Kenya - Demographic and Health Survey - 2004

Publication date: 2004

Demographic and Health Survey Kenya 2003 K enya 2003 D em ographic and H ealth Sur vey Kenya Demographic and Health Survey 2003 Central Bureau of Statistics Nairobi, Kenya Ministry of Health Nairobi, Kenya Kenya Medical Research Institute Nairobi, Kenya National Council for Population and Development Nairobi, Kenya ORC Macro Calverton, Maryland, USA Centers for Disease Control and Prevention Nairobi, Kenya July 2004 British Department for International Development United Nations Population Fund Centres for Disease Control and Prevention United Nations Development Programme ORC Macro U.S. Agency for International Development United Nations Children’s Fund Japan International Cooperation Agency This report summarises the findings of the 2003 Kenya Demographic and Health Survey (2003 KDHS) carried out by Central Bureau of Statistics in partnership with the Ministry of Health and the National Council for Population and Development. ORC Macro provided financial and technical assistance for the survey through the USAID-funded MEASURE DHS+ programme, which is designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. The Centres for Disease Control and Prevention (CDC) provided technical and financial support on the HIV component of the survey. Additional funding for the KDHS was received from the United Nations Population Fund (UNFPA), the Department for International Development (DFID/U.K.), the Government of Japan through a fund managed by United Nations Development Programme (UNDP), and the United Nations Children’s Fund (UNICEF). The opinions expressed in this report are those of the authors and do not necessarily reflect the views of the donor organisations. Additional information about the survey may be obtained from Central Bureau of Statistics (CBS), P.O. Box 30266, Nairobi (Telephone: 254.20.340.929; Fax: 254.20.333.030; Email: director@cbs.go.ke). Additional information about the DHS programme may be obtained from MEASURE DHS+, ORC Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, U.S.A. (Telephone: 301.572.0200; Fax: 301.572.0999; Email: reports@macroint.com). Recommended citation: Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro. Contents | iii CONTENTS Page Tables and Figures . ix Foreword. xvii Summary of Findings . xix Map of Kenya . xxiv CHAPTER 1 INTRODUCTION Fredrick Otieno and Silas Opiyo 1.1 Geography, History, and the Economy.1 1.2 Population.2 1.3 Population and Family Planning Policies and Programmes .3 1.4 Health Priorities and Programmes.4 1.5 Strategic Framework to Combat the HIV/AIDS Epidemic.5 1.6 Objectives and Organisation of the Survey.6 1.7 Survey Organisation.7 1.8 Sample Design.7 1.9 Questionnaires .7 1.10 HIV Testing.9 1.11 Training .9 1.12 Fieldwork .10 1.13 Data Processing .11 1.14 Response Rates.11 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Francis M. Munene 2.1 Household Population by Age and Sex .13 2.2 Household Composition .15 2.3 Educational Attainment of Household Members .16 2.4 Housing Characteristics.21 2.5 Household Durable Goods .25 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS AND WOMEN’S STATUS Godfrey K. Ndeng’e 3.1 Background Characteristics of Respondents .27 3.2 Educational Attainment and Literacy.27 3.3 Access to Mass Media .32 3.4 Employment .35 iv | Contents 3.4.1 Employment Status .35 3.4.2 Occupation .37 3.4.3 Type of Employer, Form of Earnings, and Continuity of Employment .39 3.4.4 Control Over Earnings and Women’s Contribution to Household Expenditures.40 3.5 Women’s Empowerment .42 3.5.1 Women’s Participation in Decisionmaking.42 3.5.2 Women’s Attitudes Towards Wife-Beating .44 3.5.3 Attitudes Towards Refusing Sex with Husband.47 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS Collins Opiyo 4.1 Introduction .51 4.2 Current Fertility .51 4.3 Fertility Trends.54 4.4 Children Ever Born and Children Surviving .57 4.5 Birth Intervals .58 4.6 Age at First Birth .59 4.7 Teenage Fertility .60 CHAPTER 5 FAMILY PLANNING Samuel Ogola and Salome Adala 5.1 Knowledge of Contraceptive Methods .63 5.2 Ever Use of Contraception .65 5.3 Current Use of Contraceptive Methods.66 5.4 Trends in Contraceptive Use.68 5.5 Differentials in Contraceptive Use By Background Characteristics .70 5.6 Current Use of Contraceptives by Women’s Status .72 5.7 Timing of First Use of Contraception.73 5.8 Use of Femiplan Social Marketing Pill Brand .74 5.9 Knowledge of the Fertile Period.74 5.10 Source of Contraception.75 5.11 Informed Choice .76 5.12 Contraceptive Discontinuation.78 5.13 Future Use of Contraception.79 5.14 Reasons for Not Intending to Use.80 5.15 Preferred Method for Future Use .80 5.16 Exposure to Family Planning Messages.81 5.17 Contact of Nonusers with Family Planning Providers.84 5.18 Discussion of Family Planning between Couples .85 5.19 Attitudes of Respondents Towards Family Planning.85 Contents | v CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Alfred Agwanda 6.1 Introduction .89 6.2 Marital Status.89 6.3 Polygyny.90 6.4 Age at First Marriage .92 6.5 Age at First Sexual Intercourse .94 6.6 Recent Sexual Activity.96 6.7 Postpartum Amenorrhoea, Abstinence, and Insusceptibility .99 6.8 Termination of Exposure to Pregnancy. 101 CHAPTER 7 FERTILITY PREFERENCES Murungaru Kimani 7.1 Desire for More Children. 103 7.2 Need for Family Planning Services . 105 7.3 Ideal Family Size. 107 7.4 Wanted and Unwanted Fertility. 109 7.5 Ideal Family Size and Unmet Need by Women’s Status . 111 CHAPTER 8 INFANT AND CHILD MORTALITY Fredrick Otieno and Christopher Omolo 8.1 Levels and Trends in Infant and Child Mortality . 114 8.2 Socioeconomic Differentials in Infant and Child Mortality. 115 8.3 Demographic Differentials in Infant and Child Mortality . 117 8.4 Differentials in Infant and Child Mortality by Women’s Status. 118 8.5 Perinatal Mortality . 119 8.6 High-Risk Fertility Behaviour. 121 CHAPTER 9 MATERNAL AND CHILD HEALTH George Kichamu, Jones N. Abisi, and Lydia Karimurio 9.1 Antenatal Care. 123 9.2 Delivery Care . 129 9.3 Postnatal Care . 134 9.4 Reproductive Health Care and Women’s Status. 135 9.5 Vaccination of Children . 136 9.6 Acute Respiratory Infection and Fever. 140 9.7 Diarrhoeal Disease . 142 9.8 Child Health Indicators and Women’s Status . 147 9.9 Birth Registration . 148 9.10 Knowledge of Signs of Illness . 149 9.11 Smoking and Alcohol Use. 150 vi | Contents CHAPTER 10 NUTRITION John O. Owuor and John G. Mburu 10.1 Breastfeeding and Supplementation. 153 10.2 Micronutrient Intake. 159 10.3 Nutritional Status of Children Under Five. 163 10.4 Nutritional Status of Women . 168 CHAPTER 11 MALARIA Kiambo Njagi and Eric Were 11.1 Malaria Control and Prevention Strategies in Kenya . 171 11.2 Household Ownership of Mosquito Nets . 171 11.3 Use of Mosquito Nets . 173 11.4 Intermittent Preventive Treatment of Malaria in Pregnancy . 175 11.5 Malaria Case Management among Children. 178 CHAPTER 12 HIV/AIDS RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR James N. Muttunga, Robert C. B. Buluma, and Boaz K. Cheluget 12.1 Introduction . 183 12.2 Knowledge of AIDS and HIV Transmission. 184 12.3 Stigma Towards HIV-Infected People. 191 12.4 Perceived Risk of Getting AIDS . 193 12.5 Multiple Sexual Partnerships . 196 12.6 Testing and Counselling for HIV. 197 12.7 Attitudes Towards Negotiating Safer Sex . 199 12.8 Condom Use at Higher-Risk Sex . 200 12.9 Paid Sex and Condom Use . 202 12.10 Attitudes Towards Condoms . 203 12.11 Condom Brands . 205 12.12 Self-Reporting of Sexually Transmitted Infections . 205 12.13 Male Circumcision. 207 12.14 Age at First Sex Among Youth . 209 12.15 Knowledge of Condom Sources Among Youth . 210 12.16 Condom Use at First Sex Among Youth. 211 12.17 Premarital Sex . 212 12.18 Higher-Risk Sex and Condom Use Among Youth . 214 12.19 Age-Mixing in Sexual Relationships . 215 12.20 Orphanhood and Children’s Living Arrangements. 215 CHAPTER 13 HIV PREVALENCE AND ASSOCIATED FACTORS Lawrence Marum, James N. Muttunga, Francis M. Munene, and Boaz K. Cheluget 13.1 Coverage of HIV Testing . 220 13.2 HIV Prevalence. 223 Contents | vii 13.3 Distribution of the HIV Burden in Kenya. 232 CHAPTER 14 ADULT AND MATERNAL MORTALITY Christopher Omolo and Paul Kizito 14.1 Data . 233 14.2 Estimates of Adult Mortality . 234 14.3 Estimates of Maternal Mortality . 236 CHAPTER 15 GENDER VIOLENCE Betty Khasakhala-Mwenesi, Robert C.B. Buluma, Rosemary U. Kong’ani, and Vivian M. Nyarunda 15.1 Introduction . 239 15.2 Data Collection. 239 15.3 Violence Since Age 15 . 241 15.4 Marital Violence . 243 15.5 Frequency of Spousal Violence . 245 15.6 Onset of Spousal Violence Against Women. 246 15.7 Physical Consequences of Spousal Violence. 247 15.8 Violence Initiated by Women against Husbands . 248 15.9 Violence by Spousal Characteristics and Women’s Status Indicators. 248 15.10 Female Genital Cutting . 250 REFERENCES . 253 APPENDIX A SAMPLE IMPLEMENTATION . 257 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 263 APPENDIX C DATA QUALITY TABLES. 279 APPENDIX D PERSONS INVOLVED IN THE 2003 KENYA DEMOGRAPHIC AND HEALTH SURVEY. 285 APPENDIX E QUESTIONNAIRES . 289 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators. 3 Table 1.2 Results of the household and individual interviews . 12 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 14 Table 2.2 Household composition. 15 Table 2.3.1 Educational attainment of household population: females . 16 Table 2.3.2 Educational attainment of household population: males . 17 Table 2.4 School attendance . 18 Table 2.5 School attendance ratios. 20 Table 2.6 Housing characteristics . 22 Table 2.7 Household durable goods. 25 Figure 2.1 Population pyramid . 14 Figure 2.2 Percentage of males and females currently attending school, by age . 19 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Background characteristics of respondents . 28 Table 3.2.1 Educational attainment by background characteristics: women. 29 Table 3.2.2 Educational attainment by background characteristics: men. 30 Table 3.3.1 Literacy: women. 31 Table 3.3.2 Literacy: men . 32 Table 3.4.1 Exposure to mass media: women. 33 Table 3.4.2 Exposure to mass media: men . 34 Table 3.5 Employment status. 36 Table 3.6.1 Occupation: women. 37 Table 3.6.2 Occupation: men . 38 Table 3.7.1 Type of employment: women. 39 Table 3.7.2 Type of employment: men . 39 Table 3.8 Decision on use of earnings and contribution of earnings to household expenditures. 40 Table 3.9 Women’s control over earnings . 41 Table 3.10 Women’s participation in decisionmaking . 42 Table 3.11 Women’s participation in decisionmaking by background characteristics: women . 43 Table 3.12.1 Women’s attitude towards wife-beating. 45 Table 3.12.2 Men’s attitude towards wife-beating . 46 Table 3.13.1 Women’s attitude towards refusing sex with husband . 48 Table 3.13.2 Men’s attitude towards wife refusing sex with husband . 49 x | Tables and Figures Table 3.14 Men’s attitudes towards justifiable actions if wife refuses sex. 50 Figure 3.1 Access to mass media . 35 CHAPTER 4 FERTILITY Table 4.1 Current fertility . 52 Table 4.2 Fertility by background characteristics. 53 Table 4.3 Trends in fertility. 55 Table 4.4 Trends in fertility by background characteristics . 56 Table 4.5 Trends in age-specific fertility rates . 56 Table 4.6 Children ever born and living. 57 Table 4.7 Birth intervals. 58 Table 4.8 Age at first birth . 59 Table 4.9 Median age at first birth by background characteristics. 60 Table 4.10 Teenage pregnancy and motherhood . 62 Figure 4.1 Total fertility rate, by background characteristics . 54 Figure 4.2 Total fertility rates, Kenya 1975-2003 . 55 CHAPTER 5 FAMILY PLANNING Table 5.1.1 Knowledge of contraceptive methods: women . 64 Table 5.1.2 Knowledge of contraceptive methods: men . 65 Table 5.2 Ever use of contraception . 66 Table 5.3 Current use of contraception . 67 Table 5.4 Trends in current use of contraception. 68 Table 5.5 Current use of contraception by background characteristics . 71 Table 5.6 Current use of contraception by women’s status . 73 Table 5.7 Number of children at first use of contraception . 74 Table 5.8 Use of social marketing brand pills. 74 Table 5.9 Knowledge of fertile period. 75 Table 5.10 Source of contraception. 76 Table 5.11 Informed choice . 77 Table 5.12 First-year contraceptive discontinuation rates. 78 Table 5.13 Reasons for discontinuation . 79 Table 5.14 Future use of contraception . 80 Table 5.15 Reasons for not intending to use contraception. 80 Table 5.16 Preferred method of contraception for future use . 81 Table 5.17 Exposure to condom messages. 82 Table 5.18 Acceptability of media messages about condoms . 83 Table 5.19 Exposure of men to family planning messages . 84 Table 5.20 Discussion of family planning with husband. 85 Table 5.21 Attitudes towards family planning: married women . 86 Table 5.22 Attitudes towards family planning: all men. 87 Table 5.23 Men’s attitudes towards contraception. 88 Figure 5.1 Contraceptive use among currently married women, Kenya 1984-2003 . 69 Figure 5.2 Trends in current use of specific contraceptive methods among currently married women age 15-49, Kenya 1993-2003. 69 Figure 5.3 Current use of family planning among currently married women age 15-49, selected countries in east Africa and southern Africa . 70 Tables and Figures | xi Figure 5.4 Current use of any contraceptive method among currently married women age 15-49, by background characteristics . 72 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status. 90 Table 6.2 Polygyny. 91 Table 6.3 Age at first marriage . 93 Table 6.4 Median age at first marriage. 94 Table 6.5 Age at first sexual intercourse. 95 Table 6.6 Median age at first intercourse . 96 Table 6.7.1 Recent sexual activity: women. 91 Table 6.7.2 Recent sexual activity: men . 98 Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility . 99 Table 6.9 Median duration of postpartum insusceptibility by background characteristics . 100 Table 6.10 Menopause . 101 Figure 6.1 Percentage of currently married women whose husbands have at least one other wife . 92 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children. 104 Table 7.2 Desire to limit childbearing. 105 Table 7.3 Need for family planning among currently married women. 106 Table 7.4 Ideal number of children . 108 Table 7.5 Mean ideal number of children. 109 Table 7.6 Fertility planning status . 110 Table 7.7 Wanted fertility rates . 111 Table 7.8 Ideal number of children and unmet need by women’s status. 112 Figure 7.1 Fertility preferences among currently married women age 15-49 . 104 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates. 114 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 116 Table 8.3 Early childhood mortality rates by demographic characteristics . 118 Table 8.4 Early childhood mortality rates by women’s status. 119 Table 8.5 Perinatal mortality . 120 Table 8.6 High-risk fertility behaviour. 122 Figure 8.1 Trends in infant and under-five mortality, 1988 KDHS and 2003 KDHS. 115 Figure 8.2 Under-five mortality by background characteristics . 116 CHAPTER 9 MATERNAL AND CHILD HEALTH Table 9.1 Antenatal care . 124 Table 9.2 Source of antenatal care . 125 Table 9.3 Number of antenatal care visits and timing of first visit . 126 Table 9.4 Components of antenatal care . 127 xii | Tables and Figures Table 9.5 Tetanus toxoid injections . 129 Table 9.6 Place of delivery . 130 Table 9.7 Assistance during delivery . 132 Table 9.8 Delivery characteristics . 133 Table 9.9 Postnatal care by background characteristics. 135 Table 9.10 Reproductive health care by women’s status. 136 Table 9.11 Vaccinations by source of information . 137 Table 9.12 Vaccinations by background characteristics. 139 Table 9.13 Prevalence and treatment of symptoms of ARI and fever. 141 Table 9.14 Disposal of children’s stools . 143 Table 9.15 Prevalence of diarrhoea . 144 Table 9.16 Knowledge of ORS packets . 145 Table 9.17 Diarrhoea treatment . 146 Table 9.18 Feeding practices during diarrhoea . 147 Table 9.19 Children’s health care by women’s status. 148 Table 9.20 Birth registration . 149 Table 9.21 Knowledge of illness signs . 150 Table 9.22 Use of tobacco among men . 151 Table 9.23 Use of alcohol . 152 Figure 9.1 Antenatal care, tetanus vaccinations, place of delivery, and delivery assistance. 131 Figure 9.2 Percentage of children age 12-23 months with specific vaccinations according to health cards and mother’s reports . 138 CHAPTER 10 NUTRITION Table 10.1 Initial breastfeeding .154 Table 10.2 Breastfeeding status by child’s age .155 Table 10.3 Median duration and frequency of breastfeeding.157 Table 10.4 Foods consumed by children in the day or night preceding the interview .158 Table 10.5 Micronutrient intake among children .160 Table 10.6 Micronutrient intake among mothers .162 Table 10.7 Nutritional status of children.165 Table 10.8 Trends in nutritional status of children .167 Table 10.9 Nutritional status of women by background characteristics.169 Figure 10.1 Breastfeeding practices by age . 156 Figure 10.2 Frequency of meals consumed by children under 36 months of age living with their mother. 159 CHAPTER 11 MALARIA Table 11.1 Ownership of mosquito nets. 172 Table 11.2 Use of mosquito nets by children. 173 Table 11.3 Use of mosquito nets by pregnant women . 174 Table 11.4 Use of antimalarial drugs among pregnant women. 176 Table 11.5 Use of SP for intermittent treatment. 177 Table 11.6 Prevalence and prompt treatment of fever/convulsions . 179 Table 11.7 Standard treatment of fever . 180 Table 11.8 Other interventions for treatment of fever and/or convulsions . 181 Tables and Figures | xiii CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 12.1 Knowledge of AIDS. 185 Table 12.2 Knowledge of HIV prevention methods . 186 Table 12.3 Knowledge of prevention of mother-to-child transmission of HIV. 188 Table 12.4.1 Beliefs about AIDS: women . 189 Table 12.4.2 Beliefs about AIDS: men. 190 Table 12.5.1 Accepting attitudes towards those living with HIV: women . 192 Table 12.5.2 Accepting attitudes towards those living with HIV: men . 193 Table 12.6 Perception of risk of getting AIDS. 194 Table 12.7 Reasons for perception of small/no risk of getting AIDS . 195 Table 12.8 Reasons for perception of moderate/great risk of getting AIDS . 195 Table 12.9 Multiple sex partnerships among women and men . 196 Table 12.10 Population who had an HIV test and received test results . 198 Table 12.11 Attitudes towards negotiating safer sex with husband . 200 Table 12.12 Higher-risk sex and condom use at last higher-risk sex . 201 Table 12.13 Paid sex in last year and condom use at last paid sex . 203 Table 12.14 Attitude towards condoms . 204 Table 12.15 Condom brands. 205 Table 12.16 Self-reporting of a sexually transmitted infection (STI) and STI symptoms . 206 Table 12.17 Women and men seeking treatment for sexually transmitted infections. 207 Table 12.18 Male circumcision . 208 Table 12.19 Age at first sex among young women and men . 209 Table 12.20 Knowledge of a source for condoms among young people. 210 Table 12.21 Condom use at first sex among young women and men . 211 Table 12.22 Premarital sex and condom use among youth. 213 Table 12.23 Higher-risk sex and condom use among young women and men. 214 Table 12.24 Children’s living arrangements and orphanhood . 216 Figure 12.1 Reason for getting HIV test among women and men age 15-49 who have ever been tested . 199 Figure 12.2 Abstinence, being faithful, and using condoms among young women and men. 212 CHAPTER 13 HIV PREVALENCE AND ASSOCIATED FACTORS Table 13.1 Coverage of HIV testing by sex and urban-rural residence. 218 Table 13.2 Coverage of HIV testing by age, education, and wealth quintile . 220 Table 13.3 HIV prevalence by age. 222 Table 13.4 HIV prevalence by selected socioeconomic characteristics. 223 Table 13.5 HIV prevalence by selected sociodemographic characteristics. 224 Table 13.6 HIV prevalence by sexual behaviour characteristics . 226 Table 13.7 HIV prevalence by selected other characteristics. 227 Table 13.8 HIV prevalence by prior HIV testing. 228 Table 13.9 HIV prevalence by male circumcision . 229 Table 13.10 HIV prevalence among couples . 231 CHAPTER 14 ADULT AND MATERNAL MORTALITY Table 14.1 Data on siblings . 234 Table 14.2 Adult mortality rates . 235 Table 14.3 Maternal mortality . 237 xiv | Tables and Figures Figure 14.1 Trends in adult mortality, Kenya 1991-1997 and 1996-2002. 236 CHAPTER 15 GENDER VIOLENCE Table 15.1 Experience of physical mistreatment . 242 Table 15.2 Perpetrators of violence . 243 Table 15.3 Marital violence. 244 Table 15.4 Frequency of spousal violence . 246 Table 15.5 Onset of spousal violence . 247 Table 15.6 Physical consequences of spousal violence . 248 Table 15.7 Spousal violence, women’s status, and husband’s characteristics. 249 Table 15.8 Female circumcision . 251 Figure 15.1 Percentage of women who have experienced different forms of spousal violence ever (since age 15) and in the 12 months preceding the survey. 245 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Sample implementation: women . 257 Table A.2 Sample implementation: men. 258 Table A.3 Coverage of HIV testing among interviewed women by socio- demographic characteristics. 259 Table A.4 Coverage of HIV testing among interviewed men by socio- demographic characteristics. 260 Table A.5 Coverage of HIV testing among women who ever had sex by risk status variables . 261 Table A.6 Coverage of HIV testing among men who ever had sex by risk status variables . 262 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 266 Table B.2 Sampling errors for national sample . 267 Table B.3 Sampling errors for urban sample. 268 Table B.4 Sampling errors for rural sample. 269 Table B.5 Sampling errors for Nairobi sample . 270 Table B.6 Sampling errors for Central sample . 271 Table B.7 Sampling errors for Coast sample . 272 Table B.8 Sampling errors for Eastern sample. 273 Table B.9 Sampling errors for Nyanza sample . 274 Table B.10 Sampling errors for Rift Valley sample . 275 Table B.11 Sampling errors for Western sample. 276 Table B.12 Sampling errors for North Eastern sample. 277 Tables and Figures | xv APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution. 279 Table C.2 Age distribution of eligible and interviewed women and men . 280 Table C.3 Completeness of reporting . 281 Table C.4 Births by calendar years . 281 Table C.5 Reporting of age at death in days . 282 Table C.6 Reporting of age at death in months . 283 Foreword | xvii FOREWORD This detailed report presents the major findings of the 2003 Kenya Demographic and Health Sur- vey (2003 KDHS). The 2003 KDHS is the fourth survey of its kind to be undertaken in Kenya, others being in 1989, 1993, and 1998. The 2003 KDHS differed in two aspects from the previous KDHS sur- veys: it included a module on HIV prevalence from blood samples, and it covered all parts of the country, including the arid and semi-arid districts that had previously been omitted from the KDHS. The 2003 KDHS was implemented by the Central Bureau of Statistics. Fieldwork was carried out between April and September 2003. The primary objective of the 2003 KDHS was to provide up-to-date information for policymak- ers, planners, researchers, and programme managers, which would allow guidance in the planning, im- plementation, monitoring and evaluation of population and health programmes in Kenya. Specifically, the 2003 KDHS collected information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood and maternal mortality, maternal and child health, and awareness and behav- iour regarding HIV/AIDS and other sexually transmitted infections (STIs). In addition, it collected infor- mation on malaria and use of mosquito nets, domestic violence among women, and HIV prevalence of adults. The 2003 KDHS results present evidence of lower than expected HIV prevalence in the country, stagnation in fertility levels, only a very modest increase in use of family planning methods since 1998, continued increase in infant and under-five mortality rates, and overall decline in indicators of maternal and child health in the country. There is a disparity between knowledge and use of family planning meth- ods. There is also a large disparity between knowledge and behaviour regarding HIV/AIDS and other STIs. Some of the critical findings from this survey, like the stagnation in fertility rates and the declining trend in maternal and child health, need to be addressed without delay. I would like to acknowledge the efforts of a number of organisations that contributed immensely to the success of the survey. First, I would like to acknowledge financial assistance from the Government of Kenya, the United States Agency for International Development (USAID), the United Kingdom De- partment for International Development (DFID), the United Nations Population Fund (UNFPA), the Ja- pan International Co-operation Agency (JICA), the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), and the Centers for Disease Control and Prevention (CDC). Second, in the area of technical backstopping, I would like to acknowledge ORC Macro, CDC, the National AIDS and STIs Control programme (NASCOP), the Kenya Medical Research Institute (KEMRI), and the National Council of Population and Development (NCPD). Special thanks go to the staff of the Central Bureau of Statistics and the Ministry of Health who coordinated all aspects of the sur- vey. Finally, I am grateful to the survey data collection personnel and, more importantly, to the survey respondents, who generously gave their time to provide the information and blood spots that form the ba- sis of this report. Anthony K. M. Kilele Acting Director of Statistics Summary of Findings | xix SUMMARY OF FINDINGS The 2003 Kenya Demographic and Health Survey (2003 KDHS) is a nationally representa- tive sample survey of 8,195 women age 15 to 49 and 3,578 men age 15 to 54 selected from 400 sample points (clusters) throughout Kenya. It is designed to provide data to monitor the population and health situation in Kenya as a follow-up of the 1989, 1993 and 1998 KDHS surveys. The survey utilised a two-stage sample based on the 1999 Population and Housing Census and was designed to produce separate estimates for key indicators for each of the eight provinces in Kenya. Unlike prior KDHS surveys, the 2003 KDHS covered the northern half of Kenya. Data collection took place over a five-month period, from 18 April to 15 September 2003. The survey obtained detailed information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood and ma- ternal mortality, maternal and child health, aware- ness and behaviour regarding HIV/AIDS, and other sexually transmitted infections (STIs). New features of the 2003 KDHS include the collection of information on malaria and use of mosquito nets, domestic violence, and HIV testing of adults. The 2003 KDHS was implemented by the Central Bureau of Statistics (CBS) in collabora- tion with the Ministry of Health (including the National AIDS and STIs Control Programme- NASCOP and the Kenya Medical Research Insti- tute-KEMRI), and the National Council for Popu- lation and Development (NCPD). Technical assis- tance was provided through the MEASURE/DHS programme, in collaboration with the U.S. Centers for Disease Control and Prevention (CDC). Fi- nancial support for the survey was provided by the Government of Kenya and a consortium of do- nors, including: the U. S. Agency for International Development (USAID), the United Nations Popu- lation Fund (UNFPA), Japan International Coop- eration Agency (JICA)/United Nations Develop- ment Programme (UNDP), the United Nations Children’s Fund (UNICEF), the British Depart- ment for International Development (DFID), and the Centers for Disease Control and Prevention (CDC). FERTILITY Fertility Levels and Trends. One of the most surprising findings from the 2003 KDHS is that the previously documented decline in fertility appears to have stalled. The total fertility rate of 4.9 children per woman for the three-year period preceding the survey (mid-2000 to mid-2003) is almost identical to the rate of 5.0 derived from the 1999 Population and Housing Census. Comparison with the 1998 KDHS requires restricting analysis to the southern parts of the country that were sampled in both surveys; this comparison shows a slight increase in fertility from 4.7 children per woman between 1995 and 1998 to 4.8 between 2000 and 2003. Given the dramatic decline in fertility from the late 1970s to the mid-1990s (from 8.1 to 4.7), this plateau in fertility is worrisome. Fertility Differentials. There are substantial dif- ferences in fertility levels in Kenya. The total fertility rate is considerably higher in the rural areas (5.4 chil- dren per woman) than urban areas (3.3 children per woman). Regional differences are also marked. Fertil- ity is lowest in Nairobi Province (2.7 children per woman) and highest in North Eastern Province (7.0 children per woman). Fertility in Central Province is also relatively low (3.4), compared with Nyanza (5.6), Rift Valley (5.8) and Western (5.8) Provinces. In accordance with expectations, education of women is strongly associated with lower fertility. The total fertility rate (TFR) decreases dramatically from 6.7 for women with no education to 3.2 for women with at least some secondary education. In terms of trends over time, fertility has actually increased among women with no education and has only de- clined among those with some secondary education. Unplanned Fertility. Despite a relatively high level of contraceptive use, the 2003 KDHS data indi- cate that unplanned pregnancies are common in Kenya. Overall, 20 percent of births in Kenya are un- wanted, while 25 percent are mistimed (wanted later). Overall, the proportion of births considered mistimed or unwanted has changed little, compared with the xx | Summary of Findings 1998 KDHS; however, the trends show a sizeable increase in the percentage of births that are un- wanted and a comparable reduction in those that are mistimed. Fertility Preferences. The desire to have more children has increased since 1998 among both women and men. For example, the propor- tion of married women who want another child has increased from 40 to 45 percent (excluding the northern districts in order to be comparable). Na- tionally, 47 percent of married women want to have another child—29 percent later and 16 per- cent soon (within two years). There has been little change in the ideal number of children. In 2003, among women, the mean ideal family size is 3.9 children. FAMILY PLANNING Knowledge of Contraception. Knowledge of family planning is nearly universal, with 94 percent of all women age 15 to 49 and 97 percent of men age 15 to 54 knowing at least one modern method of family planning. Among all women, the most widely known methods of family plan- ning are the male condom (91 percent), pills (90 percent), and injectables (89 percent). Three- quarters of all women have heard of female ster- ilisation, while about two-thirds have heard of the IUD, implants, and periodic abstinence. Trends in contraceptive knowledge since the 1998 KDHS are mixed. Although it appears as if there has been a slight drop in knowledge since 1998, it is mostly due to the inclusion of the northern areas of Kenya in 2003. When these ar- eas are excluded, there has been no change in overall levels of knowledge of any method or any modern method. Nevertheless, the level of knowl- edge of several methods has declined slightly since 1998. For example, among all women (ex- cluding the northern districts), the percentages who know of female sterilisation, the pill, the IUD, and periodic abstinence have declined slightly since 1998. On the other hand, the per- centages who know of male sterilisation, male condoms, injectables, implants and withdrawal have increased slightly. Use of Contraception. Almost four in ten married women (39 percent) in Kenya are using a method of family planning. Most are using a modern method (32 percent of married women), while 8 per- cent use a traditional method. Injectables, pills, and periodic abstinence are the most commonly used con- traceptive methods, used by 14 percent, 8 percent, and 6 percent of married women, respectively. Trends in Contraceptive Use. Contraceptive use has increased slightly since 1998, from 39 to 41 percent of married women (excluding the northern part of the country so as to be comparable to 1998). This is far less than the 6 percentage point rise in the five years between 1993 and 1998. Nevertheless, the 2003 KDHS corroborates trends in method mix, namely, a continuing increase in use of injectables and decrease in use of the pill as was the case in earlier KDHS surveys. Differentials in Contraceptive Use. As ex- pected, contraceptive use increases with level of edu- cation. Use of modern methods increases from 8 per- cent among married women with no education to 52 percent among women with at least some secondary education. Use of modern contraception among women with no education dropped from 16 percent in 1998 to 11 percent in 2003 (excluding the northern areas). Source of Modern Methods. In Kenya, public (government) facilities provide contraceptives to slightly more than half (53 percent) of modern method users, while 41 percent are supplied through private medical sources, 5 percent through other private sources (e.g. shops) and only 1 percent through com- munity-based distribution. Discontinuation Rates. Overall, almost four in ten women (38 percent) discontinue use within 12 months of adopting a method. The 12-month discon- tinuation rate for injectables (32 percent) and periodic abstinence (33 percent) are lower than for the pill (46 percent) and male condom (59 percent). Discontinua- tion rates have increased since 1998, from 33 percent to 38 percent of users. This seems to be due to higher discontinuation rates for the pill and injectables, while rates for condoms and periodic abstinence have re- mained stable. Unmet Need for Family Planning. One-quarter of currently married women in Kenya have an unmet need for family planning, unchanged since 1998. Three-fifths of unmet need is comprised of women who want to wait two or more years before having Summary of Findings | xxi their next child (spacers), while two-fifths is com- prised of women who want no more children (lim- iters). MATERNAL HEALTH Antenatal Care. The 2003 KDHS data indi- cate that 88 percent of women in Kenya receive antenatal care from a medical professional, either from doctors (18 percent) or nurses or midwives (70 percent). A small fraction (2 percent) receives antenatal care from traditional birth attendants, while 10 percent do not receive any antenatal care. The 2003 data indicate a slight decline since 1998 in medical antenatal care coverage. Just over half of women (52 percent) re- ceived two or more tetanus toxoid injections dur- ing pregnancy for their most recent birth in the five years preceding the survey, while 34 percent received one dose. There has been little change since 1998 in the proportion of women receiving tetanus toxoid injections during pregnancy. With regard to anti-malarial indicators, the 2003 KDHS data shows that only 4 percent of pregnant women slept under an insecticide-treated mosquito net the night before the survey and 4 percent received intermittent preventive treatment with anti-malarial medication during antenatal care visits. Delivery Care. Proper medical attention and hygienic conditions during delivery can re- duce the risk of serious illness among mothers and their babies. The 2003 KDHS found that two out of five births (40 percent) are delivered in a health facility, while 59 percent are delivered at home. There has been no change since 1998 in the pro- portion of births occurring at home. Similarly, 42 percent of births in Kenya are delivered under the supervision of a health profes- sional, mainly a nurse or midwife. Traditional birth attendants continue to play a vital role in delivery, assisting with 28 percent of births. Rela- tives and friends assist in 22 percent of births. The proportion of births assisted by medically trained personnel has remained constant since 1998. Only 4 percent of births are delivered by Caesarean sec- tion, a slight decline since 1998. Maternal Mortality. Data on the survival of respondents’ sisters were used to calculate a ma- ternal mortality ratio for the 10-year period before the survey, which was estimated as 414 maternal deaths per 100,000 live births. This represents a decline from the rate of 590 maternal deaths per 100,000 live births for the ten-year period prior to the 1998 KDHS; how- ever, the sampling errors around each of the estimates are large and consequently, the two estimates are not significantly different. Thus, it is impossible to say with confidence that maternal mortality has declined. However, a comparison of data from the 1998 and 2003 KDHS surveys indicates a substantial increase in overall adult mortality rates for both males and fe- males at all ages, with the exception of age group 15 to 19 among men. CHILD HEALTH Childhood Mortality. Data from the 2003 KDHS show that child mortality levels have been more or less stable over the recent few years. For the most recent five-year period preceding the survey, infant mortality is 77 deaths per 1,000 live births and under-five mortality is 115 deaths per 1,000 live births. This means that one in every nine children born in Kenya dies before attaining their fifth birthday. Childhood Vaccination Coverage. In the 2003 KDHS, mothers were able to show a health card with immunisation data for only 60 percent of children age 12-23 months. Accordingly, estimates of coverage are based on both data from health cards and mothers’ recall. The data show that 57 percent of children 12- 23 months are fully vaccinated against the major childhood illnesses. This represents a deterioration in immunisation coverage for children. Seven percent of children 12-23 months have not received any of the recommended immunisations. Child Illness and Treatment. Among children under five years of age, 18 percent were reported to have had symptoms of acute respiratory illness in the two weeks preceding the survey, while 41 percent had a fever in the two weeks preceding the survey and 16 percent had diarrhoea. Forty-six percent of children with symptoms of ARI and/or fever were taken to a health facility or provider for treatment. Thirty percent of children with diarrhoea were taken to a facility for treatment, while half were given either a solution pre- pared from oral rehydration salt (ORS) packets or in- creased fluids. Among children with fever in the two weeks preceding the survey, 11 percent were given the recommended medicine, sulfadoxine-pyrimethamine or SP, although only 6 percent of children received SP within a day of the onset of the fever. Survey data also xxii | Summary of Findings indicate that only 5 percent of children under five slept under an insecticide-treated mosquito net the night before the survey. NUTRITION Breastfeeding Practices. Breastfeeding is nearly universal in Kenya; 97 percent of children are breastfed. The median duration of breastfeed- ing is 20 months, similar to the duration docu- mented in the 1993 and 1998 KDHSs. The 2003 KDHS data indicate that supplementary feeding of children begins early. For example, among new- borns less than two months of age, 45 percent are receiving supplementary foods or liquids other than water. The median duration of exclusive breastfeeding is estimated at less than one month. Bottle-feeding is common in Kenya; 27 per- cent of children under 6 months are fed with bot- tles with teats. Nevertheless, use of infant formula milk is minimal; only 5 percent of children below six months receive commercially produced infant formula. Intake of Vitamin A. Ensuring that children between six months and 59 months receive enough vitamin A may be the single most effec- tive child survival intervention, since deficiencies in this micronutrient can cause blindness and can increase the severity of infections, such as measles and diarrhoea. Overall, 62 percent of children un- der age three years consume vitamin A-rich foods and 33 percent of children age 6-59 months re- ceived a vitamin A supplement in the six months preceding the survey. Nutritional Status of Children. Survey data show that the nutritional status of children under five has improved only slightly in the past few years. At the national level, 30 percent of children under five are stunted (low height-for- age), while 6 percent of children are wasted (low weight-for-height) and 20 percent are underweight (low weight-for-age). Children in Coast Province are most likely to be stunted, while those in North Eastern Province are most likely to be wasted and underweight. Nutritional Status of Women. The mean body mass index (BMI) for women age 15-49 has increased very slightly since 1998 and is now 23. HIV/AIDS Awareness of AIDS. Almost all (99 percent) of Kenyan women and men have heard of AIDS. More than 4 in 5 respondents (81 percent of women and 89 percent of men) indicate that the chances of getting the AIDS virus can be reduced by limiting sex to one faithful partner. Similarly, 61 percent of women and 72 percent of men know that condoms can reduce the risk of contracting the HIV virus during sexual inter- course. As expected, the proportion of both women and men who know that abstaining from sex reduces the chances of getting the AIDS virus is high—79 percent among women and 89 percent among men. Almost three-quarters of women (72 percent) and two-thirds of men (68 percent) know that HIV can be transmitted by breastfeeding; however, only one-third of women (33 percent) and 38 percent of men know that the risk of maternal to child transmission can be reduced by the mother taking certain drugs during pregnancy. Eighty-five percent of women and 90 per- cent of men are aware that a healthy-looking person can have the AIDS virus. Attitudes Towards HIV-Infected People. Large majorities of Kenyan women and men (84 and 88 percent, respectively) express a willingness to care for a relative sick with AIDS in their own household, while far fewer (60 and 74 percent, respectively) say they would be willing to buy fresh vegetables from a vendor who has the AIDS virus. Survey results further indicate that only 57 and 60 percent of women and men, respectively, believe that a female teacher who has the AIDS virus should be allowed to continue teaching in school. Finally, 59 percent of women and 72 percent of men say that if a member of their family got infected with the virus that causes AIDS, they would not necessarily want it to remain a secret. HIV-Related Behavioural Indicators. Com- parison of data from the 2003 KDHS with similar data from the 1998 KDHS indicates that there has been an increase in the age at first sexual experience. The me- dian age at first sex among women age 20 to 49 has increased from 16.7 to 17.8, even when the northern areas of Kenya are excluded to make the data more comparable. Since the most important mechanism of HIV transmission is sexual intercourse, it is important to know the extent of multiple sexual partners. The 2003 KDHS data show that only 2 percent of women and 12 percent of men report having had more than one sexual partner in the 12 months prior to the sur- vey. Summary of Findings | xxiii HIV Prevalence. In the one-half of the households selected for the man’s survey, all women and men who were interviewed were asked to voluntarily provide some drops of blood for HIV testing in the laboratory. Results indicate that 7 percent of Kenyan adults are infected with HIV. HIV prevalence is nearly 9 percent among women age 15 to 49 and under 5 percent among men 15 to 54. The female-to-male ratio is higher than that found in most population-based studies in Africa and is due to the fact that young women are particularly vulnerable to HIV infection com- pared to young men. The peak prevalence among women is at age 25 to 29 (13 percent), while prevalence rises gradually with age among men to peak at age 40 to 44 (9 percent). Only in the 45 to 49 year age group is HIV prevalence among men higher than that for women. Patterns of HIV Prevalence. Urban resi- dents have a significantly higher risk of HIV in- fection (10 percent) than rural residents (6 per- cent). The HIV epidemic also shows regional het- erogeneity. Nyanza Province has an overall preva- lence of 15 percent, followed by Nairobi with 10 percent. All other provinces have levels between 4 percent and 6 percent overall, except North East- ern Province where no respondent tested positive. Women and men who are widowed have signifi- cantly higher rates than married respondents. Sur- vey findings indicate that there is a strong rela- tionship between HIV prevalence and male cir- cumcision; 13 percent of men who are uncircum- cised are HIV infected, compared with 3 percent of those who are circumcised. Among couples who are married or living together, 7 percent are discordant, with one partner infected and the other uninfected. GENDER-RELATED VIOLENCE Violence Since Age 15. Not only has domes- tic violence against women been acknowledged worldwide as a violation of the basic human rights of women, but an increasing amount of research highlights the health burdens, intergenerational effects, and demographic consequences of such violence. In the 2003 KDHS, women were asked if they had experienced violence since age 15. The data show that half of women have experienced violence since they were 15 and one in four reported experienc- ing violence in the 12 months preceding the survey. The main perpetrators are husbands, and to a lesser extent, teachers, mothers, fathers and brothers. Marital Violence. Twenty-six percent of ever- married women report having experienced emotional violence by husbands, 40 percent report physical vio- lence and 16 percent report sexual violence. Almost half (47 percent) of ever-married women report suffer- ing emotional, physical or sexual violence, while 8 percent have experienced all three forms of violence by their current or most recent husband. Two in three women who have experienced physical or sexual vio- lence by their husbands have experienced such vio- lence in the 12 months preceding the survey. One- quarter of ever-abused women (26 percent) have ex- perienced spousal violence three or more times in the last 12 months. The factor most strongly related to marital violence is husband’s alcohol and/or drug use; violence is 2-3 times more prevalent among women who say their husbands get drunk or take illegal drugs very often compared to those whose husbands do not drink or take illegal drugs. Attitudes Towards Marital Violence. To gauge the acceptability of domestic violence, women and men interviewed in the 2003 KDHS were asked whether they thought a husband would be justified in hitting or beating his wife in each of the following five situations: if she burns the food; if she argues with him; if she goes out without telling him; if she neglects the children; and if she refuses to have sexual relations with him. Results show that two-thirds of Kenyan women and men agree that at least one of these factors is sufficient justification for wife beating. Female Genital Cutting. Survey data show that 32 percent of Kenyan women are circumcised. This represents a decline from the level recorded in the 1998 KDHS (from 38 to 31 percent, excluding the northern districts so as to be comparable). Sudan Ethiopia Uganda Somalia NORTH EASTERN EASTERN COAST CCCENTRALC NANA ROBIROBNAIROBNAIROBAIROAIROB Tanzania NYANZAN W NRNWESTERNWESTERN RIFT VALLEY I N D I A N OCEAN L a k e T u rk a n a Laakea Victooriaooriaoria KENYA xxiv | Map of Kenya Introduction | 1 INTRODUCTION 1 Fredrick Otieno and Silas Opiyo 1.1 GEOGRAPHY, HISTORY, AND THE ECONOMY Geography Kenya is situated in the eastern part of the African continent. The country lies between 5 degrees north and 5 degrees south latitude and between 24 and 31 degrees east longitude. It is almost bisected by the equator. Tanzania borders it to the south, Uganda to the west, Ethiopia and Sudan to the north, Soma- lia to the northeast, and the Indian Ocean to the southeast. The coastline and the port in Mombasa enable the country to trade easily with other countries. The country is divided into 8 provinces and 72 districts. It has a total area of 582,646 square kilo- metres of which 571,466 square kilometres form the land area. Approximately 80 percent of the land area of the country is arid or semiarid, and only 20 percent is arable. The country has diverse physical features, including the Great Rift Valley, which runs from north to south; Mount Kenya, the second highest mountain in Africa; Lake Victoria, the largest freshwater lake on the continent; Lake Nakuru, a major tourist attraction because of its flamingos; Lake Magadi, famous for its soda ash; and a number of rivers, including Tana, Athi, Yala, Nzoia, and Mara. The country falls into two regions: lowlands, including coastal and lake basin lowlands, and high- lands, which extend on both sides of the Great Rift Valley. Rainfall and temperatures are influenced by altitude and proximity to lakes or the ocean. There are four seasons in a year: a dry period from January to March, the long rainy season from March to May, followed by a long dry spell from May to October, and then the short rains between October and December. History Kenya is a former British colony. The independence process was met with resistance and an armed struggle. The Mau Mau rebellion in the 1950s paved the way for constitutional reform and political development in the following years. The country achieved self-rule in June 1963 and gained independ- ence (Uhuru) on December 12, 1963. Exactly one year later, Kenya became a republic. The country has had a stable government and political tranquility since becoming independent. The country was a multi- party state until 1981, when the relevant parts of the constitution were amended to create a one-party state. However, in the early 1990s, the country reverted to a multiparty state. From the start of its ind- pendence until December 2002, the country was ruled by the Kenya African National Union. During the 2002 general elections, the National Alliance of Rainbow Coalition ascended to power through a land- slide victory. The country has about 42 ethnic groups which are distributed throughout the country. Major tribes include Kikuyu, Luo, Kalenjin, Luhya, Kamba, Kisii, Mijikenda, Somali, and Meru. In Kenya, English is the official language while Kiswahili is the national language. Main religions in the country are Christianity and Islam. 2 | Introduction Economy The Kenyan economy is predominantly agricultural with a strong industrial base. The agriculture sector contributes 25 percent of the gross domestic product (GDP). Coffee, tea, and horticulture (flowers, fruits, and vegetables) are the main agricultural export commodities; in 2002, the three commodities jointly accounted for 53 percent of the total export earnings (Central Bureau of Statistics, 2003a). The manufacturing sector contributes about 13 percent of the total GDP and contributes significantly to export earnings, especially from the Common Market for Eastern and Southern Africa (COMESA) region. De- spite recent declines, the tourism sector has also contributed to improving the living standards of Ken- yans. The economy has undergone a structural transformation since 1964. There has been gradual decline in the share of the GDP attributed to agriculture, from over 30 percent during the period 1964-1979 to 25 percent in 2000-2002. The manufacturing sector has expanded from about 10 percent of the GDP in the period 1964-1973 to 13 percent in 2000-2002. The performance of the Kenyan economy since the country became independent has been mixed. In the first decade after the country’s independence, the economy grew by about 7 percent per annum, attributed to expansion in the manufacturing sector and an increase in agricultural production. Since then, there has been a consistent decline in the economy, reaching the lowest GDP growth level of about 2 per- cent between 1996 and 2002. The consistent poor growth performance has failed to keep pace with popu- lation growth. The weak performance has been due to external shocks and internal structural problems, including the drought of the 1980s, low commodity prices, world recession, bad weather, and poor infra- structure. The poor growth of the economy has contributed to a deterioration in the overall welfare of the Kenyan population. Similarly, the economy has been unable to create jobs at a rate to match the rising labour force. Poverty has increased, such that about 56 percent of the population live in poverty and over half live below the absolute poverty level (Central Bureau of Statistics, 2003a). The number of poor peo- ple is estimated to have risen from 11 million in 1990 to 17 million in 2001. The worsening living stan- dard is shown by rising child mortality rates, increasing rates of illiteracy, and rising unemployment lev- els. The HIV/AIDS pandemic has also had a devastating impact on all sectors of the economy, through loss of production and labour force. Against this background, the government of Kenya in 2003 launched the Economic Recovery Strategy for Wealth and Employment Creation, aimed at restoring economic growth, generating employment opportunities, and reducing poverty levels (Ministry of Planning and Na- tional Development, 2003). The government is convinced that employment creation is the most effective strategy for halting the increasing poverty. 1.2 POPULATION The population of Kenya increased from 10.9 million in 1969 to 28.7 million in 1999 (Central Bureau of Statistics, 1994, 2001a) (see Table 1.1). The results of the previous censuses indicate that the annual population growth rate was 2.9 percent per annum during the 1989-1999 period, down from 3.4 percent reported for both the 1969-1979 and 1979-1989 inter-censal periods. The decline in population growth is a realisation of the efforts contained in the National Population Policy for Sustainable Devel- opment (National Council for Population and Development, 2000) and is a result of the decline in fertility rates since the mid-1980s. In contrast, mortality rates have risen since the 1980s, presumably due to in- creased deaths from the HIV/AIDS epidemic, deterioration of health services, and widespread poverty (National Council for Population and Development, 2000). As a result of changing population dynamics, the total population of Kenya was projected to be 32.2 million by 2003 (Central Bureau of Statistics, 2002d). Introduction | 3 The crude birth rate increased from 50 per 1,000 in 1969 to 54 per 1,000 in 1979, but has declined to 48 and 41 per 1,000 in 1989 and 1999, respectively. After a long decline, the crude death rate has in- creased from 11 per 1,000 in 1979-1989 to 12 per 1,000 for the 1989-1999 period. Similarly, the infant mortality rate decreased from 119 deaths per 1,000 live births in 1969, to 88 per 1,000 in 1979, and to 66 per 1,000 in 1989, but has since increased to 77 per 1,000 in 1999. As a result of the high fertility and de- clining mortality in the past, the country is characterised by a youthful population, with almost 44 percent younger than 15 years and only 4 percent age 65 and older. The proportion of the population that resides in rural areas is still higher than the proportion in the urban areas. The urban population has increased from 10 percent in 1969 to 19 percent in 1999. Increased urbanisation levels have mainly resulted from rural-urban migration. 1.3 POPULATION AND FAMILY PLANNING POLICIES AND PROGRAMMES In 2000, the Government of Kenya launched the National Population Policy for Sustainable De- velopment (National Council for Population and Development, 2000). This sessional paper builds on the strength of Sessional Paper No. 4 of 1984. The current policy outlines ways of implementing the pro- gramme of action developed at the 1994 International Conference on Population and Development in Cairo. The implementation of this policy is being guided by the national and district plans of action for- mulated by the National Council for Population and Development (NCPD). The policy also addresses the issues of environment, gender, and poverty, as well as problems facing certain segments of the Kenyan population, such as the youth. The goals and objectives include full integration of population concerns into the development process; motivating and encouraging Kenyans to adhere to responsible parenthood; empowerment of women; and integration of the youth, elderly, and per- sons with disabilities into mainstream and national development. The overriding concern of the policy is the implementation of appropriate policies, strategies, and programmes that will shape the population growth to fit the available national resources over time, in order to improve the well-being and quality of life of individuals, the family, and the nation as a whole. The goals of the population policy include the following: • Improvement of the standard of living and quality of life; Table 1.1 Basic demographic indicators Selected demographic indicators for Kenya, 1969, 1979, 1989, 1999 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Indicator 1969 1979 1989 1999 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Population (millions) 10.9 16.2 23.2 28.7 Density (pop./km2) 19.0 27.0 37.0 49.0 Percent urban 9.9 15.1 18.1 19.4 Crude birth rate 50.0 54.0 48.0 41.3 Crude death rate 17.0 14.0 11.0 11.7 Inter-censal growth rate 3.3 3.8 3.4 2.9 Total fertility rate 7.6 7.8 6.7 5.0 Infant mortality rate (per 1,000 births) 119 88 66 77.3 Life expectancy at birth 50 54 60 56.6 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Source: CBS, 1970; CBS, 1981; CBS, 1994; CBS, 2002a 4 | Introduction • Improvement of the health and welfare of the people through provision of information and education on how to prevent premature deaths and illness among risk groups, especially among mothers and children; • Sustenance of the ongoing demographic transition to further reduce fertility and mortality, especially infant and child mortality; • Continuing motivation and encouragement of Kenyans to adhere to responsible parenthood • Promotion of stability of the family, taking into account equality of opportunity for family members, especially the rights of women and children; • Empowerment of women and the improvement of their status in all spheres of life and elimi- nation of all forms of discrimination, especially against the girl child; • Sustainability of the population programme; • Elimination of retrogressive sociocultural practices through education. The policy has the following set targets: • Reduction of the infant mortality rate per 1,000 live births from 71 in 1998, to 67 by 2005, and to 63 by 2010; • Reduction of the under-five mortality rate per 1,000 live births from 112 in 1998, to 104 by 2005, and to 98 by 2010; • Reduction of the maternal mortality rate per 100,000 births from 590 in 1998, to 230 by 2005, and to 170 by 2010; • Maintenance of the crude death rate per 1,000 population at 12 up to the year 2000 and reduc- ing it to 10 by 2005 and to 9 by 2010; • Minimisation of the decline in life expectancy at birth for both sexes from 58 in 1995 to 53 by 2010; • Stabilisation of the population growth rate at 2.1 percent per annum by 2010. 1.4 HEALTH PRIORITIES AND PROGRAMMES On behalf of the Government of Kenya, the Ministry of Health launched a National Health Sector Strategic Plan covering the period 1999-2004 (Ministry of Health, 1999b). The current strategic plan op- erationalises Kenya’s Health Policy Framework Paper approved and launched in 1994. The strategic plan was prepared with an aim of reforming the entire health sector. These reforms are part of the larger economic reforms contained in the Economic Recovery Strategy for Employment and Wealth Creation of 2003-2007. The strategic plan sets out a number of objectives and interventions, which seek to address this situation in the context of the ongoing health sector reforms over the five-year period. The objectives of the plan are to: • Ensure equitable allocation of government resources to reduce disparities in health resources; • Increase the cost-effectiveness and the cost-efficiency of resource allocation and use; • Continue to manage population growth; • Enhance the regulatory role of the government in all aspects of health care provision; • Create an enabling environment for increased private sector and community involvement for increased private sector provision and finance; • Increase and diversify per capita financial flows to the health sector. Introduction | 5 The vision of the Ministry of Health is to create an enabling environment for the provision of sustain- able quality health care that is acceptable, affordable, and accessible for all Kenyans. Within the frame- work of the vision, the strategic plan focuses on the critical areas in the health sector development agenda. To monitor the implementation of the strategic plan, the government has set various national health tar- gets: • Reduce iron deficiency anaemia in pregnant women by 30 percent; • Achieve 90 percent childhood immunisation coverage with all antigens in 85 percent of dis- tricts (from 63 percent of districts); • Reduce measles morbidity by 95 percent and mortality by 90 percent; • Reduce the incidence of neonatal tetanus to less than 1 death per 1,000 live births with a 100 percent reporting rate; • Eliminate vitamin A deficiency in children under five years; • Reduce malnutrition by 30 percent among children under five years; • Eradicate poliomyelitis by 2000 and reach certification by 2005; • Increase areas with family planning services from the current 60 percent of health care facili- ties to 75 percent; • Reduce malaria morbidity and mortality ratios by 30 percent; • Reduce the HIV prevalence rate from the current 13 to 14 percent by 10 percent and sexually transmitted infection prevalence by 50 percent; • Reduce the proportion of under-five morbidity and mortality rates attributable to measles, pneumonia, diarrhoea, malaria, and malnutrition from 70 to 40 percent; • Increase provision of safe water and improve sanitation in rural areas by 30 percent. 1.5 STRATEGIC FRAMEWORK TO COMBAT THE HIV/AIDS EPIDEMIC To meet the challenge of the HIV/AIDS epidemic in the country, the Government of Kenya ap- proved, in September 1997, Sessional Paper No. 4 on AIDS in Kenya (Ministry of Health, 1997). This was a clear intent of the government to support effective programmes to control the spread of AIDS, to protect the human rights of those with HIV or AIDS, and to provide care for those infected and affected by HIV/AIDS. The goal of the sessional paper is to “provide a policy framework within which AIDS pre- vention and control efforts will be undertaken for the next 15 years and beyond.” Specifically, it has the following objectives: • Give direction on how to handle controversial issues while taking into account prevailing cir- cumstances and the sociocultural environment. • Enable the government to play the leadership role in AIDS prevention and control activities. Challenges posed by AIDS call for a multisectoral approach, necessitating involvement from a diversity of actors. • Recommend an appropriate institutional framework for effective management and coordina- tion of HIV/AIDS programme activities. The sessional paper recognises that responding effectively to the HIV/AIDS crisis will require a strong political commitment at the highest level; implementation of a multisectoral prevention and control strategy with priority focus on young people; mobilisation of resources for financing HIV prevention, care, and support; and establishment of a National AIDS Control Council to provide leadership at the highest level possible. 6 | Introduction 1.6 OBJECTIVES AND ORGANISATION OF THE SURVEY The 2003 Kenya Demographic and Health Survey (KDHS) is the latest in a series of national level population and health surveys to be carried out in Kenya in the last three decades. The 2003 KDHS is designed to provide data to monitor the population and health situation in Kenya and to be a follow-up to the 1989, 1993, and 1998 KDHS surveys. The survey obtained detailed information on fertility levels; marriage; sexual activity; fertility preferences; awareness and use of family planning methods; breastfeeding practices; nutritional status of women and young children; childhood and maternal mortality; maternal and child health; and awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections. New features of the 2003 KDHS include the collection of information on malaria and the use of mosquito nets, domestic violence, and HIV testing of adults. More specifically, the objectives of the 2003 KDHS were to: • At the national and provincial level, provide data that allow the derivation of demographic rates, particularly fertility and childhood mortality rates, which can be used to evaluate the achievements of the current national population policy for sustainable development; • Measure changes in fertility and contraceptive prevalence use and at the same time study the factors that affect these changes, such as marriage patterns, desire for children, availability of contraception, breastfeeding habits, and important social and economic factors; • Examine the basic indicators of maternal and child health in Kenya, including nutritional status, use of antenatal and maternity services, treatment of recent episodes of childhood ill- ness, use of immunisation services, use of mosquito nets, and treatment of children and preg- nant women for malaria; • Describe the patterns of knowledge and behaviour related to the transmission of HIV/AIDS and other sexually transmitted infections; • Estimate adult and maternal mortality ratios at the national level; • Ascertain the extent and pattern of domestic violence and female genital cutting in the coun- try; • Estimate the prevalence of HIV in the country at the national and provincial level and use the data to corroborate the rates from the sentinel surveillance system. The 2003 KDHS information is intended to provide data to assist policymakers and programme implementers to monitor and evaluate existing programmes and to design new strategies for demographic, social, and health policies in Kenya. The survey also provides data to monitor the country’s achievement of the Millenium Development Goals, as well as the Economic Recovery Strategy objectives. The 2003 KDHS was the first survey in the Demographic and Health Surveys (DHS) programme to cover the entire country, including North Eastern Province and other northern districts that had been excluded from the prior surveys (Turkana and Samburu in Rift Valley Province and Isiolo, Marsabit, and Moyale in Eastern Province). The survey collected information on demographic and health issues from a sample of women in the reproductive ages (15-49) and from men age 15-54 years in the one-in-two sub- sample of households selected for the male survey. Introduction | 7 1.7 SURVEY ORGANISATION The 2003 KDHS was implemented by the Central Bureau of Statistics (CBS) in collaboration with the Ministry of Health (including the National AIDS and STIs Control Programme [NASCOP] and the Kenya Medical Research Institute [KEMRI]) and NCPD. Technical assistance was provided through the MEASURE/ DHS+ programme, a project sponsored by the United States Agency for International Development (USAID) to carry out population and health surveys in developing countries. The Centers for Disease Control and Prevention (CDC) assisted in training the health field workers, supported the vol- untary counselling and testing of respondents who wanted to know their HIV status, and implemented the HIV testing in the laboratory. Financial support for the survey was provided by the Government of Kenya and a consortium of donors, namely, USAID, the United Nations Population Fund (UNFPA), Japan International Cooperation Agency (JICA)/United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the British Department for International Development (DFID), and CDC. 1.8 SAMPLE DESIGN The sample for the 2003 KDHS covered the population residing in households in the country. A representative probability sample of almost 10,000 households was selected for the KDHS sample. This sample was constructed to allow for separate estimates for key indicators for each of the eight provinces in Kenya, as well as for urban and rural areas separately. Given the difficulties in traveling and interview- ing in the sparsely populated and largely nomadic areas in the North Eastern Province, a smaller number of households was selected in this province. Urban areas were oversampled. As a result of these differing sample proportions, the KDHS sample is not self-weighting at the national level; consequently, all tables except those concerning response rates are based on weighted data. The survey utilised a two-stage sample design. The first stage involved selecting sample points (“clusters”) from a national master sample maintained by CBS (the fourth National Sample Survey and Evaluation Programme [NASSEP IV]). The list of enumeration areas covered in the 1999 population cen- sus constituted the frame for the NASSEP IV sample selection and thus for the KDHS sample as well. A total of 400 clusters, 129 urban and 271 rural, were selected from the master frame. The second stage of selection involved the systematic sampling of households from a list of all households that had been pre- pared for NASSEP IV in 2002. The household listing was updated in May and June 2003 in 50 selected clusters in the largest cities because of the high rate of change in structures and household occupancy in the urban areas. All women age 15-49 years who were either usual residents of the households in the sample or visitors present in the household on the night before the survey were eligible to be interviewed in the sur- vey. In addition, in every second household selected for the survey, all men age 15-54 years were eligible to be interviewed if they were either permanent residents or visitors present in the household on the night before the survey. All women and men living in the households selected for the Men’s Questionnaire and eligible for the individual interview were asked to voluntarily give a few drops of blood for HIV testing. 1.9 QUESTIONNAIRES Three questionnaires were used in the survey: the Household Questionnaire, the Women’s Ques- tionnaire and the Men’s Questionnaire. The contents of these questionnaires were based on model ques- tionnaires developed by the MEASURE DHS+ programme. 8 | Introduction In consultation with a broad spectrum of technical institutions, government agencies, and local and international organisations, CBS modified the DHS model questionnaires to reflect relevant issues in population, family planning, HIV/AIDS, and other health issues in Kenya. A number of thematic ques- tionnaire design committees were organised by CBS. Periodic meetings of each of the thematic commit- tees, as well as the final meeting, were also arranged by CBS. The inputs generated in these meetings were used to finalise survey questionnaires. These questionnaires were then translated from English into Kiswahili and 11 other local languages (Embu, Kalenjin, Kamba, Kikuyu, Kisii, Luhya, Luo, Maasai, Meru, Mijikenda, and Somali). The questionnaires were further refined after the pretest and training of the field staff. The Household Questionnaire was used to list all of the usual members and visitors in the se- lected households. Some basic information was collected on the characteristics of each person listed, in- cluding age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor and roof of the house, ownership of various durable goods, and ownership and use of mosquito nets. In addition, this question- naire was used to record height and weight measurements of women age 15-49 years and children under the age of 5 years, households eligible for collection of blood samples, and the respondents’ consent to voluntarily give blood samples. The HIV testing procedures are described in detail in the next section. The Women’s Questionnaire was used to collect information from all women age 15-49 years and covered the following topics: • Background characteristics (e.g., education, residential history, media exposure) • Reproductive history • Knowledge and use of family planning methods • Fertility preferences • Antenatal and delivery care • Breastfeeding • Vaccinations and childhood illnesses • Marriage and sexual activity • Woman’s work and husband’s background characteristics • Infant and child feeding practices • Childhood mortality • Awareness and behaviour about AIDS and other sexually transmitted diseases • Adult mortality including maternal mortality. The Women’s Questionnaire also included a series of questions to obtain information on women’s experience of domestic violence. These questions were administered to one woman per house- hold. In households with two or more eligible women, special procedures were followed, which ensured that there was random selection of the woman to be interviewed. The Men’s Questionnaire was administered to all men age 15-54 years living in every second household in the sample. The Men’s Questionnaire collected similar information contained in the Women’s Questionnaire, but was shorter because it did not contain questions on reproductive history, maternal and child health, nutrition, maternal mortality, and domestic violence. All aspects of the KDHS data collection were pretested in November and December 2002. Thir- teen teams (one for each language) were formed, each with one female interviewer, one male interviewer, and one health worker. The 39 team members were trained for two weeks and then proceeded to conduct Introduction | 9 interviews in the various districts in which their language was spoken. In total, 260 households were cov- ered in the pretest. The lessons learnt from the pretest were used to finalise the survey instruments and logistical arrangements for the survey. The pretest underscored the desirability of inluding voluntary counselling and testing (VCT) for HIV/AIDS as an integral part of the survey, since many respondents during the pretest wanted to know their HIV status. 1.10 HIV TESTING In all households selected for the Men’s Questionnaire, all eligible women and men who were in- terviewed were asked to voluntarily provide some drops of blood for HIV testing. The protocol for the blood specimen collection and analysis was based on the anonymous linked protocol developed by the DHS programme and approved by ORC Macro’s Institutional Review Board. This protocol was revised and enhanced by KEMRI and CDC. It was reviewed and approved by the Scientific and Ethical Review Committees of KEMRI and by the Institutional Review Board and Director of CDC in Atlanta, Georgia. The protocol allowed for the linking of the HIV results to the sociodemographic data collected in the in- dividual questionnaires, provided that the information that could potentially identify an individual was destroyed before the linking took place. This required that identification codes be deleted from the data file and that the back page of the Household Questionnaire, containing the barcode labels and names of respondents, be destroyed prior to merging the HIV results with the individual data file. For the purposes of blood sample collection, a health worker was included in each of the 17 field teams. The health workers were recruited with the assistance of the Ministry of Health. To obtain in- formed consent for taking blood for HIV testing, the health worker explained the procedures, the confi- dentiality of the data, and the fact that test results could not be traced back to or made available to the sub- ject; the health worker also provided respondents with information about how they could obtain their HIV status through VCT services. If consent was granted, the health worker then collected a dried blood spot (DBS) sample on a filter paper card from a finger prick, using a single-use, spring-loaded, sterile lancet. Each DBS sample was given a barcode label, with a duplicate label attached to the Household Question- naire on the line showing consent for that respondent. The health worker affixed a third copy of the same barcode label to a Blood Sample Transmittal Form in order to track the blood samples from the field to the laboratory. Filter papers were dried overnight in a plastic drying box, after which the health worker packed them in individual Ziploc bags with desiccant and a humidity indicator card and placed them in a larger Ziploc bag with other blood spots for that particular sample point. Blood samples were periodically collected in the field along with the completed questionnaires and transported to CBS headquarters in Nairobi for logging in, after which they were taken to the CDC laboratory at KEMRI headquarters in Nai- robi for HIV testing. At the laboratory, the DBS samples were each assigned a laboratory number and kept frozen until testing was started in early September. After the samples were allowed to attain room temperature, scis- sors were used to cut a circle at least 6.3 mm in diameter. The blots were placed in cryo-vials that con- tained 200 µl of elution buffer and were labeled with the lab number. The vials were left to elute over- night at 4oC, then they were centrifuged at 2,500 rpm for 10 minutes. These eluates were then tested with an Enzygnost Anti-HIV-1/2 Plus enzyme-linked immunosorbent assay (ELISA) test kit (DADE Behring HIV-1/2) for verification purposes. All positive samples and 10 percent of negative samples were then tested with a Vironostika HIV-1 MicroELISA System (Organon Teknika). Finally, 29 discrepant samples were tested by an INN-OLIA HIV confirmation Western blot kit (Innogenetics, Belgium). 1.11 TRAINING In February and early March 2003, CBS staff responsible for the survey spent considerable effort in recruiting people with the requisite skills to work as field staff. Most of those recruited were university 10 | Introduction graduates, and many had experience either with a previous KDHS or similar surveys, such as the Behav- ioural Surveillance Survey or the DHS-type survey that was conducted in Nairobi slum areas by the Afri- can Population and Health Research Centre. CBS then organized a three-week training course from March 17 to April 5, 2003, at the Izaak Walton Inn in Embu. A total of 146 field personnel were trained as interviewers, supervisors, health workers and data processing staff. Because of the large number involved, trainees were divided into three groups and trained separately on questionnaire administration. They came together in plenary sessions for special lectures. Four trainers were assigned to each group. The trainers were officers of CBS and NCPD as well as staff from ORC Macro. In addition to the 12 main trainers, guest lecturers gave presentations in ple- nary sessions on specialised topics, such as family planning; Kenya’s Program on Integrated Management of Childhood Illnesses; nutrition and anthropometric measurements; HIV/AIDS; and Kenya’s VCT pro- gramme for HIV/AIDS. All participants were trained on interviewing techniques and the contents of the KDHS question- naires. The training was conducted following the standard DHS training procedures, including class pres- entations, mock interviews, and four written tests. All of the participants were trained on how to complete the Women’s Questionnaire and how to take anthropometric measurements. Late in the second week of training, the health workers were split off from the other three groups to form a fourth group. Staff from KEMRI, CDC/Kenya, and ORC Macro trained the health workers on informed consent procedures, taking blood spots for HIV testing, and procedures for minimising risks in handling blood products (“universal precautions”). Meanwhile, the other trainees practiced interviewing in their local languages. During the final week, the whole group visited households in two sites close to the training center for practical interviews. Towards the end of the training programme, some trainees were selected as su- pervisors and field editors. This group was further trained on how to supervise fieldwork and editing of the questionnaires in the field. 