South 21.1 21.5 20.7 20.3 20.8 21.0 West 21.7 22.1 21.3 20.9 20.2 21.3 Central 2 I. 1 20.8 21.6 20.7 20.7 21.0 North and East 19.8 20.0 20.4 21.0 20.4 20.3 Education Primary/Secondary 19.8 19.9 20.6 20.0 19.0 19.9 Secondary-special 20.6 20.8 20.4 20.6 21.2 20.7 Higher 21.7 22.2 21.9 22.8 22.9 22.3 Ethnicity Kazak 22.0 21.7 21.9 21.2 21.5 21.7 Russian 19.5 19,8 20.0 20.5 20.3 20.0 Other 20.2 20.4 20.5 20.7 19.7 20.3 Total 20.7 20.9 20.7 20.8 20.6 20.8 Note: The median for cohorts 15-19 and 20-24 could not be determined because less than 50 percent of the women had bad intercourse for the first time by age 15 and 20, respectively. 6.4 Recent Sexual Activity In the absence of contraceptive use, frequency of sexual intercourse is a direct determinant of pregnancy; therefore, knowledge of frequency is a useful indicator of exposure to pregnancy. Table 6.7 shows the percent distribution of women by sexual activity in the four weeks prior to the survey and the duration of abstinence by whether or not the women have recently had a birth (are postpartum). Women are considered to be sexually active if they have had sexual intercourse at least once in the four weeks prior to the survey. Overall, 62 percent of all women interviewed were sexually active in the four weeks preceding the survey. Only 2 percent of women are postpartum abstaining, 15 percent of women are not sexually active 82 Table 6.7 Recent sexual activity Percent distribution of women by sexual activity in the four weeks preceding the survey, and among those not sexually active, the length of time they have been abstaining and whether postpartum or not postpartum, according to selected background characteristics and contraceptive method currently used, Kazakstan 1995 Not sexually active in last 4 weeks Background Sexually Abstaining Abstaining characteristic/ active (postpartum) (not postpartum) Never Number contraceptive in last had of method 4 weeks 0-1 years 2+ years 0-1 years 2+ years sex Missing Total women Age 15-19 14.7 1.0 0.0 4.7 0.0 79.5 0.1 100.0 669 20-24 58.6 4.3 0.4 11.1 1.5 23.6 0.5 100.0 567 25-29 75.6 3.4 0.0 10.3 2.1 7.7 0,8 100.0 521 30-34 81.5 1,1 0.2 9.1 4.3 3.2 0.6 100.0 557 35-39 80.3 1.0 0.2 10.0 4.2 2.9 1.5 100.0 564 40-44 73.8 0.6 0.0 11.3 11.3 1.2 1.7 100.0 537 45-49 61.1 0.0 0.0 19.6 16.4 1.2 1.7 100.0 355 Duration of union (years) Never married 7.2 0.6 0.0 5.4 1.8 84.9 0.1 100.0 885 0-4 80.3 6.6 0.3 10.7 0.9 0.0 1.1 100.0 541 5-9 82.0 2.0 0.2 11.1 3.9 0.0 0.8 100.0 564 10-14 83.4 1.1 0.1 9,7 4.8 0.0 0.9 100.0 516 15-19 79.8 0.6 0.2 11.0 7.5 0.0 0.9 100.0 524 20-24 78.6 0.5 0.0 10,7 8.3 0.0 1.9 100,0 443 25-29 66.0 0.0 0.0 19.1 13.4 0.0 1.4 100.0 257 30+ (44.7) (0.0) (0.0) (33.6) (19.0) (0.0) (2.7) 100.0 41 Residence Urban 63.1 1.3 0.1 11.9 5.4 17.5 0.7 100.0 2,133 Rural 61.0 2.2 0.1 8.1 4.4 23.1 1.2 100.0 1,638 Region Almaty City 61.6 1.6 0.3 17.1 5.2 13.7 0.5 100.0 271 South 59.8 1.6 0.2 8.1 4.7 24,3 1.3 100.0 1,206 West 57.8 1.6 0.0 11.2 5.1 23.2 1.2 100.0 477 Central 62.8 1.8 0.2 11.0 3.7 19,2 1.2 100.0 358 North and East 65.6 1.7 0.0 10,2 5.3 16.5 0.6 100.0 1,458 Education Primary/Secondary 52.1 1.6 0.3 9.1 5.2 30.7 1.0 100.0 1,380 Secondary-special 69.0 1.5 0.0 10.5 4.7 13.3 0.9 100.0 1,721 Higher 65.5 2.3 0.1 11.8 5.1 14.6 0.7 100.0 670 Ethnicity Kazak 56.8 2.1 0.1 8.6 4.9 26.3 1.3 100.0 1,696 Russian 69.3 1.5 0.2 12.1 3.7 12.4 0.8 100.0 1,309 Other 62.0 1.1 0.1 10.7 7.1 18.7 0.3 100.0 766 Contraceptive method No method 40.8 2.8 0.2 12.3 7.4 35.1 1.3 100.0 2,140 Pill 88.8 0.0 0.0 11.2 0.0 0.0 0.0 100.0 55 IUD 90.4 0.1 0.0 7.1 2.2 0.0 0.3 100.0 1,054 Condom 91.0 0.0 0.0 8.7 0.0 0.0 0.3 100.0 128 Periodic abstinence 90.0 0.0 0.0 9.7 0.3 0.0 0.0 100.0 190 Other 89.9 1.0 0.0 6.4 1.6 0.0 1.2 100.0 204 Total 62,2 1.7 0,1 10.2 4.9 19.9 0.9 100.0 3,771 Note: Figures in parentheses are based on 25-49 unweighted women. 83 for reasons unrelated to childbirth, and 20 percent of women have never had sexual intercourse. The relatively low percentage of women sexually active is mostly attributable to women in their teens who have never had intercourse, and women over age 45. At least three-quarters of women age 25-39 are sexually active. Ethnic Russians are a bit more likely than ethnic Kazaks to be sexually active (69 versus 57 percent, respectively). Not surprisingly, women who are using a method of family planning are more likely to be sexually active than women who are not using a method (much of the difference is due to the fact that many of the women using no method have not yet had intercourse). Sexual activity does not vary greatly by method of contraception. 6.5 Postpartum Amenorrhea, Abstinence and Insusceptibility Postpartum amenorrhea refers to the interval between childbirth and the return of menstruation. During this period, the risk of pregnancy is reduced. The duration of reduced risk of conception largely depends on two fac- tors: the length and intensity of breastfeeding, which tends to suppress the resumption of ovulation, and the length of time before the resumption of sexual intercourse. Women who are either amenorrheic or abstaining (or both), are considered insusceptible to the risk of pregnancy. The percentage of births during the last three years whose mothers are presently postpartum amenorrheic, abstaining or insus- ceptible is shown in Table 6.8 by the number of months since birth. These distributions are based on current status data, i.e., on the pro- portion of births occurring x months before the survey for which mothers are still amenor- rheic, abstaining or insusceptible. The esti- mates of the median and mean durations shown in Tables 6.8 and 6.9 are calculated Table 6.8 Postpartum amenorrhea T abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining and insusceptible, by number of months since birth, and median and mean durations, Kazakstan 1995 Number Months Amenor- Insus- of since birth rheic Abstaining ceptible births < 3 89.0 64.7 92.8 59 3-5 50.8 17.0 55.2 58 6-8 26.3 4.5 28.4 69 9-11 28.8 7.5 30.1 66 12-14 17.0 6.4 18.9 79 15-17 15.1 9.3 19.3 67 18~20 2.7 2.7 5.3 64 21-23 0.9 5.8 6.7 77 24.26 4.1 2.9 5.4 69 27-29 0.6 0.6 1.2 71 30-32 0.0 0.0 0.0 51 33-35 2.4 2.4 4.7 72 Total 18.7 9.7 21.2 803 Median 4.6 2.3 5. I Mean 7.4 4.1 8.3 Prevalence/ Incidence mean I 6.6 3.4 7.5 ] The prevalence-incidence mean is borrowed from epidemiology and is defined as the number of children whose mothers are amenorrheic (prevalence) divided by the average number of births per month (incidence). from the current status proportions at each time period. The prevalence/incidence mean is defined as the number of children whose mothers are amenorrheic (prevalence) divided by the average number of hirths per month (incidence). The data are grouped in three-month intervals to minimize fluctuations in the estimates. While both postpartum amenorrhea and postpartum abstinence are fairly short in duration, the former is longer than the latter and is, therefore, the principal determinant of the length of postpartum insusceptibility. Nearly all women (93 percent) are insusceptible to pregnancy in the first three months following a birth. However, three months after giving birth the proportion of insusceptible women falls quite rapidly. In the 3-5 months following a birth, 55 percent of women are still insusceptible, although only 17 percent are still abstaining and 51 percent are still amenorrheic. By 6-8 months, the proportion still insusceptible drops to just over one-quarter of mothers (28 percent). The median duration is 4.6 months for amenorrhea, 2.3 months for abstinence, and 5.1 months for insusceptibility. 84 Table 6.9 presents the median durations of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics. Differences are not very large, although median durations of amenorrhea show a bit more variability than do median durations of abstinence. The most notable difference in duration of amenorrhea is found among women in the West, who remain amenorrheic about three months longer than other women. Women with higher education, as well as ethnic Russian women remain amenorrheic about one month longer than other women. The only notable difference by background characteristics in the median duration of postpartum abstinence is that the duration increases with increasing education, from 1.6 to 3.4 months. Table 6.9 Median duration of postpartum amenorrhea T abstinence~ and insusceptibility by background characteristics Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility, by selected background characteristics, Kazakstan 1995 Postpartum Number Background Postpartum Postpartum insuscep- of characteristic amenorrhea abstinence tibility births Age <30 4.2 1.9 4,6 563 30+ 4.4 2.3 4.5 241 Residence Urban 4. I 2.0 4.3 339 Rural 4.4 2.2 5.1 464 Region Almaty City 4,5 2.5 9.8 35 South 4.8 2.0 5.0 370 West 7,3 2.2 7.3 107 Central 3.5 2.0 4.5 84 North and East 3.6 2.1 3.9 208 Education Primary/Secondary 4.2 1.6 4.9 291 Secondary-special 4. I 2.2 4.3 383 Higher 5.0 3.4 5.2 129 Ethnicity Kazak 4.3 2.2 4.7 483 Russian 5.3 2.1 6.7 174 Other 3.5 1.4 3.5 146 Total 4.2 2.1 4.6 803 Note: Medians are based on current status. 6.6 Termination of Exposure to Pregnancy Above age 30, the risk of pregnancy declines with age as increasing proportions of women become infecund. Although the onset of infecundity is difficult to determine for an individual woman, it can be estimated for a population. Table 6.10 presents data on two indicators of decreasing exposure to the risk of pregnancy for women age 30 years and older: menopause and long-term abstinence. 85 Table 6.10 Termination of exposure to the risk of pregnancy Indicators of menopause and long-term abstinence among currently married women age 30-49, by age, Kazakstan 1995 Long-term Menopause I abstinence 2 Age Percent Number Percent Number 30-34 2.0 418 0.0 458 35-39 1.4 461 0.0 482 40-41 0.6 162 2.2 165 42-43 3.4 200 0.0 203 44-45 7.5 159 2.2 159 46-47 22.2 108 0.9 108 48-49 48.0 80 6.1 80 Total 6.1 1,588 0.8 1,654 1 Percentage of nonpregnant, nonamenorrheic currently married women whose last menstrual period occurred six or more months ~receding the survey or who report that they are menopausal. Percentage of currently married women who did not have intercourse in the three years preceding the survey. The percentage of women who are in menopause refers to the proportion of currently married women who are neither pregnant nor postpartum amenorrheic and have not had a menstrual period in the six months preceding the survey, or who report themselves as being menopausal. Few women are menopausal before reaching their forties, after which time the proportion of menopausal women increases with age, from 8 percent among women age 44-45 to 48 percent among women age 48-49. The percentage of women practicing long-term abstinence refers to the proportion of currently married women who have not had sexual intercourse in the three years preceding the survey. It can be seen that long-term abstinence is a minor contributor to the lower fertility of older women. The proportion of currently married women who have not had sexual intercourse in the last three years does not exceed 2 percent except among women age 48-49, among whom 6 percent are abstaining. A potentially more significant factor in reducing risk of exposure to pregnancy than terminal abstinence may be divorce, widowhood, and separation among women in Kazakstan. As shown in Table 6.1, 15 percent of women age 40-44 and 22 percent of women age 45-49 are currently widowed, divorced, or separated. I f these women do not remarry and are not sexually active, they represent a contributing factor to loss of exposure to pregnancy. 86 CHAPTER 7 FERTILITY PREFERENCES Kia L Weinstein Women interviewed in the 1995 KDHS were asked several questions in order to determine their fertility preferences: their desire to have a(another) child; the length of time they would prefer to wait before having a(another) child; and if they were to relive their lives again, the number of children they would choose to have. These data make the quantification of fertility preferences possible and, in combination with the data on contraceptive use, allow estimation of the demand for family planning, either to space or to limit births. 7.1 Desire for More Children Table 7.1 and Figure 7.1 show the percent distribution of currently married women by their fertility preferences. The majority of women say they want no more children or are sterilized (60 percent). One-third of women do want a child in the future, although half of these women (55 percent) would like to wait two or more years before having that child. Thus, the large majority of women (79 percent) want to either delay their next birth (19 percent) or stop childbearing altogether. These are the women who are potentially in need of some method of family planning. As is true in most populations, the proportion of women who want no more children increases as the number of children they already have increases. However, in Kazakstan, the proportion who want to delay childbearing or want no more children rises steeply and quickly. Two-thirds of women with one child (68 percent) want to either delay their next birth or stop childbearing altogether (Figure 7.2). While the majority of women with one child still want another child, the majority of women with two children (67 percent) want no more or are sterilized. The proportion wanting no more children continues to rise as the number of living children increases. Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women by desire for more children, according to number of living children, Kazakstan 1995 Desire for Number ofliving children l children 0 1 2 3 4 5 6+ Total Have another soon 2 75.8 21.2 8.4 6.8 5.7 2.3 0.0 13.7 Have another later 3 7.0 39.4 17.9 9.8 8.0 4.6 2.0 18.6 Have another, undecided when 2.9 2.5 1.8 1.0 0.3 0.0 0.0 1.6 Undecided 0.0 4.1 3.2 3.9 2.3 1.3 1.9 3.1 Want no more 1.1 28.6 65.7 76.7 81.5 88.7 90.6 59.4 Sterilized 0.0 0.4 0.8 0.5 0.0 0.7 4.4 0.7 Declared infecund 13.1 3.8 2.1 1.3 2.1 2.5 1.0 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 134 555 970 410 208 122 108 2,507 i Includes current pregnancy 2 Want next birth within 2 years 3 Want to delay next birth for 2 or more years 87 Figure 7.1 Fertility Preferences among Currently Married Women 15-49 Want no more 59% Undecided 5% (wtthln 2 years) 14% "~ later (after 2 years) 19% KDHS 1995 100 Figure 7.2 Fertility Preferences among Currently Married Women by Number of Living Children Percent 80 60 40 20 0 i 0 1 2 3 4 5 Number of Living Children I lWant Soon ~Want to Wait E3 Undecided ~-Want No More ,.~lnfecundlStedlized I 6+ KDHS 1995 88 Table 7.2 shows how rapidly the desire to limit childbearing increases with age. The majority that want to either space or limit their childbearing is achieved by the time women reach their early twenties. Only 23 percent of women in their early twenties want a child within the next two years. By the time women reach their early thirties, more than half (57 percent) want to stop their childbearing altogether, when they still have many potential years of childbearing ahead of them. Three-quarters of women in their late thirties want no more children. Table 7.2 Fertility preferences by age Percent distribution of currently married women by desire for more children, according to age, Kazakstan 1995 Desire for Age of woman children 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Have another soon 1 29.7 22.6 20.3 16.5 9.9 6.1 1.6 13.7 Have another later 2 46.3 51.6 32.2 17.7 5.0 1.6 0.3 18.6 Have another, undecided when 3.3 2.0 1.6 2.1 2.4 0.6 0.2 1.6 Undecided 2.6 4.5 5.2 4.3 3.3 0.7 0.0 3.1 Want no more 18.1 19.2 39.1 55.9 74.4 85.7 90.8 59.4 Sterilized 0.0 0.0 0.6 0.9 0.4 1.9 0.3 0.7 Declared infecund 0.0 0.1 1.1 2.7 4.7 3.3 6.7 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 80 347 425 458 482 447 268 2,507 t Want next birth within 2 years 2 Want to delay next birth for 2 or more years Table 7.3 presents the percentage of currently married women who want no more children by number of l iving children and selected background characteristics. While the overall proportion of women who want no more children does not vary greatly by background characteristics, there are strong differences in how quickly women with different background characteristics reach the point of wanting no more children. Three- quarters of urban women with two children (74 percent) want no more; the same proportion is not reached among rural women until they have three children. While there exists some variability in fertility preferences across the regions of Kazakstan, the most notable are in the South and West Regions, where three-fourths of women wanting no more children is not reached until women have four children. Comparing fertility desires by ethnicity, Russians consistently are more inclined to want no more children at every parity. Seventy-seven percent of Russian women with two children want no more; a similar proportion is reached among Kazak women (79 percent) once they have four children. There is no strong relationship between education and wanting no more children. 89 Table 7.3 Desire to limit childbearing Percentage of currently married women who want no more children, by number of living children and selected background characteristics, Kazakstan 1995 Number of living children 1 Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 1.3 36.3 73.7 80.1 84.0 (87.2) * 62.0 Rural 0,8 16.3 52.9 74.6 80.2 90.1 95.5 57.6 Region Almaty City (0.0) 31.0 74.5 (80.0) * * * 52.0 South (0.0) 8.6 44.7 68.8 74.9 (88.7) 94.1 51.9 West * 30.5 64.8 67.5 79.4 (75.7) (94.3) 59.6 Central * 33.0 73.9 81.2 (86.4) (91.3) * 65.2 North and East * 38.1 75.0 91.0 (92.3) * * 66.9 Education Primary/Secondary (3.9) 29.2 61.6 76.1 75.5 91.8 94.4 62.7 Secondary-special 0.0 27.7 68.6 81.8 87.5 (86.8) (100.0) 60.2 Higher (0.0) 32.6 67.1 65.6 * * * 55.2 Ethnicity Kazak 0.0 12.7 48.6 68.8 78.7 87.6 95.1 54.4 Russian 2.9 38.4 77.2 93.1 * * * 64.7 Other (0.0) 33.6 70.8 78.5 (83.3) * * 63.4 Total 1.1 29.0 66.5 77.2 81.5 89.4 95.0 60.1 Note: Women who have been sterilized are considered to want no more children. An asterisk indicates that a figure is based on fewer than 25 unweighted women and has been suppressed. Figures in parentheses are based on 25-49 unweighted women. I Includes current pregnancy 7.2 Need for Family Planning Services Women who are potentially in need of family planning are those who either want to wait two or more years before their next birth (need for spacing), or want to stop childbearing altogether (need for limiting). Women who want to space or limit their childbearing, but are not using contraception, are considered to have an unmet need for family planning. Women who are using family planning methods are said to have a met need for family planning. Women with unmet need and met need constitute the total demand for family planning. Tables 7.4.1,7.4.2, and 7.4.3 present data on unmet need, met need and total demand for family planning, according to whether the need is for spacing or limiting births. Findings are presented for currently married women, women not currently married, and all women combined. Sixteen percent of married women in Kazakstan have an unmet need for family planning services, 4 percent for spacing births and 12 percent for limiting births (Table 7.4.1). Combined with the 59 percent of married women who are currently using a contraceptive method, the total demand for family planning comprises three-quarters of married women in Kazakstan. While contraceptive prevalence is quite high, if all married women who say they want to space or limit their births were to use methods, contraceptive prevalence would increase from 59 to 75 percent of married women. 90 Table7.4.1 Need for family planning services: currently married women Percentage of currently married women with unmet need for family planning, and met need for family planning, and the total demand for family planning services, by selected background characteristics, Kazakstan 1995 Met need for Unmet need for family planning Total demand for Percentage family planning I (currently using) 2 family planning of demand Number Background For For For For For For satis- of characteristic spacing limiting Total spacing limiting Total spacing limiting Total fled women Age 15-19 16.5 3.4 20.0 26.5 5.0 31.5 43.0 8.4 51.4 61.2 80 20-24 11.1 5.3 16.4 37.5 9.6 47.0 48.6 14.9 63.5 74.1 347 25-29 5.5 6.9 12.3 34.8 26.2 61.0 40.3 33.1 73.3 83.2 425 30-34 3.2 6.2 9.4 26.2 45.5 71.7 29.4 51.7 81.2 88.4 458 35-39 1.2 12.3 13.5 11.8 57.7 69.5 13.0 70.1 83.0 83.7 482 40-44 0.7 19.3 20.0 4.0 59.4 63.3 4.7 78.7 83.4 76.0 447 45-49 0.2 26.4 26.6 1.1 31.6 32.6 1.2 58.0 59.2 55.1 268 Residence Urban 2.6 12.8 15.5 20.1 41.8 61.9 22.8 54.6 77.3 80.0 1,398 Rural 5.6 10.5 16.1 19.4 36.2 55.6 25.0 46.6 71.7 77.6 1,109 Region Almaty City 4.6 9.2 13,7 26.4 38.0 64.4 31.0 47,2 78.2 82.4 164 South 5.8 10.0 15.8 20,5 29.7 50.2 26.3 39.7 66.0 76.0 811 West 4.1 13.4 17.4 17.5 34.4 51.9 21.6 47.7 69.3 74.9 298 Central 2.4 10.0 12.4 19.3 46.9 66.2 21.7 56.9 78.6 84.2 235 North and East 2.6 13.6 16.3 19.0 46.9 66.0 21.7 60.6 82.2 80.2 1,000 Education Primary/Secondary 5~5 13.1 18.6 14.7 37.1 51.8 20.3 50.2 70.4 73.6 798 Secondary special 3.2 11.7 14.9 20.9 41.1 62.0 24.1 52.7 76.8 80.7 1,259 Higher 3,3 9.8 13.1 25.8 38.2 64.0 29.1 48.0 77.1 83.0 450 Etbnicity Kazak 5.8 10.4 16.2 21.0 32.5 53.5 26.8 42.9 69.7 76.8 1,064 Russian 2.3 12.9 15.1 19.6 45.5 65.1 21.9 58.4 80.2 81.1 930 Other 3,2 12.7 15.9 17.8 42.1 59.9 21.0 54.7 75.7 79.1 513 Total 4.0 11.8 15.7 19.8 39.3 59.1 23.8 51.1 74.8 79.0 2,507 i Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrheic women whose last birth was mistimed, and women who are neither pregnant nor amenorrheic and who axe not using any method of family planning and say they want to wait two or more years for their next birth. Also included in unmet need for spacing are women who are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrheic women whose last child was unwanted and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are menopausal or infecund women. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 91 Table 7.4.2 Need for family p lanning services: unmarr ied women Percentage of unmarr ied women with unmet need for family planning, and met need for family planning, and the total demand for family p lanning services, by selected background characteristics, Kazakstan 1995 Met need for Unmet need for family planning Total demand for Percentage family planning I (currently using) 2 family planning of demand Number Background For For For For For For satis- of characteristic spacing limiting Total spacing limiting Total spacing limiting Total fled women Age 15-19 0.7 0.0 0.7 3.7 0.0 3.7 4.4 0.0 4.4 84.4 588 20-24 0.7 0.0 0.7 14.2 2.1 16.3 14.9 2.1 17.0 95.9 220 25-29 2.3 0.6 2.9 12.7 6.8 19.5 15.0 7.4 22.4 87.1 96 30-34 0.7 2.8 3.5 16.1 17.6 33.7 16.7 20.5 37.2 90.5 100 35-39 0.7 4.7 5.4 7.8 8.5 16.3 8.4 13.2 21.6 75.2 82 40-44 0.0 1.2 1.2 3.0 98 12.9 3.0 11.1 14.1 91.2 91 45-49 0.0 I.I 1,1 0,0 15.9 15,9 0.0 17.1 17.1 93.3 87 Residence Urban 1.2 1.1 2.2 9.5 5.3 14.9 10.7 6.4 17.1 87.0 735 Rural 0.1 0.3 0.4 3.9 3.6 7.5 4.0 3.9 7.9 95.1 529 Region Almaty City 1.2 1.6 2.9 17.2 9.4 26.6 18.4 I 1.1 29.5 90.3 108 South 0.0 0.3 0.3 1.3 1.3 2.6 1.3 1.6 2.9 90.0 395 West 1.9 1.4 3.3 7.1 3.2 10.3 9.0 4.6 13.6 75.7 179 Central 1.7 1.3 3.0 5.7 5.9 11.6 7.4 7.2 14.6 79.2 124 North and East 0.5 0.5 1.0 10.3 6.6 16.9 10.8 7.1 17.9 94.4 458 Educat ion Primary/Secondary 0.5 0.8 1.3 4.2 2.5 6.7 4.7 3.3 8.0 84.1 583 Secondary-special 0.8 0.6 1.4 7.9 6.6 14.4 8.7 7.2 159 91.0 461 Higher I . I 1.0 2.0 13.6 6.2 19.8 146 7.2 21.8 90.7 220 Ethnicity Kazak 0.4 0.5 0.9 4.3 3.1 7.4 4.8 3.6 8.4 89.0 632 Russian 1.3 1.4 2.7 13.2 8.4 21.6 14.5 9.8 24.3 88.8 378 Other 0.5 0.4 0.9 5.3 2.8 8.1 5.8 3.2 9.0 89.8 254 Total 0.7 0.7 1.5 7.2 4.6 11.8 7.9 5.4 13.3 89.0 1,264 J Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrheic women whose last birth was mistimed, and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and say they want to wait two or more years for their next birth. Also included in unmet need for spacing are women who are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrheic women whose last child was unwanted and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are menopausal or infecund women, 2 Using for .wacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 92 Table 7.4.3 Need for family planning services: all women Percentage of all women with unmet need for family planning, and met need for family planning, and the total demand for family planning services, by selected background characteristics, Kazakstan 1995 Met need for Unmet need for family planning s Total demand for Percentage family planning t (currently using) family planning of demand Number Background For For For For For For saris- of characteristic spacing limiting Tetal spacing limiting Total spacing limiting Total fied women Age 15-19 26 0.4 20-24 7.1 3.2 25-29 49 5.7 30-34 2.8 5.6 3539 1.1 11.2 40-44 0.6 16.3 45-49 0.1 20.2 Residence Urban 2.1 8.8 Rural 3.8 7.2 Region Almaty City 3.3 6.2 South 3.9 6.8 West 3.2 8.9 Central 2.2 7.0 North and East 2.0 9.5 Education Primary/Secondary 3.4 7.9 Secondary-special 2,6 8.7 Higher 2.6 6.9 Ethnicity Kazak 3.8 6.7 Russian 2.0 9.5 Other 2.3 8.6 3.0 6.5 0.6 7.1 9.1 1.0 10.1 70.2 669 10.3 28.4 6.7 35.1 35.5 9.9 45.5 77.3 567 10.6 30.7 22.6 53.3 35.6 28.3 63.9 83.4 521 8,4 24.4 40.5 64.9 27.2 46.1 73.3 88.6 557 12,3 11.2 50.6 61.8 12.3 61.8 74.1 83.4 564 16.9 3.8 51.0 54.8 4.4 67.3 71.7 76.5 537 20.4 0.8 27.8 28.5 0.9 48.0 48.9 58.4 355 10.9 16.5 29.2 45.7 18.6 38.0 56.6 80.7 2,133 II.0 14.4 25.7 40.1 18.2 32.9 51.1 78.4 1,638 9.4 22.8 26.7 49.4 26.0 32.8 58.9 84.0 271 10.7 14.2 20.4 34.6 18.1 27.2 45,3 76.3 1,206 12.1 13.6 22.7 36.3 16.8 31.5 48.4 75.0 477 9.2 14.6 t2.8 47.4 16.8 39.8 56.5 83.8 358 1.5 163 34.3 50.6 18.2 43.8 62.0 81.5 1,458 1.3 10.3 22.5 32.8 13.7 30.4 44.1 74.4 1,380 1.3 17.4 31.8 49.2 20.0 40.5 60.5 81.4 1,721 9.5 21.8 27.7 49.5 24.3 34.7 59.0 83.9 670 10.5 14.8 21.6 36.3 18.6 28.3 46.8 77.6 1,696 11.5 17.7 34.8 52.5 19.7 44.3 64.0 82.0 1,309 10.9 13.7 29.1 42.7 16.0 37.7 53.7 79.7 766 Total 2.9 8.1 10.9 15.6 27.7 43.3 18.4 35.8 54.2 79.8 3.771 i Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrheic women whose last birth was mistimed, and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and say they want to wait two or more years for their next birth. Also included in unmet need for spacing are women who are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrheic women whose last child was unwanted and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are menepausal or infecund women. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. The overall unmet need for family planning follows a clear U-shaped pattern by age group, descending with increasing age, and then increasing again after reaching a low among women in their early thirties. This pattern reflects the fact that unmet need for spacing decreases with age while unmet need for limiting increases with age, which in turn follows the pattern of demand by age. The most significant finding of Table 7.4.1 is that unmet need among currently married women does not vary greatly by urban/rural residence, region, education, or ethnicity (see Figure 7.3). While unmarried women have a greater percentage of their contraceptive needs met, their demand is quite low (13 percent). Unmet need among unmarried women is very low (1.5 percent). 93 Figure 7.3 Percentage of Currently Married Women with Unmet Need and Met Need for Family Planning Services by Background Characteristics KAZAKSTAN RESIDENCE Urban Rural EDUCATION Primary/Secondary Secondary*Special Higher 0 ,5 i ! ! : : : : : : :i TiiiiT : Zj 72 ,0 10 20 30 40 50 60 70 80 90 100 Percent i~Unmet Need ;::;Met Need (Users)! KDHS 1995 7.3 Ideal Family Size Thus far, fertility desires have been examined relative to respondents' current family size. However, the KDHS also asked women how many children they would choose to have if they could go back to the time they had no children. This question is used as an indicator of ideal family size and is meant to be independent of the number of children the respondent already has, but there is usually a correlation between ideal and actual number of children. This is because women who want larger families will tend to achieve larger families, and because women may adjust their ideal family size upwards as their actual family size increases. Table 7.5 shows the percent distribution of all women by the number of children they would ideally like to have, according to the number of children they actually have. The correlation between ideal and actual number of children is quite strong. Among women with more than one child, the number most commonly reported as ideal is equal to the number of children the woman already has, at every parity. Thus, the overall mean number of children reported as ideal steadily increases with the actual number of living children. The mean ideal number of children increases from 2.5 among childless women to 5.5 among women with six or more children. Not until women have five children does the mean ideal fall below the actual number of children. 94 Table 7.5 Ideal and actual number of children Percent distribution of all women by ideal number of children and mean ideal number of children for all women and for currently mamed women, according to number of living children, Kazakstan 1995 Number of living children t Ideal number of children 0 1 2 3 4 5 6+ Total 0 0.4 1 6.8 2 49.5 3 25.7 4 10.1 5 2.3 4.0 6+ 1.5 1.4 Nonnumeric response 3.7 3.4 Total 100.0 100.0 Number of women 1,052 710 All women: Mean ideal number 2 2.5 2.5 Number of women 1,014 686 Currently married women: Mean ideal number 2 2.6 2.5 Number of women 133 543 0.6 0.5 0.4 1.0 0.0 0.0 0.5 8.2 3.4 2.7 1.9 2.3 1.8 5.0 49.1 46.3 16.5 19.1 8.0 9.6 40.0 26.0 29.0 38.9 7.3 8.6 3.6 25.9 7.2 12.1 24.4 38.1 13.5 16.9 13.8 4.7 8.5 13.6 47.8 8.6 6.5 1.2 5.0 13.5 12.2 44.2 4.3 2.8 3.6 5.4 7.7 15.3 4.0 100.0 100.0 100.0 100.0 100.0 100.0 1,083 451 221 129 124 3,771 2.7 3.4 4.0 4.7 5.5 2.9 1,053 435 209 119 105 3,621 2.7 3.4 4.0 4.7 5.6 3.1 941 395 197 113 92 2,415 i Includes current pregnancy z The means exclude women who gave nonnumeric responses. Table 7.6 presents the mean ideal number of children for all women by age and selected background characteristics. Given how strongly reported ideal numbers correlate with the actual number of children, the data in this table should be interpreted carefully. The overall mean ideal number gradually increases with age of the respondent, although not as greatly as it increased with parity. Women in the South report higher ideal numbers than women in other regions at every age group. Rural women and women of Kazak ethnicity report ideal numbers that increase with age to numbers above the overall mean. Those women who have the lowest actual fertility exhibit a tighter clustering around the number they consider ideal. 95 Table 7.6 Mean ideal number of children by background characteristics Mean ideal number of children for all women, by age and selected background characteristics, Kazakstan 1995 Age of woman Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 2.3 2.5 2.6 2.8 2.8 2.9 2.8 2.7 Rural 2.8 2.9 3.3 3.4 3.6 3.9 4.3 3.3 Region Almaty City 2.3 2.5 2.6 2.7 2.6 2.6 2.5 2.5 South 2.9 3.2 3.5 3.8 3.9 4.2 4.6 3.6 West 2.6 2.7 3.0 3.0 3.1 3.5 3.3 3.0 Central 2.3 2.4 2.7 3.0 2.9 3.3 3.3 2.8 North and East 2.1 2.3 2.5 2.6 2.6 2.7 2.5 2.5 Education Primary/Secondary 2.5 2.7 3.3 3.6 3.5 3.6 3.7 3.1 Secondary-special 2.5 2.7 2.9 3.0 2.8 3. I 3.1 2.9 Higher (2.4) 2.7 2.6 2.9 3.0 2.8 3.0 2.8 Ethnicity Kazak 2.8 3.0 3,3 3.5 3.8 4.1 4.3 3.4 Russian 2.0 2.3 2.4 2.5 2.4 2.6 2.5 2.4 Other 2.6 2.3 2.8 3.1 2.9 2.9 3.2 2.8 Total 2.5 2.7 2.9 3.1 3.1 3.2 3.3 2.9 Note: Parentheses indicate a figure is based on 25 to 49 unweighted women. 7.4 Wanted and Unwanted Fertility There are two ways of estimating levels of unwanted fertility from the KDHS data. One is based on reports of the wanted status of recent births. For each child born in the three years before the survey, and for each current pregnancy, women were asked whether the pregnancy was wanted at that time (planned), wanted at a later time (mistimed), or not wanted at all (unwanted). These data may lead to underestimates of unplanned childbearing, since women may retrospectively declare unwanted pregnancies as planned once the children are born. Another way of measuring unwanted fertility utilizes the data on ideal family size to calculate what the total fertility rate would be if all unwanted births were avoided. This measure may also suffer from underestimation to the extent that women are unwilling to report an ideal family size lower than their actual family size. Estimates using these two approaches indicate at least the minimum level of unwanted fertility. Table 7.7 shows the percent distribution of births in the three years before the survey (and current pregnancies) by whether the birth was wanted then, wanted later, or not wanted at all. Overall, 16 percent of births in the three-year period were unplanned; 8 percent were mistimed (wanted later) and 8 percent were unwanted. The proportion of unwanted births increases with birth order of the child. More than one out of five (22 percent) of fourth or higher order births was unwanted. Thus, a larger proportion of births to older women are found to be unwanted. 96 Table 7.7 Fertility planning status Percent distribution of births in the three years preceding the survey and current pregnancies, by fertility planning status, according to birth order and mother's age, Kazakstan 1995 Planning status of birth Birth order Number and mother's Wanted Wanted Not of age then later wanted Total births Birth order I 91.7 2 81.7 3 80.7 4+ 71.9 Age at hirth <19 85.5 20-24 83.5 25-29 88.3 30-34 80.4 35-39 74.9 40-44 * Total 83.9 7.1 1.3 100.0 370 12.5 5.8 100.0 289 5.7 13.6 100.0 144 6.1 22.0 100.0 149 10.8 3.7 10t3.0 128 11.6 4.9 100.0 352 4.2 7,5 100.0 260 9.5 10.1 100.0 128 3.0 22.1 100.0 68 * * * 16 8.4 7.7 100.0 952 Note: Birth order includes current pregnancy. An asterisk indicates that a figure is based on fewer than 25 births (and current pregnancies) and has been suppressed. Table 7.8 presents "wanted" fertility rates. Wanted fertility represents the level of fertility that would have prevailed in the three years before the sur- vey if all unwanted births had been prevented. Unwant- ed births are those which exceed the number considered ideal by the respondent. The wanted fertility rate is cal- culated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. The small proportion of women who gave a nonnumeric re- sponse to the question on ideal family size are assumed to have wanted all their births. A comparison of the to- tal wanted fertility rate and the actual fertility rate sug- gests the potential demographic impact of avoiding un- wanted births. As reported ideal family size is so closely cor- related with actual family size, there is not much dif- ference between wanted and actual fertility rates in Kazakstan. The wanted fertility rate is only 0.2 children lower than the actual rate, and there are no great differ- entials by background characteristics. Table 7.8 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by selected background characteristics, Kazakstan 1995 Total wanted Total Background fertility fertility characteristic rate rate Residence Urban 1.9 2.0 Rural 2.8 3.1 Region Almaty City (1.4) (1,5) South (3.3) (3.4) West (2.4) (2.7) Central (2.4) (2.7) North and East (1.7) (I.8) Education Primary/Secondary 2.7 2.9 Secondary-special 2.2 2.4 Higher (1.9) (2.0) Ethnicity Kazak 2.9 3.1 Russian 1.6 1.7 Other (2.2) (2.4) Total 2.3 2.5 Note: Rates are based on births to women 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 3.2. Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. 