1.12 FIELDWORK Data collection took place over a five-month period, from April 18 to September 15, 2003. Sev- enteen interviewing teams were involved in the exercise. Each team consisted of one supervisor, one field editor, four female interviewers, one male interviewer, one health worker, and one driver. The Maasai- speaking team and the two Somali-speaking teams had fewer female interviewers. Five senior staff from CBS coordinated and supervised fieldwork activities. ORC Macro participated in field supervision for interviews, weight and height measurements, and blood sample collection. To ensure that respondents could learn their HIV status, CDC/Kenya (in collaboration with KEMRI and NASCOP) organised a parallel team of two VCT counselors to work with each of the data collection teams (except in Nairobi, where VCT is accessible through many fixed sites). These mobile VCT teams followed the same protocol applied in fixed VCT sites according to the National Guidelines for Voluntary Counselling and Testing for HIV (Ministry of Health, 2003). This includes discussing the clients’ reasons for coming for counselling and testing, their risk factors, and implications of test out- comes, followed by anonymous testing for HIV for those requesting the service. A finger prick was per- formed to collect several drops of blood for simultaneous (parallel) testing performed with two simple, rapid HIV test kits (Abbott Determine HIV 1/2 and Trinity Biotech Uni-Gold); for quality control, a dried blood spot filter paper was collected on every fifth client for testing in the laboratory. During the 15 min- utes while the test was developing, prevention counselling was provided. If the two test results were dis- Introduction | 11 crepant, a third test (Instascreen) was performed as a “tiebreaker.” Post-test counselling was then pro- vided. In the field, the team supervisors and counsellors worked with local officials to locate suitable places within or adjacent to the cluster in which the counsellors could provide VCT services that were accessible and allowed privacy for testing and counselling. The plan was for the two VCT counsellors to “leapfrog” each other, with one staying behind for one or two days after the interviewing team left the area and the other moving ahead of the team to set up services in advance. In practice, this was not always possible because of transport logistics problems. CDC/Kenya also printed a brochure on HIV/AIDS and VCT for the team’s health workers to provide all households and survey respondents. Similarly, numbered vouchers were printed and left with eligible respondents. The vouchers were to be given to the mobile VCT teams or the fixed VCT site when the eligible respondents went for VCT. NASCOP and CDC/Kenya also made arrangements with the few fixed VCT sites charging for services, so that they would provide free services to KDHS clients and send the vouchers back to CDC for reimbursement. Finally, although the VCT teams were to give priority to clients presenting the KDHS vouchers, they also accepted any other clients from the sampled communi- ties. Over 10,600 clients, both respondents and other community members, sought and received free VCT services through the KDHS. 1.13 DATA PROCESSING The processing of the 2003 KDHS results began shortly after the fieldwork commenced. Com- pleted questionnaires were returned periodically from the field to CBS offices in Nairobi, where they were edited and entered by data processing personnel specially trained for this task. Data were entered using CSPro. All data were entered twice (100 percent verification). The concurrent processing of the data was a distinct advantage for data quality, since CBS was able to advise field teams of errors detected during data entry. The data entry and editing phase of the survey was completed in October 2003. 1.14 RESPONSE RATES Table 1.2 shows response rates for the survey. A total of 9,865 households were selected in the sample, of which 8,889 were occupied and therefore eligible for interviews. The shortfall was largely due to structures that were found to be vacant or destroyed. Of the 8,889 existing households, 8,561 were suc- cessfully interviewed, yielding a household response rate of 96 percent. In the households interviewed in the survey, 8,717 eligible women were identified; interviews were completed with 8,195 of these women, yielding a response rate of 94 percent. With regard to the male survey results, 4,183 eligible men were identified in the subsample of households selected for the male survey, of whom 3,578 were successfully interviewed, yielding a response rate of 86 percent. The response rates are higher in rural areas, as compared with urban areas both for males and females. More detailed tables on response rates for women and men are given in Appendix A. The principal reason for nonresponse among both eligible men and women was the failure to find individuals despite repeated visits to the household and even sometimes the work place. The substantially lower response rate for men reflects the more frequent and longer absences of men from the household. Response rates for the HIV testing component were lower than those for the interviews. Details of the HIV testing response rates are discussed in Chapter 13. 12 | Introduction Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, accord- ing to residence, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence ––––––––––––––––– Result Urban Rural Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Household interviews Households selected 3,423 6,442 9,865 Households occupied 3,068 5,821 8,889 Households interviewed 2,893 5,668 8,561 Household response rate 94.3 97.4 96.3 Interviews with women Number of eligible women 3,019 5,698 8,717 Number of eligible women interviewed 2,751 5,444 8,195 Eligible woman response rate 91.1 95.5 94.0 Household interviews for male subsample Households selected 1,680 3,188 4,868 Households occupied 1,505 2,891 4,396 Households interviewed 1,420 2,814 4,234 Household response rate for male subsample 94.4 97.3 96.3 Interviews with men Number of eligible men 1,466 2,717 4,183 Number of eligible men interviewed 1,150 2,428 3,578 Eligible man response rate 78.4 89.4 85.5 Household Population and Housing Characteristics | 13 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 Francis M. Munene This chapter presents information on the social, economic, and demographic characteristics of the household population, focusing mainly on such background characteristics as age, sex, educational atten- dance and attainment, place of residence, and socio-economic conditions of households. The information provided is intended to facilitate interpretation of the key demographic, socioeconomic, and health indi- ces. It is further intended to assist in the assessment of the representativeness of the survey. One of the background characteristics used throughout this report is an index of socioeconomic status. The economic index used here was recently developed and tested in a large number of countries in relation to inequities in household income, use of health services, and health outcomes (Rutstein et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The economic index was constructed using household asset data with principal compo- nents analysis. The asset information was collected through the Household Questionnaire of the 2003 KDHS and covers information on household ownership of a number of consumer items ranging from a television to a bicycle or car, as well as dwelling characteristics, such as source of drinking water, sanita- tion facilities, and type of material used for flooring. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardised in relation to a normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles from one (low- est) to five (highest). A single asset index was developed for the whole sample; separate indices were not prepared for the urban and rural population separately. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX The 2003 KDHS Household Questionnaire solicited information on key demographic and socio- economic characteristics; parental survivorship and residence for people age 15 years and under; educa- tional attendance/attainment; and housing characteristics. A household was defined as a person or group of people, related or unrelated to each other, who live together in the same dwelling unit and share a com- mon source of food. Table 2.1 presents the distribution of the 2003 KDHS household population by five-year age groups, according to sex and urban-rural residence. The household population constitutes 37,128 persons, of which 49 percent are males and 51 percent are females. There are more persons in the younger age groups than in the older groups for both sexes. Figure 2.1 shows the age-sex structure of the Kenyan population. The household population age- sex structure is still wide based, as depicted by the population pyramid, despite evidence that the percent- age share of the younger population has been falling while the percentage of those age 15-64 has been increasing. The KDHS household population has a median age of 17.5, a slight increase from the previous 14 | Household Population and Housing Characteristics Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 KDHS 2003 Age Male Percent Female Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and resi- dence, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban Rural Total ––––––––––––––––––––––– –––––––––––––––––––––– ––––––––––––––––––––––– Age Male Female Total Male Female Total Male Female Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– <5 14.6 13.9 14.2 16.6 16.1 16.4 16.2 15.7 15.9 5-9 10.9 11.2 11.0 15.7 14.7 15.2 14.7 14.0 14.4 10-14 9.6 10.4 10.0 16.3 14.4 15.4 15.0 13.6 14.3 15-19 9.2 11.2 10.2 12.0 10.3 11.1 11.4 10.5 10.9 20-24 12.5 15.1 13.8 7.8 8.2 8.0 8.7 9.5 9.1 25-29 11.9 11.2 11.5 5.8 6.9 6.4 7.0 7.8 7.4 30-34 8.6 8.3 8.5 5.1 5.6 5.3 5.8 6.2 6.0 35-39 7.0 6.0 6.5 4.0 4.6 4.3 4.6 4.9 4.7 40-44 4.9 4.4 4.6 3.9 4.5 4.2 4.1 4.4 4.3 45-49 3.7 2.9 3.3 2.6 2.9 2.8 2.9 2.9 2.9 50-54 2.9 2.3 2.6 2.5 3.3 2.9 2.6 3.1 2.9 55-59 1.9 1.3 1.6 2.1 2.4 2.2 2.0 2.2 2.1 60-64 1.0 0.9 1.0 1.7 1.8 1.8 1.6 1.6 1.6 65-69 0.6 0.3 0.4 1.2 1.3 1.2 1.0 1.1 1.1 70-74 0.4 0.2 0.3 1.1 1.3 1.2 1.0 1.1 1.0 75-79 0.1 0.3 0.2 0.7 0.6 0.7 0.6 0.6 0.6 80+ 0.2 0.1 0.2 0.8 0.9 0.9 0.7 0.8 0.7 Don't know/missing 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,663 3,680 7,344 14,627 15,157 29,784 18,291 18,837 37,128 Household Population and Housing Characteristics | 15 observed population samples (15.3 in 1993 and 16.9 in 1998). This is an indication that the Kenyan popu- lation is aging, most probably because of the decline in fertility in the 1980s and 1990s. The share of the Kenyan population under 15 years of age is 45 percent, those age 15-64 constitute 52 percent, and those age 65 years and above make up 3 percent of the total Kenyan household population. This means that the age dependency ratio in Kenya has declined from 127 in 1989, to 98 in 1998, and to 92 in 2003.1 2.2 HOUSEHOLD COMPOSITION Table 2.2 shows the distribution of households by sex of the head of household and by household size, according to rural-urban residence and province. At the national level, women head 32 percent of Kenyan households, a pattern that has remained more or less constant since the 1993 KDHS but is lower than the 37 percent from the 1999 population census (Central Bureau of Statistics, 2002g :11). There are modest differences in female-headed households between urban (26 percent) and rural areas (34 percent). Regional differentials are relatively modest, with Western, Nyanza, and Eastern provinces registering the highest proportions of female-headed households (38, 37, and 36 percent, respectively), while Nairobi Province has the lowest (20 percent). Table 2.2 also shows that the mean size of a Kenyan household is 4.4 persons, identical to the mean household size of 4.4 found in the 1999 population census (Central Bureau of Statistics, 2002g: 15). When the northern areas of Kenya are excluded for comparison with previous surveys, the mean house- hold size is 4.3 in 2003, a drop from the 4.8 persons per household reported in the 1993 KDHS, but iden- tical to the 1998 KDHS level of 4.3. 1 The dependency ratio is defined as the sum of all persons under 15 years or over 64 years of age, divided by the number of persons age 15-64, multiplied by 100. Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size, according to residence and province, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Province ––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Rift North Characteristic Urban Rural Nairobi Central Coast Eastern Nyanza Valley Western Eastern Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Sex of head of household Male 74.4 66.2 79.9 65.8 71.9 64.2 63.4 72.4 62.2 70.2 68.3 Female 25.6 33.8 20.1 34.2 28.1 35.8 36.6 27.6 37.8 29.8 31.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of usual members 1 22.6 11.1 22.0 18.0 16.2 11.3 12.0 11.9 12.4 3.7 14.0 2 18.1 9.9 20.2 12.6 12.9 10.6 11.7 10.8 8.7 8.3 12.0 3 16.3 13.8 17.2 17.5 14.6 13.1 14.4 12.9 13.5 10.0 14.4 4 14.9 15.7 15.0 18.4 13.5 15.0 15.9 13.9 17.1 10.8 15.5 5 11.2 15.3 11.3 15.4 11.2 13.9 14.4 15.9 14.4 14.1 14.3 6 7.0 12.4 6.7 8.1 10.5 12.0 12.4 12.4 12.7 16.0 11.1 7 4.4 9.4 4.3 5.2 6.7 10.6 8.9 9.3 9.1 14.5 8.2 8 2.5 5.7 1.6 2.6 5.4 5.7 4.7 6.5 5.9 9.6 4.9 9+ 3.0 6.6 1.7 2.2 8.9 7.8 5.6 6.4 6.4 13.1 5.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 2,136 6,405 837 1,350 683 1,313 1,278 1,927 966 187 8,542 Mean size 3.5 4.7 3.3 3.8 4.4 4.7 4.5 4.6 4.6 5.7 4.4 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table is based on de jure members, i.e., usual residents. 16 | Household Population and Housing Characteristics As expected, urban households have, on average, much smaller household sizes (3.5 persons) than rural households (4.7 persons). Wide variations in the average household sizes are also observed across provinces, with the largest household sizes occurring in North Eastern Province (5.7 persons) and the smallest in Nairobi (3.3 persons). 2.3 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Tables 2.3.1 and 2.3.2 show the percent distribution of the female and male household population age six years and over by highest level of education attended, according to background characteristics. Twenty-three percent of females and 16 percent of males have no education at all, while about three in five women and men have some primary education or complete primary only. Among males, 22 percent have attained at least some secondary education, compared with only 17 percent of females. Table 2.3.1 Educational attainment of household population: females Percent distribution of the de facto female household population age six and over by highest level of education attended or completed, accord- ing to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Don’t Median Background No Primary Primary Secondary Secondary More than know/ number characteristic education incomplete complete1 incomplete complete2 secondary missing Total Number of years –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 6-9 41.8 57.9 0.0 0.0 0.0 0.0 0.3 100.0 2,166 0.0 10-14 9.6 88.1 1.2 0.8 0.0 0.0 0.2 100.0 2,566 3.1 15-19 7.8 51.9 18.5 16.7 4.5 0.6 0.0 100.0 1,981 6.5 20-24 8.1 27.4 30.9 9.6 17.4 6.4 0.2 100.0 1,797 7.5 25-29 10.3 29.4 28.6 7.6 14.6 9.2 0.2 100.0 1,462 7.4 30-34 13.0 32.0 22.9 9.2 14.4 7.9 0.5 100.0 1,159 7.2 35-39 14.7 25.3 26.4 11.3 14.3 7.3 0.7 100.0 915 6.5 40-44 25.7 24.5 20.1 9.6 12.0 7.8 0.3 100.0 837 5.9 45-49 33.2 27.5 18.0 7.4 8.1 4.9 0.8 100.0 543 4.0 50-54 40.6 29.4 18.1 2.5 4.5 3.7 1.2 100.0 587 2.4 55-59 57.8 26.5 8.6 1.1 1.5 2.6 1.9 100.0 414 0.0 60-64 73.9 20.9 3.7 0.3 0.5 0.5 0.3 100.0 305 0.0 65+ 80.5 16.2 1.8 0.3 0.0 0.2 1.0 100.0 665 0.0 Residence Urban 13.9 30.3 20.3 9.0 15.2 10.7 0.5 100.0 3,099 7.1 Rural 25.2 48.2 13.6 5.7 5.0 1.7 0.4 100.0 12,316 3.5 Province Nairobi 10.0 22.9 20.4 8.9 21.8 15.4 0.6 100.0 1,157 7.8 Central 12.0 43.1 20.5 8.2 10.8 5.0 0.5 100.0 2,234 6.1 Coast 37.8 36.7 13.0 3.5 5.8 2.7 0.5 100.0 1,222 2.0 Eastern 21.2 49.2 17.1 4.5 5.6 2.3 0.2 100.0 2,632 3.9 Nyanza 18.3 54.9 12.2 8.7 4.0 1.8 0.2 100.0 2,393 4.0 Rift Valley 28.6 43.4 13.8 5.3 5.8 2.6 0.4 100.0 3,594 3.5 Western 18.2 55.1 12.1 7.9 4.2 1.6 1.0 100.0 1,794 4.0 North Eastern 86.8 11.9 0.5 0.3 0.1 0.2 0.2 100.0 389 0.0 Wealth quintile Lowest 43.7 44.9 7.6 2.2 1.0 0.1 0.5 100.0 2,833 0.6 Second 25.9 52.5 12.9 5.6 2.3 0.3 0.4 100.0 3,085 3.2 Middle 22.8 51.3 14.5 6.3 4.3 0.5 0.3 100.0 3,205 3.6 Fourth 14.7 45.0 18.6 8.0 9.9 3.2 0.5 100.0 3,161 5.6 Highest 9.5 29.3 20.5 9.5 17.3 13.3 0.6 100.0 3,131 7.4 Total 22.9 44.6 15.0 6.4 7.1 3.5 0.4 100.0 15,415 4.3 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 16 women whose age was not stated. 1 Completed grade 8 at the primary level 2 Completed form 4 at the secondary level Household Population and Housing Characteristics | 17 There has been a slight increase in the proportion of children and young adults who have never attended school between the 1998 KDHS and the 2003 KDHS, most notably among those age 6-9 years. Differences are diminished, however, when the northern areas of the country are excluded from the 2003 data so as to be comparable to the preceding surveys. Differences in the youngest age group (6-9) may be due to the addition of a code “0” in the 2003 survey to allow for preschool, such as nursery school and kindergarten. It is possible that children in Standard 1 were erroneously coded as having reached only level “0,” instead of level “1” for primary school. The proportion of the household population age six years and above who have attended school is higher for males than females in most age groups. However, the gender gap in the proportions with no education is narrower in 2003 than in 1998. Whereas about 95 percent of children of both sexes have at least some schooling, only 25 to 30 percent of young adults are able to complete secondary school. Table 2.3.2 Educational attainment of household population: males Percent distribution of the de facto male household population age six and over by highest level of education attended or completed, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Don’t Median Background No Primary Primary Secondary Secondary More than know/ number characteristic education incomplete complete1 incomplete complete2 secondary missing Total Number of years –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 6-9 45.2 54.3 0.0 0.0 0.0 0.0 0.4 100.0 2,195 0.0 10-14 8.6 89.8 1.0 0.6 0.0 0.0 0.1 100.0 2,741 2.8 15-19 5.7 61.9 13.0 14.9 3.8 0.1 0.6 100.0 2,084 6.0 20-24 5.1 29.3 25.4 10.6 21.4 7.4 0.8 100.0 1,594 7.6 25-29 5.8 26.5 27.2 7.0 22.3 10.9 0.3 100.0 1,287 7.7 30-34 5.8 24.8 24.8 7.8 25.0 11.7 0.2 100.0 1,055 7.9 35-39 8.3 12.7 33.3 11.0 21.8 12.4 0.5 100.0 843 7.6 40-44 11.7 18.1 27.6 6.5 24.8 10.7 0.6 100.0 749 6.8 45-49 14.6 21.3 23.2 8.3 17.8 14.0 0.9 100.0 523 6.7 50-54 17.6 24.2 25.8 8.2 12.0 11.8 0.5 100.0 471 6.4 55-59 18.2 25.5 28.2 9.2 9.7 7.8 1.4 100.0 369 6.3 60-64 34.6 26.6 17.6 5.7 7.2 6.6 1.7 100.0 287 3.0 65+ 47.9 34.6 9.9 2.8 2.1 1.6 1.1 100.0 611 0.3 Residence Urban 9.6 28.4 18.4 9.0 21.7 12.3 0.6 100.0 3,051 7.5 Rural 17.4 50.9 14.4 5.8 7.6 3.2 0.5 100.0 11,774 4.2 Province Nairobi 7.3 21.2 16.0 9.4 28.9 16.4 0.7 100.0 1,212 9.2 Central 6.8 44.6 20.8 8.3 12.4 6.4 0.6 100.0 2,123 6.4 Coast 23.5 39.4 17.9 5.3 10.2 3.0 0.7 100.0 1,190 4.0 Eastern 14.3 53.9 15.7 4.8 7.2 3.6 0.4 100.0 2,484 4.0 Nyanza 10.3 55.0 13.3 8.5 8.9 3.7 0.4 100.0 2,236 4.9 Rift Valley 22.7 44.4 14.4 4.6 9.1 4.3 0.5 100.0 3,465 4.2 Western 11.4 56.8 12.6 7.6 7.2 3.5 1.0 100.0 1,705 4.3 North Eastern 65.2 28.3 2.5 1.1 2.3 0.8 0.0 100.0 410 0.0 Wealth quintile Lowest 33.6 49.9 10.1 3.0 2.8 0.4 0.3 100.0 2,781 1.7 Second 16.9 56.4 14.1 5.4 5.2 1.3 0.7 100.0 2,900 3.7 Middle 14.5 53.8 15.5 6.9 7.3 1.4 0.5 100.0 2,910 4.5 Fourth 8.8 46.4 18.4 7.3 12.7 5.8 0.6 100.0 3,084 6.1 Highest 7.3 26.8 17.5 9.1 23.1 15.4 0.7 100.0 3,149 7.8 Total 15.8 46.3 15.2 6.5 10.5 5.1 0.6 100.0 14,825 5.0 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 15 men whose age was not stated. 1 Completed grade 8 at the primary level 2 Completed form 4 at the secondary level 18 | Household Population and Housing Characteristics The median number of years of schooling completed by sex has increased slightly between 1998 and 2003 for both sexes when the northern areas of the country are excluded. Educational attainment is higher in urban areas than in rural areas. The median number of years of education is highest in Nairobi for both sexes and lowest in North Eastern Province. Almost two-thirds of males and 87 percent of fe- males age six and over in North Eastern Province have no education. Table 2.4 shows the percentage of the household population age 6-24 who are currently attending school, by age, sex, and residence. Eighty-nine percent of those age 6-15 are in school, with rural atten- dance identical to urban attendance and male attendance negligibly higher than female attendance (90 and 89 percent, respectively). However, at age group 16-20, attendance levels have dropped in half, and they are noticeably higher in rural than in urban areas and also considerably higher for males than females. A comparison of data from the 2003 KDHS and the 1998 KDHS shows that there is some im- provement in school attendance at all ages from 6 to 24 years. Excluding the north, the proportion of chil- dren age 6-15 attending school increased from 85 percent in 1998 to 93 percent in 2003. Figure 2.2 shows that attendance rates for both males and females are at par (89 percent) at age group 6-10. However, girls tend to drop out of school earlier than boys, such that at age group 11-15, 90 percent of boys and 88 percent of girls are attending school. After age 11-15, the gender gap begins to widen, such that by age 21-24, only 11 percent of males and 4 percent of females are in school. The larg- est drop in attendance for both sexes occurs at age 16-20 (51 and 37 percent for males and females, re- spectively). Table 2.4 School attendance Percentage of the de facto household population age 6-24 years currently attending school, by age, sex, and residence, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Male Female Total ––––––––––––––––––––––– –––––––––––––––––––––– ––––––––––––––––––––––– Age Urban Rural Total Urban Rural Total Urban Rural Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 6-10 89.7 89.3 89.4 93.3 88.4 89.2 91.6 88.9 89.3 11-15 91.7 90.2 90.4 82.5 89.4 88.3 87.0 89.8 89.4 6-15 90.6 89.7 89.9 88.3 88.9 88.8 89.4 89.3 89.3 16-20 35.5 55.1 51.3 23.0 41.5 36.9 28.6 48.5 44.1 21-24 13.6 9.4 10.6 4.8 3.4 3.8 8.7 6.2 6.9 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table includes children attending kindergarten/pre-school. Household Population and Housing Characteristics | 19 Figure 2.2 Percentage of Males and Females Currently Attending School, by Age KDHS 2003 , , , , # # # # 6-10 11-15 16-20 21-24 Age in years 0 20 40 60 80 100 Male Female# , Table 2.5 presents net attendance ratios (NARs) and gross attendance ratios (GARs) for the household population by level of schooling and sex, according to background characteristics. The NAR for primary school measures the proportion of children of primary school age who are attending primary school, while the GAR represents the total number of primary school students of any age from 5 to 24 as a percentage of children of primary school age. In the Kenyan context, the levels refer to 6 to 13 years for primary and 14 to 17 years for secondary. The GAR is usually higher than the NAR because the GAR includes participation of those who may be older or younger than the official age range for that level. Stu- dents who are over age for a given level of school may have started school late, may have repeated one or more grades in school, or may have dropped out of school and later returned. The NAR indicates that 79 percent of children of primary school age are attending primary school. There is no gender gap among the children who are attending primary school; the NAR is 79 per- cent for both boys and girls. NARs for primary school are higher in urban (83 percent) than in rural areas (78 percent) and are highest in the Central (91 percent), Western (86 percent), Nairobi (85 percent) and Eastern (85 percent) provinces. Ratios are lowest in North Eastern Province (36 percent). The GAR indi- cates that there are children in primary school who are not of primary school age, with ratios of 113 for males and 106 for females. As expected, both the NAR and GAR are lower at the secondary school level. The NAR indicates that only 13 percent of the secondary school age population are attending secondary school. Net secon- dary school attendance is higher for females (NAR of 13) than for males (NAR of 12). Nairobi, Central, and Nyanza provinces have the highest NARs at the secondary level of 32, 19, and 14 percent respec- tively, while North Eastern Province has the lowest (2 percent). The GAR shows that there are many sec- ondary school students who are not of secondary school age. In fact, discrepancies between the NAR and GAR indicate that there are almost as many secondary school students who are either over age or under age as there are students of secondary school age. 20 | Household Population and Housing Characteristics Table 2.5 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de jure household population by level of schooling and sex, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Net attendance ratio1 Gross attendance ratio2 Gender Background –––––––––––––––––––––––––– ––––––––––––––––––––––––– parity characteristic Male Female Total Male Female Total index3 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– PRIMARY SCHOOL ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 82.4 82.5 82.5 103.2 99.9 101.5 0.97 Rural 78.0 78.1 78.0 114.2 107.2 110.8 0.94 Province Nairobi 85.9 84.1 85.0 101.4 97.0 99.2 0.96 Central 90.6 91.1 90.8 121.9 119.4 120.7 0.98 Coast 71.9 67.2 69.7 98.8 86.0 92.8 0.87 Eastern 85.2 84.2 84.7 125.6 117.4 121.5 0.93 Nyanza 78.5 81.7 80.1 122.3 111.4 116.9 0.91 Rift Valley 70.9 73.9 72.4 101.6 98.3 99.9 0.97 Western 86.5 86.1 86.3 123.4 123.4 123.4 1.00 North Eastern 44.6 26.5 36.3 66.6 34.1 51.7 0.51 Wealth quintile Lowest 63.0 59.4 61.3 95.5 84.1 90.1 0.88 Second 79.0 81.0 79.9 116.5 112.2 114.4 0.96 Middle 83.5 84.1 83.8 122.7 116.0 119.3 0.94 Fourth 88.4 87.9 88.1 126.3 119.4 123.0 0.95 Highest 85.5 86.4 86.0 103.0 99.8 101.4 0.97 Total 78.6 78.8 78.7 112.7 106.1 109.5 0.94 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– SECONDARY SCHOOL ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 26.8 21.8 24.2 42.1 29.9 35.7 0.71 Rural 9.1 11.6 10.3 20.9 19.6 20.3 0.94 Province Nairobi 35.5 28.9 32.1 52.6 37.7 44.8 0.72 Central 19.0 19.4 19.2 31.2 29.6 30.4 0.95 Coast 8.4 11.0 9.7 17.6 12.7 15.1 0.72 Eastern 5.9 8.1 6.9 15.1 12.8 14.0 0.85 Nyanza 12.2 16.5 14.2 31.2 28.9 30.2 0.93 Rift Valley 10.6 8.6 9.7 18.0 14.6 16.4 0.81 Western 9.8 15.9 12.9 28.6 28.8 28.7 1.00 North Eastern 2.8 1.4 2.2 6.6 1.6 4.4 0.25 Wealth quintile Lowest 2.7 5.4 4.0 9.1 8.6 8.9 0.94 Second 6.7 7.9 7.3 20.9 17.3 19.2 0.83 Middle 11.1 11.6 11.4 23.9 19.4 21.8 0.81 Fourth 13.6 19.1 16.2 26.9 29.4 28.1 1.09 Highest 31.9 25.0 28.2 48.1 34.2 40.8 0.71 Total 11.7 13.4 12.5 24.0 21.4 22.7 0.89 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 The NAR for primary school is the percentage of the primary-school-age (6-13 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (14-17 years) popula- tion that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the offi- cial primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of over- age and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school GAR for females to the GAR for males. The Gender Parity Index for secondary school is the ratio of the secondary school GAR for females to the GAR for males. Household Population and Housing Characteristics | 21 The gender parity index shows the ratio of the female to male GARs. For the primary school level, the gender parity index is close to one (indicating parity between the sexes) for all groups except North East- ern Province, where the GAR for females is half that for males. For the secondary school level, the gender parity index is generally lower, especially for North Eastern Province. 2.4 HOUSING CHARACTERISTICS Given that there is a strong relationship between household economic conditions and exposure to diseases, information on housing characteristics, such as access to electricity, source of drinking water, sanitary facilities, and flooring and roofing materials, is key to explaining the interrelationships between the social and economic conditions of the household and likely exposure to and prevalence of diseases. Table 2.6 presents the percent distribution of households by housing characteristics, according to resi- dence and province. The table shows that only 16 percent of Kenyan households have electricity, with large discrep- ancies by urban-rural residence. Half of urban households have electricity, compared with only 5 percent of rural households. Wide regional variations in the supply of electricity are evident, with Nairobi Prov- ince registering the highest proportion of households (71 percent) connected to electricity supply. Western Province is least supplied, with only 2 percent of households having electricity. The predominant flooring materials used by Kenyan households are earth, mud, dung, and sand, with a share of 62 percent. Cement is the next most common flooring material, with a share of 34 percent. Seventy-one percent of urban households use cement for flooring their houses, while 77 percent of rural households use packed earth. These proportions are almost identical to those from the 1999 population census (Central Bureau of Statistics, 2002g: 30). About two-thirds of Kenyan households (69 percent) live in dwellings with corrugated iron (ma- bati) roofs, while almost all of the rest (22 percent) have grass or thatched roofs. Urban-rural differences in roofing material are not as strong as those for some of the other housing characteristics, with 73 percent of urban households having corrugated iron roofs, compared with 67 percent of rural households. Data from the 1999 population census show a slightly larger proportion of households with grass or thatched roofs (28 percent) and fewer with iron sheet roofs (64 percent), as compared with the 2003 KDHS (Cen- tral Bureau of Statistics, 2002g: 25). The 2003 KDHS collected data on the number of rooms used by members of the households for sleeping. This information provides a rough measure of the degree and severity of household crowding. Most households in Kenya (77 percent) have 1 to 2 persons sleeping together in a single room, and the mean is 2.6. For cooking fuel, two-thirds of Kenyan households depend on firewood. Urban households mostly use kerosene (51 percent) or charcoal (26 percent), while 85 percent of rural households use fire- wood. The 2003 KDHS collected information on the source of drinking water (Table 2.6). Almost one in four (24 percent) Kenyan households draws its drinking water from either rivers or streams; 21 percent have piped water connected to their dwelling, compound, or plot; and 11 percent use a public tap. Almost one in five households uses wells as a source of drinking water, the majority of which are covered or pro- tected wells. Less than 5 percent of households use other types of water supply sources. A majority of households (53 percent) are within 15 minutes of their water source. 22 | Household Population and Housing Characteristics Table 2.6 Housing characteristics Percent distribution of households by housing characteristics, according to residence and province, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Province ––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Housing Rift North characteristic Urban Rural Nairobi Central Coast Eastern Nyanza Valley Western Eastern Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Electricity Yes 50.2 4.6 71.4 19.2 19.3 6.9 5.1 10.5 1.6 3.2 16.0 No 49.8 95.2 28.5 80.4 80.5 93.1 94.9 89.5 98.2 95.9 83.9 Missing 0.0 0.2 0.1 0.4 0.2 0.0 0.0 0.1 0.2 1.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, mud, dung, sand 18.8 76.5 10.9 60.7 54.7 62.5 73.8 66.3 83.1 93.7 62.1 Wood planks 0.9 0.3 1.7 0.3 0.0 0.5 0.0 0.7 0.0 0.0 0.5 Palm, bamboo 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.1 Parquet, polished wood 1.2 0.1 3.0 0.1 0.1 0.0 0.0 0.1 0.0 0.0 0.4 Vinyl, asphalt strips 1.4 0.1 2.3 0.7 0.1 0.1 0.0 0.2 0.1 0.0 0.4 Ceramic tiles 2.1 0.3 4.4 0.8 0.4 0.1 0.3 0.5 0.1 0.1 0.8 Cement 71.4 22.1 70.7 36.2 41.8 35.6 25.8 31.4 16.5 6.0 34.4 Carpet 2.9 0.3 4.1 0.8 2.7 0.3 0.0 0.6 0.1 0.1 0.9 Other 1.2 0.0 2.7 0.0 0.1 0.3 0.0 0.0 0.0 0.0 0.3 Missing 0.2 0.2 0.1 0.3 0.1 0.6 0.0 0.0 0.1 0.0 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Roofing material Grass, thatch, makuti 4.0 28.4 0.1 2.7 39.4 18.4 30.0 24.7 34.1 89.6 22.3 Tin cans 0.3 0.4 0.7 1.1 0.3 0.2 0.0 0.3 0.0 0.0 0.4 Corrugated iron (mabati) 73.3 67.1 56.2 92.0 52.3 78.1 68.2 64.7 65.2 9.8 68.6 Asbestos sheets 3.4 0.7 4.2 0.7 2.8 2.2 0.5 0.5 0.5 0.2 1.3 Concrete 12.6 0.6 26.2 1.0 4.0 0.3 0.3 2.0 0.0 0.2 3.6 Tiles 5.9 0.6 12.2 2.2 1.3 0.3 0.7 0.4 0.0 0.1 1.9 Other 0.5 2.1 0.2 0.0 0.0 0.2 0.2 7.3 0.0 0.0 1.7 Missing 0.2 0.2 0.1 0.3 0.1 0.5 0.0 0.1 0.2 0.0 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Persons per sleeping room 1-2 persons 64.1 60.8 65.7 80.4 60.0 67.3 63.4 46.0 62.7 16.1 61.6 3-4 persons 27.3 26.4 26.9 15.6 28.8 24.5 28.4 31.9 29.9 28.7 26.6 5-6 persons 6.9 8.6 6.2 3.3 8.1 5.5 6.3 14.9 5.9 27.9 8.2 7+ persons 1.7 4.2 1.1 0.8 3.1 2.6 2.0 7.1 1.6 27.3 3.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Mean number 2.4 2.7 2.3 1.9 2.6 2.4 2.5 3.2 2.5 5.0 2.6 Type of cooking fuel Electricity 1.0 0.1 1.8 0.2 0.4 0.4 0.1 0.1 0.0 0.0 0.3 LPG, natural gas 10.8 1.1 19.8 4.3 2.4 0.7 1.0 1.5 0.9 0.0 3.5 Biogas 0.3 0.0 0.6 0.0 0.3 0.0 0.0 0.1 0.1 0.0 0.1 Kerosene 50.8 2.8 68.3 14.5 22.5 6.8 4.2 8.8 3.3 0.4 14.8 Coal, lignite 0.2 0.0 0.3 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 Charcoal 25.9 10.2 7.4 14.8 19.1 8.2 15.6 19.7 11.7 9.1 14.2 Firewood, straw 9.4 85.2 0.1 65.1 53.9 83.5 79.0 68.9 83.5 90.2 66.2 Dung 1.6 0.4 1.7 0.8 1.2 0.4 0.1 0.9 0.4 0.2 0.7 Other 0.1 0.1 0.1 0.4 0.1 0.0 0.0 0.0 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Continued… Household Population and Housing Characteristics | 23 Table 2.6—Continued ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Province ––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Housing Rift North characteristic Urban Rural Nairobi Central Coast Eastern Nyanza Valley Western Eastern Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Source of drinking water Piped into dwelling 19.2 3.8 33.2 11.8 8.1 4.1 0.6 4.5 1.3 0.6 7.6 Piped into compound/plot 30.2 7.8 43.4 19.3 9.7 18.4 2.3 8.2 2.6 1.6 13.4 Public tap 21.8 6.8 15.0 3.5 40.1 9.1 11.7 7.8 3.9 0.1 10.6 Open well in compound/plot 1.8 1.7 0.2 2.2 1.3 0.6 0.7 3.3 2.3 3.8 1.7 Open public well 4.1 6.0 0.1 3.5 9.7 6.6 5.5 6.3 3.5 25.0 5.5 Covered well in compound/plot 3.3 5.9 0.3 8.3 0.9 1.6 1.2 13.0 4.1 1.4 5.3 Covered public well 2.6 7.5 0.1 4.5 1.8 8.1 9.4 4.8 13.5 6.1 6.3 Spring 1.7 16.9 0.0 6.2 0.9 11.5 33.4 3.2 40.3 0.0 13.1 River, stream 2.5 31.1 0.0 24.8 11.7 29.9 25.0 32.4 26.2 21.1 23.9 Pond, lake 0.0 2.2 0.0 0.1 1.7 0.3 7.6 1.2 0.2 0.4 1.6 Dam 0.7 4.1 0.1 1.7 9.6 4.6 0.3 3.3 0.0 34.1 3.3 Rainwater 0.7 2.5 0.1 7.5 0.4 0.9 1.7 1.3 0.9 1.7 2.1 Bottled water 0.7 0.0 1.3 0.0 0.2 0.0 0.1 0.0 0.2 0.0 0.2 Other 10.6 3.5 6.2 6.4 3.9 4.4 0.5 10.7 1.0 4.1 5.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Time to water source Percentage <15 minutes 83.8 43.1 95.9 70.9 63.6 38.7 31.6 50.5 44.6 22.1 53.2 Median time to source 0.0 14.9 0.0 0.7 5.0 24.7 19.7 10.0 14.4 u 9.7 Water availability Usually available 70.0 82.0 64.8 85.7 77.3 77.0 90.7 67.7 95.3 67.1 79.0 Several hours per day 10.1 1.6 14.0 1.2 6.7 4.6 3.4 1.2 0.8 2.5 3.7 Once or twice per week 10.0 3.1 12.8 2.7 4.0 8.6 1.9 4.9 0.9 2.8 4.9 Infrequent 9.1 13.1 7.0 10.2 11.7 9.6 3.8 26.2 2.5 27.2 12.1 Drinks bottled water 0.7 0.0 1.3 0.0 0.2 0.0 0.1 0.0 0.2 0.0 0.2 Missing 0.1 0.2 0.2 0.3 0.1 0.3 0.0 0.0 0.3 0.4 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Sanitation facility Flush toilet 39.0 1.7 66.5 9.5 12.3 4.9 2.1 3.4 1.9 0.3 11.0 Traditional pit toilet 44.2 70.3 26.5 84.3 39.2 74.2 66.1 58.8 87.3 14.3 63.8 Ventilated improved pit latrine 11.7 7.3 2.2 5.5 14.6 8.9 5.6 13.2 7.9 1.4 8.4 No facility, bush, field 3.7 20.4 2.7 0.2 33.5 11.8 26.2 24.1 2.8 80.9 16.2 Other 1.2 0.1 1.6 0.2 0.4 0.1 0.1 0.4 0.0 2.7 0.4 Missing 0.2 0.2 0.4 0.3 0.0 0.2 0.0 0.1 0.1 0.4 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Share toilet with other households No facilities 3.7 20.4 2.7 0.2 33.5 11.8 26.2 24.1 2.8 80.9 16.2 No 28.0 47.4 32.8 59.5 27.1 55.3 35.5 36.9 48.2 7.8 42.5 Yes 68.3 32.1 64.4 40.1 39.4 32.9 38.3 39.1 48.9 11.3 41.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Wealth quintile Lowest 1.3 21.2 0.0 0.9 22.7 12.3 23.7 22.1 20.3 71.6 16.3 Second 1.4 23.3 0.0 12.7 10.6 20.7 29.6 16.5 30.2 10.8 17.9 Middle 2.6 24.9 0.0 27.7 13.6 27.3 20.1 14.6 27.6 9.3 19.3 Fourth 12.2 22.8 2.9 36.0 15.7 27.2 12.9 22.7 14.2 4.6 20.2 Highest 82.5 7.7 97.1 22.7 37.4 12.4 13.6 24.1 7.7 3.7 26.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Continued… 24 | Household Population and Housing Characteristics There are marked provincial differentials in the source of drinking water. More than three- quarters of the households in Nairobi have piped water in their dwelling, compound, or plot compared with only 2 to 4 percent of households in Western, Nyanza, and North Eastern provinces. About 83 percent of the households in Kenya have access to some type of sanitary facility. Two- thirds of households in Kenya have traditional pit toilets, while only 11 percent have flush toilets. Sixteen percent of households have no toilet facilities. As expected, flush toilets are more widely used in urban areas and in Nairobi, although pit toilets are also very common. Traditional pit toilets are the predominant type of toilet in all the provinces, with the exception of Nairobi, where flush toilets are more common, and North Eastern Province, where toilet facilities are rare. The proportion of households with private toilets is almost identical to the proportion with shared toilets. Table 2.6—Continued ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Province ––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Housing Rift North characteristic Urban Rural Nairobi Central Coast Eastern Nyanza Valley Western Eastern Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Household owns structure Owns 19.3 87.6 10.4 73.3 63.8 85.3 84.6 66.4 89.6 87.3 70.5 Pays rent, lease 76.2 6.7 84.7 20.4 29.5 9.9 14.2 24.7 7.8 4.4 24.1 No rent, with consent of owner 4.3 4.9 4.6 5.7 5.9 4.8 1.2 7.1 2.2 6.3 4.7 No rent, squatting 0.1 0.7 0.1 0.3 0.8 0.1 0.0 1.7 0.1 1.9 0.6 Missing 0.1 0.1 0.2 0.3 0.1 0.0 0.0 0.1 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Household owns land on which structure sits Owns 15.6 80.5 8.3 58.1 54.5 78.6 83.9 60.0 89.3 75.8 64.3 Pays rent, lease 58.4 5.3 49.5 18.7 27.4 9.9 12.1 19.4 6.5 4.4 18.5 No rent with consent of owner 25.4 12.7 42.0 21.5 15.6 11.2 3.9 18.2 3.9 10.7 15.9 No rent, squatting 0.5 1.4 0.1 1.3 2.4 0.1 0.1 2.3 0.2 9.1 1.2 Missing 0.1 0.2 0.1 0.3 0.1 0.2 0.0 0.1 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 State of repair of dwelling Completely dilapidated, shack 2.1 2.1 3.2 0.2 9.1 1.2 1.4 2.0 0.5 4.6 2.1 Needs major repairs 17.3 22.4 17.8 13.9 17.6 19.7 25.5 28.2 13.6 48.1 21.2 Needs no or minor repairs 79.5 72.9 78.7 85.3 69.4 74.3 70.3 67.8 84.9 43.7 74.5 Being repaired 0.5 0.5 0.3 0.1 1.8 0.4 0.4 0.3 0.0 3.6 0.5 Under construction 0.4 2.0 0.1 0.2 1.8 3.8 2.5 1.6 0.7 0.0 1.6 Missing 0.3 0.2 0.1 0.3 0.4 0.6 0.0 0.0 0.2 0.0 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 How household disposes of kitchen waste and trash Regular collection by gov’t. 2.5 0.2 2.9 0.3 2.3 0.2 0.4 0.6 0.1 0.0 0.8 Infrequent collection by gov’t. 2.4 0.0 2.8 0.3 1.1 0.3 0.1 0.4 0.2 0.1 0.6 Pays for private collection 23.6 0.4 51.7 1.6 7.8 0.3 0.1 0.7 0.3 0.0 6.2 Composted 12.3 30.5 1.7 48.2 8.8 41.9 24.3 12.6 38.9 6.3 26.0 Dumps, buries, burns in compound 29.1 55.3 10.0 37.5 59.1 42.1 59.0 64.3 56.5 42.6 48.8 Dumps in street, empty plot 24.9 8.3 22.0 7.1 18.6 1.8 15.6 15.6 3.8 49.3 12.4 Other 4.9 5.0 8.4 4.7 2.2 12.7 0.4 5.5 0.0 0.2 5.0 Missing 0.4 0.3 0.5 0.5 0.1 0.6 0.0 0.3 0.2 1.5 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 2,138 6,423 837 1,351 684 1,316 1,282 1,937 967 187 8,561 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– u = Unknown (not available) Household Population and Housing Characteristics | 25 Interpretation of trends in housing and household characteristics over time is made slightly more difficult by the inclusion of areas in the northern part of Kenya in the 2003 KDHS. Excluding these areas shows that electricity coverage has increased from 15 percent of households in 1998 to 17 percent in 2003. The proportion of households with piped water has remained stable, as have the types of toilets that households have. There are also few notable differences in the types of flooring materials used in Kenya since the 1998 KDHS. Table 2.6 provides information about household ownership of the structure and the land. Overall, 71 percent of Kenyan households own their own home, while 24 percent pay rent. As expected, in urban areas, renting is more common, with 76 percent of households renting. A similar pattern holds for owner- ship of the land. The table also shows that most homes in Kenya need only minor repairs or no repairs at all. With regard to trash disposal, almost half of Kenyan households bury or burn their trash themselves, while about one-quarter compost their trash. Urban households are almost equally likely to bury or burn their trash themselves, dump their trash in the street or an empty plot, or pay for private collection. 2.5 HOUSEHOLD DURABLE GOODS Table 2.7 shows the percentage of households possessing various durable goods by urban-rural residence. This indicator provides a rough measure of the socioeconomic status of households. Of the ten selected durable household goods, radio, bicycle, and television stand out as the three most commonly owned by a household. Seventy-four percent of Kenyan households own a radio, 29 percent own a bicy- cle, and 19 percent own a television. There is noticeable urban-rural variation in the proportion of households owning durable goods. Eighty-one percent of households in urban areas have a radio, compared with 71 percent of rural house- holds. Similarly, 33 percent of urban households have a telephone, as opposed to 6 percent of rural households. Overall, 15 percent of urban households and 24 percent of rural households have none of the selected durable goods. There has been an increase in the percentage of households owning radios, bicycles, and televi- sions since the 1998 KDHS. Those owning radios went up from 63 percent in 1998 to 76 percent in 2003 (excluding the northern parts of Kenya), while those owning television sets increased from 13 percent in 1998 to 20 percent in 2003. The percentage of households owning bicycles went up from 24 to 30 percent between the 1993 KDHS and the 2003 KDHS. Table 2.7 Household durable goods Percentage of households possessing various durable consumer goods, by residence, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence ––––––––––––––––– Durable consumer goods Urban Rural Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Radio 80.6 71.3 73.6 Television 40.6 12.4 19.4 Telephone/mobile 32.7 6.2 12.8 Refrigerator 13.4 1.2 4.3 Bicycle 17.7 33.1 29.3 Motorcycle 0.9 0.6 0.7 Car/truck 9.6 3.3 4.9 Solar power 1.1 4.0 3.3 None of the above 15.3 24.3 22.1 Number of households 2,138 6,423 8,561 Characteristics of Survey Respondents | 27 CHARACTERISTICS OF SURVEY RESPONDENTS 3 Godfrey Kyalo Ndeng’e 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Information on the basic characteristics of women and men interviewed in the survey is essential for the interpretation of findings presented later in the report. Background characteristics of the 8,195 women and 3,578 men interviewed in the Kenya Demographic and Health Survey (KDHS) are presented in Table 3.1. The distribution of respondents according to age shows a similar pattern for both genders. The proportion of respondents in each age group declines as age increases, reflecting the comparatively young age structure of the population. The distribution of sampled population by age and sex closely re- sembles that of the 1999 Population and Housing Census1 and indicates that there is no substantial selec- tion bias in the sample. In terms of rural and urban dichotomy, three-quarters of both males and females are rural respon- dents. The distribution of respondents by province shows that Rift Valley and Eastern provinces have the largest proportion of respondents, while North Eastern and Coast provinces have the least proportions. Sixty percent of female respondents are currently married or living with a man, compared with 51 percent of males. The never-married females account for slightly less than a third of all women, while 45 percent of males have never married. The proportion of female respondents who have never been to school is twice that of their male counterparts (13 versus 6 percent). Male respondents are much more likely to reach secondary school (37 percent) than females (29 percent), while only 10 percent of men and 6 percent of women manage to go beyond a secondary level of education. While the percentage of women with secondary education and above remained constant, that of men shows a downward trend since 1998. The tabulation of respondents by religion indicates that nine in ten women and men are Chris- tian (about 25 percent are Roman Catholic, and 60 to 65 percent are Protestant), while only 6 to 8 percent are Muslim. Males (7 percent) are more likely than females (2 percent) to have no religion. In terms of ethnic affiliation, Kikuyu respondents (both sexes) account for 23 percent of the total and are followed approximately in order of size by Luhya, Luo, Kamba, and Kalenjin. 3.2 EDUCATIONAL ATTAINMENT AND LITERACY Tables 3.2.1 and 3.2.2 present the distributions of female and male respondents, respectively, by the highest level of education attended according to age, urban-rural residence, province, and wealth in- dex. The large majority of respondents have not gone beyond the primary level of education. Generally, younger persons have reached higher levels of school than older people, as have urban residents. For 1 The distribution of the 2003 KDHS sample population of males and females by age matches that of the 1999 Popu- lation and Housing Census, where for males, 44 and 28 percent were age 15-24 and 25-34 years, respectively, while 29 percent were age 35-54. Similarly, for women, the pattern closely follows that of the census, where 47 percent of women were age 15-24, 29 percent were age 25-34, and 24 percent were age 35-49 years. 28 | Characteristics of Survey Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of women Number of men ––––––––––––––––––––– ––––––––––––––––––––––– Background Weighted Un- Weighted Un- characteristic percent Weighted weighted percent Weighted weighted –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 22.6 1,856 1,820 23.9 856 829 20-24 20.6 1,691 1,710 19.0 681 674 25-29 16.9 1,382 1,400 14.2 509 514 30-34 13.3 1,086 1,116 11.6 415 421 35-39 10.6 871 859 11.1 396 390 40-44 9.6 788 780 8.7 310 314 45-49 6.4 521 510 5.5 196 206 50-54 na na na 6.0 215 230 Marital status Never married 29.8 2,443 2,466 45.0 1,611 1,584 Married 54.5 4,462 4,449 49.9 1,786 1,829 Living together 5.6 457 427 0.9 31 26 Divorced/separated 5.9 488 516 3.5 126 116 Widowed 4.2 346 337 0.7 23 23 Residence Urban 25.1 2,056 2,751 25.4 907 1,150 Rural 74.9 6,139 5,444 74.6 2,671 2,428 Province Nairobi 10.2 835 1,169 11.1 397 493 Central 14.4 1,181 1,314 15.5 554 621 Coast 8.1 667 938 7.0 252 375 Eastern 16.2 1,325 993 16.4 588 468 Nyanza 14.9 1,222 1,025 13.4 481 434 Rift Valley 22.8 1,872 1,328 23.6 846 586 Western 11.3 927 991 11.1 396 435 North Eastern 2.0 168 437 1.8 65 166 Education No education 12.7 1,039 1,291 6.4 228 296 Primary incomplete 32.8 2,685 2,409 33.8 1,210 1,110 Primary complete 25.2 2,069 1,939 22.9 820 813 Secondary incomplete 11.2 914 902 11.0 392 392 Secondary complete 12.3 1,009 1,073 15.7 562 581 More than secondary 5.9 480 581 10.2 366 386 Religion Roman Catholic 25.2 2,067 1,919 26.6 953 913 Protestant/other Christian 64.9 5,322 5,045 60.3 2,156 2,055 Muslim 7.6 619 1,025 6.4 231 381 No religion 1.9 156 167 6.5 232 219 Other 0.3 22 29 0.1 5 9 Missing 0.1 10 10 0.0 1 1 Ethnicity Embu 1.6 129 101 1.7 60 46 Kalenjin 10.1 831 643 11.8 423 324 Kamba 11.4 938 786 11.7 420 371 Kikuyu 23.0 1,886 1,977 22.6 808 845 Kisii 5.7 466 454 5.6 202 208 Luhya 15.0 1,230 1,229 14.7 527 520 Luo 12.0 984 853 11.9 427 390 Maasai 2.3 189 162 2.4 87 68 Meru 5.6 460 386 5.7 203 172 Mijikenda/Swahili 5.0 407 566 4.1 147 214 Somali 3.6 298 602 3.1 111 223 Taita/Taveta 1.2 101 135 1.0 36 51 Turkana 1.4 116 121 1.5 53 51 Kuria 0.6 49 47 0.7 26 27 Other 1.4 111 133 1.4 50 68 Wealth quintile Lowest 16.6 1,364 1,376 15.3 548 540 Second 18.0 1,475 1,306 17.0 609 556 Middle 18.3 1,503 1,381 18.1 648 615 Fourth 20.9 1,711 1,568 22.2 794 752 Highest 26.1 2,141 2,564 27.4 979 1,115 Total 100.0 8,195 8,195 100.0 3,578. 3,578 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Survey Respondents | 29 example, 48 percent of females in urban areas have attended at least some secondary school, compared with 23 percent of rural women. Among the provinces, Nairobi and Central have the largest proportion of women and men who have attended secondary school and above. The educational level of women in North Eastern Province is worrying, as 93 percent of women reported that they did not attend school at all, and less than 1 percent had any secondary education. As expected, the level of education increases with the wealth index. For example, among males in the lowest quintile, only 14 percent have at least some secondary education, compared with 63 percent of those in the highest quintile. Table 3.2.1 Educational attainment by background characteristics: women Percent distribution of women by highest level of schooling attended or completed, and median number of years of schooling,, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Educational attainment –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– More Number Median Background No Primary Primary Secondary Secondary than of years of characteristic education incomplete complete1 incomplete complete2 secondary Total women schooling ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 6.8 49.6 20.8 17.3 4.9 0.6 100.0 1,856 6.7 20-24 7.3 27.7 30.8 10.0 17.7 6.5 100.0 1,691 7.5 25-29 9.4 29.0 30.4 7.6 14.8 8.7 100.0 1,382 7.4 30-34 12.9 31.7 22.1 9.5 15.2 8.5 100.0 1,086 7.3 35-39 15.7 25.0 28.3 11.1 12.6 7.3 100.0 871 6.4 40-44 26.3 24.4 19.3 10.4 12.7 6.9 100.0 788 5.9 45-49 33.5 27.0 19.7 7.0 7.5 5.3 100.0 521 3.9 Residence Urban 7.8 16.9 27.2 13.1 21.0 14.1 100.0 2,056 7.9 Rural 14.3 38.1 24.6 10.5 9.4 3.1 100.0 6,139 6.5 Province Nairobi 5.6 12.5 25.6 11.7 26.1 18.6 100.0 835 9.4 Central 2.6 22.3 33.6 15.2 18.3 8.1 100.0 1,181 7.6 Coast 29.6 28.6 21.9 5.8 9.9 4.3 100.0 667 5.5 Eastern 8.4 37.8 31.6 7.8 10.4 3.9 100.0 1,325 6.9 Nyanza 7.1 44.9 21.7 15.6 7.2 3.4 100.0 1,222 6.6 Rift Valley 17.4 33.6 23.9 9.4 11.3 4.4 100.0 1,872 6.6 Western 9.0 47.6 19.3 13.8 7.7 2.7 100.0 927 6.4 North Eastern 93.4 4.0 1.8 0.1 0.3 0.4 100.0 168 0.0 Wealth quintile Lowest 34.5 44.0 15.1 3.9 2.4 0.1 100.0 1,364 3.9 Second 13.5 45.1 25.5 10.7 4.6 0.7 100.0 1,475 6.3 Middle 10.3 40.6 27.1 12.7 8.1 1.1 100.0 1,503 6.6 Fourth 6.3 27.8 29.8 13.6 17.4 5.0 100.0 1,711 7.4 Highest 5.0 15.5 26.6 13.1 22.8 17.1 100.0 2,141 8.7 Total 12.7 32.8 25.2 11.2 12.3 5.9 100.0 8,195 7.0 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Completed grade 8 at the primary level 2 Completed form 4 at the secondary level 30 | Characteristics of Survey Respondents Unlike previous KDHS surveys in which respondents were asked if they could read, the 2003 KDHS interviewers asked respondents to read a simple, short sentence to establish literacy. The sentences were written not only in English and Kiswahili but also in the same 11 local vernaculars in which the questionnaires were translated. Tables 3.3.1 and 3.3.2 show the percent distribution of female and male respondents, respectively, by level of literacy and percent literate according to background characteristics. The data show that illiteracy among females is almost twice (21 percent) that of males (12 per- cent). The difference is almost entirely due to the gender gap at older ages; for younger respondents, there is much less difference in illiteracy between the sexes. The urban-rural differential also displays the expected pattern, such that more rural respondents are illiterate than their urban counterparts. North Eastern Province has, by far, the highest illiteracy rates (94 percent among females and 71 percent among males), and illiteracy is lowest in Nairobi and Central provinces for both sexes. Table 3.2.2 Educational attainment by background characteristics: men Percent distribution of men by highest level of schooling attended or completed, and median number of years of schooling,, ac- cording to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Educational attainment –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– More Number Median Background No Primary Primary Secondary Secondary than of years of characteristic education incomplete complete1 incomplete complete2 secondary Total women schooling ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 3.9 58.7 14.7 17.4 4.7 0.7 100.0 856 6.4 20-24 3.0 28.2 25.4 8.8 24.2 10.3 100.0 681 7.8 25-29 6.1 30.9 25.5 7.7 16.2 13.6 100.0 509 7.5 30-34 3.8 26.8 24.6 9.0 22.5 13.2 100.0 415 7.9 35-39 7.6 16.5 27.0 12.7 19.9 16.4 100.0 396 8.0 40-44 10.8 22.7 27.1 7.9 17.5 14.0 100.0 310 6.8 45-49 13.5 25.1 24.5 8.3 14.3 14.3 100.0 196 6.5 50-54 17.0 28.6 23.7 7.3 9.2 14.1 100.0 215 6.2 Residence Urban 4.3 17.1 20.9 13.3 23.1 21.3 100.0 907 9.3 Rural 7.1 39.5 23.6 10.2 13.2 6.5 100.0 2,671 6.8 Province Nairobi 4.9 10.8 16.9 13.9 25.9 27.5 100.0 397 10.6 Central 1.5 24.2 33.2 10.8 18.4 11.9 100.0 554 7.6 Coast 10.0 28.5 30.4 9.3 16.8 4.9 100.0 252 7.2 Eastern 3.5 47.4 19.0 9.9 12.4 7.9 100.0 588 6.7 Nyanza 1.8 43.3 21.0 14.3 13.3 6.3 100.0 481 6.8 Rift Valley 10.2 34.6 22.9 7.9 15.3 9.0 100.0 846 7.0 Western 3.4 44.0 20.4 14.9 11.0 6.3 100.0 396 6.9 North Eastern 71.1 10.9 7.8 2.7 7.0 0.6 100.0 65 0.0 Wealth quintile Lowest 17.9 51.6 17.0 5.2 6.3 2.0 100.0 548 5.1 Second 6.2 46.8 24.6 9.4 9.6 3.4 100.0 609 6.4 Middle 4.5 40.8 27.1 12.2 12.8 2.6 100.0 648 6.9 Fourth 2.9 30.3 26.8 12.2 18.3 9.5 100.0 794 7.5 Highest 4.0 13.9 19.3 13.4 24.6 24.8 100.0 979 10.1 Total 6.4 33.8 22.9 11.0 15.7 10.2 100.0 3,578 7.2 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Completed grade 8 at the primary level 2 Completed form 4 at the secondary level Characteristics of Survey Respondents | 31 Illiteracy decreases as wealth increases. As expected, the poorest women have the highest rate of illiteracy (47 percent), while the richest women are least likely to be illiterate (9 percent). This pattern also holds for men. Table 3.3.1 Literacy: women Percent distribution of women by level of schooling attended and by level of literacy, and percent literate, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No schooling or primary school –––––––––––––––––––––––––––––––––––––––– Secondary Can read Can read Cannot Number Background school or a whole part of a read of Percent characteristic higher sentence sentence at all Missing Total women literate1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 22.8 56.7 6.1 14.0 0.4 100.0 1,856 85.5 20-24 34.2 46.0 5.6 13.9 0.2 100.0 1,691 85.9 25-29 31.1 45.8 7.3 15.6 0.2 100.0 1,382 84.2 30-34 33.3 38.5 7.5 20.4 0.3 100.0 1,086 79.3 35-39 31.0 32.2 9.3 27.1 0.4 100.0 871 72.5 40-44 30.0 22.3 8.9 38.7 0.1 100.0 788 61.2 45-49 19.8 21.6 7.8 50.8 0.0 100.0 521 49.2 Residence Urban 48.2 36.5 3.8 11.3 0.2 100.0 2,056 88.5 Rural 23.0 44.0 8.2 24.5 0.3 100.0 6,139 75.2 Province Nairobi 56.4 32.0 3.5 7.8 0.3 100.0 835 91.8 Central 41.6 42.0 7.5 8.8 0.0 100.0 1,181 91.1 Coast 19.9 40.4 5.2 34.3 0.1 100.0 667 65.6 Eastern 22.2 49.0 10.4 17.9 0.5 100.0 1,325 81.6 Nyanza 26.2 47.6 6.0 19.7 0.5 100.0 1,222 79.8 Rift Valley 25.0 40.0 8.2 26.5 0.2 100.0 1,872 73.2 Western 24.2 46.5 6.7 22.5 0.1 100.0 927 77.4 North Eastern 0.8 4.4 1.1 93.6 0.0 100.0 168 6.4 Wealth quintile Lowest 6.4 37.2 9.0 47.0 0.5 100.0 1,364 52.5 Second 15.9 48.0 9.8 26.2 0.1 100.0 1,475 73.7 Middle 21.9 48.2 8.6 20.9 0.3 100.0 1,503 78.7 Fourth 36.1 45.2 6.0 12.5 0.2 100.0 1,711 87.3 Highest 52.9 34.4 3.8 8.5 0.3 100.0 2,141 91.2 Total 29.3 42.1 7.1 21.2 0.3 100.0 8,195 78.5 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 32 | Characteristics of Survey Respondents 3.3 ACCESS TO MASS MEDIA Information access is essential in increasing people’s knowledge and awareness of what is taking place around them, which may eventually affect their perceptions and behaviour. In the survey, exposure to media was assessed by asking respondents how often they read a newspaper, watched television, or listened to a radio. It is important to know the types of persons who are more or less likely to be reached by the media for purposes of planning programmes intended to spread information about health and fam- ily planning. Tables 3.4.1 and 3.4.2 show the percentage of male and female respondents, respectively, exposed to different types of mass communication media by age, place of residence, province, education and wealth index. Table 3.3.2 Literacy: men Percent distribution of men by level of schooling attended and by level of literacy, and percent literate, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No schooling or primary school –––––––––––––––––––––––––––––––––––––––– Secondary Can read Can read Cannot Number Background school or a whole part of a read of Percent characteristic higher sentence sentence at all Missing Total men literate1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 22.7 60.4 6.2 10.6 0.1 100.0 856 89.3 20-24 43.3 42.4 5.4 8.9 0.0 100.0 681 91.1 25-29 37.5 46.9 4.3 10.9 0.3 100.0 509 88.7 30-34 44.7 42.1 5.5 7.5 0.2 100.0 415 92.3 35-39 49.0 35.3 5.1 10.5 0.0 100.0 396 89.5 40-44 39.4 39.0 7.6 14.0 0.0 100.0 310 86.0 45-49 36.9 32.0 7.0 24.0 0.0 100.0 196 76.0 50-54 30.7 36.9 8.1 23.8 0.5 100.0 215 75.7 Residence Urban 57.7 33.3 2.7 6.3 0.0 100.0 907 93.7 Rural 29.9 49.4 6.9 13.6 0.1 100.0 2,671 86.2 Province Nairobi 67.4 25.0 1.9 5.8 0.0 100.0 397 94.2 Central 41.1 49.0 4.3 5.5 0.0 100.0 554 94.4 Coast 31.1 52.5 4.5 11.8 0.0 100.0 252 88.2 Eastern 30.2 53.6 7.9 8.3 0.0 100.0 588 91.7 Nyanza 34.0 51.2 4.3 10.4 0.2 100.0 481 89.4 Rift Valley 32.2 42.9 8.9 15.8 0.1 100.0 846 83.9 Western 32.2 46.9 5.7 15.0 0.2 100.0 396 84.8 North Eastern 10.3 16.7 2.6 70.5 0.0 100.0 65 29.5 Wealth quintile Lowest 13.5 51.3 9.4 25.7 0.0 100.0 548 74.3 Second 22.3 56.6 6.7 14.0 0.1 100.0 609 85.6 Middle 27.6 53.2 7.7 11.5 0.0 100.0 648 88.5 Fourth 39.9 46.4 5.5 7.8 0.2 100.0 794 91.9 Highest 62.8 28.9 2.4 5.9 0.0 100.0 979 94.1 Total 36.9 45.4 5.8 11.8 0.1 100.0 3,578 88.1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Survey Respondents | 33 Table 3.4.1 Exposure to mass media: women Percentage of women who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Reads a Watches Listens to newspaper television the radio at least at least at least Number Background once once once All three No of characteristic a week a week a week media media women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 23.4 28.2 74.0 11.3 22.6 1,856 20-24 27.4 32.8 79.5 16.7 17.2 1,691 25-29 24.7 29.6 77.6 14.2 19.2 1,382 30-34 22.7 28.5 74.2 14.7 23.4 1,086 35-39 18.7 26.3 74.8 12.0 22.8 871 40-44 16.4 24.4 69.4 10.1 27.0 788 45-49 13.1 27.3 68.7 9.6 28.1 521 Residence Urban 42.4 57.3 84.3 29.7 9.7 2,056 Rural 15.9 19.3 72.0 7.7 25.9 6,139 Province Nairobi 49.7 72.1 89.4 40.7 5.4 835 Central 25.7 35.5 84.5 15.5 11.5 1,181 Coast 21.0 26.2 64.7 11.1 30.4 667 Eastern 16.4 25.4 72.0 9.9 25.7 1,325 Nyanza 14.8 15.7 74.0 5.6 23.6 1,222 Rift Valley 23.6 26.7 71.3 12.7 25.6 1,872 Western 15.8 14.2 82.3 5.2 16.1 927 North Eastern 1.3 1.8 12.6 0.3 86.8 168 Education No education 0.4 8.2 39.0 0.2 59.8 1,039 Primary incomplete 7.5 16.0 71.0 2.7 26.7 2,685 Primary complete 21.0 27.8 82.2 9.7 14.4 2,069 Secondary+ 50.3 52.9 89.1 33.7 6.3 2,403 Wealth quintile Lowest 5.7 2.8 44.4 0.5 53.9 1,364 Second 8.2 6.4 71.5 1.6 27.1 1,475 Middle 12.1 14.2 77.3 3.9 20.7 1,503 Fourth 25.8 35.2 85.2 13.3 12.1 1,711 Highest 47.9 65.9 87.4 35.8 6.3 2,141 Total 22.5 28.8 75.1 13.2 21.8 8,195 34 | Characteristics of Survey Respondents In general, women are less likely than men to have access to mass media; this is true for all types of media (Figure 3.1). Twenty-three percent of women and 44 percent of men read newspapers at least once a week, 29 percent of women and 40 percent of men watch television at least once a week, and 75 percent of women and 90 percent of men listen to the radio once a week. Only 13 percent of women and 27 percent of men are exposed to all three of these media sources. Twenty-two percent of women and 8 percent of men have no access to mass media. Since 1998, the proportions of both women and men who reported reading newspapers weekly have declined, and the proportion watching television has increased slightly for women and declined for men. At least some of these apparent changes in media exposure could be due to a change in the way the questions were worded between the two surveys. Also, in 1988, the question on radio listenership referred to daily listening, further confounding trend analysis. Table 3.4.2 Exposure to mass media: men Percentage of men who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Reads a Watches Listens to newspaper television the radio at least at least at least Number Background once once once All three No of characteristic a week a week a week media media men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 32.4 34.6 86.5 17.6 10.9 856 20-24 49.8 44.8 93.6 31.6 4.7 681 25-29 49.3 44.3 91.0 31.3 7.8 509 30-34 51.1 43.9 93.6 30.8 4.4 415 35-39 52.0 43.2 91.7 33.5 6.2 396 40-44 43.0 34.8 89.0 25.1 9.6 310 45-49 41.3 33.1 85.0 23.9 13.0 196 50-54 42.4 35.4 87.0 27.4 12.7 215 Residence Urban 72.0 65.8 95.2 52.3 2.3 907 Rural 35.1 31.1 88.3 18.5 10.1 2,671 Province Nairobi 74.4 71.9 93.8 56.8 2.5 397 Central 55.9 51.9 96.8 35.9 1.8 554 Coast 45.9 39.0 93.3 29.8 5.4 252 Eastern 26.3 26.0 86.4 15.0 11.9 588 Nyanza 40.3 24.8 87.7 15.1 9.9 481 Rift Valley 44.9 41.4 87.1 27.9 11.4 846 Western 33.2 32.6 94.6 17.5 4.4 396 North Eastern 15.5 9.8 58.8 6.1 39.2 65 Education No education 1.4 13.8 62.1 0.3 37.5 228 Primary incomplete 20.9 26.7 85.0 10.0 12.8 1,210 Primary complete 40.4 33.0 95.0 20.3 4.1 820 Secondary+ 76.0 60.9 96.4 51.6 1.2 1,320 Wealth quintile Lowest 19.6 13.2 71.8 7.4 26.1 548 Second 27.7 19.2 89.3 9.6 8.1 609 Middle 32.8 30.2 92.2 16.3 7.3 648 Fourth 50.3 47.4 94.9 30.6 4.3 794 Highest 71.7 68.2 95.4 53.3 1.7 979 Total 44.4 39.9 90.1 27.1 8.1 3,578 Characteristics of Survey Respondents | 35 23 75 29 13 44 90 40 27 Reads newspapers weekly Listens to radio weekly Watches television weekly All three media 0 20 40 60 80 100 Percent Women Men Figure 3.1 Access to Mass Media KDHS 2003 Nairobi and Central provinces have the highest proportion of women and men who have access to all three media, while the least access to media is reported in North Eastern Province. The data also show that urban residents are more likely to have access to mass media than rural residents. Exposure to media is positively associated with educational attainment; the proportion with ac- cess to all three media outlets increases with increasing education level of respondents. Similarly, access to all three media outlets increases as wealth increases for both sexes. 3.4 EMPLOYMENT 3.4.1 Employment Status The KDHS asked respondents whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months preceding the survey. Table 3.5 shows that 58 percent of women and 72 percent of men are currently employed. The proportion currently employed generally in- creases with age and number of living children. Women who are divorced, separated, or widowed are most likely to be employed (76 percent), followed by those who are married (65 percent). In contrast, married men are somewhat more likely to be employed than divorced, separated, or widowed men. There are notable regional variations in the proportion currently employed. Women in Nyanza (70 percent), Western (64 percent) and Central (63 percent) provinces are the most likely to be employed, while women in North Eastern Province are least likely to be employed. Among men, Central, Rift Val- ley, and Coast provinces have the highest employment levels. Only about 20 percent of women and 30 percent of men in North Eastern Province are currently employed. Current employment shows a mixed pattern by education, generally increasing with education among women, but not among men. The pro- portion currently employed generally increases as wealth status of the respondent increases, though the relationship is not strong. 36 | Characteristics of Survey Respondents Table 3.5 Employment status Percent distribution of women and men by employment status, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––– Employed Employed in the 12 months Not in the 12 months Not preceding the survey employed preceding the survey employed ––––––––––––––––– in the –––––––––––––––– in the Not 12 months Don’t Number Not 12 months Don’t Number Background Currently currently preceding know/ of Currently currently preceding know/ of characteristic employed employed the survey missing Total women employed employed the survey missing Total men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 28.6 3.1 68.4 0.0 100.0 1,856 25.5 3.0 70.4 1.1 100.0 856 20-24 54.1 5.1 40.8 0.0 100.0 1,691 69.9 8.8 21.1 0.1 100.0 681 25-29 65.4 4.1 30.1 0.4 100.0 1,382 87.3 7.5 4.7 0.5 100.0 509 30-34 73.0 4.1 22.7 0.2 100.0 1,086 92.3 4.1 3.7 0.0 100.0 415 35-39 76.7 1.4 21.5 0.3 100.0 871 96.0 1.9 2.1 0.0 100.0 396 40-44 75.0 3.3 21.5 0.2 100.0 788 94.8 2.4 2.8 0.0 100.0 310 45-49 73.3 1.6 25.2 0.0 100.0 521 91.7 3.9 4.4 0.0 100.0 196 50-54 na na na na na na 92.2 2.5 5.4 0.0 100.0 215 Marital status Never married 39.4 3.1 57.4 0.2 100.0 2,443 45.9 6.1 47.2 0.8 100.0 1,611 Married or living together 64.9 3.7 31.3 0.2 100.0 4,919 93.7 3.1 3.1 0.0 100.0 1,818 Divorced/separated/ widowed 75.6 4.3 20.0 0.2 100.0 833 87.6 9.4 3.1 0.0 100.0 149 Number of living children 0 36.5 3.7 59.8 0.1 100.0 2,399 48.4 6.1 44.8 0.7 100.0 1,704 1-2 62.7 4.8 32.4 0.2 100.0 2,427 92.3 4.5 3.3 0.0 100.0 721 3-4 71.4 2.5 26.0 0.1 100.0 1,752 95.5 1.8 2.8 0.0 100.0 544 5+ 70.2 2.7 26.8 0.3 100.0 1,616 92.8 3.7 3.5 0.0 100.0 609 Residence Urban 58.0 5.9 35.8 0.3 100.0 2,056 74.7 6.5 18.0 0.8 100.0 907 Rural 58.5 2.8 38.7 0.1 100.0 6,139 71.0 4.1 24.7 0.2 100.0 2,671 Province Nairobi 56.6 5.1 38.1 0.1 100.0 835 68.6 9.1 21.9 0.4 100.0 397 Central 63.4 2.0 34.4 0.2 100.0 1,181 80.2 0.3 19.2 0.2 100.0 554 Coast 49.7 7.3 42.8 0.2 100.0 667 75.9 4.1 20.0 0.0 100.0 252 Eastern 48.3 3.0 48.6 0.1 100.0 1,325 71.0 4.5 24.3 0.2 100.0 588 Nyanza 69.6 3.6 26.7 0.1 100.0 1,222 68.1 4.0 27.2 0.7 100.0 481 Rift Valley 59.8 4.1 36.0 0.2 100.0 1,872 76.1 6.3 16.9 0.6 100.0 846 Western 63.5 1.2 35.3 0.0 100.0 927 65.0 4.8 30.1 0.0 100.0 396 North Eastern 19.5 2.7 77.4 0.4 100.0 168 29.8 4.2 66.0 0.0 100.0 65 Education No education 50.0 3.2 46.6 0.3 100.0 1,039 70.3 9.7 20.0 0.0 100.0 228 Primary incomplete 55.7 3.2 41.0 0.1 100.0 2,685 63.3 4.1 32.4 0.2 100.0 1,210 Primary complete 63.6 3.6 32.6 0.1 100.0 2,069 85.1 3.4 10.9 0.5 100.0 820 Secondary+ 60.4 4.1 35.4 0.2 100.0 2,403 71.9 5.2 22.4 0.4 100.0 1,320 Wealth quintile Lowest 55.6 2.0 42.2 0.1 100.0 1,364 62.0 6.9 30.7 0.4 100.0 548 Second 58.7 3.7 37.5 0.1 100.0 1,475 69.5 3.6 26.9 0.0 100.0 609 Middle 60.0 2.6 37.3 0.1 100.0 1,503 68.7 4.1 27.0 0.2 100.0 648 Fourth 56.4 3.4 40.0 0.2 100.0 1,711 76.5 3.1 20.0 0.4 100.0 794 Highest 60.3 5.2 34.3 0.2 100.0 2,141 77.5 6.0 16.0 0.5 100.0 979 Total 58.4 3.6 37.9 0.2 100.0 8,195 71.9 4.7 23.0 0.3 100.0 3,578 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Characteristics of Survey Respondents | 37 3.4.2 Occupation The distributions of women and men employed in the 12 months preceding the survey, by occu- pation and other background characteristics, are shown in Tables 3.6.1 and 3.6.2, respectively. Forty-nine percent of working women and 42 percent of working men are engaged in agricultural occupations. Among women, the next most common occupation is in the sales and services sector (26 percent), while for men, it is unskilled manual occupations (22 percent). For men, the sales and service sector is the third major occupation category, engaging 17 percent of working men. Nine percent of employed Kenyan women do domestic work, while only 7 percent work in professional, technical, or managerial fields. The proportion of women employed in agricultural activities has remained the same since 1998. Table 3.6.1 Occupation: women Percent distribution of women employed in the 12 months preceding the survey by occupation, according to background charac- teristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Professional/ Sales Un- Number Background technical/ and Skilled skilled Domestic Agri- of characteristic managerial Clerical services manual manual service culture Missing Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 1.9 0.1 20.1 0.0 6.5 24.6 46.6 0.1 100.0 587 20-24 4.1 1.6 25.9 0.0 11.2 12.7 44.3 0.2 100.0 1,001 25-29 7.4 2.8 26.0 0.1 8.9 8.2 46.4 0.2 100.0 960 30-34 7.4 2.5 31.0 0.2 5.8 4.7 48.2 0.0 100.0 838 35-39 7.7 2.6 28.7 0.1 6.7 3.8 49.9 0.5 100.0 681 40-44 9.6 3.2 26.3 0.1 4.9 1.9 54.1 0.0 100.0 617 45-49 8.3 2.7 24.0 0.5 4.4 1.5 58.6 0.0 100.0 390 Marital status Never married 7.3 3.2 22.1 0.0 12.3 26.2 28.4 0.4 100.0 1,036 Married or living together 7.2 2.0 25.8 0.1 5.8 3.2 55.8 0.1 100.0 3,371 Divorced/separated/ widowed 1.5 1.8 35.8 0.1 8.3 8.4 44.0 0.0 100.0 665 Number of living children 0 7.9 3.2 21.4 0.1 11.6 24.2 31.3 0.3 100.0 964 1-2 6.8 2.6 29.9 0.2 9.3 8.9 42.2 0.1 100.0 1,638 3-4 7.1 2.1 26.6 0.0 5.0 3.1 55.9 0.1 100.0 1,293 5+ 4.2 1.0 25.3 0.2 4.2 1.1 63.9 0.2 100.0 1,179 Residence Urban 11.4 5.6 41.0 0.4 11.4 19.4 10.7 0.1 100.0 1,314 Rural 4.8 1.0 21.3 0.0 6.1 4.7 61.9 0.2 100.0 3,759 Province Nairobi 15.5 7.2 37.2 0.7 13.0 23.9 2.2 0.2 100.0 515 Central 7.5 2.5 19.3 0.0 7.4 7.3 56.1 0.0 100.0 772 Coast 4.9 1.7 39.8 0.2 14.5 8.1 30.6 0.2 100.0 380 Eastern 7.1 1.4 26.0 0.2 10.3 12.4 42.5 0.0 100.0 679 Nyanza 3.4 1.3 26.6 0.0 5.1 3.6 59.9 0.0 100.0 895 Rift Valley 5.3 1.9 23.5 0.0 5.2 6.9 56.8 0.5 100.0 1,195 Western 4.9 1.0 21.1 0.0 3.5 3.7 65.8 0.0 100.0 600 North Eastern 0.0 1.9 64.1 0.0 2.7 1.6 27.8 1.9 100.0 37 Education No education 0.3 0.0 30.3 0.0 3.6 3.2 62.4 0.1 100.0 552 Primary incomplete 0.4 0.0 21.7 0.0 3.7 8.5 65.7 0.0 100.0 1,580 Primary complete 1.0 0.2 27.7 0.1 11.5 12.2 47.1 0.1 100.0 1,391 Secondary+ 19.9 7.0 28.5 0.3 9.0 7.2 27.8 0.4 100.0 1,549 Wealth quintile Lowest 0.8 0.0 20.6 0.0 4.3 1.7 72.3 0.4 100.0 786 Second 2.1 0.0 19.6 0.0 6.7 2.7 68.9 0.0 100.0 920 Middle 3.5 0.4 20.7 0.0 7.4 3.3 64.7 0.0 100.0 942 Fourth 7.2 1.6 27.1 0.2 5.9 6.6 51.2 0.3 100.0 1,023 Highest 14.1 6.5 37.3 0.3 10.9 21.1 9.5 0.2 100.0 1,402 Total 6.5 2.2 26.4 0.1 7.5 8.5 48.7 0.2 100.0 5,073 38 | Characteristics of Survey Respondents Table 3.6.2 Occupation: men Percent distribution of men employed in the 12 months preceding the survey by occupation, according to background characteris- tics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Professional/ Sales Un- Number Background technical/ and Skilled skilled Domestic Agri- of characteristic managerial Clerical services manual manual service culture Missing Total men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 0.6 1.1 9.3 4.9 17.1 7.5 58.6 0.7 100.0 244 20-24 4.7 1.7 21.9 4.1 23.9 5.0 37.2 1.6 100.0 537 25-29 8.0 1.1 22.6 5.6 21.1 3.1 38.4 0.0 100.0 482 30-34 10.6 0.9 17.3 4.9 21.8 3.2 40.9 0.4 100.0 400 35-39 10.8 0.9 16.5 6.3 27.2 0.9 37.4 0.0 100.0 388 40-44 18.4 2.4 13.8 5.3 21.5 0.8 37.8 0.1 100.0 301 45-49 13.6 0.8 13.1 1.4 16.1 1.7 53.3 0.0 100.0 188 50-54 16.9 1.6 14.1 3.4 14.9 1.4 47.3 0.3 100.0 204 Marital status Never married 5.3 1.4 16.5 4.0 19.7 6.7 45.2 1.2 100.0 837 Married or living together 12.0 1.4 18.0 5.0 21.7 1.4 40.4 0.1 100.0 1,761 Divorced/separated/ widowed 6.6 0.0 15.8 6.3 29.1 3.0 39.2 0.0 100.0 145 Number of living children 0 5.7 1.5 17.6 4.3 19.5 6.0 44.3 1.0 100.0 928 1-2 9.9 1.0 21.8 6.4 23.2 1.9 35.5 0.4 100.0 698 3-4 14.6 1.2 17.0 4.5 25.3 1.1 36.2 0.1 100.0 529 5+ 11.2 1.6 12.1 3.8 19.2 1.7 50.4 0.1 100.0 588 Residence Urban 14.1 2.9 30.3 10.5 33.7 1.9 6.3 0.2 100.0 736 Rural 8.0 0.7 12.7 2.6 17.0 3.6 54.8 0.6 100.0 2,006 Province Nairobi 18.1 4.2 30.3 12.9 31.2 1.6 1.4 0.3 100.0 308 Central 6.7 1.6 15.2 4.5 19.7 1.8 50.4 0.2 100.0 446 Coast 8.3 1.1 31.0 6.3 28.3 2.5 21.7 0.8 100.0 201 Eastern 9.2 0.7 14.1 2.1 20.0 9.4 44.3 0.3 100.0 444 Nyanza 10.0 1.1 12.4 5.4 22.6 0.8 47.4 0.3 100.0 347 Rift Valley 8.7 0.5 15.5 2.4 19.0 2.3 51.0 0.6 100.0 698 Western 8.1 1.0 12.6 4.5 17.0 2.5 53.1 1.2 100.0 277 North Eastern 16.6 2.9 23.8 0.0 11.4 0.0 45.3 0.0 100.0 22 Education No education 0.9 0.0 18.0 0.9 11.6 1.9 66.7 0.0 100.0 183 Primary incomplete 0.7 0.1 13.7 2.9 23.5 5.5 53.0 0.6 100.0 816 Primary complete 2.2 0.2 17.0 5.2 25.6 3.2 46.3 0.3 100.0 726 Secondary+ 23.8 3.3 20.6 6.5 18.8 1.3 25.1 0.6 100.0 1,018 Wealth quintile Lowest 0.8 1.4 9.9 2.6 15.2 0.7 69.0 0.5 100.0 378 Second 5.5 0.0 10.5 1.9 19.7 1.3 60.9 0.1 100.0 445 Middle 5.2 0.6 12.0 3.4 18.7 3.7 55.9 0.5 100.0 472 Fourth 10.5 1.0 13.5 3.0 21.9 4.9 44.4 0.7 100.0 632 Highest 18.0 2.6 30.7 9.4 26.8 3.4 8.6 0.5 100.0 817 Total 9.7 1.3 17.4 4.7 21.5 3.1 41.8 0.5 100.0 2,743 Characteristics of Survey Respondents | 39 Table 3.7.1 Type of employment: women Percent distribution of women employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Employment Agricultural Nonagricultural characteristic work work Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Type of earnings Cash only 25.2 84.1 55.4 Cash and in-kind 30.3 8.9 19.3 In-kind only 13.4 0.7 6.8 Not paid 31.1 6.3 18.3 Total 100.0 100.0 100.0 Type of employer Employed by family member 15.8 5.7 10.6 Employed by nonfamily member 11.8 41.6 27.1 Self-employed 72.4 52.5 62.2 Total 100.0 100.0 100.0 Continuity of employment All year 54.6 74.1 64.5 Seasonal 39.3 17.7 28.2 Occasional 6.0 8.2 7.1 Total 100.0 100.0 100.0 Number of women 2,468 2,596 5,073 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 8 women with missing information on type of employ- ment, who are not shown separately. Table 3.7.2 Type of employment: men Percent distribution of men employed in the 12 months preceding the survey by type of earnings, according to type of employment (agricultural or nonagri- cultural, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Agricultural Nonagricultural Type of earnings work work Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Cash only 49.2 93.4 74.6 Cash and in-kind 23.6 3.9 12.1 In-kind only 5.8 0.3 2.6 Not paid 21.4 2.4 10.3 Missing 0.0 0.1 0.4 Total 100.0 100.0 100.0 Number of men 1,146 1,583 2,743 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 13 men with missing information on type of employ- ment, who are not shown separately. Differences by background characteristics show that, as expected, rural women and men are more likely to be employed in agricultural jobs than urban residents. Among women, domestic service is par- ticularly high among never-married and younger respondents, as well as those who live in urban areas, in Nairobi, and in wealthier households. The latter finding could be due to the fact that the wealth index is derived from household-based information; to the extent that female domestic workers live in the house- holds in which they work, they take on the characteristics of that household. 3.4.3 Type of Employer, Form of Earnings, and Continuity of Employment Tables 3.7.1 and 3.7.2 present the percent distribution of employed women and men, respectively, by type of earnings and employment character- istics, according to type of employment (agricultural or nonagricultural). Sev- enty-five percent of women receive cash for their work, while almost one in five is unpaid. Women are more likely to be paid in kind or not paid at all if they are employed in agricultural activities. Men are more likely than women to be paid in cash for their work (87 percent); men engaged in nonagricultural work are almost all (93 percent) paid cash only. Three in five working women are self-employed, with only 27 per- cent employed by a nonfamily mem- ber. Women are more likely to be self- employed if they are doing agricultural work than if they are engaged in non- agricultural work. Women are more prone to seasonal and occasional work if they are employed in agricultural activities (45 percent) than if they are in nonagricultural occupations (26 percent) and, conversely, conti- nuity of employment is more assured for women who are engaged in nonagricultural work. 40 | Characteristics of Survey Respondents 3.4.4 Control Over Earnings and Women’s Contribution to Household Expenditures Women who were working and receiving cash earnings were asked to state who decides how their earnings are used. In addition, they were asked what proportion of household expenditures is met by their earnings. Table 3.8 shows that two in three working women decide by themselves how their earnings are used, while 23 percent make the decision jointly with someone else. Only about one in ten women Table 3.8 Decision on use of earnings and contribution of earnings to household expenditures Percent distribution of women employed in the 12 months preceding the survey receiving cash earnings by person who decides how earnings are to be used and by proportion of household expenditures met by earnings, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Person who decides Proportion of household how earnings are used expenditures met by earnings ––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––– Someone Almost Less Number Background Self else none/ than Over of characteristic only Jointly1 only2 Missing Total none half half All Missing Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 62.4 12.7 24.8 0.0 100.0 33.6 20.6 35.4 10.4 0.0 100.0 363 20-24 71.4 15.7 13.0 0.0 100.0 15.2 31.5 41.1 12.2 0.0 100.0 755 25-29 63.8 26.5 9.7 0.0 100.0 8.0 25.3 50.6 16.1 0.0 100.0 705 30-34 59.6 31.7 8.8 0.0 100.0 4.0 25.3 50.6 20.1 0.0 100.0 654 35-39 66.8 25.6 7.5 0.2 100.0 4.1 24.6 51.6 19.5 0.2 100.0 521 40-44 70.5 22.1 7.1 0.3 100.0 3.5 24.4 47.9 23.9 0.3 100.0 494 45-49 70.6 20.4 9.0 0.0 100.0 1.3 25.8 47.1 25.8 0.0 100.0 298 Marital status Never married 85.5 2.9 11.6 0.0 100.0 29.5 23.7 33.9 12.9 0.0 100.0 786 Married or living together 53.3 33.7 12.9 0.1 100.0 3.8 28.2 51.7 16.2 0.1 100.0 2,458 Divorced/separated/ widowed 96.8 2.0 1.1 0.1 100.0 6.4 18.9 43.2 31.3 0.1 100.0 546 Number of living children 0 75.9 9.6 14.5 0.0 100.0 29.3 24.8 34.4 11.5 0.0 100.0 705 1-2 65.9 24.1 10.0 0.0 100.0 7.3 26.9 50.2 15.6 0.0 100.0 1,255 3-4 60.6 29.6 9.7 0.1 100.0 3.1 24.2 52.0 20.7 0.1 100.0 984 5+ 65.3 23.8 10.8 0.2 100.0 3.9 27.4 45.9 22.7 0.2 100.0 846 Residence Urban 75.4 17.1 7.5 0.1 100.0 13.2 22.2 46.9 17.7 0.1 100.0 1,182 Rural 62.1 25.3 12.5 0.1 100.0 7.9 27.6 46.7 17.7 0.1 100.0 2,608 Province Nairobi 80.6 14.0 5.3 0.0 100.0 16.0 20.7 43.1 20.2 0.0 100.0 482 Central 63.3 29.3 7.3 0.1 100.0 12.0 22.6 47.2 18.1 0.1 100.0 565 Coast 69.3 19.9 10.8 0.0 100.0 7.1 23.4 54.7 14.8 0.0 100.0 281 Eastern 67.2 22.3 10.4 0.0 100.0 13.3 30.2 46.1 10.4 0.0 100.0 601 Nyanza 63.5 23.0 13.6 0.0 100.0 3.4 31.6 51.1 14.0 0.0 100.0 639 Rift Valley 59.4 27.3 13.2 0.1 100.0 9.2 22.2 44.6 23.9 0.1 100.0 847 Western 68.7 16.6 14.4 0.2 100.0 5.1 29.8 43.6 21.2 0.2 100.0 349 North Eastern 67.3 11.3 21.5 0.0 100.0 0.0 53.1 40.0 6.9 0.0 100.0 26 Education No education 76.0 12.4 11.2 0.5 100.0 6.9 24.1 43.5 25.0 0.5 100.0 337 Primary incomplete 65.2 20.1 14.7 0.0 100.0 8.5 27.9 44.0 19.5 0.0 100.0 1,092 Primary complete 65.3 21.9 12.7 0.0 100.0 12.1 26.4 44.5 17.0 0.0 100.0 1,061 Secondary+ 65.4 28.3 6.3 0.0 100.0 9.0 24.3 51.7 14.9 0.0 100.0 1,300 Wealth quintile Lowest 62.6 22.0 15.4 0.0 100.0 5.1 33.1 43.9 18.0 0.0 100.0 486 Second 63.1 22.8 13.8 0.3 100.0 5.4 29.9 45.0 19.4 0.3 100.0 613 Middle 63.9 25.1 11.0 0.0 100.0 5.0 26.4 49.5 19.1 0.0 100.0 636 Fourth 60.2 25.9 13.8 0.0 100.0 10.2 26.3 48.2 15.3 0.0 100.0 774 Highest 74.0 19.9 6.1 0.0 100.0 15.1 20.9 46.4 17.5 0.0 100.0 1,281 Total 66.3 22.8 10.9 0.1 100.0 9.5 25.9 46.8 17.7 0.1 100.0 3,791 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 With husband or someone else 2 Includes husband Characteristics of Survey Respondents | 41 report that the decision on how to use their earnings is made by some else only. The proportion of women who say that they decide by themselves how their earnings are used increased from 55 percent in 1998 to 66 percent in 2003.2 Table 3.8 also shows how the respondent’s degree of control over her earnings varies by back- ground characteristics. Irrespective of age, most respondents make their own decisions on how their cash earnings are used. Unmarried women tend to make their own decisions about the use of their earnings, while married women, compared with unmarried women, are more likely to involve another person in making the decision. Urban women are more independent in making their own decisions than rural women (75 and 62 percent, respectively). In rural areas, 25 and 13 percent of the decisions on the use of women’s earnings are made either jointly or by someone else, respectively. There are regional variations in the way decisions are made on how women’s earnings are used. The percentage of women who make decisions on their earnings by themselves ranges from 81 percent in Nairobi Province to 59 percent in Rift Valley Province. There are no clear patterns by education and pov- erty status. Regarding the proportion of household expenditures met by their earnings, 18 percent of working women reported that their earnings supported all household expenditures, while 47 percent reported that their earnings constitute over half of household expenditures. Older women; women who are widowed, divorced, or separated; and less educated women are more likely to support their households financially. Table 3.9 shows information on how decisions on use of women’s earnings are related to the pro- portional contribution of these earnings to the household expenditures, according to marital status. The analysis indicates that independence in decisionmaking is slightly inversely related to the proportion of women’s contribution to the household expenses. For instance, 75 percent of women whose contribution to household expenditures is minimal decide for themselves how their earnings are used. On the other hand, only 57 percent of women who support all of their household’s expenses decide by themselves how their earnings are used, while 30 percent share the decision with their husband and 14 percent say that their husband alone makes decisions. Almost all unmarried women (between 87 and 96 percent) make their own decisions regarding their earnings, regardless of their contribution to the household expendi- tures. 2 The figure is 66 percent for the entire sample, as well as for the sample excluding the northern districts. Table 3.9 Women’s control over earnings Percent distribution of women who received cash earnings for work in the past 12 months by person who decides how earnings are used, according to marital status, and the proportion of household expenditures met by earnings, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Currently married or living together Not married1 ––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––– Jointly Jointly Some- Jointly Some- Contribution with with Hus- one Number with one Number to household Self hus- someone band else of Self someone else of expenditures only band else only only Total women only else only Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Almost none/none 75.3 19.9 0.0 4.8 0.0 100.0 94 89.0 3.2 7.9 100.0 267 Less than half 59.1 29.5 0.5 10.5 0.4 100.0 693 87.4 3.3 9.2 100.0 290 Over half 47.5 37.8 0.3 14.0 0.4 100.0 1,270 89.3 1.9 8.8 100.0 502 All 56.8 29.7 0.0 13.5 0.0 100.0 399 96.1 2.1 1.8 100.0 273 Total 53.3 33.4 0.3 12.6 0.3 100.0 2,458 90.2 2.5 7.3 100.0 1,332 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Never-married, divorced, separated, or widowed women 42 | Characteristics of Survey Respondents 3.5 WOMEN’S EMPOWERMENT In addition to information on women’s education, employment status, and control over earnings, the 2003 KDHS collected information from both women and men on other measures of women’s auton- omy and status. In particular, questions were asked about women’s roles in making household decisions, on acceptance of wife beating, and on their opinions about when a wife should be able to deny sex to her husband. Such information provides insight into women’s control over their environment and their atti- tudes towards gender roles, both of which are relevant to understanding women’s demographic and health behaviour. 3.5.1 Women’s Participation in Decisionmaking To assess women’s decisionmaking autonomy, the 2003 KDHS sought information on women’s participation in five different types of household decisions: on the respondents’ own health care; on mak- ing large household purchases; on making household purchase for daily needs; on visits to family or rela- tives; and on what food should be cooked each day. Table 3.10 shows the percent distribution of women according to who in the household usually has the final say on each aspect. The autonomy of women in this case would be gauged by either their independently making such decisions or jointly deciding on such issues. Among currently married women, independence in making decisions ranges from 81 percent on what food to cook daily to only 12 percent on making large household purchases. Although 40 percent of married women make decisions on their own health care by themselves, 43 percent of women say that their husbands make such decisions alone. Husbands are more likely to decide on making large purchases (61 percent) and visits to family or relatives (39 percent). Among unmarried women, decisions on their own health care are made by the respondents (42 percent) or someone else (55 percent). The other decisions are made mostly by either the respondents themselves or by someone else, possibly because the majority are younger women who still live with their guardians or parents. Table 3.11 shows that although one in four women have a say in all five areas of decisionmaking, another one in four have no say at all in any of the specified areas. Generally, women’s participation in making all of the specified decisions increases with age, from 3 percent among women age 15-19 to 50 Table 3.10 Women’s participation in decisionmaking Percent distribution of women by person who has the final say in making specific decisions, according to current marital status and type of deci- sion, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Currently married or living together Not married1 ––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––– Decision Decision not not Jointly made/ Jointly made/ Jointly with Some- not with Some- not with some- Hus- one appli- Number some- one appli- Number Self hus- one band else cable/ of Self one else cable/ of Decision only band else only only missing Total women only else only missing Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Own health care 39.8 14.3 0.3 42.9 2.3 0.4 100.0 4,919 41.6 2.9 54.7 0.8 100.0 3,276 Large household purchases 11.8 24.2 0.2 61.3 2.3 0.2 100.0 4,919 24.4 2.5 70.4 2.7 100.0 3,276 Daily household purchases 40.5 19.2 0.5 37.3 2.2 0.3 100.0 4,919 25.6 3.5 68.3 2.4 100.0 3,276 Visits to family or relatives 22.9 35.1 0.4 39.4 1.7 0.5 100.0 4,919 32.7 6.1 59.2 1.9 100.0 3,276 What food to cook each day 81.2 5.0 1.1 10.0 2.4 0.1 100.0 4,919 28.0 5.2 64.9 1.9 100.0 3,276 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Never-married, divorced, separated, or widowed women Characteristics of Survey Respondents | 43 percent among those age 45-49. Women who have never married, have no children, have incomplete pri- mary education, and who are not employed are the least likely to participate in decisionmaking in the household. About four in ten women (38 percent) who are employed for cash participate in making all decisions, compared with 20 percent who are employed but do not earn cash and 12 percent of unem- ployed women. This implies that cash employment increases women’s decisionmaking power. Table 3.11 Women’s participation in decisionmaking by background characteristics Percentage of women who say that they alone or jointly have the final say in specific decisions, by background charac- teristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Alone or jointly has final say in: ––––––––––––––––––––––––––––––––––––––––––––––– What None Own Making Making Visits to food All of the Number Background health large daily family or to cook specified specified of characteristic care purchases purchases relatives each day decisions decisions women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 20.8 5.5 8.5 15.7 17.3 3.2 65.7 1,856 20-24 47.2 20.1 36.1 44.3 59.3 14.6 24.1 1,691 25-29 56.2 35.8 55.5 56.0 78.9 25.1 11.2 1,382 30-34 64.0 44.8 65.9 65.9 87.7 34.6 5.9 1,086 35-39 64.6 51.2 73.2 69.5 92.5 39.8 4.2 871 40-44 69.7 59.2 78.8 74.6 92.8 47.2 4.8 788 45-49 70.2 62.6 77.6 80.7 92.4 49.9 3.9 521 Marital status Never married 32.0 11.5 13.5 24.5 18.0 9.6 59.1 2,443 Married or living together 54.4 36.2 60.2 58.4 87.4 24.5 8.1 4,919 Divorced/separated/ widowed 81.0 72.2 75.1 80.7 77.8 68.2 11.9 833 Number of living children 0 28.9 10.9 15.0 24.4 22.6 8.4 57.4 2,399 1-2 57.2 34.3 52.6 56.7 74.6 25.7 14.5 2,427 3-4 60.0 43.8 66.2 63.9 88.9 32.9 6.5 1,752 5+ 61.8 49.6 69.1 65.8 91.3 37.3 5.8 1,616 Residence Urban 61.4 40.4 53.1 59.9 69.5 32.6 17.3 2,056 Rural 46.8 29.8 46.0 47.5 64.5 21.8 25.8 6,139 Province Nairobi 62.6 40.6 55.0 63.6 68.9 33.7 16.2 835 Central 63.8 36.5 51.1 63.6 67.2 30.0 20.5 1,181 Coast 42.6 35.1 41.7 48.8 61.5 27.3 28.8 667 Eastern 60.6 35.5 46.2 50.9 63.5 26.8 21.6 1,325 Nyanza 31.3 27.9 51.6 42.0 61.2 18.4 30.2 1,222 Rift Valley 57.6 32.0 48.5 52.9 72.0 24.1 18.3 1,872 Western 29.0 21.0 38.4 31.2 59.6 13.3 35.8 927 North Eastern 24.0 32.3 40.5 42.4 71.3 20.2 24.1 168 Education No education 48.1 40.3 52.9 52.6 79.8 30.3 15.4 1,039 Primary incomplete 42.4 27.3 42.1 42.8 59.5 19.6 31.1 2,685 Primary complete 52.5 31.2 47.9 52.6 67.4 22.2 19.4 2,069 Secondary+ 58.7 36.1 51.7 56.7 65.1 29.4 22.6 2,403 Employment Not employed 36.0 17.7 26.4 33.8 48.1 12.3 41.2 3,397 Employed for cash 65.6 48.2 67.9 66.7 80.4 37.6 8.7 3,561 Employed not for cash 46.7 28.2 49.1 50.7 72.9 20.3 18.0 1,218 Wealth quintile Lowest 41.1 30.1 45.8 43.6 67.0 22.4 26.6 1,364 Second 40.7 28.7 45.7 45.7 64.9 18.5 25.5 1,475 Middle 46.6 30.2 45.7 45.2 63.9 21.5 27.5 1,503 Fourth 52.9 31.1 45.8 51.8 62.5 23.3 25.0 1,711 Highest 63.9 39.4 53.4 61.2 69.4 32.9 16.7 2,141 Total 50.4 32.5 47.8 50.6 65.7 24.5 23.7 8,195 44 | Characteristics of Survey Respondents 3.5.2 Women’s Attitudes Towards Wife-Beating Violence against women is an area that is increasingly being recognised as affecting women’s health and autonomy. Violence against women has serious consequences for their mental and physical well-being, including their reproductive and sexual health (World Health Organization, 1999). If violence against women is tolerated and accepted in a society, its eradication is made more difficult. To gauge the acceptability of domestic violence, women and men interviewed in the 2003 KDHS were asked whether they thought a husband would be justified in hitting or beating his wife in each of the following five situa- tions: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual relations with him.3 Tables 3.12.1 and 3.12.2 show that many women and men, respectively, find wife-beating to be justified in certain circumstances. Overall, about two-thirds of Kenyan women and men agree that at least one of these factors is sufficient justification for wife-beating. This is not unexpected because many tradi- tional customs in Kenya teach and expect women to accept, tolerate, and even rationalise wife-beating. This custom impedes women’s empowerment and has serious health consequences. The most widely accepted reasons for wife-beating are neglecting the children (55 percent of women and 50 percent of men) and arguing with the husband (46 percent of women and 41 percent of men). Four in ten women and one in three men think that going out without informing the husband is a justifiable reason for beating. Only about one-quarter of women and men feel that denying sex to the hus- band is a justification for wife-beating. Even smaller proportions believe that burning the food is a justifi- able reason to hit or beat the wife. The tables also show attitudes towards wife-beating by background characteristics. Acceptance of wife-beating for at least one of the specified reasons is generally lower among urban women and men as well as among those in Nairobi Province. Women in Nyanza Province and men in North Eastern Prov- ince are the most likely to agree that wife-beating is justified for some reason. Acceptance of wife-beating declines steeply as level of education increases. For all reasons, poorer women and men are more likely than their wealthier counterparts to believe that wife-beating is justified. 3 The 2003 KDHS also included questions on the actual prevalence of gender violence (see Chapter 15). Characteristics of Survey Respondents | 45 Table 3.12.1 Women’s attitude towards wife-beating Percentage of women who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Husband is justified in hitting or beating his wife if she: –––––––––––––––––––––––––––––––––––––––––––––––– Agrees Goes out Refuses with at Burns without Neglects to have least one Number Background the Argues telling the sex specified of characteristic food with him him children with him reason women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 18.1 47.4 41.0 56.8 23.3 69.2 1,856 20-24 14.1 44.6 37.8 52.5 27.7 66.1 1,691 25-29 16.5 47.6 40.8 56.1 30.0 68.0 1,382 30-34 16.7 40.3 37.3 53.5 28.2 66.3 1,086 35-39 15.6 46.3 39.3 55.4 32.9 70.1 871 40-44 16.8 47.5 37.5 54.7 37.2 67.3 788 45-49 16.7 48.2 41.9 58.7 39.9 69.5 521 Marital status Never married 13.9 37.5 32.8 47.8 19.9 59.0 2,443 Married or living together 17.5 49.2 42.3 58.5 32.9 71.4 4,919 Divorced/separated/widowed 16.6 50.6 41.3 56.8 36.5 73.6 833 Number of living children 0 14.6 40.5 35.2 49.0 21.0 61.2 2,399 1-2 15.3 44.7 38.1 53.8 27.4 66.6 2,427 3-4 16.3 46.7 40.3 58.5 32.8 71.0 1,752 5+ 20.6 54.8 46.2 62.6 41.3 76.5 1,616 Residence Urban 12.3 33.5 31.6 42.8 22.1 54.0 2,056 Rural 17.7 50.0 41.9 59.3 31.8 72.6 6,139 Province Nairobi 10.1 24.4 23.9 33.7 16.0 42.6 835 Central 10.6 39.3 28.7 52.2 28.5 61.0 1,181 Coast 19.4 50.3 55.2 55.4 37.8 69.6 667 Eastern 9.4 34.8 32.8 56.7 21.8 65.6 1,325 Nyanza 18.7 69.3 38.0 56.8 31.9 79.2 1,222 Rift Valley 21.1 45.4 45.7 61.8 34.6 73.2 1,872 Western 26.1 53.3 50.9 58.1 30.7 74.4 927 North Eastern 6.1 61.5 55.0 66.0 45.6 77.1 168 Education No education 23.5 61.4 57.7 66.0 47.4 79.2 1,039 Primary incomplete 22.2 57.1 47.7 64.1 35.3 78.1 2,685 Primary complete 14.2 45.4 38.7 56.5 28.9 70.1 2,069 Secondary+ 8.6 27.0 22.6 39.2 15.5 49.8 2,403 Employment Not employed 15.5 43.9 40.5 56.2 27.0 68.0 3,397 Employed for cash 15.0 42.6 35.9 51.2 28.3 64.3 3,561 Employed not for cash 22.7 61.2 46.3 63.7 39.4 78.9 1,218 Number of decisions in which woman has final say1 0 18.4 45.2 39.3 52.8 25.0 65.8 1,939 1-2 16.0 50.3 44.3 59.0 32.4 72.9 2,285 3-4 16.7 47.3 37.9 58.6 31.9 71.2 1,965 5 14.4 40.1 35.1 49.6 27.8 61.1 2,006 Wealth quintile Lowest 23.2 61.2 52.6 66.3 39.5 80.0 1,364 Second 21.1 54.3 43.5 60.2 34.9 75.6 1,475 Middle 16.1 48.7 41.7 58.9 31.9 72.9 1,503 Fourth 14.1 43.9 36.6 57.3 27.5 69.1 1,711 Highest 10.7 29.9 28.6 40.0 19.0 50.4 2,141 Total 16.3 45.9 39.4 55.1 29.4 67.9 8,195 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 19 women missing information on employment status 1 Either by herself or jointly with others 46 | Characteristics of Survey Respondents Table 3.12.2 Men’s attitude towards wife beating Percentage of men who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Husband is justified in hitting or beating his wife if she: –––––––––––––––––––––––––––––––––––––––––––––––– Agrees Goes out Refuses with at Burns without Neglects to have least one Number Background the Argues telling the sex specified of characteristic food with him him children with him reason men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 20.3 51.3 41.0 58.6 30.1 73.1 856 20-24 14.3 41.3 34.0 48.2 24.7 63.8 681 25-29 7.7 37.0 31.3 46.8 19.7 59.0 509 30-34 8.8 36.0 28.2 43.6 17.6 56.8 415 35-39 11.6 33.8 32.2 44.5 24.5 55.6 396 40-44 11.9 41.3 37.7 47.3 25.5 61.5 310 45-49 15.9 38.3 36.8 50.8 25.2 61.6 196 50-54 9.0 39.8 34.3 48.2 25.6 62.9 215 Marital status Never married 15.4 44.0 36.0 52.3 27.1 65.9 1,611 Married or living together 11.7 38.8 33.7 46.9 22.3 60.5 1,818 Divorced/separated/widowed 12.8 45.7 37.8 52.8 25.6 68.1 149 Number of living children 0 15.3 44.5 36.5 52.4 26.2 65.9 1,704 1-2 9.7 38.5 29.9 46.1 20.1 61.5 721 3-4 11.8 38.4 31.6 44.6 23.0 57.4 544 5+ 13.9 38.7 39.4 50.3 27.0 63.0 609 Residence Urban 8.3 33.7 26.0 37.6 17.3 52.0 907 Rural 15.2 44.0 38.0 53.7 27.1 67.1 2,671 Province Nairobi 5.2 27.1 17.6 29.7 15.2 42.5 397 Central 13.7 53.4 33.2 59.0 34.0 65.0 554 Coast 10.3 29.7 44.4 51.6 31.7 65.5 252 Eastern 6.2 31.9 31.0 42.2 18.0 54.8 588 Nyanza 25.7 61.8 41.4 50.0 28.6 71.8 481 Rift Valley 16.4 40.5 36.3 60.8 24.9 72.7 846 Western 10.7 34.2 39.0 36.3 18.2 58.3 396 North Eastern 26.0 62.7 63.5 81.5 39.5 87.1 65 Education No education 25.0 61.7 62.9 76.8 48.2 83.6 228 Primary incomplete 19.9 52.8 45.0 60.4 31.0 76.6 1,210 Primary complete 13.4 45.3 36.8 53.3 28.6 68.8 820 Secondary+ 5.5 24.9 19.7 32.7 12.2 44.1 1,320 Employment Not employed 16.2 41.8 35.5 51.6 25.6 65.0 1,004 Employed for cash 11.6 40.1 33.5 47.5 23.3 61.3 2,261 Employed not for cash 17.7 49.9 43.1 59.0 30.7 71.8 310 Number of decisions in which wife should have a say1 0 30.0 56.3 53.3 68.3 46.0 81.2 229 1-2 20.5 54.3 46.7 62.0 36.2 76.7 1,276 3-4 8.8 37.3 30.9 45.9 18.4 60.4 1,413 5 3.8 20.0 14.2 27.3 7.9 37.1 661 Wealth quintile Lowest 21.1 49.1 49.0 63.6 32.1 76.3 548 Second 17.8 44.3 38.1 51.3 27.4 68.5 609 Middle 14.3 43.3 38.2 50.3 27.4 64.3 648 Fourth 12.0 42.8 32.6 53.5 24.5 65.3 794 Highest 7.0 32.9 24.8 37.1 16.9 50.4 979 Total 13.4 41.4 34.9 49.6 24.6 63.3 3,578 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 2 men missing information on employment status 1 Either by herself or jointly with others Characteristics of Survey Respondents | 47 3.5.3 Attitudes Towards Refusing Sex with Husband The extent of control women have over when and with whom they have sex has important impli- cations for demographic and health outcomes, such as transmission of HIV and other sexually transmitted infections. To measure beliefs about sexual empowerment of women, the 2003 KDHS asked women and men respondents whether they think a wife is justified in refusing to have sex with her husband in the fol- lowing circumstances: when she knows that her husband has a sexually transmitted disease, when she knows that her husband has sex with other women, when she has recently given birth, and when she is tired or not in the mood. Tables 3.13.1 and 3.13.2 show the responses of women and men, respectively. Overall, acceptance of women’s sexual autonomy is rather high in Kenya. Half of women and 56 percent of men agree that all of the above reasons are rational justifications for a woman to refuse to have sexual relations with her husband, and only 7 percent of women and 2 percent of men agree with none of the reasons. The most accepted reasons for refusing to have sex among women and men are if the wife knows her husband has a sexually transmitted disease and if the wife has recently given birth. For both women and men, the least acceptable reason for a wife to refuse sex is being tired or not in the mood. Young women and men, men who have never married, men who have no children, women and men who live in rural areas (particularly in North Eastern Province), uneducated respondents, unem- ployed respon-dents, those who have no say in household decisions, and poorer women and men are the least likely to agree with all of the reasons for refusing sex. Male respondents in the 2003 KDHS were further asked whether they thought that a husband had the right to take specific actions if his wife refused to have sex with him. The specified actions were to get angry and reprimand her, to refuse to give her money or other means of financial support, to use force and have sex with her even if she does not want to, and to go and have sex with another woman. Table 3.14 presents the results. 48 | Characteristics of Survey Respondents Table 3.13.1 Women’s attitude towards refusing sex with husband Percentage of women who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Wife is justified in refusing sex with her husband if she: –––––––––––––––––––––––––––––––––––––––––––– Knows Knows Agrees Agrees husband has husband Is tired with all with none a sexually has sex Has or not of the of the Number Background transmitted with other recently in the specified specified of characteristic infection women given birth mood reasons reasons women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 80.9 76.1 76.6 59.1 47.6 11.9 1,856 20-24 88.7 80.9 83.0 63.1 53.0 6.6 1,691 25-29 88.9 79.9 88.4 62.4 53.0 4.8 1,382 30-34 90.1 80.4 88.2 59.0 51.2 4.5 1,086 35-39 88.8 77.2 85.7 58.9 49.9 6.5 871 40-44 87.2 77.7 85.1 56.2 47.8 6.6 788 45-49 89.4 79.5 85.1 59.6 50.8 5.7 521 Marital status Never married 83.4 78.6 77.8 60.4 49.6 10.3 2,443 Married or living together 88.4 78.8 86.4 60.3 51.2 5.8 4,919 Divorced/separated/widowed 89.9 78.9 85.8 58.8 50.1 5.4 833 Number of living children 0 83.3 78.0 77.2 59.8 48.6 10.6 2,399 1-2 89.5 80.8 86.9 63.1 54.1 5.3 2,427 3-4 89.4 79.6 86.7 58.3 50.4 5.5 1,752 5+ 86.5 76.0 85.7 58.7 48.4 6.5 1,616 Residence Urban 92.1 85.1 86.6 63.2 55.3 4.0 2,056 Rural 85.4 76.7 82.8 59.2 49.0 8.2 6,139 Province Nairobi 94.1 88.2 88.5 64.7 57.2 2.7 835 Central 91.4 85.2 85.2 47.8 41.4 3.4 1,181 Coast 88.1 78.8 86.3 59.0 50.7 6.3 667 Eastern 89.0 82.7 86.4 66.1 58.0 6.0 1,325 Nyanza 80.5 70.3 77.1 63.6 50.9 14.1 1,222 Rift Valley 83.2 73.4 81.8 57.3 45.9 8.4 1,872 Western 89.2 82.5 87.1 67.9 57.5 5.2 927 North Eastern 81.4 57.4 72.7 48.0 33.8 14.3 168 Education No education 78.6 65.9 77.3 51.7 40.6 13.2 1,039 Primary incomplete 83.6 75.7 81.1 60.6 49.8 9.2 2,685 Primary complete 90.1 80.7 85.9 59.9 50.9 5.1 2,069 Secondary+ 92.0 86.1 87.7 63.7 55.5 3.9 2,403 Employment Not employed 84.1 76.3 80.5 58.0 48.1 9.3 3,397 Employed for cash 89.4 81.1 86.1 62.2 52.2 5.3 3,561 Employed not for cash 89.4 79.7 86.8 61.0 53.0 5.6 1,218 Number of decisions in which woman participates1 0 80.0 75.3 75.4 60.0 49.2 13.5 1,939 1-2 88.1 78.9 83.8 58.5 49.2 6.1 2,285 3-4 90.0 79.6 88.4 62.2 52.1 4.8 1,965 5 89.8 81.3 87.3 60.4 52.1 4.5 2,006 Number of reasons wife- beating is justified 0 86.6 79.0 83.3 60.0 51.3 8.9 2,630 1-2 88.3 79.2 84.3 60.1 50.1 6.1 2,566 3-4 87.6 78.3 83.5 58.1 48.3 6.6 2,253 5 82.9 77.8 84.1 67.8 56.1 6.5 747 Wealth quintile Lowest 82.5 73.0 80.5 60.2 49.7 10.4 1,364 Second 82.9 72.3 82.3 59.8 47.4 9.5 1,475 Middle 84.9 77.5 82.2 57.8 48.4 8.4 1,503 Fourth 89.4 81.4 84.0 58.2 50.3 6.1 1,711 Highest 92.6 85.7 87.8 63.8 55.0 3.3 2,141 Total 87.1 78.8 83.8 60.2 50.6 7.1 8,195 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 19 women missing information on employment status 1 Either by herself or jointly with others Characteristics of Survey Respondents | 49 Table 3.13.2 Men’s attitude towards wives refusing sex with husband Percentage of men who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by back- ground characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Wife is justified in refusing sex with her husband if she: –––––––––––––––––––––––––––––––––––––––––––– Knows Knows Agrees Agrees husband has husband Is tired with all with none a sexually has sex Has or not of the of the Number Background transmitted with other recently in the specified specified of characteristic infection women given birth mood reasons reasons men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 86.1 71.8 87.9 54.9 43.0 5.8 856 20-24 92.2 78.8 96.2 70.8 57.5 0.8 681 25-29 94.8 78.5 96.4 74.6 63.9 1.6 509 30-34 96.9 81.5 96.4 75.4 63.9 1.0 415 35-39 96.2 79.1 96.3 72.6 59.3 0.2 396 40-44 95.2 78.7 96.0 66.2 56.6 1.6 310 45-49 94.6 80.2 99.0 67.8 60.2 1.0 196 50-54 96.8 81.2 96.3 71.2 60.5 1.3 215 Marital status Never married 89.2 74.9 91.7 62.6 50.0 3.7 1,611 Married or living together 95.8 80.4 96.8 72.4 61.6 0.9 1,818 Divorced/separated/widowed 93.9 72.7 94.8 66.2 55.4 1.0 149 Number of living children 0 89.7 76.2 92.0 63.4 51.5 3.6 1,704 1-2 95.0 79.2 96.8 73.5 61.9 0.6 721 3-4 95.5 79.7 95.6 71.8 61.2 1.7 544 5+ 96.4 78.0 97.4 69.4 57.6 0.5 609 Residence Urban 94.3 80.8 94.1 74.5 62.5 1.3 907 Rural 92.3 76.6 94.5 65.4 54.0 2.5 2,671 Province Nairobi 93.9 82.1 94.7 77.6 64.1 1.2 397 Central 93.4 81.0 93.3 61.4 52.2 2.9 554 Coast 93.0 71.2 91.6 59.7 46.4 2.6 252 Eastern 89.5 76.0 92.5 60.8 54.1 4.5 588 Nyanza 93.6 79.0 95.0 69.8 58.0 2.0 481 Rift Valley 93.1 74.8 96.8 71.5 57.5 1.0 846 Western 93.3 77.4 94.4 76.2 60.8 1.1 396 North Eastern 96.2 88.5 97.1 38.8 37.5 1.9 65 Education No education 92.5 71.2 94.1 52.2 38.6 2.4 228 Primary incomplete 89.0 71.7 92.0 60.2 47.6 3.3 1,210 Primary complete 93.6 78.4 95.4 66.5 55.4 2.1 820 Secondary+ 95.8 83.7 96.2 78.1 67.4 1.1 1,320 Employment Not employed 88.0 74.8 90.4 57.8 47.7 4.9 1,004 Employed for cash 95.2 79.6 96.0 72.3 60.8 1.0 2,261 Employed not for cash 90.6 72.4 96.4 66.6 49.5 1.7 310 Number of decisions in which wife has say1 0 86.8 60.3 91.3 51.4 37.8 7.7 229 1-2 91.3 76.1 92.6 59.7 48.6 2.6 1,276 3-4 93.3 78.9 95.7 71.2 58.8 1.4 1,413 5 96.5 83.8 96.4 81.4 71.4 1.0 661 Number of reasons wife- beating is justified 0 93.5 81.9 94.3 75.8 65.7 2.8 1,315 1-2 93.0 78.4 94.9 68.6 56.7 1.5 1,129 3-4 91.9 71.3 94.6 58.1 44.3 1.9 914 5 91.2 74.4 92.1 55.5 45.3 2.8 221 Wealth quintile Lowest 90.2 72.7 94.9 59.5 44.4 2.7 548 Second 91.3 75.1 92.5 63.8 54.1 3.6 609 Middle 92.1 76.2 94.1 67.0 54.5 2.1 648 Fourth 92.9 78.2 94.6 66.3 56.2 2.5 794 Highest 95.4 82.4 95.5 76.4 65.0 0.8 979 Total 92.8 77.6 94.4 67.7 56.1 2.2 3,578 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 2 men missing information on employment status 1 Either by herself or jointly with others 50 | Characteristics of Survey Respondents Table 3.14 shows that almost four in ten men agree with at least one of the four specified actions. The most acceptable response to a wife’s refusal to have sex is for men to get angry and reprimand her (33 percent). Only 13 percent of men say that it is justifiable for a man to refuse to provide financial sup- port, and only about one in ten men say that it is justifiable to force the wife to have sex or to have sex with another woman. Differences by background characteristics are not large. However, men in North Eastern Province appear to be the most tolerant of women’s sexual autonomy, with only 14 percent agree- ing that a man is justified in taking any of the specified actions when his wife refuses sex. Men in Nyanza and Coast provinces, on the other hand, are the most likely to believe that a man is justified in taking some action, mainly getting angry. Table 3.14 Men’s attitudes towards justifiable actions if wife refuses sex Percentage of men who believe a wife's refusal of sex justifies specific actions, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Husband’s justifiable actions if wife refuses sex: ––––––––––––––––––––––––––––––––––––––––––– Having Agrees with sex with at least one Number Background Getting Refusing Using another specified of characteristic angry money force woman reason men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 36.2 16.7 13.0 12.0 41.7 856 20-24 30.5 13.3 6.3 11.2 36.9 681 25-29 29.5 10.5 6.2 9.9 35.0 509 30-34 29.9 9.9 8.0 9.7 34.7 415 35-39 31.5 11.4 8.9 12.1 39.3 396 40-44 32.4 13.9 9.3 12.5 41.5 310 45-49 34.8 8.1 8.0 9.2 39.5 196 50-54 36.4 15.7 11.5 9.7 39.8 215 Marital status Never married 32.7 15.0 9.7 11.5 38.9 1,611 Married or living together 31.3 10.7 8.3 10.0 37.2 1,818 Divorced/separated/widowed 46.0 19.7 11.9 18.4 50.6 149 Number of living children 0 32.7 14.6 9.8 11.3 38.8 1,704 1-2 29.6 9.8 6.6 10.8 35.1 721 3-4 32.3 13.0 8.4 10.4 37.6 544 5+ 35.6 12.5 10.4 11.4 42.7 609 Residence Urban 26.9 10.3 5.7 11.5 33.7 907 Rural 34.4 14.0 10.2 10.9 40.1 2,671 Province Nairobi 25.0 7.7 6.2 8.1 30.4 397 Central 21.8 14.1 5.7 10.4 27.7 554 Coast 45.4 22.5 17.6 20.8 51.9 252 Eastern 33.9 13.3 5.3 6.9 37.4 588 Nyanza 45.8 13.4 14.4 14.3 53.0 481 Rift Valley 32.5 12.2 11.8 10.8 40.3 846 Western 32.1 13.3 5.6 13.0 37.6 396 North Eastern 11.1 3.0 1.8 0.6 13.6 65 Educational attainment No education 37.1 13.4 15.4 20.0 46.8 228 Primary incomplete 42.6 18.4 13.5 15.3 49.7 1,210 Primary complete 34.4 12.9 7.8 8.7 38.7 820 Secondary+ 21.3 8.1 4.7 7.1 26.7 1,320 Employment Not employed 32.9 13.2 9.6 8.5 37.8 1,004 Employed for cash 32.2 12.3 8.5 11.6 38.3 2,261 Employed not for cash 33.3 17.7 11.1 15.1 42.1 310 Wealth quintile Lowest 45.2 17.2 13.8 14.1 53.2 548 Second 39.2 14.7 13.4 13.1 44.7 609 Middle 33.3 16.2 9.4 11.4 39.7 648 Fourth 27.5 10.8 6.9 8.7 32.9 794 Highest 24.8 9.3 5.1 9.8 30.2 979 Total 32.5 13.0 9.0 11.1 38.5 3,578 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 2 men missing information on employment status Fertility Levels, Trends, and Differentials | 51 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4 Collins Opiyo 4.1 INTRODUCTION Fertility is one of the three principal components of population dynamics, the others being mor- tality and migration (United Nations, 1973). Collection of data on fertility levels, trends and differentials has remained a prime objective of the Demographic and Health Surveys (DHS) programme since its in- ception in the 1980s. In Kenya, continued collection of such data through birth histories and other means has been important in recognsing the important role that fertility plays in balancing Kenya’s overall popu- lation growth equation. The fact that fertility reduction became the thrust of the country’s population pol- icy as early as 1967 underlines the deliberate efforts made by the Government to contain it. The 2003 KDHS was conducted against the backdrop of a dramatic fertility transition that was first reported in the 1989 KDHS. On the basis of the 1999 Kenya Population and Housing Census, fertil- ity was projected to continue to decline to a total fertility rate of 3.2 by 2015-2020 (Central Bureau of Sta- tistics, 2002d: 27). The government and other stakeholders are therefore keen to monitor developments with respect to the fertility transition process, with a view to evaluating the course of the fertility transi- tion through population and development policies and programmes. This chapter presents an analysis of the fertility data collected in the 2003 KDHS. It includes a discussion on levels, trends, and differentials in fertility by selected background characteristics; data on lifetime fertility (children ever born and living); and a scrutiny of age at first birth and birth intervals. Thereafter, a brief discussion on adolescent fertility, which has become critical to the issue of fertility transition, particularly in the wake of a new policy modelled on adolescent reproductive health, is pre- sented. The fertility data were collected by asking all women of reproductive age (15-49 years) to pro- vide complete birth histories of all children they had given birth to, those who were currently living with them, those who were living away, and those who had died. In addition, the following information was collected for each live birth: name, sex, date of birth, survival status, current age (if alive), and age at death (if dead). It is important to mention at the outset that the birth history approach has some limitations that might distort fertility levels and patterns. For instance, women may include relatives’ children as their own or omit children who died young, while older women may forget grown children who have left home (United Nations, 1983). Accordingly, the results should be viewed with these caveats in mind. 4.2 CURRENT FERTILITY Measures of current fertility are presented in Table 4.1 for the three-year period preceding the survey, corresponding to the period from mid-2000 to mid-2003. Several measures of current fertility are shown. Age-specific fertility rates (ASFRs) are calculated by dividing the number of births to women in a specific age group by the number of woman-years lived during a given period.1 The total fertility rate (TFR) is a common measure of current fertility and is defined as the average number of children a woman 1 Numerators for the age-specific fertility rates are calculated by summing all births that occurred during the 1 to 36 months preceding the survey, classified by the age of the mother at the time of birth in 5-year age groups. The de- nominators are the number of woman-years lived in each specific 5-year age group during the 1 to 36 months pre- ceding the survey. 52 | Fertility Levels, Trends, and Differentials Table 4.1 Current fertility Age-specific and cumulative fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by urban-rural residence, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––– Residence –––––––––––––– Age group Urban Rural Total –––––––––––––––––––––––––––––––––––––––––––– 15-19 88 123 114 20-24 162 278 243 25-29 168 254 231 30-34 136 217 196 35-39 78 137 123 40-44 23 62 55 45-49 (6) 17 15 TFR 3.3 5.4 4.9 GFR 123 187 170 CBR 35.3 38.1 37.5 –––––––––––––––––––––––––––––––––––––––––––– Note: Rates for age group 45-49 may be slightly biased because of truncation. Rates in parentheses are based on 125 to 249 unweighted woman-years of exposure. TFR: Total fertility rate for women age 15-49, ex- pressed per woman GFR: General fertility rate (births divided by the number of women age 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 popula- tion would have if she went through her entire reproductive period (15-49 years) reproducing at the prevailing ASFR. Two additional measures of fertility reported in this chapter are the general fertility rate (GFR), which represents the annual number of births per 1,000 women age 15-44, and the crude birth rate (CBR), which represents the annual number of births per 1,000 population. The CBR was estimated using the birth history data in conjunction with the population data collected in the household schedule. Table 4.1 shows a TFR of 4.9 children per woman for the three-year period preceding the survey (mid-2000 to mid-2003). Fertility is considerably higher in the rural areas (5.4 children per woman) than urban areas (3.3 children per woman), a pattern that is evident at every age and that widens with age, with fertility of rural women age 35 and over becoming around twice that of urban women. Overall, peak fertility occurs at age 20-24. In the rural areas, fertility also peaks at age 20-24, falling sharply after age 39. In the urban areas, however, fertility peaks at age 25-29 years (actually it tends to peak broadly at age 20-29) and tapers off sharply after age 34. The persistence of a disparity in fertility between urban and rural women is due to favourable factors most probably associated with urbanisation (e.g., better education, higher status of women, better access to family planning information and services and later marriage). This is well documented in the literature both in Kenya and elsewhere. Differentials in fertility levels by urban-rural residence, province, educational attainment and wealth quintile are shown in Table 4.2 and Figure 4.1. Regionally, disparities are still large. Fertility is lowest in Nairobi Province (2.7 children per woman) and highest in North Eastern Province (7.0 children per woman). Fertility in Central Province is also relatively low (3.4), compared with Nyanza (5.6), Rift Valley (5.8), and Western (5.8) provinces. Regional differentials in fertility are closely associated with regional dis- parities in knowledge and use of family planning methods (see Chapter 5). In accordance with expectations, education of women is strongly associated with lower fertility. The TFR decreases dramatically from 6.7 for women with no education to 3.2 for women with at least some secondary education. While some primary education is associated with lower fertility, complete primary education is associated with a reduction in fertility of almost two children per woman. Fertility is also very closely associated with wealth. The disparity in fertility between the poorest and the richest women is on the order of almost five children per woman. Table 4.2 also presents a crude assessment of trends in fertility in the various subgroups by com- paring current fertility with a measure of completed fertility, the mean number of children ever born to women age 40-49. Current fertility always falls substantially below lifetime fertility, except for respon- dents from the poorest households. This provides further evidence that fertility has fallen substantially over time for all of these subgroups. Overall, the table shows that fertility has fallen by about one child per woman in recent periods. However, it seems to have increased slightly for women from the poorest households. Fertility Levels, Trends, and Differentials | 53 Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, per- centage of women 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––– Mean number of children Total Percentage ever born Background fertility currently to women characteristic rate1 pregnant1 age 40-49 ––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 3.3 6.6 4.4 Rural 5.4 8.2 6.4 Province Nairobi 2.7 6.6 3.5 Central 3.4 5.0 4.9 Coast 4.9 8.5 6.2 Eastern 4.8 7.9 5.8 Nyanza 5.6 8.3 6.8 Rift Valley 5.8 8.4 6.8 Western 5.8 9.4 6.5 North Eastern 7.0 11.5 8.3 Education No education 6.7 9.1 6.9 Primary incomplete 6.0 9.1 6.8 Primary complete 4.8 8.4 6.0 Secondary+ 3.2 5.3 4.4 Wealth quintile Lowest 7.6 9.4 7.4 Second 5.8 9.3 6.8 Middle 5.1 7.9 6.5 Fourth 4.0 6.8 5.5 Highest 3.1 6.5 4.2 Total 4.9 7.8 6.0 ––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Women age 15-49 Table 4.2 indicates that 8 percent of women were pregnant at the time of the survey. This is likely to be an underestimate, as women in the early stages of pregnancy may be unaware or unsure that they are pregnant, while some may refuse to declare that they are pregnant. Noticeably, differentials in pregnancy rates are generally consistent with the pattern depicted by fertility across the various subgroups. 54 | Fertility Levels, Trends, and Differentials 4.9 3.3 5.4 2.7 3.4 4.9 4.8 5.6 5.8 5.8 7.0 6.7 6.0 4.8 3.2 KENYA RESIDENCE Urban Rural PROVINCE Nairobi Central Coast Eastern Nyanza Rift Valley Western North Eastern EDUCATION No education Primary incomplete Primary complete Secondary+ 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 Births per woman Figure 4.1 Total Fertility Rate, by Background Characteristics KDHS 2003 4.3 FERTILITY TRENDS Kenya is endowed with a wealth of demographic data. Accordingly, changes in fertility levels over time can be tracked by examining fertility estimates from various surveys and censuses, spanning the last three decades. Table 4.3 and Figure 4.2 indicate that the TFR declined dramatically during the last two decades of the 20th century, changing from a high of 8.1 children per woman in the late 1970s, through 6.7 in the late 1980s, to 4.7 during the last half of the 1990s. However, fertility seems to have started rising, albeit marginally, from 1998, reaching a TFR of 4.9 children per woman during the period from mid-2000 to mid-2003.2 This upturn in birth rates has especially affected age groups 25-39. The stagnation in fertility is one of the most surprising and worrisome findings from the 2003 KDHS, since fertility decline was first observed about 15 years ago. Nevertheless, this trend seems to be corroborated by the findings of the 1999 Population and Housing Census, where a TFR of 5.0 was esti- mated for a period varying from 12 months to a little less than 5 years before the census (Figure 4.2). Further, data on other fertility correlates collected in the 2003 KDHS are internally consistent with this new trend: contraceptive use has only inched up from 39 percent of married women in 1998 to 41 percent in 2003 (excluding the northern areas); pronatalist desires have reemerged (the proportion of women who either want no more children or are sterilised decreased from 53 percent in 1998 to 50 per- cent in 2003 excluding the north); child mortality has risen since the early 1990s, which tends to reintro- duce the “insurance effect” phenomenon; and age at first marriage and age at first birth have largely re- mained the same or have slightly increased. 2 Although both the census data and the 2003 KDHS are nationally representative, data from all previous surveys exclude the northern half of the country. Retabulation of the 2003 KDHS data excluding the same northern areas produces a TFR of 4.8. Fertility Levels, Trends, and Differentials | 55 8.1 6.7 5.4 4.7 5.0 4.9 1975-1978 1984-1989 1990-1993 1995-1998 1995-1999 2000-2003 0.0 2.0 4.0 6.0 8.0 10.0 Births per woman Figure 4.2 Total Fertility Rates, Kenya 1975-2003 Note: Rates for the first four time periods exclude the northern half of Kenya, while the rates from the 1999 census and the 2003 KDHS cover the entire country. Table 4.4 shows the changes in fertility between the 1998 KDHS and the 2003 KDHS by selected background characteristics. Overall, the table shows that the rise in the TFR was statistically insignificant, from 4.7 children per woman during the 1995-1998 period to 4.8 during the 2000-2003 period. Across the provinces, fertility increased in all except Central and Coast provinces. Nyanza Province recorded the highest increase in TFR (12 percent). With respect to education, the data show that fertility increased for women with no education and those who had not completed primary education. However, fertility re- mained the same for women who completed primary education and declined for women with at least some secondary education. According to place of residence, fertility increased in both urban and rural areas, but the rise was a little larger for women in the urban areas (7 percent) than those in the rural (4 percent). Table 4.3 Trends in fertility Age-specific fertility rates (per 1,000 women) and total fertility rates from selected surveys and censuses: 1977-78 KFS, 1989 KDHS, 1993 KDHS, 1998 KDHS, 1999 Population and Housing Census, and 2003 KDHS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1977-1978 1989 1993 1998 2003 2003 KFS1 KDHS1 KDHS1 KDHS1 1999 KDHS KDHS Age group 1975-1978 1984-1989 1990-1993 1995-1998 Census 2000-031 2000-03 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 168 152 110 111 142 114 114 20-24 342 314 257 248 254 241 243 25-29 357 303 241 218 236 227 231 30-34 293 255 197 188 185 193 196 35-39 239 183 154 109 127 119 123 40-44 145 99 70 51 56 55 55 45-49 59 35 50 16 7 15 15 TFR 8.1 6.7 5.4 4.7 5.0 4.8 4.9 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Rates refer to the three-year period preceding the surveys, except for the 1989 KDHS, which uses a five-year period, and the 1999 census, which uses a period that varies with the age groups used to make the correction. Sources: National Council for Population and Development et al., 1999: 31 and Central Bureau of Statistics, 2002b: 25 1 Excludes the northern part of the country 56 | Fertility Levels, Trends, and Differentials Table 4.4 Trends in fertility by background characteristics Total fertility rates and percent change according to province, residence, and education, Kenya 1998 and 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––– 1998 2003 Background KDHS KDHS Percentage characteristic 1995-1998 2000-2003 change ––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 3.1 3.3 +6.5 Rural 5.2 5.4 +3.8 Province Nairobi 2.6 2.7 +3.8 Central 3.7 3.4 -8.1 Coast 5.1 4.9 -3.9 Eastern 4.7 4.8 +2.1 Nyanza 5.0 5.6 +12.0 Rift Valley 5.3 5.8 +9.4 Western 5.6 5.8 +3.6 Education No education 5.8 6.7 +15.5 Primary incomplete 5.2 6.1 +17.3 Primary complete 4.8 4.8 +0.0 Secondary and above 3.5 3.2 -8.6 Total 4.7 4.8 +2.1 ––––––––––––––––––––––––––––––––––––––––––––––––––– Note: The TFRs for the 2003 KDHS in this table differ from those in Table 4.2 because, for comparison the areas covered in the 1998 KDHS, areas in the northern part of Kenya have been excluded. - Indicates net decline/decrease + Indicates net rise/increase Table 4.5 presents the ASFRs for five-year periods preceding the 2003 KDHS. A mixed pattern is observed, in which fertility seems to have declined steadily for women age 20-24 and 25-29, while it tended to increase between the most recent periods for women age 15-19 and 30-34. Table 4.5 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother’s age at the time of the birth, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––– Number of years preceding survey Mother’s age –––––––––––––––––––––––––––––––––– at birth 0-4 5-9 10-14 15-19 –––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 116 113 147 145 20-24 248 266 287 317 25-29 231 245 280 294 30-34 196 190 233 [272] 35-39 128 139 [203] - 40-44 58 [90] - - 45-49 [19] - - - –––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Fertility Levels, Trends, and Differentials | 57 4.4 CHILDREN EVER BORN AND CHILDREN SURVIVING Table 4.6 shows the distribution of all women and of currently married women age 15-49 years by number of children ever born and mean number of living children. More than four-fifths of women age 15-19 (82 percent) have never given birth. However, this proportion declines rapidly to less than 4 percent for women age 30 years and above, indicating that childbearing among Kenyan women is nearly univer- sal. On average, Kenyan women attain a parity of 6.5 children per woman at the end of their childbearing. This is a little more than 1.5 children above the total fertility rate, a discrepancy that is attributable to the dramatic decline in fertility during the 1980s and 1990s. The same pattern is replicated for currently married women, except that only a little more than one-third (35 percent) of the married women age 15-19 have not borne a child. As with all women, this proportion diminishes, although more rapidly, to 4 percent or less for women age 25 and above. This dif- ference in childbearing can be explained by the presence of many young and unmarried women in the “all women” category, who are known to exhibit extremely low fertility. On average, currently married women age 45-49 have borne 6.9 children each, of which one child on average has died. As expected, women above 40 years have much higher parities, with substantial proportions having 10 or more births by the end of their childbearing years. Consonant with expectations, the mean number of children ever born and mean number living rise monotonically with rising age of women, thus presupposing minimal or no recall lapse, which height- ens confidence in the birth history reports. Table 4.6 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, and mean number of children ever born and mean number of living children, according to age group, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Mean Mean Number of children ever born Number number number ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– of of children of living Age 0 1 2 3 4 5 6 7 8 9 10+ Total women ever born children –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALL WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 81.5 14.7 3.4 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,856 0.23 0.21 20-24 32.7 31.1 22.1 10.9 2.8 0.2 0.2 0.0 0.0 0.0 0.0 100.0 1,691 1.21 1.09 25-29 10.6 17.9 20.5 22.5 16.3 7.3 3.2 1.0 0.3 0.1 0.2 100.0 1,382 2.60 2.32 30-34 3.8 8.5 16.7 17.7 17.5 13.0 11.1 6.0 3.8 1.1 0.8 100.0 1,086 3.88 3.48 35-39 2.8 3.7 8.9 13.2 15.0 15.9 13.4 11.1 8.3 3.5 4.2 100.0 871 5.01 4.34 40-44 1.9 3.1 4.4 11.9 13.5 15.6 12.4 11.5 9.2 7.5 9.0 100.0 788 5.72 5.07 45-49 2.7 2.8 4.6 6.9 7.9 11.8 12.9 11.0 13.9 8.6 17.1 100.0 521 6.52 5.53 Total 28.1 14.8 12.7 11.5 9.0 6.9 5.5 4.0 3.2 1.8 2.5 100.0 8,195 2.75 2.43 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CURRENTLY MARRIED WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 34.7 46.4 16.8 1.9 0.2 0.0 0.0 0.0 0.0 0.0 0.0 100.0 333 0.86 0.80 20-24 10.7 33.5 32.6 17.7 4.9 0.3 0.3 0.0 0.0 0.0 0.0 100.0 965 1.75 1.57 25-29 4.0 13.3 22.6 26.3 19.2 9.2 3.5 1.1 0.4 0.2 0.2 100.0 1,056 2.96 2.65 30-34 2.0 6.5 15.3 18.8 18.3 13.7 12.2 6.9 4.3 1.1 1.0 100.0 873 4.11 3.70 35-39 1.0 2.7 7.8 12.6 15.6 16.1 13.2 12.5 10.0 3.6 5.0 100.0 691 5.31 4.62 40-44 1.5 1.7 3.3 11.0 13.6 16.1 12.6 11.9 10.2 8.0 10.2 100.0 614 5.97 5.30 45-49 2.8 0.6 3.7 6.4 6.7 13.1 11.6 11.0 14.5 10.2 19.5 100.0 388 6.87 5.86 Total 6.2 14.3 16.9 16.2 12.7 9.8 7.3 5.6 4.7 2.5 3.7 100.0 4,919 3.80 3.36 58 | Fertility Levels, Trends, and Differentials 4.5 BIRTH INTERVALS Examination of birth intervals is important in providing insights into birth spacing patterns and, subsequently, maternal and child health. Studies have shown that children born less than 24 months after a previous sibling risk poorer health and also threaten maternal health. Table 4.7 provides a glimpse into the birth intervals of children born to Kenyan women of reproductive age during the five years preceding the survey across selected subgroups. Table 4.7 Birth intervals Percent distribution of nonfirst births in the five years preceding the survey, by number of months since preceding birth, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Median Number number of Months since preceding birth of months since Background ––––––––––––––––––––––––––––––––––––––––––––––––– nonfirst preceding characteristic 7-17 18-23 24-35 36-47 48+ Total births birth ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 22.4 29.3 35.5 8.1 4.8 100.0 79 23.7 20-29 10.8 16.4 42.4 16.0 14.4 100.0 2,289 29.6 30-39 7.5 10.9 32.5 17.2 31.9 100.0 1,801 35.6 40-49 7.6 6.9 22.4 21.2 41.9 100.0 454 42.1 Birth order 2-3 10.1 14.5 36.3 15.8 23.3 100.0 2,168 32.1 4-6 8.1 11.7 37.5 16.8 25.9 100.0 1,628 33.3 7+ 10.1 14.6 34.8 19.8 20.8 100.0 828 32.2 Sex of preceding birth Male 9.3 14.6 37.0 15.3 23.8 100.0 2,329 32.4 Female 9.4 12.5 36.0 18.4 23.7 100.0 2,294 32.7 Survival of preceding birth Living 7.0 12.6 37.4 18.0 24.9 100.0 4,069 33.5 Dead 26.8 20.3 29.2 8.3 15.4 100.0 554 24.6 Residence Urban 9.8 14.1 26.1 17.3 32.8 100.0 748 36.0 Rural 9.3 13.4 38.5 16.8 22.0 100.0 3,875 32.1 Province Nairobi 11.3 14.5 26.3 15.2 32.7 100.0 242 34.9 Central 6.3 9.3 32.7 14.7 37.0 100.0 449 36.6 Coast 9.0 12.5 35.4 19.6 23.5 100.0 384 34.0 Eastern 8.5 9.9 37.3 17.4 26.9 100.0 731 33.7 Nyanza 10.2 15.0 36.6 17.3 20.9 100.0 786 31.6 Rift Valley 9.2 14.2 37.7 17.1 21.8 100.0 1,266 31.9 Western 8.6 17.1 40.1 16.1 18.0 100.0 609 30.3 North Eastern 20.5 17.3 36.4 15.0 10.8 100.0 157 27.2 Education No education 10.0 14.8 35.0 18.4 21.8 100.0 801 32.5 Primary incomplete 8.5 13.6 42.0 16.1 19.7 100.0 1,764 31.4 Primary complete 9.6 13.6 35.8 16.2 24.7 100.0 1,218 32.7 Secondary+ 10.2 12.0 27.2 17.8 32.8 100.0 840 36.2 Wealth quintile Lowest 11.1 15.3 41.7 16.8 15.1 100.0 1,285 30.2 Second 8.0 11.5 40.4 18.5 21.7 100.0 1,005 32.2 Middle 9.1 14.6 34.3 16.0 26.0 100.0 896 33.6 Fourth 8.4 11.2 35.1 15.3 30.0 100.0 721 34.0 Highest 9.6 14.3 25.7 17.3 33.1 100.0 716 36.1 Total 9.4 13.5 36.5 16.9 23.7 100.0 4,623 32.6 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Fertility Levels, Trends, and Differentials | 59 Overall, the median birth interval has remained constant since 1998, changing marginally from 32.9 months in the 1998 KDHS to 32.6 months in the 2003 KDHS. However, the median birth interval is relatively shorter for children born to younger women; to women in the rural areas; to women in North Eastern, Western, Nyanza, and Rift Valley provinces; to women with less than secondary education; and to women from poorer households. The shortest birth interval is observed among children born to women age 15-19 (23.7 months) and children whose preceding sibling died (24.6 months), while the longest is among children born to women with at least some secondary education (36.2 months) and women age 40-49 (42.1 months). Overall, 23 percent of Kenyan children are born less than 24 months after a previous birth, an in- terval perceived to be “too short.” This is identical to the level in 1998. A larger proportion of such chil- dren is born to younger women age 15-19 (52 percent) relative to other age groups, to women in North Eastern Province (38 percent) compared with other provinces, and to women with no education (25 per- cent) relative to other education categories. 4.6 AGE AT FIRST BIRTH The onset of childbearing has a direct bearing on fertility. Early initiation into childbearing lengthens the reproductive period and subsequently increases fertility. Table 4.8 shows median age at first birth as well as the percentage of women who gave birth by a given exact age, by five-year age groups of women. The youngest cohort of women for whom median age at first birth can be calculated is 25-29 years (the medians for groups age 15-19 and 20-24 cannot be de- termined, as less than half of the women had a birth before reaching the lowest age of the age group). The median age at first birth is 20.1 years for women age 25-29 in 2003, reflecting a marginal rise from the 19.6 years recorded for the same women in the 1998 KDHS. Generally, age at first birth has shown some slight increase over the years, being later for younger women as compared with older women. However, caution should be exercised in interpreting these slight changes, as they are likely to be statistically insignificant. Further insights into the onset of childbearing can be discerned by examining the percentage of women who had a first birth by the given exact ages for various age groups of women. While this per- Table 4.8 Age at first birth Among all women, percentage who gave birth by exact age, and median age at first birth, by current age, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Median Percentage who gave birth by exact age who have Number age at ––––––––––––––––––––––––––––––––––––––––––––––––––– never of first Current age 15 18 20 22 25 given birth women birth ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 1.5 na na na na 81.5 1,856 a 20-24 3.4 22.7 45.4 na na 32.7 1,691 a 25-29 4.4 24.9 48.3 68.0 84.8 10.6 1,382 20.1 30-34 5.7 30.6 54.9 71.2 85.7 3.8 1,086 19.6 35-39 6.1 27.6 50.7 72.8 89.0 2.8 871 19.9 40-44 5.7 31.3 56.9 75.2 89.9 1.9 788 19.4 45-49 7.6 33.8 57.3 73.5 88.5 2.7 521 19.3 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable a Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group 60 | Fertility Levels, Trends, and Differentials centage increases progressively by increasing exact ages as expected, the proportion having their first birth by age 18, for instance, is slightly lower for younger women, compared with older ones. This obser- vation is consistent with a slightly rising age at first birth. Table 4.9 depicts the differential patterns in age at first birth using the median among women age 25-49 by current age, according to selected background characteristics. A significantly higher median age at first birth is observed in the urban areas, compared with rural areas for all age groups. Among the prov- inces, a higher median is recorded in Nairobi (22.0 years) for women age 25-49, followed by Central Province (20.3 years), while the lowest was recorded in Nyanza Province (18.4 years). This implies that women in Nyanza Province, on average, have their first birth nearly four years earlier than those in Nai- robi. Clearly, the onset of childbearing is significantly related to education of women. According to Table 4.9, women with some secondary education and above begin their childbearing more than three years (22.2 years) later than women with no education (18.7 years). Delayed onset of childbearing of about three years is also exhibited by wealthier women, relative to poorer ones. 4.7 TEENAGE FERTILITY Adolescent fertility in Kenya occupies a prime place in the design and implementation of repro- ductive health strategies, policies, and programmes. In an attempt to address the reproductive health needs Table 4.9 Median age at first birth by background characteristics Median age at first birth among women age 25-49, by current age and background characteris- tics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Current age Women Background ––––––––––––––––––––––––––––––––––––––––––––––– age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 22.4 21.3 20.8 20.4 20.7 21.2 Rural 19.6 19.3 19.7 19.2 19.0 19.4 Province Nairobi 23.0 22.0 21.7 21.6 21.0 22.0 Central 21.0 20.6 20.7 19.7 19.2 20.3 Coast 20.0 20.4 19.0 19.5 19.0 19.8 Eastern 19.9 19.7 20.3 20.1 19.0 19.9 Nyanza 19.1 18.0 18.6 18.0 18.3 18.4 Rift Valley 20.0 19.1 19.8 19.0 20.1 19.6 Western 19.9 19.2 19.6 19.0 18.5 19.4 North Eastern 18.0 19.0 19.6 21.5 (21.6) 19.4 Education No education 18.7 17.4 18.8 19.1 19.4 18.7 Primary incomplete 18.7 18.3 18.5 18.3 18.4 18.5 Primary complete 19.9 19.7 19.8 19.1 18.4 19.6 Secondary+ 23.0 22.2 22.0 21.2 22.2 22.2 Wealth quintile Lowest 18.9 18.1 18.2 18.9 18.9 18.6 Second 19.7 18.7 19.5 18.8 18.7 19.3 Middle 19.1 19.3 20.1 19.1 19.0 19.3 Fourth 20.6 19.9 20.4 19.4 19.4 20.0 Highest 22.6 21.8 21.2 21.2 21.0 21.8 Total 20.1 19.6 19.9 19.4 19.3 19.8 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Figures in parentheses are based on fewer than 25 unweighted women. Fertility Levels, Trends, and Differentials | 61 and to reduce fertility of this special group, the government, through the Ministry of Health and the National Council for Population and Development, has recently put in place an Adolescent Reproductive Health Policy to help meet the needs of this group. It is important to examine the fertility of adolescents for various reasons. First, children born to very young mothers are normally predisposed to higher risks of illness and death. Second, adolescent mothers are more likely to experience complications during pregnancy and are less likely to be prepared to deal with them, which often leads to maternal deaths. Third, their early entry into reproduction denies them the opportunity to pursue basic and further academic goals. This is detrimental to their prospects for good careers, which often lowers their status in society. Table 4.10 displays the percentage of women age 15-19 who were mothers or were pregnant with their first child at the time of the 2003 KDHS, by selected background characteristics. Generally, teenage fertility has edged slightly upward, with the proportion that have begun childbearing rising from 21 per- cent in 1998 to 23 percent in 2003. The proportion of teenage mothers rose from 17 percent in 1998 to 19 percent in 2003, while the proportion of those pregnant with their first child rose as well, from 4 percent in 1998 to 5 percent in 2003. Table 4.10 also shows that the proportion of teenagers who have begun childbearing increases dramatically from 4 percent at age 15 to 46 percent at age 19. Not much disparity, though, is observed in this parameter between rural and urban women. Teenage fertility is much higher in Rift Valley, North Eastern, Coast, and Nyanza provinces, where at least one-fourth of women age 15-19 have began child- bearing. Almost half of uneducated teenagers (46 percent) have begun childbearing, compared with only 10 percent of those with some secondary education and above. Teenagers from poorer households are more likely to have begun childbearing (29 percent), as compared with those from wealthier households (21 percent). 62 | Fertility Levels, Trends, and Differentials Table 4.10 Teenage pregnancy and motherhood Percentage of women age 15-19 who are mothers or pregnant with their first child, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage who are: Percentage ––––––––––––––––––––– who have Pregnant begun Number Background with first child- of characteristic Mothers child bearing women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15 2.4 1.8 4.1 351 16 5.3 3.0 8.3 360 17 12.0 4.1 16.1 365 18 30.4 7.2 37.7 397 19 39.4 6.2 45.6 383 Residence Urban 17.7 4.5 22.2 388 Rural 18.7 4.5 23.3 1,467 Province Nairobi 15.2 4.4 19.5 144 Central 13.8 1.5 15.3 230 Coast 23.5 5.9 29.4 145 Eastern 11.0 3.7 14.8 316 Nyanza 21.3 5.8 27.1 325 Rift Valley 25.5 5.0 30.5 390 Western 16.4 4.7 21.1 268 North Eastern 20.8 8.2 29.0 39 Education No education 40.2 5.7 45.9 127 Primary incomplete 18.1 5.2 23.3 921 Primary complete 23.6 5.1 28.7 386 Secondary+ 8.1 2.3 10.4 422 Wealth quintile Lowest 21.5 7.3 28.8 316 Second 21.4 4.8 26.1 360 Middle 18.1 3.8 21.8 380 Fourth 15.6 3.1 18.7 401 Highest 16.8 4.3 21.2 398 Total 18.5 4.5 23.0 1,856 Family Planning | 63 FAMILY PLANNING 5 Samuel Ogola and Salome Adala This chapter presents results from the 2003 KDHS regarding various aspects of contraceptive knowledge, attitudes, and behaviour. Although the focus is on women, some results from the male survey are also presented, since men play an important role in the realisation of reproduction goals. To get an indication of interspousal communication and agreement in knowledge and attitudes of couples regarding family planning, the study compared the responses of men, where possible, with responses of their wives in the same household. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS One major objective of the 2003 KDHS was to develop a profile of Kenyan women and men re- garding knowledge of family planning methods. Individuals who have adequate information about the available methods of contraception are better able to develop a rational approach to planning their fami- lies. Information on knowledge of contraception was collected during the survey by asking the respon- dents to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent recognised it. In this manner, information was collected about nine modern meth- ods (female sterilisation, male sterilisation, the pill, intrauterine device [IUD], injections, implants, male condoms, female condoms, and emergency contraception) and two traditional methods (calendar or rhythm method and withdrawal). Provision was also made in the questionnaire to record any other meth- ods named spontaneously by the respondent. This presentation places more emphasis on women, since they have the greatest level of exposure to the risk of pregnancy and most methods are designed for them. Tables 5.1.1 and 5.1.2 show the knowledge of contraceptive methods among all women age 15-49 and men age 15-54, as well as among those who are currently married, unmarried, and sexually active. Knowledge of family planning is nearly universal, with 95 percent of all women age 15-49 and 97 percent of men age 15-54 knowing at least one method of family planning. Modern methods are more widely known than traditional methods. For example, 94 percent of women have heard of at least one modern method, while only 70 percent know of a traditional method. Among all women, the male condom, pills, and injectables are the most widely known methods of family planning, with about 90 percent of all women saying they had heard of these methods. The least widely known methods are emergency contraception, the female condom, and male sterilisation. About two- thirds of all women have heard of periodic abstinence (calendar or rhythm method), while about four in ten know about withdrawal. As expected, contraceptive knowledge is higher among currently married women and sexually active women than among all women. The mean number of methods recognised by all women is 7.0, compared to 7.6 among married women and 7.4 among sexually active women. Unmarried women who have never had sexual intercourse are the least likely to know about contraceptive methods; nevertheless, they have heard of an average of 4.8 methods. Although knowledge of the male condom is high among all groups of women, it is highest among sexually active, unmarried women (98 percent). The gap in knowl- edge between women who are married and those who are unmarried and sexually active is most apparent for long-term and permanent methods (i.e., sterilisation, IUD). 64 | Family Planning Contraceptive knowledge is slightly higher among all men and currently married men than among all women and currently married women. However, among those who are unmarried, men are somewhat less likely to know about contraceptive methods. Men are more likely than women to know about female and male condoms, female and male sterilisation, periodic abstinence, and withdrawal, while women are more likely to know about such female-oriented methods as the pill, IUD, injectables, and implants. Trends in contraceptive knowledge since the 1998 KDHS are mixed. Although it appears as if there has been a slight drop in knowledge since 1998, it is mostly due to the inclusion of the northern ar- eas of Kenya in 2003; when these areas are excluded, there has been no change in overall levels of knowledge of any method or any modern method. Nevertheless, the level of knowledge of several meth- ods has declined slightly since 1998. For example, among all women (excluding the north), the percent- ages who know of female sterilisation, the pill, the IUD, and periodic abstinence have declined slightly since 1998. On the other hand, the percentages who know of male sterilisation, male condoms, in- jectables, implants, and withdrawal have increased slightly. Table 5.1.1 Knowledge of contraceptive methods: women Percentage of all women, of currently married women, of sexually active unmarried women, of sexually inactive unmarried women, and of women with no sexual experience who know any contraceptive method, by specific method, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Unmarried women who ever had sex ––––––––––––––––– Unmarried Currently Not women All married Sexually sexually who never Contraceptive method women women active1 active2 had sex ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Any method 94.6 95.5 99.2 96.8 87.9 Any modern method 94.4 95.3 99.2 96.7 87.7 Female sterilisation 73.9 80.3 77.9 75.6 48.2 Male sterilisation 47.2 52.1 45.9 47.5 29.3 Pill 89.5 93.1 93.2 92.7 72.0 IUD 67.0 74.6 67.7 70.0 36.3 Injectables 88.9 93.5 93.3 93.1 66.5 Implants 63.7 72.3 68.6 64.6 31.5 Male condom 90.6 91.6 97.8 93.2 82.7 Female condom 41.6 43.1 48.8 44.4 31.4 Emergency contraception 23.7 25.2 27.5 25.5 15.3 Any traditional method 70.0 76.3 71.4 72.3 44.8 Periodic abstinence 64.7 70.1 64.9 68.2 41.5 Withdrawal 41.3 46.8 45.0 40.9 21.4 Folk method 9.3 12.2 10.2 6.4 2.6 Mean number of methods known 7.0 7.6 7.4 7.2 4.8 Number of women 8,195 4,919 267 1,621 1,389 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Had sexual intercourse in the month preceding the survey 2 Did not have sexual intercourse in the month preceding the survey Family Planning | 65 5.2 EVER USE OF CONTRACEPTION All women interviewed in the 2003 KDHS who said that they had heard of a method of family planning were asked whether they had ever used that method. Table 5.2 shows the percentage of all women, currently married women, and sexually active unmarried women who have ever used specific methods of family planning, by age.1 Table 5.2 shows that 64 percent of currently married women have ever used a contraceptive method, 55 percent have used a modern method, and 24 percent have used a traditional method. The methods most commonly used by married women are injectables (33 percent), pills (32 percent), periodic abstinence (20 percent), and male condom (10 percent). Ever use of other methods does not exceed 10 percent. Ever use of any method is highest among sexually active unmarried women, 71 percent of whom have used a method at some time. Sexually active unmarried women are much more likely (34 percent) than either all women or currently married women to have used the male condom. 1 In the 2003 KDHS, men were only asked about ever use of male-oriented methods, so the data are not comparable. Table 5.1.2 Knowledge of contraceptive methods: men Percentage of all men, of currently married men, of sexually active unmarried men, of sexually inactive unmarried men, and of men with no sexual experience who know any contraceptive method, by specific method, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Unmarried men who ever had sex –––––––––––––––––– Unmarried Currently Not men All married Sexually sexually who never Contraceptive method men men active1 active2 had sex ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Any method 97.2 97.7 98.9 99.7 90.7 Any modern method 96.9 97.2 98.7 99.7 90.2 Female sterilisation 76.9 86.9 79.5 74.8 44.0 Male sterilisation 58.8 69.5 59.2 55.2 27.5 Pill 86.4 92.0 92.3 86.6 62.2 IUD 49.2 61.7 45.9 42.5 19.6 Injectables 80.7 91.0 82.3 76.3 51.3 Implants 36.2 47.4 32.4 27.6 14.1 Male condom 95.9 96.5 98.7 99.0 86.8 Female condom 56.1 61.9 63.0 56.6 30.5 Foam/jelly 0.8 1.1 0.1 0.7 0.6 Emergency contraception 25.6 28.2 33.4 24.7 12.1 Any traditional method 81.5 93.6 88.1 81.1 35.7 Periodic abstinence 79.2 92.2 84.7 77.8 32.8 Withdrawal 55.1 64.5 66.7 51.9 18.3 Folk method 4.1 5.8 3.2 2.6 1.5 Mean number of methods known 7.1 8.0 7.4 6.8 4.0 Number of men 3,578 1,818 432 791 537 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Had sexual intercourse in the month preceding the survey 2 Did not have sexual intercourse in the month preceding the survey 66 | Family Planning Ever use of family planning has increased slightly since the 1998 KDHS. For example, excluding the northern areas of Kenya, the percentage of married women who have ever used any method of contra- ception has increased from 64 percent in 1998 to 67 percent in 2003. Similarly, the proportion who have ever used a modern method has increased from 53 to 57 percent (data not shown). 5.3 CURRENT USE OF CONTRACEPTIVE METHODS The percentage of currently married women age 15-49 who are using any method of family plan- ning is known as the contraceptive prevalence rate (CPR). As shown in Table 5.3, the CPR for Kenya in 2003 is 39 percent. Most currently married women use modern methods (32 percent), while 8 percent use a traditional method. As expected, current contraceptive use is higher among sexually active women than among married women and, in turn, among all women. However, current use is highest among sexually active unmarried women (54 percent). Table 5.2 Ever use of contraception Percentage of all women, currently married women, and sexually active unmarried women who have ever used any contraceptive method, by specific method and age, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Modern method Traditional method –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––– Female Male Emer- Any Any steri- steri- In- Male Female gency tradi- Periodic Number Any modern lisa- lisa- ject- Im- con- con- Foam/ contra- tional absti- With- Folk of Age method method tion tion Pill IUD ables plants dom dom jelly ception method nence drawal method women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALL WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 14.7 10.5 0.0 0.0 3.4 0.1 3.1 0.3 6.1 0.0 0.0 0.3 6.6 5.9 1.7 0.1 1,856 20-24 47.1 38.0 0.1 0.0 17.3 0.9 21.2 0.8 12.9 0.4 0.0 1.4 20.4 18.1 3.9 1.2 1,691 25-29 64.9 55.1 0.4 0.0 31.9 2.5 36.4 2.7 12.8 0.4 0.0 1.3 25.4 22.0 6.8 1.5 1,382 30-34 70.8 64.8 2.3 0.1 41.4 9.4 39.8 3.1 11.7 0.4 0.4 1.1 21.9 18.3 5.7 2.0 1,086 35-39 68.8 61.4 6.0 0.0 39.1 13.3 37.1 4.7 10.5 0.3 0.3 1.0 23.0 20.2 6.1 1.2 871 40-44 65.5 58.6 11.8 0.2 34.9 16.0 31.8 2.6 10.6 0.0 0.1 0.3 19.6 17.3 3.0 1.5 788 45-49 60.1 50.2 12.0 0.2 28.5 14.5 20.8 1.6 5.9 0.5 0.9 0.8 21.5 17.6 3.3 4.0 521 Total 50.8 43.5 2.9 0.0 24.5 5.7 24.8 1.9 10.2 0.3 0.1 0.9 18.6 16.2 4.2 1.3 8,195 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CURRENTLY MARRIED WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 33.9 22.8 0.0 0.0 11.4 0.1 9.3 0.2 8.0 0.0 0.0 0.3 16.9 15.0 6.1 0.4 333 20-24 57.3 47.4 0.1 0.0 23.5 0.9 29.9 1.2 11.9 0.6 0.0 1.1 23.6 20.8 4.9 1.5 965 25-29 68.9 58.0 0.5 0.0 35.1 2.7 40.0 2.8 10.6 0.2 0.0 1.0 27.3 23.2 7.5 1.7 1,056 30-34 72.0 65.5 2.6 0.2 41.8 10.3 39.9 3.2 10.7 0.4 0.5 1.4 23.9 20.0 6.5 2.3 873 35-39 69.7 62.0 6.6 0.0 38.7 14.4 37.2 5.1 9.5 0.2 0.3 1.1 24.2 20.7 6.8 1.2 691 40-44 66.1 59.0 13.5 0.2 33.8 17.0 33.3 2.9 9.9 0.0 0.1 0.3 20.6 18.1 3.5 1.6 614 45-49 63.9 52.4 14.6 0.0 29.3 14.8 20.6 1.9 6.8 0.7 1.0 1.1 24.9 20.2 3.1 5.3 388 Total 64.2 55.1 4.3 0.1 32.3 7.9 33.2 2.6 10.2 0.3 0.2 1.0 23.8 20.4 5.8 1.9 4,919 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– SEXUALLY ACTIVE UNMARRIED WOMEN1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 55.6 47.2 0.0 0.0 9.5 0.0 7.6 1.3 37.3 0.0 0.0 2.0 26.5 25.3 7.0 0.0 68 20-24 73.2 65.8 0.0 0.0 32.9 4.6 31.3 1.3 37.1 0.0 0.0 5.4 25.3 22.1 8.7 3.2 75 25+ 77.5 71.3 3.1 0.0 41.6 8.9 43.2 6.4 30.2 0.0 0.6 1.6 26.6 24.4 2.8 0.9 125 Total 70.8 63.6 1.4 0.0 31.0 5.5 30.9 3.7 34.0 0.0 0.3 2.8 26.2 24.0 5.5 1.3 267 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Women who had sexual intercourse in the month preceding the survey Family Planning | 67 Injectables, pills, and periodic abstinence are the most commonly used contraceptive methods, used by 14, 8, and 6 percent of married women, respectively. However, among sexually active unmarried women, male condoms are the most commonly used method after injectables. Use of any contraceptive method rises with age, from 16 percent among married women age 15-19, to a peak of 50 percent at age 35-39, and then declines to 38 percent at age 45-49. As expected, female sterilisation is used more commonly by women age 40-49, while pills and injectables are mostly used by women at the peak of childbearing years (age 20-39). Table 5.3 Current use of contraception Percent distribution of all women, currently married women, all sexually active women, and sexually active unmarried women, by contraceptive method currently used, according to age, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Modern method Traditional method –––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––– Female Any Any steri- In- Male tradi- Periodic Not Number Any modern lisa- ject- con- tional absti- With- Other currently of Age method method tion Pill IUD ables Implant dom method nence drawal method using Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALL WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 6.7 4.8 0.0 0.8 0.0 2.0 0.2 1.8 1.8 1.6 0.1 0.1 93.3 100.0 1,856 20-24 21.6 16.8 0.1 4.2 0.4 10.1 0.4 1.6 4.7 3.9 0.4 0.4 78.4 100.0 1,691 25-29 36.7 29.5 0.4 6.5 1.3 17.3 1.8 2.3 7.1 5.9 0.6 0.7 63.3 100.0 1,382 30-34 41.2 34.0 2.3 8.7 2.9 16.9 1.8 1.4 7.2 6.1 0.4 0.7 58.8 100.0 1,086 35-39 45.6 36.5 6.0 8.1 3.6 13.8 2.8 2.0 9.1 7.4 1.1 0.6 54.4 100.0 871 40-44 41.1 35.0 11.8 6.1 3.5 10.8 1.8 1.1 6.0 5.1 0.4 0.6 58.9 100.0 788 45-49 31.0 22.3 12.0 2.4 2.7 4.6 0.3 0.4 8.7 6.4 0.3 2.0 69.0 100.0 521 Total 28.4 22.7 2.9 4.9 1.6 10.5 1.2 1.7 5.6 4.7 0.4 0.5 71.6 100.0 8,195 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CURRENTLY MARRIED WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 16.4 12.7 0.0 3.6 0.0 6.8 0.2 2.1 3.7 3.1 0.6 0.0 83.6 100.0 333 20-24 27.8 22.4 0.1 6.4 0.5 14.1 0.7 0.6 5.4 4.4 0.5 0.5 72.2 100.0 965 25-29 40.7 32.6 0.5 8.2 1.5 19.0 1.9 1.5 8.0 6.4 0.8 0.9 59.3 100.0 1,056 30-34 45.0 36.6 2.6 10.1 3.3 17.4 1.9 1.2 8.4 7.0 0.5 0.8 55.0 100.0 873 35-39 50.1 39.7 6.6 9.5 4.2 14.2 3.2 1.9 10.4 8.5 1.1 0.7 49.9 100.0 691 40-44 47.9 40.8 13.5 7.5 3.9 12.8 2.3 0.9 7.0 5.9 0.5 0.6 52.1 100.0 614 45-49 38.4 26.7 14.6 2.8 3.6 4.9 0.4 0.6 11.7 8.6 0.3 2.7 61.6 100.0 388 Total 39.3 31.5 4.3 7.5 2.4 14.3 1.7 1.2 7.8 6.3 0.6 0.8 60.7 100.0 4,919 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALL SEXUALLY ACTIVE WOMEN1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 25.9 19.7 0.0 4.3 0.0 7.0 0.5 7.9 6.2 5.6 0.6 0.0 74.1 100.0 314 20-24 35.0 28.5 0.0 7.5 0.7 17.4 0.8 2.1 6.5 5.2 0.6 0.7 65.0 100.0 796 25-29 47.8 38.9 0.6 9.7 1.9 21.9 2.6 2.3 8.9 7.2 0.7 0.9 52.2 100.0 872 30-34 53.8 44.4 2.9 12.2 4.1 21.2 2.4 1.6 9.4 7.9 0.6 0.9 46.2 100.0 685 35-39 57.3 46.1 7.6 11.2 5.0 16.6 3.0 2.4 11.2 9.2 1.5 0.5 42.7 100.0 536 40-44 56.4 48.8 15.8 9.3 4.6 15.0 2.7 1.5 7.6 6.7 0.4 0.5 43.6 100.0 456 45-49 44.5 32.9 17.7 3.3 5.2 5.8 0.6 0.4 11.5 7.5 0.5 3.4 55.5 100.0 250 Total 46.6 38.0 4.6 9.0 2.8 17.1 2.0 2.4 8.6 7.0 0.7 0.9 53.4 100.0 3,909 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– SEXUALLY ACTIVE UNMARRIED WOMEN1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 49.4 37.1 0.0 3.7 0.0 5.7 1.3 26.4 12.3 12.3 0.0 0.0 50.6 100.0 68 20-24 53.1 42.0 0.0 4.0 0.0 20.4 0.8 16.8 11.1 7.8 1.5 1.8 46.9 100.0 75 25+ 57.8 49.6 3.1 6.8 1.7 25.2 3.0 9.8 8.2 8.2 0.0 0.0 42.2 100.0 125 Total 54.4 44.3 1.4 5.2 0.8 18.9 2.0 15.9 10.1 9.2 0.4 0.5 45.6 100.0 267 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Women who had sexual intercourse in the month preceding the survey 68 | Family Planning 5.4 TRENDS IN CONTRACEPTIVE USE Table 5.4 shows that contraceptive use has increased very slightly since 1998, from 39 to 41 per- cent of married women. This is far less than the 6 percentage point rise in the five years between 1993 and 1998. The largest increase since 1998 has been among the small number of sexually active unmarried women. This slowing of the increase in contraceptive use is in sharp contrast with previous trends. Since the early 1980s, there had been a steady increase in family planning use among married women, as shown in Figure 5.1. The 1984 Contraceptive Prevalence Survey (CPS), 1989 KDHS, 1993 KDHS, and 1998 KDHS documented the increase in use of modern contraceptive methods from 10, to 18, to 27, and to 32 percent, respectively. The rate of increase slowed between 1993 and 1998 and now appears to have slowed even more. Nevertheless, the 2003 KDHS corroborates trends in method mix, namely, a continuing increase in use of injectables and decrease in use of the pill, as was the case in earlier KDHS surveys (Figure 5.2). The increase in use of injectables (from 7 percent in 1993, to 12 percent in 1998, and to 15 percent in 2003) has been the most dramatic, making it the predominant method in 2003. Table 5.4 Trends in current use of contraception Percent distribution of all women, currently married women, and sexually active unmarried women, by contraceptive method currently used, according to age, Kenya 2003,a 1998, and 1993 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Modern method Traditional method ––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––– Female Any Any steri- In- tradi- Periodic Folk Not Number Background Any modern lisa- ject- Im- Male tional absti- With- method/ currently of characteristic method method tion Pill IUD ables plants condom method nence drawal other using Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– All women 2003a 29.5 23.6 3.0 5.1 1.6 10.8 1.2 1.7 5.9 4.8 0.5 0.6 70.5 100.0 7,875 1998 29.9 23.6 4.2 6.5 1.9 8.8 0.7 1.5 6.3 5.3 0.4 0.6 70.1 100.0 7,881 1993 25.9 20.7 3.9 7.5 2.8 5.5 0.0 0.9 5.2 4.5 0.3 0.4 74.1 100.0 7,540 Currently married women 2003a 41.0 32.9 4.5 7.9 2.5 14.9 1.7 1.3 8.1 6.6 0.7 0.9 59.0 100.0 4,706 1998 39.0 31.5 6.2 8.5 2.7 11.8 0.8 1.3 7.5 6.1 0.6 0.8 61.0 100.0 4,834 1993 32.7 27.3 5.5 9.5 4.2 7.2 0.0 0.8 5.5 4.4 0.4 0.6 67.3 100.0 4,629 Sexually active unmarried women1 2003a 54.4 44.3 1.4 5.2 0.8 18.9 2.0 15.9 10.1 9.2 0.4 0.5 45.6 100.0 267 1998 46.5 36.2 2.5 10.7 1.4 12.2 1.4 8.1 10.2 9.9 0.3 0.0 53.5 100.0 434 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: If more than one method is used, only the most effective method is considered in this tabulation. a Excludes all of North Eastern Province and five other northern districts so as to be comparable to prior surveys 1 Women who have had sexual intercourse in the one month preceding the survey Family Planning | 69 Figure 5.1 Contraceptive Use among Currently Married Women, Kenya 1984-2003 (excluding northern districts) 10 18 27 32 33 17 27 33 39 41 1984 1989 1993 1998 2003 0 10 20 30 40 50 Percent Modern methods All methods Note: The value for 2003 differs from Table 5.3 because of exclusion of northern areas. 