97 CHAPTER 8 INFANT AND CHILD MORTALITY Jeremiah M. Sullivan 8.1 Background and Assessment of Data Quality This chapter presents information on mortality among children under five years of age. The rates shown provide information on levels and time trends in mortality as well as differentials between population subgroups. The information on mortality differentials should be of particular use to agencies providing health services because the population subgroups at high risk of mortality are identified. The rates of mortality presented in this chapter are defined as follows: Neonatal mortality (NN): the probability of dying within the first month of life, Pustneonatal mortality (PNN): the arithmetic difference between infant and neonatal mortality, Infant mortality (~qo): the probability of dying between birth and the first birthday, Child mortality (4ql): the probability of dying between exact ages one and five, Under-five mortality (sqo): the probability of dying between birth and the fifth birthday. All rates are expressed as deaths per 1,000 live births, except child mortality which is expressed as deaths per 1,000 children surviving to age one. The mortality estimates were calculated from information in the reproductive section of the women's questionnaire. In the 1995 KDHS, survey respondents were asked to report reproductive events in terms of international definitions. The definition of a live birth is a birth, irrespective of the duration of pregnancy, which after separation from the mother breathes or shows any other signs of life such as beating of the heart or movement of voluntary muscles. Infant deaths are deaths of live-born infants under one year of age (United Nations, 1992). The reproductive section of the KDHS questionnaire includes a pregnancy history in which specific questions are asked about each pregnancy that a woman has had. For each live birth reported in the pregnancy history, questions are asked about the month and year of birth, sex of the child, survivorship status and current age (for surviving children) or age at death (for deceased children). The accuracy of mortality estimates calculated from pregnancy history data depends upon the sampling variability of the estimates and the nonsampling error (i.e., the completeness and accuracy with which births and deaths are reported and recorded). Sampling variability is discussed in the next section of this chapter. Usually, the most serious source of nonsampling error in mortality data collected by a retrospective survey is underreporting of the births and deaths of children who do not survive (United Nations, 1982); this results in underestimated mortality rates. When there is underreporting of deceased children in a survey, it is usually most severe for deaths which occur in early infancy, i.e., in the neonatal period. If there is underreporting of early neonatal deaths, this would result in an abnormally low ratio of neonatal mortality to infant mortality. In retrospective surveys, underreporting of early infant deaths is usually more common for births that occurred further back in time. 99 Hence, when considering the quality of mortality data, it is useful to examine the ratios of neonatal to infant mortality for different retrospective time periods. Neonatal and infant mortality rates from the 1995 KDHS are shown in Table 8.1. For the periods 0-4, 5-9 and 10-14 years before the survey, the values of the ratio of the former to the latter are .49, .44 and .42, respectively. In countries known for having complete and accurate mortality data, at a level of infant mortality of about 40 per 1,000 (the rate estimated for Kazakstan), the value of this ratio is typically between .50 and .60) The ratios for Kazakstan are somewhat lower than this but not greatly so. The value of the ratio is lower for the time periods more distant from the survey date, but the decrease in value is not significant. Accordingly, this inspection of the data does not suggest substantial underreporting of neonatal deaths. Table 8.1 Infant and child mortality Infant and child mortality rates by five-year periods preceding the survey, Kazakstan 1995 Years Neonatal Postneonatal Infant Child Under-five preceding mortality mortality mortality mortality mortality survey (NN) (PNN) (lqo) qq0 (sqo) 0-4 19.5 20.1 39.7 6,1 45.5 5-9 18.5 23.2 41.7 8,8 50.1 10-14 18.6 25.6 44.2 9.8 53.6 8.2 Levels and Trends in Early Childhood Mortality Table 8.1 shows infant and childhood mortality estimates for 0-4, 5-9, and 10-14 years before the survey. For the period 0-4 years before the survey (i.e., approximately 1990-94), infant mortality was estimated at 40 per 1,000 births. The estimates of neonatal and postneonatal mortality were about equal at 20 per 1,000. The estimate of child mortality (age 1-5 years) was much lower at 6 per 1,000. Overall, for the period 1990-94, under-five mortality was 46 per 1,000. During the period from 10-14 years to 0-4 years before the survey, infant mortality declined by about 10 percent from 44 per 1,000 to 40 per 1,000 births. All of this decline was in the postneonatal period. The pace of mortality decline was more pronounced for the child age interval (age 1-5 years) and, over the 10-year period, mortality rates fell by about 38 percent from 10 to 6 per 1,000. The mortality estimates of the KDHS are based on data provided by a sample of 3,771 women and are subject to sampling variability. A result of interest is the 95-percent confidence interval for the estimated infant mortality rate for the period 0-4 years before the survey (40 per 1,000). This confidence interval is broad and extends from 28 to 51 per 1,000 (see Appendix B). Thus, the point estimate of 40 per 1,000 cannot be considered exact and the tree rate could be higher or lower. However, the estimates for the time periods 5-9 and 10-14 years before the survey are of the same order of magnitude which tends to substantiate that estimate. i For example, see the neonatal and infant mortality rates for Austria (1959), Canada (1952), and Belgium (1956) in the U.N. Demographic Yearbook, 1961 and for Cuba (1968), Puerto Rico (1965), and Poland (1966) in the U.N. Demographic Yearbook, 1974. 100 8.3 Mortality Rates from the Ministry of Health The Republic of Kazakstan has a long history of demographic and health data collection--primarily through the use of registration systems which are designed to collect information on specified events throughout the country. These systems collect data at lower administrative levels and the data are forwarded to the oblast level reporting offices and then to the national statistical agencies of the Government Statistical Office and the Ministry of Health. In the case of live births and infant deaths, the protocols for data collection were established during the period of the former Soviet Union. Those protocols define live births somewhat differently than the definitions of the World Health Organization which were used in the KDHS. A pregnancy terminating at a gestation age of less than 28 weeks (i.e., weighing less than 1,000 grams or measuring less than 35 centimeters) is considered premature and is classified as a late miscarriage even if signs of life are present at the time of delivery. Only ifa premature birth survives for seven days is the child classified as a live birth. A pregnancy terminating at 28 or more weeks of gestation is considered a live birth if the child breathes, and it is considered a stillbirth if breathing is not evident at the time of delivery. Thus, some events classified as late miscarriages in the Kazakstan statistical system would be classified as live births and infant deaths according to the definitions used in the KDHS. Official government statistics on infant mortality are published in the annual statistical reports of the Ministry of Health (MOH). The rates of the MOH are also published in the annual statistical reports of the State Committee on Statistics of the Republic of Kazakstan (Goskomstat). 2 Table 8.2 and Figure 8.1 show infant mortality rates based on MOH and KDHS data for the years 1980-84, 1985-89 and 1990-94. The KDHS rates decline from 44 to 40 per 1,000. The MOH rates decline from 32 to 27 per 1,000. Both sets of rates show a declining trend: 10 percent for the KDHS and 15 percent for the MOH. However, the most important fea- ture of the table is that the MOH rates are consistently about 30 percent lower than the rates from the KDHS. Table 8.2 Comparison of infant mortality rates Infant mortality rates, Ministry of Health and KDHS Time period Percent Source 1980-84 1985-89 1990-94 decline KDHS 44.2 41.7 39.7 10 Ministry of Health 31.9 28.7 27.0 15 Sources: Church and Koutanev (1995) and Ministry of Health (1995) There is no doubt that the MOH rates would be greater if intemational definitions of live births and infant deaths were used. Some of the difference between the estimates is due to definition. However, an assessment of the two sets of rates must also consider the sampling variability of the KDHS rates. The lower boundary of the 95-percent confidence interval for the 1990-94 KDHS infant mortality estimate is 28 per 1,000 which is equal to the MOH rate for 1990-94, also 28 per 1,000. Thus, it is not clear to what extent the differences in the two sets of rates are due to definitional differences, sampling variability, or other data collection problems in the KDHS survey or the registration system of the MOH. 2 It is worth noting that the rates published by the MOH and Goskomstat are shown at the national level and separately for the 19 oblasts of Kazakstan and the municipalities of Almaty and Leninsk. 101 Figure 8.1 Trends in Infant Mortality Deaths/1000 Live Births 50 . . . . . . 40 30 20 10 KDHS U MOH 0 r T 1950 1985 1990 Calendar Year of Health (MOH) -~Kazaksten DHS (KDHS) 1 ~ Minist~ J 1995 8.4 Socioeconomic Differentials in Childhood Mortality Differentials in infant and child mortality by urban-rural residence, mother's education and mother's ethnic group are shown in Table 8.3 and Figure 8.2. The estimated rates for subgroups of the population are for a 10-year period preceding the survey. Table 8.3 Infant and child mortality by background characteristics Infant and child mortality rates for the 10-year period preceding the survey, by selected background characteristics, Kazakstan 1995 Neonatal Posmeonatal Infant Child Under-five Background mortality mortality mortality mortality mortality characteristic (NN) (PNN) (lqs) (4q0 (sqo) Residence Urban 26.3 12.9 39,2 4.3 43.3 Rural 13.2 28.9 42,1 10.2 51.9 Education Primary/Secondary 18.9 23.2 42.0 8.4 50.1 Secondary-special 18.5 21.9 40.3 6.2 46.3 Higher 20.7 18.4 39,1 8.9 47.7 Ethnicity Kazak 15.3 29.7 45.1 10.0 54,6 Russian 29.7 2.9 32.5 5.5 37.9 Other 16.0 22.6 38.7 3.4 42.0 Total 19.0 21.8 40.7 7.4 47.9 102 Figure 8.2 Under-five Mortality by Selected Characteristics KAZAKSTAN RESIDENCE Urban Rural MATERNAL EDUCATION Primar,/ISecondary Secondary-Special Higher BIRTH INTERVAL < 2 years 2-3 years 4 years + ETHNICITY 47.9 ! . . . . . . . . . . . . . . ~ 43,3 i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ] 51.9 ~ . ' ~ ~ ~ =~ ~ ~ ~ ;:-~ ~ ~ ?~5 ?~ ~ ~; ~ ~ ~ :=~i~ ~/ ] 50.1 ! . . . . . . . . . . . . . . . • .~ ~ ~J 46 3 47~ I i ~ % , ~ ~ ~ 57.2 = Kazak _ _ 37 .9 54.6 Russian 00 10.0 20.0 30.0 400 50.0 60.0 Deaths per 1000 Live Births Note : Rates re fe r to a 10-year period preceding the survey KDHS1995 Under-five mortality is higher in rural areas (52 per 1,000) than in urban areas (43 per 1,000) and the urban-rural differential is particularly pronounced for child mortality (age 1-4). On the other hand, there is little difference in mortality risks of children born to women with different levels of education. The estimates of infant mortality for children of women with primary/secondary, secondary-special, and higher levels of education are all between 39 and 42 per 1,000. Under-five mortality rates by mother's education cluster between 46 and 50 per 1,000. The most striking differentials in early childhood mortality are associated with mother's ethnicity. The children of Russian women have the lowest mortality levels, with infant and under-five mortality rates of 33 and 38 per 1,000, respectively. Rates for the children of women of Kazak ethnicity are about 40 percent higher at 45 and 55 per 1,000, respectively. Mortality risks for children of other ethnic groups are intermediate in level. 8.5 Demographic Differentials in Childhood Mortality The relationship between early childhood mortality and various demographic variables is shown in Table 8.4. As is the case in most populations, male children experience higher mortality than female children. Under-five mortality rates for males and females are 56 and 39 deaths per 1,000 births, respectively. The relationship between childhood mortality and birth order indicates that first births and births of order 4 and higher are at higher risk of mortality. 103 Table 8.4 Infant and child mortality by demographic characteristics Infant and child mortality rates for the 10-year period preceding the survey, by selected demographic characteristics, Kazakstan 1995 Neonatal Posmeonatal Infant Child Under-five Demographic mortality mortality mortality mortality mortality characteristic (NN) (PNN) (Iq0) (4ql) (sq0) Sex of child Male 24.5 22.2 46.7 10.1 56.3 Female 13.3 21.3 34.6 4.7 39.1 Age of mother at birth < 20 (21.4) (12.3) (33.6) (4.1) (37.6) 20-29 18.4 22.3 40.6 8.6 48.9 30-39 20.4 22.8 43.2 5.0 47.9 40-49 * * * * * Birth order 1 26.5 15.7 42.2 8.8 50.7 2-3 15.9 21.4 37.3 4.1 41.3 4+ 12.4 33.1 45.5 12.3 57.2 Previous birth interval < 2 yrs 5.9 41.2 47.1 10.6 57.2 2-3 yrs 11.5 21.3 32.8 6.3 38.9 4+ yrs 28.7 12.3 41.0 3.4 44.3 Total 19.0 21.8 40.7 7.4 4%9 Note: Parentheses indicate that the rate is based on 250-499 births. An asterisk indicates that there are fewer than 250 births in this category, and the rate has been suppressed. A clear association is indicated between mortality risk and the length of the preceding birth interval. The data indicate that births which occur after an interval of less than two years are at greater risk of mortality than births occurring after longer intervals. The risk of infant mortality for births with a birth interval of less than two years is 47 per 1,000, while the risk is 33 per 1,000 for births with an interval of 2-3 years and 41 per 1,000 for births with an interval of four or more years. The relationship between the pace of childbearing and infant mortality suggests that some mortality reduction would result if the proportion of births occurring after a short birth interval were reduced. 8.6 H igh-R isk Fert i l i ty Behav ior Previous research has shown a strong relationship between maternal fertility patterns and children's risk of mortality (United Nations, 1994). Typically, mortality risks are greater for children who are born to mothers who are too young or too old, who are born after a short birth interval, or who have a high birth order. In the following analysis, a mother is classified as "too young" if she is less than 18 years of age, and "too old" if she is over 34 years of age at the time of delivery. A "short birth interval" is defined by a birth occurring less than two years after the previous birth, and a child is of "high-order" if the mother had previously given birth to four or more children. Table 8.5 shows the distribution of children born in the five years before the survey according to these risk categories. The table also shows the relative mortality risks of children by comparing the proportion dead of children in each high-risk category with the proportion dead of children not in any high- 104 Table 8.5 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality, and the percent distribution of currently married women at risk of conceiving a child with an elevated risk of mortality, by category of increased risk, Kazakstan 1995 Births in 5 years preceding the survey Percentage of currently Risk Percentage Risk married category of births ratio women a Not in any high.risk category 31.3 1.0 Unavoidable risk category First birth between ages 18 and 34 35.2 1.7 5.6 Single hlgh-risk category Mother's age < 18 3.4 0.0 0.1 Mother's age > 34 3.3 3.1 33.8 Birth interval < 24 months 17.3 0.9 9.8 Birth order > 4 3.0 0.0 2.3 30.8 b Subtotal 27.0 1.0 46.0 Multiple high-risk category Age <18 & birth interval <24 c months 0.5 0.0 0.0 Age >34 & birth interval <24 months 0.7 7.2 0.6 Age >34 & birth order >4 3.2 1.7 15.1 Age >34 & birth interval <24 & birth order >4 0.3 2.8 0.7 Birth interval <24 & birth order >4 1.8 1.3 1.3 Subtotal 6.6 2.1 17.6 In any high-risk category 33.5 1.2 63.6 Total 100.0 100.0 Number of births 1,412 2,507 Note: Risk ratio is the ratio of the proportion dead of births in a specific high-risk category to the proportion dead of births not in any high-risk category. a Women were assigned to risk categories according to the status they would have at the birth of a child, if the child were conceived at the time of the survey: age less than 17 years and 3 months, age older than 34 years and 2 months, latest birth bess than 15 months ago, and latest birth of order 4 or higher. Includes sterilized women c Includes the combined categories Age <18 and birth order >4. risk category. First births to women age 18 to 34 are shown separately in Table 8.5, but they are excluded from the analysis of high-risk behavior because they are not considered an avoidable risk. Column 1 of Table 8.5 shows the prevalence of high-risk births in the five-year period before the survey. Thirty-four percent of births were in at least one high-risk category and 7 percent had multiple high- risk characteristics. Column 2 of the table shows risk ratios for high-risk births relative to births not having any high-risk characteristics. Overall, the risk ratio for children in a single high-risk category (1.0) is the same as for children in no risk category. However, for children having multiple high-risk characteristics, the risk ratio is clearly elevated (2.1). 105 Column 3 of Table 8.5 looks to the future and addresses the following question: how many currently married women have the potential for having a high-risk birth? The results were obtained by simulating the risk category into which a birth to a currently married woman would fall if she were to become pregnant at the time of the survey. For example, a woman who was 37 years old at the time of the survey and had four previous births, the last of which occurred three years earlier, would be classified into the multiple high-risk category of being too old (35 or older) and at risk of having a high-order birth (greater than four). Overall, 64 percent of currently married women had the potential to give birth to a child with an elevated risk of mortality. Eighteen percent of women had the potential to give birth to a child with multiple high-risk factors. 106 CHAPTER 9 MATERNAL AND CHILD HEALTH Amangeldy D. Duisekeev and Temirkhan K. Bekbosynov This chapter presents f indings concerning maternal and child health in Kazakstan. Information is presented on maternal care during pregnancy and delivery, vaccinations of children and child illnesses (respiratory infection, fever and diarrhea) in the two weeks preceding the survey. Data on maternal care were obtained for all live births in the three years prior to the survey, while data on child vaccinations and illnesses were obtained for surviving children. 9.1 Antenata l Care Interviewers recorded in the KDHS questionnaires all medical personnel that a woman reported having seen for antenatal care for each live birth in the three years preceding the survey. For the purpose of presenting results, antenatal care is classified in terms of the provider with the highest medical qualifications. Table 9.1 and Figure 9.1 show the percentage of births for which mothers received antenatal care. A very high proportion of mothers received care from professional health providers (93 percent); the majority from a doctor (69 percent) and a significant proportion from a nurse or midwife (23 percent). Only 7 percent of women report no antenatal care. Differences in antenatal care between age groups of women are negligible. Differences by birth order are more pronounced. Mothers are more apt to receive care by a doctor for first births (78 percent) than for births of order four and higher (55 percent). Significant differences in the source of antenatal care are found for mothers classified by urban/rural residence and by region. The percentage of mothers who receive care from a doctor is greater in urban (82 percent) than in rural areas (60 percent), and greater in Almaty City (96 percent) and the North and East Region (94 percent) than in the South Region (48 percent). In the South Region, the percent of mothers who receive no antenatal care ( 14 percent) is several times higher than in any other region. Mother' s education and ethnicity are also associated with antenatal care. More educated women and women of Russian ethnicity are more likely to receive antenatal care and receive care from a doctor than less educated women and women of Kazak or other ethnicity. Antenatal care is most beneficial when it is sought early in pregnancy and is continued throughout a pregnancy. The first visit to the women's consulting center should occur in the first three months of pregnancy so that a timely assessment of each woman's health can be made and appropriate procedures can be employed for the management of the pregnancy. 107 Table 9.1 Antenatal care Percent distribution of births in the three years preceding the survey by source of antenatal care during pregnancy, according to selected background characteristics, Kazakstan 1995 Antenatal care provider ] Nurse/ Number Background Trained of characteristic Doctor midwife Others No one Total births Mother's age at birth < 20 78.5 16.5 0.0 5.0 100.0 115 20-34 66.6 25.2 0.1 8.2 I00.0 625 35+ 78.1 16.8 1.4 3.7 IOO.O 70 Birth order 1 78.4 17.4 0.3 3.9 100.0 320 2-3 66.2 24.4 0.0 9.4 100.0 360 4+ 55.0 34.4 0.3 10.2 100.0 130 Residence Urban 82.2 9.5 0.3 8.0 100.0 343 Rural 59.8 33.3 0.I 6.8 I00.0 466 Region Almaty City 96.3 0.0 1.2 2.5 100.0 36 South 48.3 37.6 0.0 14. I 100.0 373 West 83.7 13.9 0.0 2.5 100.0 107 Central 69.8 27.4 1.2 1.7 100.0 84 North and East 94.4 4.7 0.0 0.9 100.0 210 Mother's education Primary/Secondary 61.0 29.5 0.3 9.1 100.0 293 Secondary-special 70.0 22.7 0.0 7.3 100.0 386 Higher 85.4 10.8 0.3 3.4 100.0 131 Ethnicity Kazak 61.2 31.2 0.2 7.4 100.0 487 Russian 92.7 5.4 0.3 1.6 100.0 175 Other 68.2 17.9 0.0 13.8 100.0 148 All births 69.3 23.2 0.2 7.3 100.0 810 Note: Figures are for births in the period 0-35 months preceding the survey. i If the respondent mentioned more than one provider, only the most qualified provider is considered. 108 Figure 9.1 Percent Distribution of Births by Antenatal Care and Delivery Characteristics ANTENATAL CARE ~ ~ ~ , / ~ Doctor 69,3 Nurse/Midwife ~ 23.2 NO one ~ 7.3 pLACE OF DELIVERY Delivery Hospital Hospital FAP I Respondenrs Home 964 11.2 08 I 14 DELIVERY ASSISTANCE / Doe or J • 78 4 Nurse/Midwife ~: : . ' : ,:I 21.2 0 20 40 60 80 Percent Note: Based on births in the three years preceding the survey 100 KDHS 1995 Table 9.2 shows information on the timing and number of visits made to health providers during pregnancy for live births in the three years preceding the survey. By the start of the third month of pregnancy, 32 percent of women have made their first antenatal visit and by the start of the sixth month of pregnancy, 86 percent have made a visit. The median duration of pregnancy for the first antenatal visit is 3.6 months. Table 9.2 also indicates that 82 percent of women make four or more antenatal care visits. The median number of antenatal care visits is 11. It is clear that in Kazakstan antenatal care is received early in pregnancy and, for most women, it is continued throughout pregnancy. 9.2 Assistance and Medical Care at Delivery Hygienic conditions during delivery and supervision of delivery by trained medical staff reduce the risk of infections and ensure that complications of delivery are effectively handled. The KDHS collected information on the place of delivery for all children bom in the three years preceding the survey and the type of medical staff assisting during delivery. Table 9.3 indicates that virtually all births are delivered at health facilities (98 percent). The great majority of births occur in a Table 9.2 Number of antenatal care visits and stage of pregnancy Percent distribution of live births in the three years preceding the survey by number of antenatal care visits, and by the stage of pregnancy at the time of the first visit, Kazakstan 1995 Characteristic Percent Number of visits 0 7.3 1 1.9 2-3 5.7 4+ 81.9 Don't know/missing 3.2 Total 100.0 Median 10.7 Number of months pregnant at time of first visit No antenatal care 7.3 <3 mouths 31.9 3-5 mouths 53.6 6+ mouths 6.4 Don't know/missing 0.8 Total 100.0 Median 3.6 Number of births 810 Note: Figures are for births in the period 0-35 months preceding the survey. 109 Table 9.3 Place of delivery Percent distribution of births in the three years preceding the survey by place of delivery, according to selected background characteristics, Kazakstan 1995 Place of delivery Respond- Number Background Delivery ent's Other of characteristic hospital Hospital FAP 1 home home Other Total births Mother's age at birth < 20 98.3 1.7 0.0 0.0 0.0 0.0 100.0 115 20-34 96.1 1.2 0.9 1.5 0.1 0.2 100.0 625 35+ 95.4 1.3 0.7 2.7 0.0 0.0 100.0 70 Birth order 1 97.1 1.9 0.7 0.3 0.0 0.0 100.0 320 2-3 96.9 0.6 0.2 1.8 0.1 0.3 100.0 360 4+ 93.1 1.5 2.4 2.6 0.3 0.0 100.0 130 Residence Urban 99.2 0.7 0.0 0.0 0. I 0.0 100.0 343 Rural 94.3 1.6 1.3 2.4 0.1 0.2 100.0 466 Region Almaty City 97.5 1.2 0.0 0.0 1.2 0.0 100.0 36 South 96.4 0.3 1.2 1.8 0.0 0.3 100.0 373 West 94.5 1.9 0.5 3.2 0.0 0.0 100.0 107 Central 93.8 3.1 1.5 1.0 0.5 0.0 100.0 84 North and East 98. I 1.9 0.0 0.0 0.0 0.0 100.0 210 Mother's education Primary/Secondary 94.7 2.2 1.3 1.6 0.1 0.0 100.0 293 Secondary-special 97.8 0.5 0. I 1.3 0.0 0.3 100.0 386 Higher 95.9 1.3 1.5 0.9 0.3 0.0 100.0 131 Ethnicity Kazak 94.9 1.4 1.2 2.2 0.1 0.2 100.0 487 Russian 98. I 1.9 0.0 0.0 0.0 0.0 100.0 175 Other 99.1 0.0 0.3 0.3 0.3 0.0 100.0 148 Antenatal care visits None 95.4 0.0 0.0 4.6 0.0 0.0 100.0 59 1-3 visits 94.6 1.4 1.4 2.5 0.0 0.0 100.0 62 4 or more visits 96.5 1.4 0.8 0.9 0.1 0.2 100.0 663 Don't know/Missing 98.1 0.0 0.0 1.9 0.0 0.0 100.0 26 All births 96.4 1,2 0.8 1.4 0.1 0.1 1(30.0 810 Note: Figures are for births in the period 0-35 months preceding the survey. FAP = Doctor s assistant/midwife post delivery hospital (96 percent) and another 2 percent in either a general hospital or a FAP (doctor's assistant/midwife post). Only 2 percent of births are reported as occurring outside the setting of a health facility (i.e., primarily at the respondent's home). The high proportion of births delivered in delivery hospitals leaves little potential for differentials in place of delivery by age groups. Table 9.3 indicates that the percentage of births delivered in a hospital setting is 94 percent or higher for all population groups. Table 9.4 indicates that almost all births are delivered under the supervision of persons with medical t ra in ing- -78 percent by a doctor and 21 percent by a nurse or trained midwife. 110 Table 9.4 Assistance during delivery Percent distribution of births in the three years preceding the survey by reported provider during delivery, according to selected background characteristics, Kazakstan 1995 Attendant assisting during delivery I Nurse/ Number Background Trained Relative/ of characteristic Doctor midwife Other Total births Mother's age at birth < 20 84.0 16.0 0.0 100.0 115 20-34 76.8 22.7 0.5 100.0 625 35+ 83.6 16.4 0.0 100.0 70 Birth order 1 83.4 16.6 0.0 100.0 320 2-3 77.3 22.1 0.6 100.0 360 4+ 69.1 30.0 0.9 100.0 130 Residence Urban 89.3 10.7 0.0 100.0 343 Rural 70.3 28.9 0.7 100.0 466 Region Almaty City 95.1 4.9 0.0 I00.0 36 South 69.5 29.6 0.9 100.0 373 West 88.4 11.6 0.0 100.0 107 Central 68.3 31.7 0.0 100.0 84 North and East 90.4 9.6 0.0 100.0 210 Mother's education Primary/Secondary 75.7 24.3 0.0 100.0 293 Secondary-special 77.8 21.6 0.6 100.0 386 Higher 86.0 13.2 0.9 100.0 131 Ethnielty Kazak 71.7 27.6 0.7 100.0 487 Russian 90.2 9.8 0.0 100.0 175 Other 86.5 13.5 0.0 100.0 148 Antenatal care visits None 53.6 46.4 0.0 100.0 59 I-3 visits 70.6 27.5 1.8 100.0 62 4 or more visits 81.2 18.5 0.3 100.0 663 Total 78.4 21.2 0.4 100.0 810 Note: Figures are for births in the period 0-35 months preceding the survey. Total includes 26 births for which data on antenatal care are missing. 1 If the respondent mentioned more than one attendant, only the most qualified attendant is considered. While virtually all births are delivered by trained medical staff, there are differences in the percentage of deliveries assisted by a doctor and, alternatively, by a nurse or midwife by residence and region. Relatively more deliveries are attended by doctors in urban areas (89 percent) than in rural areas (70 percent), and more deliveries are attended by a doctor in Almaty City (95 percent) and the North and East Region (90 percent) than in the South and Central Regions (70 and 68 percent, respectively). As observed with antenatal care, the likelihood of delivery under a doctor's supervision increases with a woman's educational level and is greater for women of Russian ethnicity (90 percent) than for women of Kazak ethnicity (72 percent). 111 9.3 Characteristics of Delivery Respondents were asked in the KDHS if their births were delivered by caesarean section. Respondents were also asked if their children were weighed at the time of birth, and if so, how much each baby weighed. In addition, mothers were asked for their subjective assessment of their baby's size at birth (very large, larger than average, average size, smaller than average, or very small). Table 9.5 indicates that according to mothers' reports, 5 percent of births in the three years before the KDHS were delivered by caesarean section. This estimate is consistent with the reported statistic of 5.2 percent of deliveries by caesarean section (Ministry of Health, 1996). Delivery by caesarean section is more common among births to older women, women residing in urban areas, more educated women, and women of Russian ethnicity. However, the most pronounced differential in the prevalence of caesarean section delivery is associated with region. The rate of caesarean section is several times higher among births in Almaty City (19 percent) than among births in the other survey regions (4 to 5 percent). Table 9.5 Delivery characteristics: caesarean section~ birth weight and size Among births in the three years preceding the survey, the percentage of deliveries by caesarean section, and the percent distribution by birth weight and the mother's estimate of baby's size at birth, according to selected background characteristics, Kazakstan 1995 Birth weight Size of child at birth Delivery Less 2.5 kg Smaller Average Number Background by than or Don't Very than or Don't of characteristic C-section 2,5 kg more know Total small average larger know Total births Age <20 2.2 14.4 85,3 0.4 100.0 7.6 18.0 74.4 0.0 100.0 115 20-34 4.8 8.5 89.4 2.1 100.0 8.0 11.0 80.9 0.1 100.0 625 35+ 6.9 4.7 92,3 3.0 100.0 8,5 21.2 689 1.3 100.0 70 Birth order I 4.9 12.8 85.9 1.2 100.0 10.1 15.8 73.9 0.1 100.0 320 2-3 5.4 5.9 92.2 1.9 100.0 6.4 9.3 84.0 0.3 100.0 360 4+ 1.8 8.2 88.1 3.6 100.0 7.3 15.3 77.4 0.0 100.0 130 Residence Urban 7.2 9.9 88.7 1.4 100.0 8.2 I 1.8 79.7 0.3 100.0 343 Rural 2.7 8.3 89.4 2.3 100.0 7.9 137 784 01 100.0 466 Region Almaty City 18.5 4.9 95.1 0.0 100.0 6.2 I l.I 81.5 1.2 100.0 36 South 3,6 8.5 88.8 2.7 100,0 4.4 15.1 80.5 0.0 100.0 373 West 3.9 8.6 89.2 2.2 100.0 6.2 16.2 765 1.1 100.0 107 Central 5.1 10.0 86.4 3.6 100.0 14.5 9.6 75.9 0.0 100.0 84 North and East 4.2 10.4 89.6 0.0 100.0 13,0 8.7 78,3 0.0 100.0 210 Mother's education Primary/Secondary 1.2 7.1 90.7 2.2 100.0 5.4 15.0 79.5 0.2 100.0 293 Secondary-special 6.4 10.2 88.7 1.2 100.0 9.5 12.2 78.0 0,3 100.0 386 Higher 7.1 9.7 86.8 3,5 100.0 9.5 9.8 80.6 0.0 100.0 131 Ethnlcity Kazak 4.2 9.1 88.0 2.9 100.0 7.2 12.9 79.7 0.2 100.0 487 Russian 7.1 8.8 91.2 0.0 100.0 12.6 12.5 74.6 0.3 100.0 175 Other 3.1 8.9 90.2 0.9 1(30.0 5.3 13.2 81.5 0.0 100.0 148 Total 4.6 9.0 89.1 1.9 100.0 8.0 12.9 78.9 0.2 100.0 810 Note: Figures are for births in the period 0-35 months preceding the survey. Figures may not add to 100,0 due to rounding. 112 Mothers who report that their baby was weighed at birth are able to report the birth weight for 98 percent of all births in the last three years. As Table 9.5 indicates, 9 percent of births have a weight of less than 2.5 kilograms, which is classified as low birth weight and is considered to have a higher than average risk of early infant mortality. According to the mother's subjective evaluation of birth size, 8 percent of children are reported as very small at birth and another 13 percent are smaller than average. The percentage of births reported as very small at birth is consistent with the 9 percent of births with a birth weight below 2.5 kilograms. 9.4 Vaccinations According to guidelines developed by the World Health Organization, a child should have received a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis and tetanus, three doses of the polio vaccine, and a measles vaccination by the age of 12 months. Information on vaccination coverage was collected in the KDHS for all children under three years of age. If the mother was able to show the interviewer a child's health card, the interviewer recorded the information on vaccinations directly from the card. If the mother could not show a health card, she was asked to recall whether or not the child had received vaccines for BCG, polio and DPT (including the number of doses of each), and measles. In Kazakstan, child health cards are maintained at health facilities. Accordingly, the health card was with the mother for only 8 percent of children so that most of the information collected on vaccinations was based on mother's recall. It is important to note that the information reported by mothers was not validated by checking the health cards at the health facilities. Table 9.6 and Figure 9.2 show rates of vaccination coverage for children 12-23 months of age (i.e., children who should be fully vaccinated). BCG vaccination is usually given in delivery hospitals soon after delivery and is found to be nearly universal (97 percent). A high proportion of children have received the first dose of DPT (98 percent) and polio (100 percent). However, almost half of those who start the DPT and the polio series do not finish. In the case of the measles vaccine, 72 percent of children 12-23 months of age have been vaccinated. Table 9.6 Vaccinations by source of information Percentage of children 12-23 months who had received specific vaccines at any time before the survey, by whether the information was from a vaccination card or from the mother, Kazakstan 1995 Percentage of children who received: Percent DPT Polio with Number Source of vaccination of information BCG I 2 3+ 1 2 3+ Measles card children Vaccination card 7.3 8.6 9.1 8.7 8.0 8.4 7.0 6.4 8.1 23 Mother's report 89.9 89.3 76.3 42.3 91.9 88.1 51.7 65.5 91.9 257 Either source 97.2 97.9 85.4 51.2 99.8 96.5 58.7 71.9 100.0 280 113 Figure 9,2 Percentage of Children Age 12-23 Months with Specific Vaccinations Percent 97 100 , . . ~.331~i)i, 80 :::i:i:i:: : . . . . : . , .<> 60 '3 3:3:i' ; : z : z .> i : i .3 . ! 40 20 iiiii!i!~i 0 BCG 1 2 3+ Polio Note: Based on hesIth cards and mothers' reports 2 3+ Measles DPT KDHS1995 Table 9.7 shows rates of vaccination coverage for children 12-23 months of age according to selected background characteristics. In general, there is little variation in the level of BCG vaccination coverage between groups of children, which is also observed for the first dose of DPT and polio and for measles. Thus, children classified by gender, birth order, residency or region all have high coverage rates for BCG and the first doses of DPT and polio (94 percent or higher), while coverage rates for the measles vaccine are similar, although at lower levels across population groups. The most important finding of Table 9.7 is the much greater decrease in coverage between the first and third doses of DPT and polio among children in the rural areas as opposed to the urban areas and in the South Region as opposed to the other regions. For example, DPT coverage dropped from 96 to 74 percent in Almaty City, but dropped from 97 to 37 percent in the South Region. 114 Table 9.7 Vaccinations by background characteristics Percentage of children 12-23 months who had received specific vaccines by the time of the survey (according to the vaccination card or the mother's report) and the percentage with a vaccination card, by selected background characteristics, Kazakstan 1995 Percentage of children who received: Percent with DPT Polio vacci- Number Background nation of characteristic BCG 1 2 3+ 1 2 3+ Measles card children Sex Male 98.3 96.9 82.3 49.2 100.0 95.0 59.8 69.7 7.8 134 Female 96.1 98.8 88.4 53.1 99.7 97.9 57.6 73.8 8.4 145 Birth order 1 97.3 99.5 92.2 63.8 100.0 97.5 66.0 77.4 13.3 101 2-3 97.9 98.2 85.0 47.0 100.0 97.6 56.1 71.8 4.2 126 4+ 95.3 94.4 74.9 40.5 99.2 92.1 50.7 60.8 7.5 52 Residence Urban 100.0 97.7 92.6 61.2 99.6 99.1 69.0 75.8 4.6 118 Rural 95.1 98.1 80.0 43.8 100.0 94.7 51.7 69.0 10.7 161 Region Almaty City 100.0 96.3 91.3 73.9 96.3 91.3 82.6 76.0 25.0 12 South 95.7 96.9 77.1 36.7 100.0 93.1 47.8 69.3 1.7 133 West 98.7 100.0 89.7 59.0 100.0 100.0 56.6 82.6 3.1 37 Central 94.0 96.3 92.6 71.3 100.0 100.0 59.1 72.0 49.2 29 North and East 100.0 100.0 96.2 63.5 100.0 100.0 74.8 70.3 2.9 68 Mother's education Primary/Secondary 99.0 98.9 81.4 42.7 99.6 96.3 52.2 71.1 5.3 113 Secondary-special 95.1 98.0 88.2 54.] 