10 4 7 1 6 4 9 3 12 1 6 6 8 3 15 1 5 7 Pill IUD Injectables Condoms Female sterilisation Periodic abstinence 0 2 4 6 8 10 12 14 16 Percentage 1993 1998 2003 Figure 5.2 Trends in Current Use of Specific Contraceptive Methods among Currently Married Women Age 15-49, Kenya 1993-2003 (excluding northern districts) When compared with other countries in east and southern Africa where Demographic and Health surveys are conducted, Kenya’s level of contraceptive use is exceeded only by Zimbabwe and South Africa (Figure 5.3). 70 | Family Planning 56 54 39 34 25 23 13 8 8 South Africa 1998 Zimbabwe 1999 KENYA 2003 Zambia 2001-2002 Tanzania 1999 Uganda 2000-2001 Rwanda 2000 Ethiopia 2000 Eritrea 2000 0 10 20 30 40 50 60 70 Modern methods Traditional methods Figure 5.3 Current Use of Family Planning among Currently Married Women Age 15-49, Selected Countries in East Africa and Southern Africa 5.5 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS As shown in Table 5.5 and Figure 5.4, some women in Kenya are more likely to use contracep- tives than others. Married women in urban areas are more likely to use modern contraceptives (40 per- cent) than those in rural areas (29 percent), which also applies for each of the specific modern methods except female sterilisation, which is very slightly higher among rural women. Use of modern methods among currently married women is highest in Central Province (58 per- cent) and Nairobi (44 percent) and lowest in North Eastern Province (less than 1 percent), Coast Province (19 percent), and Nyanza Province (21 percent). Use of injectables is particularly high in Central Prov- ince, where almost one-quarter of married women are using the method. As expected, contraceptive use increases with level of education. Use of modern methods in- creases from 8 percent among married women with no education to 52 percent among women with at least some secondary education. Use of modern contraception among women with no education dropped from 16 percent in 1998 to 11 percent in 2003 (excluding the northern areas). The proportion of married women using modern methods increases with the number of children they have, reaching a peak at four children and then dropping for those with five or more children. Use of modern methods rises from 12 percent among married women in the lowest wealth quintile to 45 percent among those in the highest wealth quintile. Family Planning | 71 Table 5.5 Current use of contraception by background characteristics Percent distribution of currently married women, by contraceptive method currently used, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Modern method Traditional method –––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––– Female Any Any steri- In- Male tradi- Periodic Other Not Number Background Any modern lisa- ject- Im- con- tional absti- With- meth- currently of characteristic method method tion Pill IUD ables plants dom method nence drawal method using Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 47.6 39.9 4.1 10.4 4.2 16.2 2.6 2.2 7.7 6.5 0.2 0.9 52.4 100.0 1,091 Rural 37.0 29.2 4.4 6.7 1.9 13.8 1.4 0.9 7.8 6.2 0.8 0.8 63.0 100.0 3,828 Province Nairobi 50.7 44.3 5.9 12.5 4.5 16.1 2.6 2.7 6.4 6.0 0.2 0.2 49.3 100.0 418 Central 66.4 57.9 7.2 15.6 8.3 22.5 3.5 0.7 8.5 7.5 0.2 0.8 33.6 100.0 656 Coast 24.1 19.1 3.0 3.6 0.7 9.9 1.5 0.4 5.0 3.8 0.5 0.7 75.9 100.0 418 Eastern 50.6 38.4 4.5 9.6 1.8 19.9 1.7 1.1 12.2 11.1 0.4 0.7 49.4 100.0 783 Nyanza 24.7 21.0 4.7 4.1 0.5 10.9 0.6 0.3 3.7 3.2 0.3 0.2 75.3 100.0 775 Rift Valley 34.4 24.5 3.1 4.9 1.9 11.3 1.4 1.8 9.9 7.1 1.6 1.2 65.6 100.0 1,186 Western 34.1 27.3 3.8 6.5 0.4 13.5 1.3 1.9 6.8 4.3 0.6 1.8 65.9 100.0 559 North Eastern 0.2 0.2 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 99.8 100.0 125 Education No education 12.0 8.0 3.1 1.4 0.3 3.0 0.2 0.0 4.0 2.7 0.9 0.4 88.0 100.0 762 Primary incomplete 30.2 23.1 3.3 4.3 0.7 13.2 0.9 0.7 7.1 5.8 0.5 0.8 69.8 100.0 1,569 Primary complete 44.2 35.7 4.5 9.5 1.9 17.6 1.1 1.2 8.5 7.2 0.4 0.9 55.8 100.0 1,312 Secondary+ 61.8 51.7 6.1 13.2 6.3 19.2 4.0 2.6 10.1 8.2 0.9 1.0 38.2 100.0 1,276 Number of living children 0 7.2 3.8 0.0 2.1 0.2 0.6 0.2 0.8 3.3 3.1 0.0 0.2 92.8 100.0 355 1 32.1 26.8 0.4 8.4 1.8 12.8 1.1 2.2 5.4 4.5 0.6 0.3 67.9 100.0 795 2 44.2 36.7 0.8 10.8 3.5 17.8 2.4 1.4 7.4 5.8 0.6 1.0 55.8 100.0 915 3 49.1 40.8 4.7 8.7 4.5 19.5 1.8 1.4 8.3 6.6 1.0 0.7 50.9 100.0 827 4 48.3 41.2 6.0 10.1 2.4 19.0 2.2 1.5 7.1 6.0 0.3 0.8 51.7 100.0 644 5+ 38.5 27.9 9.1 4.3 1.3 11.2 1.5 0.4 10.6 8.5 0.8 1.2 61.5 100.0 1,383 Wealth quintile Lowest 17.9 11.8 1.3 2.2 0.2 7.2 0.3 0.7 6.0 4.9 0.7 0.4 82.1 100.0 947 Second 31.9 24.2 3.4 5.3 0.8 12.5 0.7 1.4 7.8 6.1 0.9 0.7 68.1 100.0 954 Middle 42.0 33.4 4.8 7.7 1.4 17.7 1.2 0.6 8.5 6.7 0.5 1.3 58.0 100.0 915 Fourth 50.7 41.0 7.1 10.2 3.4 16.4 2.8 1.1 9.7 7.4 1.1 1.2 49.3 100.0 965 Highest 51.5 44.5 4.9 11.4 5.5 17.4 3.1 2.1 7.0 6.3 0.1 0.6 48.5 100.0 1,139 Total 39.3 31.5 4.3 7.5 2.4 14.3 1.7 1.2 7.8 6.3 0.6 0.8 60.7 100.0 4,919 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: If more than one method is used, only the most effective method is considered in this tabulation. 72 | Family Planning 48 37 51 66 24 51 25 34 34 0 12 30 44 62 RESIDENCE Urban Rural PROVINCE Nairobi Central Coast Eastern Nyanza Rift Valley Western North Eastern EDUCATION No education Primary incomplete Primary complete Secondary+ 0 20 40 60 80 Percent Figure 5.4 Current Use of Any Contraceptive Method among Currently Married Women Age 15-49, by Background Characteristics KDHS 2003 5.6 CURRENT USE OF CONTRACEPTIVES BY WOMEN’S STATUS Table 5.6 shows the level of current use of contraceptive methods by various women’s status in- dicators. Current use of a modern contraceptive method increases steadily with the number of decisions in which a woman has a final say, from 18 percent among married women with no say in any decision to 40 percent among women who participate in five decisions. The more reasons a married woman cites for justifying a wife’s refusing to have sex with her husband, the more likely she is to be currently using a modern contraceptive method. Current use of mod- ern contraceptives rises from 22 percent among women who believe there is no justifiable reason for re- fusing sex with a husband to 33 percent among women with three or four reasons for refusing to have sex with a husband. Women who do not believe that there is any reason to justify wife-beating are more likely to be currently using a modern contraceptive method than those who feel that wife-beating is justified. Current use of modern contraceptives decreases from 41 percent among women who do not believe in any reason to justify wife-beating to 21 percent among women who report five reasons in which wife-beating is justi- fied. The patterns in current use of modern methods observed for the indicators of women’s status also apply for the specific modern methods of contraception. Family Planning | 73 5.7 TIMING OF FIRST USE OF CONTRACEPTION Table 5.7 shows the distribution of women who have ever used contraception by age and number of living children at first use of contraception. The results indicate that Kenyan women are adopting fam- ily planning at lower parities (i.e., when they have fewer children) than in the past. Among younger women (age 20-24), 37 percent first used contraception before having any children and 43 percent used contraception by parity 1. Among older women (age 45-49), only 4 percent used contraception before having any children and 17 percent used contraception by parity 1. Conversely, while 55 percent of women age 45-49 did not use contraception before having four or more children, less than 1 percent of women age 20-24 waited until parity 4 before starting to use contraception. Sterilisation is a very effective, permanent method of family planning, which could be used by more couples who do not want to have any more children. Consequently, it is of interest to know whether the age at which women adopt sterilisation is increasing or declining. Data from the 2003 KDHS indicate that 74 percent of women who are sterilised had the procedure after reaching age 30 and 39 percent had the procedure after reaching age 35 (data not shown). The median age at the time of sterilisation is 33 years, showing a slight increase from 32 years in 1998. Table 5.6 Current use of contraception by women’s status Percent distribution of currently married women, by contraceptive method currently used, according to selected indicators of women's status, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Modern method Traditional method ––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––– Female Any Women’s Any steri- In- Male tradi- Periodic Not Number status Any modern lisa- ject- con- tional absti- With- Folk currently of indicator method method tion Pill IUD ables Implant dom method nence drawal method using Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of decisions in which woman has final say1 0 22.2 18.1 3.0 4.9 1.6 7.4 0.5 0.6 4.2 3.5 0.4 0.2 77.8 100.0 397 1-2 30.6 24.1 2.8 5.7 0.8 12.9 1.2 0.6 6.5 4.7 1.0 0.8 69.4 100.0 1,539 3-4 43.9 35.5 4.7 8.8 2.3 16.1 1.9 1.6 8.5 6.9 0.6 0.9 56.1 100.0 1,780 5 49.2 39.6 6.3 8.8 4.7 15.8 2.3 1.6 9.6 8.4 0.2 1.0 50.8 100.0 1,204 Number of reasons to refuse sex with husband 0 28.2 22.1 2.9 6.2 0.3 11.9 0.7 0.1 6.1 5.2 0.4 0.5 71.8 100.0 287 1-2 36.2 28.7 3.5 5.9 2.2 14.8 1.3 1.0 7.5 5.1 0.9 1.6 63.8 100.0 754 3-4 40.7 32.8 4.6 7.9 2.6 14.4 1.8 1.4 8.0 6.6 0.6 0.7 59.3 100.0 3,878 Number of reasons wife-beating is justified 0 49.2 40.8 5.4 10.4 4.2 16.6 2.6 1.5 8.4 7.2 0.5 0.6 50.8 100.0 1,408 1-2 41.0 32.7 4.7 7.2 1.9 15.3 1.6 1.9 8.4 6.8 1.0 0.6 59.0 100.0 1,535 3-4 32.2 25.1 3.7 6.0 1.5 12.4 0.8 0.7 7.1 5.6 0.3 1.2 67.8 100.0 1,479 5 27.3 21.1 2.3 5.1 1.2 10.7 1.7 0.0 6.2 4.4 1.0 0.9 72.7 100.0 497 Total 39.3 31.5 4.3 7.5 2.4 14.3 1.7 1.2 7.8 6.3 0.6 0.8 60.7 100.0 4,919 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Either by herself or jointly with others 74 | Family Planning Table 5.8 Use of social marketing brand pills Percentage of pill users who are using Femiplan, a social marketing brand, by urban-rural residence, province, and wealth quintile, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––– Percentage Number Residence/province/ of of wealth quintile pill users women –––––––––––––––––––––––––––––––––––––––––– Residence Urban 21.5 128 Rural 13.5 275 Province Nairobi 16.4 61 Central 15.5 111 Coast (25.4) 17 Eastern 11.7 80 Nyanza (27.6) 33 Rift Valley (23.4) 61 Western (0.0) 39 Wealth quintile Lowest * 20 Second (6.1) 56 Middle 12.6 75 Fourth 19.5 109 Highest 20.4 142 Total 16.0 402 –––––––––––––––––––––––––––––––––––––––––– Note: Table excludes pill users who do not know the brand name. Numbers in parentheses are based on 25-49 unweighted cases, while an asterisk indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. 5.8 USE OF FEMIPLAN SOCIAL MARKETING PILL BRAND Current users of pills as a method of contracep- tion were asked which brand of pills they use. Table 5.8 indicates that 16 percent of these users said that they use Femiplan, the brand that is socially marketed in Kenya. Pill users in urban areas are more likely to be using Femiplan (22 percent) than are those in rural areas (14 percent). Differentials by province are hampered by small numbers of pill users in some provinces. Use of Femiplan increases with the economic status of women. The wealthiest users of pills are more likely to be using Femiplan than are poorer users of pills. 5.9 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physi- ology provides a useful background for successful prac- tice of coitus-related methods, such as the calendar meth- od, the Billings method, and other methods collectively called “periodic abstinence.” The successful use of such methods depends in part on an understanding of when, during the ovulatory cycle, a woman is most likely to conceive. Women were asked, “From one menstrual peri- od to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?” If the answer was “yes,” they were further asked whether that time was just before her period begins, during her period, right after her period has ended, or halfway be- tween two periods. Table 5.9 provides the results for all women, as well as for women who report that they are currently using periodic abstinence and those who are not. Table 5.7 Number of children at first use of contraception Percent distribution of women who have ever used contraception by number of living children at the time of first use of contraception, according to current age, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of living children at time of first use of contraception Number –––––––––––––––––––––––––––––––––––––––––––––– of Current age 0 1 2 3 4+ Missing Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 69.4 27.5 2.5 0.0 0.0 0.6 100.0 273 20-24 37.4 43.0 14.8 3.6 0.7 0.5 100.0 796 25-29 19.3 43.0 22.8 8.3 6.2 0.3 100.0 897 30-34 10.0 36.2 23.9 13.0 16.9 0.0 100.0 769 35-39 6.2 28.4 23.1 12.1 30.1 0.0 100.0 599 40-44 4.5 18.9 15.4 18.5 42.6 0.0 100.0 516 45-49 3.7 17.1 10.3 14.4 54.5 0.0 100.0 313 Total 19.4 33.7 18.3 10.0 18.3 0.2 100.0 4,163 Family Planning | 75 Among all women, less than one in five (19 percent) understand that a woman is most likely to conceive halfway between her menstrual periods. Almost one-third wrongly believe that the fertile period is right after a woman’s period has ended, one-quarter of women say they do not know when the fertile period falls, and 11 percent believe that there is no specific fertile time. As expected, users of periodic abstinence are more likely than nonusers to know that the fertile time in a woman’s menstrual cycle is halfway between periods. There has been an apparent deterioration in knowledge of the menstrual cycle since 1998, with fewer women—even periodic abstinence users— mentioning the correct fertile time. 5.10 SOURCE OF CONTRACEPTION Information on where women obtain their contraceptives is useful for family planning programme managers and implementers for logistic planning. In the 2003 KDHS, women who reported using a mod- ern contraceptive method at the time of the survey were asked where they obtained the method the last time they acquired it. Since some women may not exactly know in which category the source they use falls (e.g., government hospital, mission health centre), interviewers were instructed to note the full name of the source or facility. Supervisors and field editors were instructed to verify that the name and source type were consistent, asking informants in the clusters for the names of local family planning outlets, if necessary. This practice, used during the 1993 KDHS and 1998 KDHS as well, was designed to improve the accuracy of source reporting. Table 5.10 shows that public (government) facilities provide contraceptives to 53 percent of us- ers, while 41 percent are supplied through private medical sources, 5 percent through other private sources (e.g., shops), and only 1 percent through community-based distribution. The most common single source of contraceptives in Kenya is private hospitals and clinics, which supply about one-quarter of all users of modern methods. Government hospitals supply about one-fifth of users, followed closely by gov- ernment health centres and government dispensaries. As expected, government sources supply a larger proportion of users of long-term methods, such as implants, injectables, and female sterilisation, com- pared with users of pills, IUDs, and especially male condoms. Nevertheless, almost half of all women who are sterilised obtained the procedure at a private source, especially a private hospital or clinic, or a mission facility. More than half of all condom users get their supplies from private, nonmedical sources, such as shops and friends. Table 5.9 Knowledge of fertile period Percent distribution of all women by knowledge of the fertile period during the ovulatory cycle, according to current use/nonuse of periodic abstinence, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Users Nonusers of of periodic periodic All Perceived fertile period abstinence abstinence women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Just before her period begins 14.2 11.2 11.3 During her period 4.1 2.6 2.7 Right after her period has ended 41.3 30.0 30.5 Halfway between two periods 30.4 18.8 19.3 Other 0.0 0.5 0.5 No specific time 3.9 11.1 10.8 Don't know 6.1 25.8 24.9 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of women 381 7,814 8,195 76 | Family Planning The contribution of public sources in the provision of family planning supply has continued to shrink, from 68 percent in 1993, to 58 percent in 1998, and to 53 percent in 2003, as private medical sources continue to expand from 25 percent in 1993, to 33 percent in 1998, and to 41 percent in 2003. The largest decline in the public sector is for government hospitals, which supplied 30 percent of contracep- tive users in 1998 but only 20 percent in 2003. 5.11 INFORMED CHOICE Current users of modern methods who are well informed about the side effects and problems as- sociated with methods and know of a range of method options are better placed to make an informed choice about the method they would like to use. Current users of various modern contraceptive methods were asked whether at the time they were adopting the particular method, they were informed about side effects or problems that they might have with the method. Table 5.11 shows the percentage of current us- ers of modern methods who were either informed about side effects or problems of the method used, in- formed of other methods they could use, and informed that sterilisation is a permanent method; these are broken down by method type, initial source, and various background characteristics. Almost all women (92 percent) who were sterilised during the five-year period preceding the sur- vey were informed that they would not be able to have any more children. Forty-seven percent of users of modern contraceptives were informed of other methods available and 45 percent were informed about the side effects or health problems of the method they were provided. The results indicate that users of im- plants are more likely than other users to be informed about side effects or problems (67 percent) and other methods available (69 percent). Less than half of all pill users and IUD users were informed of side effects or of other methods they might use. Table 5.10 Source of contraception Percent distribution of current users of modern contraceptive methods, by most recent source of method, according to specific method, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Female Inject- Male Source sterilisation Pill IUD ables Implants condom Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Public source 53.9 48.5 48.9 61.5 61.2 16.1 53.4 Government hospital 48.6 10.8 33.7 14.2 39.8 8.5 20.1 Government health centre 4.3 17.0 7.9 24.8 18.0 6.7 17.6 Government dispensary 1.0 20.7 7.3 22.5 3.5 1.0 15.7 Private medical 45.3 45.5 50.5 37.7 38.8 25.9 40.5 Mission, church hospital/clinic 14.6 4.2 4.9 6.3 5.0 0.8 6.3 FPAK health centre/clinic 4.8 1.2 12.1 1.4 13.0 2.0 3.3 Private hospital/clinic 25.3 17.6 31.9 29.3 20.0 5.2 24.2 Pharmacy/chemist 0.0 21.9 0.0 0.5 0.0 17.9 6.3 Nursing/maternity home 0.7 0.6 1.6 0.2 0.8 0.0 0.4 Other private 0.0 2.2 0.0 0.0 0.0 56.2 4.6 Shop 0.0 0.7 0.0 0.0 0.0 39.9 3.1 Friend/relative 0.0 1.5 0.0 0.0 0.0 16.3 1.5 Mobile clinic 0.3 0.3 0.0 0.4 0.0 0.3 0.3 Community-based distributors 0.0 3.5 0.5 0.5 0.0 0.5 1.1 Other/missing 0.5 0.0 0.0 0.0 0.0 1.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 238 402 129 858 95 137 1,862 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes two users of female condoms. Family Planning | 77 Table 5.11 Informed choice Among current users of modern contraceptive methods who adopted the current method in the five years preceding the survey, percentage who were informed about the side effects of the method used, percentage who were informed of other methods that could be used for contraception, and percentage of women who were sterilised in the five years preceding the survey who were informed that they would not be able to have any more children, by specific method, initial source of method, and background charac- teristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Informed Informed of about side effects other methods Informed that Method/source/ or problems of that could sterilisation is background characteristic method used1 be used2 permanent3 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Method Female sterilisation 18.8 21.3 91.7 Pill 42.4 47.9 na IUD 41.5 41.6 na Injectables 52.0 51.6 na Implants 67.1 68.5 na Initial source of method4 Public source 61.6 62.2 (88.5) Government hospital 68.2 70.6 (89.4) Government health centre 59.4 59.1 * Government dispensary 57.1 56.1 na Private medical 57.4 58.1 (91.1) Mission, church hospital/clinic 65.3 58.5 * FPAK health centre/clinic (77.4) (90.9) * Private hospital/clinic 59.7 60.9 * Pharmacy/chemist 32.2 31.8 na Other private (41.7) (63.5) na Residence Urban 50.7 53.1 91.5 Rural 42.9 44.1 91.8 Province Nairobi 52.9 59.6 (96.9) Central 38.2 36.2 92.5 Coast 54.0 55.0 * Eastern 46.0 52.7 (88.1) Nyanza 44.1 45.2 (89.9) Rift Valley 45.3 39.6 (94.2) Western 47.9 56.2 (93.3) Education No education 22.6 21.4 (90.5) Primary incomplete 40.6 38.5 92.4 Primary complete 44.7 45.9 89.0 Secondary+ 51.0 55.4 93.9 Wealth quintile Lowest 46.3 49.1 * Second 42.1 47.9 (90.3) Middle 45.3 43.3 91.1 Fourth 37.1 40.6 91.0 Highest 52.5 52.8 92.8 Total 45.2 46.8 91.7 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Some categories (e.g., North Eastern Province) have been omitted because of small sample size. Numbers in parentheses indicate a figure based on 25-49 unweighted cases. An asterisk indicates a figure based on fewer than 25 unweighted cases that has been suppressed. na = Not applicable 1 Among users of female sterilisation, pill, IUD, injectables, and implants 2 Among users of female sterilisation, pill, IUD, injectables, implants, and female con- dom 3 Sterilised women who were told that they would not be able to have any more chil- dren 4 Source at start of current episode of use 78 | Family Planning With regard to the source of supply, users who obtained their methods from pharmacies or chem- ists were less likely to be informed about side effects or problems associated with the method and about other methods that could be used. Users in urban areas were more likely to be informed about the side effects or problems associated with method used than those in rural areas. Current users of modern con- traceptive methods in Coast Province and Nairobi were more likely to be informed of the side effects and problems associated with the method being used than users in other provinces. Provision of information about the effects or problems associated with the method used rose with the level of education. 5.12 CONTRACEPTIVE DISCONTINUATION Couples can realise their reproductive goals only when they use contraceptive methods continu- ously. A prominent concern for managers of family planning programmes is the discontinuation of meth- ods. In the 2003 KDHS “calendar” section, all segments of contraceptive use between January 1998 and the date of interview were recorded, along with reasons for any discontinuation. One-year contraceptive discontinuation rates based on the calendar data are presented in Table 5.12.2 The data show that more than one-third (38 percent) of family planning users in Kenya discon- tinue using the method within 12 months of starting its use. Six percent of users stop using as a result of method failure (i.e., unintended pregnancy), while 5 percent discontinue because of a desire to become pregnant, and 8 percent switch to another method. Discontinuation rates are highest for condom users (59 percent) and pill users (46 percent) and lowest for users of injectables (32 percent). Pill users are the most likely to switch to another method, while method failure is highest for periodic abstinence users. There has been an apparent increase in contraceptive discontinuation rates over the previous five years, from 33 percent of users in 1998 to 38 percent in 2003. This seems to be due to higher discontinua- tion rates for the pill and injectables, while rates for condoms and periodic abstinence have remained sta- ble. 2 The discontinuation rates presented here include only those segments of contraceptive use that began since January 1998. The rates apply to the 3-63 month period prior to the survey; exposure during the month of interview and the two months prior are excluded to avoid the biases that may be introduced by unrecognised pregnancies. These cu- mulative discontinuation rates represent the proportion of users discontinuing a method within 12 months after the start of use. The rates are calculated by dividing the number of women discontinuing a method by the number ex- posed at that duration. The single-month rates are then cumulated to produce a one-year rate. In calculating the rate, the various reasons for discontinuation are treated as competing risks. Table 5.12 First-year contraceptive discontinuation rates Percentage of contraceptive users who discontinued use of a method within 12 months after beginning its use, by reason for discontinuation and specific method, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Reason for discontinuation –––––––––––––––––––––––––––––––––––– Desire Switched Method to become to another Other Method failure pregnant method1 reason Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pill 4.0 4.7 12.8 24.6 46.2 Injectables 1.0 3.9 7.3 19.6 31.8 Male condom 3.7 6.1 9.1 40.4 59.4 Periodic abstinence 15.4 6.1 3.2 8.7 33.3 All methods 5.5 5.0 7.7 19.4 37.6 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table is based on episodes of contraceptive use that began 3 to 59 months prior to the survey. 1 Used a different method in the month following discontinuation or said they wanted a more effective method and started another method within two months of discontinuation Family Planning | 79 Table 5.13 also presents reasons for discontinuation, but from a different perspective. All of the 3,041 contraceptive discontinuations occurring in the five years preceding the survey, regardless of dura- tion of use, are distributed by the main reason for discontinuation, according to method. Side effects of the method is the most prominent reason for discontinuation (25 percent), followed closely by the desire to become pregnant (23 percent). This is a reverse of what was shown in the 1998 KDHS, where 27 per- cent of clients discontinued because of the desire to become pregnant, followed by 20 percent who dis- continued because of side effects. Injectables, pills, the IUD, and implants are the methods that contribute most to discontinuation because of side effects. 5.13 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which non- users of contraception plan to use family planning in the future. Women who were not currently using a method of contraception were asked about their intention to use family planning in the future. The results are presented in Table 5.14. Fifty-eight percent of currently married nonusers say that they intend to use family planning in future, 38 percent do not intend to use, and 4 percent are unsure. The proportion of those intending to use varies with the number of living children, increasing from 45 percent for those with no child to a peak for those with two children (70 percent). Those who do not intend to use contraception in the future are con- centrated among those with no child and those with four or more children. There has been a slight decline in the proportion of nonusers who say that they intend to use in the future, from 63 percent in 1998 to 61 percent in 2003 (excluding the northern areas). Table 5.13 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey, by main reason for discontinuation, according to specific method, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Periodic Inject- Con- absti- With- All Source Pill IUD ables Implants dom nence drawal Other methods –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Became pregnant while using 9.9 6.7 4.0 (0.0) 9.7 44.2 33.5 20.1 15.7 Wanted to become pregnant 21.6 24.5 23.9 (27.9) 13.6 27.9 27.2 25.6 23.3 Husband disapproved 2.7 3.0 3.7 (1.9) 10.8 1.6 6.3 0.0 3.5 Side effects 35.7 32.3 41.7 (32.0) 1.0 0.0 0.0 5.6 25.4 Health concerns 4.0 9.3 4.9 (6.9) 0.1 0.1 0.0 0.2 3.2 Access/availability 2.9 0.0 2.0 (7.6) 2.3 0.0 0.0 1.7 1.8 Wanted a more effective method 4.6 2.9 1.2 (0.0) 7.4 5.2 4.7 10.4 3.9 Inconvenient to use 4.9 3.7 0.3 (3.2) 9.9 2.9 4.8 0.0 3.3 Infrequent sex/husband away 5.0 4.5 5.4 (2.7) 27.8 5.5 11.9 9.1 7.5 Cost too much 0.6 0.0 2.3 (0.0) 1.0 0.0 0.0 0.0 1.0 Difficult to get pregnant/ menopausal 0.0 1.6 0.5 (0.0) 0.0 0.5 0.0 4.0 0.4 Marital dissolution/separation 0.9 0.6 0.6 (0.0) 0.5 0.6 0.0 2.1 0.7 Other 5.1 10.1 6.2 (17.8) 8.6 2.4 2.9 10.7 5.6 Don't know 0.2 0.0 0.5 (0.0) 0.3 0.4 0.0 0.0 0.3 Missing 2.0 0.8 2.7 (0.0) 7.0 8.8 8.6 10.5 4.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 928 101 937 36 273 626 73 64 3,041 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes two discontinuations of female condom use which are not shown separately. Figures in paren- theses are based on 25-49 unweighted cases. 80 | Family Planning Table 5.15 Reason for not intending to use contraception Percent distribution of currently married women who are not using a contraceptive method and who do not intend to use in the future by main reason for not intending to use, according to age, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age –––––––––––––––– Reason 15-29 30-49 Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Fertility-related 21.7 51.4 40.3 Infrequent sex 2.8 6.5 5.1 Menopausal, hysterectomy 0.0 14.2 8.9 Subfecund, infecund 2.4 18.4 12.4 Wants more children 16.5 12.3 13.9 Opposition to use 42.8 23.9 30.9 Respondent opposed 13.4 8.6 10.4 Husband opposed 9.0 2.6 5.0 Others opposed 0.9 0.1 0.4 Religious prohibition 19.5 12.5 15.1 Lack of knowledge 3.3 1.8 2.4 Knows no method 2.8 1.6 2.0 Knows no source 0.5 0.2 0.3 Method-related 28.6 20.7 23.6 Health concerns 6.9 9.7 8.6 Fear of side effects 19.6 9.8 13.4 Lack of access 0.6 0.0 0.2 Inconvenient to use 0.0 0.4 0.3 Interfere with body 1.5 0.9 1.1 Other 0.0 0.5 0.3 Don’t know 3.2 1.6 2.2 Missing 0.4 0.0 0.1 Total 100.0 100.0 100.0 Number of women 421 709 1,130 5.14 REASONS FOR NOT INTENDING TO USE Table 5.15 presents the main reasons for not using contraception as reported by currently married nonusers who do not intend to use a contraceptive method in future. Fertility-related reasons (40 percent), opposi- tion to use (31 percent), and method-related reasons (24 percent) were mainly cited. The most common single reasons for not intending to use are religious prohibitions (15 percent), a desire for more children (14 percent), and fear of side effects (13 percent). Among women under age 30, the most frequently cited reasons for not using contraception were opposition to use (43 percent)—either due to religious prohibition or by the respondent herself—and method-related reasons (29 percent), mainly fear of side effects. The most important reasons among nonusers 30 years and above were fertility- related (51 percent) because of subfecundity and infecundity. 5.15 PREFERRED METHOD FOR FUTURE USE Demand for specific methods can be assessed by asking nonusers which method they intend to use in the future. Table 5.16 presents information on method preferences for married women who are not using contraception but say they intend to use in the future. The largest percentage of prospective users reported injectables as their preferred method (47 percent), with 13 percent citing pills, and 8 percent favouring female sterilisation. Method preference among women under 30 and those over 30 years is similar, except that older women are more likely than younger women to prefer female sterili- sation. Table 5.14 Future use of contraception Percent distribution of currently married women who are not using a contraceptive method by intention to use in the future, according to number of living children, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of living children1 ––––––––––––––––––––––––––––––––––––– Intention 0 1 2 3 4+ Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Intends to use 45.4 61.5 70.2 62.8 51.1 57.8 Unsure 6.3 3.4 3.9 3.5 3.7 3.9 Does not intend to use 47.7 35.0 25.7 33.4 44.4 37.9 Missing 0.7 0.1 0.3 0.3 0.8 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 212 507 534 490 1,242 2,985 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes current pregnancy Family Planning | 81 5.16 EXPOSURE TO FAMILY PLANNING MESSAGES Information on the level of public exposure to a particular type of media allows policymakers to use the most effective media for various target groups in the population. To assess the effectiveness of such media on the dissemination of family planning information, the 2003 KDHS asked all female re- spondents whether they had heard about condoms on the radio or television, or read about them in a newspaper or magazine in the few months preceding the interview. Women were also asked whether they considered it acceptable or unacceptable for condoms to be advertised through these same three media. On the other hand, men were asked whether they had heard about family planning on the radio or televi- sion, or read about it in a newspaper or magazine during the few months preceding the interview. Men were also asked the same question about acceptability of condom advertising. Table 5.17 shows that only one in four women has not been exposed to a condom message through the media. Most women (73 percent) hear about condoms through the radio, 37 percent hear mes- sages on the television, and 35 percent see messages in print. There is a sharp contrast in exposure to condom messages through television and the print media between urban and rural areas; 65 percent of urban women are exposed to condom messages through television, compared with only 28 percent of rural women. Variation by province in exposure of women to condom messages through the media is not large, except that in Nairobi, exposure is highest, while in North Eastern Province, exposure is minimal. Exposure to condom messages through the media rises with the level of education and with the wealth index. Table 5.16 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 age, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––– Age –––––––––––––––– Method 15-29 30-49 Total ––––––––––––––––––––––––––––––––––––––––––––––––––– Female sterilisation 3.9 15.2 7.9 Male sterilisation 0.1 0.5 0.2 Pill 13.8 11.7 13.0 IUD 1.1 1.8 1.4 Injectables 50.4 39.8 46.6 Implants 7.4 7.0 7.2 Condom 1.0 1.8 1.3 Female condom 0.1 0.4 0.2 Periodic abstinence 4.7 5.8 5.1 Withdrawal 0.2 0.2 0.2 Other 0.2 0.7 0.4 Unsure 16.3 13.6 15.3 Missing 0.9 1.6 1.2 Total 100.0 100.0 100.0 Number of women 1,106 620 1,725 82 | Family Planning Overall, two in three women interviewed reported that it was acceptable to use electronic and print media to air messages about condoms (Table 5.18). All three media are equally acceptable as vehi- cles for advertising condoms. Urban women are more likely than rural women to view dissemination of condom messages in the media as acceptable. Other variations in the acceptability of condom messages in the print and elec- tronic media are not large, except for women in North Eastern Province and those with no education; both of these groups are less likely to consider as acceptable the use of print and electronic media to spread condom messages. Table 5.17 Exposure to condom messages Percentage of women who heard or saw a condom message on the radio or television, or in a newspaper/magazine in the past few months, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– None of these three Number Background Newspaper/ media of characteristic Radio Television magazine sources women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 66.4 33.8 34.0 30.5 1,856 20-24 79.0 44.0 42.3 18.7 1,691 25-29 76.9 38.5 36.3 21.0 1,382 30-34 75.2 37.8 38.5 22.4 1,086 35-39 73.3 34.6 30.8 25.5 871 40-44 66.0 32.2 27.7 31.4 788 45-49 66.0 28.3 22.8 31.4 521 Residence Urban 81.5 64.6 55.5 14.9 2,056 Rural 69.6 27.5 28.2 28.4 6,139 Province Nairobi 84.6 75.7 65.1 11.2 835 Central 77.4 47.9 44.3 19.3 1,181 Coast 67.7 33.5 30.7 30.1 667 Eastern 68.1 32.7 34.4 29.7 1,325 Nyanza 76.3 27.1 32.6 21.8 1,222 Rift Valley 68.2 35.3 30.9 29.2 1,872 Western 82.1 18.2 18.2 17.1 927 North Eastern 4.1 1.4 1.2 95.9 168 Education No education 39.9 11.8 6.9 59.6 1,039 Primary incomplete 69.0 22.9 19.7 29.3 2,685 Primary complete 78.4 37.3 35.4 19.6 2,069 Secondary+ 85.8 62.8 64.1 9.9 2,403 Wealth quintile Lowest 52.3 9.2 10.4 47.1 1,364 Second 68.4 14.6 20.0 30.5 1,475 Middle 71.7 25.5 27.8 25.8 1,503 Fourth 78.5 44.9 41.0 18.4 1,711 Highest 84.4 71.2 61.5 11.8 2,141 Total 72.6 36.8 35.1 25.0 8,195 Family Planning | 83 Table 5.19 shows that only 29 percent of men have not been exposed to a family planning mes- sage through the media in the few months before the survey. Two-thirds of men are exposed to family planning messages through the radio, 37 percent have seen a message on television, and 43 percent saw a message in the newspaper or in a magazine. Differentials in exposure to family planning messages among men mirror those in exposure to messages about condoms among women. Table 5.18 Acceptability of media messages about condoms Percentage of women who believe that media messages about condoms are acceptable on the radio or television, or in a newspaper/magazine, according to background charac- teristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– None of these three Number Background Newspaper/ media of characteristic Radio Television magazine sources women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 58.2 55.2 56.5 40.8 1,856 20-24 72.4 69.5 71.6 26.3 1,691 25-29 73.5 69.2 72.1 25.3 1,382 30-34 70.9 67.7 69.8 27.7 1,086 35-39 69.6 65.9 68.9 28.6 871 40-44 62.3 58.2 61.5 36.6 788 45-49 59.5 55.4 57.7 39.4 521 Residence Urban 72.8 70.2 72.9 25.7 2,056 Rural 65.2 61.4 63.5 33.7 6,139 Province Nairobi 75.2 73.1 75.6 23.3 835 Central 58.1 55.8 58.6 40.4 1,181 Coast 65.8 62.6 64.5 33.0 667 Eastern 65.3 62.5 64.2 34.1 1,325 Nyanza 78.0 73.8 75.2 21.2 1,222 Rift Valley 65.7 61.5 65.1 32.5 1,872 Western 74.6 68.6 70.2 24.2 927 North Eastern 4.8 4.2 4.3 95.2 168 Education No education 41.6 37.8 38.2 58.0 1,039 Primary incomplete 67.2 63.6 65.0 31.7 2,685 Primary complete 73.2 69.9 71.9 25.9 2,069 Secondary+ 72.8 69.3 73.6 25.2 2,403 Wealth quintile Lowest 57.7 53.6 54.8 41.6 1,364 Second 67.2 63.4 65.1 31.9 1,475 Middle 64.7 60.9 63.1 33.7 1,503 Fourth 67.8 64.3 67.4 31.0 1,711 Highest 74.1 71.4 74.3 24.3 2,141 Total 67.1 63.6 65.9 31.7 8,195 84 | Family Planning 5.17 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS In the 2003 KDHS, women who were not using any family planning method were asked whether they had been visited by a fieldworker who talked with them about family planning in the 12 months pre- ceding the survey. This information is especially useful for determining whether nonusers of family plan- ning are being reached by family planning programmes throughout Kenya. The results show that only a small proportion (4 percent) of nonusers are being reached by field- workers to discuss family planning issues (data not shown). Table 5.19 Exposure of men to family planning messages Percentage of men who heard or saw a family planning message on the radio or television, or in a newspaper/magazine in the past few months, according to background character- istics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– None of these three Number Background Newspaper/ media of characteristic Radio Television magazine sources men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 47.6 20.7 25.4 48.5 856 20-24 67.8 39.8 46.9 25.5 681 25-29 73.1 44.7 50.2 22.4 509 30-34 78.6 44.5 49.6 18.6 415 35-39 76.9 48.1 53.5 19.7 396 40-44 73.1 44.8 49.7 23.8 310 45-49 72.8 34.8 42.6 25.6 196 50-54 67.3 36.1 43.7 29.0 215 Residence Urban 70.9 52.8 60.2 20.8 907 Rural 65.3 32.1 37.3 32.0 2,671 Province Nairobi 63.9 50.8 60.6 23.1 397 Central 61.1 42.7 50.1 33.8 554 Coast 60.2 36.2 40.9 37.4 252 Eastern 65.5 37.4 35.8 33.5 588 Nyanza 71.5 36.0 49.3 24.1 481 Rift Valley 70.4 33.0 37.1 26.4 846 Western 78.7 33.3 39.3 19.6 396 North Eastern 9.8 3.5 5.0 90.0 65 Education No education 34.6 9.2 5.5 64.5 228 Primary incomplete 60.4 24.3 23.5 38.5 1,210 Primary complete 70.3 35.9 43.4 25.8 820 Secondary+ 75.7 55.0 67.2 16.6 1,320 Wealth quintile Lowest 52.2 16.1 20.5 46.1 548 Second 66.8 30.0 35.6 31.2 609 Middle 68.8 34.1 40.5 28.8 648 Fourth 70.2 41.0 46.7 26.4 794 Highest 70.5 53.0 59.1 21.0 979 Total 66.7 37.3 43.1 29.2 3,578 Family Planning | 85 5.18 DISCUSSION OF FAMILY PLANNING BETWEEN COUPLES Use of family planning methods is facilitated when husbands and wives discuss the issue and air their views. To assess the extent to which couples discuss family planning, the 2003 KDHS asked married women how often they had talked with their husbands/partners about family planning in the year preced- ing the survey. Table 5.20 shows the number of times currently married women who know about contra- ception reported having discussed family planning with their husbands in the 12 months before the sur- vey. Thirty-six percent of women have not discussed family planning with their husbands at any time in the previous year, 37 percent have discussed it one or two times, and 27 percent have discussed the is- sue three or more times during the last 12 months. 5.19 ATTITUDES OF RESPONDENTS TOWARDS FAMILY PLANNING Use of effective contraceptive methods is facilitated when couples have a positive attitude to- wards family planning. Widespread disapproval of contraception can act as a barrier to the adoption of family planning methods. Attitudinal data were collected by asking women whether they approved of couples using family planning and what they perceived as their husband’s attitude towards family plan- ning. Men were also asked whether they approved of family planning. The results presented in Table 5.21 are confined to currently married women and exclude those who have never heard of a contraceptive method. Overall, 85 percent of married women approve of fam- ily planning, with 62 percent of women saying that their husbands also approve of family planning. Thir- teen percent of women disapprove of family planning. Approval of family planning is particularly low among women in North Eastern Province (only 7 percent approve). Better educated and wealthier women are more likely to approve of family planning than less educated and poorer women. Table 5.20 Discussion of family planning with husband Percent distribution of currently married women who know a contraceptive method by the number of times they discussed family planning with their husband in the past year, accord- ing to current age, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of times family planning discussed with husband ––––––––––––––––––––––––––––––––––––– Number One or Three of Age Never two or more Missing Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 38.1 42.9 19.0 0.0 100.0 310 20-24 30.4 40.2 29.3 0.1 100.0 929 25-29 26.2 40.6 33.0 0.1 100.0 999 30-34 32.1 36.8 30.5 0.5 100.0 840 35-39 40.7 32.1 27.1 0.1 100.0 662 40-44 46.3 32.5 20.1 1.2 100.0 585 45-49 58.1 26.6 14.6 0.7 100.0 372 Total 36.0 36.7 27.0 0.4 100.0 4,696 86 | Family Planning Table 5.21 Attitudes towards family planning: married women Percent distribution of currently married women who know of a method of family planning , by approval of family planning and their perception of their husband's attitude towards family planning, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Respondent approves Respondent disapproves of family planning of family planning –––––––––––––––––––––––––– –––––––––––––––––––––––––– Husband’s Husband’s Husband attitude Husband attitude Number Background Husband disap- unknown, Husband disap- unknown, Woman of characteristic approves proves missing approves proves missing unsure1 Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 46.5 17.8 8.8 1.1 14.8 4.8 6.3 100.0 310 20-24 59.2 17.6 9.1 1.4 8.5 2.8 1.3 100.0 929 25-29 66.1 17.1 6.1 1.0 6.5 1.8 1.3 100.0 999 30-34 65.8 13.6 6.8 0.7 9.3 1.3 2.4 100.0 840 35-39 63.6 14.7 9.0 1.3 6.1 2.8 2.4 100.0 662 40-44 62.8 12.7 8.3 2.2 9.4 2.0 2.7 100.0 585 45-49 55.6 12.8 9.9 1.4 13.1 3.2 4.0 100.0 372 Residence Urban 67.4 16.3 5.0 1.0 6.6 2.3 1.3 100.0 1,075 Rural 60.1 15.1 8.9 1.3 9.4 2.4 2.7 100.0 3,621 Province Nairobi 73.3 13.5 3.9 0.8 5.8 1.6 1.0 100.0 415 Central 78.0 10.8 3.9 1.7 3.5 0.7 1.5 100.0 656 Coast 43.4 19.9 8.2 1.1 15.5 5.3 6.6 100.0 397 Eastern 67.0 10.0 7.9 1.7 9.4 2.3 1.7 100.0 777 Nyanza 50.3 21.1 15.2 0.8 8.0 2.1 2.5 100.0 774 Rift Valley 60.8 14.7 8.0 1.5 9.8 2.2 3.1 100.0 1,094 Western 61.1 20.6 6.1 0.8 9.0 1.6 0.8 100.0 555 North Eastern 2.3 3.5 0.9 0.0 46.0 46.3 1.0 100.0 28 Education No education 33.6 14.9 11.6 0.6 23.2 9.6 6.5 100.0 563 Primary incomplete 53.5 20.5 10.2 1.5 10.2 1.9 2.3 100.0 1,552 Primary complete 66.8 14.4 7.6 1.8 6.0 1.8 1.6 100.0 1,306 Secondary+ 79.3 10.5 4.1 0.7 3.6 0.4 1.4 100.0 1,276 Wealth quintile Lowest 44.5 19.1 13.2 1.8 12.7 4.9 3.7 100.0 799 Second 55.4 17.3 8.9 1.4 11.4 3.4 2.3 100.0 915 Middle 60.5 16.5 8.9 1.5 8.3 1.8 2.6 100.0 895 Fourth 73.0 9.7 5.3 1.0 7.5 1.1 2.4 100.0 958 Highest 70.8 15.2 5.1 0.8 5.4 1.5 1.2 100.0 1,129 Total 61.8 15.4 8.0 1.3 8.8 2.4 2.4 100.0 4,696 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes missing Family Planning | 87 Table 5.22 shows the distribution of all men by attitudes towards family planning. Almost 80 per- cent of all men approve of family planning. Differentials in approval reflect the same patterns as among married women. Table 5.22 Attitudes towards family planning: all men Percent distribution of men by their attitude towards family planning, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Respondent Respondent Background approves of disapproves of Respondent Number characteristic family planning family planning unsure Total of men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 65.5 22.7 11.8 100.0 856 20-24 80.6 16.7 2.7 100.0 681 25-29 84.5 14.1 1.4 100.0 509 30-34 87.7 10.5 1.8 100.0 415 35-39 86.8 12.6 0.6 100.0 396 40-44 85.7 12.7 1.7 100.0 310 45-49 80.0 16.3 3.7 100.0 196 50-54 79.0 20.4 0.6 100.0 215 Marital status Never married 73.1 19.2 7.7 100.0 1,611 Married, living together 84.9 13.7 1.3 100.0 1,817 Divorced/separated/widowed 79.0 19.6 1.6 100.0 149 Residence Urban 81.5 15.7 2.8 100.0 907 Rural 78.6 16.7 4.7 100.0 2,671 Province Nairobi 86.2 11.9 1.9 100.0 397 Central 74.7 21.8 3.6 100.0 554 Coast 77.1 19.1 3.8 100.0 252 Eastern 81.3 8.5 10.2 100.0 588 Nyanza 81.4 14.8 3.8 100.0 481 Rift Valley 81.5 16.0 2.5 100.0 846 Western 83.7 13.7 2.6 100.0 396 North Eastern 0.6 94.5 5.0 100.0 65 Education No education 43.9 49.7 6.4 100.0 228 Primary incomplete 71.9 19.5 8.6 100.0 1,210 Primary complete 83.8 14.4 1.8 100.0 820 Secondary+ 89.6 9.2 1.3 100.0 1,320 Wealth quintile Lowest 65.3 28.0 6.7 100.0 548 Second 78.1 16.3 5.7 100.0 609 Middle 80.7 14.5 4.9 100.0 648 Fourth 82.7 14.2 3.1 100.0 794 Highest 84.5 13.1 2.3 100.0 979 Total 79.4 16.4 4.2 100.0 3,578 88 | Family Planning In addition to questions about general approval of family planning, men were also asked whether they agreed or disagreed with three statements about family planning use: 1) contraception is women’s business and a man should not have to worry about it; 2) women who use contraception may become promiscuous; and 3) a woman is the one who gets preg- nant so she should be the one to get steril- ised. Results are shown in Table 5.23. The data show that only one in four men believe that contraception is women’s business only, while almost half believe that women who use family plan- ning may become promiscuous. Forty- four percent of men believe that women should be the ones to get sterilised, since they are the ones who get pregnant. Dif- ferences by background characteristics are not large. However, men in Nairobi and men with more education are less likely to express sexist views about family plan- ning use, being less likely to believe that women should bear the burden of dealing with contraception. Table 5.23 Men’s attitudes towards contraception Percentage of men who agree with statements about contraceptive use, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Woman Woman is the may one who Number Background Woman’s become becomes of characteristic business promiscuous pregnant men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 25.5 45.9 42.4 856 20-24 22.4 51.9 43.3 681 25-29 23.7 47.3 42.1 509 30-34 21.6 43.7 39.5 415 35-39 19.5 47.3 42.3 396 40-44 28.7 50.0 49.8 310 45-49 25.7 42.7 49.8 196 50-54 25.2 47.6 48.0 215 Marital status Never married 23.3 49.1 41.8 1,611 Married, living together 23.9 45.1 44.8 1,817 Divorced/separated/ widowed 28.2 57.2 47.2 149 Residence Urban 21.5 48.1 34.2 907 Rural 24.6 47.2 46.7 2,671 Province Nairobi 16.8 42.5 29.9 397 Central 17.6 59.9 47.0 554 Coast 40.7 63.5 49.7 252 Eastern 26.6 36.5 46.6 588 Nyanza 30.3 39.9 51.2 481 Rift Valley 22.2 49.3 48.0 846 Western 20.0 45.4 27.6 396 North Eastern 25.7 52.2 28.8 65 Education No education 37.8 58.2 49.4 228 Primary incomplete 34.7 50.7 53.5 1,210 Primary complete 25.6 54.1 50.2 820 Secondary+ 10.3 38.5 29.3 1,320 Wealth quintile Lowest 32.5 49.2 53.5 548 Second 24.9 50.4 47.1 609 Middle 26.6 48.6 46.3 648 Fourth 21.5 46.2 44.5 794 Highest 18.4 44.8 33.1 979 Total 23.8 47.4 43.5 3,578 Other Proximate Determinants of Fertility | 89 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 Alfred Agwanda 6.1 INTRODUCTION Research on fertility demonstrates that fertility levels in most populations can be explained by five key proximate determinants that define the risk of becoming pregnant. These are marriage, sexual intercourse, postpartum amenorrhoea and abstinence from sexual relations, onset of menopause, and con- traceptive use. This chapter addresses all of these determinants except contraception (see Chapter 5). Marriage is a principal indicator of women’s exposure to risk of pregnancy. Early age at marriage in a population is usually associated with a longer period of exposure to the risk of pregnancy and higher fertility levels. The early initiation of childbearing associated with early marriage may also adversely af- fect women and children’s health. The durations of postpartum amenorrhoea and postpartum abstinence that affect the length of time a woman is insusceptible to pregnancy determine the interval between births. The onset of menopause marks the end of a woman’s reproductive life cycle. These factors taken together determine the length and pace of reproduction, hence they are important in understanding fertility levels and differences. 6.2 MARITAL STATUS The distribution of women and men by marital status at the time of survey is presented in Table 6.1. The categories “married” and “living together” when combined are referred to as “currently married,” while those who are divorced, separated, or widowed are referred to as “formerly married.” The currently married and the formerly married combined gives the proportion ever married. Thirty percent of women of childbearing age have never been married; 60 percent are either mar- ried or living together with a man; and the remaining 10 percent are either divorced, separated, or wid- owed. The low proportion (3 percent) of women age 45-49 who have never been married indicates that marriage is still nearly universal in Kenya. Divorce and separation (6 percent) are uncommon in Kenya. These patterns have not changed since the 1993 KDHS. Forty-five percent of the men interviewed have never been married; half of the men are currently married; and only 4 percent are separated, divorced, or widowed. Compared with women, a greater pro- portion of men have never been married (15 percentage points more), while a smaller proportion are for- merly married. Although women enter into marriage earlier than men, by age 35 a higher proportion of men have ever been in a marital union, compared with women. Women are also more likely than men to report liv- ing together (informal union). Compared with the 1993 KDHS and the 1998 KDHS, the proportion cur- rently married among women has declined and the proportion living together has increased slightly. 90 | Other Proximate Determinants of Fertility 6.3 POLYGYNY The extent of polygyny was measured by asking married women respondents the question, “Does your husband/partner have any other wives besides yourself?” For currently married men, the question was, “Do you have one wife or more than one wife?” If more than one, he was asked, “How many wives do you have?” Table 6.2 shows the distribution of the respondents by the number of co-wives for women and the number of wives for men, according to background characteristics. Sixteen percent of currently married women live in polygynous unions (having one or more co- wives). Older women are more likely to be in polygynous unions. Polygyny is more prevalent in rural than in urban areas (Figure 6.1). The regional distribution shows substantial variation, with North Eastern Province having the highest proportion of women in polygynous marriages (34 percent) and Central Prov- ince the lowest (3 percent). Nyanza, Rift Valley, Western, and Coast provinces all have proportions rang- ing between 20 and 23 percent. Women with no or low education and those who are poor are more likely to live in polygynous marriages. Table 6.1 Current marital status Percent distribution of women and men by current marital status, according to age, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Marital status Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––– of Never Living women/ Age married Married together Divorced Separated Widowed Total men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 79.7 13.9 4.0 0.3 1.9 0.2 100.0 1,856 20-24 36.2 49.4 7.6 1.0 4.7 1.1 100.0 1,691 25-29 14.8 68.9 7.6 1.7 5.1 1.9 100.0 1,382 30-34 5.9 73.9 6.5 2.5 5.3 5.9 100.0 1,086 35-39 4.1 75.9 3.4 2.7 6.4 7.5 100.0 871 40-44 3.8 73.2 4.6 2.7 5.0 10.7 100.0 788 45-49 3.3 72.1 2.4 1.8 4.2 16.1 100.0 521 Total 29.8 54.5 5.6 1.6 4.4 4.2 100.0 8,195 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 98.1 1.3 0.0 0.2 0.5 0.0 100.0 856 20-24 79.2 17.1 1.3 0.6 1.8 0.0 100.0 681 25-29 32.1 61.9 0.3 3.5 2.2 0.0 100.0 509 30-34 12.0 79.3 1.9 1.4 4.8 0.6 100.0 415 35-39 2.8 89.3 1.3 1.4 3.5 1.7 100.0 396 40-44 1.9 88.6 2.4 2.5 2.7 1.8 100.0 310 45-49 0.7 94.3 0.0 0.4 0.8 3.9 100.0 196 50-54 0.1 93.8 0.3 2.3 2.9 0.6 100.0 215 Total 45.0 49.9 0.9 1.3 2.2 0.7 100.0 3,578 Other Proximate Determinants of Fertility | 91 Table 6.2 Polygyny Percent distribution of currently married women by number of co-wives, and percent distribution of currently married men by number of wives, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––– Number Number of co-wives Number of wives Number Background –––––––––––––––––––––––––––––– of ––––––––––– of characteristic 0 1 2+ Missing Total women 1 2+ Total men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 90.2 6.8 1.3 1.7 100.0 333 * * 100.0 11 20-24 88.2 7.8 1.8 2.2 100.0 965 98.3 1.7 100.0 125 25-29 83.8 10.5 3.4 2.3 100.0 1,056 97.0 3.0 100.0 316 30-34 80.1 13.0 4.5 2.4 100.0 873 93.4 6.6 100.0 337 35-39 75.3 15.4 6.4 2.8 100.0 691 89.8 10.2 100.0 359 40-44 74.9 17.2 5.9 2.0 100.0 614 86.3 13.7 100.0 282 45-49 71.9 17.3 7.7 3.2 100.0 388 78.4 21.6 100.0 185 50-54 na na na na na na 85.8 14.2 100.0 203 Residence Urban 84.4 9.5 2.2 3.8 100.0 1,091 92.4 7.6 100.0 483 Rural 80.3 13.0 4.8 1.9 100.0 3,828 89.4 10.6 100.0 1,335 Province Nairobi 86.4 7.0 1.5 5.1 100.0 418 94.8 5.2 100.0 214 Central 93.5 3.0 0.3 3.2 100.0 656 97.6 2.4 100.0 254 Coast 77.7 14.8 5.6 1.9 100.0 418 89.8 10.2 100.0 138 Eastern 90.9 6.2 1.5 1.4 100.0 783 95.3 4.7 100.0 267 Nyanza 76.0 15.2 7.3 1.4 100.0 775 84.0 16.0 100.0 267 Rift Valley 74.6 17.3 5.0 3.1 100.0 1,186 86.2 13.8 100.0 454 Western 76.5 16.9 5.4 1.2 100.0 559 88.5 11.5 100.0 182 North Eastern 65.6 19.6 14.5 0.3 100.0 125 80.2 19.8 100.0 42 Education No education 63.0 24.6 11.6 0.8 100.0 762 70.5 29.5 100.0 154 Primary incomplete 79.7 13.6 4.6 2.1 100.0 1,569 89.2 10.8 100.0 477 Primary complete 86.1 9.0 1.9 2.9 100.0 1,312 91.9 8.1 100.0 477 Secondary+ 88.8 6.4 1.6 3.1 100.0 1,276 94.0 6.0 100.0 710 Wealth quintile Lowest 72.5 19.7 6.3 1.5 100.0 947 80.5 19.5 100.0 312 Second 79.5 12.2 6.2 2.1 100.0 954 88.6 11.4 100.0 283 Middle 83.6 10.9 3.8 1.7 100.0 915 91.3 8.7 100.0 312 Fourth 84.0 10.7 2.9 2.4 100.0 965 92.8 7.2 100.0 380 Highest 85.6 8.4 2.2 3.9 100.0 1,139 94.2 5.8 100.0 532 Total 81.2 12.2 4.2 2.4 100.0 4,919 90.2 9.8 100.0 1,818 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 92 | Other Proximate Determinants of Fertility 16 12 18 9 3 20 8 23 22 22 34 36 18 11 8 KENYA RESIDENCE Urban Rural PROVINCE Nairobi Central Coast Eastern Nyanza Rift Valley Western North Eastern EDUCATION No education Primary incomplete Primary complete Secondary+ 0 10 20 30 40 Percentage Figure 6.1 Percentage of Currently Married Women Whose Husbands Have at Least One Other Wife KDHS 2003 Data for currently married men show that 10 percent of men report having more than one wife. The pattern for men remains the same as that of women, reflecting similar regional and socioeconomic status differences. Although the 1993 KDHS indicated that polygyny declined in the early 1990s, the 2003 data reflect little change from the observed prevalence in 1998. 6.4 AGE AT FIRST MARRIAGE Marriage in most African societies defines the onset of the socially acceptable time for childbear- ing. Women who marry early will have, on average, a longer period of exposure to pregnancy, often lead- ing to a higher number of children ever born. Table 6.3 shows the percentage of women and men who have married by specific ages, according to current age group. The proportion of women marrying by age 15 appears to have declined over time. More than half of all women enter marriage before their 20th birthday. Among women age 25-49, the median age at first marriage is 19.7 years (19.8 excluding the northern areas), indicating a slight increase when compared with the median of 19.2 from the 1998 KDHS. This corroborates the observations across the age cohorts in Table 6.3, which show the median age at marriage increasing over time. The median age rises from 18.9 years among women age 45-49 to 20.3 among those age 25-29. The lower panel of Table 6.3 shows the distribution among men. Only 11 percent of men marry before their 20th birthday, and about half marry before age 25. The median age at marriage among men age 30 and above is 25.1 years, only a slight increase from the 24.8 years derived for men age 25-54 from the 1998 KDHS. Unlike for women, the median age at first marriage for men is almost constant across the age cohorts, reflecting stability over time. Other Proximate Determinants of Fertility | 93 Table 6.4 further examines the median age at first marriage for women age 20-49, by background characteristics. Urban women tend to marry two years later than their rural counterparts; the difference is larger among the younger age cohorts. The variation by provinces is even larger. Women from North Eastern, Nyanza, and Coast provinces generally enter into marriage earlier than women in other prov- inces. The difference in median age at marriage between North Eastern and Nairobi provinces is as great as seven years among women age 25-29, but this declines among older women. The pattern of provincial differences has remained constant over time, although the median age has increased slightly for all prov- inces since 1998. Similarly large variations exist with education and wealth index. Although variations exist in median age at first marriage for men, the differences are not as great as those of the women. The 2003 KDHS shows little difference in the median age between men in the rural and urban areas. The provincial difference between the highest (Nairobi) and lowest (Nyanza) is only 2.5 years. Men and women (especially) who are relatively poor or have little education enter into marriage earlier than other men and women. Table 6.3 Age at first marriage Percentage of women age 15-49 and men age 15-54 who were first married by specific exact ages and median age at first marriage, according to current age, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Median Percentage first married by exact age Percentage age at ––––––––––––––––––––––––––––––––––––––––––– never first Current age 15 18 20 22 25 married Number marriage ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 3.5 na na na na 79.7 1,856 a 20-24 3.8 24.6 45.2 na na 36.2 1,691 a 25-29 6.2 28.0 48.0 65.0 80.7 14.8 1,382 20.3 30-34 8.8 32.1 52.6 66.5 81.3 5.9 1,086 19.8 35-39 9.2 30.9 54.6 69.0 84.4 4.1 871 19.6 40-44 10.6 37.2 58.4 74.0 85.8 3.8 788 19.1 45-49 12.6 42.1 60.1 76.2 87.0 3.3 521 18.9 20-49 7.5 30.5 51.2 na na 15.2 6,339 19.9 25-49 8.8 32.6 53.4 68.9 83.1 7.6 4,648 19.7 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 0.0 na na na na 98.1 856 a 20-24 0.0 2.5 5.9 na na 79.2 681 a 25-29 0.1 2.8 8.9 24.2 48.5 32.1 509 a 30-34 0.0 3.9 11.6 22.9 42.1 12.0 415 25.6 35-39 0.0 4.8 9.0 21.0 47.7 2.8 396 25.2 40-44 0.0 4.2 12.5 27.7 55.5 1.9 310 24.3 45-49 0.0 4.5 11.6 28.8 54.0 0.7 196 24.7 50-54 1.0 4.5 11.8 24.7 48.8 0.1 215 25.1 25-54 0.1 4.0 10.6 na na 11.4 2,041 a 30-54 0.1 4.4 11.1 24.4 48.7 4.5 1,532 25.1 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable a = Omitted because less than 50 percent of the women/men married for the first time before reaching the beginning of the age group 94 | Other Proximate Determinants of Fertility 6.5 AGE AT FIRST SEXUAL INTERCOURSE Although age at marriage is often used as a proxy measure for the beginning of exposure to the risk of pregnancy, some women engage in sexual activity before marriage. The 2003 KDHS gathered in- formation on the timing of the first sexual intercourse for both men and women. The percentage of women and men who had had sexual intercourse by exact ages is given in Table 6.5. Eighteen percent of women age 25-49 had sex before age 15, while more than half had their first sex by their 18th birthday. Older women are more likely to have had their first sexual encounter at an ear- lier age. This is further reflected in the median age at first sex, which is about 18 years for those under age 40 and about 17 for women age 40 and above. The data for the male respondents show an earlier age at first sex at most age groups, compared with female respondents. Twenty-five percent of men age 20-54 had sex before age 15, with no clear trend across the age cohorts. The median age at first sex is 17 years, although older men have a slightly higher median age. This trend is different from that of women. Table 6.4 Median age at first marriage Median age at first marriage among women age 20-49 and men age 30-54, by current age (women) and background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age Women Men Background –––––––––––––––––––––––––––––––––––––––––––––––– age age characteristic 20-24 25-29 30-34 35-39 40-44 45-49 25-49 30-54 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban a 22.4 21.9 20.7 20.1 20.1 21.4 25.6 Rural 19.9 19.6 19.3 19.3 18.9 18.5 19.3 25.0 Province Nairobi a 23.2 22.1 21.6 20.9 20.8 22.1 26.2 Central a 21.7 21.5 20.9 20.5 19.9 21.1 26.0 Coast 19.9 19.3 19.3 17.1 17.5 17.6 18.6 24.6 Eastern a 21.1 19.7 20.0 20.4 19.4 20.1 25.4 Nyanza 19.4 18.5 17.7 18.2 17.0 17.4 17.8 23.7 Rift Valley 19.9 19.8 19.2 19.4 18.9 19.3 19.4 25.0 Western 19.6 19.8 19.4 19.1 18.2 17.8 19.2 24.3 North Eastern 17.5 15.8 17.8 17.3 18.5 * 17.5 24.9 Education No education 17.5 17.4 16.5 17.6 17.5 17.4 17.3 24.6 Primary incomplete 18.6 18.5 18.1 18.1 17.9 17.9 18.2 23.6 Primary complete a 20.5 20.3 19.3 18.8 19.1 19.7 24.5 Secondary+ a 23.3 22.6 22.8 21.9 21.9 22.7 26.1 Wealth quintile Lowest 18.5 18.2 17.7 17.4 17.8 17.4 17.8 23.6 Second 19.6 19.6 18.5 19.2 18.5 18.0 19.0 24.2 Middle a 19.2 19.7 19.6 18.7 18.8 19.3 24.8 Fourth a 21.2 20.2 20.5 19.4 19.2 20.2 25.6 Highest a 22.6 22.0 21.5 21.2 21.1 22.0 26.0 Total a 20.3 19.8 19.6 19.1 18.9 19.7 25.1 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Other Proximate Determinants of Fertility | 95 Comparison of data from the 2003 KDHS with similar data from the 1998 KDHS indicates that there has been an increase in age at first sex. The median age at first sex among women age 20-49 has increased from 16.7 to 17.8. Among younger women age 20-24, the median age at first sex has increased from 17.3 to 18.1, even when the northern areas of Kenya are excluded to make the data more compara- ble. There has been a smaller increase in age at first sex among men age 20-24, from 16.2 in 1998 to 16.6 in 2003. Table 6.6 shows the median age at first sex by background characteristics for women age 20-49 and men age 20-54 years. Women in the rural areas start sexual activity about one year earlier than their urban counterparts. Sexual activity begins earliest in Nyanza Province (15.9 years) and latest in Nairobi (19.2 years). With respect to education, women with at least some secondary education begin sexual ac- tivity at least three years later than those with no education. Poor women tend to initiate sexual activity two years earlier than those who are wealthy. Table 6.5 Age at first sexual intercourse Percentage of women and men who had first sexual intercourse, by exact ages and median age at first intercourse, according to current age, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage who had first Percentage Number Median sexual intercourse by exact age who never of age at ––––––––––––––––––––––––––––––––––––––––––– had women/ first Current age 15 18 20 22 25 intercourse men intercourse –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 14.5 na na na na 57.9 1,856 a 20-24 12.8 48.1 71.7 na na 15.0 1,691 18.1 25-29 16.7 50.5 72.7 82.2 89.4 3.3 1,382 18.0 30-34 16.2 52.9 72.4 81.4 87.4 1.0 1,086 17.7 35-39 16.5 52.9 73.9 85.4 89.8 0.5 871 17.7 40-44 20.3 61.0 79.1 88.2 92.2 0.1 788 17.1 45-49 22.4 60.8 76.2 86.7 91.3 0.2 521 16.9 20-49 16.5 52.8 73.6 na na 5.0 6,339 17.8 25-49 17.8 54.4 74.3 84.1 89.7 1.3 4,648 17.6 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 30.9 na na na na 49.6 856 a 20-24 26.2 61.2 79.9 na na 13.2 681 16.6 25-29 23.6 54.8 78.8 89.3 94.2 3.3 509 17.4 30-34 26.6 60.0 77.3 88.2 92.0 1.2 415 16.9 35-39 22.7 58.4 77.2 88.9 94.4 0.2 396 17.1 40-44 25.8 55.8 74.8 87.2 91.9 0.2 310 17.2 45-49 21.6 52.4 76.0 89.5 91.1 0.0 196 17.6 50-54 23.2 51.3 76.3 89.9 92.8 0.0 215 17.8 20-54 24.6 57.4 77.7 na na 4.2 2,722 17.1 25-54 24.1 56.1 77.0 88.8 93.0 1.1 2,041 17.2 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable a = Omitted because less than 50 percent of the women/men had intercourse for the first time before reaching the beginning of the age group 96 | Other Proximate Determinants of Fertility The data for men show a different pattern from that for women, with almost no differences in the timing of first sexual activity between those in the rural and the urban areas. The lowest median age at first sex is in Rift Valley Province (15.9 years), and the highest median age is in Central Province (18.5 years). Like women, the median age at first sex among men increases with the level of education, whereas the differences according to wealth status are small. 6.6 RECENT SEXUAL ACTIVITY In the absence of contraception, the chance of becoming pregnant is related to the frequency of sexual intercourse. Thus, the information on sexual activity can be used to refine measures of exposure to pregnancy. Women and men were asked how long ago their last sexual activity occurred. The responses to this question allow for an assessment of recent sexual activity (in the four weeks preceding the survey). Tables 6.7.1 and 6.7.2 show the distribution of women and men, respectively, according to the timing of last sexual activity, by background characteristics. Seventeen percent of women age 15-49 and 15 percent of men age 15-54 have never had sexual intercourse. Eleven and 13 percent of women and men, respectively, report that their last sexual encounter occurred more than one year before the survey. About half of the female and male respondents had a re- cent sexual encounter. Table 6.6 Median age at first intercourse Median age at first sexual intercourse among women age 20-49 and men age 20-54, by current age (women) and background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age Women Men Background ––––––––––––––––––––––––––––––––––––––––––––––– age age characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 20-54 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 18.6 18.9 18.7 18.3 18.2 18.3 18.6 17.3 Rural 17.9 17.6 17.4 17.6 16.9 16.7 17.4 16.9 Province Nairobi 19.3 19.4 19.4 18.5 19.0 18.4 19.2 17.2 Central 18.7 18.5 18.6 18.6 17.7 17.3 18.4 18.5 Coast 18.7 17.9 18.5 16.9 16.9 17.1 18.0 18.0 Eastern 18.1 17.7 17.8 17.5 17.4 15.8 17.6 16.4 Nyanza 16.4 15.8 15.7 15.8 15.3 15.6 15.9 16.4 Rift Valley 18.2 18.1 17.5 18.2 17.3 18.4 18.0 15.9 Western 17.4 17.6 17.1 17.3 16.7 16.6 17.2 17.0 North Eastern 17.5 16.1 18.1 19.1 18.5 * 17.9 a Education No education 17.0 16.4 16.4 16.5 16.0 16.2 16.4 a Primary incomplete 16.6 16.4 16.0 16.5 16.0 16.6 16.4 16.4 Primary complete 18.0 18.0 18.1 17.8 17.1 16.2 17.8 16.9 Secondary+ 19.8 19.9 19.4 19.9 18.8 19.9 19.6 17.4 Wealth quintile Lowest 16.9 17.0 16.4 16.2 16.3 16.7 16.6 16.9 Second 17.2 17.4 16.6 17.5 16.5 16.5 17.0 16.4 Middle 17.9 17.2 17.2 17.8 16.6 16.6 17.3 16.8 Fourth 18.4 18.3 18.3 18.4 17.6 16.6 18.1 17.4 Highest 18.8 19.3 19.3 18.4 18.6 18.6 18.9 17.5 Total 18.1 18.0 17.7 17.7 17.1 16.9 17.8 17.1 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. a Omitted because less than 50 percent of the men had intercourse for the first time before reaching the beginning of the age group Other Proximate Determinants of Fertility | 97 Table 6.7.1 Recent sexual activity: women Percent distribution of women by timing of last sexual intercourse, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Timing of last sexual intercourse –––––––––––––––––––––––––––– Within One or Never had Number Background the last Within more sexual of characteristic 4 weeks 1 year1 years Missing intercourse Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Current age 15-19 16.9 16.7 7.1 1.4 57.9 100.0 1,856 20-24 47.1 25.6 10.4 2.0 15.0 100.0 1,691 25-29 63.0 23.6 7.5 2.7 3.3 100.0 1,382 30-34 63.0 23.2 10.1 2.7 1.0 100.0 1,086 35-39 61.6 25.6 10.7 1.6 0.5 100.0 871 40-44 57.8 22.6 17.5 2.0 0.1 100.0 788 45-49 48.1 23.1 26.2 2.5 0.2 100.0 521 Marital status Never married 6.1 19.5 15.8 1.7 56.8 100.0 2,443 Married or living together 74.0 21.6 2.8 1.5 0.0 100.0 4,919 Divorced/separated/widowed 14.2 36.0 43.3 6.5 0.0 100.0 833 Marital duration2 Married only once 0-4 years 75.9 21.6 0.6 1.7 0.1 100.0 1,227 5-9 years 79.6 18.2 1.1 1.0 0.0 100.0 1,007 10-14 years 74.8 21.4 2.3 1.5 0.0 100.0 763 15-19 years 74.9 21.2 2.5 1.3 0.0 100.0 645 20-24 years 66.9 25.0 6.6 1.6 0.0 100.0 498 25+ years 63.1 25.2 9.9 1.9 0.0 100.0 439 Married more than once 71.5 23.7 3.4 1.4 0.0 100.0 340 Residence Urban 47.2 20.5 13.2 1.9 17.2 100.0 2,056 Rural 47.8 23.1 10.0 2.1 16.9 100.0 6,139 Province Nairobi 45.9 20.7 14.2 1.2 18.1 100.0 835 Central 49.0 18.3 12.4 1.7 18.6 100.0 1,181 Coast 49.8 21.9 8.8 2.9 16.5 100.0 667 Eastern 51.8 21.0 8.4 1.2 17.6 100.0 1,325 Nyanza 49.9 28.1 8.4 1.1 12.5 100.0 1,222 Rift Valley 44.4 22.9 12.9 3.6 16.2 100.0 1,872 Western 43.1 24.6 9.9 1.8 20.6 100.0 927 North Eastern 52.1 17.8 9.6 3.1 17.4 100.0 168 Education No education 45.0 26.2 18.1 4.6 6.1 100.0 1,039 Primary incomplete 46.9 22.1 8.3 1.8 20.9 100.0 2,685 Primary complete 51.5 24.6 10.5 1.8 11.7 100.0 2,069 Secondary+ 46.4 19.5 10.8 1.5 21.8 100.0 2,403 Contraceptive method Female sterilisation 76.1 15.0 7.0 1.9 0.0 100.0 238 Pill 87.5 10.7 1.2 0.6 0.0 100.0 402 IUD 85.9 8.2 4.6 1.2 0.0 100.0 129 Condom 67.8 27.2 3.9 1.1 0.0 100.0 137 Periodic abstinence 72.0 22.1 4.3 1.0 0.7 100.0 381 Other method 78.2 16.5 3.7 1.2 0.4 100.0 1,036 No method 35.5 24.9 13.6 2.4 23.6 100.0 5,871 Wealth quintile Lowest 46.0 26.3 10.3 3.1 14.3 100.0 1,364 Second 48.0 24.5 10.4 2.3 14.8 100.0 1,475 Middle 48.5 22.5 9.7 2.0 17.3 100.0 1,503 Fourth 47.8 21.0 10.6 1.7 18.8 100.0 1,711 Highest 47.7 19.8 12.5 1.6 18.4 100.0 2,141 Total 47.7 22.5 10.8 2.1 17.0 100.0 8,195 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Excludes women who had sexual intercourse within the last four weeks 2 Excludes women who are not currently married 98 | Other Proximate Determinants of Fertility Table 6.7.2 Recent sexual activity: men Percent distribution of men by timing of last sexual intercourse, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Timing of last sexual intercourse –––––––––––––––––––––––––––– Within One or Never had Number Background the last Within more sexual of characteristic 4 weeks 1 year1 years Missing intercourse Total men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Current age 15-19 11.5 18.7 20.3 0.0 49.6 100.0 856 20-24 33.9 33.5 19.3 0.0 13.2 100.0 681 25-29 50.0 32.8 13.9 0.0 3.3 100.0 509 30-34 69.6 22.8 6.1 0.3 1.2 100.0 415 35-39 72.7 23.9 3.2 0.0 0.2 100.0 396 40-44 74.0 20.3 5.5 0.0 0.2 100.0 310 45-49 76.0 17.6 6.0 0.3 0.0 100.0 196 50-54 69.5 25.4 4.7 0.5 0.0 100.0 215 Marital status Never married 15.1 27.2 24.3 0.0 33.4 100.0 1,611 Married or living together 77.0 21.7 1.2 0.2 0.0 100.0 1,818 Divorced/separated/widowed 30.3 42.8 26.9 0.0 0.0 100.0 149 Marital duration2 Married only once 0-4 years 79.0 20.5 0.5 0.0 0.0 100.0 418 5-9 years 72.2 26.9 0.8 0.2 0.0 100.0 324 10-14 years 77.0 20.9 1.9 0.2 0.0 100.0 259 15-19 years 80.1 19.4 0.1 0.4 0.0 100.0 212 20-24 years 75.8 21.4 2.3 0.5 0.0 100.0 188 25+ years 74.2 23.2 2.6 0.0 0.0 100.0 170 Married more than once 79.9 19.1 0.9 0.0 0.0 100.0 247 Residence Urban 51.0 26.6 10.3 0.2 11.9 100.0 907 Rural 45.9 24.5 13.5 0.0 16.1 100.0 2,671 Province Nairobi 48.9 27.8 10.6 0.5 12.2 100.0 397 Central 44.8 19.6 15.2 0.0 20.3 100.0 554 Coast 51.6 26.2 7.2 0.0 15.0 100.0 252 Eastern 45.2 21.7 16.3 0.0 16.9 100.0 588 Nyanza 48.6 22.2 11.6 0.0 17.5 100.0 481 Rift Valley 49.1 32.1 12.2 0.1 6.5 100.0 846 Western 41.7 25.2 13.5 0.0 19.7 100.0 396 North Eastern 55.6 9.3 1.1 0.0 34.0 100.0 65 Education No education 51.8 26.2 8.0 0.2 13.7 100.0 228 Primary incomplete 40.0 23.1 13.5 0.0 23.4 100.0 1,210 Primary complete 50.8 27.4 11.8 0.1 10.0 100.0 820 Secondary+ 50.7 25.2 13.2 0.1 10.7 100.0 1,320 Wealth quintile Lowest 48.4 23.6 11.3 0.0 16.6 100.0 548 Second 45.7 22.2 16.2 0.0 15.9 100.0 609 Middle 42.5 23.3 13.0 0.0 21.3 100.0 648 Fourth 47.6 25.0 13.8 0.1 13.6 100.0 794 Highest 50.2 28.8 10.2 0.2 10.6 100.0 979 Total 47.2 25.1 12.7 0.1 15.0 100.0 3,578 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Excludes men who had sexual intercourse within the last four weeks 2 Excludes men who are not currently married Other Proximate Determinants of Fertility | 99 Table 6.8 Postpartum amenorrhoea, abstinence, and insus- ceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and me- dian and mean durations, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of births for which the mother is: –––––––––––––––––––––––––––––– Number Months Amenor- Insuscep- of since birth rhoeic Abstaining tible births –––––––––––––––––––––––––––––––––––––––––––––––––––– <2 96.6 92.0 99.7 179 2-3 85.8 46.2 90.8 237 4-5 68.0 31.5 75.8 215 6-7 58.1 26.4 66.5 210 8-9 55.6 19.5 62.2 221 10-11 50.5 18.3 57.6 232 12-13 33.5 13.5 40.2 220 14-15 40.6 13.5 45.6 208 16-17 18.7 10.9 25.7 227 18-19 13.9 11.0 19.7 175 20-21 10.2 8.2 15.7 215 22-23 11.3 11.9 18.9 183 24-25 5.7 7.3 11.0 203 26-27 4.5 5.2 8.2 158 28-29 5.7 4.8 9.2 204 30-31 3.8 4.4 8.1 164 32-33 5.1 4.7 8.8 181 34-35 2.3 2.8 5.1 209 Total 33.0 18.6 38.6 3,640 Median 9.7 2.9 11.8 na Mean 11.7 6.9 13.6 na –––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Estimates are based on status at the time of the survey. na = Not applicable As expected, recent sexual activity is less common among the youngest age group, 15-19; 58 per- cent of women and about half of men in this age group have never had sex. Recent sexual activity is more common among the currently married, with about three-quarters of women and men having had sex in the four weeks before the survey. Male-female differences are greatest for those who have never married and those formerly married. Among those who have never married, the proportion of males who report a re- cent sexual encounter is more than twice that of women (15 and 6 percent, respectively). This is also the case for those who were formerly married (30 and 14 percent, respectively). The proportions reporting recent sexual activity do not differ much across the other characteris- tics. However, women who report using no contraceptive method are less likely to have had a recent sex- ual encounter. This is not surprising, as many of them also reported not to have ever had sex. There has been a slight decline in recent activity since 1998; the proportion of women having sex in the four weeks preceding the survey declined from 52 percent in 1998 to 48 percent in 2003 (excluding areas in northern Kenya that were not covered in the 1998 KDHS). For men, the decline was from 56 per- cent in 1998 to 47 percent in 2003. 6.7 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea is defined as the period between childbirth and the return of ovula- tion, generally approximated by the resumption of menstruation following childbirth. This period is largely determined by the duration and intensity of breastfeeding. The risk of conception in this pe- riod is very low. The duration of the postpartum amenorrhoea and the period of sexual abstinence following birth jointly determine the length of the insusceptibility period. Thus, women are consid- ered insusceptible if they are abstaining from sex following childbirth or are amenorrhoeic. Women who gave birth three years pre- ceding the survey were asked about the duration of their periods of amenorrhoea and sexual absti- nence following each birth. The results are pre- sented in Table 6.8. Almost all women are insus- ceptible to pregnancy within the first two months following childbirth. After the second month, the contribution of abstinence is greatly reduced. At 10 to 11 months after birth, about half of all women are still amenorrhoeic, but only 18 percent are abstaining. After about one year, the propor- tion amenorrhoeic drops sharply, such that at 26 to 27 months following childbirth, less than 5 per- cent are amenorrhoeic and only 8 percent are still insusceptible to the risk of pregnancy. 