100.0 97.3 60.7 74.7 11.5 115 Higher 97.8 95.4 87.9 63.9 100.0 95.2 68.5 67.4 6.8 51 Ethnicity Kazak 96.2 97.9 81.1 47.3 100.0 95.5 49.1 74.1 9.4 167 Russian 100.0 100.0 96.3 60.4 100.0 99.1 85.4 64.3 5.6 57 Other 97.1 95.5 87.3 53.8 99.2 96.9 60.2 73.6 7.0 55 All children 97.2 97.9 85.4 51.2 99.8 96.5 58.7 71.9 8.I 280 9.5 Acute Respiratory Infection Acute respiratory infection (ARI) is aprimary cause of morbidity among children and a leading cause of infant mortality throughout the world. In Kazakstan, over 20 percent of all infant deaths are attributed to ARI (Goskomstat, 1993). In the KDHS, mothers were asked if their children under three years of age had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These symptoms are compatible with ARI. It should be noted that the morbidity data collected in the KDHS are subjective in the sense that they are based on the mother' s perception of illness without validation by medical personnel. Also, the data apply to the period from May to September, while the peak prevalence of ARI is in mid-winter. 115 Table 9.8 and Figure 9.3 indicate that 5 percent of children under three years of age were ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. Differentials in the prevalence of ARI are most pronounced by age with children 24-35 months of age being twice as likely (8 percent) to have suffered an illness episode than children of any other age group (4 percent each). Table 9.8 Prevalence of acute respiratory infection and fever Percentage of children under three years who were ill with a cough accompanied by short, rapid breathing (acute respiratory infection) during the two weeks preceding the survey, and the percentage of children with fever during the two weeks preceding the survey, by selected background characteristics, Kazakstan 1995 Percentage of children Percentage Background with cough and of children Number of characteristic rapid breathing with a fever children Child's age < 6 months 3.8 6.4 114 6-11 months 3.8 20.9 132 12-23 months 3.9 10.9 280 24-35 months 7.8 9.3 253 Sex Male 7.0 13.4 366 Female 3.5 9.7 413 Birth order 1 4.1 11.4 308 2-3 6.4 12.5 345 4+ 4.0 8.3 126 Residence Urban 7.0 13.1 334 Rural 3.7 10.2 445 Region Almaty City I 1.7 14.3 34 South 3.0 10.6 358 West 3.3 12.8 101 Central 6.6 11.9 82 North and East 8.1 I 1.5 204 Education Primary/Secondary 3.0 9.0 281 Secondary-special 7.6 12.8 370 Higher 2.8 12.8 128 Ethnicity Kazak 4.4 12.3 464 Russian 7.7 11.5 171 Other 4.6 8.5 144 All children 5.1 11.4 779 Note: Figures are for children born in the period 0-35 months preceding the survey. 116 30 Figure 9.3 Prevalence of Respiratory Illness and Diarrhea in the Last Two Weeks by Age of the Child Percent 2O 15 10 I -- -- ~ I I o I ~ r -T . . . . , . . . . . . . , . I 0 6 12 18 24 30 36 41. Respirator'/illness -k- Diarrhea Age of Child (Months) KDHS1995 Differentials in ARI also exist according to sex of child, area of residence, education, and ethnicity. Whether these differentials in illness prevalence reflect genuine differences in morbidity or are due to differences in perceptions of illness cannot be ascertained from these data. Overall, 48 percent of children with ARI were taken to a health facility or health provider for treatment. (Because of the relatively small number of reported cases of ARI, data on treatment are not shown.) 9.6 Fever Table 9.8 also shows that 11 percent of children had an episode of fever during the two weeks prior to the survey. Differentials in the prevalence of fever are most pronounced by age with children 6-11 months of age being twice as likely to have had a fever than children of any other age group. 9.7 D iar rhea Dehydration caused by severe diarrhea is a major cause of morbidity among young children. In Kazakstan, over 11 percent of all infant deaths are attributed to diarrhea (Goskomstat, 1993). A prompt increase in a child's fluid intake is a simple and effective procedure to prevent diarrhea from developing into a life-threatening illness. Increased fluid intake should be administered in the form of a sugar, salt, and water solution, i.e., oral rehydration therapy (ORT). A product called Rehydron is widely available throughout Kazakstan for use in ORT. 117 All women who had a birth in the last three years were asked some basic questions about the care which should be given to a child with diarrhea: namely, if the intake of liquids and solid foods should be increased and if they had ever heard of Rehydron as a treatment for diarrhea. Table 9.9 indicates that most women had heard of Rehydron (82 percent). However, a surprisingly high proportion of women indicated that it is appropriate to reduce the amount of liquid offered to a child with diarrhea (26 percent). Mothers were also asked if their children had an episode of diarrhea in the last two weeks and, if so, whether there was blood in the stools, whether Rehydron or any other treatment was given in response to the diarrhea, and whether fluid intake was increased or decreased. The results of these questions are presented in Tables 9.10-9.12. Table 9.9 Knowledge of diarrhea care Percentage of mothers with births in the last three years who know about Rehydron for treatment of diarrhea and the ~ercent distribution by knowledge of appropriate feeding during diarrhea, according to background characteristics, Kazakstan 1995 Quantities that should be given during diarrhea Liquids Solid foods Percent who Don't Background know know/ characteristic Rehydron Less Same More Missing Total Less Don't Number know/ of Same More Missing Total mothers Age 15-19 45.0 23.9 35.0 25.7 15.3 100.0 35.7 48.2 1,0 15,1 100.0 45 20-24 79.0 30.0 28.8 31,4 9.8 100.0 56.8 34.2 2.1 6,9 ~00.0 240 25-29 91.1 24.9 18.8 54.8 1.6 100.0 68.8 27.1 1.9 2.3 100.0 201 30-34 86.2 20.7 17.6 56.3 5.5 100.0 70.4 24.7 1.6 3.2 100.0 127 35+ 80.7 25.0 20.0 49.7 5.3 100.0 68.6 26.8 0.8 3.9 100.0 89 Residence Urban 79.8 19.7 20.4 53.0 6,9 100.0 64.3 28.7 1.2 5.8 100.0 306 Rural 83.3 30.5 25.4 38.0 6.1 100.0 61.7 31.7 2.1 4.5 100.0 396 Region Almaty City 78.4 12.2 25,7 52.7 9.5 100.0 66.2 24.3 4.1 5.4 100.0 33 South 90.0 25.0 24.6 43.8 6.6 100.0 63.6 29.8 2.0 4,6 100.0 316 West 91.0 23.8 18.8 53.2 4.2 100.0 75.4 20.4 1.8 2.5 100.0 93 Central 86.4 31.9 13.6 44.5 10,0 100.0 61.9 28.2 1.2 8.7 100.0 73 North and East 62.0 28.2 26.3 40.1 5.4 100.0 55.1 38.3 1.0 5.6 100.0 187 Mother's education Primary/Secondary 77.7 37.9 22.2 32.4 7.5 100.0 64.2 28.7 2.5 4.6 100.0 252 Secondary-special 82.6 20.0 25.3 48.1 6.6 100.0 58.5 34.3 1.1 6.1 100.0 333 Higher 88.2 16.3 19.5 60.5 3.7 1000 72.3 22.9 17 3.1 100.0 116 Ethnieity Kazak 87.8 23.0 25.3 45.1 6.6 100.0 66.3 28.4 1.3 4.0 100.0 407 Russian 71.9 24.5 26.2 42.1 7.3 100.0 56.7 32.6 1.4 9.2 100.0 166 Other 75.2 36.4 12.7 46.0 4.9 100.0 59.6 33.8 3.4 3.2 100.0 129 All mothers 81.8 25.8 23.2 44.5 6.5 100.0 62.8 30.4 1.7 5.1 100.0 702 118 Table 9.10 Prevalence of diarrhea Percentage of children under three years who had diarrhea and diarrhea with blood in the two weeks preceding the survey, by selected background characteristics, Kazakstan 1995 Diarrhea in the preceding 2 weeks Number Background All Diarrhea of characteristic diarrhea with blood children Child's age < 6 months 9.3 0.4 114 6-11 months 25.0 1.3 132 12-23 months 19.6 0.8 280 24-35 months 9.5 0.0 253 Sex Male 17.1 0.1 366 Female I4.5 1.0 413 Birth order 1 17.3 0.7 308 2-3 15.2 0.7 345 4+ 13.6 0.0 126 Residence Urban 15.0 0.9 334 Rural 16.3 0.4 445 Region Almaty City 9.1 0.0 34 South 12.9 0.8 358 West 11.8 I. 1 101 Central 16.9 0.7 82 North and East 23.3 0.0 204 Mother's education Primary/Secondary 11.4 0.2 281 Secondary-special 18.9 1.1 370 Higher 16.3 0.0 128 Ethnicity Kazak 16.2 1.0 464 Russian 18.8 0.0 171 Other 10.7 0.0 144 All children 15.7 0.6 779 Note: Figures are for children born in the period 0-35 months preceding the survey. Table 9.10 and Figure 9.3 indicate that 16 percent of children under three had experienced diarrhea and that 1 percent had blood with the diarrhea. The age pattem of diarrhea shows a peak in late infancy of 6-11 months (i.e., around the time when a child begins to crawl and experience more exposure to the environment). The prevalence of diarrhea is lowest among children under 6 months of age (9 percent), increases to a peak among children ages 6-11 months (25 percent), remains high at 12-23 months (20 percent) and declines at 24-35 months of age (10 percent). Table 9.10 also indicates that region is associated with the most pronounced differentials in diarrhea. Children in Almaty City are least likely to have diarrhea (9 percent), while children in the Central and the North and East Regions are most likely to have diarrhea (17 and 23 percent, respectively). 119 Table 9.11 shows the treatment received by children who had diarrhea in the last two weeks. Twenty- six percent of children with diarrhea were taken to a health facility or health provider for treatment. In terms of other treatments, 28 percent of children received Rehydron and 4 percent received a homemade sugar-salt- water solution, so that 31 percent received some type of ORT. Overall, increased fluids were used to treat 40 percent of children with diarrhea. Table 9.12 summarizes the feeding practices which mothers followed when children had diarrhea. Eighty-five percent of children were given fluids in either the same or increased amounts while 14 percent were given reduced amounts of fluids. Table 9.11 Treatment of diarrhea Among children under three years who had diarrhea in the two weeks preceding the survey, the percentage taken to a health facility or provider for treatment, the percentage who received oral rehydration therapy, the percentage who received increased fluids, and the percentage who received neither oral rehydration therapy nor increased fluids, Kazakstan 1995 Treatments received Percentage Taken to a health facility or provider I 25.8 Received oral rehydration therapy Rehydron 28.2 Home sugar-salt-water solution 3.9 Either 31.2 Received increased fluids Neither Rehydron, home sugar-salt-water solution nor increased fluids Number of children 1 Includes health center, hospital, clinic and private doctor 39.6 46.7 123 Table 9.12 Feeding practices during diarrhea Percent distribution of children under three who had diarrhea in the past two weeks by amount of solid foods given and amount of fluids given, Kazakstan 1995 Feeding practices Total Amount of solid foods Same 42. I Increase 0.8 Decrease 57. I Amount of fluids Same 45.8 Increase 39.6 Decrease 14.2 Don't know/Missing 0.4 Total 100.0 Number of children 123 Note: Figures are for children born in the period 0-35 months preceding the survey. 120 CHAPTER 10 NUTRITION OF WOMEN AND CHILDREN Toregeldy S. Sharmanov and Temirkhan K. Bekbosynov This chapter covers two topics: infant feeding practices and the nutritional status of women and children. The former is described in terms of breastfeeding practices, supplementary feeding practices, and the use of bottles for supplementary feeding. Nutritional status is reported in terms of the height and weight of women and children. 10.1 Breastfeeding and Supplementation Infant feeding practices have important influences on both the child and the mother. For example, they determine a child's nutritional status and susceptibility to morbidity. Additionally, breastfeeding affects the health of a woman because of its influence on the return of ovulation following a birth and a woman's risk of another pregnancy. In the 1995 KDHS, for each child born in the last three years, mothers were asked if they had breastfed the child and, if so, how long after delivery breastfeeding was initiated. Women were also asked if their children were still breastfeeding and the age at which supplemental feeding began. Finally, for children not currently breastfeeding, the age at which they stopped breastfeeding was obtained. With these data, it is possible to look at several aspects of breastfeeding. For children born in the last three years, the length of time between delivery and initiation of breastfeeding can be investigated. From the data on current breastfeeding status (i.e., status at the time of the survey), the percentage of children breastfeeding by age can be calculated as well as median durations of breastfeeding by background characteristics of mothers. 10.1.1 Initiation of Breastfeeding Colostrum, which is contained in a mother's breast milk, has been proven to be highly nutritious and to contain the antibodies necessary to protect babies from infection before their immune system is fully mature. Table 10.1 indicates that breastfeeding is almost universal in Kazakstan; 96 percent of children born in the three years preceding the survey were breastfed. Overall, 10 percent of children were breastfed within an hour of delivery and 40 percent within 24 hours of delivery. There was no significant variation between population groups in the percent of children breastfed. However, there were significant differences in the timing of initiation of breastfeeding. Initiation within an hour of delivery is more likely among urban women (12 percent) than rural women (7 percent) and in Almaty City (l 5 percent) and the North and East Region (19 percent) than in other regions of the country. The most pronounced differentials in the initiation of breastfeeding were by mother's ethnicity. Breastfeeding was more likely within an hour of delivery among Russian women (17 percent) than among Kazak women (6 percent) and this differential was maintained at 24 hours of delivery (60 and 33 percent, respectively). It appears that more rapid initiation of breastfeeding following delivery would benefit many children in Kazakstan and would be particularly beneficial to Kazak children. 121 Table 10.1 Initial breastfeeding Percentage of children born in the three years preceding the survey who were ever breastfed, and the percentage of last-born children who started breastfeeding within one hour of birth and within one day of birth, by selected background characteristics, Kazakstan 1995 Among last-born children, percentage who started breast feeding: Percentage Within Within Number Background ever 1 hour 1 day of characteristic breastfed of birth of birth I children Sex Male 95.1 9.8 37.9 390 Female 96.0 9.3 41.5 419 Residence Urban 96.4 12.4 40.5 343 Rural 95.0 7.4 39.2 466 Region Almaty City 92.6 14.7 32.0 36 South 96.8 4.7 28.6 373 West 96.9 8.5 42.2 107 Central 93.3 6.4 49.9 84 North and East 94.1 19.3 56.1 210 Mother's education Primary/Secondary 94.7 11.3 42.4 293 Secondary-special 96.0 7.8 36.7 386 Higher 96.4 10.7 43.0 131 Ethnicity Kazak 96.1 6.3 33.0 487 Russian 94.0 17.2 60.1 175 All children 95.6 9.5 39.8 810 I Includes children who started breastfeeding within 1 hour of birth. 10.1.2 Age Pattern of Breastfeeding Research has shown that breast milk contains all the nutrients needed by children in the first several months of life. Supplementation of breast milk before four months of age is not necessary and is discouraged since early supplementation increases the risk of a child having diarrhea. Early supplementation also reduces a woman's output of breast milk since milk production is influenced by the frequency and intensity of breastfeeding. Table 10.2 shows information on breastfeeding status of children by age in months. As can be seen, a high proportion of children are breastfed in Kazakstan. At 0-3 months of age, 88 percent of children are breastfed and at 8-11 months of age, 73 percent are still breastfed. This falls to 21 percent by 20-23 months of age and all children have stopped breastfeeding by their third birthday. 122 Table 10.2 Breastfeeding status Percent distribution of living children by current breastfeeding status, according to child's current age in months, Kazakstan 1995 Percentage of living children who are: Breastfeeding and: Number Not Exclusively Plain of breast- breast- water Supple- living Age in months feeding fed only ments Total children 0-3 11.8 12.3 24.3 51.6 100.0 74 4-7 30.3 3.4 2.5 63.8 100.0 89 8-11 26.7 0.6 0.0 72.7 100.0 84 12-15 47.1 0.0 0.0 52.9 100.0 98 16-19 72.9 0.0 0.0 27.1 100.0 83 20-23 79.3 0.0 0.0 20.7 100.0 99 24-27 91.0 0.0 0.0 9.0 100.0 89 28-31 91.7 0.0 0.0 8.3 100.0 77 32-35 100.0 0.0 0.0 0.0 100.0 87 0-3 months 11.8 12.3 24.3 51.6 100.0 74 4-6 months 28.7 2.9 3.5 64.9 100.0 64 7-9 months 37.4 2.5 0.0 60.1 100.0 64 Note: Breastfeeding status refers to preceding 24 hours. Children classified as breastfeeding and plain water only receive no supplements. However, while breastfeeding is lengthy, supplementary feeding starts early in Kazakstan. Exclusive breastfeeding during early infancy, as recommended by the World Health Organization, 1 is not common. At ages 0-3 months, only 12 percent of children were exclusively breastfed. During these early months of infancy, most breastfed children receive either plain water (24 percent) or other foods and liquids (52 percent). Table 10.3 shows information on the median duration of breastfeeding. For all of Kazakstan, the median duration of any breastfeeding is lengthy (14 months) but the duration of exclusive and full breastfeeding (breastfeeding plus plain water) are short (0.4 and 0.7 months, respectively). The most pronounced differentials in breastfeeding are by region and ethnicity. The median duration of any breastfeeding is longer in the South, West, and Central Regions (14-15 months) than in Almaty City (9 months) or in the North and East Region (5 months). The median duration of any breastfeeding is longer for Kazak women (15 months) than for Russian women (6 months). t Exclusive breastfeeding is the practice of feeding with breast milk only. Supplementation with water is discouraged (WHO/UNICEF, 1990). 123 Table 10.3 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and full breastfeeding among children under three years of age, according to background characteristics, Kazakstan 1995 Median duration in months I Number of children Any Exclusive Full under Background breast- breast- breast- 3 years characteristic feeding feeding feeding 2 of age Sex Male 13.5 0.5 1.0 390 Female 14.5 0.4 0.6 419 Residence Urban 13.0 0.4 I. I 343 Rural 14.3 0.5 0.6 466 Region Almaty City 8.5 0.5 0.8 36 South 13.8 0.4 1.3 373 West 14.6 0.6 3. I 107 Central 14.6 0.6 1.6 84 North and East 4.8 0.4 0.5 210 Mother's education Primary/Secondary 14.9 0.5 0.6 293 Secondary-special 14.3 0.4 1.2 386 Higher 5.8 0.4 0.6 131 Ethnicity Kazak 14.8 0.5 1.8 487 Russian 6.2 0.4 0.5 175 Other 6.5 0.5 0.5 148 Total 13.9 0.4 0.7 Mean 13.7 1.3 2.3 Prevalence/incidence 3 13.0 0.6 1.4 810 I Medians and means are based on current status. 2 Either exclusive breastfeeding or breastfeeding and plain water only 3 Prevalence-incidence mean 10.1.3 Types of Supplemental Foods In the KDHS, mothers were asked about the types of foods that were given to children in the 24 hours preceding the survey. The foods given to a child are not mutually exclusive, and as a result, a child could be reported as receiving several types of food. Table 10.4 indicates the types of foods given to children according to breastfeeding status. Among children 0-3 months of age who are breastfeeding, infant formula was commonly used to supplement breast milk (20 percent) as well as powdered and evaporated milk (17 percent). Tea is especially popular in Kazakstan and was given in the last 24 hours to 21 percent of infants 0-3 months of age. Meat, poultry, fish, and eggs contain protein and other nutrients important for the physical and mental development of young children. Twenty-five percent of breastfeeding infants age 4-7 months receive these foods. Cereals and fruits and vegetables were also commonly given to infants who are breastfeeding; over 45 percent of infants 4-7 months of age were given these foods in the 24 hours before the survey interview. 124 Table 10.4 Types of foods received by children in preceding 24 hours Percentage of children under 36 months of age by type of food received in the 24 hours before the interview, and the percentage using a bottle with a nipple, according to breastfeeding status and child's age in months, Kazakstan 1995 Powdered/ Fer- Poultry/ Using Breast evape- mented fish/ Grain/ Fruit/ Sweets/ bottle Number Age milk Infant rated milk Other eggs/ flour/ Tubers/ vege- choco- with a of (in months) only formula milk products I Juice Tea liquids meat cereal potatoes tables late nipple children BREASTFEEDING CHILDREN 0-3 13.9 19.6 17.3 0.7 14.4 21.2 21.7 0.0 0.7 0.0 1.7 3.5 64.9 65 4-7 4.9 14.8 49.3 20.3 18.9 68.4 36.5 25.0 49.1 34.2 46.5 23.9 41.9 62 8-11 0.8 6.8 71.8 30.3 15.3 93.6 63.0 52.4 93.0 52.7 69.3 49.4 24.2 61 0-11 6.7 13.9 45.6 16.8 16.2 60.3 40.0 25.3 46.7 28.4 38.4 25.2 44.1 188 12-23 0.0 5.4 72.3 42.4 26.1 98.3 76.4 67.7 94.2 65.7 75.6 60.4 15.4 95 Total 4.2 10.7 55.0 25.8 19.5 74.3 52.7 41.7 63.5 41.8 52.5 38.3 33.4 297 NON-BREAS t I-bEDING CHILDREN 0-11 NA 32.0 84.4 14.6 36.8 54.2 66.7 48.6 63.6 46.1 49.6 24.7 87.2 58 12-23 NA 9.5 84.6 41.7 24.2 90.4 74.3 82.9 94.5 69.8 83.8 73.4 29.6 185 24-29 NA 4.0 68.8 35.9 31.7 87.1 68.8 78.8 88.4 67.5 79.3 68.8 10.8 123 30-35 NA 5.3 81.8 42.3 25.9 97.0 79.0 84.3 95.9 60.3 76.6 82.8 6.1 116 Total NA 9.8 79.8 37.1 28.1 86.8 74.0 78.1 89.6 64.1 76.8 68.7 26.0 482 i Kefir, airan, kumys and yogurt NA = Not applicable A relatively high percentage of children still being breastfed were also fed using a bottle with a nipple: 65 percent at age 0-3 months and 42 percent at 4-7 months of age. Among non-breastfeeding children, a high proportion at all ages receive powdered or evaporated milk (about 80 percent). Also, a high proportion receive high protein foods (poultry, fish, meat, or eggs) after the first birthday (about 80 percent of children). 10.1.4 Frequency of Food Supplementation The nutrition requirements of young children are more likely to be met if they are fed a variety of foods. In the KDHS, interviewers read a list of specific foods and asked the mother to report the number of days during the last seven days that the child received each food. Table 10.5 shows the percentage of children who received specific foods in the last seven days by age and breastfeeding status. At 0-3 months of age, a high percentage of breastfeeding infants received plain water (83 percent). Milk products were given to a smaller proportion of breastfeeding children 0-3 months old (21 percent). Poultry, eggs, fish and meat were only given to children over four months of age. Grains/cereals and fruits/vegetables were received by a significant proportion of children after four months of age (50 percent or more). As expected, a high percentage of non-breastfeeding children were given plain water and milk products at all ages (approximately 90 percent). Table 10.5 Types of food received by children in preceding week Percentage of children under 36 months of age who received specific types of food in the seven days preceding the interview, by breastfeeding status and age of the child in months, Kazakstan 1995 Milk and Poultry/ Grains/ Number Age milk Other eggs/ flour/ Tubers/ Fruits/ of (in months) Water products liquids fish Meat cereal potatoes vegetables children BREASTFEED1NG CHILDREN 0-3 82.8 21.3 20.8 0.0 0.0 0.7 0.0 1.7 65 4-7 93.9 67.6 63.6 32.6 32.8 61.4 50.3 63.7 62 8-11 89.5 90.3 92.6 54.6 69.0 97.6 84.8 78.2 61 0-11 88.6 59.0 58.3 28.5 33.2 52.2 44.2 47.0 188 12-23 93.9 95.6 98.0 64.6 85.8 100.0 91.4 91.4 95 Total 90.8 70.9 71.8 42.1 52.6 69.2 61.2 63.1 297 NON-BREAS t PbEDING CHILDREN 0-11 92.8 89.3 73.5 52.0 42.2 72.7 64.9 65.5 58 12-23 96.1 95.0 96.4 74.8 91.5 97.6 89.8 93.6 185 24-29 88.2 90.2 93.5 68.4 83.3 94.4 87.6 88.9 123 30-35 97.8 95.5 95.7 80.8 93.5 97.8 89.2 94.1 116 Total 94.1 93.2 92.7 71.9 84.0 93.8 86.1 89.2 482 10.1.5 Differentials in Food Supplementation Table 10.6 shows the percentage of children who received specific kinds of foods during the last seven days and, during that period, the mean number of days that each food type was received by background characteristics. Overall, the table indicates that a high proportion of children received each food type (above 126 -.d Table 10.6 Types of food received by children by background characteristics Percentage of chi ldren under 36 months of age who received specific types of food in the seven days preceding the interview, and the mean number of days chi ldren were fed these foods, by selected background characteristics, Kazakstan 1995 Milk and Poultry/ GrainsJ Tubers/ Fruits/ Iodized Water milk products Other liquids eggs/fish Meat flour/cereal potatoes vegetables salt in Number Background house- of characteristics Percent Mean Percent Mean Percent Mean Percent Mean Percent Mean Percent Mean Percent Mean Percent Mean hold children Sex of child Male 93.5 6.7 86.2 6.3 85.6 5.4 57.9 2.9 72.1 5.5 85.0 6.6 75.0 5.0 78.3 5.6 48.2 366 Female 92.3 6.7 83.4 6.0 84.0 5.4 62.8 3.3 71.9 5.4 84.0 6.6 78.1 5.0 80.0 5.9 47.4 413 Residence Urban 92.8 6.8 82.3 6.0 84.4 5.5 63.8 3.2 70.2 5.4 83.2 6.6 80.7 5.4 82.6 5.8 51.7 334 Rural 92.9 6.6 86.5 6.2 85.0 5.3 58.1 3.0 73.4 5.4 85.4 6.6 73.6 4.7 76.7 5.7 44.9 445 Region Alma~ 87.0 6.8 83.1 6.2 87.0 5.7 66.2 3.6 70.1 5.7 76.6 6.6 77.9 5.9 80.5 5.2 71.4 34 South 93.8 6.7 84.1 6.3 83.4 5.2 51.9 2.6 71.1 5.6 85.5 6.5 78.4 4.4 80.9 6.3 35.3 358 West 93.9 6.7 82.8 6.2 77.1 4.9 59.3 3.4 70.5 5.2 84.0 6.6 68.6 4.5 73.4 5.1 88.7 101 Central 89.5 6.5 83.8 6.1 83.8 5.3 55.6 3.1 73.5 5.2 80.7 6.9 63.3 5.2 69.4 5.0 30.2 82 North and East 93.0 6.7 87.4 5.8 90.9 5.9 77.3 3.5 74.1 5.3 85.6 6.7 82.6 5.8 82.9 5.6 52.4 204 Edueat i~ Primal~/ Secondary 93.3 6.6 85.4 6.1 83.3 5.3 54.3 3.2 72.9 5.3 83.9 6.5 74.6 4.8 77.5 5.7 45.6 281 Secondary- special 93.1 6.7 85.3 6.2 86.5 5.4 64.6 3.0 70.5 5.5 85.5 6.6 77.8 5.0 80.0 5.7 44.1 370 Higher 91.2 6.8 81.4 6.2 82.8 5.6 62.5 3.3 74.4 5.6 82.5 6.8 77.7 5.4 80.9 6.0 63.2 128 .,Ulmkny Kazak 90.9 6.6 83.7 6.2 82.6 5.0 53.1 2.7 71.6 5.6 85.2 6.7 72.6 4.4 76.2 5.7 49.1 464 Russian 97.4 6.8 85.7 5.9 87.6 5.8 70.0 3.5 68.0 5.1 78.8 6.5 79.7 5.9 83.7 5.7 47.6 171 Other 94.0 6.8 86.8 6.1 88.5 6.0 73.3 3.5 78.3 5.3 88.7 6.6 85.8 5.5 83.8 6.0 43.7 144 Total 92.9 6.7 84.7 6.1 84.8 5.4 60.5 3.1 72.0 5.4 84.4 6.6 76.6 5.0 79.2 5.8 47.8 779 70 percent except in the case of poultry, eggs, and fish) and that those foods were received frequently (five or more days except in the case of poultry, eggs, and fish). Even meat, which contains high amounts of protein needed by growing children, was frequently given to children. The data indicate only modest variation in feeding patterns by sex of the child, residence, region, education, and ethnicity. Table 10.6 also indicates that about half of the children (48 percent) live in households where iodized salt is available. 10.2 Nutritional Status of Children under Age Three The data on height and weight of children in the KDHS permit the evaluation of nutritional status and the identification of subgroups of children that are at increased risk of faltered growth and morbidity. 10.2.1 Measures of Nutritional Status in Childhood The evaluation of nutritional status is based on the rationale that, in a well-nourished population, there is a statistically predictable distribution of children of a given age with respect to height and weight. The distribution of children in such a well-nourished population can be used as a reference for assessing the nutritional status of children in other populations. The reference population recommended by the World Health Organization, which is used in this report, is the NCHS (U.S. National Center for Health Statistics) standard. Three standard indices of physical growth that describe the nutritional status of children are presented: height-for-age weight-for-height weight-for-age. Each of these indices gives different information about growth and body composition that can be used to assess nutritional status. Height-for-age is a measure of growth. A child who is below minus two standard deviations (-2SD) from the median of the NCHS reference population in terms of height-for-age is considered short for his/her age, or stunted, a condition reflecting chronic undemutrition. If a child is below minus three standard deviations (-3SD) from the reference median, the child is considered to be severely stunted. Weight-for-height describes current nutritional status. A child who is below minus two standard deviations (-2SD) from the reference median is considered too thin for his/her height, or wasted, a condition reflecting an acute or recent nutritional deficit. If a child is below minus three standard deviations (-3SD) from the reference median, the child is considered severely wasted. The weight-for-age index does not distinguish between chronic undemutrition (stunting) and acute undernutrition (wasting). A child can be underweight for age because he is stunted, because he is wasted, or because he is both wasted and stunted. Weight-for-age is a good overall indicator of a population's nutritional health. In a healthy, well-nourished population of children, it is expected that 2.3 percent of children will fall below minus two standard deviations (-2SD) of the median of the reference population on these nutritional indices (i.e., will be classified as moderately or severely undernourished). 128 In the survey, all surviving children born since January 1992 were eligible for height and weight measurement. Of the 779 children under three years of age at the time of the survey, plausible values for height and weight were obtained for 717 children (92 percent). The most commonly reported reason for not measuring a child was that the child was not at home. The following analysis pertains to the 717 children, age 0-35 months, for whom complete and plausible anthropometric data were collected. 10.2.2 Levels of Child Undernutrition in Kazakstan Table 10.7 shows the percentage of children under three years of age classified as undernourished according to demographic characteristics. For all of Kazakstan, 16 percent of children are moderately or severely stunted, 3 percent are moderately or severely wasted, and 8 percent are moderately or severely under- weight for age. In terms of demographic characteristics, the most pronounced differentials are found by age and birth interval. Children age 12-23 months and 24-35 months are less well-nourished than infants by almost all indices of undemutrition. Children bom after a birth interval of less than 24 months are generally less well- nourished than children born after longer birth intervals. Figure 10.1 shows nutritional differentials by selected demographic variables in terms of the stunting index. Moderate or severe stunting is found in a significant proportion of children 12-23 months of age (23 percent) and those born within a birth interval of less than 24 months (28 percent). Table 10,7 Nutritional status of children by demographic characteristics Percentage of children 0-35 months of age who are classified as undernourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by demographic characteristics, Kazakstan 1995 Demographic characteristic Height-for-age Weight-for-height Weight-for-age Percentage Percentage Percentage Percentage Percentage Percentage Number below below below below below below of -3 SD -2 SD ~ -3 SD -2 SD ~ -3 SD - 2 SD 1 children Age <6 months 1.1 4.2 0.0 2.1 0.0 1.6 106 6-11 months 1.3 9.6 0.0 3.5 0.9 5.1 124 12-23 months 33 23.0 1.5 4,1 1.9 11.1 262 24-35 months 50 16.3 0.3 27 2.0 100 224 Sex Male 44 17.8 0.7 44 1.7 103 330 Female 20 14.1 0.6 23 1.3 6.6 387 Birth order 1 3.1 11.8 0.0 2.0 0.0 5.2 275 2-3 3.3 17.0 12 3.3 2.3 103 327 4+ 2.9 22.0 0.4 6.3 2.9 10.1 115 Birth interval 2 < 24 months 43 28.3 2.5 4.9 4.1 155 135 24-47 months 4.4 20.1 0.3 3.0 2.7 8.6 166 48+ months 0.7 6.6 0.5 4.7 0.5 7.3 139 Total 3.1 15.8 0.6 3.3 1.5 8.3 717 Note: Figures are for children born in the period 0-35 months preceding the survey. Each index is expressed m terms of the number of standard de'.iation (SD) units from the median of the NCHS/CDC/WHO international reference population. Children are classified as undernourished if their z-scores are below minus two or minus three standard deviations /-2 SD or -3 SD) from the median of the reference population. 1Includes children who are belo'~. -3 SD -'Excludes first births 129 of KAZAKSTAN AGE OF CHILD (MOS.) 1-5 6-11 12-23 24-35 BIRTH INTERVAL(MOS) <24 24-47 48+ ~ 00 Figure 10.1 Prevalence of Stunting by Age Child and Length of Birth Interval ~ 4 . 2 ========================================= 9,6 ~; i ; i ; i ; :~ :~.~i . :~ .~.3½~, ~ ~ 230 16,3 I . . . . . . . . . . . ~T~:~ u ~ ~ >- ~. <~.;*;~ 4444~< ;~T4~7 <~-~.~ ~ , . 2ol ~6.6 5.0 100 150 20.0 25.0 30.0 Percent of children stunted :t~Severe E:dModerate J KDHS 1995 Table 10.8 shows nutritional indices by background characteristics. In terms of almost all indices, children in the urban areas suffer less undernutrition than children in rural areas. Similarly, children in Almaty City and in the North and East Region suffer less underuutrition than children in the South and Central Regions. Figure 10.2 shows nutritional differentials in terms of the stunting index. Moderate or severe stunting is found in a significant proportion of children in rural areas (22 percent), those in the South and Central Regions (23 and 22 percent, respectively), those born to women with a primary/secondary education (20 percent) and those born to women of Kazak ethnicity (21 percent). 130 Table 10.8 Nutritional status of children by background characteristics Percentage of children 0-35 months of age who are classified as undernourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Kazakstan 1995 Background characteristic Height-for-age Weight-for-height Weight-for-age Percentage Percentage Percentage Percentage Percentage Percentage Number below below below below below below of -3 SD -2 SD 1 -3 SD -2 SD 1 -3 SD - 2 SD 1 children Residence Urban 1.5 7.5 1.4 3.7 0.8 7.9 300 Rural 4.3 21.8 0.1 3.0 2.0 8.6 416 Region Almaty City 0.0 3.2 0.0 1.6 0.0 6.5 27 South 3.9 22.7 1.1 5.9 1.9 11.0 318 West 2.7 10.9 1.2 3.7 1.7 6.7 95 Central 5.0 21.5 0.0 1.2 1.2 8.4 72 North and East 1.9 7.0 0.0 0.0 1.0 5.1 204 Mother's education Primary/Secondary 3.2 19.9 0.8 4.5 1.7 9.3 262 Secondary-special 3.8 16.3 0.2 2.9 1.8 9.0 343 Higher 0.9 4.7 1.5 1.5 0.0 3.8 112 Ethnicity Kazak 4.6 21.1 0.7 3.6 1.8 10.3 421 Russian 1.2 7.2 1.1 1.7 1.2 4.3 161 Other 0.8 9.3 0.0 4.0 0.8 6.8 135 Total 3.1 15.8 0.6 3.3 1.5 8.3 717 Note: Figures are for children born in the period 0-35 months preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international reference population. Children are classified as undernourished if their z-scores are below minus two or minus three standard deviations (-2 SD or -3 SD) from the median of the reference population. llncludes children who are below -3 SD Figure 10.2 Prevalence of Stunting by Background Characteristics RESIDENCE ~ Urban 73 Rural 21. REGION AmatyCty ~ '~7; ] 3.2 vve,t lO.9 Central 21.~ = North and East ~ i i i i i~L J 7.0 MOTHER'S EDUCATION i Primary/Secondary i?i :.:.: : ::!:!:!: : :~:?:?:~: .:?:?:?:~!:!:!:i:!:!;!~!;~;~:~l 19.9 Secondary-special le.3 Higher ~:~;!;!;:;;i~1 4.7 ETHNICITY / Russian 7.2 Other 9.3 00 5.0 10.0 15.0 20.0 Percent of children stunted ~ Severe ~Moderatej ;~ - 15.8 21.8 22.7 21.5 25.0 30.0 KDHS 1995 131 10.3 Women's Anthropometr i c S tatus In the KDHS, data were collected on the height and weight of women 15-49 years of age. Measurements were obtained for 98 percent of surveyed women. Two indices of women's nutritional status are presented in this report: the height of women and the body mass index (BMI) - -an indicator combining height and weight data. A woman's height is associated with past socio- economic status and her access to nutritional foods dur- ing childhood and adolescence. Maternal height can be used to predict the risk of difficult delivery, since small stature is often associated with small pelvis size. The height below which a woman can be considered at risk is in the range of 140-150 centimeters. Table 10.9 shows the percent distribution of women by height. The mean height of women is 159 cm. Less than 1 percent of women are under 145 cm in height. 2 Indices of body mass are used to assess thinness and obesity. The most common is the body mass index (BMI), which is defined as weight (in kilograms) divided by squared height (in meters). A cutoff point of 18.5 kg/m 2 has been recommended for defining energy defi- ciency among nonpregnant women. Table 10.9 indicates that the mean BMI among nonpregnant, weighed and measured women 3 is 24.8, with 8 percent having a BMI below 18.5 kg/m 2. Table 10. I 0 shows mean values and the percent distribution of women for the BMI index by background characteristics. There are significant differentials in the percentage of women with a BMI less than 18.5 kg/m 2. Women in the 15-19 age group, those residing in the West Region, those with primary/secondary education, and Kazak women are more likely to have a low BMI value than other women. Table 10.9 Anthropometric indicators of female nutritional status Percent distribution and mean and standard deviation for all women by height and body mass index (BMI), Kazakstan 1995 Percent distribution including Indicator Percent missing Height (cm) 130.0-134.9 0.0 0.0 135.0-139.9 0.0 00 140.0-144.9 0.8 0.8 145.0-149.9 5.3 5.2 150.0-154.9 18.1 17.7 155.0-159.9 31.9 31.3 160.0-164.9 28.0 27.5 165.0-169.9 12.5 12.2 170.0 174.9 2.7 2.7 175.0-179.9 0.8 0.8 Missing 18 Total 100.0 100.0 Mean 159.0 Standard deviation 60 Number of women 3~704 3,771 BMI (kg]m 2) 12.0-15.9 0.6 0.6 16.0-16.9 1.2 1.2 17.0-18.4 6.1 5.9 18.5-20.4 14.9 14.6 20.5 22.9 23.2 22.7 23.0-24.9 15 6 15.2 25.0-26.9 9.8 9.6 27.0-28.9 8.8 8.6 29.0-29.9 3.3 3.2 30.0-31.9 5.5 5.4 32.0-33.9 3.6 3.5 34.0-35.9 3.0 30 36.0-37.9 1.3 1.3 38.0-39.9 1.3 1.3 >40.0 1.8 1.8 Missing 2.1 Total 100.0 100.0 Mean 24.8 Standard deviation 5.7 Number of women 3,518 3,594 Note: The BMI index excludes pregnant women and those who are less than 3 months postpartum. 2 If 150 cm is used as the cutoff, 6 percent of women would be considered at risk. 3 Pregnant women were excluded from the BMI analyses because precise data on gestational age, necessary for adjustments, were not available. 132 Table 10.10 Nutritional status of women by background characteristics Mean height and percentage of women shorter than 145 centimeters, mean body mass index (BMI), and percent distribution by BMI, for women age 15-49, by selected background characteristics, Kazakstan 1995 Height Body Mass Index Percent distribution Background Percent 18.5- characteristic Mean <145 cm Number Mean <18.5 29.9 > 30.0 Total Number Age 15-19 159.6 0,7 657 21.7 16.8 80.2 3.0 100.0 638 20-24 159.4 0.7 558 22.4 9.8 84.8 5.4 100.0 494 25-29 160.0 1.0 515 23.2 11.4 80.8 7.8 1130.0 460 30-34 158.9 1.0 543 24.8 7.9 78.1 14.0 100.0 522 35-49 158.3 0.9 1,431 27.6 1.9 67.2 30.8 10O.0 1,412 Residence Urban 160.0 0.6 2,079 25.0 7.3 75.0 17.6 100.0 2,018 Rural 157.8 1.2 1,625 24.5 8.5 75.9 15.6 100.0 1,507 Region Almaty City 161.3 0.3 258 24.7 6.1 78.7 15.2 100.0 252 South 158.2 0.9 1,182 24.0 8.4 79.3 12.3 100.0 1,096 West 158.4 1.8 461 24.0 10.6 77.1 12.3 100.0 437 Central 158.4 1.1 354 24.7 8.7 75.1 16.2 100.0 341 North and East 159.7 0.5 1,449 25.7 6.7 71.3 22.0 100.0 1,400 Mother's education Primary/Secondary 158.3 1.6 1,352 24.4 10.0 74.7 15.3 100.0 1,290 Secondary-special 159.1 0.5 1,693 25.3 6.6 74.3 19.1 100.0 1.611 Higher 160.3 .0.1 658 24.3 6.7 79.7 13.6 100.0 625 Ethnicity Kazak 157.5 1.0 1,660 23.5 11.0 78.1 10.9 100.0 1,564 Russian 160.8 0.5 1,289 25.7 5.2 74.1 20.7 100.0 1,245 Other 159.3 1.0 754 26.0 5.7 71.8 22.5 100.0 716 Total 159.0 0.8 3,704 24.8 7.9 75.4 16.7 100.0 3,525 Note: The BMI index excludes pregnant women and those who are less than 3 months postpartum. 133 CHAPTER 11 ANEMIA Almaz T. Sharmanov 11.1 Introduction Anemia is a condition which is characterized by reduction in the red blood cell volume and a decrease in the concentration of hemoglobin in the blood. Commonly, anemia is the final outcome of a nutritional deficiency of iron, folate, vitamin B~2 and some other nutrients. Although many other causes of anemia such as hemorrhage, infection, genetic disorders or chronic disease have been identified, nutritional deficiency due primarily to a lack of bioavailable dietary iron accounts for the majority of cases of anemia (INACG, 1979, 1989; DeMaeyer et al., 1989; Hercberg and Galan, 1992; Yip, 1994). Anemia is known to have detrimental health implications, particularly for mothers and young children. Compared to non-anemic mothers, unfavorable pregnancy outcomes have been reported to be more common in anemic mothers (1NACG, 1989). Women with severe anemia can experience difficulty meeting oxygen transport requirements near and at delivery, especially if significant hemorrhage occurs. This may be an underlying cause of maternal death, and prenatal and perinatal infant loss (Fleming, 1987; Omar et al., 1994; Thonneau et al., 1992). Iron deficiency anemia among children has been demonstrated in many studies to be associated with impaired cognitive performance, motor development, coordination, language development and scholastic achievement (Scrimshaw, 1984; Lozoff et al., 1991 ). Anemia increases morbidity from infectious diseases because several immune mechanisms are adversely affected. Anemia due to iron deficiency is recognized as a major public health problem throughout the world. According to the epidemiological data collected from multiple countries by the World Health Organization, some 35 percent of women and 43 percent of young children in the world are affected by anemia. In developing countries, about 50 percent of women and young children are anemic. In the U.S. and Europe, the prevalence of anemia is 7 to 12 percent among women and children. The highest overall rates of anemia are reported in southern Asia and certain regions of Africa (DeMaeyer et al., 1989). Anemia has been considered to be among the leading public health problems in Kazakstan for decades. According to the 1988 nutrition survey conducted by the Nutrition Institute in four regions of Kazakstan, 60 percent of nonpregnant and non-lactating women and 60 to 80 percent of pregnant women were diagnosed as having anemia based on hemoglobin and hematocrit measurement (Izmukhambetov, 1990). A study conducted in 1993 by the Crosslink Group in Muynak District of adjoining Uzbekistan, found anemia levels of over 60 percent for women of reproductive age and approximately 80 percent for children under the age of three (Morse, 1994). Because of correspondingly low serum levels of iron and ferritin, iron deficiency was recognized as the major cause of anemia among women and young children in that area. In a July 1994 study of women and children in Kazalinsk District of Kzyl-Orda Region of Kazakstan conducted by the London Institute of Tropical Medicine and the Kazakstan Institute of Geography, the prevalence of anemia among women age 15-45 was estimated at 46 percent and among children age 6-60 months at 64 percent (London School of Hygiene and Tropical Medicine, 1994). 135 11.2 Anemia Measurement Procedures Testing of women and children for anemia was one of the major efforts of the 1995 KDHS. This was the first anemia study in Kazakstan done on a nationally representative sample. The study involved hemoglobin testing for anemia to determine the prevalence and severity of anemia among women and children, and to identify demographic, socioeconomic, nutritional and other risk factors for anemia by residence, region, education, and other subgroups of population in Kazakstan. This chapter presents findings of the anemia study. Anemia testing was done on 3,658 women age 15-49 and 739 of their children age three and under. Prior to participating in the study, each respondent was asked to sign a consent form giving permission for the collection of a blood droplet from herself and her children. For hemoglobin measurement, capillary blood was taken from the finger using Tenderlett lancets (i.e., sterile disposable instruments that allow a relatively painless skin puncture). Hemoglobin was measured in the blood using the Hemocue system that allows the detection of the level of hemoglobin within a minute. This system consists of a battery-operated portable photometer and a disposable cuvette which serves as both a blood collection device and the site where reaction occurs. The procedure was performed by specially trained medical personnel and was determined to be suitable tbr the field conditions of the survey. Levels of anemia were classified as severe, moderate, and mild based on the hemoglobin concentration in the blood and according to criteria developed by the World Health Organization (DeMaeyer et al., 1989). Severe anemia was diagnosed when hemoglobin concentration was less than 7.0 g/dl, moderate anemia when the hemoglobin concentration was 7.0-9.9 g/dl, and mild anemia when the hemoglobin concentration was 10.0- I 1.9 g/dl ( 10-10.9 g/dl for pregnant women and children under age three). 11.3 Anemia Prevalence Among Women Table I 1.1 shows the results of anemia testing of women age 15-49. Almost half (49 percent) of the women in the sample were found to be anemic. Twelve percent had moderate or severe anemia with hemoglobin levels less than 10 g/dl. The group with the highest prevalence of anemia were women of the West Region. Among them, 19 percent were diagnosed as having moderate or severe anemia. The rates of moderate and severe anemia tire higher among ethnic Kazaks as compared to ethnic Russians, and among rural women as compared to urban. Women with higher education are less frequently anemic than women with primary or secondary education. There are no significant differences in anemia rates across women's age except for a low prevalence of moderate anemia among women age 15-19. Figure 11.1 shows the prevalence of moderate anemia among pregnant, breastfeeding, and nonpregnant, non-breastfeeding women. Among pregnant women in Kazakstan, moderate anemia is two to three times more common than among nonpregnant women (breastfeeding or non-breastfeeding). Figure 11.2 illustrates hemoglobin distributions of pregnant women, breastfeeding women, and nonpregnant, non-breastfeeding women. The entire hemoglobin distribution for pregnant women is shifted downward as compared to the distribution for nonpregnant women. The hemoglobin distribution for breast- feeding women is also shifted downward compared to the distribution for nonpregnant and non-breastfeeding women, but to a lesser extent than the distribution for pregnant women. 136 Table 11.1 Anemia among women Percentage of women age 15-49 classified as having anemia by background characteristics, Kazakstan 1995 Percentage of women with: Background Severe Moderate Mild Women characteristic anemia I anemia 2 anemia 3 measured Age 15-19 0.4 6.4 38.8 657 20-24 0.6 11.4 39.0 557 25-29 0.9 10.5 35.8 514 30-34 2.1 11.8 39.4 539 35-39 1.5 12.2 37.4 552 40-44 0.8 10.1 34.0 521 45-49 2.0 13.8 33,0 344 Residenee Urban 0.7 9.0 36.5 2,058 Rural 1.7 12.6 37.8 1,626 Region Almaty city 1.1 9.4 27.7 249 South 0.8 10.6 38.9 1,177 West 2.5 16.4 40.0 459 Central 0.7 8.0 35.1 354 North and East 1.1 9.5 36.8 1,445 Education Primary/Secondary 1.3 11.6 37.8 1,352 Secondary-Special 1.0 10,7 37.9 1,681 Higher 1.1 8.2 33.5 651 Ethnidty Kazak 1.9 14.3 40.7 1,654 Russian 0.7 7.2 33.8 1,283 Other 0.3 8.2 34.7 747 Total I. I 10.6 37.1 3,684 I Hemoglobin level less than 7g/dl 2 Hemoglobin level 7 + 9.9 g/dl 3 Hemoglobin level 10 - 11.9 g/dl (10 - 10.9 g/dl for pregnant women) 137 Figure 11.1 Prevalence of Moderate Anemia among Women Age 15-49 by Pregnancy Status and Breasffeeding Status Percent 35 ~ - - - -7 Pregnant Breastfeeding Nonprognant, non-breasffeeding Figure 11.2 Percent Distribution of Hemoglobin Levels among Women Age 15-49 Percent 35 . . . . 3O 20 15 0 ; ~ ' T 3 5.5 75 9,5 11.5 13.5 15.5 175 Hemoglobin (g/dl) [41-Nonprognant and non-breasffeeding . . . . . . . . . ~-Prognant {~Breasffeed~ 138 There is sufficient evidence to suggest that the majority of cases of anemia among women in Kazakstan are due to nutritional deficiency of iron. Testing blood for hemoglobin, which is an iron-containing conjugated protein occurring in red blood cells, can be used as a screening procedure for iron deficiency. However, anemia represents only the severe end of iron deficiency, and the real magnitude of iron deficiency in a population is greater than that reflected by hemoglobin measurement alone. Iron deficiency results primarily from low consumption of food products containing bioavailable iron and promoters of iron absorption, such as animal protein and ascorbic acid. In a series of dietary assessment studies done by the Kazakstan Nutrition Institute during the last decade, an overall decrease of consumption of animal protein, essential vitamins and microelements by various population groups in Kazakstan has been documented (National Institute of Nutrition, 1996). Deficiencies of iron and other nutrients are especially critical during pregnancy and growth in early childhood. When iron deficiency is the main etiologic factor of anemia, population groups with high iron requirements are disproportionately affected and develop anemia more frequently. Negative iron balance due to an imbalance of iron requirements versus iron intake often occurs during pregnancy and growth. For this reason, when iron deficiency is highly prevalent in a population, pregnant women, who provide the fetus with a considerable amount of iron, are at greater risk of developing anemia than nonpregnant women. It has been shown previously that the mean monthly menstrual blood loss has increased from 30 ml for women who are not using contraception to 50 ml for those who rely on the IUD (INACG, 1989). The chronic use of the IUD can lead to iron depletion and iron deficiency anemia (Palomo et al., 1993). Based on the KDHS data, almost 40 percent of currently married women in Kazakstan are using the IUD. The prevalence of anemia among women according to whether or not the respondent is currently using the IUD as a method of contraception is presented in Figure 11.3. As a result, the rates of severe and moderate anemia among IUD users are higher than among nonusers. Figure 11.3 Percentage of Women with Moderate or Severe Anemia among Those Who Are Current ly Using or Not Using the IUD Percent i: 14 I I 13.2 i 12 10 S 6 4 2 Severe Anemia Moderate Anemia ~Using ILJD ~:~Not Using I~ 139 11.4 Anemia Prevalence Among Children Table 11.2 presents anemia rates for children. A high national rate of anemia (69 percent) is found among children under the age of three. One-third of all children of Kazakstan are diagnosed as having moderate anemia, while 6 percent of children have severe anemia. Similar to women, the highest prevalence of anemia is observed among the children of the Western Region of Kazakstan; almost half are moderately anemic, and 8 percent are severely anemic. The most pronounced differentials are observed in terms of the prevalence of severe anemia. Nine percent of ethnic Kazak children have severe anemia, while no ethnic Russian children are severely anemic, and the prevalence for other ethnic groups is 1 percent. Similarly, percentages of severe anemia for children of mothers with a primary/secondary education and for children residing in the South, West, and Central Regions of Kazakstan are two to five times higher than those for other groups of children. Children residing in rural areas are more likely to have severe or moderate anemia. Table 11.2 Anemia among children Percentage of children under three years classified as having anemia by background characteristics, Kazakstan 1995 Percentage of children with: Background Severe Moderate Mild Children characteristic anemia I anemia 2 anemia 3 measured Residence Urban 4.5 26.9 32.3 293 Rural 6.1 38.2 28.6 422 Region Almaty city 1.5 20.0 26.2 29 South 7.4 32.8 32.7 319 West 7.7 47.3 26.0 93 Central 5.1 40.0 21.7 73 North and East 2.0 27.9 31.7 200 Education of mother Primary/Secondary 6.7 35.3 25.7 261 Secondary-Special 5.3 32.9 33.8 340 Higher 3.0 31.7 29.5 I13 Ethnlcity Kazak 8.9 40.6 28.2 420 Russian 0.0 27.5 31.0 159 Other 1.3 19.0 35.1 135 Total 5.5 33.6 30.1 714 J Hemoglobin level less than 7g/dl 2 Hemoglobin level 7 - 9.9 g/dl 3 Hemoglobin level 10 - 10.9 g/dl 140 Table 1 1.3 shows the percentage of children under age three classified as having anemia by selected demographic characteristics. The prevalence of severe anemia increases with increasing birth order. On average, at least 10 percent of children of birth order 4-5 and 6 or more have severe anemia, and about one- third are diagnosed as having moderate anemia. The percentages of severe anemia for these groups of children are twice as high as for the children who are first born. The prevalence of moderate and severe anemia increases with age, peaking at 12-23 months (48 percent). The percentage of children 12-23 months of age who are diagnosed as having severe anemia is four times greater than the percentage among children under six months of age. The high rate of anemia found among children 12-23 months of age can be explained by the rapid rate of growth and increased iron requirements during this stage of childhood. This is in accordance with several physiological studies which show that iron deposits are more likely to become depleted between six months and two to three years of age during weaning and the introduction of transitional food (INACG, 1979; Cook and Bothwell, 1984; Oski, 1993). Customs in Kazakstan which include the early introduction of cow's milk as a breast milk substitute, the relatively low consumption of meat products (a major source of bioavailable iron), and the widespread practice of giving children tea, which inhibits iron absorption, could also lead to the depletion of iron reserves and development of anemia. Children born within an interval of 24-47 months have higher rates of severe anemia than children born within interwds of less than 24 months or more than two years (Table 11.3). The proportions of severe and moderate anemia are higher among male than female children. Table I 1.3 Anemia among children by demographic characteristics Percentage of children under three years classified as having anemia by demographic characteristics, Kazakstan 1995 Percentage of children with: Demographic Severe Moderate Mild Children characteristic anemia I anemia 2 anemia 3 measured Sex Male 6.6 38.3 27, I 33 I Female 4.5 29,5 32.8 384 Age <6 months 1,7 38,3 24.9 103 6 11months 2,8 25.4 48.1 126 12-23 months 7.2 40.6 28.2 264 24-35 months 6.6 27.7 24.6 222 Birth order 1 4,2 33.8 26,0 271 2-3 4.6 32.5 34,3 324 4-5 10.3 38,4 28.3 93 6+ 12.3 28.0 29.3 26 Birth interval <24 months 4.5 39.3 31.4 138 24-47 months 8.4 36.9 34.3 164 48+ months 5,4 24.1 31.4 140 Total 5.5 33.6 30.1 714 i Hemoglobin level less than 7g/dl 2 Hemoglobin level 7 - 9.9 g/dl 3 Hemoglobin level 10 - 10,9 g/dl 14] Certain relationships are observed between the prevalence of anemia among mothers and their children. Table 11.4 shows the prevalence of anemia for children according to the anemia status of their mothers. Among children of mothers with moderate anemia, 12 percent have severe anemia and 45 percent have moderate anemia. The proportion of severe anemia among these children is more than three times greater than among children of non-anemic mothers. Thus, there are some demographic predisposing factors which increase the likelihood of anemia in children. These factors include the age of 12-23 months, high birth order, and having an anemic mother. Table 11.4 Anemia among children born to anemic mothers Percent distribution of children under three years by anemia status according to mothers' anemia status at the time of the survey, Kazakstan 1995 Child's anemia status Severe Moderate Mild Not Children Mother's anemia status anemia I anemia 2 anemia 3 anemic Total measured Severe anemia I * * * * * 4 Moderate anemia 2 12.1 44.9 25.0 18.0 100.0 103 Mild anemia 3 5. I 33.4 31.6 29.9 100.0 264 Not anemic 3.6 29.3 30.3 36.7 100.0 291 Total 5.5 33.6 30.1 30.8 100.0 714 I Hemoglobin level less than 7g/dl 2 Hemoglobin level 7 - 9.9 g/dl 3 Hemoglobin level 10 - 11.9 g/dl (10 - 10.9 g/dl for pregnant women and children under age three) Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 11.5 Summary The high prevalence of anemia among the women and children of Kazakstan is documented by the 1995 KDHS study. Negative iron balance is probably a major cause of anemia among both women and young children. The KDHS results are in accordance with data from the two recent studies mentioned earlier: the 1993 Crosslink study in Muynak District of adjoining Uzbekistan (Morse, 1994), and the study done by the London School of Hygiene and Tropical Medicine in Kzyl-Orda oblast of Kazakstan (London School of Hygiene and Tropical Medicine, 1994). Both studies showed similarly high rates of anemia among women and children living in the area of environmental crisis around the Aral Sea. In the KDHS, the area of the Aral sea is covered by the survey regions located in the South and West of Kazakstan, where the prewdence of anemia is among the highest. It is unlikely that hemoglobinopathies contribute substantially to the overall high prevalence of anemia in Kazakstan. In the study by the Crosslink group, only 0.14 percent of individuals residing in Muynak district of Karakalpakstan are diagnosed as having hemoglobinopathy (thalassemia was not determined) (Morse, 1994). Considering the common genetic features of the people of Kazak and Karakalpak origin, the prevalence of hemoglobinopathies among the Kazaks is also probably low. 142 The KDHS findings, as well as other geographically focused studies, provide an important information base for development of health intervention programs to prevent many severe complications of pregnancy and delivery related to iron-deficiency anemia among women of certain ethnic, educational, and residential groups in Kazakstan. These data are important as a background for public health policy decisions that pertain to the iron fortification of food in Kazakstan. Since anemia represents only the severe end of the iron deficiency spectrum, it is assumed that the total proportion of iron deficient individuals in the population is greater than that reflected by the prevalence of anemia detected by hemoglobin measurement alone. Therefore, in Kazakstan, where the prevalence of anemia is 49 percent among women and almost 70 percent among children based on hemoglobin measurement, the real magnitude of iron deficiency is greater, and therefore universal iron fortification or supplementation may be justified. Another solution would be selective supplementation of iron for certain population groups, such as pregnant women and young children. 143 REFERENCES Abylgozhin, Z. B., M.K. Kozybayev, and M.B. Tatimov. 1989. Kazakhstanskaya tragediya. Voprosy Istorii 7:53-72. Baishev, S.B., S.B. Beysembaev, and G.F. Kenesbaev, eds. 1979. History ofKazakstan. Vol. 3. Alma-Ata, Kazakstan: Nauka. Barr, D.A., and M.G. Field. 1996. The current state of health care in the former Soviet Union: Implications for health care policy and reform. American Journal of Public Health 86:307-312. Church, Mary, and Eugene Koutanev. 1995. 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Almaty, Kazakstan: Goskomstat. Goskomstat (State Committee on Statistics of the Republic of Kazakstan). 1993. Demographic yearbook of Kazakstan. Almaty, Kazakstan: Goskomstat. Goskomstat (State Committee on Statistics of the Republic of Kazakstan). 1996. Kazakstan brief statistical yearbook. Almaty, Kazakstan: Goskomstat. Hercberg, S., and P. Galan. 1992. Nutritional anemias. Baillikire's Clinical Haematology 5( 1): 143. Hobcraft, J. and D. Guz. 1991. Breastfeeding and fertility: A comparative analysis. Population Studies 45 (1): 91-108. International Nutritional Anemia Consultative Group (INACG). 1979. Iron Deficiency in Infancy and Childhood. Geneva, Switzerland: INACG, World Health Organization. International Nutritional Anemia Consultative Group (INACG). 1989. Iron Deficiency in Women. Geneva, Switzerland: INACG, World Health Organization. 145 Izmukhambetov, T. 1990. Iron deficiency anemia and health of the population of Kazakstan. In Iron deficiency anemia as a regional problem in Kazakstan: Epidemiological and nutritional aspects, ed. T. Sh. Sharmanov. Alma-Ata, Kazakstan: National Institute of Nutrition. 3-9. London School of Hygiene and Tropical Medicine. 1994. Preliminary report of a survey on anemia in the Kzyl Orda region of Kazakhstan. Washington, D.C.: IMPACT Project, USAID. Lozoff, B., E. Jimenez, and A.W. Wolf. 1991. Long-term development outcome of infants with iron deficiency. New England Journal of Medicine 325(10):687-694. Ministry of Health. 1995. Health of the population of the Republic of Kazakstan and health services in 1994. Almaty, Kazakstan: Ministry of Health. Ministry of Health. 1996. Health of the population of the Republic of Kazakstan and health services in 1995. Almaty, Kazakstan: Ministry of Health. Morse, C. 1994. A study of the prevalence and causes of anemia, Muynak district, Karakalpakistan, the Republic of Uzbekistan. Washington, D.C.: IMPACT Project, USAID. Mroz, Thomas and Barry Popkin. 1995. Family planning and abortion in the Russian Federation: The Russian Longitudinal Monitoring Survey, 1992-94. Chapel Hill, North Carolina: University of North Carolina. National Institute of Nutrition. 1996. Kazakstan National Nutrition Policy. Almaty, Kazakstan: National Institute of Nutrition. Olcott, M.B. 1995. The Kazakhs. 2d ed. Stanford: Hoover Institute Press. Omar, M.M., U. Hogberg, and B. Bergstrom. 1994. Maternal health and child survival in relation to socioeconomic factors. Gynecologic and Obstetric Investigation 38(2): 107-112. Oski, F.A. 1993. Iron deficiency in infancy and childhood. New England Journal of Medicine 329(3):190- 193. Palomo, I., G. Grebe, M. Ferrada, J.M. Carrasco, M. Maffioletti, and E. Felix. 1993. Effects of the prolonged use of intrauterine devices (IUDs) and oral contraceptives on iron nutrition. Revista M~dica de Chile 121(6):639-644. Potts, M., S. Thapa, and M.A. Herbertson. 1985. Breastfeeding and fertility. Journal of Biosocial Science Supplement No. 9. Scrimshaw, N.S. 1984. Functional consequences of iron deficiency in human populations. Journal of Nutritional Science and Vitaminology 30:47-63. Sharmanov, T., A. McAlister, and A. Sharmanov. 1996. Health care in Kazakstan. World Health Forum 17(2):197-199. Thonneau, P., B. Toure, P. Cantrelle, T.M. Barry, and E. Papiemik. 1992. Risk factors for maternal mortality: Results of a case-control study conducted in Conakry (Guinea). International Journal of Gynecology and Obstetrics 39(2):87-92. 146 United Nations. 1982. Non-samplingerrorsinhouseholdsurveys:Sources, assessment and control. National Household Survey Capability Program. New York: United Nations. United Nations. 1992. 1990 Demographic yearbook. New York: United Nations. United Nations. 1994. Report of the United Nations lnteragency Mission on Urgent Social Issues in Kazakstan. Almaty, Kazakstan: UNDP/UNICEF. United Nations Development Program (UNDP). 1995. Kazakstan human development report 1995. Almaty, Kazakstan: UNDP. World Health Organization (WHO). 1978. Declaration of Alma-Ata. Report on the International Conference on Primary Health Care. Geneva: Switzerland: WHO. World Health Organization (WHO)/UNICEF. 1990. Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding. Adopted at the WHO/UNICEF meeting, Breastfeeding in the 1990s: A Global Initiative, August, Florence, Italy. Yip, R. 1994. Iron deficiency: Contemporary scientific issues and international programmatic approaches. Symposium: Clinical nutrition in developing countries. Journal of Nutrition 124:1479S- 1490S. 147 APPENDIX A SAMPLE DESIGN APPENDIX A SAMPLE DESIGN Thanh U A.1 Introduction The Kazakstan Demographic and Health Survey (KDHS) employed a nationally representative probability sample of women age 15-49. The country was divided into five survey regions. Almaty City constituted a survey region by itself, while the remaining four survey regions consisted of groups of contiguous oblasts (except the East Kazakstanskaya) oblast which is not contiguous. The five survey regions were defined as follows: 1) Almaty City 2) South Region: Taldy-Kourganskaya, Almatinskaya (except Almaty City), Zhambylskaya, South Kazakstanskaya, and Kzyl-Ordinskaya 3) West Region: Aktiubinskaya, Mangistauskaya, Atyrauskaya, and West Kazakstanskaya. 4) Central Region: Semipalatinskaya, Zhezkaganskaya, and Tourgaiskaya. 5) North and East Region: East Kazakstanskaya, Pavlodarskaya, Karagandinskaya, Akmolinskaya, Kokchetauskaya, North Kazakstanskaya, and Koustanaiskaya. The oblast composition of regions outside of Almaty City was determined on the basis of geographic proximity and demographic characteristics. The South and West Regions are comprised of oblasts which traditionally have a high proportion of Kazak population and high fertility levels. The Central Region includes three oblasts in which the fertility level is similar to the national average. The North and East Region contains seven oblasts situated in northern Kazakstan in which a relatively high proportion of the population is of ethnic Russian origin and the fertility level is lower than the national average. A.2 Characteristics of the KDHS Sample In Almaty City, the sample for the KDHS was selected in two stages. In the first stage, 40 census counting blocks were selected with equal probability from the 1989 list of counting blocks created for the 1989 population census) A complete listing of the households residing in the selected counting blocks was carried out. The lists of households obtained served as the frame for second-stage sampling which is the selection of the households to be visited by the KDHS interviewing teams. In each selected household, women age 15-49 were identified and interviewed. L Census materials that were in good condition could only be found for Almaty City. For the rest of the country, census materials concerning the counting blocks were not centrally available, nor were they available in all oblasts. Consequently, different sampling frames had to be constructed, separately for the other urban areas and for the rural areas. 151 In the rural areas, the primary sampling units (PSUs) corresponded to the raions which were selected with probabilities proportional to size, the size being the 1993 census population, published by Goskomstat (1993). At the second stage, one village was selected in each selected raion from the 1989 Registry of Villages. This resulted in 50 rural clusters being selected. At the third stage, households were selecled in each cluster following the household listing operation as in Almaty City. In the urban areas other than Almaty City, the PSUs were the cities and towns themselves. In the second stage, one health block 2 was selected from each town except in self-representing cities (large cities that were selected with certainty) where more than one health block was selected. The selected health blocks were segmented prior to the household listing operation which provided the household lists for the third stage selection of households. In total, 86 health blocks were selected. A.3 Sample Allocation Tables A. 1 and A.2 show the distribution of the population in Kazakstan to the different survey regions, according to the 1993 Demographic Yearbook ofKazakstan (Goskomstat, 1993) as folh)ws: Table A.1 Population Distribution (1993) Region Urban Rural Total Total 9718000 7267700 16985700 Almaty City 1197900 0 1197900 South 2271300 3102200 5373500 West 1271200 956800 2228000 Central 931300 721100 1652400 North and East 4046300 2487600 6533900 Table A.2 Percent Distribution of Population (1993) Region Urban Rural Total Total 57.2 42.8 100.0 Almaty City 100.0 0.0 7.1 South 42.3 57.7 31.6 West 57.1 42.9 13.1 Central 56.4 43.6 9.7 North and East 61.9 38.1 38.5 2 In Kazakstan, each city or town is divided into health blocks, each of which is the responsibility of one physician. People living in the health block would go to a designated health center for service. This is where the physician in charge is located and maintains a map of the health block and even lists of households residing in the health block. The average population size of the health block is about 2,000. There are three different types of health blocks: the internist's block, the pediatrician's block, and the obstetrician/gynecologist's block, each serving a different group of patients as the names indicate. The internist blocks are largest in number (and correspondingly serve smaller groups of patients), and therefore were selected as the area sampling units for the KDHS. The literal Russian translation of internist' s block is actually therapeutical block. For the KDHS, it is referred to simply as the health block. 152 The regions, stratified by urban and rural areas, were the sampling strata. Therefore, there were nine strata with Almaty City constituting an entire stratum. As shown in Table A.3, a proportional allocation of the target number of 4,000 women to the nine strata would yield the following sample distribution: Table A.3 Proportional Sample Allocation Region Urban Rural Total Total 2289 1711 4000 Almaty City 282 0 282 South 535 730 1265 West 300 225 525 Central 219 170 389 North and East 953 586 1539 This proportional allocation would result in a completely self-weighting sample but would not allow for reliable estimates for three regions: Almaty City, West, and Central. Results of other demographic and health surveys show that a minimum sample of 1,000 women is required in order to obtain estimates of fertility and childhood mortality rates at an acceptable level of sampling errors. Given that the total sample size for the KDHS could not be increased so as to achieve the required level of sampling errors, it was decided that the sample would be divided equally to the five regions, and within each region, it would be distributed proportionally to the urban and the rural areas. With this type of allocation, demographic rates (fertility and mortality) could not be produced for the regions. Table A.4 shows the proposed sample allocation. Table A.4 Proposed Sample Allocation Region Urban Rural Total Total 2540 1460 4000 Almaty City 800 0 800 South 338 462 800 West 456 344 800 Central 451 349 800 North and East 495 305 800 The number of sample points (or clusters) to be selected for each stratum was calculated by dividing the number of women in the stratum by the average "take" in the cluster. Analytical studies of surveys of the same nature suggest that the optimum number of women to be interviewed is around 20-25 in each urban cluster and 30-35 in each rural cluster. If on average 20 women in each urban cluster and 30 women in each rural cluster were to be interviewed, then the distribution of sample points would be as follows: The number of clusters in the South Region in Table A.5 would yield a slightly smaller number of women than expected because of rounding errors. Consequently, the number of clusters were rearranged in each stratum so that it was an even number, but in such a way that the expected regional sample size did not fall short of the required 800 minimum. The even number of clusters is recommended for the purpose of calculating sampling errors in which the first step is to form pairs of homogeneous clusters. 153 Table A.5 Number of Sample Points Region Urban Rural Total Total 128 48 176 Almaty City 40 0 40 South 17 15 32 West 23 11 34 Central 23 12 35 North and East 25 10 35 Table A.6 Proposed Number of Sample Points Region Urban Rural Total Total 126 50 176 Almaty City 40 0 40 South 16 16 32 West 22 12 34 Central 22 12 34 North and East 26 10 36 The number of households to be selected for each stratum was calculated as follows: Number of HHs = Number of women Number of women per HH x Overall response rate According to the 1989 census, the proportion of women age 15-49 in Kazakstan was 25 percent. By applying this figure to the average household size of 4.0 obtained from a household survey conducted by Goskomstat, the number of women age 15-49 was estimated to be 1.0 per household. The overall response rate was assumed to be 90 percent (95 percent for households and 95 percent for women), which was the average overall response rate found in DHS surveys. Using these two parameters in the previous equation, approximately 4,500 households had to be selected in order to yield the target sample of women. This resulted in selecting on average 22 households in each urban cluster and 33 households in each rural cluster. A.4 Stratification and Systematic Selection of Clusters Stratification of the area sampling units was mostly geographic within each sampling stratum. A.4.1 Almaty City After ordering the raions geographically, and maintaining the order of the counting blocks within the raion, the counting blocks were selected with equal probability. Selection with probability proportional to size was not necessary since the counting blocks were relatively uniform in size (average population size of 417, standard deviation of 36, and coefficient of variation of 8.6 percent). 