100 | Other Proximate Determinants of Fertility The principal determinant of the length of the period of insusceptibility is postpartum amenor- rhoea. The median duration of amenorrhoea is 9.7 months; of abstinence, 2.9 months; and insusceptibil- ity, 11.8 months. The duration of abstinence has been constant since 1993, while the median period of amenorrhoea declined from 11 months in 1993 to 9 months in 1998 and 2003 (excluding the northern part of the country). Table 6.9 displays the median durations of postpartum amenorrhoea, abstinence, and insuscepti- bility by background characteristics of the respondents. Older women (age 30 and over) have a longer median period of insusceptibility, mainly because of the longer duration of postpartum amenorrhoea. Women living in urban areas also have a shorter median duration of amenorrhoea and, hence, a shorter period of insusceptibility. There are considerable variations by province in the period of insusceptibility. The median duration in Rift Valley Province (13.5 months) is almost double that of Nairobi (7.5 months) and Central (8.5 months) provinces, respectively. Whereas the median duration of insusceptibility has increased in Nairobi and Rift Valley provinces, there is a slight decline in Central and Eastern provinces since 1998. There is clearly an inverse relationship between the median duration of amenorrhoea and the level of education. However, the duration of abstinence is similar across the educational categories except for those with no education. Similarly, the median duration of postpartum amenorrhoea declines as the wealth status increases. The poorest women have the longest durations of amenorrhoea, abstinence, and hence insusceptibility. Table 6.9 Median duration of postpartum insusceptibility by background characteristics Median number of months of postpartum amenorrhoea, postpartum absti- nence, and postpartum insusceptibility following births in the three years pre- ceding the survey, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Postpartum: –––––––––––––––––––––––––––– Number Background Amenor- Insuscep- of characteristic rhoea Abstinence tibility births ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Mother's age 15-29 8.7 2.9 10.4 2,426 30-49 12.7 3.1 13.1 1,214 Residence Urban 6.2 3.2 8.2 684 Rural 10.5 2.8 12.7 2,956 Province Nairobi 6.8 2.8 7.5 239 Central 5.9 2.5 8.5 377 Coast 9.6 2.8 11.0 311 Eastern 10.2 2.6 10.4 564 Nyanza 11.7 2.7 12.8 605 Rift Valley 11.1 4.4 13.5 995 Western 9.5 2.2 10.2 446 North Eastern (7.6) (2.5) (14.4) 104 Education No education 14.9 4.4 16.6 554 Primary incomplete 10.2 2.4 12.8 1,351 Primary complete 8.5 3.0 10.2 1,000 Secondary+ 7.9 3.0 9.1 735 Wealth quintile Lowest 13.7 3.6 14.9 893 Second 9.7 3.1 10.4 756 Middle 8.9 2.3 11.0 683 Fourth 8.6 2.6 12.0 622 Highest 6.2 3.1 7.5 687 Total 9.7 2.9 11.8 3,640 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Medians are based on status at the time of the survey. Figures in paren- theses are based on 25-49 unweighted cases and have been suppressed. Other Proximate Determinants of Fertility | 101 Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Kenya 2003 –––––––––––––––––––––––––––––––– Number Percentage of Age menopausal1 women –––––––––––––––––––––––––––––––– 30-34 4.2 1,086 35-39 7.5 871 40-41 10.8 375 42-43 16.9 288 44-45 17.4 271 46-47 31.6 215 48-49 52.7 160 Total 12.2 3,266 –––––––––––––––––––––––––––––––– 1 Percentage of all women who are not pregnant and not postpartum amenor- rhoeic whose last menstrual period oc- curred six or more months preceding the survey 6.8 TERMINATION OF EXPOSURE TO PREGNANCY While the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a given population. One indicator of infecundity is the onset of menopause. Meno- pausal women are defined by the KDHS as women who are neither pregnant nor postpartum amenor- rhoeic, but who have not had a menstrual period in the six months before the survey. The prevalence of menopause increases with age, typically from around age 30. Table 6.10 presents the indicator for women age 30-49, which ranges from 4 percent for women age 30-34 to 53 percent for women age 48-49. Twelve percent of women age 30-49 were reported to be menopausal, compared with 14 percent in 1998. Fertility Preferences | 103 FERTILITY PREFERENCES 7 Murungaru Kimani Analysis and interpretation of the need for contraception as assessed by whether or not respon- dents want another child, their preferred interval between children, and the number of children they con- sider ideal have revealed important implications for the planning and implementation of family planning programmes. Therefore, in the 2003 KDHS, as in the previous KDHS surveys, women and men were asked a series of questions to ascertain fertility preferences. These data are utilised in this chapter to quan- tify fertility preferences and, in combination with data on contraceptive use, to permit estimation of unmet need for family planning, both to space and limit births. 7.1 DESIRE FOR MORE CHILDREN Women and men in the 2003 KDHS sample were asked, “Would you like to have (a/another) child or would you prefer not to have any (more) children?” Respondents who said that they would like to have more children were asked, “How long would you like to wait from now before the birth of (a/another) child?” Responses to these questions are presented in Table 7.1 by the number of living chil- dren for both married women and men. Overall, 49 percent of married women either do not want another child or are sterilised, 47 per- cent want to have another child—29 percent later, 16 percent soon (within two years) and 2 percent unde- cided when—and the remainder are undecided (Figure 7.1). Fertility preferences among married men show a similar pattern, although the percentage of men who do not want any more children is lower (39 percent) than among women, while the proportion who would like to have another child is higher (54 per- cent). Comparing the 2003 KDHS results with those of the 1998 KDHS shows that the desire to have children among both men and women has increased since 1998. For example, the proportion of married women who want another child has increased from 40 percent in 1998 to 45 percent (excluding the north- ern districts) in 2003. As expected, the desire to stop childbearing increases with the number of living children reaching 80 percent and 61 percent for women and men with six or more living children, respectively. Only about 1 percent of childless women and men do not want to have any children. Among women and men who want to have another child, the reverse is observed; that is, the proportion who want to have another child decreases with the number of living children. The desire to stop childbearing by residence, province, education, and wealth index is shown in Table 7.2. Although women in rural areas appear to have a higher overall preference for not having more children, this is mainly because rural women already have more children than urban women do. Among women with two to five children, the desire for no more children is higher in urban areas than in rural ar- eas as would be expected. Wide regional variations are observed in the desire for more children. Sixty- one percent of currently married women in Central Province do not want to have another child, compared with 33 percent of women in Coast Province and 4 percent of women in North Eastern Province. How- ever, desire to limit fertility seems to have spread in all regions after the sixth birth except in North East- ern Province; desire to have no more children is over 73 percent in all other provinces after the sixth birth. 104 | Fertility Preferences Figure 7.1 Fertility Preferences among Currently Married Women Age 15-49 KDHS 2003 Wants no more 44% Wants child later (after 2 years) 29% Wants child soon (within 2 years) 16% Wants child, undecided when 2% Sterilised 4% Infecund 2% Undecided 3% Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men by desire for children, according to number of living children, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of living children1 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Desire for children 0 1 2 3 4 5 6+ Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Have another soon2 79.4 27.8 13.9 11.9 7.5 7.8 5.2 15.7 Have another later3 6.9 58.2 45.4 31.7 20.6 9.9 7.9 29.0 Have another, undecided when 3.5 3.3 1.9 1.7 0.9 0.6 1.2 1.8 Undecided 2.1 1.1 3.9 4.0 1.6 2.9 2.5 2.7 Want no more 0.8 8.1 32.9 45.6 61.0 68.8 70.7 44.3 Sterilised4 0.0 0.4 0.7 4.3 5.9 8.1 9.3 4.3 Declared infecund 6.7 1.1 1.1 0.8 2.5 1.6 2.9 1.9 Missing 0.6 0.1 0.1 0.0 0.0 0.2 0.3 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 237 762 939 897 662 501 921 4,919 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Have another soon2 47.4 27.0 21.9 15.8 12.6 11.6 11.2 18.8 Have another later3 45.6 62.4 42.8 30.1 22.9 19.8 17.4 33.4 Have another, undecided when 3.8 1.0 1.7 2.4 1.4 2.2 0.3 1.6 Undecided 0.5 3.6 4.6 6.5 3.3 6.9 5.6 4.8 Want no more 1.4 5.8 28.2 41.7 56.9 53.7 61.4 38.7 Declared infecund 1.2 0.1 0.8 3.1 2.9 5.7 3.6 2.5 Missing 0.0 0.0 0.0 0.3 0.0 0.0 0.5 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 122 266 322 296 218 211 384 1,818 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes current pregnancy 2 Wants next birth within two years 3 Wants to delay next birth for two or more years 4 Includes both female and male sterilisation Fertility Preferences | 105 Substantial differences in fertility preferences among women by levels of education are apparent. For example, 38 percent of married women with no education want to stop childbearing, compared with 54 percent of those with some secondary education. A similar pattern is observed with the wealth index. Desire for no more children generally increases with the wealth index, except for the highest quintile. Fertility preference among men show similar patterns to those for the women, although overall proportions of men who do not want to have more children are lower. 7.2 NEED FOR FAMILY PLANNING SERVICES Women who are currently married and who say either that they do not want any more children or that they want to wait two or more years before having another child, 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 to- tal demand for family planning. Table 7.3 presents information for currently married women on unmet need, met need, and total demand for family planning, according to whether the need is for spacing or limiting births. Table 7.2 Desire to limit childbearing Percentage of currently married women and men who want no more children, by number of living children and background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of living children1 Background ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– All All characteristic 0 1 2 3 4 5 6+ women men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 0.4 10.9 45.5 66.1 71.2 80.6 77.4 44.5 36.5 Rural 1.1 7.3 28.6 45.5 65.9 76.2 80.2 49.9 39.5 Province Nairobi (0.0) 7.7 48.4 62.0 68.7 (88.4) * 41.7 37.7 Central * 11.8 46.1 75.5 89.7 88.9 87.5 61.0 46.1 Coast (1.3) 9.8 17.6 37.1 29.9 (57.5) 73.8 33.2 24.7 Eastern * 12.6 40.7 54.5 82.5 87.7 86.3 57.6 50.0 Nyanza (2.6) 4.5 26.6 38.1 67.3 75.7 86.7 47.0 43.5 Rift Valley (0.0) 8.1 25.7 46.0 63.1 75.7 78.9 48.1 35.2 Western * 7.3 25.8 38.0 58.9 75.8 92.4 52.0 34.4 North Eastern * (0.0) (0.0) (1.5) (2.5) (0.0) 9.3 4.0 0.0 Education No education (1.0) 7.5 14.5 23.4 30.2 52.4 61.0 38.0 17.7 Primary incomplete 0.0 9.6 21.6 39.4 57.2 76.7 86.2 46.9 34.9 Primary complete 2.7 5.9 35.6 51.9 81.0 87.0 91.1 51.5 41.3 Secondary+ 0.0 10.3 47.3 67.8 83.5 86.0 90.1 54.3 44.2 Wealth quintile Lowest (0.0) 4.7 14.1 25.2 46.3 58.1 69.7 41.8 27.8 Second * 3.6 19.0 37.7 57.7 74.8 84.1 46.9 35.4 Middle (0.0) 5.8 26.7 48.5 76.6 78.7 85.8 53.1 43.0 Fourth (0.8) 13.0 40.7 61.5 76.5 86.1 85.1 55.1 45.6 Highest 0.0 10.6 47.6 69.0 77.3 89.7 89.2 46.8 39.5 Total 0.8 8.4 33.7 49.9 66.8 76.9 80.0 48.7 38.7 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Women who have been sterilised are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases, while an asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes current pregnancy 106 | Fertility Preferences Table 7.3 Need for family planning among currently married women Percentage of currently married women with unmet need for family planning and with met need for family planning, and the total demand for family planning, along with percentage of demand satisfied, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Met need for Unmet need for family planning Total demand for family planning1 (currently using)2 family planning3 Percentage –––––––––––––––––––– ––––––––––––––––––––– –––––––––––––––––––– of Number Background For For For For For For demand of characteristic spacing limiting Total spacing limiting Total spacing limiting Total satisfied women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 26.6 1.2 27.8 12.7 3.7 16.4 40.6 5.6 46.1 39.7 333 20-24 27.6 4.8 32.4 19.8 8.0 27.8 50.2 13.2 63.4 48.9 965 25-29 16.8 6.7 23.5 24.0 16.6 40.7 42.8 24.5 67.3 65.0 1,056 30-34 13.3 14.2 27.4 16.9 28.1 45.0 31.9 42.6 74.6 63.2 873 35-39 6.4 16.5 22.9 8.2 41.9 50.1 15.5 58.8 74.3 69.2 691 40-44 2.3 15.0 17.3 1.9 46.0 47.9 4.2 61.3 65.5 73.7 614 45-49 0.6 11.8 12.4 0.2 38.2 38.4 0.8 50.0 50.8 75.6 388 Residence Urban 10.8 6.3 17.2 20.5 27.1 47.6 32.2 33.8 66.1 74.0 1,091 Rural 15.4 11.2 26.6 12.5 24.4 37.0 29.6 36.2 65.8 59.6 3,828 Province Nairobi 12.5 3.5 16.0 23.3 27.5 50.7 36.7 31.4 68.1 76.5 418 Central 6.1 5.2 11.4 20.6 45.8 66.4 28.6 51.8 80.4 85.9 656 Coast 16.2 8.7 24.9 12.1 12.0 24.1 29.5 21.0 50.6 50.7 418 Eastern 10.9 10.8 21.7 17.7 32.9 50.6 31.5 44.4 76.0 71.4 783 Nyanza 20.5 14.2 34.7 7.7 17.0 24.7 29.1 31.4 60.5 42.6 775 Rift Valley 15.6 12.1 27.7 12.5 21.9 34.4 29.2 34.4 63.6 56.4 1,186 Western 19.3 12.7 32.1 13.3 20.8 34.1 34.2 34.7 68.9 53.5 559 North Eastern 8.9 1.3 10.1 0.0 0.2 0.2 8.9 1.5 10.3 1.6 125 Education No education 11.3 10.1 21.4 2.7 9.3 12.0 15.2 19.8 35.0 38.9 762 Primary incomplete 21.7 13.4 35.1 11.4 18.8 30.2 34.6 32.6 67.2 47.8 1,569 Primary complete 13.9 10.7 24.7 16.1 28.1 44.2 31.9 39.5 71.4 65.5 1,312 Secondary+ 7.8 5.4 13.2 22.9 38.9 61.8 32.0 44.9 76.9 82.9 1,276 Wealth index Lowest 18.8 13.9 32.7 7.6 10.3 17.9 28.1 24.4 52.6 37.8 947 Second 16.5 13.8 30.3 12.3 19.6 31.9 30.0 33.9 64.0 52.7 954 Middle 15.7 11.1 26.8 13.3 28.6 42.0 30.9 40.3 71.2 62.4 915 Fourth 10.0 7.4 17.4 15.4 35.3 50.7 27.0 43.6 70.6 75.4 965 Highest 11.7 5.4 17.0 21.3 30.2 51.5 34.2 35.9 70.1 75.7 1,139 Currently married women 14.4 10.1 24.5 14.3 25.0 39.3 30.2 35.7 65.8 62.8 4,919 Unmarried women 1.9 0.8 2.7 6.2 5.7 11.9 8.6 6.7 15.3 82.5 3,276 All women 9.4 6.4 15.8 11.1 17.3 28.4 21.6 24.1 45.6 65.4 8,195 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrhoeic women who are not using family planning and whose last birth was mistimed, and fecund women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and say that they want to wait two or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say that they are unsure whether they want another child or who want another child but are unsure when to have the birth (unless they say that it would not be a problem if they discovered they were pregnant in the next few weeks). Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhoeic women whose last child was unwanted, and fecund women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are pregnant and amenorrhoeic women who became pregnant while using a method (these women are in need of a better method of contraception). 2 Using for spacing is defined as women who are using some method of family planning and say that 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. The specific methods used are not taken into account here. 3 Nonusers who are pregnant or amenorrhoeic and women whose pregnancy was the result of a contraceptive failure are not included in the category of unmet need, but they are included in total demand for family planning (since they would have been using had their method not failed). Fertility Preferences | 107 One-quarter of currently married women in Kenya have an unmet need for family planning, 14 percent for spacing, and 10 percent for limiting. This shows that unmet need has remained unchanged since 1998. Because 39 percent of currently married women are using a contraceptive method, it implies that the total demand for family planning comprises two-thirds of married women in Kenya, which is about the same level estimated in 1998. The 2003 KDHS (as did the 1998 KDHS) shows that if all women who want to space or limit childbearing were to use family planning, the contraceptive prevalence rate could increase from the current level of 39 percent to about 66 percent. The data in this table, how- ever, show that only 63 percent of this total demand among married women is satisfied. Unmet need is higher among women younger than 35 years and declines thereafter. Analysis of the unmet need for spacing and limiting reveals the expected patterns, where unmet need for spacing de- clines with age, while that for limiting increases. Unmet need for family planning is higher in rural (27 percent) than urban (17 percent) areas. It is highest among women with incomplete primary education and decreases with the women’s wealth status. Unmet need is highest in Nyanza (35 percent) and Western (32 percent) provinces and lowest in North Eastern (10 percent) and Central (11 percent) provinces. In 1998, unmet need was highest in Western and Coast provinces. Demand for family planning is also associated with demographic and socioeconomic indicators. Demand generally increases with age up to age 30-39, is highest in Central (80 percent) and Eastern (76 percent) provinces, and is much lower in North Eastern Province (10 percent). Variations in the other provinces are modest. Demand among women with no education is about half that of those with at least some secondary school. According to the wealth index, demand is much lower among the poorest. Similar patterns are observed for the percentage of demand satisfied. Thus, the percentage of demand that is satis- fied is highest in Central, Nairobi, and Eastern provinces; among married women with secondary and higher education; and among the wealthy. Satisfied demand is also substantially higher in urban areas. Table 7.3 also presents the unmet need for family planning for women who are not currently mar- ried and all women. Unmet need for all women and unmarried women is much lower (16 and 3 percent), compared with that for currently married women (25 percent). The overall demand is also lower—46 per- cent of all women, compared with 66 percent of married women. An important observation is that, over- all, the percentage of demand that is satisfied is higher among unmarried women (83 percent), compared with married women (63 percent). 7.3 IDEAL FAMILY SIZE Women and men who were interviewed in the 2003 KDHS were asked two questions for deter- mining ideal family size. Respondents who did not have any living children were asked, “If you could choose exactly the number of children to have in your lifetime, how many would that be?” For respon- dents who had living children the question was rephrased as follows, “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 lifetime, how many would that be?” The results are presented in Table 7.4 for both women and men. Results indicate that the vast majority of both women and men gave a numeric response; only 5 percent of women and 4 percent of men failed to give a numeric response, which is about the same pro- portion as in the 1998 KDHS. Among the women who gave a numeric response, the mean ideal family size is 3.9 children. Excluding areas in northern Kenya for comparison with prior KDHS surveys shows that the mean ideal family size is 3.7 in 2003, which is close to the 3.8 and 3.7 reported in the 1998 KDHS and the 1993 KDHS, respectively. The average ideal family size reported by men (4.3 children) is higher than for women and is also higher than the level reported by men in the 1998 KDHS (4.0); how- ever, when the northern districts are excluded, the mean family size as reported by men in 2003 is 4.1 children. These results suggest that there has been little change in the ideal family size over the last 10 years in Kenya. 108 | Fertility Preferences The ideal number of children increases with the number of living children. Women with six or more living children have an ideal family size of 5.5, compared with 3.4 for those with no children or one child. Among men, ideal family size ranges from 3.9 for those without a child to 7.0 for men with six or more living children. This pattern could be attributed to either those with smaller family sizes tending to achieve these desired small families or to “adjustments” of ideal number of children as the actual number increased (rationalisation). However, despite the likelihood of rationalisation, the results are similar to those obtained from the 1998 KDHS, which showed considerable proportions of women and men report- ing ideal family sizes smaller than their actual family sizes. For example, 56 percent of women and 47 percent of men with six or more living children report ideal family sizes of less than six children. As in the 1998 KDHS, four children is the most commonly reported ideal for both women and men. Table 7.4 Ideal number of children Percent distribution of all women and all men by ideal number of children, and mean ideal number of children for all women and for all men and for currently married women and for currently married men, according to number of living children, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of living children1 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Ideal number of children 0 1 2 3 4 5 6+ Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 0 2.6 0.7 0.6 1.0 0.9 0.4 0.9 1.3 1 2.6 6.0 3.1 2.4 1.4 0.1 0.2 2.6 2 28.4 24.8 24.7 13.1 13.5 12.1 6.1 19.8 3 22.3 28.3 22.2 22.7 10.6 12.7 7.0 19.5 4 25.1 22.8 31.9 34.2 41.3 29.1 32.1 29.6 5 7.4 6.1 6.5 9.5 9.0 16.2 9.2 8.4 6+ 7.7 7.7 7.3 11.8 17.9 23.3 33.4 13.6 Non-numeric responses 4.0 3.6 3.6 5.3 5.3 6.1 11.2 5.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,240 1,297 1,158 1,042 800 594 1,064 8,195 Mean ideal number of children for2 All women 3.4 3.4 3.5 3.9 4.3 4.8 5.5 3.9 Number 2,150 1,250 1,117 987 757 557 945 7,764 Currently married women 4.0 3.7 3.6 4.0 4.3 4.8 5.6 4.3 Number 224 734 904 850 627 469 816 4,624 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 0 1.2 0.4 0.4 0.2 0.0 0.4 0.7 0.8 1 1.4 1.0 0.8 0.0 1.5 0.5 0.2 1.0 2 20.3 20.2 20.7 9.6 15.1 8.7 5.6 16.8 3 24.1 28.8 26.8 23.9 10.0 14.5 10.3 21.8 4 27.1 27.4 28.6 36.4 37.2 20.3 27.1 28.4 5 11.2 7.3 9.2 11.8 14.6 18.0 3.4 10.4 6+ 12.4 11.4 11.0 13.6 18.4 31.6 41.9 17.0 Non-numeric responses 2.3 3.6 2.4 4.4 3.3 6.1 10.9 3.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,704 347 374 315 229 217 393 3,578 Mean ideal number of children for2 All men 3.9 3.8 3.8 4.3 4.5 5.3 7.0 4.3 Number 1,665 335 365 301 221 204 350 3,440 Currently married men 3.6 3.8 3.8 4.4 4.6 5.3 7.0 4.8 Number 119 256 313 282 211 198 344 1,723 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes current pregnancy 2 Means are calculated excluding respondents giving non-numeric responses. Fertility Preferences | 109 Table 7.5 presents data on the mean ideal number of children for all women and men, by age (for women) and background characteristics. The ideal family size for both men and women increases with age, from 3.6 for women age 15-19 to 4.8 for women age 45-49. Ideal family size is higher in rural areas, compared with urban areas, and it decreases with the level of education, particularly between those with- out and those with some education. A similar trend is observed with the wealth index. Provincial varia- tions in ideal family size among both women and men are modest, ranging from about 3 to 5 children, except in North Eastern Province, where the ideal family size is much higher (about 11 children for both women and men). 7.4 WANTED AND UNWANTED FERTILITY Interviewers asked women a series of questions regarding children born in the five years preced- ing the survey date and any current pregnancy to determine whether each birth/pregnancy was wanted then, wanted later, or unwanted. These questions provide a powerful indicator of the degree to which couples successfully control fertility. Also, the data can be used to gauge the effect of the prevention of unwanted births on fertility rates. Table 7.6 shows the percent distribution of births in the five years pre- ceding the survey by whether the birth was wanted by the mother then, wanted later, or not wanted. Table 7.5 Mean ideal number of children Mean ideal number of children for all women and men, by age (women) and background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age Background ––––––––––––––––––––––––––––––––––––––––––––––––––––––––– All All characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 women men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 3.1 3.1 3.3 3.4 3.7 4.3 4.5 3.4 4.0 Rural 3.8 3.6 4.1 4.2 4.6 4.8 4.9 4.1 4.5 Province Nairobi 3.0 3.0 3.2 3.2 3.5 3.8 4.0 3.2 3.8 Central 2.8 2.7 2.9 3.3 3.4 3.9 4.2 3.1 3.4 Coast 4.3 4.0 4.2 4.5 4.9 4.8 6.5 4.5 5.1 Eastern 3.2 2.9 3.4 3.5 4.0 4.1 4.1 3.5 3.5 Nyanza 3.8 3.6 3.8 4.1 4.6 4.8 4.9 4.1 4.2 Rift Valley 3.9 3.6 4.2 4.1 4.3 5.2 5.2 4.1 5.1 Western 3.6 3.6 3.9 4.1 4.7 4.8 4.6 4.0 4.3 North Eastern 9.9 10.9 11.8 11.4 11.9 11.2 * 11.1 10.9 Education No education 7.3 6.7 7.8 6.9 6.7 6.4 5.8 6.7 9.4 Primary incomplete 3.6 3.8 4.2 4.1 4.5 4.9 4.7 4.0 4.5 Primary complete 3.3 3.3 3.4 3.6 4.1 4.1 4.5 3.6 4.1 Secondary+ 2.9 2.8 2.9 3.1 3.4 3.6 3.9 3.1 3.5 Wealth quintile Lowest 4.9 5.1 5.3 5.4 5.6 6.1 6.5 5.4 6.2 Second 3.7 3.8 4.4 4.1 4.8 5.1 5.1 4.3 4.6 Middle 3.7 3.3 3.9 3.9 4.5 4.8 4.3 3.9 4.0 Fourth 3.2 3.2 3.3 3.7 4.0 4.0 4.4 3.5 3.8 Highest 3.0 2.9 3.1 3.2 3.2 3.8 4.1 3.1 3.8 Total 3.6 3.4 3.8 4.0 4.3 4.7 4.8 3.9 4.3 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 110 | Fertility Preferences The data indicate that nearly 20 percent of births in Kenya are unwanted and 25 percent are mis- timed (wanted later). Overall, the proportion of births considered mistimed or unwanted has changed lit- tle, compared with the 1998 KDHS; however, the trends show a sizeable increase in the percentage of births that are unwanted (from 11 to 21 percent, excluding northern districts) and a comparable reduction in those that are mistimed (from 37 to 28 percent).1 The percentage of births considered to have been un- wanted is highest for births of order four and above. Similarly, a larger proportion of births to older women are reported as unwanted, compared with births to young women. Only slightly more than 10 percent of births to women age 20-24 are unwanted, compared with nearly 60 percent among women age 45-49. Table 7.7 presents wanted fertility rates. These rates are calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. Women who did not report a numeric ideal family size were assumed to want all of their births. These rates represent the level of fertil- ity that would have prevailed in the three years preceding the survey if all unwanted births had been pre- vented. A comparison of the total wanted fertility rate and the actual total fertility rate suggests the poten- tial demographic impact of the elimination of unwanted births. The total wanted fertility rate for Kenya is 3.6 (3.5 excluding the northern districts), which is the same as that obtained from the 1998 KDHS. This rate is more than one child less than the actual fertility rate (4.9). The gap between wanted and observed fertility is greatest among poor women, those living in rural areas, and those with less than secondary education. 1 In order to be comparable to the 1998 KDHS, only births in the three years preceding the survey were examined. Table 7.6 Fertility planning status Percent distribution of births in the five years preceding the survey (including current pregnancies), by fertility planning status, according to birth order and mother’s age at birth, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Planning status of birth Birth order –––––––––––––––––––––––––––– Number and mother's Wanted Wanted Wanted of age at birth then later no more Missing Total births –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Birth order 1 61.3 19.9 18.4 0.4 100.0 1,613 2 61.3 28.9 9.8 0.0 100.0 1,334 3 58.9 29.6 11.3 0.2 100.0 1,108 4+ 46.9 24.1 28.6 0.5 100.0 2,686 Age at birth <20 53.2 26.1 20.5 0.2 100.0 1,175 20-24 60.7 27.7 11.3 0.2 100.0 2,103 25-29 59.2 26.9 13.6 0.3 100.0 1,592 30-34 50.4 22.0 27.5 0.0 100.0 1,060 35-39 43.0 18.0 38.2 0.8 100.0 577 40-44 39.8 11.7 46.1 2.4 100.0 210 45-49 37.2 4.2 58.6 0.0 100.0 24 Total 55.2 24.9 19.6 0.3 100.0 6,742 Fertility Preferences | 111 Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––– Total wanted Total Background fertility fertility characteristic rates rate –––––––––––––––––––––––––––––––––––––– Residence Urban 2.6 3.3 Rural 3.9 5.4 Province Nairobi 2.3 2.7 Central 2.8 3.4 Coast 4.3 4.9 Eastern 3.3 4.8 Nyanza 3.8 5.6 Rift Valley 4.1 5.8 Western 4.0 5.8 North Eastern 6.5 7.0 Education No education 5.7 6.7 Primary incomplete 4.2 6.0 Primary complete 3.5 4.8 Secondary+ 2.3 3.2 Wealth quintile Lowest 5.3 7.6 Second 4.1 5.8 Middle 3.9 5.1 Fourth 2.9 4.0 Highest 2.5 3.1 Total 3.6 4.9 –––––––––––––––––––––––––––––––––––––– Note: Rates are calculated on the basis of births to women age 15-49 in the period 1 to 36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. 7.5 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS The ability of women to effectively make decisions has important implications on their fertility preferences and practise of family planning. Table 7.8 shows the ideal family size and unmet need for family planning by some indicators of women status. The table shows that generally, unmet need and ideal family size are related to a woman’s status. For example, mean ideal family size declines as the number of decisions in which a woman has a final say and the number of reasons to refuse sex with the husband increase. Also, women who think that wife-beating is not justified for any reason have a mean ideal family size of 3.8, compared with 4.9 for women who gave five reasons why beating a wife is justi- fied. Women who give no reason to justify wife beating have an overall unmet need of 18 percent, com- pared with 29 percent for those who gave five reasons. Unmet need is also lower among women who par- ticipate in more household decisions. 112 | Fertility Preferences Table 7.8 Ideal number of children and unmet need by women’s status Among currently married women, the mean ideal number of children and unmet need for spacing and limiting, by women’s status indicators, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Unmet need for family planning 2 Mean ideal ––––––––––––––––––––––––––––– Number number of For For of Women’s status indicator children1 Number spacing limiting Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of decisions in which woman has final say3 1-2 4.5 1,433 18.1 9.7 27.8 1,539 3-4 4.0 1,696 13.5 10.8 24.3 1,780 5 4.1 1,143 8.9 10.4 19.3 1,204 Number of reasons to refuse sex with husband 0 5.1 247 13.8 10.2 23.9 287 1-2 4.8 690 13.9 9.7 23.5 754 3-4 4.1 3,688 14.6 10.2 24.7 3,878 Number of reasons wife-beating is justified 0 3.8 1,326 10.1 8.1 18.1 1,408 1-2 4.0 1,458 17.0 10.8 27.7 1,535 3-4 4.7 1,378 15.1 10.6 25.6 1,479 5 4.9 462 16.7 12.4 29.2 497 Total 4.3 4,624 14.4 10.1 24.5 4,919 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Totals are calculated excluding the women giving non-numeric responses. 2 See Table 7.3 for definition of unmet need for family planning. 3 Either by herself or jointly with others Infant and Child Mortality | 113 INFANT AND CHILD MORTALITY 8 Fredrick Otieno and Christopher Omolo This chapter reports information on levels, trends, and differentials in neonatal, postneonatal, in- fant and child mortality. The information is critical for assessment of population and health policies and programmes. Estimates of infant and child mortality are required as an input into population projections, particularly if the level of adult mortality is known from another source or can be inferred with reasonable confidence. Information on mortality of children also serves the needs of health ministries by identifying sectors of the population that are at high risk. Infant and child mortality are also regarded as indices re- flecting the degree of poverty and deprivation of a population. The primary causes of childhood mortality change as children age, from factors related mostly to biological conditions to factors related mostly to their environment. After the neonatal period, postneona- tal and child mortality are caused mainly by childhood diseases and accidents. In this chapter, age- specific mortality rates are defined as follows: Neonatal mortality: the probability of dying within the first month of life Postneonatal mortality: the difference between infant and neonatal mortality Infant mortality: the probability of dying before the first birthday Child mortality: the probability of dying between the first and fifth birthdays Under-five mortality: the probability of dying before the fifth birthday. All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. The data for mortality estimates were collected in the birth history section of the Women’s Ques- tionnaire. The section begins with questions about the aggregate childbearing experience of respondents (i.e., the number of sons and daughters who live with the respondent, those who live elsewhere, and the number who have died). For each of the births, more detailed information was collected on the sex, the month and year of birth, survivorship status, and current age if the child was alive, or age at death if the child had died. The quality of mortality estimates calculated from retrospective birth histories depends upon the completeness with which births and deaths are reported and recorded. Potentially the most serious data quality problem is the selective omission from the birth histories of births who did not survive, which can lead to underestimation of mortality rates. Other potential problems include displacement of birth dates, which may cause a distortion of mortality trends, and misreporting of the age at death, which may distort the age pattern of mortality. When selective omission of childhood deaths occurs, it is usually most severe for deaths in early infancy. If early neonatal deaths are selectively underreported, the result is an unusu- ally low ratio of deaths occurring within seven days to all neonatal deaths, and an unusually low ratio of neonatal to infant deaths. Underreporting of early infant deaths is most commonly observed for births that occurred long before the survey; hence it is useful to examine the ratios over time. An examination of the ratios (see Appendix Tables C.5 and C.6) shows that no significant num- ber of early infant deaths was omitted in the 2003 KDHS. The 2003 proportion of neonatal deaths occur- ring in the first week of life (82 percent) is higher than the proportions recorded in the 1998 KDHS (74 114 | Infant and Child Mortality percent) and the 1993 KDHS (75 percent).1 Moreover, the proportions are roughly constant over the 20 years preceding the survey (between 77 and 83 percent). The proportion of infant deaths that occur during the first month of life is entirely plausible in level (47 percent); it is the same as the proportion recorded in the 1993 KDHS but higher than the proportion recorded in the 1998 KDHS (42 percent). The proportions are also stable over the 20 years preceding the survey (varying between 44 and 47 percent). This inspec- tion of the mortality data reveals no evidence of selective underreporting or misreporting of age at death that would significantly compromise the quality of the KDHS rates of childhood mortality. 8.1 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Table 8.1 shows the variation in neonatal, postneonatal, infant, child, and under-five mortality rates for three successive five-year periods preceding the survey. The use of rates for five-year periods conceals any year-to-year fluctuations in early childhood mortality. For the most recent five-year period preceding the survey, infant mortality is 77 deaths per 1,000 live births, and under-five mortality is 115 deaths per 1,000 live births. This means that one in every nine children born in Kenya dies before attain- ing his or her fifth birthday. The pattern shows that 29 percent of deaths under-age five occur during the neonatal period and 38 percent occur during the postneonatal period. Figure 8.1 shows the infant and under-five mortality rates for each of the three five-year periods preceding the 1998 KDHS and the 2003 KDHS.2 Both infant and under-five mortality rates are increas- ing. The increases are more pronounced during the period between the mid-1980s and mid-1990s, espe- cially from the 1998 KDHS. The subsequent period shows a slowdown in the increases, with the mortal- ity rates nearing stagnation. The results from the 2003 KDHS indicate that under-five mortality has in- creased from 110 deaths per 1,000 live births in the period five to nine years before the survey (i.e., 1993- 1997) to 115 deaths per 1,000 live births for the period zero to four years before the survey (i.e., 1998- 2003). 1 There are no models for mortality patterns during the neonatal period. However, one review of data from several developing countries concluded that, at neonatal mortality levels of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma, 1988). 2 Since the 2003 KDHS covered areas in northern Kenya that were excluded in the prior KDHS surveys, the data were retabulated for 2003, excluding North Eastern Province; Samburu and Turkana districts in Rift Valley Prov- ince; and Isiolo, Moyale, and Marsabit districts in Eastern Province, so as to be comparable with previous KDHS surveys. However, the results were largely identical to the national figures. Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Neonatal Postneonatal Infant Child Under-five Years preceding mortality mortality1 mortality mortality mortality the survey (NN) (PNN) (1q0) (4q1) (5q0) ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 0-4 33 44 77 41 115 5-9 32 41 73 40 110 10-14 31 42 73 35 105 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Computed as the difference between the infant and the neonatal mortality rates Infant and Child Mortality | 115 Figure 8.1 Trends in Infant and Under-Five Mortality 1998 KDHS and 2003 KDHS # ## , ,, # # # , ,, 1985 1990 1995 2000 Calendar year 0 20 40 60 80 100 120 Deaths per 1,000 live births 1998 KDHS Infant 1998 KDHS Under-five 2003 KDHS Infant 2003 KDHS Under-five , # , # Under-five mortality Infant mortality Childhood mortality rates from the 2003 KDHS are comparable with those from the 1999 popula- tion census. The under-five mortality rate based on the 1999 census was estimated at 116 deaths per 1,000 live births for 1989-1999 (Central Bureau of Statistics, 2002c), almost identical to the under-five mortal- ity based on the 2003 KDHS. Similarly, the infant mortality rate of 77 based on the 1999 population cen- sus, is equivalent to the 2003 KDHS estimate of 77 deaths per 1,000 live births (Central Bureau of Statis- tics, 2002c). In interpreting the mortality data, it is useful to keep in mind that sampling errors are quite large. For example, the 95 percent confidence intervals for the under-five mortality estimate of 115 deaths per 1,000 live births are 100 and 129 per 1,000 (Appendix B), indicating that, given the sample size of the 2003 KDHS, the true value may be 15 points higher or lower than the estimated rate of 115 per 1,000. 8.2 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Mortality differentials by place of residence, province, educational level of the mother, and wealth index are presented in Table 8.2 and Figure 8.2. For a sufficient number of births to study mortal- ity differentials across population subgroups, period-specific rates are presented for the ten-year period preceding the survey (mid-1993 to mid-2003). Differentials by place of residence show that the under-five mortality rate is 26 percent higher in rural areas than in urban areas (117 and 93 deaths per 1,000 live births, respectively). The rates by prov- ince display considerable differentials. Except for neonatal mortality, all childhood mortality indicators are highest in Nyanza Province and lowest in Central Province. Under-five mortality is highest in Nyanza Province (206 deaths per 1,000 live births), followed by North Eastern Province (163 per 1,000), and lowest in Central (54 per 1,000) and Rift Valley (77 per 1,000) provinces. This implies that a child born in Nyanza Province is four times more likely than a child born in Central Province to die before celebrat- ing his or her fifth birthday. The same pattern is also observed in infant mortality rates, with the highest rate in Nyanza Province (133 deaths per 1,000 live births) and the lowest in Central Province (44 deaths per 1,000 live births). Rates by province should be interpreted cautiously because of the high level of sampling errors (see Appendix B). 116 | Infant and Child Mortality 115 93 117 95 54 116 84 206 77 144 163 127 145 98 63 KENYA RESIDENCE Urban Rural PROVINCE Nairobi Central Coast Eastern Nyanza Rift Valley Western North Eastern EDUCATION No education Primary incomplete Primary complete Secondary+ 0 20 40 60 80 100 120 140 160 180 200 220 Deaths per 1,000 live births Figure 8.2 Under-Five Mortality by Background Characteristics KDHS 2003 Table 8.2 Early childhood mortality rates by soecioeconomic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Neonatal Postneonatal Infant Child Under-five Background mortality mortality1 mortality mortality mortality characteristic (NN) (PNN) (1q0) (4q1) (5q0) –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 26 36 61 35 93 Rural 34 44 79 41 117 Province Nairobi 32 35 67 30 95 Central 27 17 44 10 54 Coast 45 33 78 41 116 Eastern 32 24 56 29 84 Nyanza 27 106 133 84 206 Rift Valley 37 25 61 17 77 Western 25 54 80 70 144 North Eastern 50 41 91 79 163 Mother’s education No education 43 37 80 51 127 Primary incomplete 35 62 97 54 145 Primary complete 29 40 69 31 98 Secondary + 25 19 44 20 63 Wealth quintile Lowest 38 58 96 59 149 Second 33 42 75 37 109 Middle 35 47 82 43 121 Fourth 30 23 53 26 77 Highest 26 36 62 31 91 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Computed as the difference between the infant and the neonatal mortality rates Infant and Child Mortality | 117 A comparison of the rates from the 2003 KDHS excluding the northern districts, with those from the 1998 KDHS indicates that all provinces have experienced an increase in under-five mortality and, ex- cept for Nyanza Province, an increase in infant mortality. Nyanza Province experienced an increase in postneonatal mortality (from 97 to 106 deaths per 1,000 live births) and a considerable decline in neonatal mortality (from 38 to 27 deaths per 1,000 live births), while Rift Valley Province experienced an increase in neonatal mortality from 28 to 37 deaths per 1,000 births. Neonatal mortality rates are higher than post- neonatal mortality in Central, Coast, Eastern, Rift Valley, and North Eastern provinces. As observed in most studies, the mother’s level of education is strongly linked to child survival. Higher levels of educational attainment are generally associated with lower mortality rates, since educa- tion exposes mothers to information about better nutrition, use of contraceptives to space births, and knowledge about childhood illness and treatment. Children of women with no education are an exception to this pattern, since they experience lower mortality than children of women with incomplete primary education. Larger differences exist between the mortality of children of women who have attained secon- dary education and above and those with primary level of education or less. According to Table 8.2, un- der-five mortality rates of children born to mothers with incomplete primary education are the highest (145 deaths per 1,000 live births), higher than mothers without any education (127 deaths per 1,000 live births). Children whose mothers have at least some secondary education have the lowest under-five mor- tality rates (63 deaths per 1,000 live births). 8.3 DEMOGRAPHIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Childhood mortality rates by sex of child, age of mother at birth, birth order, previous birth inter- val, and birth size are presented in Table 8.3. Differences between the mortality of male and female chil- dren at birth are found in nearly all populations. The results show that female mortality is lower than that of males at all ages up to five years. The relationship between mother’s age at birth and childhood mortality shows the expected U- shaped pattern, with children of the youngest and oldest women experiencing the highest risk of death. Childhood mortality rates are considerably higher among children born to women in their forties and low- est among children whose mothers are age 20–29 years at the time of birth. A similar U-shaped pattern occurs with the birth order of the child, but only for neonatal mortality. After the neonatal period, first- order births show lower mortality risks than births of order two to six. The length of birth interval has a significant impact on a child’s chances of survival, with short birth intervals considerably reducing the chances of survival. As the birth interval gets longer, the mortal- ity risk is reduced considerably. Children born less than two years after a prior sibling suffer substantially higher risks of death than children born after intervals of two or more years. For example, the infant mor- tality rate is 134 deaths per 1,000 live births for children born after an interval of less than two years, compared with a rate of 60 deaths per 1,000 live births for birth intervals of three years. Size of the child at birth also has a bearing on the childhood mortality rates. Children whose birth size is small or very small have a 50 percent greater risk of dying before their first birthday than those whose birth size is average or larger. The birth size of the child appears to affect only the neonatal mortal- ity rate and does not have any effect during the postneonatal period. The same pattern was recorded in the 1998 KDHS. 118 | Infant and Child Mortality 8.4 DIFFERENTIALS IN INFANT AND CHILD MORTALITY BY WOMEN’S STATUS The ability to access information, make decisions, and act effectively in their own interest, or the interest of those who depend on them, is an essential aspect of empowerment of women. It follows that if women, the primary caretakers of children, are empowered, the health and survival status of their infants would be enhanced. In fact, mother’s empowerment fits into Mosley and Chen’s (1984) framework on child survival as an individual-level variable that affects child survival through proximate determinants. Table 8.4 shows information on the impact of women’s status as measured by three specific indicators— participation in household decisionmaking, attitude towards refusing to have sex with husband, and atti- tude towards wife-beating. The data show that women who have no final say in any decision in the household have higher childhood mortality rates than those who have a say in some decisions in the household. For example, the infant mortality rate of children whose mothers have no final say in any decision is 95 deaths per 1,000 live births, compared with 69 deaths per l,000 live births for those who participate in five decisions in the household. There is no consistent pattern in mortality rates by the number of reasons to justify a wife’s refusing to have sex with her husband. As expected, rates of childhood mortality increase with the number of reasons a woman mentions as justifying wife-beating. The under-five mortality rate is 42 percent higher among women who cite 5 reasons to justify wife beating than among those with no reasons. Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by demographic characteristic, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Neonatal Postneonatal Infant Child Under-five Demographic mortality mortality1 mortality mortality mortality characteristic (NN) (PNN) (1q0) (4q1) (5q0) ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Child’s sex Male 36 47 84 42 122 Female 29 38 67 39 103 Mother's age at birth <20 34 45 79 41 117 20-29 31 40 71 36 104 30-39 32 45 76 46 119 40-49 (75) 57 132 (89) 209 Birth order 1 35 27 62 29 90 2-3 28 42 69 34 101 4-6 28 48 77 42 116 7+ 51 61 112 73 176 Previous birth interval2 <2 57 77 134 56 182 2 years 22 40 62 49 108 3 years 28 32 60 38 95 4+ years 21 38 59 25 83 Birth size3 Small/very small 63 40 103 na na Average or larger 26 43 68 na na ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Rates based on 250 to 499 exposed persons are in parentheses. na =Not applicable 1 Computed as the difference between the infant and the neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period preceding the survey Infant and Child Mortality | 119 8.5 PERINATAL MORTALITY Pregnancy losses occurring after seven completed months of gestation (stillbirths) plus deaths to live births within the first seven days of life (early neonatal deaths) constitute perinatal deaths. When the total number of perinatal deaths is divided by the total number of pregnancies reaching seven months ges- tation, the perinatal mortality rate is derived. The distinction between a stillbirth and an early neonatal death may be a fine one, depending often on the observed presence or absence of some faint signs of life after delivery. The causes of stillbirths and early neonatal deaths are overlapping, and examining just one or the other can understate the true level of mortality around delivery. Table 8.5 presents the number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey by place of residence, by province, and for selected demographic and socioeconomic characteristics. The results indicate that the perinatal mortality rate is 40 deaths per 1,000 pregnancies. Pregnancies with an interpregnancy interval of less than 15 months have a higher perinatal risk (102 deaths per 1,000 pregnancies) than all other pregnancies. There are no apparent rural and urban differences in perinatal mortality rates, which contradicts the findings in the previous section that showed that neonatal mortality is higher in rural areas than in ur- ban areas. There are, however, considerable differences in perinatal mortality by province. Coast Province has the highest perinatal mortality rate (57 deaths per 1,000) and Western Province has the lowest rate (28 deaths per 1,000). Perinatal mortality rates according to educational attainment show that women with no education experience higher rates (54 deaths per 1,000) than those with primary (37 deaths per 1,000) or at least some secondary (39 deaths per 1,000) education. Surprisingly, the relationship between perinatal mortality and the wealth index is positive; that is mortality increases with wealth. Table 8.4 Early childhood mortality rates by women’s status Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by women’s status indicators, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Neonatal Postneonatal Infant Child Under-five Women’s status mortality mortality1 mortality mortality mortality indicators (NN) (PNN) (1q0) (4q1) (5q0) –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of decisions in which woman has final say2 0 39 56 95 38 129 1-2 33 45 78 42 117 3-4 33 41 73 35 105 5 30 38 69 45 110 Number of reasons to refuse sex with husband 0 50 39 89 30 116 1-2 35 39 74 38 109 3-4 31 44 75 42 113 Number of reasons wife- beating is justified 0 33 29 61 29 89 1-2 34 48 81 38 116 3-4 32 48 80 48 124 5 35 43 78 53 126 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Computed as the difference between the infant and the neonatal mortality rates 2 Either by herself or jointly with others 120 | Infant and Child Mortality Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five- year period preceding the survey, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number Perinatal Number of Number of early mortality rate pregnancies of Background of neonatal (per 1,000 7+ months characteristic stillbirths1 deaths2 pregnancies) duration3 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Mother’s age at birth <20 11 31 38 1,081 20-29 43 85 38 3,366 30-39 23 36 39 1,523 40-49 7 13 * 217 Previous pregnancy interval in months First pregnancy 17 42 41 1,460 <15 8 28 102 355 15-26 20 36 39 1,439 27-38 14 30 31 1,393 39+ 25 28 35 1,539 Residence Urban 20 27 40 1,162 Rural 64 138 40 5,024 Province Nairobi 7 13 49 405 Central 11 13 35 663 Coast 7 23 57 517 Eastern 13 26 41 959 Nyanza 20 19 38 1,020 Rift Valley 13 56 41 1,651 Western 11 11 28 787 North Eastern 3 5 45 184 Education No education 17 35 54 955 Primary incomplete 31 53 37 2,254 Primary complete 21 42 37 1,699 Secondary + 15 35 39 1,278 Wealth index Lowest 6 48 36 1,516 Second 16 28 34 1,287 Middle 29 22 43 1,188 Fourth 13 35 46 1,045 Highest 20 33 46 1,151 Total 84 165 40 6,186 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a rate is based on fewer than 250 pregnancies and has been suppressed. 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months' duration. Infant and Child Mortality | 121 8.6 HIGH-RISK FERTILITY BEHAVIOUR Numerous studies have found a strong relationship between children’s chances of dying and cer- tain fertility behaviours. Typically, the probability of dying in early childhood is much greater if children are born to mothers who are too young or too old, if they are born after a short birth interval, or if they are born to mothers with high parity. Very young mothers may experience difficult pregnancies and deliver- ies because of their physical immaturity. Older women may also experience age-related problems during pregnancy and delivery. For purposes of this analysis, a mother is classified as “too young” if she is less than 18 years of age and “too old” if she is over 34 years of age at the time of delivery; a “short birth in- terval” is defined as a birth occurring within 24 months of a previous birth; and a “high-order” birth is one occurring after three or more previous births (i.e., birth order four or higher). First-order births may be at increased risk of dying, relative to births of other orders; however, this distinction is not included in the risk categories in the table because it is not considered avoidable fertility behaviour. Also, for the short birth interval category, only children with a preceding interval of less than 24 months are included. Short succeeding birth intervals are not included, even though they can influence the survivorship of a child, because of the problem of reverse causal effect (i.e., a short succeeding birth interval can be the result of the death of a child rather than being the cause of the death of a child). Table 8.6 presents the distribution of children born in the five years preceding the survey by these categories of increased risk of mortality. Column 2 shows the percentage of children falling into specific categories. Column 3 shows the risk ratio of mortality for children by comparing the proportion dead among children in each high-risk category with the proportion dead among children not in any high-risk category (i.e., those whose mothers were age 18-34 at delivery, who were born 24 or more months after the previous birth, or who are of birth order two or three). Fifty-six percent of children in Kenya fall into a high-risk category, with 38 percent in a single high-risk category and 19 percent in a multiple high-risk category. High risks are associated with birth intervals of less than 24 months, births to mothers older than 34 years, and births to mothers younger than 18 years under the single high-risk category. In general, risk ratios are higher for children in a multiple high-risk category than for children in a single high-risk category. The highest risk (3.0) is associated with fourth and higher births that occur less than 24 months after a previous birth to mothers who are over age 34 years; however, only 2 percent of births fall into this multiple high-risk category. Seven percent of births in Kenya occur after a short birth interval to mothers who have had three or more births, with these children twice as likely to die in early childhood as children who are not in any high-risk category. The last column of Table 8.6 addresses the question of what percentage of currently married women have the potential for a high-risk birth. This was obtained by simulating the distribution of cur- rently married women by the risk category in which a birth would fall if a woman were to conceive at the time of the survey. Although many women are protected from conception because of use of family plan- ning, postpartum insusceptibility, and prolonged abstinence, for simplicity only those who have been ster- ilised are included in the “not in any high-risk category.” Overall, 73 percent of currently married women have the potential for having a high-risk birth, with 30 percent falling into a single high-risk category and 43 percent into a multiple high-risk category. 122 | Infant and Child Mortality Table 8.6 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently mar- ried women by category of risk if they were to conceive a child at the time of the survey, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Births in the 5 years Percentage preceding the survey of –––––––––––––––––––– currently Percentage Risk married Risk category of births ratio women1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Not in any high-risk category 25.8 1.00 22.1a Unavoidable risk category First-order births between ages 18 and 34 years 18.0 0.89 5.1 Single high-risk category Mother’s age <18 6.5 1.60 0.7 Mother’s age >34 0.7 1.80 3.2 Birth interval <24 months 8.4 1.84 10.3 Birth order >3 22.1 1.12 15.7 Subtotal 37.6 1.38 29.9 Multiple high-risk category Age <18 and birth interval <24 months2 0.4 2.49 0.3 Age >34 and birth interval <24 months 0.0 na 0.1 Age >34 and birth order >3 9.6 1.47 25.8 Age >34 and birth interval <24 months and birth order >3 2.0 3.04 4.3 Birth interval <24 months and birth order >3 6.7 2.15 12.5 Subtotal 18.6 1.90 42.9 In any avoidable high-risk category 56.2 1.55 72.8 Total 100.0 na 100.0 Number of births 6,102 na 4,919 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age younger than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilised women Maternal and Child Health | 123 MATERNAL AND CHILD HEALTH 9 George Kichamu, Jones N. Abisi, and Lydia Karimurio This chapter presents findings from key areas in maternal and child health namely, antenatal, postnatal and delivery care, childhood vaccination and common childhood illnesses and their treatment. One of the priorities of the Ministry of Health in Kenya is the provision of medical care and counselling services during pregnancy and at delivery that impact the survival of both the mother and infant. The 2003 KDHS results provide an evaluation of the utilisation of these health services, as well as information useful in assessing the need for service expansion. The information can be used to identify women whose babies are at risk due to non-use of maternal health services. The findings are also valuable to policy makers and programme implementers in strengthening implementation of programmes and activities to improve maternal and child care services. The results in the following sections are based on data collected from mothers about live births that occurred in the five years preceding the survey. 9.1 ANTENATAL CARE Antenatal Care Coverage Table 9.1 shows the percent distribution of women who had a live birth in the five years preced- ing the survey by the type of antenatal care provider for the most recent birth. Interviewers recorded all persons a woman may have seen for care, but in the table, only the provider with the highest qualification is considered (if more than one person was seen). The data indicate that 88 percent of women in Kenya receive antenatal care from a medical pro- fessional, either from doctors (18 percent) or nurses or midwives (70 percent). A small fraction (2 per- cent) receives antenatal care from traditional birth attendants, while 10 percent do not receive any antena- tal care. The 2003 data indicate a slight decline since 1998 in medical antenatal care coverage. In the 1998 KDHS, the questions on antenatal care were asked only of women who had a birth in the three years be- fore the survey. Moreover, the sample excluded the entire North Eastern Province and five other northern districts. Examining trends shows that the proportion of women who had antenatal care from a trained medical provider for their most recent birth in the three years before the survey declined very slightly from 92 to 90 percent (data not shown). Moreover, there has been a shift away from doctors (28 percent in 1998 versus 19 percent in 2003) towards nurses and midwives (64 percent in 1998 versus 71 percent in 2003). Examination of differentials in antenatal care in Table 9.1 shows that the mother’s age at birth and the child’s birth order are not strongly related to use of antenatal care. However, higher parity women are more likely than lower parity women to see no one for antenatal care. Rural women are less likely than their urban counterparts to get antenatal care from a doctor and more likely to get no care at all. There are marked regional variations in antenatal care coverage, with over two-thirds of women in North Eastern Province not getting any antenatal care at all. Women in Western Province have low use of doc- tors for antenatal care compared to nurses, while for Coast Province the reverse is true. 124 | Maternal and Child Health Women’s education is associated with antenatal care coverage. Women with higher education are much more likely to have received care from a medical doctor than those with no education (24 percent versus 15 percent), while the proportion of women who get no antenatal care declines steadily as education increases. Source of Antenatal Care Table 9.2 shows the types of places where women say they obtained antenatal care. Since women can obtain care from several sources, multiple answers were allowed. The vast majority of women who obtained antenatal care went to government sources (71 percent), while private medical sources were only reported by 28 percent of women. The most common sources of antenatal care are government health Table 9.1 Antenatal care Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth, according to background characteris- tics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Traditional birth Number Background Nurse/ attendant/ No of characteristic Doctor midwife other one Missing Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age at birth <20 15.1 69.2 3.9 11.5 0.3 100.0 647 20-34 19.7 70.5 1.2 8.1 0.6 100.0 2,821 35-49 12.5 69.9 2.4 14.4 0.7 100.0 584 Birth order 1 17.7 72.2 1.7 7.9 0.5 100.0 946 2-3 20.4 70.9 1.5 6.9 0.3 100.0 1,404 4-5 18.5 70.2 1.1 8.7 1.4 100.0 842 6+ 13.5 66.8 2.8 16.5 0.4 100.0 859 Residence Urban 22.5 70.7 1.0 5.4 0.3 100.0 835 Rural 16.7 70.1 2.0 10.6 0.6 100.0 3,217 Province Nairobi 28.7 66.7 0.5 3.8 0.3 100.0 307 Central 21.1 71.8 0.4 6.3 0.4 100.0 495 Coast 35.2 52.3 1.2 11.3 0.0 100.0 336 Eastern 11.4 80.2 0.7 7.4 0.3 100.0 646 Nyanza 14.7 70.6 5.0 9.1 0.6 100.0 643 Rift Valley 19.3 69.0 0.9 9.6 1.2 100.0 1,052 Western 7.1 84.0 2.5 6.1 0.3 100.0 470 North Eastern 10.1 15.1 6.5 68.3 0.0 100.0 102 Education No education 14.6 53.6 3.4 27.7 0.7 100.0 582 Primary incomplete 16.0 71.7 2.3 9.4 0.7 100.0 1,395 Primary complete 16.7 74.5 1.5 6.5 0.8 100.0 1,143 Secondary + 24.4 73.1 0.3 2.2 0.0 100.0 932 Wealth quintile Lowest 15.6 59.5 4.2 19.9 0.8 100.0 869 Second 16.4 71.0 2.3 9.8 0.5 100.0 830 Middle 17.3 75.1 0.7 6.5 0.3 100.0 777 Higher 14.8 78.2 0.7 5.6 0.8 100.0 725 Highest 24.9 69.0 0.6 4.9 0.5 100.0 851 Total 17.9 70.2 1.8 9.6 0.6 100.0 4,052 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. Maternal and Child Health | 125 centres and government hospitals. The public-private distribution of sources is similar for urban and rural women; however, urban women are more likely to go to government hospitals and private hospitals and clinics than rural women, who are more likely to visit government dispensaries and Mission hospitals and clinics. Women in Nairobi use private sources more than women in other provinces, while women in Cen- tral and Coast Provinces are most likely to use public (government) sources for antenatal care. Twenty- two percent of women in North Eastern Province reported having received antenatal care at home, and very few used the private sector for this service. Number and Timing of Antenatal Care Visits Health professionals and providers recommend that the first antenatal visit should occur within the first trimester of pregnancy and continue on a monthly basis through the 28th week of pregnancy and fortnightly up to the 36th week or until birth. This implies that 12-13 visits should be made during the entire pregnancy. Antenatal care can be more effective in preventing adverse pregnancy outcomes when it is sought early in pregnancy and continues through to delivery. Table 9.3 provides information on the number of antenatal care visits and the timing of the first visit. Early detection of problems in pregnancy leads to more timely referrals in case of women in higher- risk categories or complications; this is particularly true in Kenya, where 80 percent of the population lives in rural areas and where physical barriers pose a challenge to health care delivery. In Kenya, slightly over half (52 percent) of all women make four or more antenatal visits. In addi- tion, 36 percent of mothers make fewer than four visits, far below the recommended number of 12. Two- thirds of urban women (67 percent) make four or more antenatal care visits, compared to less than half of rural women (49 percent). Moreover, women do not receive antenatal care early in the pregnancy. Only 11 percent of women obtain antenatal care in the first trimester of pregnancy and less than half have received care be- fore the sixth month of pregnancy. Overall, the median number of months of pregnancy at first visit is 5.9. Table 9.2 Source of antenatal care Percentage of women who had a live birth in the five years preceding the survey and who received antenatal care for the most recent birth, by place(s) antenatal care was received, according to residence and province, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Province ––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Rift North Source of antenatal care Urban Rural Nairobi Central Coast Eastern Nyanza Valley Western Eastern Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Home 1.4 3.4 0.5 0.0 1.8 0.8 6.1 0.9 10.2 21.6 3.0 Public sector 70.9 71.1 64.8 81.7 81.9 72.5 65.8 65.4 73.5 77.7 71.1 Government hospital 32.9 20.4 12.7 33.1 24.0 26.0 18.9 22.0 20.8 55.2 23.1 Government health centre 30.3 26.7 41.9 27.0 29.3 18.1 29.6 24.9 33.5 12.8 27.5 Government dispensary 7.2 24.5 9.0 22.0 29.6 27.8 18.6 18.8 19.4 9.7 20.7 Other public 0.7 0.5 1.4 1.0 0.2 0.7 0.3 0.3 0.1 0.0 0.5 Private medical sector 28.4 27.8 34.6 18.6 19.2 27.4 30.5 34.6 24.1 0.7 27.9 Mission hospital/clinic 8.0 16.8 6.8 8.0 5.2 18.4 18.6 19.7 14.9 0.0 14.9 Private hospital/clinic 19.4 10.6 26.8 9.8 13.4 8.2 10.9 14.7 9.3 0.7 12.5 Nursing/maternity home 1.0 0.3 0.9 1.0 0.6 0.2 0.7 0.1 0.2 0.0 0.4 Other private medical 0.6 0.3 0.5 0.0 0.0 0.8 0.6 0.2 0.0 0.0 0.3 Other 0.3 0.3 0.5 0.0 0.2 0.2 0.2 0.1 1.2 0.0 0.3 Number of women 787 2,855 294 462 298 596 581 938 440 32 3,642 126 | Maternal and Child Health Comparing trends since the 1998 KDHS requires re-tabulating both sets of data to reflect infor- mation on the most recent birth in the three years prior to the survey to women who live in the southern half of the country. That analysis shows a decline in the proportion of women who have four or more an- tenatal visits, from 60 percent in 1998 to 54 percent in 2003. Overall, there has been less change in the pattern of antenatal attendance by gestational age. The median gestational age at first visit has increased slightly from 5.7 months in the 1998 KDHS to 5.9 in the 2003 survey. This calls for programme interven- tions that will encourage more women to attend antenatal clinics in the first trimester of pregnancy. Components of Antenatal Care Pregnancy complications are an important cause of maternal and child morbidity and mortality. Consequently, informing women about the danger signs associated with pregnancy and the actions they should take in case complications arise, are important elements of antenatal care services. In the 2003 KDHS, women who had a live birth in the five years before the survey were asked about antenatal care services, including whether they were told about the signs of pregnancy complications, whether they were weighed, whether their height and blood pressure were measured, whether urine and blood samples were taken, and whether they were given any information or counseled about HIV/AIDS or about breastfeed- ing.1 1 They were also asked whether they took iron supplements (see Chapter 10) and antimalarial drugs (see Chapter 11) during the pregnancy. Table 9.3 Number of antenatal care visits and timing of first visit Percent distribution of women who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent birth, and by the timing of the first visit according to resi- dence, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Number and timing –––––––––––––––– of ANC visits Urban Rural Total –––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of ANC visits None 5.4 10.6 9.6 1 2.5 4.7 4.2 2-3 22.1 33.7 31.3 4+ 66.7 48.6 52.3 Don't know/missing 3.3 2.5 2.6 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 5.4 10.6 9.6 <4 15.8 9.9 11.1 4-5 38.4 36.3 36.7 6-7 36.2 37.3 37.1 8+ 3.3 5.3 4.9 Don't know/missing 0.9 0.6 0.7 Total 100.0 100.0 100.0 Median months pregnant at first visit (for those with ANC) 5.7 5.9 5.9 Number of women 835 3,217 4,052 Maternal and Child Health | 127 Table 9.4 shows that among women who had a birth in the five years preceding the survey, only 36 percent who received antenatal care for the most recent birth reported that they had been informed about pregnancy complications. Urban women and those with more education are more likely to have been told about pregnancy complications than rural or uneducated women. Similarly, the likelihood of a woman being told about pregnancy complications declines as parity increases. Women in the highest wealth quintile are twice as likely to receive information on pregnancy complications than those in the lowest quintile. As concerns antenatal tests and examinations, 92 percent of pregnant women said they were weighed, 28 percent had their heights measured, and 83 percent had their blood pressure measured. Half of the women had a urine sample taken, while 58 percent had a blood sample taken. Thirty-three percent of pregnant women said they were given information or counseled about HIV/AIDS during an antenatal care visit, while 39 percent were given information or counselling about breastfeeding. Table 9.4 Components of antenatal care Percentage of women with a live birth in the five years preceding the survey who received antenatal care for the most recent birth, by content of antenatal care, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Among women who received antenatal care –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Informed Given of signs of information pregnancy Blood Urine Blood Given on Number Background compli- Weight Height pressure sample sample information breast- of characteristic cations measured measured measured taken taken on AIDS feeding women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age at birth <20 32.4 88.1 29.8 78.6 45.3 56.4 27.7 34.9 570 20-34 37.6 92.4 27.1 84.0 51.3 58.6 33.7 39.5 2,575 35-49 32.5 91.3 27.0 86.0 50.8 56.0 34.1 41.1 496 Birth order 1 40.9 91.2 29.9 84.3 56.8 66.6 35.4 41.7 867 2-3 38.0 92.4 28.3 83.2 50.9 57.5 32.7 38.7 1,304 4-5 33.1 93.0 24.4 84.2 47.9 55.7 34.6 40.7 757 6+ 30.0 89.1 26.5 82.0 43.7 50.4 28.0 34.3 714 Residence Urban 53.3 96.0 42.6 94.8 71.1 83.3 42.5 49.7 787 Rural 31.3 90.4 23.4 80.3 44.6 50.9 30.2 36.0 2,855 Province Nairobi 58.7 96.5 51.3 94.7 67.5 85.4 49.6 53.6 294 Central 39.5 92.2 22.1 92.8 60.2 71.1 41.4 45.6 462 Coast 39.4 91.2 28.2 86.6 78.6 80.1 29.6 31.2 298 Eastern 35.3 92.3 28.5 75.9 46.1 49.9 33.8 37.3 596 Nyanza 30.1 89.5 21.5 75.7 35.0 42.1 27.0 31.8 581 Rift Valley 29.5 91.8 26.5 85.2 47.5 55.9 27.2 39.4 938 Western 39.4 91.0 23.9 82.5 40.4 46.0 33.5 40.1 440 North Eastern 18.6 64.7 52.2 57.9 58.3 63.2 26.5 17.2 32 Education No education 21.5 85.5 31.6 77.2 45.8 48.1 23.0 25.3 417 Primary incomplete 29.4 89.5 22.8 77.4 39.1 48.2 26.0 31.2 1,255 Primary complete 38.9 93.5 26.4 85.6 51.3 61.9 35.9 39.9 1,059 Secondary + 48.6 95.0 33.5 92.1 66.7 71.0 43.2 55.0 911 Wealth quintile Lowest 24.5 88.7 22.8 73.9 35.9 42.1 24.0 30.7 690 Second 32.7 90.7 22.4 77.2 39.5 44.1 29.6 36.5 745 Middle 30.4 89.4 21.0 80.5 43.2 50.9 29.8 34.2 724 Fourth 36.1 92.4 26.5 89.3 58.0 66.0 34.3 40.8 678 Highest 54.1 96.2 42.9 95.0 72.4 83.7 44.8 51.2 805 Total 36.1 91.6 27.5 83.4 50.3 57.9 32.8 39.0 3,642 128 | Maternal and Child Health The socio-economic characteristics that appear to influence the content of antenatal care include residence, wealth, and level of education. Women in urban areas are more likely to receive all the speci- fied components of antenatal care than rural women. Similarly, women with more education and those higher on the wealth index are more likely to receive most of the components of ANC compared to less educated and poorer women. In general, women in Nairobi who receive antenatal care are the most likely and those in North Eastern Province are the least likely to have received the stated services. This is not the case for height measurement and urine and blood samples, which pregnant women in North Eastern who receive antenatal care are not the least likely to receive. Tetanus Toxoid Immunisation Tetanus toxoid injections are given during pregnancy for the prevention of neonatal tetanus, his- torically one of the principal causes of death among infants in many developing countries. To achieve protection for herself and her newborn baby, typically, a pregnant woman will receive at least two doses of tetanus toxoid. On the other hand, if a woman has been fully vaccinated during a previous pregnancy, she may only require one dose during her current pregnancy to achieve such protection. Five doses are considered adequate to provide lifetime protection. In order to estimate the extent of tetanus toxoid cover- age during pregnancy, the 2003 KDHS collected data on the number of tetanus injections women received during pregnancy for the most recent birth in the five years preceding the survey. These results are pre- sented in Table 9.5. The data may underestimate the actual extent of protection against tetanus, since women who had received prior vaccinations may not have received additional injections, as they were considered unnecessary. The data indicate that 52 percent of mothers received two or more doses of tetanus toxoid during pregnancy, while 34 percent received one dose. The remaining 14 percent of mothers did not receive any tetanus injection. Lower parity births and those occurring in urban areas are more likely to have been pro- tected by tetanus vaccination than higher parity and rural births. Similarly, births to wealthier and more educated women are more likely to be protected than those to poorer and less educated women. Coverage with two doses of tetanus toxoid ranges from a low of 18 percent of women in North Eastern Province to 62 percent of those in Central Province. There has been little change in the proportion of women receiving tetanus toxoid injections dur- ing pregnancy. The proportion of women (excluding those in the northern areas) who received two or more tetanus injections during the pregnancy that resulted in their most recent birth in the three years be- fore the survey increased from 51 percent in 1998 to 54 percent in 2003; however, the proportion who did not receive any tetanus injection at all also increased from 10 to 13 percent (data not shown). Maternal and Child Health | 129 9.2 DELIVERY CARE Place of Delivery The objective of providing safe delivery services is to protect the life and health of the mother and her child. An important component of efforts to reduce the health risk to mothers and children is to increase the proportion of babies delivered under the supervision of health professionals. Proper medical attention under hygienic conditions during delivery can reduce the risk of complications and infections that may cause death or serious illness either to the mother, baby or both. In the 2003 KDHS, women were asked where they delivered their children born in the five years preceding the survey (Table 9.6 and Figure 9.1). Table 9.5 Tetanus toxoid injections Percent distribution of women who had a live birth in the five years preceding the survey by number of tetanus toxoid injections received during pregnancy for the most recent birth, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Two Don’t Number Background One or more know/ of characteristic None injection injections missing Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age at birth <20 19.1 30.0 50.2 0.8 100.0 647 20-34 11.2 34.5 53.5 0.8 100.0 2,821 35-49 20.2 32.6 46.2 1.0 100.0 584 Birth order 1 13.9 27.7 57.2 1.2 100.0 946 2-3 10.0 34.8 54.4 0.8 100.0 1,404 4-5 12.6 35.0 51.8 0.7 100.0 842 6+ 20.7 36.3 42.3 0.7 100.0 859 Residence Urban 8.4 32.6 57.2 1.8 100.0 835 Rural 15.1 33.7 50.6 0.6 100.0 3,217 Province Nairobi 8.5 33.4 55.3 2.8 100.0 307 Central 7.8 29.4 61.7 1.1 100.0 495 Coast 15.9 28.9 54.6 0.6 100.0 336 Eastern 12.4 30.5 56.6 0.5 100.0 646 Nyanza 16.2 40.4 42.7 0.8 100.0 643 Rift Valley 13.5 33.3 52.2 0.9 100.0 1,052 Western 9.6 39.7 50.6 0.1 100.0 470 North Eastern 64.6 17.3 18.1 0.0 100.0 102 Education No education 30.4 28.7 40.3 0.6 100.0 582 Primary incomplete 15.0 36.2 48.2 0.6 100.0 1,395 Primary complete 11.0 34.6 53.5 0.9 100.0 1,143 Secondary + 4.8 31.1 63.0 1.1 100.0 932 Wealth quintile Lowest 28.0 32.7 38.7 0.5 100.0 869 Second 12.3 35.4 52.2 0.1 100.0 830 Middle 10.3 33.1 55.8 0.8 100.0 777 Fourth 8.8 36.1 54.1 1.0 100.0 725 Highest 7.9 30.6 59.9 1.7 100.0 851 Total 13.7 33.5 51.9 0.8 100.0 4,052 130 | Maternal and Child Health Table 9.6 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery, according to back- ground characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Health facility ––––––––––––––––– Number Background Public Private of characteristic sector sector Home Other Missing Total births –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Mother's age at birth <20 32.4 13.3 53.6 0.6 0.2 100.0 1,070 20-34 26.0 14.8 58.2 0.8 0.2 100.0 4,287 35-49 17.7 10.3 69.4 1.6 1.0 100.0 745 Birth order 1 39.8 19.2 40.2 0.4 0.3 100.0 1,469 2-3 26.5 15.6 56.8 0.9 0.1 100.0 2,177 4-5 21.7 11.4 65.9 0.9 0.2 100.0 1,215 6+ 13.6 7.4 77.0 1.2 0.8 100.0 1,240 Residence Urban 44.9 25.3 29.2 0.4 0.2 100.0 1,143 Rural 21.8 11.4 65.5 0.9 0.3 100.0 4,959 Province Nairobi 38.2 39.7 21.5 0.5 0.1 100.0 398 Central 50.3 16.6 31.9 1.1 0.0 100.0 652 Coast 23.7 7.5 67.4 0.8 0.6 100.0 510 Eastern 26.4 11.3 60.8 1.4 0.1 100.0 946 Nyanza 22.1 14.1 62.6 0.9 0.4 100.0 1,000 Rift Valley 23.1 12.8 63.0 0.7 0.4 100.0 1,639 Western 16.8 11.6 70.6 0.6 0.4 100.0 776 North Eastern 7.4 0.3 91.9 0.0 0.4 100.0 181 Mother's education No education 7.8 6.4 83.9 1.0 0.8 100.0 938 Primary incomplete 19.6 9.9 69.2 0.9 0.4 100.0 2,222 Primary complete 33.4 12.6 52.9 1.0 0.1 100.0 1,678 Secondary + 41.4 28.7 29.5 0.3 0.1 100.0 1,263 Antenatal care visits1 None 6.8 3.4 89.1 0.7 0.0 100.0 387 1-3 21.8 13.5 63.9 0.8 0.0 100.0 1,438 4+ 35.0 18.9 45.2 0.8 0.0 100.0 2,119 Don't know/missing 26.9 20.3 45.9 1.7 5.2 100.0 107 Wealth quintile Lowest 9.2 6.8 82.9 0.6 0.5 100.0 1,509 Second 19.1 12.3 66.7 1.6 0.3 100.0 1,271 Middle 27.8 8.7 62.3 1.0 0.2 100.0 1,159 Fourth 38.5 14.7 45.8 0.7 0.3 100.0 1,032 Highest 43.5 30.3 25.8 0.2 0.2 100.0 1,131 Total 26.1 14.0 58.7 0.8 0.3 100.0 6,102 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes only the most recent birth in the five years preceding the survey Maternal and Child Health | 131 Figure 9.1 Antenatal Care, Tetanus Vaccinations, Place of Delivery, and Delivery Assistance KDHS 2003 18 70 2 10 14 34 52 40 59 11 30 28 22 8 ANTENATAL CARE Doctor Nurse/midwife TBA No one TETANUS VACCINATION None One Two or more PLACE OF DELIVERY Health facility Home DELIVERY ASSISTANCE Doctor Nurse/midwife TBA Relative/other No one 0 20 40 60 80 Percent TBA = Traditional birth attendant Two out of five births (40 percent) in Kenya are delivered in a health facility, while 59 percent are delivered at home. Births to older women and births of higher order are more likely to occur at home. Similarly, rural children are twice as likely to be born at home than urban children. The proportion of children born at home decreases with increasing education and wealth quintile of the mother. For exam- ple, 84 percent of children whose mothers have no education are born at home, compared with 30 percent of those whose mothers have some secondary education. Similarly, children whose mothers had more antenatal care visits during the pregnancy are less likely to deliver at home. Births at home are substan- tially lower among women who live in Nairobi or Central Provinces and extremely high (92 percent) for those in the North Eastern Province. There has been no change since 1998 in the proportion of births occurring at home. Excluding the northern areas and analysing births in the three years prior to the surveys in order to maintain comparabil- ity, the proportion of births occurring at home has remained steady at 57 percent. Assistance at Delivery The type of assistance a woman receives during birth has important health consequences for both the mother and the child. Women interviewed in the 2003 KDHS were asked who assisted with the deliv- ery of their children born in the five years preceding the survey. Interviewers were able to record multiple responses if more than one person assisted during delivery; however, for the purpose of this tabulation, only the most highly qualified attendant was considered if there were more than one response. Table 9.7 shows that 42 percent of births in Kenya are delivered under the supervision of a health professional, mainly a nurse or midwife. Traditional birth attendants continue to play a vital role in deliv- ery, assisting with 28 percent of births. Relatives and friends assist in 22 percent of births. Maternal age and child’s birth order are associated with the type of assistance at delivery. Births to older women and those of higher birth order are more likely to occur with no assistance, compared to births to younger women and those of lower birth order. 