154 The selection interval was calculated as follows: 2515 1 = 40 where 2,515 is the total number of counting blocks in Almaty City and 40 is the number of counting blocks to be selected. The counting blocks to be selected were the ones with the following serial numbers: R, R+I, R+2I, . R+391, where R is a random number between 1 and 1. A.4.2 Other u rban areas In the other urban areas, the cities and towns were selected with probabilities proportional to size, the size being the 1993 population count. Large cities, or self-representing cities, that had to be selected with certainty (probability = 1.0) were separated out before towns were selected. The limit above which a city became self-representing was calculated as follows: L = Population in stratum Number of Health Blocks to be Selected Within each city, the required number of health blocks were selected with equal probability. The selection intervals for the towns were calculated as follows: EM~ a where EM~ is the size of the stratum (total population in the stratum according to the sampling frame) and a is the number of towns to be selected in the stratum. The selection procedure consisted of: (1) calculating the cumulated size of each town; (2) calculating the series of sampling numbers R, R+I, R+21, ., R+(a-1)1, where R is a random number between 1 and 1; and (3) comparing each sampling number with the cumulated sizes. The town to be selected was the first town whose cumulated size was greater or equal to the sampling number. Within each town, one health block was selected using a random number between 1 and the number of health blocks that exist in the town. A.4.3 Rura l areas In the rural areas, the raions were selected with probabilities proportional to size. One village was then selected within each raion using a random number between 1 and the number of villages that exist in the raion. Selection of raions followed the same procedure of town selection. Health blocks and villages that were very large in size were divided into segments of approximately 200-300 households and only one segment was retained for the KDHS. 155 A.5 Sampling Probabilities The sampling probabilities were calculated separately for each sampling stage, and independently for each stratum. The following notations were used: P~ is the first-stage sampling probability (counting blocks, towns, or raions). P2 is the second-stage sampling probability (health blocks, villages). P3 is the third-stage sampling probability (households). A.5.1 Almaty City Let a be the number of counting blocks selected and A be the total number of counting blocks in Almaty City. The probability of inclusion of the i 'h counting block in the sample is calculated as follows: a 40 Pli = ~ = 2515 In the second stage, a number, b,, of households was selected from the number M~" of households listed in the ith selected counting block by the KDHS teams. It follows that: b i P2t - M~ / In order for the sample to be self-weighting within the stratum, the overall probability f= PwP2~ must be the same for each household within the stratum. This implies that: bi Pu .P2~ = _ _ - f 40M/ wheref is the sampling fraction for Almaty City calculated as follows: f=_n N where n is the number of households selected in Almaty City and N is the estimated number of households that existed in Almaty City in 1995, at the time of fieldwork. A.5.2 Other urban areas First, towns will be discussed. Let a be the number of towns selected in a given stratum M,, the size (population according to the sampling frame) of the i th town in the stratum, and ZM~, the total size of the stratum (population according to the sampling frame). The probability of inclusion of the ith town in the sample is calculated as follows: aM~ Pu = ~M~ i 156 In the second stage, one health block was selected in each town. The probability of selection of the fh health block in the i th town is as follows: mtj P2q = Emq ] where mii is the size of thej th health block. An intermediary sampling stage was introduced between the second and third sampling stages. This selection stage was not considered an effective stage but only a pseudo-stage in order to reduce the size of the health block. Let t~jk be the estimated size (in proportion) of the k th segment selected for the fh health block. Note that Ytii k = 1. The sampling probabilities are: aM~ mqtqk Pn'P2ii = EM~" Emo i 1 In the third stage, a number, b~, of households was selected from the number M~' of households listed in the k ~h segment of thef h health block by the KDHS teams. It follows that: aM i motiy k b~ Pn'P2o'P3iJk = Y~M i" ~mo " M/ i J In order for the sample to be self-weighting within the stratum the overall probability f= Pn.Pzo.Pa,ik must be the same for each household within the stratum, wherefis the sampling fraction calculated as in Almaty City, separately for each stratum. The selection of the households was systematic with equal probability and the selection interval was calculated as follows: 1 Pli'P2ij li P3ijk f In the case of self-representing cities, P~ = 1. If more than one health block were selected then: _ a/mq P20 ~m ij where a' is the number of health blocks selected in the city. The other parameters were calculated as those for towns. A.5.3 Rural areas The calculations of the selection probabilities for the different stages of sampling were the same as for the towns, with raions equivalent to towns, and villages equivalent to health blocks. 157 APPENDIX B ESTIMATES OF SAMPLING ERRORS APPENDIX B ESTIMATES OF SAMPLING ERRORS Thanh U The estimates from a sample survey are affected by two types of errors: (1) nonsampling errors, and (2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the KDHS to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the KDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the KDHS sample is the result of a multistage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the KDHS is the ISSA Sampling Error Module. This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: .1 -Ira; var ( r ) - - - -z Zhi - h=l mh 161 in which Zhi = yh i - r .Xh i , and Z h = Yh- r .Xh where h mh Yhi xh, f represents the stratum which varies from 1 to H, is the total number of clusters selected in the h th stratum, is the sum of the values of variable y in the t ~h cluster in the h th stratum, is the sum of the number of cases in the i th cluster in the h th stratum, and is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo-independent replications are thus created. In the KDHS, there were 176 non-empty clusters. Hence, 176 replications were created. The variance of a rate r is calculated as follows: k SE2(R) = var ( r ) - k(l_l)i~=l(ri - r ) 2 in which r i = k r - (k-1)r(0 (4) where r r,j k is the estimate computed from the full sample of 176 clusters, is the estimate computed from the reduced sample of 175 clusters (t ~h cluster excluded), and is the total number of clusters. In addition to the standard error, ISSA computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result i fa simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. ISSA also computes the relative error and confidence limits for the estimates. Sampling errors for the KDHS are calculated for selected variables considered to be of primary interest. The results are presented in this appendix for the country as a whole, for urban and rural areas, for five survey regions, and for three ethnic groups (Kazak, Russian, and other ethnic groups together). For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B. 12 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFI" is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). Estimates and sampling errors of total fertility and childhood mortality rates only apply to the national sample, the urban and rural samples, and the Kazak and Russian ethnic groups. In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to childbearing. 162 The confidence interval (e.g., as calculated for children ever born to women age 15-49) can be interpreted as follows: the overall average from the national sample is 1.816 and its standard error is .033. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e.,. 1.816±2(.033). There is a high probability (95 percent) that the true average number of children ever born to all women age 15 to 49 is between 1.750 and 1.882. Sampling errors are analyzed for the national sample and for two separate groups of estimates: (1) means and proportions, and (2) complex demographic rates. The relative standard errors (SE/R) for the means and proportions range between 0.2 percent and 21.4 percent with an average of 7.3 percent; the highest relative standard errors are for estimates of very low values (e.g., severe anemia among women who were tested). If estimates of very low values (less than 10 percent) are removed, then the average drops to 5 percent. In general, the relative standard errors for most estimates for the country as a whole are small, except for estimates of very small proportions. The relative standard error for the total fertility rate is small at 5 percent. However, for mortality rates, the average relative standard error is much higher at 22 percent. If the neonatal, postneonatal, and child mortality rates, which are considered rare events, are removed, then the relative standard error for the mortality rates drops to 14 percent. There are differentials in the relative standard error for the estimates of subpopulations. For example, for the variable secondary-special education, the relative standard errors as a percent of the estimated mean for the whole country, for the rural areas, and for Almaty city are 3.1 percent, 4.5 percent, and 6.2 percent, respectively. For the total sample, the value of the design effect (DEBT) averaged over all variables is 1.26, which means that due to multistage clustering of the sample, variance is increased by a factor of 1.6 over that of an equivalent simple random sample. 163 Table B.I List of selected variables for sampling errors~ Kazakstan 1995 Variable Description Base population WOMEN Primary/secondary education Proportion Secondary-special education Proportion Higher education Proportion Never married (in union) Proportion Currently married (in union) Proportion Married before age 20 Proportion Had first sexual intercourse before 18 Proportion Children ever born Mean Children ever born to women over 40 Mean Children surviving Mean Knowing any contraceptive method Proportion Knowing any modem contraceptive method Proportion Ever used any contraceptive method Proportion Currently using any method Proportion Currently using a modern method Proportion Currently using pill Proportion Currently using IUD Proportion Currently using condom Proportion Currently using periodic abstinence Proportion Currently using withdrawal Proportion Using public sector source Proportion Want no more children Proportion Want to delay at least 2 years Proportion Ideal number of children Mean Severe anemia Proportion Moderate anemia Proportion Mild anemia Proportion BMI < 18.5 Proportion BMI between 18.5 and 30.0 Proportion BMI > 30.0 Proportion Weight-lot-height Proportion Mothers received medical care at birth Proportion Had diarrhea in the last 2 weeks Proportion Treated with ORS packets Proportion Consulted medical personnel Proportion Having health card, seen Proportion Received BCG vaccination Proportion Received DPT vaccination (3 doses) Proportion Received polio vaccination (3 doses) Proportion Received measles vaccination Proportion Fully immunized Proportion Children with severe anemia Proportion Children with moderate anemia Proportion Children with mild anemia Proportion Weight-lbr-height Proportion Height-for-age Proportion Weight-for-age Proportion Total fertility rate (3 years) Rate Neonatal mortality rate (0-4 years) Rate Postneonatal mortality rate (0-4 years) Rate Infant mortality rate (0-4 years) Rate Child mortality rate (0-4 years) Rate Under-five mortality rate (0-4 years) Rate All women 15-49 All women 15-49 All women 15-49 All women 15-49 All women 15-49 Women 25-49 Women 25-49 All women 15-49 Women 40-49 All women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Current users of modern method Currently married women 15-49 Currently married women 15-49 All women 15-49 Women 15-49 who were tested Women 15-49 who were tested Women 15-49 who were tested Women 15-49 who were measured Women 15-49 who were measured Women 15-49 who were measured Women 15-49 who were measured Births in last 3 years Children under 3 Children under 3 with diarrhea in last 2 weeks Children under 3 with diarrhea in last 2 weeks Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children under 3 who were tested Children under 3 who were tested Children under 3 who were tested Children under 3 who were measured Children under 3 who were measured Children under 3 who were measured Women-years of exposure to childbearing Number of births Number of births Number of births Number of births Number of births 164 Table B.2 Sampl ing errors - National sample: Kazakstan 1995 Number of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEIZ'I ") (SE/R) R-2SE R+2SE Primary/secondary education .365 .015 Secondary-special education .456 .014 Higher education .178 .011 Never married (in union) .235 .007 Currently married (in union) .665 .009 Married before age 20 .343 .015 Had first sexual intercourse before 18 . I 18 .009 Children ever born 1.816 .033 Children ever born to women over 40 3.114 .080 Children surviving 1.713 .031 Knowing any contraceptive method .993 .002 Knowing any modern method .993 .002 Ever used any contraceptive method .835 .012 Currently using any method .591 .015 Currently using a modem method .461 .012 Currently using pill .018 .003 Currently using IUD .396 .012 Currently using condom .037 .004 Currently using periodic abstinence .065 .007 Currently using withdrawal .032 .005 Using public sector source .924 .011 Want no more children .594 .010 Want to delay at least 2 years .186 .008 Ideal number of children 2.937 .045 Severe anemia .011 .002 Moderate anemia .106 .007 Mild anemia .371 .010 BMI < 18.5 .079 .005 BMI between 18.5 and 30.0 .754 .007 BMI > 30.0 .167 .009 Weight-for-height .039 .004 Mothers received medical care at birth .996 .002 Had diarrhea in the last 2 weeks .157 .018 Treated with ORS packets .282 .049 Consulted medical personnel .258 .059 Having health card, seen .081 .014 Received BCG vaccination .968 .012 Received DPT vaccination (3 doses) .417 .037 Received polio vaccination (3 doses) .483 .041 Received measles vaccination .669 .033 Fully immunized .234 .028 Severe anemia .055 .008 Moderate anemia .336 .017 Mild anemia .301 .022 Weight-for-height .033 .007 Height-for-age .158 .018 Weight-for-age .083 .012 Total fertility rate (3 years) 2.492 .134 Neonatal mortality rate (0-4 years) 19.528 4.504 Posmeonatal mortality rate (0-4 years) 20.128 4.352 Infant mortality rate (0-4 years) 39.656 5.588 Child mortality rate (0-4 years) 6.076 2.336 Under-five mortality rate (0-4 years) 45.490 6.286 3771 3771 1.876 .040 .336 .394 3771 3771 1.737 .031 .428 .484 3771 3771 1.718 .060 .156 .199 3771 3771 1.074 .032 .220 .249 3771 3771 1.169 .014 .647 .683 2525 2535 1.570 .043 .313 .372 2525 2535 1.441 .078 .099 .136 3771 3771 1.127 .018 1.750 1.881 875 892 1.133 .026 2.954 3.275 3771 377I 1.136 .018 1.652 1.774 2457 2507 1.136 .002 .989 .997 2457 2507 1.128 .002 .989 .997 2457 2507 1.572 .014 .811 .858 2457 2507 1.511 .025 .561 .621 2457 2507 1.158 .025 .437 .484 2457 2507 1.186 .178 .011 .024 2457 2507 1.174 .029 .372 .419 2457 2507 .951 .098 .030 .044 2457 2507 1.422 .109 .051 .079 2457 2507 1.543 .172 .021 .043 1259 1266 1.498 .012 .902 .947 2457 2507 1.057 .018 .573 .614 2457 2507 1.058 .045 .169 .203 3602 3621 1.868 .015 2.847 3.026 3658 3683 1.385 .214 .007 .016 3658 3683 1.463 .070 .091 .121 3658 3683 1.311 .028 .350 .392 3507 3525 1.074 .062 .069 .088 3507 3525 1.007 .010 .739 .769 3507 3525 1.349 .051 .150 .184 3500 3519 1.232 .103 .031 .047 846 810 1.056 .002 .991 1.000 811 779 1.301 .112 .122 .193 116 123 1.171 .174 .183 .380 116 123 1.379 .229 .139 .376 294 280 .836 .168 .054 .109 294 280 1.159 .013 .943 .992 294 280 1.250 .089 .343 .491 294 280 1.353 .084 .402 .564 294 280 1.152 .049 .603 .734 294 280 1.097 .119 .178 .290 739 714 .967 .149 .038 .071 739 714 .949 .050 .302 .369 739 714 1.277 .073 .257 .346 735 717 .988 .201 .020 .046 735 717 1.318 .116 .121 .195 735 717 1.178 .148 .059 .108 NA 10669 1.705 .054 2.224 2.760 1495 1450 1.243 .231 10.520 28.536 1497 1452 1.158 .216 11.423 28.833 1497 1451 1.107 .141 28.479 50.833 1498 1452 1.129 .384 1.403 10.748 1500 1453 1.140 .138 32.919 58.062 NA = Not applicable 165 Table B.3 Sampl ing errors - Urban sample: Kazakstan 1995 Number of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) IN) (WN) (DEFT) (SE/R) R-2SE R+2SE Primary/secondary education Secondary-special education Higher education Never married (in union) Currently married (in union) Married before age 20 Had first sexual intercourse before 18 Children ever born Children ever born to women over 40 Children surviving Knowing any contraceptive method Knowing any modem method Ever used any contraceptive method Currently using any method Currently using a modem method Currently using pill Currently using IUD Currently using condom Currently using periodic abstinence Currently using withdrawal Using public sector source Want no more children Want to delay at least 2 years Ideal number of children Severe anemia Moderate anemia Mild anemia BMI < 18.5 BMI between 18.5 and 30.0 BMI > 30.0 Weight-for-height Mothers received medical care at birth Had diarrhea in the last 2 weeks Treated with ORS packets Consulted medical personnel Having health card, seen Received BCG vaccination Received DPT vaccination (3 doses) Received polio vaccination (3 doses) Received measles vaccination Fully immunized Severe anemia Moderate anemia Mild anemia Weight-for-height Height-for-age Weight-for-age Total fertility rate (3 years) Neonatal mortality rat* (0-9 years) Posmeonatal mortality rate (0-9 years) Infant mortality rate (0-9 years) Child mortality rate (0-9 years) Under-five mortality rate (0-9 years) .279 .018 2056 2133 1.808 .064 .243 .314 .483 .020 2056 2133 1.790 .041 .444 .523 .238 .017 2056 2133 1.814 .072 .204 .272 .224 .010 2056 2133 1.055 .043 .204 .243 .656 .011 2056 2133 1.079 .017 .633 .678 .331 .019 1448 1513 1.515 .057 .293 .368 .115 .010 1448 1513 1.199 .087 .095 .135 1.563 .043 2056 2133 1.366 .028 1.476 1.649 2.464 .076 550 586 1.099 .031 2.313 2.615 1.489 .041 2056 2133 1.377 .027 1.408 1.570 .996 .002 1304 1398 1.206 .002 .991 1.000 .996 .002 1304 1398 1.206 .002 .991 1.000 .881 .014 1304 1398 1.537 .016 .854 .909 .619 .022 1304 1398 1.639 .036 .575 .663 .470 .015 1304 1398 1.098 .032 .439 .500 .023 .005 1304 1398 1.197 .217 .013 .033 .392 .015 1304 1398 1.142 .039 .361 .423 .044 .006 1304 1398 1.022 .131 .033 .056 .079 .009 1304 1398 1.240 .117 .061 .098 .021 .006 1304 1398 1.550 .294 .009 .033 .895 .017 707 742 1.479 .019 .860 .929 .613 .012 1304 1398 .887 .020 .589 .637 .152 .012 1304 1398 1.202 .079 .128 .176 2.660 .051 1984 2065 1.810 .019 2.558 2.763 .007 .002 1958 2058 1.085 .287 .003 .011 .090 .009 1958 2058 1.342 .096 .073 .107 .365 .017 1958 2058 1,569 .047 .331 .399 .073 .007 1932 2018 1.116 .090 .060 .087 ,750 .009 1932 2018 .950 .012 .732 .769 .176 .011 1932 2018 1.298 .064 .154 .199 .029 .004 1931 2017 .981 .130 .021 .036 1.000 .000 326 343 Und Und 1.000 1.000 .150 .026 315 334 1.242 .170 .099 .201 .255 .076 44 50 1.101 .297 .104 .407 .254 .086 44 50 1.253 .339 .082 .426 .046 .015 114 118 .760 .325 .016 .076 1.000 .000 114 118 Und Und 1.000 1.000 .504 .057 114 118 1.219 .113 .390 .618 .554 .065 114 118 1.405 .118 .423 .685 .698 .049 114 118 1.147 .071 .600 .797 .292 .048 114 118 1.120 .163 .197 .388 .045 .012 275 293 1.017 .278 .020 .070 .269 .030 275 293 1.099 .110 .210 .328 .323 044 275 293 1.588 .136 .235 .411 .037 014 277 300 1.245 .377 .009 .064 .075 .024 277 300 1.576 .325 026 .124 .079 .021 277 300 1.365 .273 .036 .122 2.001 .169 NA 6079 1.593 .084 1.663 2.338 26.344 5.135 1296 1350 1.189 .195 16.075 36.613 12.851 3.425 1297 1350 1.112 .267 6.000 19.701 39.195 6.100 1297 1350 1.170 .156 26.994 51.396 4.317 2.153 1297 1351 1.189 .499 0.011 8.623 43.343 6.377 1298 1352 1.161 .147 30.588 56.097 NA = Not applicable Und = Undefined 166 Table B.4 Sampling errors - Rural sample: Kazakstan 1995 Number of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE /R) R-2SE R+2SE Primary/secondary education .477 .023 1715 1638 1.904 .048 .431 .523 Secondary-special education .421 .019 1715 1638 1.599 .045 .383 .460 Higher education .099 .011 1715 1638 1.539 .112 .077 .121 Never married (in union) .249 .011 1715 1638 1.081 .045 .226 .271 Currently married (in union) .677 .015 1715 1638 1.311 .022 .647 .707 Married before age 20 .360 .024 1077 1022 1.651 .067 .312 ,409 Had first sexual intercourse before 18 .122 .018 1077 1022 1.756 .144 .087 ,157 Children ever born 2.145 .042 1715 1638 .819 .020 2.061 2.229 Children ever born to women over 40 4.362 .161 325 306 1.239 .037 4.040 4.684 Children surviving 2.005 .039 1715 1638 .834 .020 1,926 2,083 Knowing any contraceptive method .989 .003 1153 1109 1.130 .003 ,983 .996 Knowing any modem method .989 .003 1153 1109 1.119 .003 ,982 .996 Ever used any contraceptive method .775 .020 1153 1109 1.619 .026 ,735 .815 Currently using any method .556 .019 I 153 1109 1.272 .033 ,519 .593 Currently using a modem method .449 .018 1153 1109 1.228 .040 .413 .485 Currently using pill .011 .004 1153 1109 1.120 ,307 ,004 ,018 Currently using IUD .400 .018 1153 1109 1.217 .044 .365 .435 Currently using condom .028 .004 1153 1109 .783 .136 .021 .036 Currently using periodic abstinence .047 .011 1153 1109 1.723 .230 .025 .068 Currently using withdrawal .045 .010 1153 1109 1.596 .216 ,026 .065 Using public sector source ,966 .012 552 524 1.501 .012 .943 ,989 Want no more children .569 .018 I 153 1109 1.225 .031 .534 .605 Want to delay at least 2 years .229 .010 1153 1109 ,823 .045 .209 .249 Ideal number of children 3.304 .069 1618 1555 1.777 ,021 3.166 3,442 Severe anemia ,017 .005 1700 1625 1.547 .289 .007 .026 Moderate anemia .126 .012 1700 1625 1.547 .099 .101 .151 Mild anemia .378 .010 1700 1625 .830 .026 .358 .398 BMI < 18.5 .085 .007 1575 1507 .994 .082 .071 .099 BMI between 18.5 and 30,0 .759 .012 1575 1507 1.086 .015 .736 .783 BMI > 30.0 .156 .013 1575 1507 1.407 .083 .130 .181 Weight-for-height .053 .008 1569 1502 1,355 .145 ,038 .068 Mothers received medical care at birth .993 .004 520 466 1.074 .004 .985 1.000 Had diarrhea in the last 2 weeks .163 .024 496 445 1.352 .148 .I 15 ,212 Treated with ORS packets .300 .063 72 73 1.195 .209 .175 .425 Consulted medical personnel .260 .080 72 73 1.480 .309 .099 .421 Having health card. seen ,107 .020 180 161 .850 .189 .067 .148 Received BCG vaccination .944 .020 180 161 1.128 ,021 905 .984 Received DPT vaccination (3 doses) .353 .044 180 161 1.184 .124 .266 ,441 Received polio vaccination (3 doses) .431 .047 180 161 1.226 .109 .337 .525 Received measles vaccination ,647 .043 180 161 1.153 .066 .561 .733 Fully immunized .191 .031 180 161 1.024 .162 .129 .253 Severe anemia .061 .011 464 422 .936 .172 .040 .082 Moderate anemia .382 .019 464 422 .846 .050 .344 .421 Mild anemia .286 .021 464 422 .983 .075 .244 .329 Weight-for-height .030 .005 458 416 ,638 .173 .020 .040 Height-for-age .218 .026 458 416 1.285 .120 .166 .270 Weight-for-age .086 .015 458 416 1.060 .168 .057 .116 Total fertility rate (3 years) 3.060 .205 NA 4590 1,594 .067 2.651 3.470 Neonatal mortality rate (0-9 years) 13.168 3.897 1839 1705 1.451 .296 5.374 20.962 Posmeonatal mortality rate (0-9 years) 28.928 5.950 1843 1711 1.456 .206 17.029 40.827 Infant mortality rate (0-9 years) 42.097 6.774 1843 1711 1.394 .161 28.548 55.645 Child mortality rate (0-9 years) 10.242 3.054 1845 1710 1.216 ,298 4.134 16.351 Under-five mortality rate (0-9 years) 51.908 7.753 1849 1717 1.414 .149 36.402 67.414 NA = Not applicable 167 Table B.5 Sampl ing errors - Almaty City~ Kazakstan 1995 Number of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect enror Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE Primary/secondary education .259 .018 Secondary-special education .333 .021 Higher education .408 .021 Never married (in union) .220 .017 Currently married (in union) .603 .022 Married before age 20 .287 .022 Had first sexual intercourse before 18 .100 .015 Children ever born 1.247 .042 Children ever born to women over 40 1.938 .087 Children surviving I. 192 .038 Knowing any contraceptive method 1.000 .000 Knowing any modern method 1.000 .000 Ever used any contraceptive method .941 .014 Currently using any method .644 .026 Currently using a modern method .472 .028 Currently using pill .051 .008 Currently using IUD .299 .026 Currently using condom 092 .019 Cuxxently using periodic abstinence .113 .013 Currently using withdrawal .019 .009 Using public sector source .826 .028 Want no more children .504 .024 Want to delay at least 2 years .208 .020 Ideal number of children 2.535 .042 Severe anemia .011 .005 Moderate anemia .094 .014 Mild anemia .277 .027 BMI< 18.5 .061 .011 BMI between 18.5 and 30.0 .787 .017 BMI > 30.0 .152 .012 Weight-for-height .017 .005 Mothers received medical care at birth 1.000 .000 Had diarrhea in the last 2 weeks .091 .028 Treated with ORS packets .143 .129 Consulted medical personnel .143 .129 Having health card, seen .250 .077 Received BCG vaccination 1.000 .000 Received DPT vaccination (3 doses) .607 .078 Received polio vaccination (3 doses) .607 .108 Received measles vaccination .679 .088 Fully immunized .429 .106 Severe anemia .015 .015 Moderate anemia .200 .051 Mild anemia .262 .038 Weight for-height .016 .016 Height-for-age .032 .022 Weight for age .065 .031 615 271 1.043 .071 .222 .295 615 271 1.080 .062 .292 374 615 271 1.038 .050 .367 .449 615 271 1.028 .I)78 .185 .254 615 271 1.098 .036 .560 .647 439 194 1.031 .078 .242 .332 439 194 1.044 .149 .070 .130 615 271 .907 .033 1.164 1.331 162 71 .929 .045 1.763 2.113 615 271 .850 .032 1.117 1.267 371 164 Und Und 1.000 1.000 371 164 Und Und 1.000 1.000 371 164 1.128 .015 .913 .968 371 164 1.042 .040 .592 .696 371 164 1.073 .059 .416 .527 371 164 .730 .163 034 .068 371 L64 1.096 .087 247 .351 371 164 1239 .203 .054 .129 371 164 .772 L12 .088 139 371 164 1.230 .461 .001 .036 224 99 1.105 .034 .770 .882 371 164 .913 .047 .457 .551 371 164 .945 .096 .168 .247 596 263 .896 .017 2.451 2.619 564 249 1.196 .486 .000 .021 564 249 1.111 .145 .067 .121 564 249 1.457 .099 .222 .332 572 252 1.079 .177 .040 .083 572 252 .998 .022 .752 .821 572 252 .809 .080 .128 .176 572 252 .856 .269 .008 .027 81 36 Und Und 1.000 1.000 77 34 .844 .306 .035 .147 7 3 .975 .904 .000 .401 7 3 .975 .904 .000 .401 28 12 .938 .307 .096 .404 28 12 Und Und 1.000 1.0(30 28 12 .849 .129 .450 .764 28 12 1.171 .178 .391 .824 28 12 .997 .130 .502 .855 28 12 1.133 .247 .216 641 65 29 1.012 1.006 .000 d)46 65 29 1.046 .255 .098 .302 65 29 .700 .144 .186 .337 62 27 .995 .989 000 .048 62 27 .991 .691 .000 077 62 27 Und .477 .003 .126 Und = Undefined 168 Table B.6 Sampl ing errors - South Region t Kazakstan 1995 Number of c~es Standard Design Relative Confidence limits Value ercor Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+28E Primary/secondary education .454 .039 920 1206 2.350 .085 .377 .531 Secondary-special education .401 .028 920 1206 1.727 .070 .345 .457 Higher education .142 .016 920 1206 1.354 .110 I 11 .174 Never married (in union) .253 .014 920 1206 .942 053 226 .280 Currently married (in union) .672 .014 920 1206 .886 .020 645 700 Married before age 20 ,361 .024 571 758 1210 .067 312 .410 Had first sexual intercourse before 18 .122 .017 571 758 1.208 .135 .089 .156 Children ever born 2.131 .080 920 1206 1.129 .037 1.972 2.291 Children ever born to women over 40 4.269 .201 171 232 1.066 .047 3.867 4.671 Children surviving 1.989 .078 920 1206 1.193 .039 1.832 2.145 Knowing any contraceptive method .984 .005 621 810 1.017 .005 974 .994 Knowing any modern method .984 .005 621 810 1.017 .005 .974 994 Ever used any contraceptive method .712 ,027 621 810 1,504 .038 .658 .767 Currently using any method .502 ,022 621 810 1.084 .043 .458 .545 Currently using a modern method .443 .020 621 810 1.020 .046 .402 .483 Currently using pill ,006 .003 621 810 1.110 ,595 .000 .012 Currently using IUD .415 .021 621 810 1.044 .050 .373 .456 Currently using condom .016 .004 621 810 .818 .257 .008 ,024 Currently using periodic abstinence .033 .008 621 810 1.103 .241 .017 .049 Currently using withdrawal .008 .005 621 810 1.308 ,572 .000 018 Using public sector source .955 ,014 281 367 1.096 .014 .928 982 Want no more children .518 .021 621 810 1.035 .040 .476 ,559 Want to delay at least 2 years .247 .014 621 810 .819 .057 .219 .276 Ideal number of children 3.606 .094 895 1175 1.708 ,026 3.418 3.794 Severe anemia .008 .003 901 1177 .935 .355 .002 .013 Moderate anemia .106 .012 901 1177 1.199 .116 .082 .131 Mild anemia .389 .015 901 1177 .951 .040 .358 .420 BMI < 18.5 .084 .007 834 1096 .747 .085 .070 .098 BMI between 18.5 and 30.0 .793 .013 834 1096 .915 .016 .768 .819 BMI > 30.0 .123 .016 834 1096 1.420 .132 .090 .155 Weight-for-height .042 .(308 832 1094 1.108 .184 .026 .057 Mothers received medical care at birth .991 .005 292 373 .919 .005 .981 1,000 Had diarrhea in the last 2 weeks .129 .028 280 358 1.315 .219 .073 .186 Treated with ORS packets .524 .088 36 46 1.043 .169 .347 .701 Consulted medical personnel ,281 .102 36 46 1.232 .365 .076 .485 Having health card, seen .017 .012 106 133 .900 .681 .000 ./)40 Received BCG vaccination .949 .024 106 133 I. 103 .025 .901 .997 Received DPT vaccination (3 doses) .305 .055 106 133 I. 197 ,180 .195 .415 Received polio vaccination (3 doses) .365 .057 106 133 1.194 .157 .250 .479 Received measles vaccination .640 .050 106 133 1.030 .078 .540 .740 Fully immunized .157 .036 106 I33 1.000 .230 .085 .229 Severe anemia .074 .015 253 319 .932 .208 .043 .105 Moderate anemia .328 .025 253 319 .824 .075 .279 .378 Mild anemia .327 .032 253 319 1.066 .097 .263 .391 Weight-for-height .059 .013 251 318 .875 .225 .032 .085 Height-for-age .227 ,029 251 318 1.074 ,128 .169 ,285 Weight-for-age .110 ,023 251 318 1.133 .212 .063 .156 169 Table B.7 Sampl ing errors - West Region r Kazakstan 1995 Nu tuber of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE Primary/secondary education .414 .019 830 477 1.082 .045 .377 .451 Secondary-special education .424 .024 830 477 1.416 .057 .375 .473 Higher education .161 .023 830 477 1.833 .145 .114 .207 Never married (in union) .268 .012 830 477 .776 .045 .244 .291 Currently married (in union) .625 .014 830 477 .842 .023 .596 .653 Married before age 20 .256 .022 555 321 1.213 .088 .211 .301 Had first sexual intercourse before 18 .068 .013 555 321 1.181 .186 .043 .093 Children ever born 1.922 .051 830 477 ,756 .027 1.819 2.024 Children ever born to women over 40 3.423 .157 197 116 1.018 .046 3.109 3.737 Children surviving 1.781 .045 830 477 .732 .025 1.692 1.870 Knowing any contraceptive method .994 .002 522 298 .662 .002 .989 .998 Knowing any modern method .994 .002 522 298 .662 .002 .989 .998 Ever used any contraceptive method .794 .029 522 298 1.626 .036 .737 .852 Currently using any method ,519 .029 522 298 1.346 .057 .460 .578 Currently using a modern method ,416 .024 522 298 I. 112 .058 .368 .464 Currently using pill .008 .005 522 298 1.301 .618 .000 .019 Currently using IUD ,375 .023 522 298 1.069 060 .330 .421 Currently using condom .030 .009 522 298 1.213 .301 .012 .048 Currently using periodic abstinence .062 .012 522 298 I. 125 .192 .038 .086 Currently using withdrawal .015 .006 522 298 1.068 .384 .003 .026 Using public sector source .943 .012 239 137 ,820 .013 .918 .968 Want no more children .594 .019 522 298 .906 .033 .555 .633 Want to delay at least 2 years .178 .022 522 298 1.285 ,121 .135 .221 Ideal number of children 3.011 .067 771 444 1.374 .022 2.876 3.145 Severe anemia .025 .006 801 458 I, 120 .248 .013 .037 Moderate anemia .164 .016 801 458 1.201 .096 .133 .196 Mild anemia .400 .025 801 458 1.455 .063 .350 450 BMI < 18.5 .106 .010 759 437 .938 .099 .085 .127 BMI between 18.5 and 30.0 .771 .013 759 437 .871 .017 .745 .798 BMI > 30.0 .123 .017 759 437 1.390 .135 .090 .156 Weight Ior-height .066 .010 756 435 1.052 .143 .047 .085 Mothers received medical care at birth 1.000 .000 196 106 Und Und 1.000 1.000 Had diarrhea in the last 2 weeks .118 .033 186 101 1.369 .280 .052 .183 Treated with ORS packets .350 .078 21 12 .746 .224 .193 506 Consulted medical personnel .293 .119 21 12 1.187 .406 055 .530 Having health card, seen .031 .022 67 37 1.034 .717 .000 .076 Received BCG vaccination .987 .013 67 37 .903 .013 .962 1.000 Received DPT vaccination (3 doses) .475 .070 67 37 1.131 .148 .335 .616 Received polio vaccination (3 doses) .369 .079 67 37 1.323 .215 .210 .528 Received measles vaccination .779 .045 67 37 .868 .057 .690 .869 Fully immunized .262 .055 67 37 1.003 .209 .153 .372 Severe anemia .077 .025 173 93 1.247 .332 .026 .127 Moderate anemia .473 .039 173 93 .991 .083 .394 .551 Mild anemia .260 .039 173 93 1.099 .149 182 .337 Weight- for height .037 .011 175 95 .773 .310 .014 .059 Height-for-age .109 .023 175 95 ,913 .212 .063 ,155 Weight-fnr-age 067 .014 175 95 .762 216 .038 .096 Und = Undefined 170 Table B.8 Sampl ing errors - Central Region~ Kazakstan 1995 Num~rofc~es Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE Primary/secondary education .311 .018 726 358 1.061 .059 .274 .347 Secondary-special education .500 .017 726 358 .917 .034 .466 .534 Higher education .187 .013 726 358 .926 .072 .161 .214 Never married (in union) .244 .015 726 358 .923 .060 .214 .273 Currently married (in union) .655 .018 726 358 .996 .027 .620 .691 Married before age 20 .304 .024 486 241 1.148 .079 .256 .352 Had first sexual intercourse before 18 .091 .011 486 241 .863 .124 .069 .114 Children ever born 1.816 .065 726 358 .953 .036 1.687 1.945 Children ever born to women over 40 3.167 .193 166 83 1.126 .061 2.780 3.554 Children surviving 1.710 .059 726 358 .948 .034 1.592 1.827 Knowing any contraceptive method .995 .005 477 235 1.484 .005 .986 1.000 Knowing any modern method .993 .005 477 235 1.345 .005 .983 1.000 Ever used any contraceptive method .869 .020 477 235 1.277 .023 .829 .908 Currently using any method .662 .024 477 235 1.124 .037 .613 .711 Currently using a modern method .525 .027 477 235 I. 187 .052 .471 .579 Currently using pill .015 .007 477 235 1.317 .490 .000 .030 Currently using IUD .448 .031 477 235 1.350 .069 .387 .510 Currently using condom .046 .011 477 235 1.137 .237 .024 .068 Currently using periodic abstinence .053 .013 477 235 1.281 .247 .027 .080 Currently using withdrawal .027 .009 477 235 1.226 .337 .009 .045 Using public sector source .923 .020 269 133 1.214 .021 .883 .962 Want no more children .640 .015 477 235 .701 .024 .610 .671 Want to delay at least 2 years .117 .016 477 235 1.110 .139 .085 .150 Ideal number of children 2.777 .063 689 341 1.309 .023 2.651 2.903 Severe anemia .007 .003 718 354 1.024 .451 .001 .014 Moderate anemia .080 .011 718 354 1.088 .138 .058 .102 Mild anemia .351 .016 718 354 .880 .045 .319 .382 BMI< 18.5 .087 .016 690 341 1.485 .184 .055 .118 BMI between 18.5 and 30.0 .751 .018 690 341 1.083 .024 .716 .787 BMI > 30.0 .162 .014 690 341 .989 .086 .134 .190 Weight-for-height .038 .010 689 340 1.391 .268 .017 .058 Mothers received medical care at birth 1.000 .000 177 84 Und Und 1.000 1.000 Had di~wrhea in the last 2 weeks .169 .031 171 82 1.081 .184 .107 .231 Treated with ORS packets .269 .106 29 14 1.258 .392 .058 .48 I Consulted medical personnel .166 .072 29 14 1.015 .430 .023 .309 Having health card, seen .492 .091 61 29 1.396 .185 .310 .674 Received BCG vaccination .940 .019 61 29 .622 .021 .902 979 Received DPT vaccination (3 doses) .613 .083 61 29 1.305 .135 .447 .779 Received polio vaccination (3 doses) .553 .072 61 29 1.103 .129 410 .696 Received measles vaccination .678 .079 61 29 1.300 . 