132 | Maternal and Child Health As expected, births in urban areas and those whose mothers have more education or are in wealthier quintiles are more likely to be assisted by medical personnel than those whose mothers are ru- ral, have less education, or are in poorer wealth quintiles. Regional differentials in type of assistance at delivery are also pronounced, with North Eastern Province recording the lowest proportion (9 percent) of births assisted by medical professionals, followed by Western Province (29 percent). Nairobi has the highest proportion of births assisted by medical personnel (79 percent). The proportion of births assisted by medically trained personnel has remained constant since 1998, at 44 percent, considering births in the three years prior to the survey and excluding those in the northern areas of the country. Table 9.7 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during deliv- ery, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Traditional Don’t Number Background Nurse/ birth Relative/ know/ of characteristic Doctor midwife attendant friend No one missing Total births ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Mother's age at birth <20 13.8 33.2 29.5 18.8 4.4 0.2 100.0 1,070 20-34 11.4 30.9 27.3 23.0 7.1 0.3 100.0 4,287 35-49 7.7 21.7 29.8 21.5 18.4 1.0 100.0 745 Birth order 1 18.8 41.5 21.6 15.6 2.0 0.4 100.0 1,469 2-3 11.0 32.8 26.4 23.6 6.0 0.1 100.0 2,177 4-5 9.0 25.2 30.2 24.8 10.7 0.2 100.0 1,215 6+ 5.7 16.9 36.3 24.3 15.9 0.9 100.0 1,240 Residence Urban 24.0 48.0 12.5 11.1 4.2 0.1 100.0 1,143 Rural 8.5 26.0 31.6 24.6 8.9 0.4 100.0 4,959 Province Nairobi 33.8 45.2 9.4 7.8 3.6 0.1 100.0 398 Central 17.9 50.0 4.9 19.3 7.5 0.3 100.0 652 Coast 12.2 21.6 28.0 32.1 5.7 0.4 100.0 510 Eastern 9.0 29.6 25.5 28.4 7.5 0.0 100.0 946 Nyanza 5.8 32.8 33.1 18.0 9.8 0.4 100.0 1,000 Rift Valley 12.1 25.2 27.6 25.8 8.8 0.5 100.0 1,639 Western 4.9 24.5 41.6 18.1 10.6 0.4 100.0 776 North Eastern 1.5 7.0 82.8 7.9 0.2 0.6 100.0 181 Mother's education No education 3.3 12.5 47.0 23.4 13.0 0.8 100.0 938 Primary incomplete 8.0 22.5 31.7 27.7 9.6 0.5 100.0 2,222 Primary complete 12.2 35.5 24.1 21.6 6.5 0.1 100.0 1,678 Secondary + 22.3 49.7 12.7 11.7 3.4 0.1 100.0 1,263 Wealth quintile Lowest 4.0 13.0 48.2 23.9 10.3 0.6 100.0 1,509 Second 7.8 25.0 28.1 27.3 11.4 0.4 100.0 1,271 Middle 7.4 30.8 27.5 26.7 7.5 0.2 100.0 1,159 Fourth 13.4 41.5 17.2 21.3 6.1 0.4 100.0 1,032 Highest 27.5 47.9 11.4 9.6 3.5 0.1 100.0 1,131 Total 11.4 30.2 28.0 22.1 8.0 0.3 100.0 6,102 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Maternal and Child Health | 133 Delivery Characteristics The 2003 KDHS obtained information on a number of aspects of deliveries, including the fre- quency of caesarean sections and low-birth-weight babies. The caesarean section rate is sometimes con- sidered to be a proxy indicator of women’s access to care for complicated deliveries. Table 9.8 shows that only 4 percent of live births in Kenya are delivered by caesarean section. Caesarean section is slightly more common among first births (7 percent), births to urban women (9 per- cent), births in Nairobi (10 percent), births to mothers with some secondary education (10 percent) and births to women in the highest wealth quintile (11 percent). Table 9.8 Delivery characteristics Percentage of live births in the five years preceding the survey delivered by caesarean section, and percent distribution by birth weight and by mother's estimate of baby's size at birth, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Birth weight Size of child at birth –––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––– Delivery Less 2.5 kg Don’t Smaller Average Don't Number Background by C- Not than or know/ Very than or know/ of characteristic section weighed 2.5 kg more missing Total small average larger missing Total births ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Mother's age at birth <20 4.3 51.6 4.4 41.6 2.4 100.0 4.5 13.0 82.2 0.3 100.0 1,070 20-34 4.1 53.6 3.2 41.9 1.3 100.0 3.3 12.7 83.4 0.6 100.0 4,287 35-49 3.1 64.2 3.6 29.9 2.3 100.0 5.1 10.9 82.6 1.4 100.0 745 Birth order 1 6.7 38.2 5.6 54.0 2.2 100.0 4.1 13.6 81.7 0.5 100.0 1,469 2-3 4.6 52.9 3.5 42.2 1.4 100.0 3.3 12.3 83.9 0.5 100.0 2,177 4-5 2.5 58.7 2.2 38.5 0.6 100.0 3.5 12.0 83.9 0.6 100.0 1,215 6+ 1.4 72.6 2.1 23.0 2.3 100.0 4.1 12.2 82.6 1.0 100.0 1,240 Residence Urban 9.4 23.8 5.8 68.4 2.1 100.0 5.0 9.6 84.6 0.8 100.0 1,143 Rural 2.8 61.6 2.9 33.9 1.5 100.0 3.4 13.2 82.7 0.6 100.0 4,959 Province Nairobi 10.3 17.8 4.8 76.1 1.3 100.0 5.4 8.7 85.0 1.0 100.0 398 Central 6.2 26.2 4.7 68.7 0.4 100.0 3.2 11.9 84.5 0.4 100.0 652 Coast 4.3 50.5 5.8 41.4 2.3 100.0 5.5 12.3 81.6 0.6 100.0 510 Eastern 4.2 58.1 4.4 36.1 1.4 100.0 3.1 15.3 81.1 0.5 100.0 946 Nyanza 1.9 63.2 2.4 32.7 1.7 100.0 2.0 10.8 86.7 0.5 100.0 1,000 Rift Valley 3.8 57.8 2.6 37.7 1.9 100.0 4.3 13.0 81.9 0.9 100.0 1,639 Western 2.2 69.3 2.8 26.4 1.5 100.0 3.0 13.6 83.0 0.4 100.0 776 North Eastern 2.5 88.4 1.2 7.0 3.4 100.0 7.6 11.4 79.8 1.2 100.0 181 Mother's education No education 1.8 75.1 2.2 19.6 3.0 100.0 6.8 15.7 76.1 1.5 100.0 938 Primary incomplete 2.1 65.8 3.1 29.7 1.4 100.0 3.6 12.5 83.3 0.7 100.0 2,222 Primary complete 3.7 48.1 3.2 47.3 1.4 100.0 2.7 12.5 84.4 0.4 100.0 1,678 Secondary + 9.5 28.0 5.4 65.5 1.2 100.0 3.1 10.4 86.2 0.2 100.0 1,263 Wealth quintile Lowest 1.2 78.8 2.0 17.9 1.3 100.0 3.8 15.0 80.4 0.8 100.0 1,509 Second 3.0 65.2 2.4 31.3 1.1 100.0 3.0 12.9 83.6 0.5 100.0 1,271 Middle 2.6 55.8 3.2 39.3 1.7 100.0 3.4 12.0 84.0 0.6 100.0 1,159 Fourth 3.2 41.0 5.2 51.3 2.4 100.0 4.2 14.1 81.1 0.6 100.0 1,032 Highest 11.2 21.3 5.2 71.8 1.7 100.0 4.3 8.1 86.9 0.7 100.0 1,131 Total 4.0 54.5 3.5 40.4 1.6 100.0 3.7 12.5 83.1 0.6 100.0 6,102 134 | Maternal and Child Health Considering trends, the caesarean section rate has declined since 1998. Among births in the three years prior to the survey to women living in the southern part of the country, the proportion delivered by caesarean section declined from 7 percent in 1998 to 4 percent in 2003. Information was also collected on the baby’s birth weight and size, because low birth weight is associated with higher neonatal morbidity and mortality. To obtain the birth weight data, mothers were asked whether their baby was weighed at birth, and if so, how much the baby weighed. Two and a half kilograms or more is considered normal birth weight and babies weighing less than that are regarded as small or low birth weight. Because most women do not deliver in a health facility, the mothers were also asked whether the baby was very large, larger than average, average, smaller than average or very small at birth. The data in Table 9.8 show that more than half (55 percent) of babies are not weighed at birth, presumably in part because of the low percentage of deliveries occurring in health facilities. Four percent of all births (8 percent of those who were weighed) are underweight. A large majority of babies (83 per- cent) are considered by their mothers to be of average or larger weight; 13 percent are considered to be smaller than average and 4 percent are considered very small. Socioeconomic differentials in child’s birth weight are not large. However, children whose moth- ers have no education are more likely to be smaller than average or very small than children whose moth- ers have at least some education. Similarly, there is a decrease in the proportion of babies considered to be smaller than average or very small as the wealth quintile of the mother increases. 9.3 POSTNATAL CARE Postnatal care is important for mothers for treatment of complications arising from delivery, es- pecially for births that occur at home. For non-institutional births particularly, postnatal care enables de- tection of complications that may threaten the survival of the mother. The timing of postnatal care is im- portant. To provide the best outcome possible, it should occur within two days of the delivery since this is the critical period when most maternal deaths occur. In the 2003 KDHS, to assess the extent of postnatal care utilisation, women whose last birth was delivered outside a health facility were asked whether they received a postnatal check up from a health professional or a traditional birth attendant. It is assumed that deliveries in any health facility will entail a postnatal check before the mother is discharged. Table 9.9 shows the percent distribution of women whose last birth in the five years preceding the survey occurred outside a health facility by timing of postnatal care. The table shows that 81 percent of women who deliver outside a health facility do not receive postnatal care. Only 10 percent attend postna- tal care within two days of delivery, while 2 percent get care three to six days after delivery and 7 percent get a checkup seven to 41 days after delivery. Women with at least some secondary education and those in the highest wealth quintile are more likely to utilise postnatal services than other women. There are marked provincial differentials in postnatal care coverage. Nyanza Province shows the highest proportion of women with non-institutional births obtaining postnatal care within two days of the birth (20 percent), compared with North Eastern (1 percent) and Eastern (4 percent) Provinces. Maternal and Child Health | 135 9.4 REPRODUCTIVE HEALTH CARE AND WOMEN’S STATUS Table 9.10 shows how antenatal, delivery and postnatal care coverage differ according to certain measures of women’s status. The table shows only a very slight positive correlation between the number of household decisions in which a woman participates and all three variables: the proportion of women who receive antenatal care from a medical professional, the proportion who receive postnatal care within two days of delivery, and the proportion who receive delivery assistance from a doctor, nurse, or midwife. Table 9.9 Postnatal care by background characteristics Percent distribution of women who had a noninstitutional live birth in the five years preceding the survey by timing of postnatal care for the most recent noninstitutional birth, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Timing of first postnatal checkup –––––––––––––––––––––––––––––––––––––– Within Did not 2 days 3-6 days 7-41 days Don't receive Number Background of after after know/ postnatal of characteristic delivery delivery delivery missing checkup1 Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age at birth <20 11.6 3.2 6.2 0.5 78.5 100.0 319 20-34 9.4 2.4 6.7 0.2 81.4 100.0 1,582 35-49 11.2 1.7 6.7 0.0 80.4 100.0 409 Birth order 1 11.4 2.5 8.2 0.1 77.7 100.0 331 2-3 10.3 2.2 7.0 0.5 79.9 100.0 766 4-5 9.1 2.7 4.6 0.0 83.6 100.0 539 6+ 9.7 2.2 7.1 0.0 81.0 100.0 674 Residence Urban 9.3 3.9 7.9 0.0 78.9 100.0 225 Rural 10.1 2.2 6.5 0.2 81.0 100.0 2,086 Province Nairobi 8.3 4.9 10.7 0.0 76.0 100.0 59 Central 7.9 2.3 10.8 0.0 78.9 100.0 159 Coast 6.1 2.5 7.0 0.2 84.1 100.0 222 Eastern 3.5 0.4 4.2 0.3 91.6 100.0 380 Nyanza 20.4 3.5 8.9 0.0 67.3 100.0 411 Rift Valley 9.8 2.2 6.3 0.2 81.5 100.0 650 Western 11.4 3.3 5.7 0.3 79.3 100.0 336 North Eastern 1.4 1.2 2.3 0.0 95.1 100.0 94 Education No education 4.8 1.7 6.5 0.3 86.8 100.0 496 Primary incomplete 10.4 3.5 5.0 0.0 81.1 100.0 967 Primary complete 10.1 1.3 8.9 0.4 79.2 100.0 584 Secondary + 18.1 1.9 8.1 0.0 71.8 100.0 263 Wealth quintile Lowest 10.1 2.8 5.5 0.3 81.3 100.0 729 Second 8.4 2.7 6.2 0.0 82.8 100.0 569 Middle 10.0 1.4 6.5 0.0 82.1 100.0 483 Fourth 9.1 1.2 9.5 0.5 79.8 100.0 331 Highest 16.0 4.4 7.9 0.0 71.8 100.0 198 Total 10.0 2.4 6.6 0.2 80.8 100.0 2,310 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes women who received the first postnatal checkup after 41 days 136 | Maternal and Child Health The number of reasons for which women feel that a wife is justified in refusing to have sex with her husband has a stronger positive relationship with all three variables. For example, the proportion of women who receive postnatal care within two days of delivery increases from 37 percent among women who think a wife is not justified in refusing to have sex with her husband for any of the specified reasons to 51 percent of those who said three or four reasons cited were justifiable. Similarly, there is a mostly steady decline in all three of the reproductive health indicators as the number of reasons for which women believe wife beating is justified increases. Among women who say wife beating is not justified under any of the situations described, 55 percent of their births are attended by medical professionals. This compares to only 30 percent of births to women who say that wife beating is justified in all five of the cited circumstances. 9.5 VACCINATION OF CHILDREN To assess the Kenya Expanded Programme of Immunisation (KEPI), the 2003 KDHS collected information on vaccination coverage for all children who were born in the five years preceding the sur- vey; however, the focus of the data presented here is on children age 12-23 months at the time of the sur- vey, since they are the age group that should be fully immunised. The KEPI largely follows the World Health Organisation’s (WHO) guidelines for vaccinating children. These guidelines stipulate that for a Table 9.10 Reproductive health care by women’s status Percentage of women with a live birth in the five years preceding the survey who received antenatal and postnatal care from a health professional for the most recent birth, and percentage of births in the five years preceding the survey for which mothers received professional delivery care, by women's status indicators, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Percentage Percentage of of women of women births for which who received who received mothers received antenatal care postnatal delivery care from a doctor, care within from a doctor, nurse, or first two days Number nurse, or Number Women’s status indicator midwife of delivery1 of women midwife of births ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of decisions in which woman has final say2 0 83.0 48.2 503 42.7 716 1-2 86.8 41.7 1,307 35.2 2,073 3-4 91.1 52.9 1,255 44.7 1,880 5 88.7 52.9 986 46.1 1,433 Number of reasons to refuse sex with husband 0 78.4 37.2 248 34.1 374 1-2 85.3 42.5 603 35.3 926 3-4 89.4 50.7 3,201 43.3 4,802 Number of reasons wife beating is justified 0 89.9 59.0 1,090 54.6 1,523 1-2 90.1 50.0 1,303 41.6 1,978 3-4 85.3 41.8 1,221 35.2 1,908 5 85.3 38.2 438 30.1 692 Total 88.1 48.7 4,052 41.6 6,102 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes mothers who delivered in a health facility 2 Either by herself or jointly with others Maternal and Child Health | 137 child to be considered fully vaccinated, he/she should receive the following vaccinations: one dose of BCG, three doses each of DPT/HepatitisB/Influenza2 and polio, and one dose of measles. BCG should be given at birth or first clinic contact and protects against tuberculosis. DPT-HepB- Hib protects against diptheria, pertussis, tetanus, Hepatitis B and Haemophilus influenza. DPT-HepB-Hib and polio require three vaccinations at approximately 6, 10 and 14 weeks of age; measles should be given at or soon after reaching 9 months of age. The government of Kenya has adopted the WHO goal to ensure completion of vaccinations by 12 months of age; the target is to fully vaccinate 80 percent of children in 80 percent of districts by that age by the year 2005. Information presented in Table 9.11 was collected in two ways: from vaccination cards (under- five cards) seen by the interviewer and from mothers’ verbal reports if the card was not available. Health facilities and clinics in Kenya routinely provide cards on which vaccinations and other important health indicators are recorded. If a mother presented such a card to the interviewer, it was used as the source of information by directly transferring dates of vaccination to the questionnaire. Besides collecting vaccination information from cards, there were two ways of collecting information from the mother herself. If a card was pre- sented, but a vaccine was not recorded as having been given, then the mother was asked to recall whether that particular vaccine had been given. In the event that the mother was not able to present a card for a child at all, she was asked to recall whether or not the child had received BCG, DPT-HepB-Hib and polio (including the number of doses for each), and measles vaccination. Table 9.11 presents information on vaccination coverage, according to the sources of information. The data presented are for children aged 12-23 months, thereby including only those children who have reached the age by which they should be fully vaccinated. Vaccination cards were available for 60 percent of the children. 2 In 2001, the government adopted the DPT-HepB-Hib, (pentavalent) vaccine in place of DPT alone. Table 9.11 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of children who received: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– DPT-HepB-Hib Polio1 No Number –––––––––––––––– ––––––––––––––––––––––– vacci- of Source of information BCG 1 2 3 0 1 2 3 Measles All2 nations children ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Vaccinated at any time before the survey Vaccination card 57.0 59.3 57.1 52.6 43.5 59.3 57.2 52.2 46.4 42.5 0.0 678 Mother's report 30.3 29.9 26.8 19.6 5.9 31.7 28.3 20.3 26.1 14.4 7.4 453 Either source 87.3 89.2 83.9 72.2 49.4 91.0 85.5 72.5 72.5 56.8 7.4 1,131 Vaccinated by 12 months of age3 87.0 88.2 83.0 70.5 49.1 89.6 84.1 70.3 62.8 48.7 8.1 1,131 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Polio 0 is the polio vaccination given at birth. The data on polio vaccinations is adjusted for a likely misinterpretation of polio 0 and polio 1; for children who received three doses of DPT-HepB-Hib and polio 0, polio 1, and polio 2, it was assumed that polio 0 was in fact polio 1, polio 1 was polio 2, and polio 2 was polio 3. 2 BCG, measles, and three doses each of DPT-HepB-Hib and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. 138 | Maternal and Child Health According to information from both the vaccination card and the mothers’ reports, 87 percent of children 12-23 months have received BCG, 89 percent have received the first dose of DPT-HepB-Hib, while 91 percent have received the first dose of polio.3 Coverage declines for subsequent doses of DPT- HepB-Hib and polio, so that only 72 percent and 73 percent of children receive the third doses of these vaccines, respectively (Figure 9.2). These figures represent a drop out rate of 19 percent for DPT-HepB- Hib and 20 percent for polio. Overall, 57 percent of children are considered fully immunised. Seven per- cent of children have not received any of the recommended immunisations. Figure 9.2 Percentage of Children Age 12-23 Months with Specific Vaccinations According to Health Cards and Mother’s Reports 87 89 84 72 91 86 73 73 57 7 BCG 1 2 3 1 2 3 Measles All None 0 20 40 60 80 100 KDHS 2003 DPT Polio Vaccinations are most effective when given at the proper age; thus it is recommended that chil- dren complete the schedule of immunisations during their first year of life, i.e. by 12 months of age. Overall, 49 percent of children age 12-23 months had all the recommended vaccinations before their first birthday. Table 9.12 presents vaccination coverage (according to card information and mothers’ reports) among children age 12-23 months by selected background characteristics. The table shows that 60 percent of mothers of children age 12-23 months presented a vaccination card. There is no marked difference in vaccination status by sex of the child. Birth order, however is related to immunisation coverage, with first born children more likely to be fully vaccinated than those of sixth or higher birth order (66 percent com- pared to 42 percent, respectively). Full vaccination coverage among urban children (59 percent) is only slightly higher than among rural children (56 percent). 3 Data for polio vaccinations were adjusted for a likely underreporting. It appeared that for some children who did not receive polio at birth, interviewers may have mistakenly written the date polio 1 was given in the space for re- cording the date of polio 0. To correct for any such errors, the total number of doses of DPT and polio was checked, since the two vaccines are usually given at the same time. For children reported as having received all three doses of DPT and polio 0, polio 1, and polio 2 only, it was assumed that polio 0 was in fact polio 1, polio 1 was in fact polio 2, and polio 2 was in fact polio 3. Maternal and Child Health | 139 Provincial variation in vaccination coverage needs to be interpreted with caution since the num- bers of observation in which the estimates are based are, in some cases small. However, some important differences are apparent. The highest proportion of children fully vaccinated is in Central Province (79 percent), followed by Coast Province with 66 percent. North Eastern Province has the lowest proportion of children fully immunised—9 percent. Table 9.12 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report, and percentage with a vaccination card, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of children who received: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage DPT-HepB-Hib Polio1 No with a Number Background ––––––––––––––– ––––––––––––––––––––––– vacci- vaccina- of characteristic BCG 1 2 3 0 1 2 3 Measles All2 nations tion card children ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Sex Male 86.6 88.6 83.2 71.0 49.4 90.7 85.3 71.6 72.9 56.4 7.7 58.3 570 Female 88.1 89.8 84.7 73.3 49.4 91.2 85.7 73.5 72.1 57.2 7.0 61.6 561 Birth order 1 92.2 92.6 90.3 77.3 59.7 93.1 90.6 77.7 81.1 65.6 5.1 62.8 276 2-3 90.9 92.5 85.5 73.1 51.8 93.8 87.5 71.9 76.9 57.4 4.8 62.5 397 4-5 86.6 89.1 86.4 75.0 49.1 89.8 87.5 74.7 71.3 58.8 8.1 60.9 243 6+ 75.3 79.0 69.9 60.6 32.1 84.1 72.8 64.6 54.7 42.1 14.2 50.3 214 Residence Urban 95.9 93.7 88.0 68.7 55.4 95.2 89.7 69.0 85.9 58.7 3.0 48.2 199 Rural 85.5 88.3 83.1 72.9 48.2 90.1 84.6 73.3 69.7 56.4 8.3 62.4 932 Province Nairobi 97.6 97.6 88.8 73.6 59.1 98.4 96.5 73.8 87.6 63.1 0.7 49.9 60 Central 97.9 96.3 95.0 87.5 66.2 96.3 94.2 88.5 90.0 78.5 2.1 64.9 125 Coast 88.8 95.4 88.9 76.7 53.0 95.4 91.1 83.1 79.4 65.8 4.6 70.7 104 Eastern 85.4 95.7 93.9 87.1 54.6 94.9 93.1 84.7 74.1 65.0 4.3 77.6 188 Nyanza 76.0 74.0 65.0 54.6 35.5 80.6 71.0 51.4 48.2 37.6 18.3 39.6 142 Rift Valley 90.4 88.8 85.0 70.3 54.0 90.8 85.6 70.4 74.4 55.5 6.8 58.9 326 Western 90.6 92.2 83.0 66.7 33.9 93.7 83.3 70.1 70.9 50.0 3.9 59.7 157 North Eastern 29.7 39.7 27.4 25.0 10.9 47.8 34.9 23.1 37.4 8.8 45.7 18.4 28 Education No education 61.6 69.1 59.6 51.9 27.2 73.5 63.0 50.7 51.1 33.6 23.9 45.9 163 Primary incomplete 90.1 91.1 84.5 70.9 47.0 92.4 86.3 71.0 66.6 53.8 5.8 65.8 398 Primary complete 91.7 93.5 89.4 76.5 55.5 93.9 90.5 78.6 81.3 61.8 3.8 61.9 329 Secondary + 94.2 93.9 91.9 82.0 60.1 96.4 92.5 81.5 84.9 70.6 3.6 57.1 241 Wealth quintile Lowest 70.0 74.3 65.7 56.5 33.7 79.1 69.5 58.1 54.8 40.0 18.5 55.1 286 Second 88.7 93.2 85.5 71.2 48.1 93.3 87.9 72.6 68.1 53.3 5.1 66.2 232 Middle 93.0 93.5 91.6 85.8 53.8 95.3 91.2 84.7 79.3 69.3 4.1 64.3 220 Fourth 95.7 95.8 94.1 80.7 61.1 95.2 93.0 79.9 80.3 63.7 2.0 64.5 193 Highest 96.2 94.9 89.9 72.4 57.5 96.3 91.9 72.5 88.0 64.5 2.9 50.4 201 Total 87.3 89.2 83.9 72.2 49.4 91.0 85.5 72.5 72.5 56.8 7.4 59.9 1,131 Excluding north 2003 89.3 91.0 86.0 74.2 50.6 92.3 87.7 76.2 74.4 60.1 6.1 61.1 1,075 1998 95.9 95.8 90.0 79.2 u 95.4 90.4 80.8 79.2 65.4 2.7 55.4 1,097 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– u = Unknown (not available) 1 Polio 0 is the polio vaccination given at birth. The data on polio vaccinations is adjusted for a likely misinterpretation of polio 0 and polio 1; for children who received three doses of DPT-HepB-Hib and polio 0, polio 1, and polio 2, it was assumed that polio 0 was in fact polio 1, polio 1 was polio 2, and polio 2 was polio 3. 2 BCG, measles, and three doses each of DPT-HepB-Hib and polio vaccine (excluding polio vaccine given at birth) 140 | Maternal and Child Health Education of the mother is associated with higher chances of their children having been fully vac- cinated; 71 percent of children whose mothers had at least some secondary education are fully vaccinated as opposed to 34 percent of children whose mothers had no schooling. Table 9.12 also shows that children in the middle wealth quintile are the most likely to be fully vaccinated (69 percent), compared with those in the lowest quintile (40 percent). Table 9.12 provides some comparable data from the 1998 KDHS, as well as data from the 2003 KDHS excluding the northern half of the country so as to be comparable to the 1998 KDHS. The result of this comparison indicates a worsening picture in the fight against vaccine-preventable diseases in Kenya. Full coverage has fallen from 65 percent to 60 percent. BCG coverage has declined from 96 percent to 89 percent, while measles coverage has declined from 79 percent to 74 percent. Failure to complete the DPT- HepB-Hib and polio series as described above has resulted in a decline of coverage from 79 to 74 percent for DPT-HepB-Hib and from 81 to 76 percent for polio. 9.6 ACUTE RESPIRATORY INFECTION AND FEVER Medical records show that pneumonia is among the top three causes of hospital admissions and among the top five causes of infant and under five mortality in Kenya. The Kenya Government adopted the Integrated Management of Childhood Illness (IMCI) strategy in 1998. However, implementation be- gan much later, in November 2000, when the first national capacity-building training was conducted. Dis- trict level implementation began in three districts (Kajiado, Embu, and Vihiga). To date, 18 districts are implementing the strategy in some health facilities. The aim is to achieve a level of 60 percent of health workers trained. The strategy’s core interventions are integrated management of the five most important causes of death among children under five, namely: acute respiratory infection (ARI), diarrhoea, measles, malaria, and malnutrion and anaemia. One of the IMCI approaches to combating ARI is to treat cases of ARI early before complications develop. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths due to pneumonia. Emphasis is therefore placed on early recognition of signs of impending severity, both by mothers and primary health care workers so that help can be sought. It should be noted that prevalence of ARI as measured by the 2003 KDHS is based on mothers’ subjective assessment of the child’s symptoms, i.e., whether the child has been ill with a cough accompa- nied by short, rapid breathing in the two weeks preceding the survey. These signs are compatible with pneumonia. It should, however, be noted that morbidity data collected in surveys are subjective, i.e. mother’s perception of illness, unvalidated by medical examination. Malaria is endemic in most parts of Kenya and is also a common cause of hospital admission for all age groups. To assess the prevalence of malaria, whose major manifestation is fever, mothers were asked whether their children under age five had a fever in the two weeks preceding the survey. Whereas fever is the primary symptom of malaria, fever can also be a symptom of a large variety of diseases, in- cluding pneumonia, common colds/coughs and flu, etc. However, according to malaria guidelines, if fever is present, and the malaria risk in the area is high, a diagnosis of malaria is made and treated accordingly. Table 9.13 shows that 18 percent of children under five were ill with a cough and rapid breathing during the two weeks preceding the survey. The reported prevalence of symptoms suggestive of pneumo- nia peaks at age 6-11 months. ARI prevalence is slightly higher in rural areas (19 percent), compared to urban areas (16 per- cent). Provincial differentials are large, with Western Province having the highest level (30 percent) and North Eastern Province the lowest level (10 percent). ARI prevalence is lower for children whose mothers have some secondary education. Maternal and Child Health | 141 Table 9.13 Prevalence and treatment of symptoms of ARI and fever Percentage of children under five years who had a cough accompanied by short, rapid breathing (symptoms of ARI) and percentage of children who had fever in the two weeks preceding the survey, and percentage of children with symptoms of ARI and/or fever for whom treatment was sought from a health facility or pro- vider, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Among children with symptoms of ARI and/or fever, percentage Percentage for whom of children Percentage treatment was with of children Number sought from a Number Background symptoms with of health facility/ of characteristic of ARI fever children provider1 children ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 18.5 37.0 619 46.4 259 6-11 25.9 53.9 630 53.7 371 12-23 19.5 48.3 1,131 48.2 592 24-35 17.3 40.4 1,031 46.5 465 36-47 16.8 35.5 1,123 39.4 444 48-59 15.3 31.7 1,026 38.2 366 Sex Male 18.7 40.9 2,797 46.0 1,258 Female 18.1 40.2 2,762 45.0 1,239 Residence Urban 16.4 39.8 1,063 53.6 461 Rural 18.9 40.8 4,497 43.6 2,035 Province Nairobi 16.4 38.5 369 56.3 160 Central 19.6 48.9 622 45.9 314 Coast 15.9 40.7 467 58.3 209 Eastern 13.8 27.1 883 53.3 288 Nyanza 20.3 48.0 832 40.5 443 Rift Valley 16.5 35.8 1,532 47.1 614 Western 29.7 57.2 691 34.2 427 North Eastern 10.2 22.9 163 26.7 41 Education No education 17.6 33.3 852 46.2 320 Primary incomplete 21.2 43.2 1,980 45.9 950 Primary complete 18.9 41.2 1,539 42.9 703 Secondary + 13.7 40.5 1,189 47.8 524 Wealth quintile Lowest 18.0 37.5 1,343 41.7 568 Second 22.8 43.6 1,159 40.8 565 Middle 17.5 42.0 1,054 43.5 491 Fourth 17.5 41.1 957 49.5 423 Highest 15.7 39.3 1,046 54.6 450 Total 18.4 40.6 5,560 45.5 2,496 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ARI = Acute respiratory infection 1 Excludes pharmacy, shop, and traditional practitioner 142 | Maternal and Child Health Table 9.13 shows that 41 percent of children under five were reported to have had fever in the two weeks preceding the survey. Fever is more common among children aged 6-11 months (54 percent) and decreases with age, the lowest prevalence being at age 48-59 months (32 percent). Prevalence of fe- ver is similar in the different sexes, residence groups, and education of the mother. Regional differentials show that the proportion of children with fever was highest in Western Province (57 percent) and lowest in North Eastern Province (23 percent). Forty-six percent of children with symptoms of ARI and/or fever were taken to a health facility or provider for treatment. Younger children and urban children with ARI and/or fever are more likely to have been taken to a health facility/provider than older children and those from rural areas. 9.7 DIARRHOEAL DISEASE Poor hygiene, which includes poor faecal matter disposal, contributes to the spread of disease, es- pecially diarrhoea. In Kenya, most communities have believed that young children’s faecal matter is safe, consequently, not much effort is made to ensure safe disposal. Table 9.14 shows that the most commonly used method of disposal of young children’s stools is throwing them into a toilet or latrine (42 percent). Other methods of disposal include rinsing stools away (15 percent) and throwing them either outside the yard or outside the dwelling. A closer look at the table shows marked differentials by province in the disposal of faecal matter. In North Eastern Province, only 13 percent of mothers throw their child’s faecal matter into a latrine, while 64 percent either throw it outside the dwelling or outside the yard. Data for Western Province show that in 71 percent of cases disposal is by the child using a toilet, or faecal matter is thrown into the toilet. Use of diapers is highest in Central Province. Uneducated women are less likely to use toilets or latrines for faecal disposal, compared with more educated women (25 versus 68 percent). As expected, mothers who have no toilet facilities in their household are much less likely to dispose of their children’s stools in toilets. Maternal and Child Health | 143 Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among chil- dren in Kenya. In the 2003 KDHS, women with children under age five were asked if the youngest child had diarrhoea in the two weeks preceding the survey. Table 9.15 presents the prevalence of diarrhoea among children under five. Sixteen percent of children had experienced diarrhoea in the two weeks pre- ceding the survey. Diarrhoea prevalence increases with age to peak at 6-11 months (29 percent), then falls at older ages. There are only small variations in the prevalence of diarrhoea by sex, residence, and wealth quin- tile. Central Province has a considerably lower prevalence of diarrhoea (7 percent) than other provinces. Diarrhoea is less common among children whose mothers have some secondary education than those whose mothers have less education. Diarrhoea seems less common among children drinking rain water or bottled water than those drinking water from other sources, though the percentage is based on a small sample size. Table 9.14 Disposal of children’s stools Percent distribution of mothers whose youngest child under five years is living with her by way in which child's faecal matter is disposed of, ac- cording to background characteristics and type of toilet facilities in household, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Stools contained ––––––––––––––––––––––– Child Stools uncontained Uses diapers always Thrown –––––––––––––––––––––––––––––––––– ––––––––––––––– uses into Buried Thrown Thrown Not Dis- Number Background toilet/ toilet/ in outside outside Rinsed disposed pos- Wash- of characteristic latrine latrine yard dwelling yard away of able able Missing Total mothers –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 12.7 49.1 1.1 1.4 3.0 16.4 0.4 1.6 14.1 0.3 100.0 742 Rural 12.1 40.0 5.2 3.9 14.0 14.4 1.9 0.3 8.0 0.2 100.0 3,017 Province Nairobi 11.5 48.7 0.3 0.5 2.9 20.8 0.4 2.5 12.5 0.0 100.0 268 Central 19.1 37.7 2.1 0.0 0.4 14.2 0.5 0.8 25.3 0.0 100.0 468 Coast 11.6 30.7 10.7 4.0 28.6 7.2 0.6 0.5 5.6 0.3 100.0 309 Eastern 18.6 45.5 3.4 1.3 9.4 11.2 1.4 0.0 9.0 0.2 100.0 618 Nyanza 5.5 49.7 12.8 4.0 11.0 11.0 1.3 0.0 4.7 0.0 100.0 576 Rift Valley 9.0 34.8 0.7 5.9 17.3 20.1 3.6 0.9 7.3 0.3 100.0 984 Western 15.6 55.6 2.4 1.1 3.7 16.1 0.3 0.0 4.9 0.3 100.0 442 North Eastern 0.0 13.0 9.8 21.8 42.3 10.9 2.0 0.0 0.0 0.3 100.0 93 Education No education 5.0 19.8 6.9 12.1 38.6 8.6 3.5 0.4 4.8 0.2 100.0 548 Primary incomplete 12.1 40.4 5.7 2.6 12.5 17.1 1.9 0.5 6.9 0.3 100.0 1,280 Primary complete 12.2 47.5 4.0 2.1 5.1 14.8 1.2 0.4 12.5 0.1 100.0 1,053 Secondary + 16.9 50.7 1.4 0.7 2.3 15.2 0.3 0.9 11.4 0.0 100.0 878 Toilet facilities None 3.4 3.5 13.3 12.8 47.0 12.3 4.0 0.0 3.2 0.4 100.0 761 Pit latrine 14.0 51.3 2.5 1.2 3.3 15.7 1.1 0.5 10.2 0.2 100.0 2,422 Improved latrine 18.3 54.5 0.6 0.8 2.1 11.9 0.5 0.3 10.8 0.1 100.0 259 Flush toilet 15.7 51.2 0.2 0.0 0.1 15.8 0.0 2.2 14.9 0.0 100.0 306 Wealth quintile Lowest 5.9 22.7 8.8 9.6 31.4 15.8 2.6 0.2 2.8 0.2 100.0 818 Second 11.6 45.6 4.2 3.1 13.0 14.3 2.2 0.2 5.4 0.3 100.0 788 Middle 15.2 46.7 4.6 1.7 7.6 13.6 1.4 0.2 8.7 0.1 100.0 727 Fourth 15.7 44.5 3.4 1.0 3.4 13.3 1.3 1.2 15.9 0.2 100.0 681 Highest 13.8 51.4 0.4 0.8 1.0 16.7 0.3 1.0 14.6 0.0 100.0 745 Total 12.2 41.8 4.4 3.4 11.8 14.8 1.6 0.6 9.2 0.2 100.0 3,759 144 | Maternal and Child Health Table 9.15 Prevalence of diarrhoea Percentage of children under five years with diarrhoea in the two weeks preceding the survey, by background char- acteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––– Diarrhoea in the two weeks Number Background preceding of characteristic the survey children –––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 14.2 619 6-11 28.6 630 12-23 26.1 1,131 24-35 16.2 1,031 36-47 8.0 1,123 48-59 6.7 1,026 Sex Male 17.5 2,797 Female 14.5 2,762 Residence Urban 17.0 1,063 Rural 15.8 4,497 Province Nairobi 13.9 369 Central 7.0 622 Coast 21.9 467 Eastern 12.6 883 Nyanza 17.2 832 Rift Valley 16.7 1,532 Western 23.1 691 North Eastern 12.9 163 Mother's education No education 17.2 852 Primary incomplete 19.7 1,980 Primary complete 15.3 1,539 Secondary + 9.9 1,189 Source of drinking water Piped 15.4 1,415 Protected well 17.3 634 Open well 18.0 449 Surface 15.7 2,706 Rainwater/bottled water 4.9 85 Other/missing 18.8 271 Wealth quintile Lowest 18.2 1,343 Second 17.5 1,159 Middle 15.0 1,054 Fourth 13.0 957 Highest 15.2 1,046 Total 16.0 5,560 Maternal and Child Health | 145 Table 9.16 Knowledge of ORS packets Percentage of mothers with births in the five years preceding the survey who know about ORS packets for treatment of diarrhoea, by background character- istics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––– Percentage of mothers who know Number Background about ORS of characteristic packets mothers –––––––––––––––––––––––––––––––––––––––––– Age 15-19 48.5 343 20-24 65.1 1,084 25-29 74.9 1,052 30-34 77.6 743 35-49 77.6 829 Residence Urban 78.8 835 Rural 69.1 3,217 Province Nairobi 76.6 307 Central 68.4 495 Coast 81.4 336 Eastern 65.2 646 Nyanza 78.4 643 Rift Valley 69.9 1,052 Western 63.7 470 North Eastern 73.3 102 Education No education 65.0 582 Primary incomplete 65.9 1,395 Primary complete 73.1 1,143 Secondary + 80.2 932 Wealth quintile Lowest 70.4 869 Second 67.1 830 Middle 69.9 777 Fourth 70.7 725 Highest 77.3 851 Total 71.1 4,052 A simple and effective response to a child’s dehydration is prompt increase in intake of appropriate fluids, possibly in the form of solution prepared from oral rehydration salts (ORS). In Kenya, families are encour- aged to rehydrate children with either the commercially packaged ORS (also called Oralite), or other fluids pre- pared at home with locally obtained ingredients, e.g. water, juices, soups etc. They are also advised to prevent malnutrition from diarrhoea by continuing and increasing the feeding of children who have diarrhoea. Dehydration can be treated by the use of ORS, or, if dehydration is severe, intravenous fluids. ORS is usually distributed through health facilities and pharmacies, and is also avail- able in local shops and kiosks, while preparation of recommended home-made fluids is taught in health facilities. In order to assess the extent of familiarity with ORS, women interviewed in the 2003 KDHS who had a birth in the five years preceding the survey were asked if they had ever heard of a special product called Oralite or ORS that you can get for the treatment of diarrhoea. The results are shown in Table 9.16. Seven in ten mothers had heard of ORS packets. Knowledge of ORS increases with age and level of education of the mother. There is considerable difference in knowledge between urban (79 percent) and rural women (69 percent). Among provinces, mothers in Coast Province are more likely to know about ORS (81 percent) than women in other provinces, and women in the highest wealth quintile have slightly more knowledge of ORS (77 percent) compared with those in the other quintiles (approximately 70 percent). Table 9.17 shows data concerning treatment of recent episodes of diarrhoea among children less than five years of age, as reported by the mothers. Results indicate that 30 percent of children with diarrhoea in the two weeks preceding the survey were taken to a health facility for treatment. When results are restricted to children under age three whose mothers live in the southern part of the country, comparison with data from the 1998 KDHS shows a sharp decline in the percentage of children with diarrhoea who were taken to a health facility or provider, from 44 percent in 1998 to 31 percent in 2003 (data not shown). In 2003, female children and children in Eastern and Coast Provinces were most likely to be taken to a health facility for treatment. Overall, 29 percent of children with diarrhoea are treated with a solution made from ORS pack- ets. About half of the children with diarrhoea are given ORS or more fluids to drink than before the diar- rhoea. Twenty-two percent of children with diarrhoea are treated with a pill or syrup, while 17 percent are given home-made remedies or herbal medicines. These remedies were more likely to be given to younger children, children in rural areas, and those living in Nyanza Province. Thirty-two percent of children with diarrhoea were given no treatment at all. 146 | Maternal and Child Health To gauge knowledge about drinking and eating practices for a child with diarrhoea, mothers with children under five who had had diarrhoea in the two weeks preceding the survey were asked about the drinking and eating patterns of these children, compared with normal practice. Table 9.18 shows that roughly one-third of children with diarrhoea are given more to drink than usual, while one-third are given the same as usual, and one-third are given less to drink than usual or nothing at all. It is particularly dis- concerting to note that almost 20 percent of children with diarrhoea are given much less or nothing to drink. Table 9.17 Diarrhoea treatment Percentage of children under five years who had diarrhoea in the two weeks preceding the survey who were taken for treatment to a health provider, percentage who received oral rehydration therapy (ORT), and percentage given other treatments, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Oral rehydration therapy Other treatments Percent- ––––––––––––––––––––––– –––––––––––––––––––––––––––––– Number age ORS of taken to In- or in- Pill Intra- Home No children Background a health ORS creased creased or Injec- venous remedy/ treat- with characteristic provider1 packets fluids fluids syrup tion solution other ment diarrhoea –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 20.6 17.2 18.4 28.0 10.9 0.0 6.0 23.6 39.3 88 6-11 32.1 32.1 30.8 51.6 22.9 0.9 0.9 24.0 29.5 180 12-23 33.2 32.2 38.4 53.9 23.0 1.7 1.1 14.0 29.8 295 24-35 25.5 29.3 33.5 52.5 21.4 2.6 0.7 13.0 33.7 167 36-47 32.4 27.6 41.3 54.7 23.1 1.1 0.0 16.3 30.2 90 48-59 26.7 25.8 37.9 52.7 27.0 4.5 2.2 8.1 34.7 69 Sex Male 26.6 27.2 33.9 49.0 22.9 1.9 1.7 18.6 32.1 489 Female 33.5 31.6 34.6 52.6 20.4 1.4 1.1 14.0 31.5 400 Residence Urban 30.7 31.9 42.5 52.4 22.2 3.0 2.9 10.5 33.9 180 Rural 29.5 28.5 32.1 50.1 21.7 1.4 1.1 18.1 31.3 708 Province Nairobi 35.0 41.1 64.2 66.3 22.9 2.7 1.7 11.2 22.4 51 Central 26.5 22.5 55.7 63.4 13.2 0.0 2.3 16.3 25.6 44 Coast 42.8 43.4 37.5 61.2 28.2 3.8 0.7 19.0 25.0 102 Eastern 49.2 37.3 55.5 71.9 30.8 0.0 2.5 13.1 13.5 111 Nyanza 22.5 21.0 20.3 36.1 22.9 0.7 0.0 28.0 36.2 143 Rift Valley 26.3 29.7 25.8 47.6 15.1 2.8 2.9 17.6 35.6 257 Western 21.4 18.3 29.1 38.4 24.9 0.9 0.0 9.2 41.6 159 North Eastern 10.2 34.2 24.0 49.0 8.6 1.3 0.0 1.7 48.3 21 Mother's education No education 30.4 40.1 21.0 48.6 17.7 2.3 0.8 19.7 33.0 146 Primary incomplete 28.7 24.2 31.7 45.3 19.3 1.2 1.9 15.3 35.9 390 Primary complete 30.9 31.9 41.3 58.0 27.9 2.4 1.0 16.2 25.3 235 Secondary + 29.9 26.8 45.1 56.0 22.7 1.2 1.5 17.7 29.9 117 Wealth quintile Lowest 29.7 29.7 27.2 46.6 20.3 1.4 0.6 21.0 31.1 245 Second 25.0 26.6 34.1 48.0 18.5 1.2 0.5 19.9 36.3 202 Middle 25.2 26.4 38.8 53.1 22.0 0.8 1.7 14.1 30.7 158 Fourth 32.7 27.7 33.5 50.2 28.4 2.3 1.9 13.3 30.5 124 Highest 37.8 35.7 41.2 57.8 22.9 3.3 3.2 10.5 29.3 159 Total 29.7 29.2 34.2 50.6 21.8 1.7 1.4 16.6 31.8 888 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: ORT includes solution prepared from oral rehydration salt (ORS) packets or increased fluids. 1 Excludes pharmacy, shop and traditional practitioner Maternal and Child Health | 147 Table 9.18 Feeding practices during diarrhoea Percent distribution of children un- der five years who had diarrhea in the two weeks preceding the survey by amount of liquids and food of- fered compared with normal prac- tice, Kenya 2003 ––––––––––––––––––––––––––––––– Liquid/food offered Percent ––––––––––––––––––––––––––––––– Amount of liquids offered Same as usual 32.9 More 34.2 Somewhat less 15.1 Much less 13.4 None 4.1 Don't know/missing 0.3 Total 100.0 Amount of food offered Same as usual 34.5 More 6.6 Somewhat less 25.8 Much less 18.6 None 7.2 Never gave food 7.1 Don't know/missing 0.2 Total 100.0 Number of children 888 Food intake is curtailed even more than fluid intake during an episode of diarrhoea. One-third of children with diarrhoea are offered the same amount of food as usual, but only 7 percent were given more to eat than usual. More than one-quarter are given somewhat less food to eat than usual, while 26 percent are given much less or no food at all. These patterns reflect a gap in practical knowledge among some mothers regarding the nutritional requirements of children during episodes of diarrhoeal illness. This indi- cates a need for further health education efforts to reduce the number of children becoming dehydrated or malnourished due to diarrhoea. 9.8 CHILD HEALTH INDICATORS AND WOMEN’S STATUS Table 9.19 shows the relationship between indicators of children’s health and women’s status. The results show no relationship between the number of household decisions in which a woman partici- pates and vaccination coverage of her children or the percentage of children with ARI, fever or diarrhoea who are taken to a health provider. Similarly, there is no relationship between the child health measures and the number of circumstances in which the mother feels a woman is justified in refusing to have sex with her husband. However, there is a slight inverse correlation between the percentage of children with diarrhoea who are taken to a health provider and the number of reasons for which a woman thinks wife- beating is justified. Children whose mothers believe that wife-beating is not justified by any reason are more likely to be taken to a health provider when they have diarrhoea, compared with children whose mothers believe that wife-beating is justified for all five of the stated reasons (36 versus 26 percent). 148 | Maternal and Child Health 9.9 BIRTH REGISTRATION Kenya is a signatory to the Convention of the Rights of the Child and has an Act of Parliament on the Rights of the Child, both of which firmly establish birth registration as a fundamental right of chil- dren. In order to assess the extent of birth registration, in the 2003 KDHS, mothers of children born in a health facility in the five years before the survey were asked if the facility gave them a birth notification form for the baby. Those who were not given a form at the facility and those who did not deliver in a health facility were asked if they obtained a birth notification form, either from the assistant chief, a vil- lage elder, or at a registrar’s office. All mothers were asked if their children born in the preceding five years had a birth certificate. Table 9.20 shows that overall, 45 percent of births are notified, 30 percent in health facilities and 16 percent in the registrar’s office or by an assistant chief or village elder. However, a much smaller pro- portion of births (21 percent) can be considered to be registered with a birth certificate. Table 9.19 Children’s health care by women’s status Percentage of children age 12-23 months who were fully vaccinated, and percentage of children under five years who were ill with a fever, symptoms of ARI and/or diarrhoea, in the two weeks preceding the survey taken to a health provider for treat- ment, by women's status indicators, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Percentage of Percentage of of children children with fever children with 12-23 months Number and/or symptons Number diarrhoea Number fully of of ARI taken to of taken to a of Women’s status indicator vaccinated1 children a health provider2 children health provider2 children –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of decisions in which woman has final say3 0 60.5 134 38.8 301 29.0 116 1-2 57.6 404 46.2 913 31.3 339 3-4 57.1 351 45.7 779 30.8 270 5 59.8 241 47.9 503 25.1 163 Number of reasons to refuse sex with husband 0 48.5 57 46.6 129 43.5 41 1-2 62.6 170 41.8 381 26.4 133 3-4 58.0 904 46.1 1,986 29.5 714 Number of reasons wife- beating is justified 0 67.6 276 46.5 606 35.6 164 1-2 55.9 360 47.7 832 31.7 293 3-4 55.1 372 41.2 770 26.0 310 5 53.6 122 48.3 288 26.1 120 Total 56.8 1,131 45.5 2,496 29.7 888 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Those who have received BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 2 Excludes pharmacy, shops, and traditional practitioner 3 Either by herself or jointly with others Maternal and Child Health | 149 Notification in health facilities and presence of a birth certificate declines with birth order. There are marked urban-rural differentials, with 60 percent of urban births having a notification form and 28 percent having a birth certificate, compared to only 42 and 20 percent of rural births, respectively. Pro- vincial comparison shows variation, with Central Province having the highest notification level (76 per- cent) and North Eastern Province the lowest (6 percent). Births in Nairobi Province are most likely to be registered with a birth certificate (30 percent). Birth notification and presence of birth certificates in- creases with mothers’ education and wealth quintile. 9.10 KNOWLEDGE OF SIGNS OF ILLNESS The IMCI programme aims at contributing to the reduction of morbidity and mortality among children under five. One of its strategies is to emphasise early recognition of signs of illness and early care-seeking behaviour among mothers of children under five, to prevent complications and death result- ing from the common childhood illnesses. In the 2003 KDHS, women who have at least one child living Table 9.20 Birth registration Percentage of births in the five years before the survey for which the health facility provided a birth notification form, for which the parents obtained a birth notification form and for which there is a birth certificate, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Birth notification form –––––––––––––––– From From Has Number Background health registrar’s birth of characteristic facility office certificate births –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Birth order 1 43.7 9.9 25.2 1,469 2-3 32.4 16.0 22.3 2,177 4-5 22.3 18.8 17.8 1,215 6+ 15.5 17.9 17.2 1,240 Residence Urban 54.8 5.6 28.1 1,143 Rural 23.9 17.7 19.5 4,959 Province Nairobi 62.5 3.6 30.2 398 Central 60.5 15.6 23.6 652 Coast 20.5 31.3 26.3 510 Eastern 30.8 17.8 17.3 946 Nyanza 21.4 8.7 16.8 1,000 Rift Valley 23.8 11.8 20.1 1,639 Western 20.7 28.0 25.4 776 North Eastern 4.9 1.1 10.9 181 Education No education 8.9 11.7 14.0 938 Primary incomplete 19.8 20.0 20.1 2,222 Primary complete 34.2 15.4 21.0 1,678 Secondary + 56.7 10.3 28.3 1,263 Wealth quintile Lowest 9.0 20.8 15.9 1,509 Second 20.9 18.7 20.6 1,271 Middle 27.8 20.7 21.0 1,159 Fourth 41.5 10.6 19.2 1,032 Highest 58.4 4.0 30.3 1,131 Total 29.7 15.5 21.1 6,102 150 | Maternal and Child Health with them were asked what signs of illness would indicate that a child should be taken to a health facility or health worker. Table 9.21 shows that almost all women (99 percent) mentioned some sign of illness. It is reas- suring to note that a substantial proportion of the women were able to identify some of the general danger signs, such as not being able to drink or breastfeed (43 percent) and weakness (46 percent). Notably, many women correctly identified signs of three main killer diseases among children under five: fever and shivering for malaria (82 percent); diarrhoea (25 percent); and fast breathing for pneumonia (13 percent). 9.11 SMOKING AND ALCOHOL USE In order to measure the extent of smoking among Kenyan adults, women and men who were in- terviewed in the 2003 KDHS were asked if they currently smoked cigarettes or used tobacco. Less than 3 percent of women said they used tobacco of any kind and less than one percent said they smoked ciga- rettes (data not shown). One-quarter of men use tobacco products, with 23 percent saying that they smoke cigarettes. Although the proportion of women who smoke is too small to show details, Table 9.22 shows differentials in smoking among men. Younger men are less likely to smoke than men in their 30s and early 40s. Similarly, men with no education and in the lowest wealth quintile are less likely to smoke cigarettes than men with some educa- tion and in higher wealth quintiles. However, men with no education are much more likely to use other tobacco products (e.g., snuff, chewing tobacco). Men in Eastern Province have the highest level of smok- ing (37 percent). Table 9.21 Knowledge of illness signs Among women who have at least one child living with them, percentage who report specific signs of illness in a child that would indicate the child should be taken to a health facility or health worker, Kenya 2003 ––––––––––––––––––––––––––––––– Sign of illness Total ––––––––––––––––––––––––––––––– Not able to drink/breastfeed 42.8 Fever, shivering 81.7 Repeated vomiting 19.8 Diarrhoea 25.4 Blood in stools 1.8 Fast breathing 12.8 Convulsions 5.3 Weakness 45.5 Getting sicker 13.3 Crying 14.5 Coughing 7.1 Change in color of eyes 4.1 Sleepy 2.3 Other 2.0 Able to name one sign 99.3 Number of women 5,426 Maternal and Child Health | 151 Alcohol contributes to low birth weight babies and affects brain development during pregnancy, as well as affecting the mother’s health. It is recommended that women should avoid alcohol during preg- nancy and breastfeeding. Alcohol use, especially drunkenness, among men is related to higher prevalence of domestic violence (see Chapter 15). Table 9.23 shows that 12 percent of women interviewed in the 2003 KDHS report that they have ever drunk alcohol, compared to 50 percent of men. In the month preceding the survey, 5 percent of women drank alcohol, compared to 30 percent of men. In general, older women and men are more likely to drink alcohol than younger ones. Urban women are twice as likely as their rural counterparts to drink alcohol. Similarly, a higher percentage of urban than rural men use alcohol. Regional differentials indi- cate that alcohol use is highest among women in Nairobi and Western Provinces, while among men, it is highest in Nairobi and Eastern Provinces. Table 9.22 Use of tobacco among men Percentage of men who smoke cigarettes, smoke a pipe, or use other tobacco, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Type of tobacco ––––––––––––––––––––––––––––––– Does not Number Background Other not use of characteristic Cigarettes Pipe tobacco tobacco respondents –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 5.4 0.0 0.2 94.3 856 20-24 21.0 0.1 0.9 78.1 681 25-29 27.6 0.0 2.3 70.5 509 30-34 34.2 0.0 2.0 63.8 415 35-39 33.8 0.1 1.9 65.2 396 40-44 33.9 0.0 4.3 62.7 310 45-49 26.0 0.4 6.1 67.2 196 50-54 26.7 0.0 5.4 67.8 215 Residence Urban 23.5 0.1 0.6 75.8 907 Rural 22.7 0.0 2.5 75.1 2,671 Province Nairobi 22.7 0.0 1.0 76.1 397 Central 29.7 0.0 0.4 69.9 554 Coast 29.8 0.3 1.6 68.6 252 Eastern 37.1 0.0 0.6 62.2 588 Nyanza 11.0 0.0 0.0 89.0 481 Rift Valley 17.5 0.0 6.2 77.2 846 Western 15.5 0.2 1.0 83.0 396 North Eastern 13.0 0.0 1.5 85.5 65 Education No education 16.9 0.2 15.8 67.2 228 Primary incomplete 25.0 0.1 1.6 73.5 1,210 Primary complete 25.3 0.0 0.8 74.1 820 Secondary + 20.5 0.0 0.7 79.0 1320 Wealth quintile Lowest 16.9 0.2 6.5 77.2 548 Second 22.0 0.0 2.9 75.3 609 Middle 21.9 0.0 1.0 77.2 648 Fourth 28.4 0.0 0.4 71.1 794 Highest 23.0 0.1 0.9 76.2 979 Total 22.9 0.1 2.0 75.3 3,578 152 | Maternal and Child Health There is a greater tendency for educated men to drink alcohol than less educated men. Among women there is little difference except that uneducated women are more likely to have drunk alcohol in the month preceding the survey than women with some education. Use of alcohol by women and men in the highest wealth quintile is noticeably higher than among respondents in the lower quintiles. Table 9.23 Use of alcohol Percentage of respondents who ever have drunk alcohol and who have drunk alcohol in the past month, by background characteristics and maternity status, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––– ––––––––––––––––––––––––––– Ever Drank Number Ever Drank Number Background drank alcohol in of drank alcohol in of characteristic alcohol past month respondents alcohol past month respondents –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 6.6 2.6 1,856 24.2 10.3 856 20-24 10.0 3.9 1,691 49.7 29.6 681 25-29 12.1 4.8 1,382 57.1 33.0 509 30-34 12.3 5.8 1,086 63.8 42.0 415 35-39 14.0 6.9 871 61.5 41.4 396 40-44 18.4 8.3 788 61.2 39.0 310 45-49 18.7 9.9 521 62.9 39.8 196 50-54 na na 0 60.4 35.0 215 Residence Urban 18.2 7.4 2,056 59.7 35.4 907 Rural 9.5 4.4 6,139 46.7 28.1 2,671 Province Nairobi 23.8 10.4 835 69.4 37.6 397 Central 10.0 2.7 1,181 38.3 25.4 554 Coast 8.5 4.8 667 46.2 31.6 252 Eastern 8.8 2.9 1,325 61.6 34.3 588 Nyanza 11.6 4.4 1,222 37.6 23.8 481 Rift Valley 9.5 5.4 1,872 52.7 31.6 846 Western 16.1 8.2 927 49.4 29.5 396 North Eastern 0.0 0.0 168 0.0 0.0 65 Education No education 13.9 9.0 1,039 34.4 23.8 228 Primary incomplete 10.3 4.6 2,685 44.2 25.9 1,210 Primary complete 8.4 3.1 2,069 49.0 29.6 820 Secondary + 15.1 5.7 2403 58.5 34.8 1320 Wealth quintile Lowest 8.1 4.9 1,364 45.3 25.6 548 Second 10.0 5.3 1,475 46.4 27.6 609 Middle 9.3 4.2 1,503 42.7 27.4 648 Fourth 8.5 2.8 1,711 48.2 28.3 794 Highest 19.4 7.5 2,141 61.0 36.8 979 Total 11.7 5.1 8,195 50.0 29.9 3,578 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Nutrition | 153 NUTRITION 10 John O. Owuor and John G. Mburu Nutritional status is the result of complex interactions between food consumption and the overall status of health and care practices. Poor nutritional status is one of the most important health and welfare problems facing Kenya today and afflicts the most vulnerable groups: women and children. At the indi- vidual level, inadequate or inappropriate feeding patterns lead to malnutrition. Numerous socioeconomic and cultural factors influence the decision on patterns of feeding and nutritional status. The 2003 KDHS collected data on feeding practices, that is, breastfeeding, complementary feeding, and use of feeding bot- tles. Heights and weights of all children under five years and women age 15-49 were measured to deter- mine the adult female and child nutritional status. This chapter presents the findings on infant feeding practices and nutritional status of women and children. 10.1 BREASTFEEDING AND SUPPLEMENTATION Feeding practices play a pivotal role in determining optimal development of infants. Poor breast- feeding and infant feeding practices have adverse consequences for the health and nutritional status of children, which in turn has consequences on the mental and physical development of the child. Initiation of Breastfeeding Women delivering in health facilities and at home are encouraged to initiate breastfeeding within the first 30 minutes after birth, except for an HIV-positive mother who has chosen not to breastfeed (Min- istry of Health, 2000). Bottle-feeding is discouraged, and mothers are educated to breastfeed exclusively for six months. Early breastfeeding increases chances of breastfeeding success and generally lengthens the duration of breastfeeding. Mixed breastfeeding (breastfeeding combined with other liquids and foods) may increase the risk of HIV infection and is discouraged. Table 10.1 indicates that 97 percent of children are breastfed at some point, the same proportion as in 1998. Overall, 52 percent of children are breastfed within one hour of birth and 82 percent within one day after delivery, indicating a slight decline when compared with the 1998 KDHS. The proportion of women initiating breastfeeding within one hour of birth is highest in Eastern Province (67 percent) and lowest in Coast Province (22 percent). Two-thirds (65 percent) of children are given something before breastfeeding (prelacteal feed). Mothers in rural areas (67 percent) are more likely to practise prelacteal feeding than those in urban areas (57 percent). Prelacteal feeding is also common in Western and Coast provinces and least common in Central Province. 154 | Nutrition Table 10.1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and among children ever breastfed, percentage who started breastfeeding within one hour and within one day of birth and percentage who received a prelacteal feed, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Percentage who started who started Number of Percentage Number breastfeeding breastfeeding Received a children Background ever of within 1 hour within 1 day prelacteal ever characteristic breastfed children of birth of birth1 feed2 breastfed ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Sex Male 96.2 3,110 50.5 80.7 65.9 2,993 Female 97.4 2,992 54.1 82.8 64.1 2,913 Residence Urban 96.5 1,143 51.2 80.0 57.2 1,103 Rural 96.9 4,959 52.5 82.1 66.8 4,803 Province Nairobi 96.2 398 55.1 82.3 51.3 383 Central 98.2 652 61.8 86.4 30.1 641 Coast 95.0 510 22.4 69.0 82.9 484 Eastern 96.8 946 66.6 92.3 57.7 916 Nyanza 97.9 1,000 46.2 77.5 73.1 980 Rift Valley 96.8 1,639 62.4 84.0 67.1 1,587 Western 97.3 776 30.7 76.5 83.8 755 North Eastern 88.9 181 54.9 68.3 66.8 160 Education No education 94.9 938 56.7 80.5 67.4 890 Primary incomplete 97.2 2,222 48.0 78.8 71.1 2,159 Primary complete 97.5 1,678 54.4 86.2 62.0 1,636 Secondary+ 96.6 1,263 53.7 81.9 56.6 1,221 Assistance at delivery Health professional3 96.3 2,536 55.6 83.5 54.9 2,443 Traditional birth attendant 96.7 1,710 49.6 81.7 76.7 1,654 Other 97.1 1,347 51.4 81.3 68.8 1,308 No one 98.2 488 48.6 76.9 68.0 479 Place of delivery Health facility 96.2 2,447 56.0 83.2 54.2 2,355 At home 97.1 3,584 50.2 81.1 72.7 3,481 Other 100.0 51 39.2 81.4 60.8 51 Wealth quintile Lowest 96.0 1,509 49.8 80.2 74.1 1,449 Second 98.0 1,271 54.0 82.3 68.8 1,245 Middle 97.5 1,159 52.2 83.0 65.4 1,130 Fourth 96.6 1,032 54.6 84.0 54.1 997 Highest 96.0 1,131 51.6 79.7 58.1 1,085 Total 96.8 6,102 52.3 81.7 65.0 5,906 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table is based on all births, whether the children are living or dead at the time of interview. Total includes 21 children with information on assistance at delivery missing and 19 children with place of delivery missing. 1 Includes children who started breastfeeding within one hour of birth 2 Given something other than breast milk during the first three days of life before the mother started breastfeeding regularly 3 Doctor, nurse, or midwife Nutrition | 155 Breastfeeding Patterns For optimal growth, it is recommended that infants should be exclusively breastfed for the first six months of life. Exclusive breastfeeding in the early months of life is correlated strongly with increased child survival and reduced risk of morbidity, particularly from diarrhoeal diseases. Table 10.2 and Figure 10.1 show that only 29 percent of children under the age of two months are exclusively breastfed. This represents no change in breastfeeding patterns when compared with the 1998 KDHS. The propensity to feed infants under 2 months with plain water (26 percent), water-based liquids/juices (14 percent), other milk (15 percent), and food (16 percent) is high. At two to three months, almost half of all children are given complementary foods. By six to seven months, 81 percent of infants have been introduced to these foods. Overall, only 13 percent of infants under 6 months are exclusively breastfed. The implication of this duration is important since it is recommended that all infants be exclusively breastfed for six months. Table 10.2 also shows that bottle-feeding is common in Kenya. More than one-quarter (27 per- cent) of children under six months are fed with a bottle with a nipple. Bottle-feeding practices may poten- tially result in increased morbidity because of the unsafe water and preparation facilities. Table 10.2 Breastfeeding status by child’s age Percent distribution of youngest children under three years living with the mother, by breastfeeding status and percentage of children under three years using a bottle with a nipple, according to age in months, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Breastfeeding and consuming –––––––––––––––––––––––––––––––– Percentage Exclu- Water- using Not sively Plain based Comple- Number a bottle Number breast- breast- water liquids/ Other mentary of with a of Age in months feeding fed only juice milk foods Total children nipple1 children ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– <2 0.8 29.3 25.8 13.6 15.0 15.5 100.0 171 16.9 173 2-3 0.0 9.3 13.4 8.3 21.0 48.0 100.0 232 28.0 237 4-5 0.0 2.6 3.0 5.4 19.6 69.3 100.0 204 33.8 210 6-7 3.7 2.1 1.8 0.9 10.5 81.1 100.0 199 38.1 202 8-9 3.3 0.6 2.7 2.7 3.4 87.2 100.0 204 20.4 206 10-11 3.3 0.7 1.0 2.0 2.6 90.4 100.0 220 26.6 222 12-15 7.9 0.3 0.7 0.3 2.5 88.3 100.0 394 18.3 408 16-19 25.2 0.4 0.2 0.4 2.1 71.7 100.0 335 14.5 362 20-23 42.7 0.0 0.4 0.4 1.0 55.5 100.0 307 11.3 361 24-27 65.3 0.2 0.0 0.2 0.4 33.9 100.0 259 6.0 339 28-31 77.6 0.0 0.0 0.0 0.3 22.1 100.0 224 5.2 337 32-35 89.0 0.0 0.0 0.0 0.1 10.8 100.0 193 5.5 355 <6 0.2 12.7 13.4 8.8 18.8 46.1 100.0 607 26.9 619 6-9 3.5 1.3 2.3 1.8 6.9 84.2 100.0 403 29.2 408 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children classified as breastfeeding and con- suming plain water only consume no supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, water-based liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and water-based liq- uids and who do not receive complementary foods are classified in the water-based liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years 156 | Nutrition Figure 10.1 Breastfeeding Practices by Age <2 2-3 4-5 6-7 8-9 10-11 Age in Months 0 20 40 60 80 100 Exclusively breastfed Breast milk and plain water Breast milk and non-milk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding KDHS 2003 Table 10.3 shows that the median duration for any breastfeeding among Kenyan children is 20 months, which is similar to the duration documented in the 1993 KDHS and the 1998 KDHS, suggesting that for a decade the patterns have not changed significantly. The median duration of exclusive breast- feeding is estimated at less than one month. The median duration of any breastfeeding is slightly higher in rural areas (20 months), compared with urban (19 months). At the provincial level, duration of breastfeeding is longest in Eastern Province (25 months) and shortest in North Eastern Province (13 months). Analysis by background characteristics of the mother indicates that educational level and socio- economic status as measured by the wealth index are related to breastfeeding practices. Women with no education are more likely to breastfeed longer (24 months) than those who have at least some secondary education (19 months). Median duration of breastfeeding declines steadily with increasing wealth. Frequent breastfeeding of children is a common occurrence in Kenya. More than nine in ten (92 percent) infants under six months of age were breastfed six or more times in the 24 hours prior to the sur- vey. Nutrition | 157 Complementary Feeding Given that babies need nutritious food in addition to breast milk from the age of six months, it is recommended that children should begin receiving complementary foods at this age. To obtain full infor- mation on weaning practices, the 2003 KDHS collected data on breastfeeding and nonbreastfeeding chil- dren. Table 10.4 presents information on the types of complementary (weaning) foods received by chil- dren less than three years of age in the day or night preceding the survey. As observed in previous KDHS data, use of infant formula milk is minimal. Only 5 percent of children under six months receive commer- cially produced infant formula. Table 10.3 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey; percentage of breastfeeding children under six months living with the mother and who were breastfed six or more times in the 24 hours preceding the survey; and mean number of feeds (day/night), by background charac- teristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Median duration (months) of breastfeeding1 Breastfeeding children under six months2 ––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––– Predomi- Percentage Mean Mean Any Exclusive nant Number breastfed 6+ number number Number Background breast- breast- breast- of times in last of day of night of characteristic feeding feeding feeding3 children 24 hours feeds feeds children ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Sex Male 19.1 0.5 1.5 1,882 93.6 6.2 4.4 301 Female 21.0 0.5 1.7 1,821 90.6 5.9 4.2 309 Residence Urban 19.0 0.5 2.1 698 94.4 5.9 4.5 118 Rural 20.4 0.5 1.4 3,004 91.6 6.1 4.2 492 Province Nairobi 16.7 0.6 2.1 242 93.1 5.8 4.4 43 Central 19.0 0.4 1.4 381 95.9 6.4 5.0 65 Coast 21.5 0.5 2.1 318 95.9 6.6 4.8 50 Eastern 24.7 0.6 1.6 570 92.6 5.7 4.0 94 Nyanza 18.2 0.6 2.0 619 83.2 4.9 3.4 110 Rift Valley 19.4 0.4 0.6 1,008 96.8 6.8 4.6 159 Western 18.9 0.6 1.7 459 89.4 6.3 4.4 73 North Eastern 12.8 0.4 0.7 106 87.3 6.0 3.8 17 Education No education 23.8 0.5 1.2 565 94.8 6.5 4.6 102 Primary incomplete 19.2 0.5 1.6 1,371 92.2 6.0 4.1 229 Primary complete 20.5 0.5 1.6 1,013 91.7 5.9 4.2 167 Secondary+ 19.4 0.6 1.7 753 90.2 6.0 4.3 112 Wealth quintile Lowest 21.6 0.6 1.9 908 89.5 5.9 4.1 135 Second 21.2 0.5 1.1 768 89.2 5.7 4.0 130 Middle 19.9 0.5 1.6 695 95.1 6.2 4.3 117 Fourth 18.9 0.5 1.1 636 92.5 6.2 4.7 113 Highest 18.5 0.5 2.0 696 95.1 6.3 4.4 115 Total 20.1 0.5 1.6 3,702 92.1 6.1 4.3 610 Mean for all children 20.7 1.6 3.1 na na na na na ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Median and mean durations are based on current status. na = Not applicable 1 It is assumed that non-last-born children or last-born child not living with the mother are not currently breastfeeding. 2 Excludes children who do not have a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, water-based liquids, and/or juice only (excludes other milk) 158 | Nutrition Fifty-four percent of children under six months receive solid or semi-solid foods. The most com- monly used complementary foods for breastfeeding children under six months include milk products other than breast milk (36 percent), food made from grains (28 percent), and fruits and vegetables (23 percent). Foods made from cereals are introduced to children by two to three months (32 percent); by six to seven months, 60 percent are already receiving these foods. On the other hand, foods made from roots/tubers and legumes are introduced gradually from four to five months. By the age of 10-11 months, 31 percent are receiving root/tuber-based food, and 25 percent get legumes. Consumption of protein-rich foods (meat, fish, poultry, and eggs) generally begins at four to five months (8 percent) and increases to 27 percent by the first year of life. Generally, for all children under the age of three years, the percentage consuming protein-rich foods in the previous 24 hours does not rise above 39 percent. Fruits and vegetables rich in vitamin A are consumed much earlier. By two to three months, some children eat fruits and vegetables; this proportion rises to 69 percent by the first year of life. Figure 10.2 shows the mean number of times that solid or semi-solid food was given to young children in the 24 hours preceding the survey. As expected, as children get older, they are given more meals per day. Those who are over one year of age are generally given solid or semi-solid foods about three times per day. Table 10.4 Foods consumed by children in the day or night preceding the interview Percentage of youngest children under three years of age living with the mother and who consumed specific foods in the day or night preceding the interview, by breastfeeding status and age, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Any Food Meat/ Fruits and solid Other Food made Food fish/ vegetables or milk/ made Fruits/ from made shellfish/ rich in semi- Number Child’s age Infant cheese/ Other from vege- roots/ from poultry/ vitamin solid of in months formula yogurt liquids1 grains tables2 tubers legumes eggs A3 food children –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– BREASTFEEDING CHILDREN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– <2 2.6 17.8 23.4 3.8 5.4 2.5 0.7 0.4 2.7 22.9 169 2-3 2.9 37.3 36.0 31.9 21.3 8.7 3.1 1.8 12.0 56.0 232 4-5 8.8 49.4 45.4 44.7 40.0 16.7 5.8 8.4 32.7 78.4 204 6-7 6.1 63.0 48.2 59.5 59.1 20.6 14.8 8.9 46.3 90.1 192 8-9 4.0 53.6 55.5 67.8 69.3 24.7 23.2 22.0 55.7 91.9 197 10-11 7.5 65.5 61.3 74.3 78.5 30.7 24.6 26.9 69.0 96.0 213 12-15 4.5 58.3 61.6 78.9 83.6 28.1 29.2 28.1 77.7 97.1 363 16-19 3.1 62.7 65.3 78.8 81.6 36.3 38.9 27.9 74.3 97.4 250 20-23 2.5 62.7 64.9 80.6 84.3 25.3 35.6 26.3 78.1 96.8 176 24-35 3.6 56.7 61.2 80.5 86.8 30.5 33.7 24.7 84.6 99.2 161 <6 4.8 35.9 35.7 28.4 23.2 9.7 3.4 3.6 16.4 54.3 606 6-9 5.0 58.2 51.9 63.7 64.3 22.7 19.0 15.6 51.1 91.0 389 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– NONBREASTFEEDING CHILDREN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 16-19 1.1 71.3 67.2 75.2 85.2 38.3 25.8 25.4 82.2 98.8 84 20-23 1.9 58.3 71.3 83.9 88.2 37.6 33.9 33.0 81.1 100.0 131 24-35 3.6 63.5 66.9 85.1 87.4 36.3 38.9 38.6 83.4 98.7 515 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Breastfeeding status and food consumed refer to a "24-hour" period (yesterday and last night). 1 Does not include plain water 2 Includes fruits and vegetables rich in vitamin A 3 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mangoes, papa- yas, and other locally grown fruits and vegetables that are rich in vitamin A Nutrition | 159 0.4 1.3 1.9 2.6 2.3 2.6 2.8 3.1 3.0 3.3 1.2 2.5 2.9 3.4 3.1 <02 2-3 4-5 6.7 8-9 10-11 12-15 16-19 20-23 24-35 <06 6-9 0.0 1.0 2.0 3.0 4.0 Mean number of times consumed solid or semi-solid food per day Breastfeeding children Nonbreastfeeding children Figure 10.2 Frequency of Meals Consumed by Children under 36 Months of Age Living with Their Mother KDHS 2003 Child’s age (months) <2 <6 10.2 MICRONUTRIENT INTAKE Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. High levels of vitamin A deficiency (VAD) can cause eye damage leading to blindness and can increase the severity of infections such as measles and diarrhoeal diseases in children. Ensuring that children between 6 and 59 months receive enough vitamin A may be the single most effective child survival intervention. Additionally, adequate intake of the vitamin during pregnancy may reduce maternal deaths. According to the 1990 World Summit for Children goals and the national plan of action developed by the Government of Kenya in 1994, the target was to virtually elimi- nate VAD disorders by 2000 (Central Bureau of Statistics and UNICEF, 2003). Micronutrient Intake among Children Table 10.5 shows the percentage of youngest children under three years who consumed foods rich in vitamin A in the 24 hours preceding the survey and the percentage of children under age 6-59 months who received vitamin A supplements in the six months preceding the survey. Overall, 62 percent of chil- dren under three years consume food rich in vitamin A, and 33 percent of children under five receive vi- tamin A supplements. 160 | Nutrition Table 10.5 Micronutrient intake among children Percentage of youngest children under age three living with the mother and who consumed fruits and vegetables rich in vitamin A in the 24 hours preceding the survey and percentage of children age 6-59 months who received vitamin A supplements in the six months pre- ceding the survey, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Consumed fruits and Number Consumed Number Background vegetables rich of vitamin A of characteristic in vitamin A1 children supplements children –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 16.4 607 na 0 6-9 51.5 403 29.9 408 10-11 69.6 220 34.3 222 12-23 77.8 1,036 36.6 1,131 24-35 83.7 676 33.0 1,031 36-47 na 0 32.9 1,123 48-59 na 0 31.8 1,026 Sex Male 61.5 1,474 35.3 2,493 Female 63.0 1,469 31.4 2,447 Birth order 1 61.1 683 35.4 1,228 2-3 64.1 1,032 34.6 1,760 4-5 64.0 632 32.4 983 6+ 58.5 596 29.3 971 Breastfeeding status Breastfeeding 55.0 2,158 32.4 1,605 Not breastfeeding 82.2 782 33.9 3,309 Residence Urban 66.0 560 40.4 945 Rural 61.4 2,383 31.7 3,996 Province Nairobi 67.1 196 37.5 326 Central 72.6 330 35.0 557 Coast 58.8 251 33.2 416 Eastern 70.4 485 22.4 786 Nyanza 68.0 441 26.5 720 Rift Valley 55.2 807 36.5 1,372 Western 60.0 356 46.8 617 North Eastern 17.6 78 24.6 146 Mother’s education No education 40.6 453 25.9 746 Primary incomplete 60.3 1,040 30.3 1,748 Primary complete 67.1 819 36.1 1,372 Secondary+ 74.7 631 40.0 1,074 Mother's age at birth <20 58.6 480 34.7 866 20-24 60.1 884 35.0 1,553 25-29 64.9 704 32.5 1,165 30-34 65.5 508 33.2 777 35-49 62.6 367 28.8 580 Wealth quintile Lowest 53.1 701 29.9 1,204 Second 62.1 619 32.7 1,027 Middle 64.6 561 31.5 936 Fourth 68.4 503 36.9 842 Highest 66.0 559 37.2 931 Total 62.2 2,943 33.3 4,941 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Information on vitamin A supplements is based on mother's recall. Total includes 27 children with information on breastfeeding status missing. na = Not applicable 1 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A Nutrition | 161 The consumption of food rich in vitamin A and the intake of supplements vary substantially by background characteristics. Male children are slightly more likely than females to consume vitamin A supplements (35 and 31 percent, respectively). Children who are not breastfeeding (82 percent) are more likely to consume fruits and vegetables rich in vitamin A, compared with their breastfeeding counterparts (55 percent), presumably because they are older than breastfeeding children. Analysis of data on area of residence and provinces also reveals differences. In general, children in urban areas are more likely to eat fruits and vegetables rich in vitamin A and also receive vitamin A supplements (66 and 40 percent, re- spectively) compared with those in rural areas (61 and 32 percent, respectively). The proportion of chil- dren consuming foods rich in vitamin A is highest in Central (73 percent) and Eastern (70 percent) prov- inces and lowest in North Eastern Province (18 percent). Consumption of vitamin A supplements is high- est in Western Province (47 percent) and lowest in Eastern (22 percent) and North Eastern (25 percent) prov-inces. It appears that children in North Eastern Province are less likely to consume fruits and vege- tables rich in vitamin A as well as to receive vitamin A supplements. Micronutrient Intake among Women Table 10.6 presents the percentage of women with a birth in the five years preceding the survey who received a vitamin A dose in the first two months after birth and who took iron tablets or syrup dur- ing pregnancy. In general, 14 percent received a postpartum vitamin A dose, but this varies with area of residence, province, and educational attainment. Women in urban areas (20 percent) are more likely to receive vitamin A supplements than those in rural areas (13 percent). At the provincial level, the percent- age of women who reported receiving a postpartum vitamin A dose is highest in Coast Province (23 per- cent) and lowest in Central Province (11 percent). With regard to educational level, women with no education (12 percent) or those with incomplete primary education (11 percent) are less likely to receive vitamin A doses. The data show that 21 percent of women with some secondary education reported having received a postpartum vitamin A dose. Vita- min A supplementation is strongly associated with wealth, rising from 10 percent of the poorest mothers to 22 percent of the wealthiest. As seen in the table, the intake of iron tablets and syrup during pregnancy is low. Overall, more than half of women (54 percent) did not take iron tablets or syrup during pregnancy. Intake varies consid- erably by province. Seventy-nine percent of women in North Eastern Province and 70 percent in Central Province did not take any iron supplements during pregnancy, compared with 35 percent in Coast Prov- ince and 36 percent in Nyanza Province. Coast and Nyanza Provinces are malaria-endemic areas, and as such, women are more likely to receive iron tablets or syrup. Among women who took iron supplements during pregnancy, the vast majority took them for less than 60 days. 162 | Nutrition Table 10.6 Micronutrient intake among mothers Percentage of women with a birth in the five years preceding the survey who received a vita- min A dose in the first two months after delivery and percentage who took iron tablets or syrup for a specific number of days during pregnancy, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of days iron tablets/syrup Received taken during pregnancy vitamin A ––––––––––––––––––––––––––––––––––––– dose Don’t Number Background post- know/ of characteristic partum1 None <60 60-89 90+ missing women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age at birth <20 16.7 54.9 37.5 1.2 2.2 4.3 647 20-24 15.2 56.8 33.9 1.4 1.8 6.1 1,172 25-29 14.3 50.3 39.4 1.9 3.1 5.4 964 30-34 13.4 51.0 38.0 2.3 3.1 5.6 685 35-49 10.2 53.9 30.8 3.8 2.7 8.8 584 Number of children ever born 1 18.1 57.4 32.7 1.2 2.6 6.2 946 2-3 15.9 54.0 36.3 1.8 2.3 5.6 1,404 4-5 12.2 51.7 39.3 1.8 1.7 5.5 842 6+ 8.9 50.3 36.1 3.3 3.7 6.6 859 Residence Urban 19.9 53.1 34.2 2.0 3.2 7.5 835 Rural 12.7 53.7 36.5 2.0 2.3 5.5 3,217 Province Nairobi 20.3 56.9 30.8 1.4 3.9 6.9 307 Central 10.7 70.4 24.8 0.6 0.8 3.3 495 Coast 22.9 34.8 49.5 3.5 3.9 8.3 336 Eastern 12.2 68.0 26.4 0.7 0.0 5.0 646 Nyanza 13.7 36.0 45.3 3.8 3.6 11.3 643 Rift Valley 13.6 53.4 36.3 2.2 2.8 5.3 1,052 Western 11.9 46.1 45.4 1.8 3.9 2.9 470 North Eastern 15.6 78.9 18.3 0.4 1.4 1.1 102 Education No education 12.0 52.5 38.7 2.5 1.4 4.8 582 Primary incomplete 10.9 52.1 37.7 2.0 3.2 5.0 1,395 Primary complete 14.2 57.2 34.1 1.2 1.4 6.1 1,143 Secondary+ 20.5 51.9 34.2 2.6 3.6 7.8 932 Wealth quintile Lowest 9.6 53.3 38.6 1.8 2.7 3.5 869 Second 13.6 52.6 37.5 1.3 2.3 6.3 830 Middle 11.9 52.3 37.2 3.0 2.3 5.2 777 Fourth 13.8 56.6 32.6 1.9 1.2 7.7 725 Highest 21.8 53.2 33.8 1.9 3.8 7.3 851 Total 14.2 53.5 36.0 2.0 2.5 5.9 4,052 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: For women with two or more live births in the five-year period, data refer to the most recent birth. 1 In the first two months after delivery Nutrition | 163 10.3 NUTRITIONAL STATUS OF CHILDREN UNDER FIVE The growth patterns of healthy and well-fed children are reflected in positive changes in their height and weight. Inadequate food supply, among other factors, often leads to malnutrition, resulting in serious consequences on the physical and mental growth and development of the children. Monitoring of nutrition indicators will provide information on the progress made in achieving the Millennium Develop- ment Goals,1 as well as targets set in the Economic Recovery Strategy (Ministry of Planning and National Development, 2003). In addition to questions about infant and young children’s feeding practices, the 2003 KDHS in- cluded an anthropometric component, in which all children under five years of age were both weighed and measured. Each interviewing team carried a scale and measuring board. The scales were lightweight, bathroom-type scales with a digital screen designed and manufactured under the authority of the United Nations Children’s Fund (UNICEF). The measuring boards were specially produced by Shorr Produc- tions for use in survey settings. Children younger than 24 months were measured lying down on the board (recumbent length), and standing height was measured for older children. In previous KDHS surveys, anthropometric measurements were restricted to children born to women interviewed with the Women’s Questionnaire. However, these data do not represent all children, since they exclude children whose mothers were not in the household (either because they did not live there or because they had died), children whose mothers were not eligible for the individual interview (i.e., under age 15 or age 50 and over), and children whose mothers did not complete an individual inter- view. To overcome these biases, in the 2003 KDHS, workers weighed and measured all children who were born in the five years preceding the survey and listed in the Household Questionnaire. 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. In any large population, there is variation in height and weight; this variation approximates a normal distri- bution. Use of a standard reference population as a point of comparison facilitates the examination of dif- ferences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. One of the most commonly used reference populations, and the one used in this report, is the U.S. National Center for Health Statistics (NCHS) standard, which is recommended for use by the World Health Organisation (WHO). The use of this reference population is based on the finding that young chil- dren of all population groups have similar genetic potential for growth. Three standard indices of physical growth that describe the nutritional status of children are pre- sented: • Height-for-age (stunting) • Weight-for-height (wasting) • Weight-for-age (underweight). Each of the three nutritional indicators is expressed in standard deviations (Z-scores) from the mean of the reference population.2 Deviations of the indicators below -2 standard deviations (SD) indi- cate that the children are moderately and severely affected, while deviations below -3 SD indicate that the children are severely affected. A total of 5,913 (weighted) children under age five were eligible to be weighed and measured. Six percent of these children were not measured, 3 percent had implausibly high or low values for the height and weight measurements, and 1 percent had incomplete age information. 1 One of the 48 Millennium Development indicators is to reduce by half the proportion of malnourished children by 2015. 2 The distribution of the standard reference population has been normalised and hence the mean and median coin- cide. 164 | Nutrition The following analysis focuses on the 5,307 children under five for whom complete and plausible anthro- pometric data were collected. Stunting Height-for-age is a measure of linear growth. A child who is below -2 SD 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 the cumulative effect of chronic malnutrition. If the child is below -3 SD from the reference median, then the child is considered to be severely stunted. A child between -2 and -3 SD is considered to be moderately stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and may also be caused by recurrent and chronic illness. Height-for-age, therefore, repre- sents a measure of the long-term effects of malnutrition in a population and does not vary appreciably according to the season of data collection. Stunted children are not immediately obvious in a population; a stunted three-year-old child could look like a well-fed two-year-old. Table 10.7 shows the nutritional status of children under five as measured by stunting (height-for- age) indicator and various background characteristics. At the national level, 30 percent of children under five are stunted, while the proportion severely stunted is 11 percent. This represents a small decline from the 1998 KDHS results.3 Analysis of the indicator by various age groups shows that stunting is highest (43 percent) in children age 12-23 months and lowest (7 percent) in children age less than 6 months. Se- vere stunting shows a similar trend, where children age 12-23 months have the highest proportion of se- verely stunted children (16 percent) and those less than 6 months have the lowest proportion (1 percent). A higher proportion (33 percent) of male children under five years are stunted, compared with 28 percent of female children. The survey data show that children living in urban areas are moderately and severely stunted to a lesser extent (24 percent), when compared with rural children (32 percent). At the provincial level, Coast Province (35 percent) has the highest proportion of stunted children, while Nairobi Province has the lowest (19 percent). The mother’s level of education has an inverse relationship with stunting levels. For example, children of mothers with at least some secondary education have the lowest stunting levels (19 percent), while children whose mothers have no education have the highest level of stunting (36 percent). 3 Tabulating the data for 2003 only for children whose mothers were interviewed and omitting the northern areas of Kenya so as to be comparable to prior KDHS data shows that the proportion stunted has declined from 33 percent in 1998 to 31 percent in 2003 while the proportion severely stunted has declined from 13 to 11 percent. Nutrition | 165 Table 10.7 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height- for-age, weight-for-height, and weight-for-age, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Height-for-age Weight-for-height Weight-for-age –––––––––––––––––––––––––– –––––––––––––––––––––––––– –––––––––––––––––––––––––– Percent- Percent- Percent- Percent- Percent- Percent- age age Mean age age Mean age age Mean Number Background below below Z-score below below Z-score below below Z-score of characteristic -3 SD -2 SD1 (SD) -3 SD -2 SD1 (SD) -3 SD -2 SD1 (SD) children –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 0.9 7.4 (0.1) 0.6 3.9 0.5 0.0 2.4 0.4 511 6-9 3.6 12.1 (0.6) 0.7 4.8 (0.0) 1.9 10.2 (0.5) 395 10-11 4.3 21.2 (0.9) 2.7 8.1 (0.3) 3.9 24.1 (1.0) 215 12-23 15.9 43.1 (1.7) 2.3 9.5 (0.4) 7.8 26.8 (1.3) 1,086 24-35 13.6 35.5 (1.5) 1.4 5.5 (0.3) 5.2 25.3 (1.2) 1,005 36-47 13.3 34.1 (1.4) 0.8 4.3 (0.3) 3.2 20.8 (1.1) 1,100 48-59 10.1 27.9 (1.3) 0.5 3.4 (0.3) 2.9 17.8 (1.0) 995 Sex Male 11.6 32.9 (1.4) 1.3 6.4 (0.3) 4.6 22.0 (1.0) 2,663 Female 10.4 27.7 (1.1) 1.2 4.8 (0.2) 3.6 17.7 (0.9) 2,643 Birth order 1 8.5 26.3 (1.2) 1.2 5.5 (0.2) 2.8 17.6 (0.9) 1,127 2-3 9.8 29.6 (1.2) 0.9 5.1 (0.2) 3.5 17.5 (0.9) 1,774 4-5 13.1 33.5 (1.3) 1.8 6.6 (0.2) 5.3 22.8 (1.0) 1,035 6+ 12.7 34.6 (1.3) 1.4 5.6 (0.3) 5.0 24.1 (1.0) 995 Birth interval in months First birth 8.8 26.4 (1.2) 1.2 5.5 (0.2) 2.8 17.8 (0.9) 1,132 <24 14.5 34.5 (1.4) 0.9 6.3 (0.2) 5.5 23.9 (1.0) 810 24-47 10.9 33.0 (1.3) 1.7 6.1 (0.3) 4.6 20.8 (1.0) 2,091 48+ 9.8 27.0 (1.1) 0.6 4.2 (0.1) 3.0 17.1 (0.8) 898 Size at birth Very small 20.5 40.7 (1.7) 0.2 8.7 (0.4) 11.2 34.1 (1.4) 166 Small 17.6 40.3 (1.7) 1.5 8.4 (0.5) 7.4 33.6 (1.5) 601 Average or larger 9.4 28.9 (1.2) 1.3 5.1 (0.2) 3.3 17.4 (0.9) 4,147 Residence Urban 9.3 23.6 (1.0) 1.0 4.2 0.1 2.8 12.6 (0.6) 882 Rural 11.3 31.7 (1.3) 1.3 5.8 (0.3) 4.4 21.3 (1.0) 4,425 Province Nairobi 5.3 18.7 (0.7) 1.2 4.5 0.2 1.9 6.3 (0.3) 304 Central 8.7 27.0 (1.1) 1.1 4.4 (0.0) 2.2 14.6 (0.7) 571 Coast 13.9 34.9 (1.5) 0.0 5.7 (0.3) 5.9 25.4 (1.2) 426 Eastern 12.9 32.5 (1.4) 0.9 4.2 (0.3) 4.2 21.4 (1.1) 888 Nyanza 7.9 31.1 (1.2) 0.1 2.3 (0.0) 2.4 15.6 (0.7) 826 Rift Valley 12.3 31.6 (1.3) 1.6 7.7 (0.4) 5.2 24.0 (1.1) 1,427 Western 11.8 30.2 (1.3) 1.2 4.5 (0.2) 4.2 19.0 (0.9) 739 North Eastern 12.3 24.3 (0.6) 10.9 26.5 (1.2) 9.9 33.7 (1.4) 127 Education No education 16.3 36.4 (1.4) 3.5 14.8 (0.6) 9.9 33.1 (1.3) 731 Primary incomplete 12.5 34.8 (1.4) 1.2 5.1 (0.2) 4.0 21.9 (1.1) 1,838 Primary complete 9.9 30.5 (1.3) 0.6 2.8 (0.2) 2.9 17.3 (0.9) 1,387 Secondary+ 5.2 19.2 (0.8) 0.5 3.6 0.1 1.7 10.6 (0.5) 1,069 Mother's age 15-19 12.6 32.5 (1.3) 1.7 7.7 (0.2) 4.9 20.3 (0.9) 322 20-24 9.7 30.8 (1.3) 1.1 5.4 (0.2) 3.1 18.3 (0.9) 1,324 25-29 10.9 29.2 (1.3) 1.6 5.9 (0.3) 4.6 21.3 (1.0) 1,421 30-34 9.6 29.7 (1.2) 0.8 4.4 (0.2) 3.2 19.8 (0.9) 988 35-49 12.7 32.2 (1.3) 1.0 5.6 (0.2) 5.2 19.8 (0.9) 968 Wealth quintile Lowest 14.2 38.1 (1.5) 2.3 9.0 (0.5) 7.8 29.6 (1.3) 1,312 Second 11.3 32.6 (1.3) 1.0 5.9 (0.3) 3.0 20.3 (1.1) 1,163 Middle 11.1 29.9 (1.3) 0.6 3.7 (0.1) 3.6 18.4 (0.9) 1,041 Fourth 10.3 27.3 (1.2) 0.8 4.1 (0.1) 3.0 17.2 (0.8) 928 Highest 6.3 19.2 (0.8) 1.0 3.8 0.1 1.9 9.2 (0.4) 864 Children of interviewed mothers 10.8 30.7 (1.3) 1.2 5.6 (0.2) 4.0 19.9 (1.0) 4,931 Children of noninterviewed mothers Mother in the household 10.4 22.5 (0.9) 0.0 1.7 (0.2) 4.9 15.9 (0.8) 93 Mother not in the household 14.5 27.0 (1.1) 0.9 5.9 (0.3) 5.1 20.0 (0.9) 283 Total 11.0 30.3 (1.2) 1.2 5.6 (0.2) 4.1 19.9 (0.9) 5,307 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table is based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the NCHS/CDC/WHO International Reference Population. The percentage of children who are more than three or more than two standard deviations below the median of the International Reference Population (-3 and -2 SD) are shown according to background characteristics. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total in- cludes 14 children with size at birth missing. 1 Includes children who are below -3 SD from the International Reference Population median 2 Excludes children whose mothers were not interviewed 3 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 4 For women who are not interviewed, information is taken from the Household Questionnaire. It excludes children whose mothers are not listed in the household schedule. 5 Includes children whose mothers are deceased 166 | Nutrition There seems to be no discernible relationship between the mother’s age group and stunting levels. Wealth is negatively related to stunting; that is, stunting declines as wealth increases. Wasting Weight-for-height measures body mass in relation to body length and describes current nutritional status. A child who is below -2 SD from the reference median for weight-for-height is considered to be too thin for his/her height, or “wasted,” a condition reflecting acute malnutrition. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or recent episodes of illness causing loss of weight and the onset of malnutri- tion. As with stunting, wasting is considered severe if the child is below -3 SD from the reference mean. Severe wasting is closely linked to an elevated risk of mortality. Prevalence of wasting may vary consid- erably by season. Table 10.7 also shows the nutritional status of children under five years as measured by wasting children. Nationally, 6 percent of children are wasted, and the proportion of severely wasted children is 1 percent. This represents only a 1 percentage point decline since 1998 (from 6 percent in 1998 to 5 percent in 2003, when the northern areas have been excluded). Wasting is highest (10 percent) in children age 12-23 months and lowest (3 percent) in children age 48-59 months. The survey data show few sharp differences in wasting by background characteristics except that the level among children in North Eastern Province is extraordinarily high (27 percent). Eleven percent of children in North Eastern Province are severely wasted. These levels may reflect food stress in the province, which is traditionally a region with food deficits. Women with no education also have very high levels of wasted and severely wasted children (15 and 4 percent, respectively). Underweight Weight-for-age is a composite index of height-for-age and weight-for-height and, thus, does not distinguish between acute malnutrition (wasting) and chronic malnutrition (stunting). A child can be un- derweight for his age because he is stunted, wasted, or both. Weight-for-age is a useful tool in clinical settings for continuous assessment of nutritional progress and growth. Children whose weight-for-age is below -2 SD from the median of the reference population are classified as “underweight.” In the refer- ence population, only 2.3 percent of children fall below -2 SD for each of these three indices. As shown in Table 10.7, 20 percent of children under five are underweight, representing a slight decline from the 1998 KDHS results (22 percent). The proportion of severely underweight children is 4 percent. The proportion of underweight children is highest (27 percent) in the 12-23 months age group and lowest (2 percent) for those less than six months of age. Male children (22 percent) are more likely to be underweight than female children (18 percent). Urban children are less likely to be underweight (13 percent) than rural children (21 percent). At the provincial level, North Eastern Province has the highest proportion of moderate and severely under- weight children (34 percent), while Nairobi Province has the lowest proportion (6 percent). The proportion of underweight children is negatively correlated with the level of education of the mother. Children whose mothers have no education have the highest levels of being underweight (33 per- cent), while the proportion for children of mothers with some secondary education is lowest (11 percent). Wealth is also negatively correlated with the proportion of children who are underweight. Nutrition | 167 Trends in Nutritional Status of Children Table 10.8 compares the nutritional status indicators of children under five years from KDHS 2003 with previous surveys (Multiple Indicator Cluster Survey 2000 and 1998 KDHS). The trends show that the nutrition status of children under five years has improved only slightly at the national level. At the provincial level, Nairobi and Nyanza Provinces show remarkable declines in stunting, wasting, and un- derweight indicators when compared with previous surveys. Data from North Eastern Province cannot be compared since previous surveys did not fully cover this province. Table 10.8 Trends in nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutri- tional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Kenya 1993-2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Height-for-age Weight-for-height Weight-for-age (stunting) (wasting) (underweight) Background –––––––––––––––––––––– –––––––––––––––––––––– –––––––––––––––––––––– characteristic 19981 20002 20033 19981 20002 20033 19981 20002 20033 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 7.1 12.4 7.6 5.2 2.4 3.7 2.3 3.0 2.5 6-11 17.5 24.5 15.7 7.8 3.9 5.7 14.8 14.6 14.9 12-23 41.8 47.5 43.7 9.1 9.9 8.3 26.9 28.4 25.9 24-35 37.8 34.8 35.4 4.9 6.6 5.0 28.3 22.5 24.4 36-47 35.6 34.5 34.7 4.9 4.1 3.0 23.8 19.4 19.5 48-59 38.0 34.7 27.7 4.0 4.9 2.6 22.7 21.9 16.9 Sex Male 35.2 37.9 33.3 5.9 6.6 5.5 22.2 22.6 20.8 Female 30.8 32.6 27.8 6.2 5.3 4.0 22.0 19.6 17.3 Residence Urban 24.7 26.6 23.5 5.1 3.3 3.5 13.3 12.4 11.7 Rural 34.7 38.0 32.0 6.2 6.8 5.1 23.9 23.9 20.6 Province Nairobi 25.7 29.6 18.7 7.1 3.1 4.5 11.4 12.4 6.3 Central 27.5 27.4 27.0 5.6 4.6 4.4 14.3 15.4 14.6 Coast 39.1 33.7 34.9 4.3 6.4 5.7 27.4 21.1 25.4 Eastern 36.8 42.8 32.7 4.7 7.8 4.2 25.7 29.6 21.2 Nyanza 30.8 35.9 31.1 7.0 5.2 2.3 22.2 19.9 15.6 Rift Valley 33.1 36.8 32.0 7.4 7.6 6.8 24.9 24.9 22.8 Western 35.0 38.1 30.2 4.6 5.5 4.5 19.1 21.5 19.0 Education4 No education 46.4 37.2 41.9 8.8 7.1 11.8 36.8 24.1 32.4 Primary incomplete 39.7 na 34.8 6.5 na 5.2 26.9 na 21.9 Primary complete 31.5 na 30.3 6.4 na 2.7 19.9 na 17.0 Secondary+ 19.2 25.6 19.2 3.9 3.4 3.6 11.0 13.7 10.7 Total 33.0 35.3 30.6 6.1 6.0 4.8 22.1 21.2 19.1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Numbers refer to the percentage of children who are more than two standard deviation units (SD) from the me- dian of the NCHS/CDC/WHO International Reference Population. Table is based on children who stayed in the house- hold the night before the interview and who have valid dates of birth (month and year) and valid measurement of both height and weight. na = Not applicable 1 1998 KDHS; excludes children whose mothers were not interviewed 2 2000 Multiple Indicator Cluster Survey (CBS, 2001); total includes areas in urban Northeast Province 3 2003 KDHS; excludes northern districts 4 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the household schedule. 168 | Nutrition 10.4 NUTRITIONAL STATUS OF WOMEN The 2003 KDHS also collected data on the height and weight of women. The data are used to de- rive two measures of nutritional status: height and body mass index (BMI). A woman’s height can be used to predict the risk of having difficulty in pregnancy, given the relationship between height and pelvic size. The cutoff point at which mothers can be considered at risk because of low stature is normally taken to be between 140 and 150 centimetres (cm). The BMI or Quetelet index is used to measure thinness or obesity. It is defined as weight in kilograms divided by height in metres squared (kg/m2). A cutoff point of 18.5 is used to define thinness or acute undernutrition. A BMI of 25 or above usually indicates over- weight or obesity. Table 10.9 shows nutritional indicators for women by various background characteristics. At the national level, the mean height for women is 159 cm., with only 1 percent of women falling below the 145-cm. cutoff. Variation by background characteristics is minimal. The mean BMI for women age 15-49 is 23. Analysis by background characteristics shows that the mean BMI is less than 25 for all classifications. Since 1998, the mean BMI has increased very slightly from 22 to 23, when the same areas of the country are compared. At the national level, the proportion of severely thin women stands at 2 percent (BMI < 16.0). Differentials are few except that North Eastern Province stands out with the highest proportion of se- verely thin women (7 percent). The proportion of overweight or obese women stands at 23 percent. The proportion of over- weight or obese women is positively correlated with the woman’s age. Thus, the group age 45-49 has the highest proportion (41 percent) of overweight or obese women, while the group age 15-19 has the lowest (8 percent) proportion of overweight or obese women. The data show that the proportion of women living in urban areas who are overweight or obese (39 percent) is higher than that for women in rural areas (18 percent). Provincial comparison shows that North Eastern Province has the lowest proportion of overweight or obese women (8 percent), while Nai- robi Province has the highest proportion of overweight or obese women (39 percent). Education has a positive relationship with overweight levels; better educated women are more likely to be overweight or obese (34 percent) than those with no education (15 percent). Nutrition | 169 Table 10.9 Nutritional status of women by background characteristics Among women age 15-49, mean height, percentage under 145 centimetres (cm), mean body mass index (BMI), and percentage with specific BMI levels, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Height BMI1 (kg/m2) –––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Normal Thin Overweight/obese –––––––– ––––––––––––––––––––––––––––––––––– –––––––––––––––––––––– Percent- 17.0- 16.0- ≥25.0 25.0- Mean age Number 18.5- 18.4 16.9 <16.0 (over- 29.9 Number Background height below of Mean 24.9 <18.5 (mildly (moderately (severely) weight/ (over- ≥30.0 of characteristic in cm 145 cm women BMI (normal) (thin) thin) thin) thin) obese) weight) (obese) women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 158.0 2.0 1,746 20.9 71.7 20.4 12.7 4.1 3.6 7.9 7.5 0.4 1,612 20-24 160.0 1.0 1,605 22.2 73.7 9.3 6.8 1.9 0.6 17.0 14.6 2.4 1,378 25-29 160.2 0.4 1,289 22.4 68.9 11.0 8.5 1.5 1.0 20.1 15.4 4.8 1,128 30-34 159.8 0.9 1,033 23.5 59.2 9.6 7.1 1.5 0.9 31.3 22.7 8.6 934 35-39 159.8 0.5 828 24.1 53.4 9.8 6.5 2.6 0.7 36.8 24.2 12.6 783 40-44 159.7 1.0 749 24.2 50.2 10.9 6.7 2.3 2.0 38.9 24.2 14.7 725 45-49 158.8 1.0 488 24.4 51.0 8.3 5.5 1.9 0.9 40.7 26.8 13.9 487 Residence Urban 159.6 0.8 1,899 24.5 55.9 5.4 4.1 0.9 0.4 38.7 26.4 12.3 1,759 Rural 159.4 1.1 5,840 22.1 67.1 14.6 9.7 2.9 2.0 18.3 14.0 4.4 5,288 Province Nairobi 160.0 0.7 786 24.6 56.4 4.5 3.8 0.4 0.4 39.1 26.9 12.2 721 Central 158.9 1.5 1,120 23.8 59.1 7.1 4.6 1.9 0.6 33.9 24.3 9.5 1,046 Coast 157.1 2.5 634 23.0 60.2 13.3 8.1 3.4 1.8 26.5 16.6 9.9 567 Eastern 157.2 1.8 1,249 22.2 68.4 13.0 9.1 2.5 1.4 18.6 14.3 4.3 1,160 Nyanza 160.9 0.7 1,178 22.1 72.8 10.6 7.5 1.1 2.0 16.6 12.8 3.8 1,050 Rift Valley 160.2 0.4 1,722 22.1 60.4 18.6 12.4 3.8 2.3 21.1 15.6 5.5 1,579 Western 160.9 0.3 902 22.1 71.6 11.9 8.4 2.5 1.0 16.4 13.2 3.2 798 North Eastern 160.6 2.0 148 19.9 65.0 27.5 14.2 6.0 7.3 7.5 7.1 0.4 125 Education No education 159.2 1.1 969 21.2 60.6 24.5 15.2 5.6 3.7 15.0 10.6 4.4 858 Primary incomplete 158.4 1.8 2,554 21.6 67.4 16.8 11.0 3.1 2.7 15.8 12.8 3.0 2,300 Primary complete 159.8 0.8 1,943 23.0 67.2 8.5 6.2 1.7 0.6 24.3 18.0 6.3 1,746 Secondary+ 160.4 0.5 2,274 24.1 60.1 5.7 4.4 0.9 0.3 34.2 23.5 10.7 2,142 Wealth quintile Lowest 159.1 1.2 1,299 20.7 68.3 22.9 14.3 4.9 3.6 8.9 7.3 1.6 1,149 Second 159.1 1.2 1,409 21.4 70.3 16.9 11.7 2.9 2.3 12.9 10.5 2.4 1,256 Middle 159.6 0.8 1,426 22.3 68.6 12.3 8.7 2.3 1.3 19.1 14.4 4.7 1,303 Fourth 159.4 1.2 1,625 23.1 63.6 9.9 6.6 2.2 1.2 26.5 20.2 6.3 1,497 Highest 159.7 0.8 1,979 24.7 55.2 4.5 3.4 0.8 0.3 40.2 27.1 13.2 1,841 Total 159.4 1.1 7,739 22.7 64.3 12.3 8.3 2.4 1.6 23.4 17.1 6.3 7,047 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Excludes pregnant women and women with a birth in the preceding two months Malaria | 171 MALARIA 11 Kiambo Njagi and Eric Were 11.1 MALARIA CONTROL AND PREVENTION STRATEGIES IN KENYA Malaria affects 20 million Kenyans annually; the cumulative human suffering and economic loss caused by malaria is immense (Snow et al., 1998). It is estimated that, annually, 26,000 children under five years of age (72 per day) die from the direct consequence of malaria infection (Snow et al., 1998), and pregnant women suffer severe anaemia and have a high likelihood of delivering infants with low birth weight (Menendez, 1999). All Kenyan households are affected by the financial hardship caused by ma- laria. It is estimated that 170 million working days are lost each year because of malarial illness, which in turn affects the country’s economy, leading to increased poverty (Ministry of Health, n.d.). The distribution of malaria is not uniform, because of geographical differences in altitude, rain- fall and humidity. These factors influence transmission patterns, as they determine vector densities and intensity of biting. The country may be divided into four malaria ecozones: 1) stable malaria (Nyanza, Coast, and Western provinces, 2) seasonal malaria (Central, Eastern, and North Eastern Provinces) 3) highlands prone to malaria epidemics (mainly in Rift Valley Province and some parts of Nyanza Prov- ince), and 4) malaria free (Nairobi and some parts of Central Province). The Kenya government is committed to the control and prevention of malaria. To this effort, it has developed a strategy document outlining several intervention measures. The four intervention meas- ures outlined in the National Malaria Strategy (NMS) document are 1) management of malarial illness; 2) vector control by use of insecticide-treated mosquito nets (ITNs) and other methods, such as indoor house spraying; 3) control of malaria in pregnancy; and 4) control of malaria epidemics (Ministry of Health, no date). Data from the 2003 Kenya Demographic and Health Survey (KDHS) can be used to assess the ex- tent of implementation of several of these malaria control strategies. 11.2 HOUSEHOLD OWNERSHIP OF MOSQUITO NETS Untreated nets and window screening have long been considered useful protection methods against mosquitoes and other insects (Lindsay and Gibson, 1988). Nets reduce the human-vector contact by acting as a physical barrier and thus reducing the number of bites from infective vectors (Bradley et al., 1986). However, nets and screens are often not well fitted or are torn, thus allowing mosquitoes to enter or feed on the part of the body adjacent to the netting fabric during the night (Lines et al., 1987). The problem of ill-used nets and screens provides one of the motives for treating them with a fast-acting insecticide that will repel or kill mosquitoes before or shortly after feeding (Lines et al., 1987; Hossain and Curtis, 1989). Over the past two decades, significant advances have been made in the prevention of malaria us- ing ITNs and curtains. The treatment of nets has been made possible by the availability of synthetic pyre- throids, the only insecticides currently used for treatment of nets. This class of insecticides was developed to mimic the insecticidal compounds of natural pyrethrum. Synthetic pyrethroids have low mammalian toxicity; are repellent, highly toxic to mosquitoes, and odourless; and have low volatility with consequent long persistence. Their development has led to treatment of nets as a method of vector control. ITNs are regarded as a promising malaria control tool, and when used by all or most members of the community, they may reduce malaria transmission. The Government of Kenya is committed to 172 | Malaria achieving the goal of 60 percent of households using nets by 2006, according to the targets set in the na- tional malaria control strategy. To this end, the government has created an enabling environment by fos- tering private-sector growth in the provision of unsubsidised, affordable ITNs and ensuring complemen- tarity with alternative approaches offered by nonprofit, social marketing organisations. Moreover, free net distribution to pregnant women attending antenatal health services is carried out around Africa Malaria Day (25 April) in selected malaria-endemic districts. There have been no nationally representative net usage figures apart from periodic monitoring of net coverage and retreatment in a few sentinel districts in the Roll Back Malaria campaign, which esti- mated net usage at 15 to 20 percent of households. Regular, national evaluation of the ITN programme is important to the government for determination of the gaps in achieving the national targets. As a means of filling this gap, the 2003 KDHS Household Questionnaire included questions on net ownership and re- treatment practices. Table 11.1 provides information on the percentage of households that have a net and the percentage that have an ITN, according to residence, province, and wealth index. Overall, 22 percent of households in Kenya have mosquito nets, while 10 percent have more than one net. This is about one-third of the target of 60 percent coverage by 2006. Six percent of households have at least one ITN, and 3 percent have more than one ITN. Table 11.1 Ownership of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), and the per- centage of households that have at least one and more than one insecticide-treated net (ITN), by background char- acteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Percentage Percentage Percentage of house- of house- of house- of house- holds with holds with Average holds with holds with Average Background at least more than number at least more than number Number of characteristic one net one net of nets one ITN1 one ITN1 of ITNs1 households –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 37.6 18.8 0.7 10.6 5.0 0.2 2,138 Rural 16.6 7.2 0.3 4.4 1.9 0.1 6,423 Province Nairobi 37.0 19.5 0.7 6.9 3.0 0.1 837 Central 16.2 8.0 0.3 3.4 2.0 0.1 1,351 Coast 34.2 16.4 0.6 10.0 4.8 0.2 684 Eastern 16.8 7.8 0.3 4.6 2.5 0.1 1,316 Nyanza 32.1 13.2 0.5 11.3 5.3 0.2 1,282 Rift Valley 11.0 5.0 0.2 3.0 1.1 0.0 1,937 Western 19.8 7.6 0.3 6.7 2.4 0.1 967 North Eastern 37.0 18.9 0.7 2.7 1.2 0.0 187 Wealth quintile Lowest 11.2 2.8 0.1 2.5 0.3 0.0 1,391 Second 11.4 2.9 0.2 2.6 0.8 0.0 1,529 Middle 14.0 6.2 0.2 4.2 1.9 0.1 1,653 Fourth 24.4 12.0 0.4 5.6 3.1 0.1 1,728 Highest 39.3 20.7 0.7 11.7 5.8 0.2 2,260 Total 21.8 10.1 0.4 5.9 2.7 0.1 8,561 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 In this table, an insecticide-treated net refers to a net that was treated with insecticide within the six months pre- ceding the survey. Malaria | 173 Table 11.2 Use of mosquito nets by children Percentage of children under five years who slept under a mos- quito net (treated or untreated) the night before the survey and percentage who slept under an insecticide-treated net (ITN), by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Percentage who slept who slept Number Background under a net under an ITN of characteristic last night last night children –––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <12 17.9 5.4 1,302 12-23 14.5 4.2 1,172 24-35 15.6 5.0 1,107 36-47 11.8 3.8 1,221 48-59 12.6 4.7 1,118 Sex Male 14.9 5.1 2,972 Female 14.2 4.1 2,947 Residence Urban 32.6 9.8 1,040 Rural 10.7 3.5 4,880 Province Nairobi 38.0 8.1 344 Central 12.2 3.9 650 Coast 22.4 7.5 486 Eastern 12.3 3.9 977 Nyanza 16.9 7.4 896 Rift Valley 7.6 2.5 1,618 Western 12.4 4.8 779 North Eastern 30.2 1.2 170 Wealth quintile Lowest 6.4 1.2 1,450 Second 7.0 2.2 1,263 Middle 11.4 4.9 1,146 Fourth 18.3 4.8 1,046 Highest 35.3 12.0 1,015 Total 14.5 4.6 5,920 –––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table is based on de facto children under five in the house- hold. Although the burden of malaria is greater in rural areas, net coverage and ITN coverage are both higher in urban areas than in rural areas. Nairobi Province, which is entirely urban, has the highest per- centage of households with nets (37 percent); surprisingly, this percentage is identical to that for North Eastern Province, which is predominantly rural and arid. This implies that socioeconomic status alone does not determine the level of net ownership. Net coverage is lowest in Rift Valley Province (11 per- cent). ITN coverage patterns differ, with the highest ITN ownership in Nyanza and Coast Provinces. De- spite the various programmes to encourage subsidised net distribution, net ownership is strongly related to wealth, as shown in Table 11.1. The percentage of households with at least one net ranges from 11 per- cent among the poorest households to 39 percent among the wealthiest. 11.3 USE OF MOSQUITO NETS Age is an important factor in deter- mination of levels of acquired immunity against malaria. For the first six months of life, antibodies acquired from the mother during pregnancy protect children born in areas en- demic for malaria. This is gradually lost, as children start developing their own immunity over a period of time. The level of immunity developed depends on the level of exposure to malaria infection, but it is believed that in high- ly malaria-endemic areas, children are immune by the fifth birthday. Such children no longer suffer from severe life-threatening malaria. Immunity in areas of low malaria transmission is acquired more slowly, and malarial illness affects all members of the community, regard- less of age. The Government of Kenya recog- nises children under five years of age as a high- risk group and recommends that this group should be protected by sleeping under ITNs. Table 11.2 shows information on use of any nets and ITNs by children under five years of age. The table shows that overall, 15 percent of children under five slept under a net the night before the survey, with only 5 percent having slept under an ITN. There is a slight decline in use of any net as children age; however, there are no major differences in use of nets by sex of the child or in use of ITNs by age of the child or by sex of the child. Wealth is highly related to net use, with the proportion of children sleeping under a net ranging from 6 percent in the poorest group to 35 percent in the wealthiest group. The proportion of children who slept under any type of net ranges from 8 percent in Rift Valley Province to 38 percent in Nairobi. Use of ITNs ranges from 1 percent of children in North Eastern Prov- ince to 8 percent in Nairobi and Coast provinces. Provinces with the highest burden of malaria—Nyanza, Coast, and Western—have intermediate levels of overall net usage but have relatively high levels of use 174 | Malaria of ITNs. Nevertheless, it is surprising that Nairobi, which is malaria-free, shows the highest level of use of any net and ITNs. Pregnancy leads to a depression of immunity. In malaria-endemic areas, adults acquire some im- munity, which protects them from malaria infection. However, pregnant women, especially those in their first pregnancies, have a higher risk of malaria infection. Sometimes these malaria infections remain asymptomatic but lead to development of malaria anaemia. Asymptomatic malaria infection also inter- feres with the maternal-foetus exchange, leading to low birth weight infants. To reduce the risk of malaria infection during pregnancy, the NMS target is for 60 percent of pregnant women to sleep under ITNs. The 2003 KDHS collected information on usage of nets by women. Table 11.3 shows the percentage of all women and pregnant women who slept under nets and ITNs the night preceding the survey. Sixteen percent of all women used nets, but only 5 percent slept un- der an ITN. Among pregnant women, 13 percent slept under a net, and 4 percent slept under an ITN. Table 11.3 Use of mosquito nets by pregnant women Percentage of all women and pregnant women age 15-49 who slept under a mosquito net (treated or untreated) the night before the survey and percentage who slept under an insecticide-treated net (ITN), by background char- acteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of Percentage of Percentage of Percentage of all women all women pregnant pregnant Number who slept who slept Number women who women who of Background under a net under an ITN of all slept under slept under an pregnant characteristic last night last night women net last night ITN last night women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 30.3 9.3 2,177 25.7 4.8 132 Rural 11.0 3.2 6,538 9.9 4.3 515 Province Nairobi 31.6 7.0 882 29.5 2.1 52 Central 12.3 3.6 1,255 22.6 9.6 58 Coast 25.3 7.9 710 18.4 4.7 56 Eastern 12.6 3.8 1,406 9.9 3.8 106 Nyanza 20.4 8.0 1,300 20.3 9.1 105 Rift Valley 8.3 2.2 2,001 2.0 1.0 159 Western 12.1 4.1 984 6.2 3.1 90 North Eastern 23.9 2.1 178 26.4 6.8 20 Education No education 10.2 1.9 1,139 10.4 1.1 95 Primary incomplete 8.5 2.6 2,863 6.2 2.2 249 Primary complete 14.1 4.4 2,162 16.0 7.9 175 Secondary+ 28.1 8.6 2,537 24.6 6.6 127 Wealth quintile Lowest 5.8 1.1 1,452 5.7 1.7 131 Second 6.5 1.9 1,582 6.4 2.2 141 Middle 9.7 3.4 1,597 8.6 6.5 122 Fourth 16.4 4.6 1,808 17.4 6.3 118 Highest 32.6 9.9 2,275 27.5 5.9 135 Total 15.8 4.7 8,715 13.1 4.4 647 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table is based on de facto women in the household. Malaria | 175 Use of nets and ITNs is higher among urban than rural women. Net use also varies by province. Use of any net is highest among women in Nairobi Province, while use of ITNs is highest among all women in Nyanza and Coast Provinces and among pregnant women in Central and Nyanza Provinces. Rift Valley Province has the lowest proportion of women using nets and ITNs. As expected, the rate of net usage generally increases with the level of education. For example, 10 percent of women with no education slept under a net the night before the survey, compared with 28 percent of those with at least some secondary education. Wealth is also strongly related to use of nets and ITNs, with 33 percent of the wealthiest women using a net, compared with 6 percent of the poorest. Simi- larly, 28 percent of the wealthiest pregnant women use nets, compared with 6 percent of the poorest. 11.4 INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY Government policy calls for pregnant women to receive two doses of intermittent preventive treatment (IPT) in the second and third trimesters in order to reduce the risk of malaria infection. IPT us- ing sulphadoxine and pyrimethamine (SP) (Fansidar) was introduced in Kenya in 1998 as a replacement to chloroquine prophylaxis, because of very high levels of chloroquine resistance. All pregnant women living in areas of high malaria transmission are supposed to receive two doses of SP. Some pregnant women may have received chloroquine prophylaxis, as the drug was still in stock for some time after the change of antimalarial drug policy. In the 2003 KDHS, women who had a live birth in the five years pre- ceding the survey were asked whether they had taken any drugs to prevent getting malaria during the pregnancy for their most recent birth and, if yes, which drug. If they had taken SP, they were further asked how many times they took it and whether they had received it during an antenatal care visit. Table 11.4 shows the percentage of pregnant women who took antimalarial drugs for prevention and those who received IPT during an antenatal care visit. Twenty-one percent of women said they took drugs for malaria prevention during pregnancy. There are few differences in the percentage of pregnant women receiving antimalarial drugs for protection by urban-rural residence, birth order, or wealth quintile. There is a slight increase with education and among more recent births. Coast and Western provinces have the highest proportion of pregnant women receiving antimalarial drugs for prevention, while Nairobi Province has the lowest. Only 4 percent of women reported receiving IPT1 during an antenatal care visit. The highest pro- portion of women receiving IPT during an antenatal visit is observed in Western Province (7 percent), while the lowest are in North Eastern and Central provinces (2 percent each). There is also an increase in IPT coverage with increasing education of the mother, from 2 percent of those with no education to 6 per- cent of those with some secondary or higher education. 1 IPT is defined here as receiving at least two doses of SP during an antenatal care visit. 176 | Malaria Table 11.4 Use of antimalarial drugs among pregnant women Of women who had a live birth in the five years preceding the survey, per- centage who took antimalarial drugs for prevention during pregnancy for the most recent birth and percentage who received intermittent preventive treatment (IPT) during antenatal care visits for the most recent birth, by back- ground characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of Percentage of pregnant women pregnant women who took any who received IPT1 Number Background antimalarial drug during antenatal of characteristic for prevention care visits women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 20.3 4.2 835 Rural 21.2 3.9 3,217 Province Nairobi 11.9 2.3 307 Central 14.1 2.0 495 Coast 35.5 5.7 336 Eastern 22.6 4.8 646 Nyanza 19.7 4.8 643 Rift Valley 17.5 2.5 1,052 Western 31.6 7.0 470 North Eastern 19.1 1.8 102 Education No education 18.6 2.3 582 Primary incomplete 19.0 3.0 1,395 Primary complete 20.7 4.0 1,143 Secondary+ 25.8 6.1 932 Birth order 1-2 21.6 4.3 1,692 3-4 20.8 4.0 1,155 5+ 20.3 3.3 1,205 Timing of birth <1 year ago 23.4 4.2 1,293 1 year ago 23.0 4.9 1,123 2 years ago 17.7 3.9 735 3 years ago 16.5 2.7 533 4 years ago 19.5 1.8 368 Wealth quintile Lowest 21.6 3.0 869 Second 20.2 4.7 830 Middle 22.3 4.7 777 Fourth 19.2 3.4 725 Highest 21.5 3.9 851 Total 21.0 3.9 4,052 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Intermittent preventive treatment refers to receiving two or more doses of SP during antenatal care visits. Malaria | 177 Table 11.5 shows details about women who took an antimalarial drug during the pregnancy lead- ing to their most recent live birth in the five years preceding the survey. The data show that 60 percent of pregnant women who took antimalarial drugs took SP. Differences by background characteristics in the proportion of treated women who took SP are not large, though SP treatment is more common in North Eastern Province and increases with level of education. The IPT policy recommends that pregnant women living in areas of high malaria transmission take two doses of SP during pregnancy: the first at the beginning of the second trimester and the second at the beginning of the third trimester. Some women may receive a third dose if they become fall sick. As shown in Table 11.5, half of all women who receive SP during pregnancy take only one dose, one-quarter take two doses, and another one-quarter take three or more doses. Women who take SP in provinces with endemic malaria—Nyanza, Coast, and Western—are no more likely than women in other provinces are to take two or more doses of SP. Table 11.5 Use of SP for intermittent treatment Among women who had a live birth in the five years preceding the survey and who took antimalarial drugs for preven- tion during pregnancy for the most recent birth, percentage who took sulfadoxine-pyrimethamine (SP) and among those who took SP, percent distribution by the number of times taken, according to background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Among those who took SP, Number percentage who took it: of mothers –––––––––––––––––––––––––––––––––––– who took an Three Don’t Number Background Percentage antimalarial times or know/ of mothers characteristic who took SP drug Once Twice or more missing who took SP ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 64.3 169 53.1 26.1 18.4 2.4 109 Rural 58.4 681 49.4 23.6 24.4 2.6 398 Province Nairobi 59.4 36 (55.7) (29.7) (14.6) (0.0) 22 Central 48.6 70 (37.5) (23.9) (34.5) (4.1) 34 Coast 55.5 120 60.6 23.2 14.3 1.9 66 Eastern 51.4 146 38.9 32.7 25.7 2.8 75 Nyanza 67.6 126 51.9 23.2 24.9 0.0 85 Rift Valley 60.2 185 51.3 17.8 25.7 5.2 111 Western 65.9 148 54.4 23.8 19.6 2.2 98 North Eastern 79.9 20 (38.0) (32.3) (29.6) (0.0) 16 Education No education 53.5 108 47.9 28.5 21.2 2.4 58 Primary incomplete 51.4 265 47.5 22.9 25.3 4.4 136 Primary complete 61.4 237 52.6 20.4 25.2 1.9 145 Secondary+ 69.6 241 51.2 26.9 20.3 1.6 168 Birth order 1-2 58.2 366 47.5 24.6 24.9 3.0 213 3-4 65.9 240 49.9 27.1 20.4 2.6 158 5+ 55.5 245 54.9 20.0 23.5 1.7 136 Wealth quintile Lowest 58.2 188 51.6 21.5 22.5 4.5 109 Second 58.2 167 43.7 22.9 31.0 2.4 97 Middle 62.1 173 53.3 29.0 17.7 0.0 108 Fourth 61.8 139 44.3 24.7 26.2 4.8 86 Highest 58.3 183 56.4 22.7 19.6 1.3 107 Total 59.6 850 50.2 24.1 23.1 2.5 507 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Numbers in parentheses are based on 25-49 unweighted cases. 178 | Malaria Among women who took SP and also received antenatal care for their most recent pregnancy, 69 percent received the SP at the antenatal visit, 18 percent received it at another facility visit, and 13 per- cent obtained the SP from another source (data not shown). 11.5 MALARIA CASE MANAGEMENT AMONG CHILDREN The Government of Kenya recognises that most malarial fevers and convulsions occur at home, and it has accepted that prompt and effective malaria treatment is important to prevent the disease from becoming severe and complicated. To this effort, the government has trained shopkeepers and community health workers to treat some malaria cases at home using antimalarial drugs purchased over the counter. Mothers are also educated to give correct doses of antimalarial drugs and to recognise danger signs re- quiring referral. The 2003 KDHS asked mothers whether their children under five years had a fever and/or convulsions in the two weeks preceding the survey and, if so, whether any treatment was sought. Questions were also asked about the types of drugs given to the child and how soon and for how long the drugs were taken. Table 11.6 shows the percentage of children under five who had fever and/or convulsions in the two weeks preceding the survey, the percentage of such children who took antimalarial drugs, and the percentage taking drugs on the same or next day. Forty-two percent of children under five years of age were reported as having had fever and/or convulsions in the two weeks preceding the survey. Of those, 27 percent took antimalarial drugs; however, only 11 percent received antimalarial drugs the same or next day after the onset of illness. Prevalence of fever and/or convulsions is higher among children age 6-23 months than among younger or older children; however, treatment with antimalarial drugs is not highly correlated with age, except that children under 6 months (15 percent) are less likely to receive antimalarial drugs. Western Province has the highest percentage of children with malaria symptoms (60 percent), followed by Central and Nyanza provinces (49 percent each), while North Eastern Province has the lowest prevalence (23 per- cent). Western Province also has the highest proportion of children with fever and/or convulsions who are treated with antimalarial drugs, followed by Coast and Eastern provinces. Prompt treatment (within the same or next day) with antimalarial drugs is highest in Eastern (21 percent) and Coast (20 percent) prov- inces. Sex of the child, urban-rural residence, level of education, and the wealth index are not strongly related to the prevalence of fever and/or convulsions or the prompt treatment of symptoms. Malaria | 179 Table 11.7 presents information on the types of antimalarial drugs given to children with fever and/or convulsions and the proportion who took both the first-line drug (SP) and the second-line drug (amodiaquine) on the same or next day after the onset of the illness. In interpreting the data, it is impor- tant to remember that the information is based on reports from the mothers of the ill children. Although interviewers carried a laminated chart with pictures of the eight most common forms of antimalarial drugs used in Kenya, to show to mothers as a means of improving reporting of drug types, many mothers may not have known the specific drug given to the child. Table 11.6 Prevalence and prompt treatment of fever/convulsions Percentage of children under age five with fever and/or convulsions in the two weeks preceding the survey, and among children with fever and/or convulsions, percentage who took an antimalarial drug and percentage who took an antimalarial drug the same or next day, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Percentage Percentage who took an Percentage of children Number who took an antimalarial of children Background with fever/ of antimalarial drug same/ with fever/ characteristic convulsions children drug next day convulsions –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 37.5 619 14.6 4.6 232 6-11 54.7 630 28.2 10.2 345 12-23 49.7 1,131 26.2 10.9 562 24-35 41.4 1,031 30.4 10.8 427 36-47 37.0 1,123 27.6 13.2 415 48-59 32.4 1,026 27.3 14.4 332 Sex Male 42.2 2,797 27.5 12.0 1,181 Female 41.0 2,762 25.5 10.1 1,132 Residence Urban 40.4 1,063 21.5 8.1 429 Rural 41.9 4,497 27.7 11.7 1,883 Province Nairobi 38.5 369 9.7 3.6 142 Central 49.2 622 13.0 6.3 306 Coast 42.9 467 34.3 19.8 201 Eastern 27.9 883 32.0 20.8 246 Nyanza 48.5 832 29.4 11.6 403 Rift Valley 36.8 1,532 19.3 5.9 564 Western 59.8 691 42.2 13.8 413 North Eastern 23.2 163 27.7 8.4 38 Mother’s education No education 34.9 852 29.5 9.5 298 Primary incomplete 44.5 1,980 26.0 11.1 880 Primary complete 42.0 1,539 25.0 10.7 646 Secondary+ 41.1 1,189 27.6 12.3 489 Wealth quintile Lowest 38.4 1,343 27.5 10.7 516 Second 44.7 1,159 31.6 12.2 518 Middle 43.3 1,054 28.7 12.3 456 Fourth 42.0 957 24.9 12.1 402 Highest 40.1 1,046 18.2 7.8 420 Total 41.6 5,560 26.5 11.1 2,313 180 | Malaria Overall, 11 percent of children with fever and/or convulsions took SP, with 6 percent taking SP within a day of onset of illness. Ten percent of children took amodiaquine, with 5 percent taking it within a day of onset of illness. Despite these rather low proportions, it is encouraging that only 3 percent of children are reported to have taken chloroquine, which was withdrawn from the Kenyan market in 1998, because of the high level of resistance to the drug. Quinine, reserved for severe and complicated malaria illness in health facilities, was taken by 4 percent of children with fever and/or convulsions. Half (48 per- cent) of all children with fever and/or convulsions took non-antimalarial drugs, such as Panadol, paracetamol, aspirin, and Calpol, while 22 percent took other medications. Table 11.7 Standard treatment of fever Among children under age five who had fever and/or convulsions in the two weeks preceding the survey, percentage who took various drugs and percentage who took SP and amodiaquine the same or next day after developing fever and/or convulsions, according to background charac- teristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Number of Percentage who took Percentage Percentage children who took Percentage amodiaquine Percentage Percentage who took who took with Background Percentage SP same/ who took same/ who took who took aspirin/ other fever/ characteristic who took SP next day amodiaquine next day chloroquine quinine calpol medications convulsions –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age in months <6 4.8 1.4 6.7 3.2 2.7 1.0 49.1 23.0 232 6-11 10.1 5.6 10.0 4.8 5.3 5.4 50.9 20.8 345 12-23 10.2 5.6 9.5 5.3 3.5 3.6 48.1 26.5 562 24-35 12.7 6.4 9.6 4.9 3.6 6.0 46.7 21.0 427 36-47 14.0 8.0 9.4 5.8 2.3 3.9 47.7 19.0 415 48-59 12.1 8.4 11.6 6.4 2.6 3.9 48.7 17.3 332 Sex Male 11.9 7.2 9.4 5.2 3.7 4.8 48.6 22.3 1,181 Female 10.2 5.1 9.8 5.1 3.0 3.4 48.1 20.9 1,132 Residence Urban 7.6 4.6 9.5 4.1 2.6 2.9 46.0 24.5 429 Rural 11.9 6.5 9.6 5.4 3.5 4.4 48.9 21.0 1,883 Province Nairobi 2.7 1.6 4.3 2.0 0.5 2.1 47.4 21.7 142 Central 7.5 4.9 4.0 1.4 1.6 0.2 36.4 41.9 306 Coast 19.3 16.4 8.3 4.9 7.3 2.3 52.4 21.9 201 Eastern 12.4 10.0 13.7 11.4 1.4 7.1 44.9 15.6 246 Nyanza 13.2 6.1 8.6 5.7 5.6 4.3 70.6 8.1 403 Rift Valley 6.2 2.1 9.0 3.8 1.8 3.1 37.1 24.0 564 Western 15.9 6.8 15.7 7.4 4.8 8.3 53.5 21.9 413 North Eastern 16.2 8.4 7.5 0.0 4.8 0.0 23.7 0.0 38 Mother’s education No education 13.2 7.0 9.0 3.0 5.7 2.7 33.8 11.1 298 Primary incomplete 10.3 6.2 10.1 5.4 3.8 3.5 51.8 18.5 880 Primary complete 9.8 5.8 9.3 5.1 2.2 6.0 49.6 24.3 646 Secondary+ 12.9 6.1 9.3 6.2 2.7 3.6 49.5 30.0 489 Wealth quintile Lowest 11.1 6.1 8.1 5.0 6.5 3.9 49.6 11.7 516 Second 12.5 6.6 12.1 6.1 4.7 4.7 53.3 19.4 518 Middle 15.1 7.3 9.6 5.1 1.7 3.5 48.7 23.2 456 Fourth 8.3 6.3 10.9 5.8 0.9 6.2 44.2 30.1 402 Highest 7.6 4.4 7.0 3.6 2.1 2.3 44.3 26.6 420 Total 11.1 6.2 9.6 5.2 3.4 4.1 48.4 21.6 2,313 Malaria | 181 Coast Province has the highest percentage of children with fever treated with SP (19 percent) and also the highest percentage who received SP on the same or next day of the onset of the illness (16 per- cent). North Eastern and Western provinces follow, with Eastern Province also having a relatively high proportion of children receiving SP the same or next day. Nairobi has the lowest level of treatment with SP, perhaps indicating the low level of malaria transmission. Table 11.8 presents information on other interventions for treatment of fever and/or convulsions for children under age five in the two weeks preceding the survey. Exploring other intervention methods for fever and/or convulsion management among various communities is important in designing suitable health education messages. The table shows that 74 percent of children with fever and/or convulsions in the two weeks pre- ceding the survey received some sort of treatment (medication or another intervention). Some of the non- medication interventions were giving children herbs (4 percent), giving children tepid sponging (2 per- cent), and taking children to traditional healers (less than 1 percent). The results provided in this report highlight the enormous gap between the national targets set for 2006 within the NMS and the present coverage of the interventions. Advocacy programmes need to be carried out among women to increase the use of ITNs, their retreatment, management of paediatric fevers, and uptake of IPT. Subsidised nets and insecticides should be put in place to break the gap between the poor and the rich in net use, especially ITN use. Rural-urban imbalances also need to be addressed, as transmission of malaria is higher in rural areas than urban areas. The prevalence of childhood fever and/or convulsions in the two weeks preceding the survey was high in all provinces. However, in the majority of cases, the fever and/or convulsions were not managed appropriately, with SP not being given within 24 hours of illness onset as recommended in the NMS. Table 11.8 Other interventions for treatment of fever and/or convulsions Percentage of children under five years who had fever/convulsions in the two weeks preceding the survey who received various interventions, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Among children with fever/convulsions, percentage who were Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––– of Given any Taken to a Given Given children Background intervention traditional tepid Given other with fever/ characteristic drug healer sponging herbs treatments convulsions –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 73.3 0.0 1.1 1.2 3.9 429 Rural 74.0 0.4 2.1 5.0 3.1 1,883 Province Nairobi 70.1 0.0 1.2 0.0 3.7 142 Central 72.4 0.0 1.4 0.0 5.5 306 Coast 78.4 2.8 3.9 5.8 6.1 201 Eastern 73.8 0.0 0.4 1.3 1.6 246 Nyanza 82.6 0.5 2.4 11.6 0.9 403 Rift Valley 61.4 0.0 2.0 3.7 3.9 564 Western 85.8 0.0 2.1 3.0 2.7 413 North Eastern 36.5 0.0 0.0 12.7 0.0 38 Mother’s education No education 57.5 1.4 1.5 8.4 0.4 298 Primary incomplete 74.1 0.2 2.1 5.3 3.5 880 Primary complete 77.5 0.1 2.2 3.2 3.4 646 Secondary+ 78.5 0.1 1.4 1.6 4.5 489 Total 73.8 0.3 1.9 4.3 3.3 2,313 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 183 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 12 James N. Muttunga, Robert C. Buluma, and Boaz K. Cheluget 12.1 INTRODUCTION Acquired Immune Deficiency Syndrome (AIDS), is caused by a human immunodeficiency virus (HIV) that weakens the immune system, making the body susceptible to and unable to recover from other opportunistic diseases that lead to death through these secondary infections. This is a serious public health and socioeconomic problem in many countries around the world. The most affected countries are found in sub-Saharan Africa, especially those located in the eastern, central, and southern parts of the continent. HIV/AIDS remains a major concern in Kenya because of relatively high prevalence rates reported among adult populations and significantly higher rates among younger ages (Ministry of Health, 2001). The prevalence rate of HIV is lower in rural areas, where about 80 percent of the total population lives, than urban areas. About 75 percent of all AIDS cases occur among people in the most economically pro- ductive age group, 20 to 45 years (Ministry of Health, 2001). The deaths of these individuals constitute a serious economic and social tragedy in the lives of surviving family, friends, and employers. The principal mode of transmission of HIV is through heterosexual contact. This accounts for 75 percent of all HIV infections in Kenya (Ministry of Health, 2001). Although the probability of transmit- ting HIV in a single act of intercourse may be low, a number of factors increase the risk. These factors include the viral load of the infected partner; the presence in either partner of sexually transmitted dis- eases (STDs), such as syphilis, chancroid, or herpes, which cause genital ulcers; lack of male circumci- sion; or trauma during sexual contact. A significant number of Kenyan adults suffer from STDs and some have multiple sexual partners, which increases their vulnerability and exposure to HIV. Consequently, most new HIV infections are because of heterosexual contact. This is followed in importance by perinatal transmission, whereby the mother passes the HIV vi- rus to the child during pregnancy, at the time of birth, or through breastfeeding. Approximately 30 to 40 percent of babies born to HIV-positive mothers in Kenya will themselves be infected with the HIV virus. The remainder may not be infected by HIV but are at risk of becoming orphans when one or both of their parents die from AIDS-related diseases. More than 100,000 children under the age of five are estimated to be infected (Ministry of Health, 2002). Programmes designed to slow the spread of HIV need to focus on reducing transmission through sexual contact. Transmission risk is also high among men who have sex with other men, through blood transfusions, and use of unsterilised needles and skin piercing instruments. The future direction of this pandemic depends on the level of knowledge of how the virus is spread and changes in sexual behaviour. The information obtained from the 2003 KDHS provides a unique opportunity to assess the level of knowledge and practices regarding transmission of the AIDS virus and other STDs. The main objective of this chapter is to determine the level of relevant knowledge, perceptions, attitudes, and behaviours at the national and provincial levels and for socioeconomic sub- groups of the population. The results are useful for AIDS control programmes to target those individuals and groups of individuals most in need of information and those who are at risk of contracting the disease. 184 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour The 2003 KDHS included a series of questions related to HIV/AIDS and STDs in both the woman’s and man’s questionnaires. Both female and male respondents were asked if they have ever heard of AIDS; what a person could do to avoid getting AIDS; if they know a person with AIDS or who died of AIDS; if they are aware of mother-to-child transmission; and if they ever talked to their spouse about ways of preventing AIDS. Other questions concerned stigma or discrimination towards people with HIV/AIDS; attitudes towards teaching children about condom use; chances of getting HIV/AIDS; testing for HIV/AIDS; knowledge of other STDs and infection with STDs. 12.2 KNOWLEDGE OF AIDS AND HIV TRANSMISSION Awareness of AIDS Table 12.1 shows the percentage of women and men who have heard of AIDS and the percentage who know someone personally who has the AIDS virus or has died of AIDS, according to background characteristics. The data show that the level of knowledge of AIDS is almost universal, with 99 percent of women and men indicating that they have heard about AIDS. The results further show that there are al- most no differences in level of knowledge by age, marital status, urban-rural residence, province, level of education, and wealth index, with the possible exception of respondents in North Eastern Province and those with no education, fewer of whom have heard of AIDS. The level of awareness about HIV/AIDS for both women and men has been very high since the 1993 KDHS (98 percent of women and 99 percent of men). The table also shows that three in four respondents either know someone who is HIV positive or has died of AIDS. This proportion is high throughout all groups of Kenyans, although North Eastern Province appears to have been far less affected by the epidemic than other provinces. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 185 Knowledge of Ways to Reduce AIDS Transmission Abstaining from sex, being faithful to one uninfected partner, and using condoms are important ways to avoid the spread of HIV/AIDS. To ascertain the depth of knowledge about modes of HIV/AIDS transmission, respondents were asked general questions as to whether there is anything a person can do to avoid getting AIDS or the virus that causes AIDS, and if so, what can be done. They were further prompted with specific questions about whether it is possible to reduce the chance of getting AIDS by having just one faithful sexual partner, using a condom at every sexual encounter, and not having sex at all. Table 12.2 shows the percentage of women and men by their answers to these questions, according to background characteristics. Table 12.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––– Percentage Percentage who know who know someone someone Has personally Has personally heard who has Number heard who has Number Background of AIDS or died of of AIDS or died of characteristic AIDS of AIDS women AIDS of AIDS men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 98.0 65.3 1,856 98.9 60.2 856 20-24 98.6 72.7 1,691 99.7 77.9 681 25-29 98.1 74.2 1,382 99.6 77.5 509 30-39 98.9 77.5 1,957 99.8 80.9 811 40-49 99.0 80.6 1,309 99.3 79.4 506 15-24 98.3 68.8 3,547 99.3 68.0 1,537 Marital status Never married 98.4 69.4 2,443 99.3 68.7 1,611 Ever had sex 99.2 74.1 1,055 99.9 75.6 1,073 Never had sex 97.8 65.9 1,388 97.9 54.8 537 Married/living together 98.5 74.8 4,919 99.7 79.3 1,615 Divorced/separated/ widowed 98.9 79.4 833 98.7 81.9 137 Residence Urban 99.2 74.9 2,056 99.8 82.8 856 Rural 98.3 73.3 6,139 99.3 71.8 2,506 Province Nairobi 99.6 71.1 835 99.8 81.9 376 Central 99.8 89.0 1,181 99.7 85.7 515 Coast 99.1 68.4 667 99.4 77.0 234 Eastern 99.2 68.7 1,325 99.8 63.8 541 Nyanza 99.9 74.0 1,222 99.7 75.8 443 Rift Valley 95.4 69.8 1,872 99.6 70.5 818 Western 99.7 86.7 927 99.8 84.5 378 North Eastern 94.1 8.3 168 86.0 7.9 57 Education No education 92.6 51.6 1,039 94.5 41.3 191 Primary incomplete 98.8 70.6 2,685 99.4 67.8 1,148 Primary complete 99.6 76.1 2,069 100.0 78.3 769 Secondary+ 99.8 84.6 2,403 100.0 84.4 1,254 Wealth quintile Lowest 95.4 61.4 1,364 97.6 52.5 510 Second 98.3 70.7 1,475 99.9 71.7 572 Middle 99.1 76.4 1,503 99.7 74.1 616 Fourth 99.7 79.7 1,711 99.6 81.0 741 Highest 99.2 76.8 2,141 99.9 84.0 924 Total 98.5 73.7 8,195 99.4 74.6 3,363 186 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour The results show that knowledge of HIV prevention methods is widespread, although there are differences between women and men. More than four in five respondents (81 and 89 percent of women and men, respectively) indicate that the chances of getting the AIDS virus can be reduced by limiting sex to one faithful partner. Similarly, 61 percent of women and 72 percent of men know that condoms can reduce the risk of contracting the HIV virus during sexual intercourse. Knowledge of both these means of avoiding HIV transmission is also high, with 58 percent of women and 70 percent of men citing both as ways of reducing the risk of getting the AIDS virus. As expected, the proportion of both women and men who know that abstaining from sex reduces the chances of getting the AIDS virus is high—79 percent among women and 89 percent among men. Table 12.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to a prompted question, say that people can reduce the risk of getting the AIDS virus by using condoms, by having sex with just one partner who has no other partners, or by abstaining from sex, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––– Using Using condoms condoms Limiting and limiting Ab- Limiting and limiting Ab- sex to one sex to one staining Number sex to one sex to one staining Number Background Using faithful faithful from of Using faithful faithful from of characteristic condoms partner partner sex women condoms partner partner sex men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 52.6 72.0 47.8 74.2 1,856 60.4 77.2 56.9 80.5 856 20-24 65.1 82.9 61.8 80.0 1,691 78.1 92.5 75.6 93.4 681 25-29 69.7 84.1 67.0 80.3 1,382 75.7 90.9 74.0 90.6 509 30-39 65.2 84.2 62.5 83.1 1,957 77.6 94.5 76.7 92.1 811 40-49 52.3 79.9 50.1 78.5 1,309 71.0 92.2 69.2 90.3 506 15-24 58.6 77.2 54.5 76.9 3,547 68.3 84.0 65.2 86.2 1,537 Marital status Never married 57.5 77.5 53.6 79.2 2,443 68.5 84.6 65.7 86.5 1,611 Ever had sex 69.1 82.9 65.1 82.6 1,055 79.5 91.1 76.3 91.6 1,073 Never had sex 48.7 73.3 44.8 76.6 1,388 46.5 71.6 44.5 76.4 537 Married/living together 62.6 81.8 59.8 79.3 4,919 75.1 93.2 73.8 91.6 1,615 Divorced/separated/ widowed 62.0 81.2 58.5 79 833 77.7 87.4 73.8 86.0 137 Residence Urban 69.2 85.2 66.3 83.5 2,056 79.6 92.3 77.6 90.8 856 Rural 58.3 78.9 55.0 77.8 6,139 69.5 87.6 67.3 88.3 2,506 Province Nairobi 75.2 88.7 71.8 86.2 835 82.1 93.6 80.7 92.2 376 Central 62.4 87.3 60.4 87.0 1,181 68.6 94.1 67.9 93.0 515 Coast 57.8 72.5 55.6 69.7 667 72.8 79.0 64.4 80.6 234 Eastern 62.7 85.5 60.3 84.4 1,325 59.2 82.9 57.7 84.7 541 Nyanza 62.0 84.9 60.1 83.0 1,222 76.7 90.6 75.1 90.1 443 Rift Valley 56.1 71.7 50.1 71.0 1,872 77.4 91.8 75.5 90.9 818 Western 65.2 85.4 62.4 84.0 927 76.8 89.3 73.4 91.3 378 North Eastern 6.1 21.6 5.3 25.1 168 11.3 46.6 11.3 51.6 57 Education No education 29.8 51.9 27.2 49.4 1,039 39.9 61.5 37.1 63.9 191 Primary incomplete 57.8 76.4 53.9 76.9 2,685 66.6 81.5 63.7 83.1 1,148 Primary complete 67.3 86.0 63.9 83.2 2,069 71.8 92.6 69.8 93.0 769 Secondary+ 72.8 92.6 70.3 91.3 2,403 82.1 97.3 80.7 95.6 1,254 Wealth quintile Lowest 46.2 66.6 43.0 64.6 1,364 63.0 79.0 59.9 81.2 510 Second 56.5 76.4 52.6 76.6 1,475 68.4 86.3 66.4 86.5 572 Middle 60.7 81.7 57.4 79.9 1,503 69.1 88.6 67.2 90.5 616 Fourth 64.6 85.5 61.6 85.8 1,711 72.1 90.8 69.8 89.5 741 Highest 71.0 87.2 68.2 84.7 2,141 81.2 94.4 79.4 93.2 924 Total 61.0 80.5 57.8 79.2 8,195 72.0 88.8 69.9 88.9 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 187 Knowledge of HIV prevention methods among women and men age 15 to 19 is lower for all methods compared with people age 20 years and above. Likewise, knowledge of how people can reduce the risk of getting AIDS is lower among those who have never had sex than among those who are married or living together with a partner, and those who are divorced/separated/widowed or those who never mar- ried but have had sex. For all methods of reducing the risk of HIV infection, urban dwellers are more knowledgeable than their rural counterparts. The level of awareness by province shows that women and men in Nairobi Province are better informed than those in other provinces. By far the most disadvantaged region is North Eastern Province, which shows the lowest levels of knowledge for all methods of reducing the risk of contracting HIV/AIDS. The level of education attained is strongly related to respondents’ knowledge of ways to avoid contracting HIV/AIDS. Women and men who have no education exhibit considerably lower levels of knowledge of HIV/AIDS prevention than those with some education. The data show that the poorest, irre- spective of sex, are the most disadvantaged in terms of knowledge about methods that can be used to re- duce the risk of getting HIV/AIDS virus. Knowledge of Mother-to-Child Transmission Current strategies on HIV/AIDS in Kenya are geared towards improving the health of the HIV- infected mother and reducing the transmission to their children during pregnancy, labour, delivery, and post-delivery through breastfeeding as outlined in the National HIV/AIDS Strategic Plan 2000-2004 and the National Prevention of Mother-to-Child Transmission Strategic Plan (Ministry of Health, 1999b). In- creasing the level of general knowledge of transmission of the virus from mother to child and of reducing the risk of transmission by use of antiretroviral drugs is critical to achieving this goal. All women and men interviewed in the 2003 KDHS were asked if the virus that causes AIDS can be transmitted from a mother to a child. If the answer was in the affirmative, they were further asked whether the virus could be transmitted during pregnancy, during delivery, or during breastfeeding. They were also asked if a mother who is infected with the AIDS virus can reduce the risk of giving the virus to the baby by taking certain drugs during pregnancy. The results of the responses are shown in Table 12.3. Almost three-quarters of women (72 percent) and two-thirds of men (68 percent) know that HIV can be transmitted by breastfeeding. Only one-third of women (33 percent) and 38 percent of men know that the risk of mother-to-child transmission can be reduced by the mother taking certain drugs during pregnancy. Only 28 percent of women and 30 percent of men know that HIV can be transmitted through breastfeeding and that the risk can be reduced with drugs. The knowledge of transmission through breastfeeding and knowledge of antiretroviral drugs is lower for the youngest women and men, as well as those who have never had sex. It is also lower for rural women and men and substantially lower among women and men in North Eastern Province than else- where. Kenyans with no education and those who have not completed primary education are less likely to know about the transmission of HIV through breastfeeding than those who have completed primary or have some secondary and higher education. The data also show that wealth is positively associated with knowledge of HIV transmission. The poorest are disadvantaged in all aspects of HIV knowledge as shown in Table 12.3. 