117 .520 .837 Fully immunized .342 .085 61 29 1.372 .248 .172 .512 Severe anemia .051 .016 153 73 .901 .322 .018 .083 Moderate anemia .400 .036 153 73 .878 .091 .327 .473 Mild anemia .217 .033 153 73 .999 .152 .151 .283 Weight-for-height .012 .008 150 72 .903 .678 .000 .029 Height-for-age .215 .038 150 72 1.060 .176 .139 .290 Weight-for-age .084 .020 150 72 .905 .242 .043 .125 Und = Undefined 171 Table B.9 Sampl ing errors - North and East Region T Kazakstan 1995 Number of ca.ses Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE Primary/secondary education .308 .017 Secondary special education .525 .025 Higher education .167 .022 Never married (in union) .209 .015 Currently married (in union) ,686 .019 Married before age 20 .376 .032 Had first sexual intercourse before 18 .140 .019 Children ever born 1.625 .044 Children ever born to women over 40 2.538 .115 Children surviving 1.560 .038 Knowing any contraceptive method .998 .002 Knowing any modern method .998 .002 Ever used any contraceptive method ,920 .013 Currently using any method .660 .027 Currently using a modern method .472 .021 Currently using pill .026 .007 Currently using IUD .390 ,021 Currently using condom ,045 .007 Currently using periodic abstinence .086 .015 Currently using withdrawal .059 .012 Using public sector source .916 .024 Want no more children 658 .015 Want to delay at least 2 years ,152 .014 Ideal number of children 2.464 .044 Severe anemia .011 .005 Moderate anemia .095 .015 Mild anemia ,368 .021 BMI < 18.5 .067 .009 BMI between 185 and 30.0 ,713 .014 BMI > 30 0 .220 016 Weight-for-height .032 ,007 Mothers received medical care at birth 1.000 .000 Had diarrhea in the last 2 weeks .233 .040 Treated with ORS packets ,041 .039 Consulted medical personnel ,260 .109 Having health card, seen .029 .028 Received BCG vaccination 1.000 ,000 Received DPT vaccination (3 doses) .486 .076 Received polio vaccination (3 doses) .726 .079 Received measles vaccination .659 .079 Fully ilnmunized .289 .069 Severe anemia .020 ,002 Moderate anemia 279 .038 Mild anemia .317 055 Weight-lor height ,00l) .000 Height for-age .070 .036 Wcight-for-age .051 .019 680 1458 .978 .056 .274 .343 680 1458 1.296 .047 .475 .574 680 1458 1.555 .133 .122 ,211 680 1458 .939 .070 .180 .238 680 1458 1.081 ,028 ,647 .724 474 1022 1.440 .085 .312 .441 474 1022 1.171 .134 .102 .177 680 1458 .806 .027 1.538 1.713 179 389 .994 .045 2.308 2.768 680 1458 .751 ,024 1.485 1.636 466 1000 .971 .002 ,994 1.000 466 1000 .971 .002 .994 1.000 466 1000 1.008 .014 .895 .945 466 1000 1.236 .041 .605 .714 466 1000 .917 .045 .429 .514 466 1000 .950 .271 .012 .040 466 1000 .948 .055 .347 .433 466 1000 .742 .158 .031 .060 466 1000 1.120 .169 .057 .116 466 1000 1.137 .211 .034 .084 246 531 1.356 .026 .868 .964 466 1000 .681 .023 .628 .688 466 1000 .824 .090 .124 .179 651 1397 1.031 .018 2.376 2.552 674 1445 1.300 ,469 .001 .022 674 1445 1.316 .156 .066 .125 674 1445 1.130 .057 .326 .410 652 1399 .966 .141 .048 ,086 652 1399 .805 .020 .684 .741 652 1399 1.006 .074 .188 .253 651 1397 1.052 .226 ,018 .047 100 210 Und Und 1.000 1.000 97 204 .872 .169 ,154 .312 23 48 912 .939 .000 .118 23 48 1.052 .418 .042 478 32 68 .953 .984 .000 .085 32 68 Und Und 1.000 1.000 32 68 .850 .156 .335 ,637 32 68 .998 .109 .568 .885 32 68 .941 .121 .500 ,817 32 68 .859 .240 .150 .427 95 199 154 .112 ,015 .024 95 199 .834 .137 .203 .356 95 199 1,121 .174 .206 ,428 97 204 Und Und .000 .000 97 204 1.377 .518 .000 .143 97 204 856 .380 .012 .090 Und = Undefined 172 Table B.10 Sampl ing errors - Kazak ethnic group~ Kazakstan 1995 Ntllllber of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE Primary/secondary education .391 .015 1937 1696 1.314 .037 .362 .420 Secondary-special education .402 .013 1937 1696 1.173 .032 .376 .429 Higher education .206 .013 1937 1696 1.443 .064 .180 .233 Never married (in union) .289 .009 1937 1696 .885 .032 .271 .307 Currently married (in union) .627 .012 1937 1696 1.063 .019 .604 .651 Married before age 20 .249 .014 1224 1068 1.172 .058 .220 .278 Had first sexual intercourse before 18 .068 .008 1224 1068 1.133 .120 .052 084 Children ever born 2.029 .042 1937 1696 .876 .021 1.945 2.113 Children ever born to women over 40 4.212 .129 361 321 1.037 .031 3.954 4.470 Children surviving 1.876 .038 1937 1696 .876 .020 1.800 1953 Knowing any contraceptive method .987 .004 1212 1064 1.074 .004 .980 .994 Knowing any modern method .986 .004 1212 1064 1.064 .004 .979 .993 Ever used any contraceptive method .756 .016 1212 1064 1.333 .022 .723 .789 Currently using any method .535 .017 1212 1064 1.154 .031 .502 .568 Currently using a modern method .468 .015 1212 1064 1.026 .031 .438 .497 Currently using pill .005 .003 1212 1064 1.344 .524 .(300 .01 I Currently using IUD .436 .015 1212 1064 1.072 .035 .405 .467 Currently using condom .020 .005 1212 1064 1.204 .243 .010 .030 Currently using periodic abstinence .040 .006 1212 1064 1.135 .160 .027 .053 Currently using withdrawal .007 .002 1212 1064 .969 .344 .002 .01 I Using public sector source .941 .013 604 531 1.373 .014 .915 .967 Want no more children .541 .018 1212 1064 1.225 .032 .506 .576 Want to delay at least 2 years .242 .014 1212 1064 1.177 .060 .213 .271 Ideal number of children 3.416 .056 1833 1618 1.580 .016 3.304 3.528 Severe anemia .019 .004 1885 1654 1.321 .221 .010 .027 Moderate anemia .143 .011 1885 1654 1.352 .076 .122 .165 Mild anemia .407 .014 1885 1654 1.275 .035 .378 .436 BMI< 18.5 .110 .007 1777 1564 .930 .063 .096 .123 BMI between 18.5 and 30.0 .781 .010 1777 1564 1.029 .013 .761 .802 BMI > 30.0 .109 .011 1777 1564 1.457 .099 .088 .131 Weight-for-height .062 .007 1771 1558 1.266 .117 .047 .076 Mothers received medical care at birth .993 .004 564 487 1.126 .004 .985 1.000 Had diarrhea in the last 2 weeks .162 .023 537 464 1.392 .145 . 115 .209 Treated with ORS packets .368 .069 77 75 1.270 .187 .231 .506 Consulted medical personnel .333 .076 77 75 1.356 .228 .181 .484 Having health card, seen .094 .018 194 167 .844 .190 .058 .130 Received BCG vaccination .962 .016 194 167 1.165 .017 .930 .994 Received DPT vaccination (3 doses) .389 .048 194 167 1.361 .124 .293 .486 Received polit) vaccination (3 doses) .392 .048 194 167 1.344 .122 .297 .487 Received measles vaccination .677 .035 194 167 1.012 .051 608 .747 Fully immunized 191 .033 ]94 167 L.156 .173 .125 .257 Severe anemia .089 .013 487 420 .978 .141 .064 AI4 Moderate anemia .406 .020 487 420 .911 .050 .365 446 Mild anemia .282 .022 487 420 1.050 .077 .239 .326 Weight-for-height .036 .009 486 421 1.045 .244 .019 .054 Height-for-age .211 .024 486 421 1.273 .115 .163 .260 Weight-for-age .103 .017 486 421 1.199 .162 .070 .137 Total fertility rate (3 years) 3.106 .197 NA 4784 1.574 .063 2.713 3.500 Neonatal mortality rate (0-4 years) 18.445 4.829 981 865 1.129 .262 8.787 28.104 Posmeonatal mortality rate (0-4 years) 30.427 6.902 983 866 1.217 .227 16.623 44.232 Infant mortality rate (0-4 years) 48.873 7.279 983 866 1.055 .149 34.315 63.430 Child mortality rate (0-4 years) 6.679 2.888 984 866 1.001 ,432 0.902 12.455 Under-five mortality rate (0-4 years) 55.225 8.470 986 868 1.106 .153 38.285 72.164 NA = Not applicable 173 Table B. I 1 Sampl ing errors - Russian ethnic group~ Kazakstan 1995 Number of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) IN) (WN) (DEF]') (SE/R) R-2SE R÷2SE Primary/secondary education .272 .019 1178 1308 Secondary-special education .544 .023 1178 1308 Higher education ,182 .022 1178 1308 Never married (in union) .175 .012 1178 1308 Currently married (in union) .711 .013 1178 1308 Married before age 20 .405 .021 833 932 Had first sexual intercourse before 18 .162 .015 833 932 Children ever born 1.534 .047 I 178 1308 Children ever born to women over 40 2.251 .065 348 372 Children surviving 1.483 .043 1178 1308 Knowing any contraceptive method 1,000 .000 798 930 Knowing any modern method 1.000 .000 798 930 Ever used any contraceptive method .914 ,013 798 930 Currently using any method .651 .025 798 930 Currently using a modern method .453 ,021 798 930 Currently using pill ,039 .008 798 930 Currently using IUD .353 .020 798 930 Currently using condom .045 .008 798 930 Currently using periodic abstinence .096 .013 798 930 Currently using withdrawal .051 .011 798 930 Using public sector source .907 ,022 428 488 Want no more children .632 ,017 798 930 Want to delay at least 2 years .141 .016 798 930 Ideal number of children 2.379 .038 I 134 126 I Severe anemia .007 .003 1141 1282 Moderate anemia .072 .009 1141 1282 Mild anemia .338 ,021 1141 1282 BMI< 18.5 052 .010 1115 1245 BMI between 18.5 and 30.0 ,741 .014 1115 1245 BM[ > 30,0 .207 .012 I 115 1245 Weight-for-height .021 .007 1115 1245 Mothers received medical care at birth 1.000 .000 155 175 Had diarrhea in the last 2 weeks .188 .037 150 171 Treated with ORS packets .035 .025 24 32 Consulted unedical personnel .170 088 24 32 Having health card, seen .056 ,020 50 57 Received BCG vaccination 1000 .000 50 57 Received DPT vaccination (3 doses) .492 .082 50 57 Received polio vaccination (3 doses) .749 .063 50 57 Received measles vaccination .632 .066 50 57 Fully immunized ,301 .078 50 57 Severe anemia .000 ,000 137 159 Moderate anemia 275 .033 137 159 Mild anemia .310 ,048 137 159 Weight-for-height ,017 .011 135 161 Height-for-age .072 .033 135 161 Weight-for-age ,043 .021 135 161 Total fertility rate (3 years) 1.691 .166 NA 3736 Neonatal mortality rate (0-4 years) 20.069 12.914 277 318 Posmeonatal mortality rate (0-4 years) 0.000 0.000 277 318 Infant mortality rate (0-4 years) 20069 12.914 277 318 Child mortality rate (0-4 years) 6.818 6.898 277 318 Under five mortality rate (0-4 years) 26.750 14,162 277 318 1440 .069 .235 ,309 1595 .043 .498 591 1.996 123 137 .227 1.124 .071 150 ,200 1,013 .019 .684 738 1,255 ,053 .363 448 1.212 .096 .131 .193 1.320 .031 1.440 1.629 .997 .029 2.122 2.381 1.259 .029 1.396 1.569 Und Und 1,000 1.000 Und Und 1.000 1.000 1.336 .015 .888 ,941 1,486 039 ,601 .701 1.188 .046 .411 495 1.094 191 .024 .054 1.185 .057 313 .393 1.050 .172 .029 .060 1.208 .131 .071 ,121 1,431 .219 ,028 .073 1.575 .024 .862 .951 1,020 .028 ,597 .667 1.309 .114 .109 .174 1.184 .016 2.302 2,455 1.221 431 .001 .013 1.196 .127 .053 ,090 1.473 .061 .297 ,379 1.469 .188 032 ,071 1,030 .018 .714 .768 1.008 .059 183 .232 1,530 .315 .(308 ,034 Und Und 1.000 1.000 1.164 .197 .114 .262 ,729 .716 .000 .084 1.259 .517 .000 .346 .626 .360 .016 ,096 Und Und 1.000 1.000 1.175 .167 328 656 1,042 .084 .623 .875 ,984 .105 .499 .764 1,217 .259 ,145 .456 Und Und .000 ,000 ,901 .121 .209 .342 1.187 ,153 .215 .405 1.075 .688 .000 .039 1.516 .452 .007 .137 1.224 .483 .00l .084 1.413 .098 1.358 2.024 1.565 0.644 0.000 45,898 Und Und 0.000 0.000 1.565 0.644 0.000 45.898 1.465 1,012 0.000 20614 1.514 0.529 0.000 55.074 Und = Undefined NA = Not applicable 174 Table B. 12 Sampl ing errors - Other ethnic groups~ Kazakstan 1995 Number of cDses Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE Primary/secondary education .466 .039 656 766 2.012 .084 .388 .545 Secondary-special education .425 .033 656 766 1.692 .077 .360 .490 Higher education .107 .016 656 766 1.288 .145 .076 .138 Never married (in union) .215 .018 656 766 1.119 .083 .179 .251 Currently married (in union) .669 .022 656 766 1.188 .033 .625 .713 Married before age 20 .421 .026 468 535 1.124 .061 .370 .473 Had first sexual intercourse before 18 .141 .017 468 535 1.079 .123 .106 .175 Children ever born 1.823 .082 656 766 I. 179 .045 1.660 1.987 Children ever born to women over 40 2.954 .226 166 199 1.351 .077 2.502 3.407 Children surviving 1.744 .080 656 766 1.229 .046 1.585 1.904 Knowing any contraceptive method .992 .004 447 513 1.011 .004 .984 1.000 Knowing any modern method .992 .004 447 513 1.01 I .004 .984 1.000 Ever used any contraceptive method .852 .033 447 513 1.966 .039 .786 .918 Currently using any method .599 .036 447 513 1.538 .060 .527 .670 Currently using a modern method .460 .028 447 513 1.185 .061 .404 .516 Currently using pill .005 .002 447 513 .527 .370 .001 .008 Currently using IUD .389 .030 447 513 1.313 .078 .328 .449 Currently using condom .060 .009 447 513 .781 .147 .042 .077 Currently using periodic abstinence .060 .011 447 513 .984 .184 .038 .082 Currently using withdrawal .050 .014 447 513 1.337 .277 .022 .077 Using public sector source .922 .025 227 247 1.417 .027 .872 .973 Want no more children .632 .025 447 513 1.085 .039 .582 .682 Want to delay at least 2 years .151 .020 447 513 1.173 .132 .111 .191 Ideal number of children 2.839 .113 635 742 2.048 .040 2.613 3.066 Severe anemia .003 .003 632 747 1.311 .949 .000 .009 Moderate anemia .082 .012 632 747 1.087 .145 .058 .106 Mild anemia .347 .018 632 747 .972 .053 .310 .384 BMI < 18.5 .057 .010 615 716 1.064 .174 .037 .077 BMI between 18.5 and 30.0 .718 .017 615 716 .932 .024 .684 .752 BMI > 30.0 .225 .016 615 716 .976 .073 .192 .258 Weight-for-height .021 .008 614 716 1.328 .364 .006 .037 Mothers received medical care at birth 1.000 .000 127 148 Und Und 1.000 1.000 Had diarrhea in tbe last 2 weeks .107 .046 124 144 1.614 .427 .016 .198 Treated with ORS packets .375 .110 15 15 .822 .293 .155 .594 Consulted medical personnel .072 .057 15 15 .798 .789 .000 .187 Having health card, seen .070 .032 50 55 .858 .456 .006 .133 Received BCG vaccination .951 .034 50 55 1.084 .036 .884 1.000 Received DPT vaccination (3 doses) .423 .056 50 55 .780 .132 .311 .535 Received polio vaccination (3 doses) .484 .089 50 55 1.226 .184 .306 .662 Received measles vaccination .680 .090 50 55 1.330 .132 .500 .861 Fully immunized .296 .072 50 55 1.088 .244 .152 .440 Severe anemia .013 .012 115 135 1.199 .977 .000 .037 Moderate anemia .190 .034 115 135 .922 .178 .122 .257 Mild anemia .351 .052 115 135 1.226 .149 .246 .455 Weight-for-beight .040 .018 114 135 .953 .437 .005 .075 Height-for-age .093 .028 114 135 1.017 .297 .038 .148 Weight-for-age .068 .029 114 135 1.233 .429 .010 .127 Und = Undefined 175 APPENDIX C DATA QUALITY TABLES Table C.I Household age distribution Single-year age distribution of the de facto household population by sex (weighted), Kazakstan 1995 Males Females Males Females Age Number Percent Number Percent Age Number Percent Number Percent 0 125 1.7 155 1.9 37 137 1.8 1 I3 1.4 1 140 1.9 158 1,9 38 93 1.2 144 1.8 2 138 1.8 153 1.9 39 92 1.2 98 1.2 3 180 2.4 135 1.7 40 100 1.3 104 1.3 4 186 2.5 151 1.9 41 77 1.0 97 1.2 5 163 2.2 165 2.0 42 79 1.1 116 1.4 6 I87 2.5 186 2.3 43 115 1.5 104 1.3 7 168 2.2 166 2,0 44 99 1.3 94 1.2 8 170 2.3 179 2.2 45 85 1.1 106 1.3 9 182 2.4 175 2.1 46 96 1.3 78 1.0 10 177 2.4 148 1.8 47 75 1.0 78 1.0 11 171 2.3 180 2.2 48 73 1.0 72 0.9 12 162 2.2 196 2.4 49 47 0.6 36 0.4 13 163 2.2 186 2.3 50 45 0.6 57 0.7 14 165 2,2 162 2.0 51 27 0.4 41 0,5 15 169 2.3 150 1,8 52 36 0.5 43 0.5 16 146 2.0 158 1.9 53 54 0.7 92 I.I 17 164 2.2 147 1.8 54 63 0.8 82 1.0 18 128 1.7 122 1.5 55 70 0.9 97 1.2 19 110 1.5 132 1.6 56 78 1.0 85 1.0 20 130 1.7 113 1.4 57 55 0.7 101 1.2 21 126 1.7 123 1.5 58 84 1.1 79 1.0 22 122 1.6 132 1.6 59 57 0.8 66 0.8 23 131 1.8 130 1.6 60 51 0.7 77 0.9 24 122 1.6 100 1.2 61 15 0.2 38 0.5 25 140 1.9 104 1.3 62 41 0.5 49 0.6 26 114 1.5 102 1.3 63 33 0.4 44 0.5 27 107 1.4 103 1.3 64 41 0.5 55 0.7 28 109 1.5 123 1.5 65 51 0.7 81 1.0 29 124 1.7 111 1.4 66 30 0.4 61 0.8 30 111 1.5 125 1.5 67 44 0.6 59 0.7 31 106 1.4 110 1.3 68 30 0.4 46 0.6 32 132 1.8 117 1.4 69 14 0.2 39 0.5 33 140 1.9 109 1.3 70+ 162 2.2 456 5.6 34 110 1.5 120 1.5 Don't know/ 35 107 1.4 139 1.7 Missing 3 0.0 0 0.0 36 118 1.6 88 1.1 Total 7,495 100.0 8,141 100.0 Note: The de facto population includes all residents and nonresidents who slept in the household the night before the interview. 179 Table C.2 Age distribution of etigible and interviewed women Percent distribution of the de facto household population of women age 10-54 and of interviewed women age 15-49, and the percentage of eligible women who were interviewed (weighted) by five-year age groups, Kazakstan 1995 Household popu- lation of women Interviewed women Age Number Percent Number Percent Percent interviewed (weighted) 10-14 873 - 15-19 709 18.2 692 18.2 97.7 20-24 597 15.3 578 15.2 96.9 25-29 543 13.9 531 14.0 97.8 30-34 580 14.9 568 15.0 97.9 35-39 583 15.0 567 14.9 97.3 40-44 515 13.2 505 13.3 98.0 45-49 370 9.5 355 9.3 95.9 50-54 316 15-49 3,897 3,797 97.4 Note: The de facto population includes all residents and nonresidents who slept in the household the night before interview. 180 Table C.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Kazakstan 1995 Percentage Number missing of Subject Reference group information cases Birth date Births in last 15 years Month only 0.6 4,510 Month and year 0.0 4,510 Age at death Deaths to births in last 15 years 0.3 221 Age/date at first union t Ever-married women 0.0 2,886 Respondent' s education All women 0.0 3,771 Child's size at birth Births in last 35 months 1.4 806 Anthropometry z Living children age 0-35 months Height missing 6.6 779 Weight missing 6.2 779 Height or weight missing 6.6 779 Diarrhea in last 2 weeks Living children age 0-35 months 1.6 779 ] Both year and age missing 2 Child not measured 181 Table C.4 Births by calendar years Distribution of births by Western calendar years for l iving (L), dead (D), and all (T) chi ldren, according 1o reporting completeness, sex ratio at birth, and ratio of births by calendar year, Kazakstan 1995 Percentage with Sex ratio Number of births complete birth date t at birth z Calendar ratio 3 Male Female Year L D T L D T L D T L D T L D T L D T 95 135 5 140 100.0 100.0 100.0 74.1 422.2 78.5 NA NA NA 57 4 62 77 1 78 94 276 7 283 100.0 94.1 99.8 85.1 261.0 87.4 139.1 74.7 136.1 127 5 132 149 2 151 93 262 14 276 100.0 100.0 100.0 95.4 356.5 101.4 97.7 144.1 99.3 128 11 139 134 3 137 92 260 13 273 100.0 100.0 100,0 102.4 691,6 109,7 97.9 82.5 97.0 132 11 143 128 2 130 91 270 16 286 98.9 100.0 98.9 151.9 68.2 144.9 93.8 147.9 95.8 163 7 169 107 10 117 90 315 9 324 100.0 100,0 100.0 97,9 175.2 99.5 108.8 54.1 105.7 156 6 162 159 3 163 89 309 18 328 100.0 100.0 100.0 1132 87,1 111.6 101.7 178.9 104.2 164 9 173 145 10 155 88 293 I1 305 99,0 89.9 98,6 86.3 134.9 87.8 92.5 62.8 90.9 136 6 142 157 5 162 87 325 17 342 100.0 96.1 99.8 89,3 465 865 110.6 147.6 112.0 153 5 159 172 12 184 86 295 12 307 99.3 100,0 99.4 102.3 2174 1052 NA NA NA 149 8 157 146 ,1 149 91-95 1,202 56 1,258 99.7 99.2 99.7 101,7 219.8 105.1 NA NA NA 606 39 645 596 18 614 86-90 1,537 68 1,606 99.7 97.4 99.6 97.3 103.5 97.6 NA NA NA 758 35 793 779 34 813 81-85 1,446 88 1,534 99.4 94.9 99.2 100.9 122.7 102.0 NA NA NA 726 49 775 720 40 759 76-80 1,199 85 1,283 99.8 92.7 99.4 98.6 122.1 100.0 NA NA NA 595 46 642 604 38 642 <76 1.075 90 1,165 99,3 95.1 99.0 107.1 121.0 108.1 NA NA NA 556 49 605 519 41 56(1 All 6.459 387 6.846 99.6 95.5 99.4 100.7 128.4 102.1 NA NA NA 3,242 218 3,459 3,218 169 3,387 NA = Not applicable i Both year and month of birth given 2 (Bm/Bt). 100, where B m and Bf are the numbers of male and female births, respectively [2Bx/(Bx.t+B~+t)l* 100, where B x is the number of births in calendar year x 182 Table C.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods preceding the survey, Kazakstan 1995 Number of years preceding the survey Age at death Total (in days) 0-4 5-9 10-14 15-19 0-19 <1 3 1 3 7 13 1 4 0 7 3 15 2 3 3 7 4 17 3 0 6 2 4 12 4 0 2 2 1 5 5 0 2 0 0 2 6 0 0 0 1 1 7 0 5 2 0 7 8 0 1 0 2 3 9 2 0 0 0 2 10 0 1 3 1 6 11 2 0 0 0 2 12 1 0 0 0 1 13 0 1 0 0 1 14 2 0 1 0 3 15 0 1 0 0 1 18 1 0 2 0 3 19 1 0 0 0 1 20 5 2 1 0 8 25 2 0 0 0 2 27 0 2 0 0 3 Total 0-30 28 27 31 21 106 Percent early neonatal I 41.6 53.8 67.0 86.6 61.0 i (0-6 days/0-30 days) * 100 183 Table C.6 Report ingofageatdeathinmonths Distribution of reported deaths under two years of age by age at death in months and the percentage of infant deaths reported to occur at ages under one month, for five-year periods preceding the survey, Kazakstan 1995 Number of years preceding the survey Age at death Total (in months) 0-4 5-9 10-14 15-19 0-19 <1 a 28 27 31 21 106 1 3 6 5 5 19 2 2 6 6 6 20 3 2 3 6 5 16 4 I 7 5 3 16 5 4 o 2 I 8 6 o 5 1 3 1o 7 6 2 6 3 18 8 3 3 5 3 13 9 3 1 2 1 7 10 1 0 0 4 4 11 2 0 4 6 13 12 0 1 0 2 3 13 0 o o 1 2 17 0 2 0 0 2 18 0 I 1 0 3 24+ 1 0 0 0 1 1 year 5 1 1 3 10 Total 0-11 54 60 73 62 250 Percent neonatal b 51.4 44.1 42.1 33.9 4Z6 a Includes deaths under I month reported in days b (Under 1 month/under I year) * 100 184 APPENDIX D PERSONS INVOLVED IN THE 1995 KAZAKSTAN DEMOGRPHIC AND HEALTH SURVEY APPENDIX D PERSONS INVOLVED IN THE 1995 KAZAKSTAN DEMOGRAPHIC AND HEALTH SURVEY National Director Dr. Toregeldy Sharmanov Technical Directors Dr. Temirkhan Bekbossynov Dr. Nailya Karsybekova Senior Field Staff Dr. Igor Tsoy, Field Coordinator Dr. Yuri Sinyavsky, Field Coordinator Ms. Nagima Esenalinova, Field Coordinator Dr. Shamshiddin Balgimbekov, Field Coordinator Macro International Staff Dr. Jeremiah M. Sullivan, Deputy Director for Survey Operations Dr. Almaz Sharmanov, Health Specialist Mr. Trevor Croft, Chief of Data Processing Ms. Thanh L~, Sampling Statistician Dr. Kia Weinstein, Consultant Ms. Annie Cross, Regional Coordinator Dr. Elisabeth Sommerfelt, International Health Specialist Ms. Trina Yannicos, Editor Ms. Kaye Mitchell, Document Production Specialist Mr. Jonathan Dammons, Graphics Specialist Advisory Committee T. Sharmanov, Chairman, Director of National Institute of Nutrition, President, Academy of Preventive Medicine M.K. Kulzhanov, Deputy Minister of Health N.A. Kayupova, Director of the Research Center of Mother and Child Health K.S. Ormantayev, Director of the Research Center of Pediatry and Children's Surgery T.A. Mouminov, President, Almaty Medical University G.G. Urmurzina, Head of Health Department of Almaty B.N. Aitbembetov, Director of the Institute of Hygiene and Occupational Diseases Z.M. Sultanova, Representative of Goskomstat T.A. Izmukhambetov, Director of the National Medical College S. Bhattarai, UNICEF Representative in Kazakstan M. Schmidt, USAID Representative J. Sullivan, Deputy Director for Survey Operations, DHS, Macro International Inc. A. Sharmanov, Health Specialist, DHS, Macro International Inc. 187 Ministry of Health, Republic of Kazakstan V.N. Devyatku, Minister A.D. Duisekeev, First Deputy Minister M.K. Kulzhanov, Deputy Minister G.S. Sabyrov, Head of Statistics Department I.V. Ivasiv, Head of Maternal and Child Health Department S.K. Ayupova, Chief Pediatrician R.S. Kolokina, Leading Specialist of Matemal and Child Health Department Goskomstat (State Committee on Statistics and Analysis) A.N. Daurenbekov, Deputy Chairman Z.M. Sultanova, Leading Specialist A.D. Pak, Head of Statistics Department of Almaty K.E. Musiphullina, Leading Specialist Chiefs of Oblast Health Departments E.E. Durumbetov, Almaty A.K. Mantajev, Aktubinsk T.G. Chaklikov, Atyran Kh. T. Zhigitajev, East Kazakstan O.N. Dosculov, Zhambyl T.K. Rakhybekov, Zhezkazgan V.B. Alikov, Karaganda S.E. Ibrajev, Kokshetau V.B. Yakimov, Kostanai T.V. Makhanov, Czyl-Orda S.B. Berdavletov, Mangystau B.D. Orazgaliev, Pavladar S.R. Mussinov, Semipalatinsk B.A. Akhmetov, West Kazakstan V.V. Goncharov, Torgai TM. Dzhansegirov, Taldy-Corgan V.A. Maltsev, Akmola M.A. Mouminov, South Kazakstan S.A. Almoldin, North Kazakstan Field Staff South Region Supervisor Bedel Sarbajev Listers Balnur Myrzabieva Zhangali Urbisinov Mappers Gulnar Kamysbaeva Darkhan Zhunisov West Region Supervisor Temirkhan Bekbossynov Listers Nikolai Tkach Muslim Iklassov Mappers Kanat Matkerimov Serik Bekbossynov 188 Supervisor Guln~ Be~enova Supervisor Roza Rakhimberlina Central Region Listers Lyailya Makhatova Bazarcul Birzhanova North and East Region Listers Tatjana Subkhankulova Larissa Perevozchikova Mappers Vyacheslav Kalugin Orazkhan Kasenova Mappers Kenzhebek Nursultanov Erlan Rakhimbekov South Region Supervisor Akmaral Sissemalieva Field Editor Fatima Nurmagambetova Interviewers Zh. Abdrasilova M. Umiralieva N. Zhumabaeva M. Kurmanbaeva I. Anarkulova Medical Technician D. Bostanchiev Central Region Supervisor Zaure Kudaibergenova Field Editor Almagul Baimbetova Interviewers M. Tijaeva Sh. Kutanova E. Grivo I. Shaporova T. Popova Medical Technican E. Amantajev Interviewing Staff West Region Supervisor Gulnar Suranchieva Field Editor Gulnar Dzhubanova Interviewers A. Abil O. Egorova A. Cholanova K. Myrzabekova M. Podzorova Medical Techician B. Sarbajev North and East Region Supervisor Altyn Sarsembajeva Field Editor Iskakova Kamida Interviewers A. Malikova G. Shyngisbajeva S. Nurlybajeva E. Kryachkova E. Phedurina Medical Techician M. Imantajev R. Sissemaliev D. Kabanov I. Levenets Data Processing Staff G. Tnalieva A. Omarkhanova M. Zhamanshina 189 APPENDIX E QUESTIONNAIRES KAZAKHSTAN DEMOGRAPHIC AND HEALTH SURVEY QUESTIONNAIRE HOUSEHOLD SCHEDULE REPUBLIC OF KAZAKHSTAN [NS'l'lrl'lfrE OF NUTRITION IDENTIFICATION CITY/TOWN/VILLAGE NAME NAME OF HOUSEHOLD HEAD REGION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBLAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RAION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (urban = 1; rural = 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LARGE CITY/SMALL CITY/q~OWN/COUNTRYSIDE . . . . . . . . . . . . . . a rgecty= ,sma c ty=2, town=3, countryside= 4) HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTERVIEWER VISIT m m i i - r - - 1 2 3 FINAL VISIT DATE INTERVIEWER'S RESULT* NEXT VISIT: NAME DATE TIME * RESULT CODES: 1 COMPLETED 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 4 POSTPONED 5 REFUSED B DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER (SPECIe') DAY MONTH YEAR NAME RESULT TOTAL NO. [ ] VISITS TOTAL IN ~ 1 ~ HOUSEHOLD TOTAL ~ [ ~ EL IG IBLE WOMEN LINE NO. OF RESP. TO HOUSE-[~ HOLD SCHEDULE SUPERVISOR NAME DATE FIELD EDITOR NAME DATE OFFICE EDITOR KEYED BY 193 Now we would like some USUAL RESIDENTS AND VIS(TORS INFORMATION ABOUT HOUSEHOLD MEMBER~; AND V IS ITO~ information about the peopte who usually live in your household or who are staying with you now. RELA- TION~HIP TO HEAD OF HOUSE- HOLD" RESIDENCE SEX AGE EDUCATION ELIGIBILITY IF AGE 6 YEARS OR OLDER PARENTAL SURVIVORSHtP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD 4~ Please give me the names of the persons 0 who usually live in z your household and guests of the household who stayed here last night, starting with the head of the household. What is Does Did I s H o w "1 a s IF ATTENDED SCHOOL Is IF ALIVE S IF AUVE CIRCLE the re- )NAME) )NAME) (N~AEI O I d NAME) (NAME'S) NAME'S) LINE la t ion - USU- s tay male :is ~=ver • natura l ' , ' l a tura l ' =NUMBER mother Does {NAME'S) Iather Does (NAME'S) OF WOMEN ship L i ly here ~r NAME)? ~een What Js IF AGELESS alive? natura l alive? natura l ELIGIBLE 01 ive last e- [o the THAN 35 mother live father l ive FOR 1ere? n ight? hale? (NAME) schOOl? highest yEARS i in this in this ' INDIVIDUAL to the level , household? household? INTERVIEW head of of school IF yE S IF YES: the (NAME) What is What is house- attended? her name? his name? hold? Is {NAME) What is still in ; RECORD RECORD the school? MOTHER'S FATHER 'S highest LINE LINE grade NUMBER NUMBER (NAME) completed at that leve l?** (1] O l 02 03 04 05 (2) (3) {4) (5) (6) (7) (8 ) (g) l I l l | I YES NO YES NQ ~4 F N ~£ARS YES NO LEVEL GRADE 1 2 1 2 1 2 _ [ ~ 1 2 ~] ~ .1 2,1 2 .129q l 2 ,D~ ~.1 2.1 2.12.1T1.1 2 .D ~ i~,21 ~1 DI--T-I ! 1 • 2 a • =~2_4 M ~1 , , 2 12 .~1 2 l [q~ (10) (11) (12) ( t3 ) (14) (15) l I I I l YES NO YES NO DK (ES NO DK I 2 1 28 j1 28 j I~ I~ 02 1 2 ~t 28 : 1 28 J m 1 2 1 28 1 28 . I~ o4 1 2 1 28 1 28 , I-T1 05 1 2 1 28 1 28 HOUSEHOLD SCHEDULE CONTINUED (1 : (2 ) (3) (4) (5) (6) (7) (8 ) (9) (10) (11) (12) (13) (14) (15) I I I I I I I I I I I YES NO YES NO ~1 F IN ~=ARS YES NO LEVEL GRADE YES NO YES NO DK Y'ES NO DK 2 s 1 2 1 2 l 28 1 28 I I I I I I I I I 2 .1 2 . , 1 2 1 2 8 1 2 8 . M I-I-I M oo 1 2 t 2 1 2 1 2 1 2 1 2 8 1 28 1 2 1 2 1 2 1 2 1 2 1 28 1 28 • M io 1 2 1 2 1 2 t 2 1 2 1 28 1 28 : _- =- . : I I I I I I M M I-F-] 11 1 2 1 2 1 2 1 2 1 2 1 28 1 28 177 I-] fl-] 17-1 t2 1 2 2 1 2 1 2 1 28 1 28 i • i i i i i 06 I T ] 1 2 1 2 1 I I I 07 ~ 1 1 2 1 2 1 : _- _- : _- 08_. _ - IT ] _- .' . og: : ~ : : . 10 : F-1---1 : : : I t: _ . ~ l _ . . . . 1 ~ ~ ] 1 2 1 I I I , i TICK HERE IF CONTINUATION SHEET USED I I J us t to make sure that I have a complete l i s t ing : t) Are ,he,e any other persoos such as sma,, chi,dren or I I I I i n fants that we have not l i s ted? YES ENTER EACH IN TABLE NO 2, In add i t ion , a re there any o ther peop le who may not be I I I I members of your fami ly ( lodgers o r f r iends) who usua l ly l i ve here? YES • ENTER EACH IN TABLE NO 3) Are there any guests o r temporary v i s i to rs s tay ing here , o r I I anyone e l se who s lept here las t n ight that have not been l i s ted? YES J I ENTER EACH IN TABLE ) Nol I • CODES FOR Q.3 RELATIONASHIP TO HEAD OF HOUSEHOLD: 01 = HEAD 09 =CO-WIFE 02 = WIFE OR HUSBAND 05 = GRANDCHILD 10 = OTHER RELATIVE 03 = SON OR DAUGHTER 06 = PARENT 11 =ADOPTED~FOSTER~STEP CHILD 04=SONdN.LAW OR 07=PARENT-4N-LAW 12=NOT RELATED DAUGHTER-IN-LAW 08 = BROTHER OR SISTER 98 = DK *o CODES FOR Q 9 LEVEL OF EDUCATION: GRADE l-PRIMARY AND SECONDARY 2 SECONDARY SPECIAL 00 = LESS THAN 1 YEAR 3 HIGHER COMPLETED 8=DK 98 DK • ~* THES E QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD RECORD 00 IF PARENT NOT MEMBER OF HOUSEHOLD NO 16 t7 18 19 20 QUESTIONS AND FILTERS What is the main source o f d r ink ing water for members o f your househo ld? I CODING CATEG~)RIES I SKIP PIPED WATER PIPED INTO RESIDENCE/'(ARD/PLOT 1 1 - - ~ 1 8 PUBLIC TAp . . . . . . 12 I WELL WATER ! WELL IN REBIDENCE/'rARD/PLOT 2 L ~ 1B PUBLIC WELL . . . . . . . . . . . . . . . . . . . . . 2 2 SPRING WATER . . . . . 31 RIVER/STREAM 32 POND/LAKE 33 DAM 34 RAINWATER 4 t - - TANKERTRUCK 51 | | BOTTLED WATER 61 OTHER g6 (SPECIFY) How long does it take to go there , get water , MINUTES I I ] I and come back? ON PREMISES . . . . gg6 FLUSH TOILET What k ind o f to i le t fac i l i ty does your househo ld have? OWN FLUSH TOILET 11 SHARED FLUSH TOILET I 2 pI] TOILET/LATRINE TRADITIONAL TYPE 21 IMPROVED . VENTILATED 2 2 NO FACILITY ( BUSH/FIELD } . . . . . . . 31 OTHER 96 (SPECIFY) Does your househo ld have: E lec t r i c i ty? A rad io? A te lev i s ion? A te lephone? A re f r igerator How many rooms in your househo ld a re used for s leep ing? YES NO I 2 ELECTRICITY RADI O 2 TELEVISION 2 TELEPHONE 2 REFRIGERATOR 2 918 2 t MAIN MATERIAL OFTHE RECORD OBSERVATION 2 2 Does any member o f your househo ld own A b icyc le? A motorcyc le? A car? 2 3 i What type o f sa l t is usua l ly used for cook ing in your househo ld? (ASK TO SEE SALT pACKAGE} NATURALFLOOR EARTH/SAND . . . . . . . . . . . . . . . . . . . . I t TEZEK . . . . . 12 RUDIMENTARYFLOOR WOOD PLAI~KS 21 STRAW/SAWDUST . . . . 22 FINISHED FLOOR PARQUET OR POUSHED WOOD 31 LINOLEUM OR ASPHALT 32 CERAMIC TILES . . . . . . . . . . . . . . . . . . . 33 CEMENT . . . . . 34 ~A#PFT 35 OTHER (SPECIFY) 96 YES NO BICYCLE 1 2 MOTORCYCLE 1 2 CAR . . . . . . 1 2 LOCALSALT . . . . . 01 pACKAGED SALT(IODIZED) O~ pACKAGED SALT[NOTIODIZED) 03 OTHER 96 (SPECIFY) 196 INDIVIDUAL WOMAN'S QUESTIONNAIRE REPUBLIC OF KAZAKHSTAN INSTI'I'LITE OF NUTRITION IDENTIFICATION CITY/TOWN/VILLAGE NAME NAME OF HOUSEHOLD HEAD REGION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBLAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RAION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (urban = 1; rural = 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE . . . . . . . . . . . . . . . . . . . . . . . . (large city = 1, small city = 2, town = 3, countryside = 4) HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME AND LINE NUMBER OF WOMAN INTERVIEWER VISIT 1 2 3 FINAL VISIT DATE INTERVIEWER'S NAME RESULT* NEXT VISIT: DATE TIME DAY MONTH YEAR NAME RESULT TOTAL NO, VISITS [ ] *RESULT CODES: 7 OTHER 1 COMPLETED 4 REFUSED 2 NOT AT HOME 5 PARTLY COMPLETED 3 POSTPONED 6 INCAPACITATED {SPECIFY) 1. LANGUAGE OFINTERVIEW 2. NATIVE LANGUAGE OF RESPONDENT 3 WHETHER TRANSLATOR USED KAZAKH 1 1 YES 1 RUSSIAN 2 2 NO 2 SUPERVISOR NAME DATE FIELD EDITOR NAME DATE OFFICE EDITOR KEYED BY 197 o~ NO. 101 102 103 104 105 ~ ~J.Lo n 1, QUEST IONS AND FILTERS RECORD THE T IME R E~J~Q~L~ E N T' S B~KGROLL~D CODING CATEGORIES Rrst I wOuld bike to ask some questions about you and your household, For most of the time until you were 12 years old, did you live in a city, in a town, or in a countryside? How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)? Just before you moved here, did you live in a ci~1 in a town, or in the countryside? In what month and year were you born? I HOUR . . . . . . . . . . . . . . . . . . L~ __ SKIP MINUTES . . . . . . . . . . . . . . C ITY . . . . . . . . . . . . . . . . . . 1 TOWN . . . . . . . . . . . . . . . . . . . . COUNTRYS IDE . . . . . . . . . . . . . . . . 3 YEARS . . . . . . . . ALWAYS . . . . . . . . . . . . . . g=3 i V IS ITOR . . . . . . . . . . . . ~ C I "W . . . . . . . . . . . . . 1 TOWN . . . . . . . . . . . . . 2 COUNTRYStDE . . . . . . . . . 3 MONTH . . . . . . . . . . . . . . DON'T KNO W MONTH . . . . . . . . . . . . . YEAR . . . . . . . . . . . . . . . . ~N*T ~ YEAR . . . . . . . . . . 9~ • 105 106 How old were you at your last birthday? I l l AGE IN CO~ Pt~ 'T ED YEARS . . . . . . . . . ' . . . . . . . . . . . . . . . , I 107 Have you ever attended school? I NO . . . . . . . . . . . . . . 2 • 114 108 108A 100 111 112 114 What is the h ighest leve l o f schoo l you a t tended: p r imary , secondary , secondary -spec ia l , or h igher? What d id you s tudy? How many years /c lasses /courses did you completed at that level? pRIMARY/SECON C~R Y 1 SECONDARy SPECIAL . . . . . . . 2 HIGHER . . . . . . . . . . . . . . . 3 CHECK106: 34OR BELOW ? Are you current ly attending school? What was the main reason you stopped attending school? Can you read or understand a letter or newspaper easily, with diflculty, or not at all? 35 OR ABOVE I (NAME OF SPECIALITy)) i-i-i I-i-I YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GOT PREGNANT 01 GOT MARRIED : 02 TO CARE FOR YOUNGER CHILDREN 03 FAMILY NEEDED HELD AT WORK 04 NEEDED TO EARN MONEY . . . . . . . . . . . . . . . . 0S HAD ENOUGH SCHOOUN~ 06 DID NOT pASS EI%q'A~'~CE E)CA~A S 07 DID NOT LIKE SCHOOL . . . . . . . . . . . . . . . . 08 SCHOOL IS TOO F~R C~ OTHER 06 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . 98 EJ~SILY . . . . . . . . . . . . 1 WITH DIFR CULTY . . . . . . . . . . . . . . . . . . 2 i'4OT AT ALL 3 • 109 I ; 114 I )114 116 I t~ No. 115 116 QUEST IONS AND FILTERS DO you usually read a newspaper or magazine at least once a week? CODING CATEGORIES YES . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . Do you usua l ly l i s ten to the rad io every day? YES . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 117 DO you usua l ly watch te lev i s ion a t leas t once a week? YES . . . . . . . . . . . . . . . . 1 J NO . . . . . 2 118 MUSUM . . . . . . . . . . . . . . 1 What is your re l ig ion : Are you Mus l im, Chr i s t ian , another re l ig ion o r do you not p rac t i ce any re l ig ion? CHRISTIAN . . . . . . 2 OTHER 6 119 What is your nationality? Are you Kazakh? Russian? Ukrainian? German? Korean? Other? What language is easiest for you to read: Only Kazakh? Kazakh more than Russian? Both equally? Russian more than Kazakh? Only Russian? Other language? 119A (SPECIFY) NOT REIJGIC4JS . . . . . . . . 7 DON'T ~ . . . . . . . . . 8 KATAKH 1 RUSStAN . . . . . . . . . 2 UKRAINIAN . . . . 3 GERMAN . . . . . . . . . . . . . . . . . . . . . . . . . . 4 KOREAN . . . . . . . . . 5 OTHER 6 (SPECIFY) DON'T KNOW . . . . . 6 ONLY KAZAKH . . . . . . . . . . . . . . . . . . . . . . . 1 MORE KA,7~=KH THAN RUSSIAN . . . . . 2 SAME KAZAKH AND RUSS4AN . . . . . . 3 MORE RUSSIAN THAN KAZAKH . . . . . . . . . 4 ONLY RUSSIAN . . . . 5 OTHER 6 (SPEGIF~') SKIP 11gB 11gC 11gD 11gE 121 What language do you usually speak at home: Only Kazakh? Kazakh more than Russian? Both equally? Russian more than Kazakh? Only Russian? Other language? Do you own dacha , o r do you have access to a garden f rom which you obtain fruits and vegetables during the growing seasons? Do you have any chronic diseases? What kind of disease do you have? ONLY KAZAE~ . . . . 1 MORE K /~AKH THAN RUSSIAN . 2 SAME ~ /~NO RUSSIAN . . . . 3 MORE RUSSIAN THAN K/~J~KH 4 ONLY RUSSIAN . . . . . . . . . . . . . 5 OTHER 6 (SPECIFY) YES . . . . . . . . . . . . . . I NO . . . . . . . . . . . . . . . . . . . . . . . . 2 OTHER 6 (SPECIFY) YES . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . 2 M (NAME OF DISEASE) CHECK INT ~RVt EWER'S AS~NM D~T SHEET: THE WOMAN INTER'~EWED IS NOT A USUAL RESIDENT Now I would like to ask about the place in which you usually live. What is the name of the place in which you usually live? (NAME OF PLACE) IS that a c i ty , town, o r the count~s ide? ? THE WOMAN INTERVIEWED IS A USUAL RESIDENT CAP ITAL C~TY LARGE CITY 1 SMALL C I ]Y . . . . . . . . . . . . 2 TOWN . . . . . 3 COUNTRYSIDE . . . . 4 ~, 12(3 0 NO. 122 123 QUEST IONS AND F ILTERS In which oblast is that located? Now I would like to ask about the household in which you usually live. What is the main source of drinking water for members of your household? CODING CATEGORIES Q~LA~T AKMOUNSKAyA . . . . . 01 AKT IUB INSKAyA . . . . . 02 ALMATINS KAyA . . . . . . . . 03 ATYP.AUSKAYA . . . . . . 0 4 EAST - KAZAKH STANSKAY;~ 05 ZHAMBYLSKAYA . . . . . . . 06 Z H EZ KAZ P-P-P-P-P-P-P-P-P-P~ S KAyA . . . . . . . . 07 WEST-KAZAKHSTANSKAYA O 8 KARAGANOl NSKAYA 09 KZ~I=-OR~NS;<Ay~= . . . . . . . . . . . I 0 KOKSHETAUSKAyA . . . . . . . . . . . . . . . . . . . . . 11 KOUSTANAIS KAYA . . . . . . . . . . . . . . . . . . I 2 MANGISTAUSKAyA . . . . . . . . . . . 13 pAVLODARSKAyA 1 4 NORTH. KAZAKHSTAN S KAyA . . . . . . . . 15 SEMIpALAT]NSKAyA . . . . . 16 TALDYKORGANS KAyA . . . . . . . . . . . . . ~ 7 TOURCiAJSKAyA . . . . . . 1 8 SOUTH - KAZAKHSTANSKAyA 19 THE CiTY OF ALMATy . . . . . . . . 2 0 OTHER 9 6 SPECIFY P IpED WATER P IPED INTO RES IDENCE/YARD/PLOT 11 pUBL IC TAP . . . . . . . . . . . . 12 WATER WELL IN RESIO~ENC FJYARD/Pt OT . . . . . . . . 21 PUBUC WELL 2 2 SURFACE WATER SPR ING WATER . . . . . . 31 RMER/STREAM . . . . . . . . 32 POND/LAKE . . . . . . . 33 DAM . . . . . . . . . . 34 RA]NWATER . . . . . . 4 1 TANK~ER TRUCK . . . . . . . 51 BOTT LF_D WATER . . . . . . . . 61 SKIP ;' t25 )125 ~25 }" 125 OTHER (SPECIFY) bo O 124 How long does it take to go there, get water, and come back? MINUTES I ] ] J ON PREMISES . . . . . . . . . . . . . . . . . . . . 996 125 What kind of toilet facility does your household have? 126 127 128 Does your househo ld have : E lec t r i c i ty? A rad io? A te lev i s ion? A te lephone? A re fhgerator Cou ld you descr ibe the main mater ia l o f the f loor o f your home? Does any member o f your househo ld own A b icyc le? A motorcyc le? A car? FLUSH TOILET OWN FLUSH TC4LET 11 SHA~ED FLUSH TOILET . . . . . . . . . . . . . . . . 12 RT TOILET/LATRINE TRADITIONAL TYPE . . . . 21 IMPRO~:D - VENTILATED 2 2 NO FACILITy (BUSH/RELD) . . . . . . . . . . . . . . . . 31 OTHER g6 (SPECIFY) YFS NO ELECTRICITY . . . . . . . . . . . . . . . . . . . . . 1 2 TELE~SION . . . . . . . . . . . 1 2 TELEPHONE . . . . . . . . . . . . . . . . . . 1 2 REFRIGERATOR . . . . . . . . . . . . . . . . . . . 1 2 NATLIRAL FLOOR EARfH/SAND . . . . . . . . . . . . . . . . . . . . . . . 11 TEZEK . . . . . . . . . . . . . . . . . . 1 2 RUE4M EN]rAIw FLOOR WOOD PLANKS 21 , STRAW/~AW~JST . . . . . . . . . . . . . . . 2 2 FINISHED FLOOR pARQUE[ OR POLISHED WOOD . . . . . 31 UNOLEUM OFt ASPHALT . . . . . . . 32 CERAMIC TILES . . . . . . . . . . . . . . . 33 CEMENT . . . . . . . . . . . . . . . 34 CARPET . . . . . . . . . . . . . . . . . . 35 OTHER 95 (SPECIFY) YES NO B$CYCLE . . . . . . . . 1 2 MOTORCYCLE . . . . . . . . . . . . . . . . . . . 1 2 CAR . . . . . . . . . . . . . . . . . . 1 2 No. 201 202 203 204 205 206 Sect ion 2 . PREGNANCY H ISTORY QUEST IONS AND F ILTERS Now I would like to ask you about all the births you have had during your life. Have you ever given birth? DO you have any sons or daughters to whom you have given birth who are now li~qng with you? HOW many sons live with you? And how many daughters live with you? IF NONE RECORD "00" Do you have any sons or daughters to whom you have given birth who are alive but do not live with you? How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? IF NONE, RECORD '00' Have you ever given birth to a boy or a girl who was born alive but later died? IF NO, PROBE: Any baby or days? who cried or showed signs of life but survived only a few hours CODING CATEGORIES YES . . . . . . . . . . . . . . . . . . . . . . . . 1 NO 2 YES 1 NO 2 DAUGP~T ERSAT HOME (ES . . . . . . . 1 NO 2 DAUGHT ERSELSEW~ERE YES 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 I SKIP2o6 j 204 206 • 20B I 207 How many boys have died? How many girls have died? GIRLS DEt~ . . . . . 208 SUM ANSWERS TO 203 205 , 207 , IF NONE RECORD '00 ' TOTAL BIRTHS 199 209 Women sometime have pregnancies which do not result in a live born child. That is, a pregnancy can ended very early by a mini abortion or by an induced abortion, a miscarriage or a stillbirth. In total how many mini abor~ons, and induced abortions have you had? ORTIONS 210 HOW many miscarriages? TOTAL MLSCARRtAGES . . . . . . . . . . . . . . I I I I I 211 How many stillbirths? I I I TOTAL ST~U~IRTHS . . . . . . . . ! ! 21 2 sum ANSWERS TO 208 , 209 , 210 , 211 , AND ENTER TOTAL I I I IF NO PREGNANCIES RECORD "00" TOTALPREGNANCIES . . . . . . . . . . . I I 2 1 3 c HECK 212 ONE OR MORE : PREGNANCY [~ NO P"EG"ANCIESI~ 227 214 Now I want to talk to you about each of your pregnacies, including those which ended in a live birth, an induced abortion, a miscarriage, and a stillbirth. Starting with your last pregnancy, please tell me the following information t~ m 215 Vhen did your last/r~xt-to-las~ ,tc.) pregnancy }nd? In what nonth and yea~ 7 I ~ R fEAR 216 Did this pregnancy end in a live birth, an induced abortion, a miscarriage, or a stillbirth? UVE BIRTH 1 INDUCE) ABORTION 2 - - MISCARRIAGE 3 STILLBIRTH 4 - - IJV~- BIRTH 1 INDUCED ABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 UVEBIRTH 1 INDUCED ABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 - - UV E BIRTH 1 INDUCED ABORTION 2 MISCARRIAGE 3 STlU31RTH 4 217 FROM YEAR OF LAST/NEXT-TO- THE LAST, ETC PREGNANCY SUBTRACT YEAR OF PREVIOUS PREGNANCY IS THE DIFFE- RENCE 4 OR MORE? TRY TO DETER- MINE:IF THERE WAS ANOTHER PREGNANCY BETWEEN THIS AND PRE- VIOUS PREG- NANCY YES 1 NO 2 YES . . . . 1 NO 2 YES . . . . 1 NO 2 YES 1 NO 2 218 CHECK 2~6 RECORD SAME RESPONSE UVE BIRTH . . . . . . 1 IINDUCED ABORTION 2q AISCARI:IIAGE 3 ~TI~II:IT H 4 ~exv ~AeaN.~C, • JVE BIRTH 1 INDUCED ABORTION 2q MISCARRIAGE 3 STILLBIRTH 4 ~[x~ ~REGNANC, • JVt: BIRTH 1 NDUCED ABORTION 2 " - - I 4 AISCARRIAGE 3 STILLBIRTH 4 NEXT PmeGMANC~ • JVE BIRTH 1 NDUCED ABORTION 2 q AISCARRIAGE 3 ~TII~I31NTH 4 NEXT PREGNANC~ ~ 219 Was this a single or a multiple birth? SING 1 MULT 2 SING 1 MULT 2 SING 1 MULT 2 SING 1 MULT 2 m 220 What name was given to this chi ld? N.~ME NAME NAME 221 Is (NAME) a boy or girl? BOY . . . . . l YES 1 GIRL 2 NO 2 ~224 BOY 1 YES . . . . . 1 GIRL 2 NO 2 L224 BOY yEN 1 GIRL NO 2 ~224 BOY . . . . . . YES I GIRL NO 2 I ~-224 222 223 Is (NAME) HOW old was still alive? (NAME) on his/ her last birthday?. RECORD AGE IN COMPLETED YEARS AGE iN YEARS AGE IN YEARS AGE IN YEARS AGE IN YEARS 224 How old was (NAME) when he/she d ied? IF '1 yR . ' PROBE: HOW ma~y months o ld was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS MONTHS 2 YFJ~:]S 3 DAYS . . . . 1 I I MONTH~ 2 YEARS 3 DAYS . . . . 1 MONTHS 2 yEARS . . . . 3 DAYS 1 I I MONTHS 2 yEARS 3 t 'O LfV1E BIRTH 1 INDUCED ABORTfON 2 MISCARRI,~3E 3 STILLBIRTH . . . . . 4 LIVE BIRTH 1 INCUCED ABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 LIVE BIRTH 1 INDUCE{) ABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 LIVE BIRTH INDLICED ABORTION 2 MISCARRIAGE . . . . . 3 STILLBIRTH . . . . 4 ES 1 NO • 2 yE S 1 NO . . . . . . . 2 YES . . . . 1 NO 2 YES . . . . . . . 1 NO LiVE BIRTH 1 ~NDUCED ABORTION 2 - - MISCARRIAGE 3 STILLBIRTH 4 - - NEX~ PnEGN,*NCV • UV~BIE[H 1 INDLICFOABORTION 2 - - MISCARRIAGE 3 STILLBIRTH 4- - NEXT PREGNANCY LIVE BIRTH . . . . . . . 1 INDUCED ABoR'rlON 2 - - MtSCARRIAGE 3 STILLB{RTH 4 - - N~XT PRf~NANCV • UVE BIRTH 1 INDUCEr) ABORTION 2 - - MISCARRIAGE 3 ;TI LLBIRT H 4 - - NeXT P~C~NANCY SING . . . . . . . . 1 MULT . . . . . . . . 2 SING . . . . . . . 1 MULT 2 SING 1 MULT 2 SING . . . . . . . . 1 MULT . . . . . . 2 NAME NAME NAME NAME OY . . . . . . . 1 GIRL . . . . . . . . . 2 B O Y . . . . . . . . 1 G;RL . . . . . . . . 2 80Y 1 ~IRL . . . . . 2 tOY 1 ~IRL . . . . . . . . 2 YES 1 NO 2 L224 YES . . . . . 1 NO . . . . . 2 L224 YES . . . . 1 NO 2 L~224 NO 2 L224 AGE IN YEARS AGE IN YEARS AGE IN YEARS AGE IN yEARS MONTHS . . . . . 2 YEARS . . . . . 3 r - ] -q DAyS . . . . . 1 MONTHS . . . . . 2 YEARS . . . . . 3 MONTHS . . . . . 2 yEARS 3 O OC D ~ ~ I U V E BIRTH 1 MONT H INDUCED ABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 UV E BIRTH 1 INO(,ICED ABORTION 2 MISCARR~U3E . . . . . . 3 ;TIL/~IRTH . . . . . . 4 UVlE B~RTH 1 INDUCE) ABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 ~ ~"~1 UV~: BIRTH 1 H ~ 1 INDUCED ABORTION 2 MISCARRIAGE 3 STILLBIRTH . . . . . . . 4 YES 1 NO 2 YES . . . . . . 1 NO 2 YES 1 NO 2 yE S 1 NO UVI'BIRTH I INEXJCEDABORTION 2~ MISCARRIAGE 3 STILLBIRTH 4 N~XT pAI~NA~C',' • UVEBIRTH l INOUCEDABORTION 2~ MISCARRIAGE 3 STILLBIRTH 4 ~Ex* PREGNAnCy • UVI: BIl~r H 1 INI~d~F~) ~3ORTIO N 2~ MISCARRIAGE 3 STILLBIRTH 4 Nexr P~EG~ANCY • UVE BIRTH . . . . . 1 INDUCED ABORTION 2. MISCARRIAGE . . . . 3 STILLBIRTH 4 HeXT pACG'~CY ~ SiNG 1 MULT 2 SING 1 MULT 2 SING 1 MULT 2 SING . . . . 1 MULT . . . . . . . . . 2 NAME NAME NAME NAME BOY . . . . GIRL 2 BOY 1 GIRL . . . . . . . . 2 BOY I GSRL 2 BOy 1 GIRL 2 YES 1 NO 2 L224 YES 1 NO . . . . . 2 ~224 YES I NO 2 L224 YES I NO 2 L224 AGE IN YEARS 218 • AGE IN YEARS AGE IN YEARS AGE IN YEARS DAYS 1 MONTHS . . . . 2 YEARS 3 DAYS . . . . . 1 I I I MONTHS 2 yEARS 3 DAYS . . . . . . 1 J J J MONTHS 2 YFJ~RS . . . . . 3 DAyS 1 MONTHS 2 yEARS 3 tO MONTH yEAR aVE BIRTH 1 INDUCED ABORTION 2 MtSCARRIAQE 3 STILLBIRTH 4 UVEBIRTH 1 INDLJCEDABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 UVEBIRTH 1 INDUCED ABORTION 2 MISCARRIAGE 3 STILLBIRTH 4 UVEBIRTH 1 INOUCBDABORTION2 MISCARRIAGE 3 STILLBIRTH 4 YES 1 NO YES 1 NO YES 1 NO YES 1 NO . . . . . IJVE BIRTH 1 INDUCED ABORNON 2~ MISCARRIAGE 3 STILLBIRTH . . . . . . . 4 NEXT PR¢~A~C~ ( UVEBIRTH . . . . . 1 INDUCEDABORTION2~ MISCARRIAGE 3 STILLBIRTH 4 NEXT PREGNANCY UVE BIRTH . . . . . 1 INDUCED ABORTION 2q MISCARRIAGE 3 STILLBIRTH 4 UV~ BIRTH 1 IND~JCED ABORTION 2~ MISCARRIAGE 3 STILLBIR'FH 4 NEXt PREC.*NO, • S4NG 1 MULT . . . . . . . . . 2 SING 1 MtJL/ SING . . . . 1 MULT 2 SING 1 MULT 2 NAME NAME 2 NAME NAME BOY 1 yFS 1 31RL . . . . 2 NO 2 L224 ~Oy YES 1 ,GIRL 2 NO 2 ~224 3OY . . . . . . . 1 YES 1 ,GIRL 2 NO . . . . 2 L~224 BOY 1 YES 1 ~RL 2 NO 2 ~224 AGE IN YEARS M-- 218 ,( AGE IN YEARS AGE IN YEARS AGE IN YEARS 21B • DAYS • 1 MONTI4~ 2 YEARS . . . . . . . 3 ~YS 1 MONTHS 2 YEARS 3 DAYS . . . . . . 1 I l l MONTHS 2 yEARS 3 I - -T- - I DAYS 1 MONTHS 2 yEARS . . . . 3 225 CAMPARE 212 WITH TOTAL PREGNANCIES IN PREGNANCy H ISTORy IN QUEST ION 215 NUMBERSA"ET"ESAME I I O'FrERENT NOMBERSARE I ] 1 CHECK: Q215 FOR EACH PREGNANCY YEAR OF pREGNANCY ENDED IS RECORDED 0223 FOR EACH L IV ING CHILD CURRENT AGE IS RECORDED Q224 FOR AGE AT DEATH 12 MONTHS OR 1 YEAR PROBE TO DETERMINE EXACT NUMBER OF MONTHS • (PROBE AND RECONCILE) 226 CHECK2,SANDENTERTHENOMBE O PREONANCIESENOEDSNOE ANUAR¥1002FNONE¸RECORD 0 I I NO I QUEST IONS AND F ILTERS I CODING CATEGORIES ISK IP YES . . . . . . 1 227 Are you pregnant now? NO . . . . 2 --1 I UNSURE . . . . . 8 ~ ). 230 228 How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS MONTHS I I I 229 At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or THEN 1 did you not~ant to become pregnant at al~? LATER 2 NOT AT ALL 3 t " t " 2 3 O When did your last menstrual period start? DAYS AGO 231 232 (DATEIF GIVEN) Between the first day of a woman's period and the first day of her next period, are there certain times when she has a greater chance of becoming pregnant then other times? During which times of the monthly cycle does a woman have the greatest chance of becoming pregnant? WEEKS AGO MONTHS AGO YEARS AGO IN MENOPAUSE 994 BEFORE LAST BIRTH 995 NEVER MENSTRUATED 996 YES NO 2q DON'T KNOW 8 DURING HEIR pERIOD 01 RIGHT AFTER HER PERIOD HAS ENDED 02 IN THE MIDDLE OF 1HE CYCLE 03 JUST BEFORE HER PERIOD BEGINS 04 OTHER 96 (SPECIFY) DON'T KNOW 9 B ~30~ Sect ion 3 . OUTCOME OF PREGNANCIES bo I 301 CHECK 22B ONE OR MORE PREGNANCY ~ NO PREGNANCY S}NCE SINCE JANUARY 1992 JANUARY 1992 L, I I 302 ENTER THE LINE NUMBER FOR EACH PREGNANCY ENDED S}NCE JANUARY 1992 tN THE TABLE PF [HERE ARE MORE THAN FOUR PREGNANCIES t Now I would like to ask you some questions about the pregnancies you have had in the last three years. L&ST PREGNANCy N~k'T.TO.THE.LAST PREGNANCy 303 UNE NUMBER FROM Q 215 I LINE NUMBER UNE NUMBER i m ! m 304 SEE Q 216 AND 220: l OUTCOME OR NAME OUTCOME OR NAME / OUTCOME OF PREGNANCY OR THE NAME OF CHILD / 305 105A 306 306A i At the time you became pregnant (with NAME), did you want to become pregnant then, did you want to wait un~31 later, or did you want nO (morel children at all? THEN . . . . . . 1 THEN (SKIP T O 306A} ( I (SKIP TO 306A) • LATER 2 LATER NO MORE 3 ~ NO MORE . . . . . . {SKIP TO 3~} • I {SKIP TO 306) • . . . . . l j 2 How much longer would you to have waited? At the time you became pregnant, were you using a method of contraception? Wh~h method? CHECK 304: OUTCOME OF PREGNANCY like • YEARsMONTHS 21 J ' ~ DON'T KNOW 998 YES . . . . . . 1 NO 2 IORTION . . . . . E ~ 316 MISCARRIAG E } ~ 32"¢ STILLBIRTH DVE BIRTH MONTHS 1 [ [ yEARS 2 ~ON'T KNOW 998 YES I NO . . . . . 2 M INDUCED ABORTION . . . . ~]~316 MISCARRIAGE ~ 2 5 ,T, RT. UVE BIRTH . . . . (S KIP TO 458) I USE ADDITIONAL QUESTIONNAIRE 1 I SECOND FROM LAST PREGNANCY - [HIR o FROM LAST pR EGN,A,~IC y UNE NUMBER . . . . . [ ~ UNENUMBER I T ] I I I OUTCOME OR NAME OUTCOME OR NAME THEN . . . . 1 I (SKIP TO 306A) • I LATER 2 NO MORE 3 (SKIP TO 306) • YEARS DON'T KNOW 998 YES 1 NO 2 INDUCED ABORTION . . . . . . [ ~ 316 MISCARRIAGE ~ 3L~5 STILU3~RTH i uw"'mB THEN 1 (SKIp TO 306A) • 2 U~TER ) MOPE 3 ISKIP TO 306) • I yEARS DON'T KNOW 998 YES 1 NO 2 M INDUCED ABORTION ~ 316 MISCARRIAGE ~ 3 2 5 STILLBIRTH . . . . . E~[ UV~ BIRTH I I----4 m bo b~ )7 38 09 12 When you were pregnant (wi~ NAME), did you see anyone for antenatal care for this p regnancy? L.~ST PREGNANCY OUTCOME OR NAME 4EALTH PROFESSIONAL DOCTOR A NURSE/M~DWIFE B %LONMEDICAL PERSON~ NEXT.TO.THELAST PREGNANCY OUTCOMEORNAME HEALTH PROFESSIONAL DOCTOR A NURSE/MIDWq FE B NONMEDICAL pERSON~ NEXT.TONE)3TO THE LASTFREGN OUTCOMEORNAME HEALTH PROFESSIONAL DOCTOR NURSE/MIDWIFE NONMEDICAL PERSON~ NEXT.TO-NEXT40.NEXX-TO LAST PREG OUTCOME O~R NAME I HEALTH PROFESSIONAl A DOCTOR A 8 NURSE/MLDWIFE B NONMEDICAL PERSONS IF YES: Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSONS PROVIDED ANTENATAL CARE RECORE~ ALL PERSONS SEEN How many months pregnant were you when you first received antenata l care? How many times did you receive antenatal care during this p regnancy? Where did the (birth of NAME/stillbirth} take place? TRADITIO NALMIDwlFE C RELATIVE/FRIEND . . . . . . O OTHER X (SPECIPf) MO ONE Y i (S~P TO 3~21 ~ I MONTHS I ~ l {3ON~ KNOW 98 NUMBER ~i~ DONT KNOW 98 40ME RESPONDENTS HOME 11 OTHERHOME 12 HEALTH FACIUTY OSGyN HOSPITAL 21 HO£PITAL 2 2 DOCTOR'S ASSISTANT/MIDWIFE ~3ST(FAP) 23 OTHER HEALTH PACIUTY 26 (~pEcIFY) 3THER 96 (SPECIFY) T RADITIONALMIDw]FE C TRADITIONAL MIDWlFE C TRADITIONAl-MID wIFE RELATIVE/FRIEND D RELATIVE/FRIEND D RELAT[VE/PRIEND OTHER X OTHER X OTHER (SPECIFY} NE Y ( SKIP TO 312) • I MONTHS DON'~ KNOW 98 NUMBER ~98 DON] KNOW 4OME RESPONDENT'SHOME 11 OTHERHOME 12 I OBGYN HOSPITAL 21 HOSPITAL DOCTOR'S ASSISTANT/MIDWIFE POST IFAP) 23 OTHER HEALTH F~ILITy 26 (~IJEL.Ipy) i OTHER (SpLC[Fy I 96 NO ONE (SKIPTO 312) MONTHS . . . . ~ ' ] DON'T KNOW 98 NUMBER [ - -~ DON~ KNOW ~OME RESPONDENT'S HOME OTHER HOME (5p~(~IF-Y) Y NO ONE • I ( SKIP TO 312) ~ - - MONTHS ~F~ DON*T KNOW 98 NUMBER gg CON ~r KNOW g8 HOME 11 RESPONDENT'S HOME 11 12 OTHER HOME 12 HEALTH FAClUTY OBGYN HOSPITAL 21 HOSPITAL 2 2 OOCTOR'S ~SISTAN[T/MIDWiFE POST (FAP) 23 OTHER HEALTH FACILITY 26 OTHER 96 (SPECIFY) OBGYN HOSPITAL 21 HOSPITt~t. 2 2 DOCTOR'S ASSISTANT/MFDW1EE POST IF~) 23 OTHER HEALTH FACIUTY 26 OTHER 96 ISPECIFY) t - J L~J 313 314 Who ass i s ted w i th the (de l ivery o f NAME/St i l lb i r th )? Anyone e l se? PROBE FOR THE TYPE OF PERSON RECORD ALL PERSONS ASSISTING At the t ime o f "die (b i r th o f ( NAME) /s t i l Ib i r th} , d id you have any o f the fo l low ing prob lems: Long labor , that is, d id your regu lar cont rac t ions las t more than 18 hours? Excess ive b leed ing that was so much that you feared i t was l i fe th reaten ing? A h igh fever w i th bad smel l ing vag ina l d i scharge? Convu ls ions not caused by fever? Ear ly rupture o f amniobc f lu id sac? HEALTH PROFESSIONAL I HEALTH PROFESSIONAL DOCTOR A DOCTOR . . . . . . . . . . . . . . . A NURSE/MI[~'IFE B i~JRSE/MIDWlFE . . . . . . . . . . . . . B NONME~CALPERSONS TRA~TIONALMIDWIFE REALTIVE/FRIEND . . . . . OTHER (SPECI~W) YES NO LONG LABOR . . . . . . . . 1 2 1 2 FEVER/BAD SMELLING 1 2 CONVULSIONS 1 2 NONMED~CAL pERSONS TRADITIONAL MIOW1FE . . . . . . . . C D REALTNFJ F-RIENO . . . . . . . . . . . D X O THER X (SPECIFY) y NO ONE . . . . . . . . . . . . . . . Y YES NO LONG LABOR . . . . . . . . . . . 1 2 BLFEDING 1 2 FEVER/BAD SMELLING 1 2 CONVULSIONS . . . . 1 2 HEALTH PROFESSIONAL DOCTOR A NURSE/M~OV~ FE . . . . B NONMED4CAL PERSONS TRADfTIOh~k MIDWIFE C R EALTIV~RIEND . . . . . D OTHER X (SPECIFY) NO ONE Y YES NO LONG LABOR 1 2 1 2 FEVER/BAD SMELUNG 1 2 CONVULSIONS 1 2 HEALTH PROFESSIONAL DOCTOR . . . . . . . . . . A NURSE/IMID~IFE . . . . . B NONME~CAL pERSONS TRADITIONAL MIO~IFE . . . . . . C REALTIVE/FRt ENO . . . . . D OTHER X (SPECIFY) NO ONE . . . . . . . . Y YES NO LONG LASOR . . . . 1 2 1 2 FEV~R/BADSMELLING 1 2 CONVULSIONS . . . . . . . . . . . 1 2 EARLY RUPTURE OF AMNIOT~C 1 2 EARLy RUPTURE OF AMNIOTIC 1 2 EARLy RUPTURE OF AMNIOTIC 1 2 EARLy RUPTURE OF AMNIOTIC 1 2 FLUID SAC FLU40 SAC FLUID SAC . . . . . . . . . FLUID SAC . . . . . . . . }15 316 317 Was the (b i r th o f (NAME) /S t i l l b i r th ) by caesar ian sect ion? Where was the induced abor t ion per fo rmed? L&STPREGNANCy CUTCQ~EORNAME YES . . . . . . . . . . . NO . . . . . . . . . . 325 • PUBUCSECTOR N I~I " . TO- TH E.L~ST PREGNANCy NEXT-T0-NEXT-TO THE L~ST PREGN NE~T.TO NEXT-TO-M~(T.TO LAST PREG PRIVATE SECTOR PRIVATE SECTOR PRIVATE SECTOR PRIVATE SECTOR pRIVATE CUMC . . . . . . . . . 21 pRIVATE CUNtC 21 PRIVATE CUNIC 21 pRIVATE CUNIC 21 PRIVATE DOCTOR . . . . . 22 PR IVATE DOCTOR 22 pRIVATE DOCTOR 22 PRIVATE DOCTOR 22 Can you te l l me what p rocedure was used to te rminate the pregnancy? OTHER PRIVATE HEALTH FACILITy 26 (SPECIFY) PRIVATE PERSON (NON MEDICAL) 31 OTHER g6 (SPECIPf) OTHER PRIVATE HEALTH FACIUTY 26 (~PECIFY) PRIVATE PERSON {NON MEDICAL) 31 O THER 96 {SPECIP() OTHER pRIVATE HEALTH FACiUTY 25 (SPECIe-y) PRIVATE PERSON (NON MEDICAL) 31 OTHER 96 (SPECIFY) OTHER PRIVATE HEALTH EACIUTY 26 (SPECIFY) PRIVATE PERSON (NON MEDICAL) 31 OTHER 96 (SPECIFY) E )&C . . . . . . 1 D&C . . . . 1 O&C 1 O& C 1 AS pIF{ATIO N 2 /~SF1 RATIO N 2 ASPIRATION . . . . 2 ASPIRATION 2 CAESARIAN SECTION 3 CAESARIAN SECTION . . . . . 3 CAESARIA N SECTION 3 CAESARIA N SECTION 3 TRACTIONAL METHOD . . . . . . 4 TRADITIONAL METHO0 4 TF~D~TIONAL METHOD . . . . . . 4 TRADITIONAl. M Eq-HO 0 4 OTHER OTHER OTHER OTHER .6 6 6 .6 [SPECIFY) (SPECIFY) (SPECIFY) (SPECIFY) DON'T KNOW . . . . 8 DON, T K ~ 8 DON,T ~ . . . . 8 DON" T KNOW . . . . . 8 . . . . . . . . . . . : . . . . . . : . . . . . . . . . . . 3~5< 325( PUBUC SECTOR I~JBUC SECTOR HOSPITAL 11 HOSPITAL . . . . . . . . . . . . . 11 HOSPITAL . . . . 1 POLYCUNIC 12 pOLYCIJNIC . . . . . . . . . 12 pOLYCUNIC . . . . . 12 AMBULATORY . . . . 13 AMBULATORY 13 AMBULATORY . . . . . 13 MOBILE CUNIC . . . . 14 MOBILE CUNiC . . . . . . . . . . 14 MOBILE CUNIC . . . . . . . 14 OTHER HEALTH FAClUTY OTHER HEALTH EACIUTY OTHER HEALTH EACIUTY 16 16 16 ISPECIFY} (SPECIFY) (SPECIFY) PUBLIC SECTOR HOSRTAL . . . . . . 11 POLYCUNIC . . . . 12 AMBULATORY . . . . . . . . 13 MOBIU" CUNIC . . . . 14 OTHER HEALTH FACIU~( 16 (NPECIFY) YES . . . . . . . . . . . 1 . -3 NO . . . . . . . . . . . . . . . . . . . 2 "~ / 32~, OUTCOMEORNAME OUTCOME OR NAME O=JTCOM E OR NAME F J Who he lped you to per fo rm f f~at p rocedure? RECORD ALL PERSONS ASSISTIN(3 DOCTOR . . . . . . . NURSE/MIDWI FE . . . . . . . . . TRACTIONAL MIDW1FE . . . . . . . OTHER PERSON Somet imes , a woman has hea l th prob lems a f te r an induced abor t ion . D id you have any hea l th prob lems a f te rwards? What hea l th prob lems d id you have : pe lv ic pa in? s te r i l i ty? in fec t ion? lack o f menst ruat ion? b leed ing? o ther? RECORD ALL REPORTED D id you seek care because o f these compl i ca t ions? (SPECIFY) NO ONE . . . . YES . . . . . . . . . 1 NO . . . . . . . . . . . . . . . 2 - DON'T KNOW . . . . . . . . . . . . . 8 . 325 • LACK OF MENSTRUATION . . . . . . BI~" EDIi~G . . . . . . . . . . . . OTHER i SPECIFY I DON'T K I~W . . . . . . NO . . . . . . 2 A DOCTOR . . . . . . . . . . . . . A B NUph3E/MIDW] FE . . . . . . . . B C TRACTIONAL MIOW1FE . . . . . . . C I OTH~ N I~J~ON 1 X X i (SPECIFy) y NO ONE . . . . . . . . . . . y I YES . . . . . . . . . 1 NO . . . . . . . . . . . . . 2 . DON'T KNOW . . . . . . . . . 8 - 325 I A PELV1C pAIN A 8 STF~RILrry . . . . . . . . . . B C INFECTION . . . . . . . . . . . . . . . c C LACK OF MENSTRUATION . . . . . . . O E BLEEDING . . . . . . . . . . . E X OTHER X (SPECIFY] Z DON'T KNOW . . . . . Z | 1 YES . . . . . . . . . . . t NO . . . . . . . . . . . . . . . . . 2 OOCTOR . . . . . NURSF~MIDW] FE T RADfTIONAL M10~IFE OTHEFt PERSON (SPECIFY) NO ONE . y YES . . . . . . . . . . . . . . . . 1 NO . . . . 2" CON't" KNO W . . . . . . . 8 . 325 ( PELVIC pAIN . . . . . . . . . . . . . . A STERlUTY . . . . . . . . . . . . . . . . . . . B INFECTION . . . . . . . . . . . . . C LACK OF MENSTRUATION . . . . D BLEEDING E OTHER X (SpECIF~f) DON'T KNOW Z YES . . . . . . . 1 NO 2 325( A DOCTOR . . . . . . . . . . . A B NURSE/MID~/IFE . . . . . . . . B C TRAI~TIONAL MI I~ I FE . . . . . . C OTHER PERSON x i x I (SPECIFY) L NOONE . . . . . . . . . . . . . . . . y I YES . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . 2 - DON'T KNOW 8 -- 325 • I PELV1C p~N . . . . , STERI[JTy . . . . I INFECTION LACK OF MENSTRUATION BLEEDING . . . . . . . I OTHER (SPECIFY) DO~rT KNOW . . . . . . . . . . . . . . . I YES . . . . . . . . . . . . . NO . . . . . . . . . . . : 325( A 8 C D E X 1 2 I I~STPREGNANCy OUTCOMEORNAME NEXT*TO-THELAST PREGNANCy OUTCOMEORNAME NEXT .TO.NEX~ .T O THE LAST F~EGN OUTCOME OR NAME NE)~T.TO.NE~T.TO NE~TTOLAST PREG O~JTCOMEORNAME hO ]22 323 324 325 Where d id you seek care? R ECORE) ALL MENTIONED PUBUC SECTOR PUBUC SECTOR PUBUC SECTOR PUBUC SECTOR HOSPITAL . . . . . . . . . . . A HOSPITAL . . . . . . . . . . . A HOS~TAL . . . . . . . . . . . . A HOSPITA L . . . . . . A I~OLYCUNIC B POLYCUNIC B pOLYCUN$ c B POLYCUNI C B AMBULATORY . . . . C AMBULATORY C AMBULATORY C AMBULATORY . . . . . . . C MOBILE CUNIC . . . . D MOBIIJE CUN[C O MOBILE CUNIC O MOBILE CUNIC . . . . . . . D OTHER HEALTH F,~CIUTY OTHER HEALTH FACILITy OTHER HEALTH FACIUTY OTHER H F~LT H FACIUTY E E E E (SPECIFY) {SPECIFY) (SPLC~FYI (SPECIFY) I PRIVATE HEALTH SECTOR PRIVATE HEALTH SECTOR PRIVATE SECTOR PRIVATE HEALTH SECTOR PRIVATE CUNIC F PRIVATE CUNIC F PRIVATE CUNIC F PRIVATE CUNK~ . . . . . F PRIVATE DOCTOR . . . . . . . . . G PRIVATE DOCTOR G PRIVATE DOCTOR . . . . . G PRIVATE DOCTOR . . . . . . . . . . G OTHER PRWATE HEALTH FACIU~ OTHER PRIVATE HEALTH FACIUTY OTHER PRIVATE HEALTH FACIUTY OTHER PRIVATE HEALTH FACIUTY H N H H (;Sp~(~IFy) (~pLCIFy) (SPECIFY) (SPt:CIFy) PRIVATE PERSON (NON MEDICAL) t PRfVATE PERSON (NON MEC4CAL} I PAIVATE PERSON (NON MEDICAL) ~ PRWATE PERSON (NON ME[~CAL} ¢ Have you been hosp i ta l i zed because o f these prob lems? OTHER (SPECIF'(} YES . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . 2 HOW many days? NUMBER I ~ 1 DON'T KNOW 96 GO BACK TO Q 305 IN NDcr COLUMN IF NO MORE PREGNANCy, CO TO Q 401 OTHER (SPECIFY) NO . . . . . K OTHER K (SPECIFY) 1 y~'S 1 NO . . . . . . . . . . 2 ] 32'5 ( OTHER {SPECIFY) YES 1 .o 2 7 3~3 • NUMBER NUMBER . . . . . I I I DON'T KNOW 98 DON'T KNOW 98 DON'T KNOW . . . . . . . 98 GOBACKTOQ 305 [N NEXT COLUMN GOBACKTOQ 3051N NEXT COLUMN GOBACKTOQ 3051NNEXI COLUMN IF NO MORE PREGNANCY GO TO Q401 IF NO MORE PREGNANCy, GO TO Q 401 IF NO MORE PREGNANCy, GO TO Q401 Sect ion 4A. CHILD HEALTH AND NUTRIT ION PRACTICES 401 CHECK 306A: ONE OR MORE UVE BIRTHS NO UVE BIRTHS SINCE JANUARy 1~,92 I I ) (SFJP TO 458) 402 403 404 CHECK 303 AND 306A: ENTER THE LINE NUMBER FOR EACH LIVE BIRTH ASK THE QUESTIONS ABOUT EACH OF THESE B~RTHS BEGINNING WITH THE LAST BIRTH ({F THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRE} NOW I wou ld l i ke to ask you some quest ions about your ch i ld ren born in the past th ree years . Le t ' s ta lk about one ch i ld a t a t ime. = LINE NUMBER FROM 303 L&ST BIRTH [ ~ 1 NEXT-TO LAST BIRTH I - - ~ UNE NUMBER UNE NUMBER . . . . ! ! = I NAME FROM 304 NAME NAME bo --4 405 When (NAME) WaS born , was he /she : very large, la rger than average , average , smal le r than average , o r very smal l ? 406 Was (NAME) we ighed a t b i r th? i 407 How much d id (he /she) we igh? RECORD W~IGHT FROM HEALTH CARD IF AVAILABLE RECALL . . . . 2 | 408 Was the length o f (NAME) measured a t b i r th? 409 VERy LARGE 1 VERy LARGE . . . . . . . . . 1 LARGER THAN AVERAGE . . . . . . . . . 2 LARGER THAN AVERAGE 2 AVERAGE 3 AVERAGE . . . . . . . . . . . . . 3 SMALL . . . . . . . . . . . . . 4 SMAt~ . . . . . . . . . . . . . . 4 VERy SMALl . . . . . . . . . . . . . 5 VERY SMALL . 5 i DON*T KNOW 8 DON'T KNOW . . . . . . . . . . . . 8 1 i( F YES . . . . . . . . 1 YES 1 NO NO (SKIP TO 408} • ~" CARD . . . . . . . . 1 CARD 1 GRtWIS RECALl 2 DON'T KNOW . . . . 99998 DON'T KNOW . . . . . . . . . . . . . . 99~:38 • ye S 1 • YES 1 • No .o (SKIP TO 41Q I ( (SKJp TO 410) • ! ! I CENTIMETERS ~ CENTIMETERS [ ~ FROM CARD . . . . . . . . . . 1 FROM CARD . . . . 1 What was leng l~ o f (NAME) at birth? CENTIMETERS ~ = ] CENTIMETERS M FROM RECALl 2 FROM RECALL . . . . . . 2 DON'[ KNOW . . . . . . . . . . . . . . . . ~ DON'[ KNOW . . . . . . . . . . . . . gg6 410 L.~ST {}[laTH NEXT.TO.LAST BIRTH Has your period returned since the birth of (NAME)? NAME NAME YES (SKIP TO 412) NO . . . . . . 2 (SKIP TO 413) • 4 1 1 Did your period return between the birth of (NAME) and your next pregnancy? ~ YES 1 NO . . . . 2 (SKIP TO 415) • I 412 For how many months after the birth of (NAME} did you n~ have a pedod? m MOh~r HS I I I I I I DONor KNOW 98 98 413 C NOT I :~NANT [~ PREG I ~ OR IS R ESPON~ENT CURRE ~ UNSURE (SKIP TO 415) 414 415 416 417 Have you resumed sexual realtJons since the birth of (NAME]? YES I NO 2 (SKIP TO 416) • For how many months a f te r the b i r th OI (NAMEI d id yOU n~ have sexua l re la t ions? I I I I I I MONTHS L - -L J . . . . . 98 DOI 98 YrS YES . . . . . . . . . . . . . . . 1 D id you ever b reast feed (NAME)? NO 2 NO . . . . . . 2 (SKIP TO 422) • (SKIP TO 422} ( I LMMED~ATELY . . . . . . . . . . . 000 IMMECqATELY 000 How long a f te r b i r th d id you f i r s t put (NAME) to the breast? . . . . . . . . . HOURS 1 HOUR REC= LESS THAN 24 HOURS, RECORD HOURS OTHERWISE, RECORD 1 DAYS . . . . . . . . . 2 DAYS DAYS 2 b.,,) 418 419 420 421 CHILD CHECK 2"~2:AL[VE? ALIVE L ~ NOT ALIME I ~ ALIVE [ "~ NOT ALIVIE [ ~ ! (SKIp TO 420) (SKIP TO 420) I I I I t s t i l l b reast feed ing (NAME)? yES . . . . . . . . . . . . . . . . 1 Y~S . . . . . . . . . . . . . . . . 1 (SKIP TO 423) • I (SKIp TO 423) • I NO . . . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . . . . . . . . 2 Are you For how many months did you breastfeed (NAME)? I I I I I I MONTHS . . . . . . . . . . . I I I MONTHS . . . . . . I I I DON'T KNOW . . . . . . . 9B DON'T KNOW . . . . . . . 98 Why d id you s top breast /eed ing (NAME)? MOTHER ILL/WEAK . . . . . . . . . . . 01 CHILD I ~ . . . . . . . . . . . . . 02 CHILD DIED . . . . . . 03 NIPPLE pROBLEM . . . . . . . . . . . 04 NOT ENOLIGH MILK . . . . . . . 05 MOTHER W~RKI NG . . . . . . . . . 06 CHILD RtcFUSED . . . . . . . . (]7 WEANING AGFJAGE TO STOP 08 BECAME pREGNANT . . . . . . . . . . . 09 STATED USING CONTRAC EFTfON I0 OTHER 96 (SPECIFY) MOTHER I ~ . . . . . . . . . 01 CHILO ILL /WE~ . . . . . . . . . . . . 02 CHILD DIED 03 NIPPII" PROBkF3~t . . . . . . . . . . . . . 04 NOT ENOI I~H i} l~ . . . . . . . . . 05 I MOTH~ ~RKING . . . . . . . . . 06 CHILD REFUSED . . . . . . . . . . . . . . 07 WEANING AGE/AGE TO STOP 08 BECAME pREGNANT . . . . . . . . 09 STARTED UStNG CONTRAC EFTION 10 OTHER 96 (SPECIFY) 422 LAST BImH NEXT-TO-LAST BIRTH NAME NAME AL'VE E l (SKIp TO 425) (CO BACK TO 405 ALIVE I~ NOT AUVE I~ (SKIP TO 4251 (CO BACK TO 405 OR, IF NO MORE OR, IF NO MORE BIRTHS, GO TO 433) BIRTHS, GO TO 433 FJ 423 I HOW many times did you breastfeed last night between sunset and sunrise? NUMBE'R OF NUMBER OF NK~]TIME M N~TrlME I ~ FEEC~NGS FEEDINGS IF ANSWER IS NOT NUMERIC, pROBE FOR APpRoxiMATE NUMBER 424 425 NUMBE~ OF ~ NUMBER OF HOW many times did you breastfeed yesterday during the daylight hours? OAYTtM E I J I DAYTIM E ~1~ I I I I I I fEEDINGS . . . . . . . . . FEEDINGS . . . . . . . . IF ANSWER IS NOT NUMERtC PROBE FOR APPROXrMATE NUMBER I yE S 1 I YES . . . . . . . . . . . . . . . . . . . . . 1 Did (NAME) drink any~ing from a bol~le with a nipple yesterday or last night? NO 2 NO 2 [X3N~ KNOW . . . . . . . . . . . 8 DON- T KNOW B 426 427 430 At any time yesterday or last night, was (NAME) given any of the following? Water (boiled and not boiled)? Sugar water? Juice? Tea? Baby formula? Milk products (fresh. powdered, tinned milk)? Fermented milk (kefir, airan, kumys, yogurt)? Any other liquids (soups, coca-eola, etc.)? Fruits and vegetables? Any food made from wheat, dce. maize, such as bread, noodles, pasta, etc.? Any food made from potatoes, carrots, or tuber? Eggs, fish, poultry? Meat (lamb, beef, ham, horse meat, etc.)? Sweets, chocolate, cookies, etc.? Any other solid or semi-solid foods? YES NO DK WATER 1 2 SWEET WATER . . . . . . . . . 1 2 JUICE . . . . . . . . . . . . I 2 TEA . . . . . . . . . . . . . . . . 1 2 BABy FORMULA . . . . . . . . 1 2 MILK . . . . . . . . . . . . . . . . 1 2 FERMENTED MILK . . . . . . 1 2 OTHER UOUIDS . . . . . . . t 2 FF~UITS AND VEOETABI FB. 1 2 rOOD MADE FROM GRAIN 1 2 8 POTATOE AND TUBER 1 2 8 EGG/FISH/POULTRY 1 2 8 MFAT . . . . . . 1 2 8 SWEETS 1 2 8 YES NO DK CHECK 426 FOOD C (Aside from breastfeeding,) how many times did (NAME( eat yesterday, including both meals and snacks? IF 7 OR MORE TIMES RECORD 'T SOUD FOODS . . . . . . . . 1 2 8 WATER . . . . . . . . . . . . . . 1 SWEET WATER . . . . . . . 1 JUICE . . . . . . . . 1 TEA . . . . . . . . . . . . . 1 BABy FORMUtA . . . . . 1 MILK . . . . . . . . . . . . 1 FERMENTED MILK . . . . . . 1 2 OTHER UC~JIDS . . . . 1 2 FRur~s AND VEGETABLES 1 2 re'YES'oNE [~ TO "NO/DK" D "YES" ~'~ AL_ TO ONE TO "NO/DK" D ALL ~R MORE OR MORE l I (SKIP TO 4311) | (SKIp TO 43111 NUMBER OF T IMES . . . . . . . . HUNGER OF T IMES. DON~I KNOW B DON~( KNOW . . . . . . 8 FOOD MA~E FROM GF~JN t 2 8 POTATOE AND TUBER . . . 1 2 8 ECG/RSH/POLILT RY 1 2 8 MEAT . . . . . . . . . . . . . 1 2 8 SWFETS . . . . . . . 1 2 8 ! OTHER SOUD OR SEMI= SOUD FOODS 1 2 8 t~ t~O 431 432 L~T BIRTH NAME On how many days during the last seven days was (NAME} given any of the following? Water? Milk and fermented milk products? Any other liquids? Fruits and vegetables? Any food made from wheat, rice, maize, such as bread, noodles, pasta, etc.? Any food made from potatoes, carrots, or tuber? Eggs, fish, poultry? Meat products.? Any other solid or semi-solid foods? RECTO THE NUMBER OF DAYS WATER . . . . . . OTHER UQUIOS P~TA AND GRAIN ECC~/FISH/POU LT RY M~AT OTHER SOUD OR NEXT-TO-LA~ BIRTH NAME RECOAI~ THE NUMBER OF DAYS WATER MILK = I OTHER UQUIDS pASTA AND GRAJN EGG, S/FISH/POULTRY MEAT . . . . . . OTHER SOUD OR . . . . SEMI-SOUO FOOOS GO 13ACK TO ~ IN NEXT COLUMN; GO BACK TO 406 IN NEXT COLUMN; OR IF NO MORE BIRTHS. GO TO 433 OR IF NO MORE BIRTHS, GO TO 433 Sect ion 4B . IMMUNIZAT ION AND HEALTH h.) h.) 3 3 CHECK 403 404 AND 4%8: ENTER UNE NUMBER FOR E~CH UVE BIRTH SINCE J~NUARy 1992 IN THE TABLE IN[3~CATE W~ETHER THE CHILD IS ALIVE OF{ NOT ALNI: ~SK THE QUESTIONS ABOUT EACH OF THESE BIRTHS BEGINNING WITH THE LAST BIRTH [IF THERE ARE MORE THAN 2 BIRTHS USE AD[:4TIONAI QUESTIONN~RE) ! - - | 3 4 LINE NUMBER F ROM 4(~3 LAST BIRTH ~ l qEXT'TO'L~ST BIR~H i I 1 1 I I I UNE NUMBER LINE NUMBER I I I I 3 5 i NAME FROM 404 NNVlE NAME ALIVE ] NOT AUV E [ ~ (GO TO Q 435 IN NEXT COLUMN IF NO MORE BII:~ HS GO TO 458) (GO TO O 435 IN NEXT COLUMN IF NO MORE BIRTHS, GO TO 458) 436 437 Do you have a card where (NAME'S) vacc inat tons are writteN? IF YES: May I see it p lease? Did you ever have a vaccinat ion card for (NAME)? f YES, SEEN (SKIp TO 438) • YES, NOT SEEN . . . . . . . (SKIP TO 44(}) YES 1 {SKIP TO 4401 • ] NO . . . . . . 2 . . . . . 1 ~ YES, SEEN . . . . . . . . . (SKIp TO 438) • 2 ~ YES'(SKI P~T SEENTo 440) . . . . . . . . . .( 3 NO CARD . . . . . . . . . . . YES . . . . . . . . . . . . (SKIP TO 440) • NO . . . . . . . . . . . 17 2 7 3 1 2 - t~ b~ 4~ 438 439 ( 1 ) COPY VACCINATION DATES FOR EACH VACCINE FROM THE CARD (2) WRITE '44' IN 'DAY" COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN SR~OR~D BCG (IMMUNIZATION AC~ N~T TUBERCULOSIS} BCG MANTU pROBE ( 1 2000 DltUTION) MANTU IMMUN[ZAT~ON AGAINST POUOMYEUTIS PO POUO 0 (AT THE HOSPITAL) PI POUO 1 P2 . . . . . POUO 2 FOLIO 3 P3 . . . . . POIJO 4 p4 F~UO 5 p5 ~MMLINIZATIOt4 AG~N~T DSpHTHERIA~ PERTUSS~S, TEl Af~JS ([3~T); OR AGAINST DIPHTHERIA AND T ET/~fUS (OT) DI DPT/DT 1 O2 OPT/DT 2 • D~f/DT 3 D3 • DPT-DT 4 04 . IMMUNIZATION AGAINST MEASLES B(R~ 4EXT-TO-LAST BIRTH NAME MAME DAy MONTH yEAR DAY MONTH yEAR Has (NAME) rece ived any vacc inat ions that a re not recorded on th is card? RECORO "YES" ONLY IF RESPONDENT MENTIONS BCG, POUO 1 . 5 DPT/DT I 4. AND/OR MEASLES VACCINE(S) YES . . . . . . L ~ YES (.OBE FO. V'CC,NAT,ONS. GO - - ("OBEFOR V*CCi.AT,0"S. ~ < q BACK TO 4.38 AM:) WRITE '66" IN THE BACK TO 4.38 ANO WRrTE '66" t N THE NO~RRESPONOIN~ DAy COLUMN) CORRESPON~NG DAy COLUMN) DOi~T KNOW 8 DON'[ KNOW . . . . . . . . . . : (SKIp TO 442) • (SKIp TO 442) • I'0 L~ 140 Did {NAME) ever receNe any vacc inahons to p revent h im(her ) #om d iseases? get t ing I 4 1 P lease te l l me if {NAME) rece ived any o f the fo l low ing vacc inat ions : 4 1 A ' A BCG vacc inahon aga ins t tubercu los i s , that is, an in jec t ion in the arm or shou lder that le f t a scar? I 4 1 E" Po l io vacc ine , that is d rops in the mouth? t 4 1 C • How many t imes? t 4 1 E • When was the f i r s t po l io vacc ine g iven , jus t a f te r b i r~ or la te r? 4 1 E" DPT/DP vacc inat ion , that is, an in jechon usua l ly g iven a t the same t ime as po l io d rops? YES . . . . . 1 yES . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . 2 ~ NO . . . . . . . . 2 - (SKIp TO 442) ( / (SFJP TO 442) • DON'T KNOW 8 J DON" T KNOW . . . . . . . . . . . 8 - YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 DON' [ KNOW . . . . . . 8 DON'T KNOW . . . . . . . . . . 8 = • YES . . . . . . . . . . . . . . . . . . . . . 1 YES . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2~ (SKIp TO 441E) • 1 (SKIp TO 441E} • DONrr KNOW . . . . . . . . . . B DON'T KNOW . . . . 8 NUMBER OF TIMES . . . . . . . . . D NUMBEROFT IMES . . . . . [ ] JUST AFTER BIRTH 1 JUST AFTER BIRTH . . . . 1 LATER 2 LATER 2 YES . . . . . . . . . . . . . . . . . . I YES 1 NO 2 ~ NO . . . . . . . . . . . . . . . 2 m (SKIP TO 441 G) • DON'T KNOW 8 (SKIP TO 441 G) • DON'T KNOW 8 4 1 F How many t imes? NUMBER OF TIMES . . . . . . . . . [ ] NUMBER OF TIMES . . . . . . [ ] I 4 t G An in jec t ion to p revent meas les? YES 1 YES . . . . . . . 1 NO 2 NO . . . . . . . . . . . . 2 DONr l KNOW . . . . . . . . . . . . 8 DON'T KNOW . . . . 8 t~ 442 443 444 445 446 LAST B~RTH N IEXT-TO-L~ BIRTH NAME NAME Has (NAME) been i l l w i th a fever a t any t ime in the las t 2 ~eeeks? Has (NAME) been i l l w i th cough a t any t ime in the las t 2 weeks? When (NAME) was i l l w i th cough, d id he /she breathe fas ter than usua l shor t , fas t b reaths? D id you seek adv ice o r t reatment fo r the cough? Where d id you seek adv ice o r t reatment~ Anywhere e l se? RECORD ALL MENTIONED wi th YES . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . 2 DONT I~OW . . . . . . . . . . . . . . . . . . . 8 DOWT KNOW . . . . . . . . . . . 8 YES 1 YES . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . 2 : . 8 ]&°=" , YES . . . . . . . . . . . . . . . . . . . . 1 YES 1 NO . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 DON~T I<~OW . . . . . . . . . . . . . 8 DO N*T KNC~N . . . . . . . . . . . 8 YES . . . . . . . . . . . . . . . . . . . I YES . . . . . . . . . . . . . . . . . . . t NO . . . . . . . . . . . . . . . . . . . . 2_ I NO . . . . . . . . . . . . 2_ I (SKIp TO 447) • (SKIp TO 447) J( i PUBUC SECTOR PUBUC SECTOR HOSPITAL . . . . . . . . . . . . . . . . . A HOSPtTAL . . . . . . . . . . . . . . . . . A POLyCUNIC . . . . . . . . . . . B pOLYCUNiC . . . . . . . . . . . . . . . . B AMBULATORY . . . . . . . . . . . . . . C AMBULATORY . . . . . . . . C MOBILE CUNIC O MO(31LE CUNK~ O SANITARY DOCTOR E SANITARy DOCTOR E OTHER PUBLIC HEALTH FACtUTY OTHER PUBUC HEALTH FACIUTY F . F (SPECIFY] (SPECIFY) PRIVATE HEALTH SECTOR FRIVAT E HEALTH SECTOR PRIVATE CUNIC . . . . . . . . . G pRIVATE CUNIC . . . . . . . . . G PRNAT E PHARMACy . . . . . . . . H PRIVATE PP, ARMACy H PRIVATE DOCTOR . . . . . . . . . . L OTHER PRIVATE HEALTH FACIUTY J (SPECIFY) SHOP . . . . . . . . . . . . . . . . . . . . K PRIVATE PERSON (NON MEC(CAL) L OTHER x (SPECIFY) PRIVATE DOCTOR . . . . . . . L OTHER PRIVATE HEALTH FAClUTY 3 (SPECtFY) OTHER PRNATE SHOP . . . . . . . . . . . . . K pRIVATE WcRSON (NON MEOW) L OTHER X (SPECIFY) t~ t~ 447 448 449 450 451 452 453 454 Has (NAME) had diarrhea in the last two weeks? Was there any blood in the stools? On the worst day of the diarrhea, how many bowel mowments did (NAME) have? Was he/she given the same amount to drink as before the diarrhea, or more, or less? Was he/she given the same amount food to eat as before the diarrhea, or more, or less? Was (NAME) given rehydron, fluid made from a special packet to drink? Was anything (else) given to treat the diarrhea? YES . . . . . . . . . . . 1 YES . . . . . . . . . . 1 t~3(SKip . . . . . . . . . . . . . . . . . . . TO 457) • 2 = ! NO(SKIp . . . . . . . . . . . . . . . . . . . . . . . . TO 457) ~ 2 -8_ 1[3ONT ~ . . . . . . . . . . 8 CON'T KJ~tOW . . . . . YES . . . . . . . . . . . . . . 1 ~ . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . 2 CON'T KNOW . . . . . . . . . . . . . . . . 8 DON'T ICJ~OW . . . . . . . . . . . . . . 8 NUMBER . . . . . . . . I T ] NUMBER . . . . . . . . . ~] DON'T KNOW . . . . . . . 98 DON' t KNOW . . . . . . . . . . . 98 SAME . . . . . . . . . . . . . 1 5 ,~AE . . . . . . . . . . 1 MORE . . . . . . . . . . . . . . . 2 MORE . . . . . . . . . . . . . . 2 LESS . . . . . . . . . . . . . . . . . 3 LESS . . . . . . . . . . . . . . . . . 3 OON'T KNOW . . . . . . . . . . . . . . . . 8 OONT KNOW . . . . . . . . . . . . 8 SAME . . . . . . . . . . . . 1 S,~ME . . . . . . . . . . . . . 1 MORE . . . . . . . . . . . . . . . . . 2 MORE . . . . . . . . . . . . . . 2 LESS . . . . . . . . . 3 LESS . . . . . . . . . . . 3 DON~ KNOW . . . . . . . . . 8 DON'T ~ . . . . . . . . . 6 YES . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . 2 DON~T KNOW . . . . . . . . . . . . . . . . 8 DON'T KNOW . . . . . . . . . 8 YES . . . . . . . . . . . . . . . . . . . . t YES . . . . . . . . . . . . . 1 What was given to treat the diarrhea? Anything else? RECOF~ALLMENTIONED NO . . . . . . . (SK Ip TO 455) • DON'T KNOW . . . . . RECOMMENDED HOME FLUIC~ . . . . . . A P lLLS OR SYRUP . . . . . . . . B IN JECT ION . . . . . . . . . . . . . . . . . . . C ( IV ) INTRAVENC~S . . . . . . . . . D HOME REMEC~ES/H ERSS . . . . . E OTHER X (SPECIFY) 2 NO . . . . . . . . . . . 2 . (SKI P TO 455) 8 OON% KNOW . . . . . . . . . . 8 • RECO~M ENDED HOME RUIDS A RLLS OR SYRUP . . . . . . . . . . . . B IN JECT ION . . . . . . . . . . . . . . . . . . . C (I V ) INTRAVENOUS . . . . . . D HOME REMEDiES /HERBS . . E OTHER X {SPECIFY) t~ oo 455 456 D id you seek adv ice o r t reatment fo r the d ia r rhea? Where d id you seek adv ice o r t reatment? Anywhere e l se? RECORD ALL MENTIONED U~T BIRTH NEXT-TO.LAST BIRTH NAME NAME YES . . . . . ~ YES . . . . . . . . . . . . . . . . . . . . . . . . . NO 2 . . . . • NO . . . . . . . 2 (SKIP TO 457) ,( ~ ( SKIP TO 457) ~ [ J J DON'T KNOW . . . . 8 DON'T KNOW . . . . . . B I:~JBUC SECTOR PIJBUC SECTOR HOSPITAL . . . . A HOSPI1t~L . . . . . A POLYCUNIC . . . . . . . . B POLYCIJNIC . . . . B AMBULATORY C AMBULATORY . . . . . . . . . C MOBILE CUNIC . . . . . . . . . D MOBILE CUNIO O SANITARy DOCTOR E S ANITARY DOCTOR . . . . . . . E OTHER PUBUC HEALTH FACIUTy OTHER I~JBUC HEALTH FAOIUTY F P {S I~OIFY) (SPECIFY) PRIVATE HEALTH SECTOR PRIVATE HEALTH SECTOR PRIVATE CUNIC . . . . . G I~IVAT E CUNIC . . . . . Q PRIVATE PH~MACY H PRIVATE pHARMACY . . . . . H PRIVATE DOCTOR . . . . I pRIVATE OOCTOR . . . . t OTHER PRIVATE HEALIH FACIUTy OTHER PRIVATE HEALTH FA~IUTY J J (SPECIFY) (SPECIFY) OTHER PRIVATE OTHER PRIVATE SHOP . . . . . . . . . . . . . . . . . . K SHOP . . . . . . . . . . . . . . . . . . K PRIVATE PERSON (NON MEDICAL) L PRIVATE pERSON (NON MEDICAL) L OTHER X OTHER X (SPECIFY) (SPECIFY) 5 7 GO BACK TO 435 IN NE;(T COLUMN: GO BACK TO 435 IN ND~I COLUMN; OR IF NO MORE BIRTHS GO TO 458 OR IF NO MOPE BIRTHS GO TO 458 h,) No. 458 QUEST IONS AND F ILTERS When a ch i ld has d iarrhea, shou ld he /sha be g iven less to d r ink than usua l , about the same amount , o r more than usua l? CODING CATEGORIES LESS TO DRINK . . . . . . . . . . . . . . . . . . . . . . . ABOUT SAME AMOUNT TO DRINK . . . . 2 MORE TO DRINK . . . . . . . . . . . . . . . . . . 3 C~N'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . 8 LESS TO EAT . . . . . . . . . . . . . 1 459 When a ch i ld has d iar rhea, shou ld he /she be g iven less to eat than usua l , about the same amount , o r more than usua l? . . . . . . 2 MORE TO EAT 3 DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . 8 460 When a ch i ld is s i ck w i th d iar rhea, what s igns o f i l l ness wou ld te l l you that he or she shou ld be taken to a hea l th REPEATED WATERy STOOL . . . . . . . . . . . A fac i l i ty o r hea l th worker? REPEATED VOMITING . . . . . . . . . . . . . . . . . . . . C 461 463 RECOROALLMENTIONEO When a ch i ld is s i ck w i th a cough, what s igns o f i l l ness wou ld te l l you that he or she shou ld be taken to a hea l th fac i l i ty o r hea l th worker? RECORD ALl" MENTIONED DOL. B REPEATED VOMITING . . . . . . . . . . . . . . . . . . . . C O BLOOD IN STOOL E HIGH BODY TEMPERATURE F M.ARKED THIRST G NOT EATING/NOT DRINKJ NG WELL . . . . . . . . . . . . . . H V t NOT GETTING BE3~ER . . . . . . . . . J OTHER X (~Pt:~;IPY) DON'T KNO~* . . . . . . . . . . . . . . . . . . . . . Z FAST BREATHING . . . . . . . . . . . . A DIFRCULT BREATHING . . . . . . . . . . . . . . . B NOISY BREATHING . . . . . . . . . . . . . . . . . . . . . . . C HIGH BODy T EM PFJ~ATURE . . . . . . . . . . . . . . . . D UNABLE TO DAINK . . . . . . . . . E NOT EATING/NOT DRINKING WELL F GETTING SICKER/VERy SICK G NOT GETTING BETTER . . . . . . . . . . . . H OTHER X (SPECIFY) DON% KNOW . . . . . . . . . . . Z CHECK 452 ALL COLUMNS NO CHILD RECEIVED REHyDRON y Have you ever heard o f a special p roduct t reatment o f d ia r rhea? ANy CHILD RECEIVEO REHYDRON ca l led rehydron you can get for the I I YES . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 K IP • 501 Sect iQn 5. CONTRACEPT ION Now I would Eke to talk about Conb*a~eption - the ~nous ways or methods that a couple can use to delay or avoid a pregnancy, CIRCLE CODE 1 IN 50t FOR EACH METHOD MENTIONED SPON3"ANEOUSLY THEN pROCEED DOWt~ COLUMN 502, READING THE NAME AND DESRCIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY CIRCLE CODE 2 tF METHOD IS RECOGNIZEO, AND CODE 3 IF NOT RECOGNIZED THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 501 OR 502,ASK 503. 501 Which ways Or methods have you 1 502 Have you heard about? I YES I YES D1 J PiLL women can take a I~II eveq/ day 1 2 t~.ard of {METHOD)? PROBED NO I IUD Womefl can have a I®p or coil i;4aced insK~ i 1 2 them by a doctor. 3 , l 31 IN JECT IONS Women can have an in ject ion by a doctor or nurse WhiCh s~op5 them f rom becoming pregnant fo r severa l months. 1 2 3 I 51 DIAPHRAGM, FOAM, JELLY Women can place a sponge, suppository, d iaphragm, jelly inside 1 2 thems lves be fore in tercourse 3 7 ' 1 503 Have you e~r used (METHOD)? YES 1 NO 2 YES . . . . 1 NO 2 YES . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . 2 YES NO . . . . . . . . . . . ~6 I CONDOM. Men can use a rubber sheath dur ing sexua l in te rcourse . 7 I FEMALE STERIL IZAT ION. Women can ,oi 1 2 operation to avoid haY i~g any more chi ldren. CALENDAR METHOD. Every month that a women LS ~xua l ly actn~ she can a~oid ha,mlg sexual intercourse on the days of the month she is most l ikely to get pregPant. WITHDRAWAL. Men can be care fu l pu l l out be fore c l imax . 1 2 I 2 1 2 I I I Have you heard of any o ther ways or methods that women or men can use to m,o~ pregnancy? (SPECIFy) (SPECIFY( 504 CHECK 503 NO/ A S INGLE "YES" (N EVER USED) YES . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . 2 Have you ever t lad an operat ion to avo id hav ing any more ch i ld ren? YES . . . . . . . 1 NO . . . . . . . . . . . . 2 YES . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . 2 YES . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . 2 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . 2 YES . . . . . . . . . . . 1 NO . . . . . . . . . . 2 I J AT LIE/~.ST ONE *YES" (EVER USED) :1 SKIP TO 50g NO. 505 507 509 510 511 51 51 QUEST IONS AND FILTERS Have you ever used anything or tr ied in any way to delay or avoid gett ing pregnane What have you used or done? CORRECT 503 AND 504* ( AND 502 IF NECESSARY) Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant How many living children did you have at that time, if an~P. IF NONE, RECORD '00' When you first time began to use contraception, did you want to have another child but at a later time, or did you not want to have another child at all? COOING CATEGORIES YES . . . . . . . . . 1 NO . . . . . 2 NUMBER OF CHILDREN . . . . . . I T ] WANTED CHILD LATER DiD NOT WANT ANOTHER CHILD OTHER (SPECIFY) CHECK 503 WOMAN NOT STERILIZED CHECK 227 ? NOT PREGNANT OR r - - i UNSURE Are you currently doing something or using any method to de~y or a~id geeing pregnant? WOMAN STERILIZED I I PREGNANT I I YES . . . . . . 1 NO 2 I: KIP 531 • 514A • 532 • 531 514 514A 515 516 517 518 Which method are you us ing? CIRCLE '07 FOR FEMALE STERILIZATION May I see the package o f p i l l s you are now us ing? RECORD NAME OF BRAND IF PACKAGE IS SEEN Do you know the brand name o f the p i l l s you are now us ing? RECORD How much does one packet o f p i l l s cos t you? Where d id the s ter i l i za t ion take p lace? IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF OF THE pLACE PROBE TO IDENTIFY THE fYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE (NAME OF PLACE) PILLS . . . . . 01 I IUD . . . . . . . . . . . . . . . 0(~ 2 INJECTIONS . . . . . . ) 526 DIAPHRAGM/FOAM/JELLY . . . . CONDOM . . . . . . . . . . . . FEMALE STERIUZATION 07 • 518 ~DAR METHOD 09 • 523 wTr HORAWAL . . . . . . 10 7 • 526 96 J OTHER (SPECtFY) I BRAND PACKAGE SEEN NAME . . . . . I - ~ 1 pACKAGE NOT SEEN 2 B M OON'T KNOW . . . . . . . . . . . . . . . 98 cost 99g6 g998 PUBLIC SECTOR HOSPtTAL . . . . . . . . . 11 FOLYC U NIC . . . . 12 FAMILY PLANNING CUNIC . . . . . . . 13 MOBILE CUNIC . . . . . . . . . 14 OTHER PUBMC HEALTH FAClUTY 16 (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CUNIC . . . . . . . . . . 21 PRIVATE DOCTOR 23 MOBILE CUNIC 24 OTHER pRtVATE HEALTH FACIUTY 26 (SPECIFY) OTHER { SPECIFY) DON'T KNOW . . . . . . 98 • 517 • 526 b~ 4~ No* 519 520 521 523 526 QUEST IONS AND F ILTERS Do you regret that you had the operation not to have any (more) children? Why do you regret the operation? in what month and year was the sterilization performed? How do you determine which days of your monthly cycle not to have sexual relations For how many months have you been using (METHO0} continuously? IF LESS THAN 1 MONTH, RECORD "00" CODING CATEGORIES YES . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . 2 RESPONDENT WANTS ANOTHER CHILD 01 PARTNER WANTS ANOTHER CHILD 02 SIDE EFFECTS 03 CHILD DIED . . . . . . . . . . . . . . . . . . . . 04 OTHER 96 (SPECIFY) MONTH . . . . ~ YEAR . . . . . . . . . . . . . . . . . B~,SED ON CALENDAR . . . . . . . . . . . . 01 BASED ON BODy T EMP~m~ATURE 02 BASED ON CERVICAL MUCUS {BILLING METHOD) 03 B~SEO ON RECTAL TEMPERATURE . . . . . . . . 04 NO SPECIRC SYSTEM . . . . . . . . . . . . . . . . . . . 05 OTHER g6 ( SI:~ECIFY} MONTHS . . . . . . . . . . . . . . [ ~ 8 YEARS OR LONGER . . . . . . . . . 96 SK IP • 521 • 527 ~O 527 528 529 529A CHECK 514 CIRCLE METHO0 CODE: Where did you obtain (METHOD) the last time? iF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF OF THE pLACE PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE (NAME OF pLACE) DO you know another place where you could have obtained (METHOD) the last time? At the time of the sterilization operation, did you know another place where you could have received the operation? I FILLS . . . . . . . . . . . . . . . . . . . . . . . . . . . 01 | IUO . . . . . . . . . . . . . . . . . . . . 02 I INJECI'IONS . . . . . . . . . . . . . . . . . 03 [~/'PH P, AC4~/I:OAM/J ELLY . . . . . . . . . . . . . . 05 CONDOM . . . . . . . . . . . . . . . . . . . . . 06 FEMALE STERILIZATK)N . . . . . . . . . . . . . . 07 CALENDAR METHOD . . . . . . . . . . . . . 09 - - WITHDRAWAL . . . . . . . . . . . . . . . . 10 OTHBC~ gB (SPECIFY) P~BUC SECTOR HOSPITAL . . . . . . . . . . . . . . . . . . . . 11 POLyCUNIC . . . . . . . . . . . . . . . 12 F~t lky PLANNING CUN~ . . . . . . . . . . . 13 MOBILE CUNIC . . . . . . . . . . . . . . . . . . 14 COMMUNITY HEALTH WORKER . . . . . . . . 15 OTHER F~BUC HEALTH FACILrfY 16 (SPECIFY} PRIVATE MEDICAL SECTOR PRNATE HOSPITALJCLJNIC . . . . . . . . . . . 2 t PRIVATE PHARMACY . . . . . . . . . . . . . 22 P'RWAT E DOCTOR . . . . . . . . . . . . . . . 23 MOBILE CUNIC . . . . . . . . . . . . . 24 PRWAT E HEALTH WORKER . . . . . . . . . . . 25 OTHER P'RIVAT E HEALTH FACILITy 26 (SPECIFY) OTHER SOURCE SHOP . . . . . . . . . . . . . . . 31 REUG~OUS~fZAT~N . . . . . 32 FRIENDS/RELAIIVES . . . . . . . . . 33 OTHER 36 (SPECIFY) • 52gA • 53~ YES . . . . . . . . . . . . . . . . . . . . . t NO . . . . . . . . . . . . 2 • 5.34 t'O No. 530 531 QUEST IONS AND F ILTERS CODING CATEGORIES ACCESS-RELATED REASONS CLOSER TO HOME . . . . . . . . . . . . . . . . . . . People se lect the p lace where they obtain cont racept ives for var ious reasons What was the main reason you went to CLOSER TO ~OR K . . . . . . . . . . . . . . . . . (NAME OF pLACE IN Q 526 OR Q 518) instead of the o ther place you know about? AVAJLASIUTY OF TRANSPORT . . . . . . . . . SEFMCE-RELATED R E/~SONS STAFF MORE COMPETENT/FRIENDLY 21 CLEANER FACIL[~' . . . . . . . . . . . . . . . . 22 OFFERS MORE PRIVACy . . . . . . . . . . . 23 RECORD RESPONSE AND CIRCLE CODE SHORTER WAITING TIME 24 LONGER HOURS OF OPERATION 25 USE OTHER SERVICES AT THE FACIIJTY 26 LOWER COST/CHEAPER . . . . . . . . . . . . . . . . . 31 WANTED ANONYMITY 41 OTHER g6 (SPECIFY) DON ~r KN~ 98 What is the main reason you are not using a method o f cont racept ion to avoid pregnancy? NOT MARRIED . . . . . . . . . 11 FERTIUTY=RELAT ED REASONS NO][ I-~A'vING SE~ . . . . . . . . . . . . . . . . . 21 INFREQUENT SEX . . . . . . . . . . . . . . . . . . . 22 MENOP~S,~LfHY'STERECTOMY 23 SU~ND/tNFT:C~JND . . . . . 24 POSTRARTUM/BRI~TFEE~ NG . . . . . 25 WANTS ( MORE)cHILDREN 26 PREGNANT . . . . . . . . . . . . . . . . . . . . 27 OPPOSITION TO USE RESPONDENT OPPOSED . . . . 31 HUSBAND OPPO~) . . . . 32 OTHERS OPPOSED 33 REL]G IC~S PROHIBITION . . . . . . . . . . . . . . . . 34 LACK OF K I ~ I ~ NO MET~ 41 KNOWS NO SOURCE . . . . . . . . . . . . . . 42 ME~HOO RELATED REASONS HEALTH CONCERIk~ . . . . 51 FEAR OF S iDE EFFECTS . . . . . . . . . . . . 52 LACK OF ACCESS/TOO FAR . . . . . . . . . . . . 53 COST TOO MUCH 54 INCONVENIENT TO USE 55 INTE~FERFS W1TH BOOYS NORMAL PROCFSSFS . . . . . 56 OTHE ~R 96 I SK IP 11 - - 12 13 • 534 (SPECIFY) nON'T ~NOW 98 L~ YES . . . . . . . . . . . . . . . . . . . . . . . . 1 I 5 3 2 Do you know of a p lace where you can obta in a method of contracept ion? NO . . . . . . . . . . . . . . . . . . . . . . 2- • 534 533 Where is that? PUSUC SECTOR HOSPITAL . . . . . . . . . . . . . . 11 POLYCUNIC . . . . . . . . . . . . . . . . 12 FAMILY PLANNING CUNIC . . . . . . . . . 13 MOBILE. CUNIC . . . . . . . . . . . . . . 14 COMMUNITY HEALTH W~R;KER . . . . . . . . 15 IF SOURCE IS HOSPITAL, HEALTH CENTER OR CL IN IC WRITE THE NAME OF OF THE PLACE PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE O THER PUBUC HEALTH FAClUTY 16 {SPECtF~f) PR IVATE MEDICAL SECTOR (NAME OF PLACE} PRIVATE HOSPITAI4CU NIC . . . . . . . . 21 pRIVATE PHARr~&Cy . . . . . . . . . . . 22 PRIVATE COCTOR . . . . . . . . . . . . . 23 MOBILE CUNIC . . . . . . . . . . . . . 24 PRIVATE HEALTH W~RKER . . . . . . . 25 OTHER PRIVATE HEALTH FACIUI~f 26 (SPECIFY) OTHER SOURCE REUG~US ORGANIZATION . . . . . 32 FRIEN [~/RFJATIMES . . . . . . . . . . 33 OTHETt 36 (SPECIFY) 534 Were you visited by a health worker who discussed the use of contraception during the last 12 months? YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . 2 I 535 Have you visited a health facili~ for any reason in the last 12 months? YES . . . . . . . . . . . . . . . . . . . 1 2 NO . . . . . . . . . . . . . . . . . . . . • 537 i i 536 Did any staff member at the health facility speak to you about contraception? YES . . . . . . . . . . . 1 I NO 2 ! . . . . . . . . . . . . . . . . . . . I YFS . . . . . . . . . . . . . . . . . . . . . . . . 1 537 Do you think that breast feeding can affect a woman's chance of becoming pregnant? NO . . . . . . . . . . . . . 2 - - ) 601 DON'T KNOW . . . . . . . 8 , I 538 DO you think that a woman's chance of becoming pregnant is increased or decreased by breastfeeding? • 6ol INCREASEr] . . . . . . 1 DECREASED . . . . . . . 2 DEPENDS . . . . . . . . . . 3 OON'T KNOW . . . . . 8 oo No. 540 542 QUEST IONS AND F ILTERS CHECK 208 ONE OR MORE BIRTHS ~ ] ~L Have you ever relied on breastfeecling as a method of avoiding pregnancy? CHECK 227 AND 5~4 NOT PREGNANT OR UNSURE AND NOT STERILIZED Are you currently relying on breastfeeding to avoid getting pregnant? NO ~JlRT HS [ ] EITHER OR PREGNANT ~'~ STERILIZEO CODING CATEGORIES yES 1 NO . . . . . . . . . . . . . 2 YES . . . . . . . . . . 1 NO 2 SK IP • 60 Sect ion 6 . MARRIAGE t~ NO. 601 602 603 604 606 QUESTIONS AND FILTERS PRESENCE OF OTHERS AT THiS I:~[NT Are you currently married or IMng with a man? Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all? Have you ever been married or lived with a man? What is your marital status now: are you widowed, divorced, or separated? I CODING CATEGORIES ISKIP YES NO CHILDREN UNDER 10 1 2 HUSBAND/PARTNER . . . . . . . . . . . . 1 2 OTHER MALES 1 2 OTHER FEMALES . . . . . . . . . . . 1 2 I I CURRENTLY MARRIED . . . . . . . . 1 - - LI'vING W1TH A MAN . . . . . . . 2 - - • 607 / NOT IN UNION . . . . . . . . . . 3 L P REGULAR S EKUAL pARTNER . . . . . . . . . 1 OCCASIONAL SEXUAL pARTNER . . . . . . . . 2 NO SEXUAL pARTNER . . . . . . . . . 3 I I FORMERLY MARRIED 1 NO W~OOWED . . . . . . . . . . . . . . . . 12 - - DIVORCED . . . . . . . . . . SEPARATED 3 - - • 511 • 615 1 • 611 I I 607 IS your husband/par tner l iv ing w i th you now or is he s tay ing e l sewhere? UVES WtrH HER . . . . . . . . . 1 STAYli~IG ELS E~ERE . . . . . . . . . 2 I I 611 Have you been marded or lived with a man only once, or more than once? ONCE . . . . . . . . . . . . . . . . . . . . . . . . 1 MORE THAN ONCE . . . . . . . . . . . . . 2 ho No. 612 QUESTIONS AND FILTERS CH~CK 611 M~qRIEO/IJVED WITH A MAN ONLY ONCE In what month and year did you start living with your husband/partner? MARRIEDJLIVED WITH A MAN ] I MORE THAN ONCE NOW we will talk about your first husband/ partner, In what month and year did you start living with him? CODING CATEGORIES MONTH . . . . . . . . . . . . ~ ' ~ OON*T KNOW MONTH 98 yEAR . . . . . ~ ' ~ DON'T KNOW yEAR . . . . . . . . . . . . . . . 98 SKIP • 615 How old were you when you first had sexual intercourse? 619 When was the last time you had sexual intercourse (if ever)? NEVER 000 DAYS ~ 1 WEEKS AGO . . . . . . . . . . . 2 MONTHS AGO . . . . . . 3 YEARS AGO 4 BEFORE LAST BIRTH 996 AGE . . . . . . . . . . . . . . . . . I ~ RRST TIME WHEN MARRIED 96 Now I need to ask you some questions about sexual activity in order to gain a better understanding of some issues of contraception. 613 How old were you when you started living with him? [ ~ I I I AGE 615 • 712 4:= NO. 702 703 Sect ion 7 . FERT IL ITY PREFERENCES QUEST IONS AND F ILTERS CODING CATEGORIES CHECK 514 WOMAN NOT STERILIZED [ ~ CHECK 227 NOT p~ EG~QAk rr OR UNSURE [ - -1 / 4, WOMAN STERILIZED I I PREGNANT [ ~ 4, HAVE (A/ANOTHER) CHILD . . . . 1 I I NO MORE/NONE . . . . 2 NOW I have some questions about the future. Would you like to have (a/another) child or would you prefer not to have any (more) children? CHECK 227 NOT P~EGNANT OR UNSURE How long would you like to wait from now before the birth of (a/another) child? NOW I have some questions about the future, After the child you are expecting, would like to have another child or would you prefer not to have more children? pREGNANT HOW long would you like to wait after the birth of the child you are expecting before the birth of another child? SAYS SHE CAN~" GET PREGNANT 3 UNDECIDED/OON'T KNOW 8 MONTHS . . . . . . 12 YEARS . . . . . . SOON/NOW . . . . . . . 9 g 3 - - SAYS SHE CAN*T GET PREGNANT g 94 AFTER MARRIAGE . . . . 995 OTHER g96 (SPECIFY) DON'T KNOW . . . . . . . . 998 SK IP • 706 • 704 ~,706 No, ZO5 QUEST IONS AND F ILTERS C NOT PREGNANT OR UNSURE " l I If you became pregnant in the next few weeks , wou ld you be haoDv, unhaDDV, or wou ld it not mat ter very much? CODING CATEGORIES HAPPY 1 . . . . . . 2 WOULD NOT MATTER 3 SK IP FO 4~ t~ 707 708 CHECK 513 USCNG A METHOD? NOT ASKED US ING NOT CURRENTLY CURRENTLY US ING I I YES 1 Do you th ink you w i l l use a method to de lay or avo id pregnancy w i th in the next 12 months? Do you th ink you w i l l use a method a t any t ime in the fu ture? NO . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . 8 YES . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . 8 ,71~ ~, 709 • 710 La5 709 710 Which mett,.od would you prefer to use? What is the main reason that you think you will never use a method? FILLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01 IL,O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02 INJECtOrS . . . . . . . . . . . . . . . . . . . . . . 03 ote, PH R/*GM/FOAM/JELL'," . . . . . . . . . . . . . . . 06 CO#,JOOM . . . . . . . . . . . . . . . . . . . . . . . . . . 06 FEMALE STERILIZATION . . . . . . . . . . . . . . 07 CALENDAR METHOD . . . . . . . . . . . . . . . . . 09 W~THDqRAWAL . . . . . . . 10 OTHER 96 (SPECIFy) UNSURE . . . . . . . . . . g8 NOT M~RRIED . . . . . . . . . . . . . . . . . . 11 FERTIUTY- RELATED REASONS INFREQUENT SE~ . . . . . . . 22 MENOPAUSAL~yST ERECTO MY 23 SUBFECUND/I NP~ECUND 24 WANTS (MORE)CtHILDREN 2 6 OPPOSITION TO USE RESPONDENT OPPOSED . . . . . . . . . . . . . . . . . . 31 H USl3/~*ql3 OPPOSED . . . . . . 32 OTHERS OPPOSED . . . . . . . 33 REUGIOUS PROHIBITION . . . . . . . 34 LACK OF KNOWLEDGE KN~ NO METHOD 4 1 NO SOURCE 4 2 METHOD RELATED REASONS HEALTH CONCERNS 51 FEAR OF SiDE EFFECTS 52 LACK OF ACCESS/TOO FAR 53 COST TOO MUCH 54 INCONVENIENT TO USE 55 INTERFERES WITH BODY'S NORMAL PROCESSES 56 OTHER 96 (SPECIFY) ~ON~r KNOW 98 • 7 t2 • 7~2 CODING CATEGORIES |SK IP t~ 4~ 4~ No. 711 712 713 QUEST IONS AND FILTERS Would you ever use a method if you were married? CHECK 2L~2 HAS Ll~/~ NG CHILDREN If yOU could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be? PROBE ~OA A NUMERIC RESPONSE I-3 N£ If you Gould choose exactly the number of children to have in your life, how many would that be? I--I Row many of these children would you like to be boys, how many would you like to be girls and for bow many would it not matter? YES 1 NO 2 I~N'T KNOW 8 NUMBER . . . . . . . ~- -~ OTHER 96 {SPECIFY) BOYS NUMBER . . . . . . . ~ ' ~ OTHEA 96 (SPECIFY) GII~S NUMBER [ ~ OTHER ,96 (SPECIFY) EITHER NUMB ~1 ~ OTHER 96 (SPECIFY) • 714 714 715 716 Wou ld you say that you approve or d i sapprove o f coup les us ing a method to avo id get t ing pregnant? Is it acceptab le or not acceptab le to you for in fo rmat ion on cont racept ion to be prov ided: On the rad io? On the te lev i s ion? In the las t few months have you heard about cont racept ion : On the rad io? On the te lev i s ion? In a newspaper or magaz ine? F rom a poster? F rom lea f le ts or b rochures? APPROVE . . . . . 1 D~SAPPR Or1: . . . . . . . . . . . 2 NO OPt NION . . . . . . . . . . . . . . . . . . . . . . . 3 ACCEP- NOT ACCEP- DK IONED 718 In the last few months have you d i scussed cont racept ion w i th your f r iends , ne ighbors , o r re la t ives? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . 2 • T2 : I I 719 Wi th whom? Anyone e l se? HUSBAND/PArtNER A MOTHER . . . . . . . . . . . . . . . . . . B FATHER C ~STER(S) . . . . . . . . . . . . . . . . . . . . . . D BROTHER(S} E DAUGHTER F MOTHER-IN-LAW . . . . . . . . . . . . . . . . . . . G FRIENDS/NEIGHBORS H OTHER X (SPECIFY) YES NO RA~O . . . . . . . . . . . . . . 1 2 TELE~SION . . . . . . . . . . . . . . . . 1 2 NEWSPAPER OR MAGAZINE . . . . . 1 2 POSTER . . . . . . . . . 1 2 ~ E R S O~ BROCHURES 1 2 RADIO . . . . . . . . . I 2 8 TF~SION . . . . . . I 2 B TABLE TABLE 4~ NO. I QUESTIONS AND FILTERS I CODING CATEGORIES 721 CHECK 60~ CURRENTLY MARRIED LIVtNG ? WITH A MAN / II NOT IN UNION I I Spouses/partners do not always agree on everything. Now I want to ask you about your husband's/partner's views on contraception. Do you think that your husband/partner approves or disapproves of couples using a method to avoid pregnancy? APPROVES . . . . 1 DISAPPROVES 2 DON% KNOW 8 722 How often have you talked to your husband/partner about contraception in the past year? NEVER 1 ONCE OR T~CE 2 MORE OFTEN 3 SAME NUMBER . . . . . 1 723 Do you think your husband/partner wants the same number of children that you want, or does he want more or fewer than you want? MORE CHILDREN 2 FEWER CHlU~EN 3 CON~r KNOW 6 SK IP Sect ion 8. HUSBAND'~ BACKGROUND AND WOMAN'~ WQRK No. I QUESTIONS AND FILTERS I CODING CATEGORIES 802 CHECK 602 AND 604 CURRENTLY MARRIED/ ? LIVING WITH A MAN FORMERLY MARRIED/ LIVED WITH A MAN I I INNEVERuNIO NMARRIED AND NEVER I I AGE . . . . . . [ ~ ;K iP ) 803 • 809 How old was your husband/partner on his last birthday? Did your (last) husband/partner ever attend school, technikum, or institute? YES 1 NO . . . . . . . . . . . 2 • 806 PRIMARy/SECONDARy . . . . . . . . . . . . . . . . . . . 1 What was the highest level of school he attended? SECONDARy- SPt:CtAL 2 HIGHER 3 DON'T KNOW 8 • ~06 How many years /c lasses/courses he completed at that level? YEARS I DON'T K.NOW . . . . . . . . . . . . . . . . . . . . . 98 What is (was) your ( las t )husband/par tner ' s occupat ion? That is, what kind of work does (did) he mainly do? CHECK 806 WORKS (WORKED} IN AGRICULTURE (Does/did) your husband/partner work mainly on the state or on family land, or (does/did) he rent land? DOES(DID) NOT WORK IN AGRICULTURE I I land or on his own ~and, STATE LAND . . . . . . . . . . . . . . . . 1 OWN LAND 2 FAMILY LAND 3 REi~rT ED LAND . . . . . . . . . . . 4 bO 4~ co No. QUEST IONS AND F ILTERS Aside f rom your own housework, are you currently working? iF NOT Are you on maternity leave? As you know, some women take up jobs for which they are paid in cash or kind. Others self things, have a small busiess or work on the family farm or in the family business. /~e y3u cunerdly doing any of 'these thugs or ~y o¢~- vccW? Have you done any work in the last 12 months? What is your occupaf~on, that is, what kind of work do you mainly do? CODING YES NO . . . . MJ~TEP~ CATEGORIES YES . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . 2 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . 2 I-r-I 1 ISK IP )-812 2 3 ) 812 CHECK 812 WORKS IN AGRICULTURE ~ DOES NOT WORK IN AGRICULTURE ~'~ 4, DO you work mainly on the state land or on your own land, or on family land, or do you rent land? STATE LAND . . . . . 1 OWN LAND 2 FAMILy LAND 3 RENTED LAND . . . . . . . . . . 4 }-812 -~'826 815 4~ 8t5 816 Are you public servant, owned by yourself, your se l f -employed? DO you usually work wh i le (ep isod ica l ly )? or do you work on state enterprise, a prvate f irm or enterprise husband, member of your family, or by someone else, or are you year, or do you w~rk seasonally, or only once in a GOVERNMENT/STATE ENTERPRISE . . . . . 1 FAMILY/OWN BUSINESS . . . . . . . . . 2 pRrVATE RRM/PERSON . . . . . . . . . . . . 3 SELF-EMPLOYEO . . . . . . . 4 throughout the THRC~GJdC~T THE yEAR 1 ~ 81 i SEASONALLy . . . . . . . . . . . . . 2 I I ONCE IN A WHILE (EPISO[~CALLY) . . . . . . . . . 3 • 81! 8 1 7 During the last 12 months, how many months did you work? NUMBER OF MONTHS . . . . . . . . . . . 8 1 8 (In the months you worked,) How many days a week did you usually work? D • 82( NUMBER OF DAYS . . . . . . . . . . . . . . . . . . . 8 1 9 During the last 12 months, approximately how many days did you work? NUMBER OF DAYS ~ j 820 YES . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . 2 Do you earn cash for your work? PROBE: DO YOU MAKE MONEY FOR WORKING? 82 t~ No, 822 823 QUESTIONS AND FILTERS CHECK 602 CURRENTLy MARRIED/ ~ NOT MARRIED, UVlNG W1TH A MAN ~ NOT LIVING WITH A MAN WhO main ly dec ides how the money you earn Who main ly dec ides how the wi l l be used: you, your husband/par t~er , you money you earn wi l l be used: CODING CATEGORIES RESPONDENT DECIDES . . . . . . . . . . . . . 1 HUSBAND/PARTNER DECIOES . . . . 2 JOINTLY WITH HUSEu~ND/PART NER . . . . . . . . 3 SOMEONE ELSE DECIDES . . . . . 4 and your husband/par tner jo in t ly , someone you, someone else, or you and e l se ,o r you and someone e l se jo int ly? someone e l se jo in t ly? Do you usual ly work a t home or away ITOm home? JOINTLY W1TH SOMEONE ELSE . . . . . . . . . . 5 HOME . . . . . . . 1 AWAY . . . . . . . . . . . 2 824A 825 826 CHECK 223: IS THERE A CHILD WHO IS AGE 5 OR LESS? YES ? Does (NAME O~- yOUNGEST CHILD) l ive wi th you? Who usual ly takes care o f (NAME OF YOUNGFST CHILE) AT HOME) whi le you are work ing? NO t - - I 1 YES NO . . . . . . . . . . 2 RESPONDENT . . . . . . . . 01 HUS~ND/~PARTNER . . . . . . 02 OLDER FI~4ALE CPIILD . . . . . . . . . . 03 OLDER MALE CHILD . . . . . . . . . . . 04 OTHER RELATIVES . . . . . . . 05 NEIC4,48(X'~S . . . . . . 06 FI~FJ*IDE5 . . . . . . . . . . . . . . O l BABy S I~ER . . . . . . . . . . . 08 CHILD IS IN CHILDCARE . . . . . 10 HAS NOT WORI~ED SINCE LAST B~RTH 95 OTHER 96 (SPECIFY) R ~ THE TIME. HOUR . . . . . . . . [ ~ I I I MINUTES . . . . . . . . . . SKIP )B26 > 826 ANTHROPOMETRY AND HEMOGLOBIN MEASUREMENT IN THE BLOOD I,,o Section 9. HEIGHT AND WEIGHT IN 901 AND 902 RECORD HEIGHT AND WEIGHT OF THE RESPONDENT 901 RES PONDS*CT'S HEIC~HT (IN C ENTIM ET ER S ) I *~ I . D 902 RESPONDENT'S WEK~HT (IN KILOGR&MS) [~- - - - '~ , ~ L~ t~ 903 RESULT ~EASURED . . . . . . . 1 MOT MEASURED 2 ~EFUSED . . . . . . . . . . . 3 3THER 6 (SPECIFY} CHECK 435 ONE OR MORE UV1NG CHILDREN ~ NO LJV1NG CHILDREN BORN SINCE JANUARY 1992 I I BORN SINCE JANUARY 1992 I q 1 IN 905 RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE JANUARY 1992 AND STILL ALIVE IN 906 AND 907 RECORD THE NAME AND BIRTH DATE OF THE LIVING CHILDREN IN 90g AND 911 RECORD HEIGHT AND WEIGHT OF THE LIVING CHILDREN iF THERE ARE MORE THAN TWO LIVING CHrLDREN BORN SINCE JANUARY 1992 USE ADDITIONAL FORMS • 1001 905 906 907 ] YOUNGEST LIVING CHILD L~J NEXT-TO-YOUNGEST LIVING CHILD UNE NUME~-R FROM 434 ~ NaME FROM 435 DATE OF BIRTH FROM 2~5 AND ASK FOR DAy OF BIRTH (NAME) DAY MONTH . . . . . . . . . yEAR . . . . . . . . . . (NAME) DAy . . . . . . . . . . MONTH YEAR L / I L,O 908 BCG SCAR ON TOP OF SHOULDER NO SCAR . . . . . . . . . . . . . . . 1 NO SCAR . . . . . . . . . . . . . . . . . . . . 1 SCAR 1 . 4 mrn . . . . . . . . . . . . . 2 SCAR 1 . 4 mm . . . . . . . . . . . . . . . 2 SCAR 5 mm AND MORE . . . . . . . . . . . . . 3 SCAR 5 mm AND MORE . . . . . . . . . . . . 3 909 HOGHT (IN CB~ITIMETERS) D FTA.S 910 w/~s LENGTH/HEIGHT OF CHILD M E&S~RED L~ING DOWN OR STANDING UP? LYING . . . . . . . . . . . . . 1 LYING . . . . . . . . . . . . . . . . 1 STANDING . . . . . . . . . . . . 2 STANDING . . . . . . . . . . . . . 2 911 tNEIGHT (IN I'JLOGRAMS ) ~ 1 ~ o ~ ~ . I ~ 912 DATE WEIGHED AND MEASURED DAY . . . . . . . . . . . . . . . . . . DAy . . . . . . . . . . . . . . . . . . . . MONTH . . . . . . . . . . . . . . . . . MONTH . . . . . . . . . . . . . . . . . . YEAR . . . . . . . . . . . . . . YEAR . . . . . . . . . . . . . . . . MEASURED . . . . . . . . . . . . . . 1 913 f~SUI-T CHILD IS SICK . . . . . . . . . . CHILD NOT PRESENT . . . . . . . CHILD REFUSED . . . . . . . . . . . MOTHER REFUSED . . . . . . . . . . . . OTHER (SPECIFY) MEASURED . . . . . . . . . . . . . . CHILD IS SK3K . . . . . . . . . . . . . CHILD NOT PRESENT . . . . . . . . . . . . . . . . CHILD REFUSED . . . . . . . . . MOTHER REFUSED . . . . . . . . . . . . . O f HER (SPECIFY) 914 NAME OF ME&SURER NAME OF ASSISTANT: i - ~ K, aaai<craH Pecrry6nnxacr~zrm~ YJ fF Ib lK ~hI2~IM AKa~eMH.qCbl TAFAMTAHY HHCTHTYTbI Ha[]~4OHaJTbHa,q AKa~CM]4~] HayK Pe cny6.rml, a4 Ka3axcran HHCTH'rYT HI4TAHI'I/I 12eHrp Corpy~Inqa Io~ CO BCeMh'pHOB Opr'aHI,13alJI4efl 3,apanooxpaHeHV6/ 199m Dear Respondent: The Institute of Nutrition is conducting Demographic and Health Survey in Kazakhstan. As part of this program we study the .prevalence of anemia among the women and their children. We ask you to particxpate in this program, which will assist the Ministry of Health of Kazakhstan to develop the specific measures to prevent and treat anemia. Anemia is a disease, which is characterized by a low count of red blood cells. It results from poor nutrition and can be especially damaging to the health of pregnant and breastfeeding women. Today, it is possible to rapidly (within a few minutes) diagnose this disease. A low level of hemoglobin (less than 11 g/dl) can be determined by a Hemocue machine on the basis of a single drop of blood. If you decide to participate in this program, we will ask you to provide a drop of blood from your finger for the analysis. Also, if you have a child of age 3 or less, please let our nurse to obtain drop of blood from him. The procedure will be done by sterile instruments. The blood will be analysed using the new sophisticated American equipment, Hemocue. The result of analysis wdl be available to you right after the blood is taken and assessed by Hemocue. We will also keep the results confidential. If you decide to participate in this program, please sign at the bottom of this form that you agree to provide a drop of blood from your child. If you decide not to participate, it is your right, and we will respect your choice. I am Last name, First name Middle name agree to donate a drop of blood for the purpose of anemia diagnosis. I also allow a drop of blood to be taken from my child(children) for the purposes of anemia diagnosis. Signature Date 480908 Pect~y5:[rtKa Ka3axcTatt, r. A.,qMaTbL y,~ K-10,tKoaa 66. Te.1 (3272)429-203, ~aaKc, (3272)420-720 Pac.ier/lbl.q CqeT 000608602 a A,qMa'rHIICKOM o6,1yrtparcleltnH HatIHOHa:IbHoro 6aHKa (Ka3axcTaH), KOa 190501109, MdaO 61803 255 Sect ion 10 . HEMOGLOBIN MEASUREMENT IN THE BLOOD ALL INTERVIEW1ED WOMEN ARE ELIGIBLE FOR HEMOGLOBIN MEASUREMENT iN 1001 RECORD RESPONDENT'$ HEMOGLOBIN LEVEL ¢J= 1001 10~ RESPON[~ENT'$ HEMOGLOBIN LEVEL (G/DL) PESULT CHECK 435 CT1 I-] MEASURED . . . . . . . . . . . . . . . . t NOT MEASURED . . . . . . . . . . . . . . . . . . . . . . . . 2 REFUSED . . . . . . . . . . . . 3 OTHER 6 (SPECIFY) ONE OR MORE Lrv] NO CHILDREN BORN SINCE JANUARY |~2 I I NO U~NG CHILDREN BORN SIN(]EJ,e,,NUARyIgg'2 1 J ?_ 1009 IN 1004 RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE 3ANUARY lgg2 AND STILL ALIVE IN 1005 RECORD THE NAMES OF THE LIVING Clt~LDREN IN ~006 RECORD THE HEMOGLOBIN LEVEL IN THE BLOOD OF THE LIVING CHILDREN IF THERE ARE MORE THAN TWO L~VING CHILDREN BORN SINCE JANUARY lgg2 USE ADDITIONAL FORMS ] YOUNGEST LIVING CHILD [ ] NEXT 'TO 'YOUNGEST L IVING CHILD 1004 UNE NUMBER FROM 434 ~ [ ~ 10(~ NAME FROM 435 [NAME) (NAME) 1007 F~SULT MEASURED 1 CHILD IS SICK . . . . . . . . . . . . . . 2 CHILE) NOT PRESENT 3 CHILD REFUSED 4 MOTHER REFUSED 5 OTHER 6 (SPECIFY) MEASURED . . . . . . . . . . . . . . . . . . . . CHILD IS SICK . . . . . . CHILD NOT PRESENT . . . . . . CHILD REFUSED . . . . . MOTHER REFUSED . . . . . . . . . . OTHER (SPECIFY) 1008 NAME OF MEASURER ~ F ~ ~ ' ~ NAME OF ASSISTANT 1009 CHEC~ 1001 AND 1006 NO VALUES BELOW 7 G/DL ONE OR UO"E VALUE BELOW • G/DL J J • CONSENT FORM NO 2 I'O RECORD THE RESULTS OF HEMOGLOBIN MEASUREMENT, TEAR OFF HERE AND PRESENT THIS PORTION TO THE RESFONDENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INSTITUTE OF NUTRITION RESULTS OF HEMOGLOBIN MEASUREMENT IN THE BLOOD Date Hemoglobin leve Name Respondent WHO CLASSIFICATION OF ANEMIA Normal level Hb lewel ~ 11 G/DL Mild anemia Hb (10-11G/DL) Moderate anemia Hb (7-10 G/DL) Severe anemia Hb (less than 7 G/DL) (G/DL) i Normal level Mild anemia Moderate anemia Severe anemia I- lq YOU have Lastch~d Normal level Mild anemia Moderate anemia Severe anemia 1995 Next-to-youngest child [-I-11-1 Normal level Mild anemia Moderate anemia Severe anemia In case of severe anemia (Hb level less than 7 G/DL), we recommend you to immediately co.act your doctor. If you have any question about hemoglobin measurement wocedure, please call us at (3272)429-111, or write to: Department of the National Nutrition Policy, Institute of Nutrition, 66 Klotchkov St., AImaty, Kazakstan, 480008 I~t.~KCTaH Pe c~co1~<.ac~Ii-m~ YJt rlbIK ~bIJI~IM AI~q~eMI.'I.qCbI TAFAMTAHY HH bI O l-la/.l~lOHa2/bHag AKadleMH~ HayK Peeny6Jm~a~ Ka~axCTaH HHCTHTYT I I I / I TAHI4} I Hemp CoTpyz~n~qa~otam~ co BCeMI4pHoI~ Oprai-iH3aui4eltt 3~paBooxpa/-leH/4yl 159 Dear Respondent: We detected the low level of hemoglobin in your (your child's) blood. This indicates that you (your child) have developed severe anemia, which is serious health problem. We would like to inform about this the doctor at health care facility in your area. That would help you to meet appropriate further diagnosis and treatment of your (your child's) condition. If you agree with this please sign at the bottom of this form. Thank you for your cooperation. Iam Last name, First Name, Middle Name agree that the information about the level of hemoglobin in my (my child's) blood will be disclosed to the doctor at the local health care facility. Signature Date . . . . 1995 480008 Pecm]6.1HKa I¢~3aXCTaH, r. A.rtMaTr~Z. y~. K:~oqKoBa 66. Te.~. (3272)429-203, CaKe. (3272)420-720 Pacqentbl~ c~Jcr 000608602 a A~MaVHHCr<OM o6~ynpaaaeHHH HanHo~tanbHoro 6aHKa (Ka3aXCTaH), KO2I 190501109, M(DO 61803 259 COMMENTS Comments about Respondent: Comments on Specific Quesf~ons: Any Other Comments: b~ O~ SUPERVISOR'S OBSERVATIONS Name of Superwsor: EDITOR'S OBSERVATIONS Date Name of Editor Date Front Matter World Summit for Children Indicators: Kazakstan 1995 Title Page Citation Page Table of Contents List of Tables List of Figures Contributors Preface Summary of Findings Chapter 1 - Introduction Chapter 2 - Characteristics of Households and Respondents Chapter 3 - Fertility Chapter 4 - Contraception Chapter 5 - Induced Abortion Chapter 6 - Other Proximate Determinants of Fertility Chapter 7 - Fertility Preferences Chapter 8 - Infant and Child Mortality Chapter 9 - Maternal and Child Health Chapter 10 - Nutrition of Women and Children Chapter 11 - Anemia References Appendix A - Sample Design Appendix B - Estimates of Sampling Errors Appendix C - Data Quality Tables Appendix D - Persons Involved in the 1995 Kazakstan Demographic and Health Survey Appendix E - Questionnaires Household Schedule Questionnaire Individual Woman's Questionnaire

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