188 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Rejection of Misconceptions about AIDS Transmission In addition to knowing about effective ways to avoid contracting HIV/AIDS, it is also useful to be able to identify incorrect ways of avoiding the virus, in order to eliminate misconceptions. Common misconceptions about AIDS include fear of contracting AIDS by sharing utensils with someone who is in- fected, transmission by mosquito or other insect bites, and a belief that people who are infected will show signs of illness. Respondents were asked about these three misconceptions. Table 12.3 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of maternal to child transmission (MTCT) of HIV can be reduced by a mother taking special drugs during pregnancy, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––– HIV can be HIV can be transmitted by transmitted by Risk of breastfeeding Risk of breastfeeding MTCT can be and risk of MTCT can be and risk of reduced by MTCT can be reduced by MTCT can be mother reduced by mother reduced by HIV can be taking drugs mother taking Number HIV can be taking drugs mother taking Number Background transmitted by in drugs during of transmitted by in drugs during of characteristic breastfeeding pregnancy pregnancy women breastfeeding pregnancy pregnancy men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 66.1 24.6 21.4 1,856 62.3 25.5 21.0 856 20-24 75.2 36.1 31.1 1,691 71.2 37.6 31.3 681 25-29 75.8 38.6 34.2 1,382 69.7 41.3 32.6 509 30-39 72.7 35.8 30.6 1,957 72.8 44.9 36.7 811 40-49 69.7 28.3 23.8 1,309 66.8 42.1 31.7 506 15-24 70.5 30.1 26.0 3,547 66.2 30.8 25.5 1,537 Marital status Never married 69.1 28.6 24.5 2,443 66.6 31.7 26.2 1,611 Ever had sex 72.7 34.1 29.1 1,055 70.6 36.4 30.1 1,073 Never had sex 66.3 24.5 21.0 1,388 58.6 22.3 18.5 537 Married/living together 73.3 34.9 30.2 4,919 69.9 43.5 34.4 1,615 Divorced/separated/ widowed 70.4 30.7 26.2 833 72.0 34.6 28.3 137 Residence Urban 76.5 40.8 35.7 2,056 71.8 45.4 37.0 856 Rural 70.2 29.8 25.6 6,139 67.3 34.8 27.9 2,506 Province Nairobi 77.4 45.0 39.9 835 69.9 49.2 39.7 376 Central 75.3 37.3 32.5 1,181 73.5 27.8 22.3 515 Coast 71.5 24.8 22.7 667 69.4 31.1 26.7 234 Eastern 78.4 25.2 22.1 1,325 65.0 30.2 24.5 541 Nyanza 71.9 37.5 31.7 1,222 66.6 45.3 36.8 443 Rift Valley 65.4 30.4 25.3 1,872 70.8 39.3 31.6 818 Western 72.1 35.1 30.4 927 67.4 45.8 35.7 378 North Eastern 35.6 1.1 1.1 168 27.8 2.5 2.1 57 Education No education 50.8 12.1 10.4 1,039 47.7 11.0 8.5 191 Primary incomplete 69.4 25.9 22.4 2,685 65.1 28.2 22.1 1,148 Primary complete 76.1 35.6 30.1 2,069 69.2 34.5 28.0 769 Secondary+ 79.7 46.3 40.4 2,403 74.2 51.9 42.4 1,254 Wealth quintile Lowest 60.4 19.0 16.0 1,364 57.3 24.6 18.2 510 Second 69.2 28.7 24.6 1,475 69.1 36.4 29.0 572 Middle 74.5 33.4 29.4 1,503 70.6 38.3 33.4 616 Fourth 74.5 33.6 28.1 1,711 68.0 36.3 28.8 741 Highest 76.6 42.5 37.4 2,141 73.0 45.8 36.7 924 Total 71.8 32.6 28.1 8,195 68.4 37.5 30.2 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 189 The data as shown in Tables 12.4.1 and 12.4.2 indicate that not all Kenyans understand that AIDS cannot be transmitted by mosquito bites; only 61 percent of women and 74 percent of men know that AIDS cannot be transmitted by mosquito bites. Similarly, 71 percent of women and 81 percent of men know that a person cannot become infected with the AIDS virus by sharing utensils with a person who has AIDS. Table 12.4.1 Beliefs about AIDS: women Percentage of women 15-49 who, in response to a prompted question, reject local misconceptions about AIDS trans- mission or prevention, and who know that a healthy-looking person can have the AIDS virus, by background charac- teristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of women who know that: –––––––––––––––––––––––––––––––––––––––––––––––– Percentage A person who reject both cannot become misconceptions infected by A healthy- and says a AIDS cannot be sharing utensils looking person healthy-looking Number Background transmitted by with someone can have the person can have of characteristic mosquito bites with AIDS AIDS virus the AIDS virus women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 57.3 65.3 78.3 43.5 1,856 20-24 66.2 74.2 87.8 56.0 1,691 25-29 65.3 77.0 85.6 55.7 1,382 30-39 62.6 73.9 87.8 53.6 1,957 40-49 52.7 66.0 84.5 44.2 1,309 15-24 61.6 69.5 82.9 49.4 3,547 Marital status Never married 65.2 72.6 83.7 53.9 2,443 Ever had sex 69.5 78.9 88.2 60.0 1,055 Never had sex 61.9 67.9 80.3 49.3 1,388 Married/living together 60.0 71.0 84.7 49.7 4,919 Divorced/separated/ widowed 55.2 68.9 87.9 46.7 833 Residence Urban 75.2 80.9 91.2 66.6 2,056 Rural 56.3 68.0 82.6 45.3 6,139 Province Nairobi 83.0 84.8 90.9 72.4 835 Central 69.1 82.6 93.8 63.2 1,181 Coast 56.9 57.3 79.1 44.6 667 Eastern 62.1 69.2 92.3 50.1 1,325 Nyanza 54.7 69.8 88.5 46.0 1,222 Rift Valley 56.2 69.8 74.1 43.7 1,872 Western 59.1 72.4 87.3 48.6 927 North Eastern 13.5 15.6 31.1 5.7 168 Education No education 25.2 36.1 57.3 16.3 1,039 Primary incomplete 49.5 63.4 79.6 35.3 2,685 Primary complete 68.1 79.1 91.7 58.5 2,069 Secondary+ 83.3 88.6 96.5 75.9 2,403 Wealth quintile Lowest 39.4 50.3 67.0 27.1 1,364 Second 51.7 65.6 81.9 40.3 1,475 Middle 58.1 70.9 86.4 47.6 1,503 Fourth 67.0 78.3 90.5 56.7 1,711 Highest 78.6 83.2 92.2 70.1 2,141 Total 61.0 71.3 84.7 50.7 8,195 190 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Knowledge that a healthy-looking person can have the AIDS virus is more widespread. Eighty- five percent of women and 90 percent of men know that a healthy-looking person can have the AIDS vi- rus. This reflects a moderate rise from the 1998 KDHS data, from 79 to 87 percent of women and from 85 to 91 percent of men, excluding the northern areas. Looking at all three beliefs together, 51 percent of women and 65 percent of men have correct knowledge on all these issues. Table 12.4.2 Beliefs about AIDS: men Percentage of men 15-49 who, in response to a prompted question, reject local misconceptions about AIDS transmis- sion or prevention, and who know that a healthy-looking person can have the AIDS virus, by background characteris- tics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of men who know that: –––––––––––––––––––––––––––––––––––––––––––––––– Percentage A person who reject both cannot become misconceptions infected by A healthy- and says a AIDS cannot be sharing utensils looking person healthy-looking Number Background transmitted by with someone can have the person can have of characteristic mosquito bites with AIDS AIDS virus the AIDS virus men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 64.6 70.5 79.0 50.3 856 20-24 84.3 86.5 94.6 75.3 681 25-29 78.7 82.6 93.6 71.3 509 30-39 76.3 85.6 95.0 70.0 811 40-49 68.9 78.9 90.4 60.2 506 15-24 73.3 77.6 85.9 61.4 1,537 Marital status Never married 74.1 78.1 85.9 62.4 1,611 Ever had sex 79.9 84.7 91.4 70.2 1,073 Never had sex 62.4 64.9 75.0 46.6 537 Married/living together 74.9 83.0 93.7 67.6 1,615 Divorced/separated/ widowed 66.8 78.3 92.4 59.9 137 Residence Urban 86.8 87.7 93.6 78.2 856 Rural 69.9 78.0 88.7 60.2 2,506 Province Nairobi 90.4 88.8 95.2 83.5 376 Central 73.1 85.1 94.5 66.6 515 Coast 80.7 82.4 87.4 71.6 234 Eastern 72.0 73.7 90.2 61.2 541 Nyanza 62.3 73.9 92.5 54.4 443 Rift Valley 76.2 83.5 88.5 66.2 818 Western 74.1 82.2 86.0 59.9 378 North Eastern 34.8 35.8 49.4 25.2 57 Education No education 37.1 41.9 60.3 23.7 191 Primary incomplete 61.3 70.7 83.0 48.3 1,148 Primary complete 76.2 85.2 93.6 67.5 769 Secondary+ 90.4 92.4 98.5 84.5 1,254 Wealth quintile Lowest 57.0 66.0 80.3 45.8 510 Second 69.1 76.2 87.7 58.3 572 Middle 72.1 80.8 89.0 62.7 616 Fourth 77.8 83.4 92.2 68.4 741 Highest 85.3 88.5 95.4 77.7 924 Total 74.2 80.5 89.9 64.8 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 191 The analysis shows considerable differentials in the levels of rejection of these misconceptions regarding AIDS transmission. The proportions of women and men who know that AIDS cannot be trans- mitted by mosquitoes or by sharing utensils with a person who has AIDS and who know that a healthy- looking person can have the AIDS virus are lower among those age 15 to 19, those from rural areas, those with less education, and those who are poorer. North Eastern Province has the lowest levels of correct knowledge about HIV/AIDS transmission, with only 6 percent of women and 25 percent of men rejecting all the three misconceptions, while those from Nairobi are better informed, with 72 and 84 percent of women and men, respectively, reporting correct conceptions. It is also important to note that women are less knowledgeable than men about these misconceptions. The level of education is highly associated with misconceptions about methods of transmission of the AIDS virus, with the lowest levels of correct understanding among those with no education and in- creasing with rising educational level among both women and men. 12.3 STIGMA TOWARDS HIV-INFECTED PEOPLE Beliefs about HIV/AIDS show the extent of stigma or discrimination towards people with HIV/AIDS. In the 2003 KDHS, questions were posed to respondents to measure their attitudes towards HIV-infected people, their willingness to buy vegetables from infected vegetable sellers, their willingness to let others know the HIV status of family members, and their willingness to take care of relatives who have the AIDS virus in their own households. Additionally, they were asked whether HIV-positive women teachers should be allowed to continue teaching. Tables 12.5.1 and 12.5.2 show the percentage of women and men who have heard about AIDS and who express positive attitudes toward people with HIV, by background characteristics. Large majorities of women and men (84 and 88 percent, respectively) express their willingness to care for a relative sick with the virus that causes AIDS in their own household, while far fewer (60 and 74 percent, respectively) say they would be willing to buy fresh vegetables from a vendor who has the AIDS virus. The results further indicate that only 57 and 60 percent of women and men, respectively, believe that a female teacher who has the AIDS virus should be allowed to continue teaching in school. Finally, 59 percent of women and 72 percent of men say that if a member of their family got infected with the vi- rus that causes AIDS, they would not want it to remain a secret. The percentage expressing acceptance on all the four measures is quite low at 27 and 40 percent for women and men, respectively. It is striking to note that women express less accepting attitudes towards people with HIV/AIDS than men. A lower proportion of both women (20 percent) and men (25 percent) age 15 to 19 express ac- cepting attitudes on all four measures towards people infected with HIV/AIDS, compared with those age 20 years and above. Urban women (35 percent) and men (48 percent) are more likely than rural women (24 percent) and men (37 percent) to accept all four measures towards people infected with HIV/AIDS. Accepting attitudes towards HIV-infected people are more common in Nairobi Province and least com- mon in North Eastern Province, where only 1 and 2 percent of women and men, respectively, accept all four measures. Education is strongly related to positive attitudes towards those who are HIV-positive. The pro- portion of women and men who accept all four measures increases steadily with education as well as with the wealth index. 192 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 12.5.1 Accepting attitudes towards those living with HIV: women Percentage of women age 15-49 who have heard about AIDS who express accepting attitudes toward people with HIV, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of respondents who: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Believe an Would buy HIV-positive Would Are willing fresh female teacher not want an Percentage Number to care vegetables should be HIV-positive expressing of women for relative from a allowed to status of family accepting who have Background with vendor continue member to attitudes on all heard of characteristic HIV at home with AIDS teaching remain secret four measures HIV/AIDS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 78.7 57.1 51.0 52.4 20.0 1,818 20-24 84.8 64.1 59.8 58.4 30.2 1,668 25-29 83.7 61.4 62.8 60.3 28.3 1,356 30-39 87.4 60.3 60.4 62.4 29.4 1,935 40-49 86.5 57.8 50.9 61.4 24.8 1,296 15-24 81.6 60.5 55.2 55.3 24.9 3,486 Marital status Never married 84.4 65.7 62.2 57.1 29.7 2,404 Ever had sex 87.7 71.3 67.1 58.6 33.1 1,046 Never had sex 81.9 61.3 58.5 55.9 27.1 1,358 Married/living together 83.7 57.1 54.6 59.8 25.0 4,846 Divorced/separated/ widowed 85.7 62.0 56.0 58.4 26.0 824 Residence Urban 87.4 68.7 71.6 59.0 34.9 2,040 Rural 83.0 57.2 52.1 58.8 23.7 6,033 Province Nairobi 87.4 71.4 76.9 59.9 36.2 832 Central 91.3 69.6 72.3 68.3 39.1 1,178 Coast 82.8 43.6 50.8 55.7 20.5 661 Eastern 86.2 55.1 47.4 54.1 17.0 1,314 Nyanza 80.8 64.6 53.5 47.3 20.9 1,220 Rift Valley 85.6 60.4 53.6 65.4 29.4 1,786 Western 83.1 58.8 57.1 54.0 25.8 924 North Eastern 15.4 11.0 10.2 79.1 0.9 158 Education No education 65.0 28.4 27.4 61.8 8.5 961 Primary incomplete 80.0 49.0 42.2 53.7 15.6 2,653 Primary complete 87.9 66.3 60.6 59.2 28.2 2,060 Secondary+ 93.1 79.8 82.2 63.0 44.4 2,398 Wealth quintile Lowest 73.2 39.8 34.1 56.8 12.6 1,301 Second 80.2 53.2 46.7 56.6 18.9 1,451 Middle 84.7 57.8 52.4 57.7 23.3 1,490 Fourth 88.8 68.3 64.5 60.4 31.7 1,706 Highest 89.2 72.4 75.3 61.1 38.3 2,125 Total 84.1 60.1 57.0 58.8 26.5 8,073 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 193 12.4 PERCEIVED RISK OF GETTING AIDS In order to gauge people’s perceptions of their risk of getting HIV, respondents in the 2003 KDHS were asked if they thought their chances of getting AIDS were small, moderate, great, or if they had no risk at all. Table 12.6 shows the results regarding self-perception of risk to HIV infection. About one-third of women and men say they have no risk of getting AIDS, while 40 percent of women and 52 percent of men say they have only a small chance. Fifteen percent of women and 10 per- cent of men feel they have a moderate risk of getting AIDS, while only 9 percent of women and 5 percent Table 12.5.2 Accepting attitudes towards those living with HIV: men Percentage of men 15-49 who have heard about AIDS who express accepting attitudes toward people with HIV, by background character- istics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage of respondents who: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Believe an Would buy HIV-positive Would Are willing fresh female teacher not want an Percentage Number to care vegetables should be HIV-positive expressing of men for relative from a allowed to status of family accepting who have Background with vendor continue member to attitudes on all heard of characteristic HIV at home with AIDS teaching remain secret four measures HIV/AIDS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 81.3 64.3 46.1 59.3 24.9 847 20-24 90.4 78.1 61.5 74.8 40.5 679 25-29 90.2 75.9 63.0 74.1 42.8 506 30-39 89.2 79.0 69.2 78.9 50.4 809 40-49 88.3 71.5 61.7 73.0 41.8 502 15-24 85.4 70.4 53.0 66.2 31.8 1,526 Marital status Never married 86.0 71.7 55.3 67.4 34.4 1,599 Ever had sex 88.8 76.1 57.6 71.4 37.9 1,073 Never had sex 80.3 62.8 50.6 59.1 27.3 526 Married/living together 89.1 75.2 64.4 75.7 44.7 1,610 Divorced/separated/ widowed 86.1 74.4 56.7 69.3 36.9 135 Residence Urban 89.1 80.5 70.8 72.7 47.7 854 Rural 86.9 71.1 55.9 71.1 36.7 2,490 Province Nairobi 91.3 83.5 78.4 73.4 52.5 375 Central 91.8 81.0 72.4 70.2 45.2 514 Coast 90.4 74.4 63.9 64.2 38.6 232 Eastern 86.8 65.3 46.2 74.1 29.4 540 Nyanza 88.0 72.4 48.2 62.0 31.7 442 Rift Valley 85.0 70.6 58.8 79.1 43.4 814 Western 84.9 77.3 61.5 72.9 39.3 377 North Eastern 63.1 33.2 18.7 23.8 2.2 49 Education No education 61.9 37.1 21.2 57.5 9.4 181 Primary incomplete 81.1 60.8 39.3 67.0 23.9 1,141 Primary complete 91.6 77.7 63.7 72.7 39.8 769 Secondary+ 94.4 87.7 81.5 76.8 57.8 1,254 Wealth quintile Lowest 78.8 53.3 39.0 65.2 23.4 498 Second 86.6 70.3 49.9 70.3 30.6 571 Middle 87.0 72.6 56.8 71.9 38.7 614 Fourth 91.4 78.5 64.9 72.4 44.0 738 Highest 89.8 82.9 74.8 74.5 50.6 923 Total 87.5 73.5 59.7 71.5 39.5 3,344 194 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour of men think they have a great chance of getting AIDS. In general, women perceive their risks as greater than men. Younger respondents are more likely to believe they have no chance of getting AIDS than older respondents. Similarly, those who have never married and those who have not had sex with anyone other than their spouse are more likely to fall in the “no risk” category. Risk perception is surprisingly similar among urban and rural respondents. The distribution of respondents’ perception of risk of getting AIDS by province shows that the largest proportions who think they have no chance of getting AIDS are found in North Eastern Province (78 and 98 percent of women and men, respectively). Women in Western and Nyanza provinces are the most likely to think they have a moderate or great chance of getting AIDS, while men in Nyanza, Coast, and Nairobi provinces are more likely to feel they have a great chance of getting AIDS. Differences by education and wealth index are not large. Table 12.6 Perception of risk of getting AIDS Percent distribution of women and men age 15-49 who know about AIDS by perception of risk of getting AIDS, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Don’t Number Don’t Number Background No Small Moderate Great know/ of No Small Moderate Great Has know/ of characteristic chance chance chance chance missing Total women chance chance chance chance AIDS missing Total men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 51.8 36.2 6.7 5.0 0.3 100.0 1,818 43.5 45.6 6.7 4.2 0.0 0.1 100.0 847 20-24 35.7 41.8 14.4 8.0 0.1 100.0 1,668 25.3 57.7 11.1 6.0 0.0 0.0 100.0 679 25-29 31.2 39.0 18.4 11.2 0.3 100.0 1,356 33.2 50.8 11.3 4.5 0.0 0.2 100.0 506 30-39 26.0 42.0 20.2 11.5 0.3 100.0 1,935 31.1 53.5 10.3 4.8 0.3 0.0 100.0 809 40-49 32.4 38.0 18.7 10.5 0.4 100.0 1,296 32.9 52.6 11.2 3.4 0.0 0.0 100.0 502 Marital status Never married 50.8 36.6 7.7 4.6 0.2 100.0 2,404 35.8 51.0 8.2 5.0 0.0 0.0 100.0 1,599 Currently married 28.6 40.6 19.2 11.4 0.2 100.0 4,846 31.9 53.2 10.9 3.8 0.1 0.1 100.0 1,610 Formerly married 33.5 41.7 15.6 8.8 0.5 100.0 824 29.0 44.4 16.7 9.9 0.0 0.0 100.0 135 Number of partners other than spouse No partner other than spouse 37.5 39.0 14.6 8.7 0.2 100.0 7,054 39.2 50.9 7.1 2.6 0.1 0.1 100.0 2,406 1 partner 23.9 44.9 20.7 10.1 0.4 100.0 934 19.8 56.8 16.4 7.0 0.0 0.0 100.0 716 2-3 partners 9.9 24.6 28.9 35.2 1.4 100.0 68 17.6 47.1 18.4 16.9 0.0 0.0 100.0 187 Residence Urban 36.8 38.9 13.6 10.2 0.4 100.0 2,040 31.7 53.4 10.5 4.2 0.0 0.2 100.0 854 Rural 35.3 39.7 16.0 8.7 0.2 100.0 6,033 34.3 51.3 9.6 4.8 0.1 0.0 100.0 2,490 Province Nairobi 31.1 45.2 13.3 10.1 0.4 100.0 832 23.4 58.1 13.9 4.1 0.0 0.5 100.0 375 Central 41.4 37.0 18.1 3.2 0.2 100.0 1,178 19.5 71.3 6.4 2.8 0.0 0.0 100.0 514 Coast 45.7 33.5 13.8 7.0 0.0 100.0 661 44.3 42.4 6.7 6.6 0.0 0.0 100.0 232 Eastern 28.1 53.7 14.0 4.2 0.1 100.0 1,314 25.5 61.0 9.8 3.7 0.0 0.0 100.0 540 Nyanza 25.1 42.8 17.5 14.5 0.2 100.0 1,220 36.8 41.0 12.8 8.9 0.5 0.0 100.0 442 Rift Valley 38.6 35.3 16.0 9.9 0.1 100.0 1,786 44.0 41.4 10.0 4.5 0.0 0.0 100.0 814 Western 37.5 28.6 15.8 17.0 1.0 100.0 924 33.5 53.6 9.5 3.4 0.0 0.1 100.0 377 North Eastern 77.7 21.6 0.6 0.2 0.0 100.0 158 97.8 0.0 1.4 0.8 0.0 0.0 100.0 49 Education No education 46.0 33.8 12.0 8.0 0.2 100.0 961 56.0 30.8 7.9 5.3 0.0 0.0 100.0 181 Primary incomplete 35.2 38.4 16.1 10.1 0.2 100.0 2,653 38.7 46.9 9.2 5.1 0.0 0.1 100.0 1,141 Primary complete 33.9 40.7 15.7 9.5 0.3 100.0 2,060 32.3 55.3 6.5 5.4 0.3 0.1 100.0 769 Secondary+ 33.6 42.0 15.8 8.1 0.4 100.0 2,398 26.6 57.2 12.7 3.6 0.0 0.0 100.0 1,254 Wealth quintile Lowest 38.1 39.3 14.0 8.6 0.0 100.0 1,301 41.5 44.9 7.8 5.7 0.0 0.0 100.0 498 Second 34.6 36.9 16.8 11.4 0.3 100.0 1,451 36.4 48.2 9.9 5.0 0.4 0.0 100.0 571 Middle 33.5 41.1 16.7 8.5 0.2 100.0 1,490 34.3 52.3 8.2 5.2 0.0 0.0 100.0 614 Fourth 36.2 39.4 16.1 8.0 0.3 100.0 1,706 32.9 52.9 10.5 3.7 0.0 0.0 100.0 738 Highest 36.2 40.3 13.9 9.1 0.4 100.0 2,125 27.8 56.5 11.4 4.1 0.0 0.2 100.0 923 Total 35.7 39.5 15.4 9.1 0.3 100.0 8,073 33.6 51.8 9.8 4.6 0.1 0.1 100.0 3,344 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes those with 4+ partners and number of partners missing. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 195 The main reasons that individual men and women provide to explain the perception of AIDS risk as low or nil are presented in Table 12.7. The most common reason for both men and women is that they have had just one partner (56 and 53 percent of women and men, respectively). Next in importance is that they are not having sex; 35 percent of women and 30 percent of men think they have a low risk of getting the AIDS virus because they have not been having sex. Those who have never married or who are no longer married are more likely to say they are at low risk because they are not having sex. Table 12.8 shows the distribution of men and women who believe they are at moderate or great risk of getting AIDS, by reasons for this perception. Seventy percent of women who think they are at moderate to great risk of getting AIDS, think so because their partners have other partners, compared with 29 percent of the men. Almost four in ten men think they are at moderate or great risk because they have multiple partners. Table 12.7 Reasons for perception of small/no risk of getting AIDS Among respondents who think they have small or no risk of getting AIDS, percentage who cite specific reasons for perception of risk, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––– Never Currently Formerly Never Currently Formerly Reason married married married Total married married married Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Not having sex 76.3 2.4 67.8 34.6 57.7 0.6 33.0 29.5 Uses condoms 4.5 0.7 5.2 2.5 19.2 9.4 31.0 14.9 Has only 1 partner 16.4 87.8 21.2 56.3 23.9 83.1 28.3 52.5 Limits the number of partners 2.5 2.9 5.5 3.0 9.4 11.8 23.9 11.0 Partner has no other partners 1.6 13.5 1.2 8.2 3.9 18.5 3.0 10.9 Doesn't fully trust partner 0.5 3.9 0.8 2.4 0.0 0.0 0.0 0.0 Religious 0.3 1.2 0.7 0.8 0.0 0.0 0.0 0.0 Other 4.5 2.4 3.4 3.2 6.0 7.0 9.5 6.6 Number 2,101 3,352 619 6,071 1,388 1,370 99 2,857 Table 12.8 Reasons for perception of moderate/great risk of getting AIDS Among respondents who think they have a moderate or great risk of getting AIDS, percentage who cite specific reasons for perception of risk, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––– Never Currently Formerly Never Currently Formerly Reason married married married Total married married married Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Doesn't use condoms 19.7 11.8 21.0 13.9 28.9 16.7 12.5 21.7 Has more than 1 sex partner 15.5 7.0 16.3 9.2 37.3 35.6 61.3 38.2 Partner has other partners 35.4 78.5 54.6 69.6 23.5 31.0 43.0 28.6 Homosexual contacts 0.0 0.1 0.4 0.1 0.0 0.0 0.9 0.1 Has had blood transfusions/injections 15.0 6.5 6.5 7.8 10.4 17.0 8.4 13.4 Other 23.0 5.5 11.8 8.7 26.7 19.8 16.4 22.6 Number 296 1,482 200 1,979 211 236 36 483 196 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 12.5 MULTIPLE SEXUAL PARTNERSHIPS Because the most important mechanism of HIV transmission is sexual intercourse, it is important to know the extent of multiple sexual partners. Consequently, women and men interviewed in the 2003 KDHS were asked questions about the number of partners with whom they had had sex in the 12 months preceding the survey. Information on the percentage of women and men age 15 to 49 who have had more than one sexual partner in the 12 months preceding the survey is presented in Table 12.9. The data show that only 2 percent of women and 12 percent of men report having had more than one sexual partner in the 12 months prior to the survey. Differentials by background characteristics among women are minimal. However, among men, those who are in their early twenties, ever-married, urban, and those in Coast, Nairobi, and Nyanza provinces are more likely than others to have had multiple partners. Table 12.9 Multiple sex partnerships among women and men Among women and men age 15-49, percentage who have had sex with more than one partner in the 12 months preceding the survey, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––– ––––––––––––––––––––––– Background Number of Number of characteristic Percentage women Percentage men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 1.5 1,856 7.3 856 20-24 1.8 1,691 16.4 681 25-29 1.9 1,382 13.1 509 30-39 1.7 1,957 12.5 811 40-49 2.0 1,309 10.2 506 15-24 1.6 3,547 11.3 1,537 Marital status Never married 0.9 2,443 10.3 1,611 Ever married 2.1 5,752 13.0 1,752 Residence Urban 2.1 2,056 15.4 856 Rural 1.6 6,139 10.4 2,506 Province Nairobi 1.7 835 15.9 376 Central 1.1 1,181 4.3 515 Coast 2.1 667 19.2 234 Eastern 1.9 1,325 7.9 541 Nyanza 3.4 1,222 15.2 443 Rift Valley 1.1 1,872 13.7 818 Western 1.5 927 11.7 378 North Eastern 0.2 168 0.0 57 Education No education 1.4 1,039 12.4 191 Primary incomplete 2.3 2,685 13.2 1,148 Primary complete 2.3 2,069 11.4 769 Secondary+ 0.8 2,403 10.4 1,254 Wealth quintile Lowest 2.1 1,364 10.7 510 Second 1.5 1,475 11.6 572 Middle 1.5 1,503 9.1 616 Fourth 1.5 1,711 11.0 741 Highest 2.0 2,141 14.7 924 Total 1.7 8,195 11.7 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 197 12.6 TESTING AND COUNSELLING FOR HIV Voluntary counselling and testing (VCT) is now acknowledged as an effective strategy for HIV prevention. HIV testing through VCT or in clinical settings is essential for access to AIDS care. Knowl- edge of HIV status helps HIV-negative individuals make specific decisions to reduce risk and increase safer sex practices so they can remain disease-free. For those who are HIV-infected, knowledge of their status allows them to better protect their sexual partners, to access treatment for HIV disease, and to plan for their future. In order to gauge the coverage of HIV testing as well as the unmet need for testing, respondents in the 2003 KDHS were asked if they have ever heard of “VCT.” Similarly, the interviewer asked re- spondents if they had ever been tested to see if they have the AIDS virus. Those who had been tested were asked when they were last tested, whether they had asked for the test or were required to take it, and whether they received their results. Those who had not been tested were asked if they would like to be tested and whether they know of a place to go for an AIDS test. Table 12.10 shows the percentage of women and men who have ever heard of VCT, who have ever been tested, and those who were tested and received the test results in the 12 months preceding the survey, by background characteristics. Nearly half of all women (48 percent) and three-fifths of men (62 percent) have heard of VCT. Knowledge of VCT is highest among those in their early 20s and among never-married women and men who have ever had sex. Urban respondents are one and a half times more likely to have heard of VCT as their rural counterparts. Knowledge of VCT is highest in Nairobi and Central provinces and among men in Coast Province; it is by far the lowest in North Eastern Province, where only 2 percent of women and 15 percent of men have ever heard of VCT. Knowledge of VCT increases dramatically as the level of education and the wealth index rise. Although knowledge of VCT services is quite widespread, Table 12.10 shows that the majority of those who are aware have not used the services. Only 15 percent of women and 16 percent of men say that they have ever been tested for HIV, almost identical to the levels reported in the 1998 KDHS. It is reassuring, however, that about 90 percent of those who have been tested received the test results. Half of those ever tested said they had been tested and received results in the 12 months preceding the survey. Those most likely to have ever received an HIV test are women and men in their 20s and early 30s, those living in urban areas, and those in Nairobi Province. The percentage who have been tested in- creases with education level and wealth index. Among those who were tested for HIV, 46 percent of women and 61 percent of men asked for the test, while 18 percent of women and 9 percent of men were offered the test and accepted (Figure 12.1). About one-third of those tested (35 and 30 percent of women and men, respectively) indicated that the HIV test was required. 198 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 12.10 Population who had an HIV test and received test results Percent distribution of women and men age 15-49 by status of HIV testing, and percentage of women and men who were tested for HIV and received test results in the last 12 months, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Tested Tested and and Ever tested received Ever tested received Heard –––––––––––––– Don’t results in Number Heard –––––––––––––– Don’t results in Number Background of Received No Never know/ past 12 of of Received No Never know/ past 12 of characteristic VCT results results tested missing Total months women VCT results results tested missing Total months men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 43.9 6.5 0.6 90.9 2.0 100.0 4.1 1,856 47.1 5.2 0.7 93.0 1.1 100.0 3.6 856 20-24 57.4 17.8 1.5 79.2 1.5 100.0 9.3 1,691 73.4 14.5 0.8 84.5 0.3 100.0 9.1 681 25-29 51.9 16.9 2.9 78.2 2.0 100.0 8.7 1,382 67.9 21.2 3.0 75.3 0.6 100.0 10.7 509 30-39 47.9 15.4 2.1 81.3 1.1 100.0 7.4 1,957 69.2 18.6 1.9 79.4 0.2 100.0 9.3 811 40-49 38.1 9.1 0.9 89.0 1.0 100.0 3.9 1,309 56.9 15.9 1.1 82.1 0.8 100.0 6.3 506 15-24 50.3 11.9 1.0 85.3 1.8 100.0 6.6 3,547 58.8 9.3 0.7 89.2 0.7 100.0 6.0 1,537 Marital status Never married 54.8 9.3 1.3 87.9 1.6 100.0 5.6 2,443 60.6 9.7 1.0 88.5 0.7 100.0 6.3 1,611 Ever had sex 60.4 16.0 2.2 81.0 0.8 100.0 9.7 1,055 66.5 12.4 1.3 86.2 0.1 100.0 7.9 1,073 Never had sex 50.5 4.1 0.5 93.2 2.2 100.0 2.4 1,388 48.8 4.3 0.4 93.2 2.1 100.0 3.3 537 Married/living together 45.0 14.6 1.8 82.0 1.6 100.0 7.1 4,919 64.4 18.1 1.8 79.8 0.4 100.0 8.3 1,615 Divorced/separated/ widowed 46.5 15.6 1.5 81.8 1.1 100.0 7.9 833 59.4 24.5 1.2 73.0 1.3 100.0 13.1 137 Residence Urban 70.0 22.4 1.5 75.3 0.8 100.0 11.3 2,056 81.7 22.0 1.8 75.8 0.4 100.0 12.5 856 Rural 40.7 10.0 1.6 86.6 1.8 100.0 5.1 6,139 55.8 11.7 1.3 86.4 0.7 100.0 5.9 2,506 Province Nairobi 79.6 27.0 1.5 71.2 0.4 100.0 13.1 835 86.0 25.4 1.7 72.5 0.4 100.0 14.8 376 Central 59.3 17.7 2.7 79.4 0.2 100.0 8.6 1,181 70.1 16.3 1.9 81.4 0.3 100.0 8.8 515 Coast 42.5 10.2 0.3 88.6 0.9 100.0 5.6 667 71.5 18.5 1.3 79.6 0.6 100.0 7.5 234 Eastern 32.9 10.3 1.5 87.4 0.9 100.0 4.1 1,325 46.0 9.1 1.2 89.4 0.2 100.0 3.4 541 Nyanza 47.6 10.3 1.7 87.8 0.1 100.0 6.6 1,222 58.3 15.9 1.6 82.2 0.3 100.0 8.8 443 Rift Valley 43.0 12.4 2.2 80.8 4.6 100.0 6.4 1,872 58.5 11.1 1.3 87.2 0.4 100.0 6.8 818 Western 50.5 8.4 0.4 90.8 0.4 100.0 5.0 927 66.6 12.4 0.9 86.4 0.3 100.0 5.8 378 North Eastern 2.1 0.6 0.0 93.5 5.9 100.0 0.2 168 15.1 2.6 0.7 82.7 14.0 100.0 1.3 57 Education No education 13.4 5.1 1.0 86.5 7.4 100.0 2.7 1,039 20.0 8.4 1.0 85.1 5.5 100.0 5.5 191 Primary incomplete 34.1 7.6 1.6 89.6 1.2 100.0 4.5 2,685 40.7 8.9 0.9 89.5 0.7 100.0 4.6 1,148 Primary complete 49.0 13.6 1.4 84.4 0.5 100.0 7.0 2,069 64.6 14.1 1.2 84.7 0.0 100.0 7.2 769 Secondary+ 77.9 22.4 2.0 75.4 0.2 100.0 10.7 2,403 87.4 20.4 2.0 77.6 0.0 100.0 10.8 1,254 Wealth quintile Lowest 23.3 5.0 0.8 89.6 4.6 100.0 2.8 1,364 36.0 9.4 1.1 87.1 2.4 100.0 5.1 510 Second 35.6 8.7 1.2 88.5 1.7 100.0 4.9 1,475 52.8 10.7 0.4 88.8 0.1 100.0 6.0 572 Middle 41.8 11.5 1.7 85.9 0.9 100.0 5.1 1,503 52.0 11.1 1.4 87.3 0.3 100.0 4.9 616 Fourth 52.0 12.9 2.3 84.5 0.3 100.0 7.2 1,711 69.4 12.4 1.7 85.5 0.4 100.0 6.1 741 Highest 73.7 22.7 1.7 74.7 0.9 100.0 11.2 2,141 84.1 23.0 2.0 74.8 0.3 100.0 12.8 924 Total 48.1 13.1 1.6 83.8 1.5 100.0 6.7 8,195 62.4 14.3 1.4 83.7 0.6 100.0 7.6 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 199 Figure 12.1 Reason for Getting HIV Test among Women and Men Age 15-49 Who Have Ever Been Tested 46 18 35 61 9 30 Asked for test Test offered and accepted Test required 0 10 20 30 40 50 60 Percent Women Men KDHS 2003 12.7 ATTITUDES TOWARDS NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent it are useless if people feel powerless to negotiate safer sex practices with their partners. To gauge attitudes towards safer sex, respondents in the 2003 KDHS were asked if they think a woman is justified in refusing to have sex with her husband if she knows he has an STD. They were also asked if they think that a woman in the same circumstances is jus- tified in asking her husband to use a condom. The results are shown in Table 12.11. About 90 percent of women and men feel that a woman is justified in refusing to have sex with her husband if she knows he has an STD, while around 80 percent believe that a woman is justified in asking her husband to use a condom if he has an STD. Ninety-four percent of women and 96 percent of men agree with one or both statements. Differences in these attitudes by background characteristics are minimal. However, women in North Eastern Province appear to be less accepting of requesting a husband to use condoms. 200 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 12.8 CONDOM USE AT HIGHER-RISK SEX As mentioned above, condom use is an important tool in the fight to curtail the spread of HIV/AIDS. Although truly effective protection would require condom use at every sexual encounter, the most important sexual encounters to cover are those considered to be “higher risk.” In the context of this survey, higher-risk sex is defined as sex with a nonmarital, noncohabitating partner in the 12 months pre- ceding the survey. Table 12.12 shows the proportion of women and men who have been sexually active in the 12 months before the survey who have engaged in higher-risk sex and use of condom during sex with such partners. Table 12.11 Attitudes towards negotiating safer sex Percentage of women and men who believe that, if a husband has a sexually transmitted disease, his wife is justified in either refusing to have sex with him or asking that he use a condom, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––– Refuse Refuse sex or sex or Propose propose Number Propose propose Number Background Refuse condom condom of Refuse condom condom of characteristic sex use use women sex use use men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 80.9 70.1 88.4 1,856 86.1 72.0 90.3 856 20-24 88.7 82.5 95.0 1,691 92.2 86.0 96.3 681 25-29 88.9 83.1 96.1 1,382 94.8 83.6 96.8 509 30-39 89.5 82.3 96.1 1,957 96.5 85.3 98.7 811 40-49 88.1 73.8 94.2 1,309 95.0 77.8 97.7 506 15-24 84.6 76.0 91.5 3,547 88.8 78.2 93.0 1,537 Current marital status Never married 83.4 75.6 90.7 2,443 89.2 77.9 93.1 1,611 Ever had sex 86.7 84.9 95.5 1,055 92.0 84.5 96.0 1,073 Never had sex 80.9 68.6 87.0 1,388 83.7 64.9 87.3 537 Married/living together 88.4 79.3 94.8 4,919 95.6 83.6 98.2 1,615 Divorced/separated/ widowed 89.9 80.7 97.0 833 95.0 78.4 96.0 137 Residence Urban 92.1 87.5 97.2 2,056 94.2 86.3 97.4 856 Rural 85.4 75.3 92.6 6,139 91.9 78.7 95.1 2,506 Province Nairobi 94.1 88.9 97.7 835 93.7 89.6 96.9 376 Central 91.4 85.3 97.4 1,181 93.1 69.0 95.9 515 Coast 88.1 79.3 93.5 667 92.5 81.6 94.4 234 Eastern 89.0 83.9 96.1 1,325 89.0 75.0 91.0 541 Nyanza 80.5 70.7 91.3 1,222 93.1 82.9 95.6 443 Rift Valley 83.2 75.6 90.7 1,872 93.0 84.1 98.0 818 Western 89.2 76.0 94.1 927 93.3 86.2 96.5 378 North Eastern 81.4 27.4 82.8 168 95.7 73.9 95.7 57 Education No education 78.6 53.9 84.6 1,039 91.3 67.7 94.5 191 Primary incomplete 83.6 74.4 91.4 2,685 88.5 73.9 91.8 1,148 Primary complete 90.1 84.2 96.5 2,069 93.5 80.2 96.9 769 Secondary+ 92.0 88.2 98.1 2,403 95.8 89.1 98.6 1,254 Wealth quintile Lowest 82.5 64.2 89.0 1,364 89.5 73.9 92.5 510 Second 82.9 72.5 91.1 1,475 90.8 78.3 93.5 572 Middle 84.9 77.3 93.5 1,503 92.0 78.0 96.0 616 Fourth 89.4 82.6 95.7 1,711 92.8 81.5 96.5 741 Highest 92.6 88.8 97.4 2,141 95.4 87.0 97.8 924 Total 87.1 78.3 93.8 8,195 92.5 80.7 95.7 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 201 The results show that 18 percent of sexually active women and 40 percent of sexually active men engaged in higher-risk sex in the 12 months prior to the survey. Of them, only one-quarter of women (24 percent) and half of men (47 percent) report using condoms at the most recent occurrence of higher-risk sex. Because the definition of higher-risk sex includes premarital sex, involvement in higher-risk sex is highest among women and men age 15-19 years, and decreases with increasing age. The percentage of those who used a condom at last higher-risk sex is alarmingly low for women (15 percent) age 40 to 49 years, compared with the highest rate of 28 percent of men age 20 to 24 years. However, among men, it is Table 12.12 Higher-risk sex and condom use at last higher-risk sex Among women and men who had sex in the last 12 months, percentage who had sex with a nonmarital, noncohabiting partner in the last 12 months and among women and men who have had higher-risk sex in the last 12 months, percentage who say they used a condom the last time they had sex with a nonmarital, noncohabiting partner, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––– Number Number Percentage Number of women Percentage Number of men engaging of women Percentage who had engaging of men Percentage who had in higher- who had who used higher-risk in higher- who had who used higher-risk risk sex sex in condom at sex in risk sex sex in condom at sex in Background in the past the past last higher- past in the past the past last higher- past characteristic 12 months 12 months risk sex 12 months 12 months 12 months risk sex 12 months –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 46.7 619 23.4 289 97.1 258 41.3 250 20-24 21.4 1,207 27.6 258 77.2 459 50.7 355 25-29 13.9 1,190 25.8 166 35.3 421 51.8 149 30-39 10.8 1,693 23.1 184 18.6 765 38.6 142 40-49 10.9 1,000 14.9 109 9.6 476 50.0 46 15-24 30.0 1,826 25.4 547 84.4 717 46.8 605 Marital status Never married 99.9 597 27.9 596 99.8 681 48.9 680 Married/living together 2.4 4,693 18.8 112 11.1 1,597 44.9 177 Divorced/separated/ widowed 70.9 420 17.8 298 84.1 101 30.6 85 Residence Urban 23.8 1,381 33.0 328 42.5 655 59.1 279 Rural 15.7 4,329 19.5 678 38.5 1,725 41.2 663 Province Nairobi 26.7 554 31.7 148 42.9 285 64.4 122 Central 16.4 790 20.8 129 32.6 321 33.1 105 Coast 16.6 482 27.3 80 45.0 178 56.3 80 Eastern 18.9 958 25.2 181 39.1 348 43.7 136 Nyanza 21.0 946 16.5 199 39.2 304 35.2 119 Rift Valley 14.3 1,236 27.5 177 42.5 659 48.7 280 Western 14.8 625 19.4 93 39.8 250 42.0 99 North Eastern 0.0 118 * 0 0.0 35 * 0 Education No education 10.3 727 10.5 75 24.5 144 (40.6) 35 Primary incomplete 17.8 1,843 17.0 328 48.9 708 36.5 346 Primary complete 18.2 1,575 23.2 286 35.1 591 43.8 207 Secondary+ 20.2 1,565 35.0 316 37.7 938 58.5 353 Wealth quintile Lowest 12.8 975 11.4 124 31.4 359 39.8 113 Second 14.5 1,067 13.8 155 42.1 379 39.1 160 Middle 16.6 1,064 15.0 177 35.3 395 33.7 139 Fourth 17.9 1,165 25.5 209 44.0 526 47.9 231 Highest 23.7 1,439 36.7 341 41.4 721 57.9 299 Total 17.6 5,710 23.9 1,006 39.6 2,380 46.5 942 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indictes that a figure is based on fewer than 25 unweighted cases and has been suppressed. Higher-risk sex refers to sex with a non-marital, non-cohabiting partner. 202 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour lowest (39 percent) in the age cohort of 30 to 39 as compared with the highest (52 percent) in the age group 25 to 29 years. By definition, all sexually active women and men who have never married engage in higher-risk sex, compared with only 2 percent of married women and 11 percent of married men. Condom use during higher-risk sex is more pronounced among women who have never married (28 percent) than those mar- ried (19 percent) or divorced/widowed/separated (18 percent). Sexually active women and men (24 and 43 percent, respectively) from urban areas are more likely to be involved in higher risk sex than women and men (16 and 39 percent, respectively) from rural areas. They are also considerably more likely to use condoms than rural respondents. Women in Nairobi Province and men in Coast and Nairobi provinces are more likely to engage in higher-risk sex and to use condoms than respondents in other provinces, especially North Eastern Province, where no women or men reported sexual activity outside of marriage. Among women, there is an increase in higher-risk sex and condom use with increasing level of education and increasing wealth index, while among men, engagement in higher-risk sex is lower for those with no education but fluctuates for other groups as well as by wealth index. 12.9 PAID SEX AND CONDOM USE A special category of higher-risk sex is sex for which compensation is paid. In the 2003 KDHS, men were asked if they had ever paid for sex and, if so, when the most recent encounter took place and if they used condoms at that most recent sex. Women were asked if they had given or received money, gifts, or favours in return for sex in the 12 months preceding the survey. Results shown in Table 12.13 indicate that only 3 percent of men have had sex with prostitutes in the 12 months before the survey, 65 percent of whom report that they used condoms at the most recent paid sex. Six percent of women indicate that they received money, gifts, or favours in exchange for sex. There are no significant variations by age in the percentage of men having paid sex in the 12 months preceding the survey. However, younger women age 15 to 19 are more likely than older women to receive money, gifts, or favours in exchange for sex (16 and 3 to 5 percent, respectively). Divorced, widowed, or separated men are more likely than married and never-married men to have paid for sex. On the other hand, never-married women are the most likely to have received money, gifts, or favours for sex, with one in four reporting such activity in the 12 months preceding the survey. The proportion of men having paid sex is higher among men in urban areas and in Coast Province than among other men. Education seems not to play a significant role among men reporting sex with pros- titutes. Men in the lowest wealth quintile are lightly less likely than those in the highest quintile to have paid for sex. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 203 12.10 ATTITUDES TOWARDS CONDOMS Questions were added in the man’s questionnaire to gauge attitudes towards condom use among men. Respondents were asked to say whether they agree or disagree with several statements about con- doms that were read by the interviewer. The statements included the following: 1) condoms diminish a man’s sexual pleasure; 2) it’s okay to reuse a condom if you wash it; 3) condoms protect against disease; 4) buying condoms is embarrassing; 5) a woman has no right to tell a man to use a condom; and (6) con- doms contain HIV. Table 12.14 presents the percentage of men who agree with each of these statements about condoms, according to background characteristics. Table 12.13 Paid sex in last year and condom use at last paid sex Percentage of men reporting that they paid for sex in the 12 months preceding the survey and among them, percentage reporting condom use the last time they had paid sex, and percentage of women re- porting they received money, gifts, or favours in return for sex in the 12 months preceding the survey, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number Number of women Percentage Percentage of men reporting Number of reporting reporting reporting receiving women who paid sex Number condom paid sex money, gifts, had sex Background in past of use at last in past or favours in the past characteristic 12 months men paid sex 12 months for sex 12 months –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 3.6 856 (35.1) 30 16.2 619 20-24 3.5 681 (86.4) 24 5.3 1,207 25-29 2.6 509 * 13 4.3 1,190 30-39 2.7 811 * 22 3.1 1,693 40-49 2.0 506 * 10 4.5 1,000 15-24 3.5 1,537 57.6 54 9.0 1,826 Marital status Never married 3.3 1,611 63.2 53 23.2 597 Married/living together 2.0 1,615 (63.5) 32 2.2 4,693 Divorced/separated/ widowed 10.3 137 * 14 17.4 420 Residence Urban 4.6 856 81.3 39 6.6 1,381 Rural 2.4 2,506 (53.7) 60 5.1 4,329 Province Nairobi 1.5 376 * 6 6.0 554 Central 1.0 515 * 5 2.2 790 Coast 10.0 234 (90.4) 23 6.3 482 Eastern 1.0 541 * 5 7.6 958 Nyanza 3.4 443 * 15 7.6 946 Rift Valley 3.9 818 * 32 4.3 1,236 Western 3.4 378 * 13 5.5 625 North Eastern 0.0 57 * 0 0.0 118 Education No education 3.2 191 * 6 3.8 727 Primary incomplete 4.0 1,148 (47.4) 46 7.5 1,843 Primary complete 2.5 769 * 19 4.7 1,575 Secondary+ 2.2 1,254 (81.9) 28 4.7 1,565 Wealth quintile Lowest 1.5 510 * 8 6.2 975 Second 2.4 572 * 14 5.9 1,067 Middle 2.1 616 * 13 5.2 1,064 Fourth 3.2 741 (61.3) 23 3.9 1,165 Highest 4.5 924 (84.6) 41 6.2 1,439 Total 2.9 3,363 64.5 99 5.5 5,710 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 204 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour It is encouraging to note that 78 percent of men indicate that condoms protect against disease. It is also notable that only 5 percent believe that it is ok to reuse a condom if it is washed and that only 8 per- cent believe that condoms contain the HIV virus. As for attitudes, 46 percent of men agree with the state- ment that condoms diminish a man’s sexual pleasure and 34 percent say that buying condoms is embar- rassing. More than one-quarter of men (28 percent) say that a woman has no right to tell a man to use a condom. With regard to differentials, teenage men (age 15-19) are less likely than older men to know that condoms can protect against disease and are more likely to believe that condoms contain HIV. They are also less likely to think that condoms diminish a man’s pleasure. Similarly, men who have never had sex Table 12.14 Attitude towards condoms Percentage of men age 15-49 who agree with particular statements about condoms, by background charac- teristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Attitudes about condoms ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Woman Condoms has no right Can protect Buying to tell man Condoms Number Background Diminish reuse against condoms is to use contain of characteristic pleasure condom disease embarrassing condom HIV men ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 29.9 5.0 67.1 36.1 31.7 9.2 856 20-24 52.8 4.0 84.8 29.0 26.9 9.5 681 25-29 52.2 4.7 80.4 33.9 24.0 6.8 509 30-39 51.3 4.5 84.0 32.9 26.5 6.7 811 40-49 47.1 5.7 74.2 39.6 28.8 6.6 506 Marital status Never married 40.5 4.6 74.6 33.2 27.3 8.6 1,611 Ever had sex 53.4 4.2 84.7 30.8 30.1 8.8 1,073 Never had sex 14.8 5.5 54.6 37.8 21.5 8.1 537 Married/living together 49.7 4.8 80.4 35.0 27.4 7.0 1,615 Divorced/separated/ widowed 58.6 5.6 85.1 33.8 41.6 10.5 137 Residence Urban 54.1 2.1 80.7 32.9 22.4 5.4 856 Rural 42.8 5.6 76.9 34.5 29.8 8.7 2,506 Province Nairobi 55.2 2.4 83.2 29.5 17.9 5.5 376 Central 41.5 3.0 70.2 32.6 20.3 13.0 515 Coast 63.0 1.5 79.9 35.5 28.1 3.0 234 Eastern 43.9 5.8 74.7 46.5 26.6 12.8 541 Nyanza 40.1 6.2 82.7 34.5 38.0 10.6 443 Rift Valley 46.9 7.7 79.5 33.0 34.4 3.6 818 Western 42.3 2.3 86.1 22.3 25.0 5.6 378 North Eastern 13.7 1.3 17.9 44.8 21.2 5.9 57 Education No education 22.5 12.6 44.9 37.2 26.6 7.3 191 Primary incomplete 43.6 7.2 75.5 38.0 38.8 12.0 1,148 Primary complete 49.1 4.4 77.8 32.2 30.3 7.7 769 Secondary+ 49.0 1.5 85.0 31.2 16.6 4.3 1,254 Wealth quintile Lowest 36.7 11.8 69.4 36.4 33.8 8.3 510 Second 40.3 4.0 79.7 34.9 34.5 9.5 572 Middle 42.2 5.7 73.8 33.4 28.1 10.3 616 Fourth 49.3 3.1 80.4 35.8 28.5 7.6 741 Highest 53.3 2.0 82.1 31.4 20.0 5.2 924 Total 45.7 4.7 77.9 34.1 27.9 7.9 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 205 are less likely to know that condoms can protect against disease and less likely to say that condoms di- minish pleasure. Rural men are slightly more likely than urban men to believe that condoms can be reused and that they contain HIV. They are also somewhat less likely to agree that condoms diminish pleasure or that they protect against disease. A larger proportion of rural than urban men feel that a woman has no right to tell a man to use a condom. Men in Coast and Nairobi provinces are the most likely to say that condoms diminish a man’s sexual pleasure, while men in Western, Nairobi, and Nyanza provinces are most likely to know that con- doms protect against disease. The belief that condoms can be reused is relatively higher among men in Rift Valley and Nyanza provinces than men in other provinces, while the belief that condoms contain HIV is highest among men in Central, Eastern, and Nyanza provinces. Men in North Eastern Province are the least likely to believe that condoms diminish pleasure or that they can be reused; however, they are also the least likely to know that condoms protect against disease. The results show that men with no education and those with only primary level of education are somewhat disadvantaged in knowledge about condoms, compared with men with at least some secondary education. Men in the highest wealth quintile are most likely to know that condoms protect against dis- ease and least likely to believe that condoms can be reused. 12.11 CONDOM BRANDS Table 12.15 shows the percent distribution of men who have ever used condoms by brand of condoms usually used, according to residence. The majority of re- spondents in both urban and rural (68 and 54 percent, re- spectively) areas indicate that they usually use Trust con- doms, the brand that is socially marketed by Population Services International. A sizeable proportion of men ei- ther do not know the brand (16 percent) or use an un- branded condom (11 percent). Condoms such as Rough Rider are more widely used in urban than rural areas, probably due to their higher cost as compared with Trust. 12.12 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS Information about the incidence of sexually transmitted infections (STIs) is not only useful as a marker of unprotected sexual intercourse but also as a cofactor for HIV transmission. Surveillance sys- tems for STIs in Kenya have primarily focused on collection of incidence and prevalence data through passive case reporting and routine screening systems. The World Health Organisation, the Joint United Nations Programme on HIV/AIDS, and other partners have been promoting the tracking of STI epidemics in the region as part of the second generation HIV surveillance programmes. Nationally, the prevalence of syphilis and other STIs is reported from seroprevalence testing among pregnant women attending antena- tal care clinics and STI clients attending clinics at selected health facilities (“sentinel sites”) annually. Studies have shown that reported declines in prevalence of HIV have been accompanied by declines in the prevalence of other STIs. Additionally, studies among sex workers and adults in the general popula- tion have shown that infections with syphilis, gonorrhoea, chlamydia, and trichomonas are common and are potential agents for the spread of HIV via unprotected sex (MOH, 2001). Table 12.15 Condom brands Percent distribution of men who have ever used con- doms by brand of condoms usually used, according to residence, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––– Residence Brand of ––––––––––––– condom Urban Rural Total –––––––––––––––––––––––––––––––––––––––––– Durex 5.7 6.3 6.1 Rough Rider 4.5 0.9 2.1 Sure 0.9 0.7 0.8 Trust 68.1 54.3 58.7 No brand 9.0 11.9 11.0 Other 2.6 3.5 3.2 Don't know brand 8.3 20.3 16.4 Missing 0.7 2.2 1.7 Total 100.0 100.0 100.0 Number 459 965 1,424 206 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour The 2003 KDHS elicited information from both female and male respondents about their knowl- edge of infections other than HIV that can be transmitted sexually. Additionally, respondents who had ever had sex were asked if they had had a sexually transmitted disease in the previous 12 months or if they had had either of two symptoms associated with STIs (a bad-smelling, unusual discharge from the vagina/penis or a genital sore or ulcer). As shown in Table 12.16, only 2 percent of women and men who have ever had sex reported hav- ing had an STI in the 12 months before the survey. Three percent of women and 2 percent of men re- ported having had an abnormal genital discharge, and 2 percent of each sex reported having had a genital sore or ulcer in the 12 months before the survey. Only 4 percent of women and 3 percent of men reported having either an STI, an abnormal discharge, or a genital sore. Table 12.16 Self-reporting of a sexually transmitted infection (STI) and STI symptoms Among women and men who ever had sex, percentage self-reporting an STI and/or symptoms of an STI in the last 12 months, by back- ground characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––– Percentage Percentage Percentage with STI/ Number Percentage with STI/ with Percentage discharge/ of with Percentage discharge/ Number Percentage abnormal with genital women Percentage abnormal with genital of men Background with genital genital sore/ who ever with genital genital sore/ who ever characteristic an STI discharge sore/ulcer ulcer had sex an STI discharge sore/ulcer ulcer had sex ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 1.1 2.7 1.5 3.9 782 1.1 1.4 1.7 2.2 432 20-24 1.6 3.4 2.5 4.7 1,438 2.2 3.0 1.3 3.7 591 25-29 1.8 2.8 2.6 4.4 1,337 2.6 2.6 1.6 3.6 492 30-39 1.5 3.3 2.1 4.1 1,941 2.1 2.1 1.3 3.1 805 40-49 1.9 3.3 2.9 4.6 1,307 2.5 1.5 1.7 2.9 506 Marital status Never married 1.1 1.5 0.9 2.4 1,055 1.4 1.9 1.3 2.5 1,073 Married/living together 1.7 3.5 2.6 4.8 4,918 2.3 2.0 1.4 3.0 1,615 Divorced/separated/ widowed 2.1 3.4 2.7 4.5 833 5.5 5.9 3.8 9.0 137 Residence Urban 1.6 3.1 2.2 4.1 1,702 2.0 1.7 1.7 3.1 748 Rural 1.6 3.2 2.4 4.4 5,104 2.1 2.3 1.4 3.1 2,077 Province Nairobi 1.6 3.7 2.2 4.3 684 1.6 0.9 1.7 3.2 327 Central 1.4 3.6 1.9 5.0 961 0.3 0.3 0.7 0.7 403 Coast 2.3 4.7 2.5 5.1 557 3.5 4.1 2.1 5.1 196 Eastern 1.0 2.0 1.1 2.3 1,092 0.7 0.7 0.0 0.7 442 Nyanza 0.9 3.8 4.1 6.6 1,069 5.1 6.0 4.8 7.6 359 Rift Valley 1.6 1.4 1.6 2.8 1,569 2.5 1.6 0.3 2.5 762 Western 3.6 6.0 4.4 6.8 736 2.1 4.2 3.4 5.4 300 North Eastern 0.0 0.3 0.0 0.3 138 0.0 0.0 0.0 0.0 35 Education No education 0.9 2.9 1.6 3.3 975 6.1 4.5 1.9 6.5 160 Primary incomplete 2.5 4.3 3.4 5.9 2,122 2.9 3.2 1.6 4.1 866 Primary complete 1.5 3.2 2.3 4.5 1,828 2.5 2.6 2.3 3.9 687 Secondary+ 1.2 2.0 1.6 3.0 1,880 0.7 0.8 0.8 1.4 1,112 Wealth quintile Lowest 1.4 3.4 3.0 4.4 1,169 4.1 3.4 2.2 5.5 419 Second 1.5 2.8 2.7 4.6 1,257 1.5 2.8 1.8 3.3 475 Middle 1.5 3.3 1.5 3.8 1,244 1.9 1.7 1.5 2.2 478 Fourth 2.3 3.2 2.3 4.7 1,389 1.5 1.6 0.9 2.3 633 Highest 1.4 3.1 2.3 4.2 1,746 2.0 1.9 1.4 3.0 820 Total 1.6 3.2 2.4 4.4 6,806 2.1 2.2 1.5 3.1 2,825 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 207 Differentials in the proportion who report having an STI or a symptom of an STI are muted, with only slightly higher levels among men who are divorced/separated or widowed and among women in Western Province and women and men in Nyanza Province. The latter finding could be one factor in the higher levels of HIV prevalence found in Nyanza Province (see Chapter 14). Table 12.17 shows the percentage of women and men who reported having an STI or symptoms of an STI in the past 12 months who sought specific types of care. Ninety percent of men and 68 percent of women sought some sort of advice or treatment for their symptoms. Proportionally more men than women (71 and 59 percent, respectively) sought treatment from a health facility or health professional. Fifteen percent of women and one-third of men sought treatment from traditional healers, while about 16 percent of each sex sought advice or medicine from a shop or pharmacy. 12.13 MALE CIRCUMCISION Circumcision is practiced in many communities in Kenya and often serves as a rite of passage to adulthood. Recently, male circumcision has been associated with lower transmission of STIs, including HIV. In order to investigate this relationship, men interviewed in the 2003 KDHS were asked if they were circumcised. Table 12.18 shows that 84 percent of Kenyan men are circumcised. A lower proportion of men age 15 to 19 are circumcised (72 percent) than those at older ages (minimum of 84 percent). This could indicate a decline in the practice, although it is also possible that some young men may not have yet gone through the circumcision process. Men living in urban and rural areas are equally likely to be circum- cised. At least 80 percent of men are circumcised in all provinces except Nyanza Province, where less than half of the men are circumcised (46 percent). Muslims (almost 100 percent) are more likely to be circumcised than those who belong to other religious groups (82 percent). Luo (17 percent) men are the least likely to be circumcised. Table 12.17 Women and men seeking treatment for sexually transmitted infections (STIs) Percentage of women and men reporting an STI or symptoms of an STI in the past 12 months who sought care, by source of advice or treatment, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––– Sought care for STI Source of advice ––––––––––––––––––– or treatment Women Men –––––––––––––––––––––––––––––––––––––––––––––––––––––––– Clinic/hospital/health professional 59.0 70.8 Traditional healer 14.8 33.1 Advice or medicine from shop/pharmacy 15.7 16.9 Advice from friends/relatives 8.7 28.5 Advice or treatment from any source 68.2 89.6 No advice or treatment 31.8 10.4 Number with STI or symptoms of STI 296 88 208 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 12.18 Male circumcision Percentage of men age 15-49 who have been circumcised, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––– Percent Number Background circum- of characteristic cised men ––––––––––––––––––––––––––––––––––––––– Age 15-19 71.5 856 20-24 89.0 681 25-29 88.3 509 30-39 89.3 811 40-49 83.7 506 Residence Urban 83.5 856 Rural 83.8 2,506 Province Nairobi 81.5 376 Central 90.3 515 Coast 96.1 234 Eastern 96.2 541 Nyanza 46.4 443 Rift Valley 86.6 818 Western 86.4 378 North Eastern 100.0 57 Education No education 85.3 191 Primary incomplete 76.5 1,148 Primary complete 85.3 769 Secondary+ 89.1 1,254 Religion Protestant 82.4 2,041 Roman Catholic 82.1 879 Muslim 99.6 214 No religion/other/missing 87.1 229 Ethnicity Embu 96.6 54 Kalenjin 90.5 409 Kamba 99.5 397 Kikuyu 93.7 758 Kisii 99.1 191 Kuria (76.1) 24 Luhya 92.5 503 Luo 16.9 396 Maasai 76.5 82 Meru 91.2 180 Mijikenda/Swahili 99.4 136 Somali 100.0 101 Taita/Taveta 97.3 35 Turkana (39.7) 47 Other/missing 64.1 47 Wealth quintile Lowest 75.3 510 Second 82.5 572 Middle 88.9 616 Fourth 86.6 741 Highest 83.3 924 Total 83.7 3,363 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 209 12.14 AGE AT FIRST SEX AMONG YOUTH Table 12.19 shows the proportion of women and men age 15 to 24 who had sex before age 15 years, by background characteristics. Fourteen percent of young women and 29 percent of young men had sex by age 15. As expected, the proportion of young people who had sex before age 15 is higher among those who have been married. It is also higher among women in Nyanza Province and among men in Rift Valley Province. Level of education is strongly related to age at first sex, especially for women. While one-quarter of women age 15 to 24 with no education had sex by age 15, the proportion declines to only 4 percent among those with at least some secondary education. Table 12.19 Age at first sex among young women and men Percentage of women and men age 15-24 who had sex by exact age 15, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––– ––––––––––––––––––––– Number Number Percentage of Percentage of Background who had sex women who had sex men characteristic by age 15 age 15-24 by age 15 age 15-24 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-17 14.5 1,076 29.3 536 18-19 14.4 780 33.5 320 15-19 14.5 1,856 30.9 856 20-22 12.0 1,027 26.6 426 23-24 14.1 665 25.5 255 20-24 12.8 1,691 26.2 681 Marital status Never married 8.6 2,090 28.2 1,379 Ever married 20.9 1,457 34.5 158 Residence Urban 10.0 912 23.5 353 Rural 15.0 2,635 30.4 1,184 Province Nairobi 8.2 381 19.6 149 Central 7.9 458 12.0 236 Coast 12.7 272 21.4 99 Eastern 16.5 580 30.4 264 Nyanza 24.2 563 29.2 219 Rift Valley 11.7 782 48.0 355 Western 12.3 444 25.3 195 North Eastern 7.8 68 0.0 20 Education No education 25.5 250 37.4 55 Primary incomplete 18.4 1,390 32.6 695 Primary complete 13.7 906 28.5 298 Secondary+ 4.1 1,001 22.6 490 Wealth quintile Lowest 17.9 536 35.9 232 Second 18.4 624 31.9 286 Middle 13.6 674 29.2 312 Fourth 11.6 764 27.5 347 Highest 9.9 948 22.8 360 Total 13.7 3,547 28.8 1,537 210 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 12.15 KNOWLEDGE OF CONDOM SOURCES AMONG YOUTH Knowledge of sources of condoms plays an important role in prevention of STI/HIV transmission and unwanted pregnancies. Younger people are often at a higher risk of contracting STIs, as they are more likely to be experimenting with sex before marriage. As shown in Table 12.20, about half of young women and three-quarters of young men say that they know of a place where one can get a condom. Knowledge of a source for condoms is considerably higher among women and men age 20 to 24 than among those age 15 to 19. Urban women and men are more likely to know a source of condoms than rural women and men. Never-married women and men are less likely to know of a source of male condoms than ever-married women and men. Women from North Eastern Province are least knowledgeable (3 percent) about a source for condoms, compared with all other women (42 percent or more) and their male counterparts (43 percent). Knowledge of a source of condoms increases with increasing educational level and wealth index of both women and men. Women and men (19 and 39 percent, respectively) with no education are less likely to know a source of condoms than women and men (74 and 92 percent, respectively) who have at least some secondary education. The poorest women and men (33 and 59 percent, respectively) are least Table 12.20 Knowledge of a source for condoms among young people Percentage of women and men age 15-24 who know at least one source of male condoms, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––– ––––––––––––––––––––––– Know a Number of Know a Number of Background source for women source for men characteristic male condom age 15-24 male condom age 15-24 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 42.7 1,856 63.2 856 20-24 63.7 1,691 89.6 681 Marital status Never married 48.8 2,090 73.6 1,379 Ever had sex 61.5 765 85.0 865 Never had sex 41.4 1,326 54.3 514 Ever married 58.4 1,457 86.2 158 Residence Urban 69.0 912 89.4 353 Rural 47.1 2,635 70.6 1,184 Province Nairobi 73.0 381 87.7 149 Central 51.2 458 78.0 236 Coast 44.9 272 77.6 99 Eastern 41.6 580 60.2 264 Nyanza 58.2 563 64.4 219 Rift Valley 55.9 782 83.8 355 Western 51.4 444 78.8 195 North Eastern 2.9 68 42.6 20 Education No education 19.0 250 38.5 55 Primary incomplete 40.1 1,390 62.2 695 Primary complete 57.4 906 83.7 298 Secondary+ 74.4 1,001 91.6 490 Wealth quintile Lowest 33.3 536 59.0 232 Second 46.0 624 72.0 286 Middle 44.9 674 67.1 312 Fourth 54.8 764 78.9 347 Highest 72.0 948 90.3 360 Total 52.7 3,547 74.9 1,537 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 211 likely to know of a source of condoms, compared with the richest women and men (72 and 90 percent, respectively). 12.16 CONDOM USE AT FIRST SEX AMONG YOUTH Table 12.21 presents the percentage of youth age 15 to 24 years who used a condom during first sex by background characteristics. Only 12 percent of young women and 14 percent of young men used condoms during their first sexual encounter. Never-married women and men are more likely to use a con- dom the first time they ever have sex than ever-married young people. Similarly, urban women and men (17 and 20 percent, respectively) tend to use condoms at first sexual activity more than rural women and men (10 and 12 percent, respectively). Table 12.21 Condom use at first sex among young women and men Among women and men age 15-24 who have ever had sex, percentage who used a con- dom the first time they had sex, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––––––– ––––––––––––––––––––– Number of Number of women age men age Used a 15-24 who Used a 15-24 who Background condom have ever condom have ever characteristic at first sex had sex at first sex had sex –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 12.3 782 10.0 432 20-24 11.7 1,438 16.8 591 Marital status Never married 20.3 765 14.8 865 Ever married 7.5 1,455 9.2 158 Residence Urban 17.1 592 19.9 252 Rural 10.0 1,628 12.0 771 Province Nairobi 19.7 249 19.1 103 Central 11.4 248 20.1 127 Coast 8.7 165 21.8 64 Eastern 11.5 356 5.7 166 Nyanza 9.9 410 11.0 135 Rift Valley 12.5 496 12.3 305 Western 11.3 257 18.0 119 North Eastern 0.0 39 * 4 Education No education 1.3 188 12.3 32 Primary incomplete 7.2 832 9.0 419 Primary complete 12.7 676 13.1 223 Secondary+ 22.2 523 20.5 349 Wealth quintile Lowest 3.5 343 12.4 147 Second 10.0 409 10.3 191 Middle 9.4 415 10.1 176 Fourth 12.8 450 13.7 245 Highest 19.1 603 20.2 263 Total 11.9 2,220 13.9 1,023 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 212 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Among women, condom use at first sex is highest among those in Nairobi Province and lowest in North Eastern province. Among men, it is highest in Coast Province, followed closely by Central and Nairobi Provinces. Level of education is strongly related to condom use at first sexual activity among women, rising from only 1 percent of young women with no education to 22 percent among those with some secondary education. Wealth index is also related to condom use at first sex among women, al- though the pattern is variable. Figure 12.2 summarises data on the proportion of young people who fall into various categories of risk for HIV. For example, 37 percent of young women and 34 percent of young men age 15 to 24 have never had sex, while 11 and 20 percent, respectively, have had sex but not in the last 12 months. Four percent of women and 13 percent of men have had sex with only one partner in the 12 months prior to the survey and used a condom at the most recent sex. Moving up the scale of risk, 46 percent of women and 23 percent of men had sex with only one partner but did use condoms at the most recent sex. Less than 1 percent of women and 6 percent of men had sex with more than one partner in the last 12 months and used a condom the last time. Finally, 2 percent of women and 5 percent of men have had sex with more than one partner in the preceding 12 months and did not use condoms at the most recent sex. As expected, a much larger proportion of women and men in the younger age group (age 15 to 19) are at lower risk because they have not yet had sex. Among those age 20 to 24, a large majority of women and one-third of men have only one partner, with whom condom use is not common. Very few young women report hav- ing more than one partner, however, 16 percent of men age 20 to 24 report having had multiple partners. Figure 12.2 Abstinence, Being Faithful, and Using Condoms Among Young Women and Men 15-19 20-24 15-24 15-19 20-24 15-24 0 20 40 60 80 100 Never had sex Had sex, but not in past 12 months Only one partner, used condom last time Only one partner, did not use condom last time More than one partner, used condom last time More than one partner, did not use condom last time KDHS 2003 WOMEN MEN Note: Refers to partners in the 12 months prior to the survey and condom use at most recent sexual encounter. 12.17 PREMARITAL SEX The period between age at first sex and age at marriage is often a time of sexual experimentation. Unfortunately, in the era of HIV/AIDS, it can also be a risky time. Information is shown in Table 12.22 on the percentage of never-married women and men age 15 to 24 years who have had sex in the 12 months before the survey and the percentage who used condoms during last sex. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 213 Twenty-two percent of never-married women age 15 to 24 years indicate that they have had sex in the 12 months before the survey compared with 41 percent of men of the same age. About one-quarter of these women and half of the men reported having used condoms the most recent time they had sex. As expected, premarital sex and condom use at last sex is higher among older respondents (age 20 to 24) than younger ones. Both are also higher among urban than rural youth. There are regional dif- ferentials in the percentage of never-married young people who have had sex in last 12 months. Among never-married women, those in Nyanza and Nairobi provinces are more likely to have had sex in the pre- vious 12 months than other women. Among men, Rift Valley Province leads in the proportion of those who have had premarital sex. On the other hand, no never-married young women or men in North Eastern Province reported having had sex in the previous 12 months. Fewer never-married young women and men with no education report having had sex in the last 12 months than those with some education. Level of education is also associated with condom use during sexual intercourse among youth. Women and men with at least some secondary education are more likely to use condoms during sex than those with less education. Wealth seems to have a mixed relationship with premarital sex and condom use. Table 12.22 Premarital sex and condom use among youth Among never-married women and men age 15-24, percentage who have had sex in the last 12 months, and, among those who had premari- tal sex in the last 12 months, percentage who used a condom at last sex, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––– Number of Number of Number women Number men age of never- age 15-24 of never- 15-24 Had sex married Used who had sex Had sex married Used who had sex Background in past women condom in the past in past men age condom in the past characteristic 12 months age 15-24 at last sex 12 months 12 months 15-24 at last sex 12 months –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 17.6 1,478 24.7 260 28.8 839 41.1 241 20-24 30.8 612 30.5 188 58.9 540 52.3 318 Residence Urban 23.6 550 32.5 130 49.5 313 58.1 155 Rural 20.7 1,540 25.0 319 37.9 1,066 43.4 404 Province Nairobi 27.4 245 31.4 67 47.1 135 65.6 64 Central 18.1 315 15.0 57 30.8 220 27.4 68 Coast 16.1 137 (30.2) 22 46.2 86 59.0 40 Eastern 23.8 371 30.7 88 31.0 242 44.0 75 Nyanza 31.7 301 20.7 95 35.6 183 39.5 65 Rift Valley 16.4 415 (40.1) 68 58.9 318 51.6 187 Western 18.3 278 22.6 51 33.8 178 43.6 60 North Eastern 0.0 29 * 0 0.0 16 * 0 Education No education 1.9 76 * 1 35.8 46 * 17 Primary incomplete 17.8 796 21.3 142 35.7 619 40.2 221 Primary complete 31.4 475 20.7 149 47.6 260 50.0 124 Secondary+ 21.0 743 38.9 156 43.6 453 54.6 197 Wealth quintile Lowest 17.9 268 (20.4) 48 36.0 194 47.2 70 Second 21.9 350 14.0 77 39.1 261 40.1 102 Middle 20.1 404 19.8 81 31.2 290 39.9 90 Fourth 20.7 480 28.9 99 41.4 311 49.5 128 Highest 24.4 588 39.4 144 52.0 324 54.5 168 Total 21.5 2,090 27.2 449 40.5 1,379 47.5 559 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 214 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 12.18 HIGHER-RISK SEX AND CONDOM USE AMONG YOUTH The most common means of transmission of HIV in Kenya is through unprotected sex with an in- fected person (Ministry of Health, 2001). To prevent HIV/AIDS virus transmission, it is important that young people practice safe sex through the most advocated “ABC” methods (abstinence, being faithful to one uninfected partner, and condom use). Table 12.23 indicates the percentage of young people who en- gage in higher-risk sex and the extent to which they use condoms in higher-risk sexual encounters (i.e., with nonmarital, noncohabiting partners). Among sexually active youths age 15 to 24 years, results show that the percentage of women and men who have engaged in higher-risk sex activity in the last 12 months is 30 and 84 percent, respectively. Men (47 percent) who engage in higher-risk sex are more likely to use condoms than women (25 percent). Table 12.23 Higher-risk sex and condom use among young women and men Among women and men age 15-24 who had sex in the 12 months preceding the survey, percentage who had sexual relations with a nonmari- tal, noncohabiting partner in the past 12 months, and among women and men age 15-24 who have had higher-risk sex in the past 12 months, percentage who say they used a condom the last time they had sex with a non-marital, non-cohabiting partner, by background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men ––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––– Number of Number of Percentage Number of women age Percentage Number of men age engaging women Percentage 15-24 who engaging men Percentage 15-24 who in higher- who had used had higher- in higher- who had used had higher- risk sex sex in condom at risk sex in risk sex sex in condom at risk sex Background in past the past last higher- the past in past the past last higher- in the past characteristic 12 months 12 months risk sex 12 months 12 months 12 months risk sex 12 months –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 46.7 619 23.4 289 97.1 258 41.3 250 20-24 21.4 1,207 27.6 258 77.2 459 50.7 355 Marital status Never married 100.0 449 27.2 449 99.8 559 47.6 558 Ever married 7.1 1,377 17.4 98 29.8 158 37.9 47 Residence Urban 32.5 475 32.4 154 85.0 195 58.2 166 Rural 29.1 1,351 22.6 393 84.1 522 42.6 439 Province Nairobi 36.8 200 30.6 74 87.7 77 66.3 68 Central 36.1 194 14.3 70 86.1 83 26.0 72 Coast 20.2 146 29.5 29 84.9 53 53.3 45 Eastern 35.3 284 29.4 100 80.1 97 42.7 78 Nyanza 36.4 354 17.0 129 74.0 101 38.0 75 Rift Valley 22.2 400 36.7 89 89.4 224 51.8 200 Western 26.2 213 24.5 56 87.6 77 44.9 68 North Eastern 0.0 35 * 0 * 4 * 0 Education No education 6.3 156 0.0 10 79.4 25 34.4 20 Primary incomplete 26.2 710 19.3 186 83.6 296 39.9 248 Primary complete 31.5 557 21.3 176 83.0 162 49.1 135 Secondary+ 43.5 404 37.3 176 86.8 234 55.0 203 Wealth quintile Lowest 21.4 294 15.6 63 77.3 108 44.6 83 Second 26.4 342 15.0 90 86.4 127 39.7 110 Middle 30.6 334 17.0 102 84.1 112 38.8 94 Fourth 35.1 366 26.2 128 85.8 165 48.2 142 Highest 33.4 491 39.4 164 85.8 205 55.6 176 Total 30.0 1,826 25.4 547 84.4 717 46.8 605 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 215 A higher proportion of young women (47 percent) age 15 to 19 engage in higher-risk sex than those age 20 to 24 (21 percent). Similarly, almost all sexually active young men (97 percent) age 15 to 19 engage in higher-risk sex, compared with those age 20 to 24 (77 percent). However, older women and men (age 20–24) are more likely than those age 15 to 19 to have used a condom when they had higher- risk sex. By definition, all sexually active women and men who have never married engage in higher-risk sex. Those who have never married are more likely to use condoms during higher-risk sexual activity than ever-married women and men. Differences in the extent of higher risk sex among youth by province are not large. Among those having higher-risk sex, women in Rift Valley Province are the most likely to use condoms, while those in Central Province are the least likely. Among men, Nairobi Province leads, while Central Province is the lowest. Higher-risk sexual activity increases dramatically with education among sexually active young women, from 6 percent among those with no education to 44 percent among those with some secondary education; however, there is little difference among young men by education. Among both sexes who en- gage in higher-risk sex, condom use increases with level of education. Engaging in higher-risk sexual be- haviour and especially condom use during higher-risk sex rises with increasing wealth index, although the differences are greater among young women than young men. 12.19 AGE-MIXING IN SEXUAL RELATIONSHIPS In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the wider spread of HIV and other STDs. To investigate this practice, in the 2003 KDHS, women age 15 to 19 who had sex in the 12 months preceding the survey with a nonmarital partner were asked whether the man was younger, about the same age, or older than they. If older, they were asked if they thought he was less than 10 years older or 10 or more years older. The results show that only 4 percent of women age 15 to 19 have had nonmarital sex with a man 10 years or more older than themselves in the last 12 months (data not shown). Differences by back- ground characteristics are small, especially since the number of cases is also small. 12.20 ORPHANHOOD AND CHILDREN’S LIVING ARRANGEMENTS Kenya has observed an upsurge in the number of orphans due to the higher deaths occasioned from HIV/AIDS related infections. The 2003 KDHS sought information on orphanhood and fostering. Table 12.24 shows the percent distribution of children under age 15, by children’s living arrangements and survival status of parents, according to background characteristics. Almost three in five children (58 percent) under age 15 live with both their parents, while 25 per- cent live with their mothers but not their fathers, 3 percent live with their fathers but not their mothers, and 11 percent do not live with either of their parents (i.e., they are considered to be “fostered”). The ob- served pattern has not changed much since the 1998 KDHS. Younger children and those in Nairobi Prov- ince are more likely than other children to be living with both their natural parents. Data on orphaned children (i.e., children under 15 who have lost either one or both of their natu- ral parents) show that 9 percent have lost their fathers, 4 percent have lost their mothers, and 2 percent have lost both of their biological parents. Altogether, 11 percent of children under 15 have lost one or both parents (i.e., they are considered orphans). Corresponding data from the 1998 KDHS show a slight increase in the level of orphanhood, from 9 to 11 percent of children under 15. 216 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Nyanza Province has by far the highest level of orphanhood, with almost one in five (19 percent) children under 15 having lost one or both of their biological parents. Orphans are usually considered to be disadvantaged compared with children whose parents are living. To assess whether orphans are educationally disadvantaged, an indicator was devised that com- pares the proportion of children age 10 to 14 who are attending school among those whose parents are both dead to those whose parents are both alive and who are living with one of them. The results indicate that 92 percent of children whose parents are both alive and who are living with one or both parents are in school compared with 88 percent of children who have lost both parents (“double orphaned”). The ratio of school attendance among orphaned to non-orphaned children is 0.95 (data not shown). This implies that orphans have only a slight disadvantage in school attendance compared with children who are living with one or both parents. Interpretation of this index by background characteristics is hampered by small numbers of orphans in many categories. Table 12.24 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 15, by children’s living arrangements and survival status of parents, according to back- ground characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Living with Living with mother but father but Not living with not father not mother with either parent Missing Living ––––––––––––– ––––––––––––– –––––––––––––––––––––––––––– informa- with Only Only tion on Number Background both Father Father Mother Mother Both father mother Both father/ of characteristic parents alive dead alive dead alive alive alive dead mother Total children ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age <2 68.5 26.0 2.1 0.2 0.0 0.5 0.1 0.2 0.1 2.3 100.0 2,433 2-4 65.2 20.3 4.0 1.2 0.5 4.5 0.7 0.6 0.9 2.2 100.0 3,443 5-9 56.7 18.9 6.4 2.3 1.2 7.5 0.6 1.6 2.3 2.5 100.0 5,348 10-14 50.6 16.5 8.3 3.1 1.8 9.6 0.9 2.1 3.7 3.5 100.0 5,304 Sex Male 58.7 19.5 5.8 2.2 1.0 6.2 0.6 1.2 2.3 2.5 100.0 8,372 Female 57.8 19.5 5.9 1.8 1.2 6.9 0.7 1.5 1.9 3.0 100.0 8,154 Residence Urban 60.5 18.2 4.8 2.4 2.0 4.9 0.8 1.4 2.0 2.9 100.0 2,609 Rural 57.8 19.7 6.0 1.9 0.9 6.8 0.6 1.3 2.1 2.7 100.0 13,918 Province Nairobi 71.5 12.8 2.7 1.8 1.8 4.6 0.6 0.9 1.0 2.4 100.0 781 Central 58.2 20.1 7.1 1.1 1.0 2.9 0.3 1.9 1.1 6.4 100.0 1,960 Coast 58.6 19.9 5.6 3.8 1.1 6.1 1.2 1.1 1.1 1.6 100.0 1,338 Eastern 51.3 27.3 4.9 2.5 1.0 5.7 0.4 1.0 2.0 4.0 100.0 2,806 Nyanza 55.9 16.7 8.2 1.4 1.4 6.0 0.9 2.0 6.0 1.5 100.0 2,614 Rift Valley 63.3 16.7 5.8 1.9 1.1 6.8 0.6 1.0 1.1 1.7 100.0 4,326 Western 52.8 21.5 4.6 2.2 0.6 11.9 0.4 1.7 1.8 2.5 100.0 2,113 North Eastern 65.8 13.1 5.2 2.7 1.7 6.9 1.9 1.2 1.0 0.4 100.0 588 Wealth quintile Lowest 64.4 15.3 6.7 1.5 1.2 5.6 0.8 1.1 1.9 1.6 100.0 3,981 Second 55.2 20.7 7.2 2.0 0.5 7.7 0.8 1.2 1.8 2.8 100.0 3,558 Middle 55.3 21.9 5.6 1.9 1.0 6.9 0.4 1.4 2.7 2.9 100.0 3,397 Fourth 53.5 22.5 4.5 2.1 1.0 7.1 0.6 2.0 2.6 4.2 100.0 3,080 Highest 62.7 17.4 4.5 2.9 2.0 5.1 0.6 1.1 1.6 2.2 100.0 2,511 Total 58.2 19.5 5.8 2.0 1.1 6.5 0.6 1.3 2.1 2.7 100.0 16,527 HIV Prevalence and Associated Factors | 217 HIV PREVALENCE AND ASSOCIATED FACTORS 13 Lawrence Marum, James N. Muttunga, Francis M. Munene, and Boaz K. Cheluget This chapter presents information on the coverage of HIV testing among those eligible, the preva- lence of HIV in the respondents, and the factors associated with HIV infection in the population. As de- scribed in Chapter 1, the 2003 KDHS is the fourth survey in the international DHS program to include HIV testing, and the first to anonymously link the HIV results with key behavioural, social and demo- graphic factors. The HIV prevalence data provide important information to plan the national response, to evaluate programme impact, and to measure progress on the National HIV/AIDS Strategic Plan 2000- 2005. The understanding of the distribution of HIV within the population and the analysis of social, bio- logical and behavioural factors associated with HIV infection offer new insights about the HIV epidemic in Kenya that may lead to more precisely targeted messages and interventions. In Kenya, as in most of sub-Saharan Africa, national HIV prevalence estimates have been derived primarily from sentinel surveillance in pregnant women. Currently, the national sentinel surveillance sys- tem consists of 42 sites in government and mission health facilities selected to represent the different groups, regions, and rural and urban populations in the country. For three months each year since 1990, pregnant women registering their first visit to these antenatal clinics (ANCs) and patients with sexually transmitted diseases in the sentinel sites have been anonymously tested for HIV and the results entered, analysed and reported by the National AIDS/STD Control Programme (NASCOP) (Ministry of Health, 2001). The latest round of sentinel surveillance was conducted between May and August 2003, during the same time period as the KDHS. While the rate of HIV infection in pregnant women has been shown to be a reasonable proxy for the level in the combined male and female adult population in a number of settings (WHO and UNAIDS, 2000), there are several well recognized limitations in estimating the HIV rate in the general adult popula- tion from data derived exclusively from pregnant women attending selected antenatal clinics. First, the ANC data do not capture any information on HIV prevalence in non-pregnant women, nor in women who either do not attend a clinic for pregnancy care or receive antenatal care at facilities not represented in the surveillance system.1 Pregnant women also are more at risk for HIV infection than women who may be avoiding both HIV and pregnancy through the use of condoms or women who are less sexually active and are therefore less likely to become pregnant or expose themselves to HIV. In addition, there may be bi- ases in the ANC surveillance data because HIV infection reduces fertility and because knowledge of HIV status may influence fertility choices. Finally, the rates among pregnant women are not a good proxy for male HIV rates. For example, a WHO study of four cities in sub-Saharan Africa, including Kisumu in Kenya, demonstrated higher risk overall in women compared to men (Buve et al., 2001). Thus, although the information from the ANC surveillance system has been very useful for moni- toring trends in HIV levels in Kenya, the inclusion of HIV testing in the KDHS offers the opportunity to better understand the magnitude and patterns in the infection level in the general reproductive age popula- tion in Kenya. The KDHS results are in turn expected to improve the calibration of annual sentinel sur- veillance data, so that trends in HIV infection can be more accurately measured in the intervals between general population surveys. 1 Nearly 90 percent of pregnant women in Kenya receive antenatal care; however, 21 percent attend dispensaries, which are not covered in the ANC surveillance system (Chapter 9). 218 | HIV Prevalence and Associated Factors 13.1 COVERAGE OF HIV TESTING Table 13.1 presents the coverage rates for HIV testing by the reason for not being tested accord- ing to gender and residence. HIV tests were conducted for 76 percent of the 4,303 eligible women and 70 percent of the 4,183 eligible men. For both sexes combined, coverage was 73 percent, with rural residents more likely to be tested than their urban counterparts (79 percent and 62 percent, respectively). There also were strong differences in HIV testing coverage rates by province. Among both sexes, Nyanza Province, which as discussed later in the chapter has the highest HIV rate among Kenya’s provinces, had the highest rate of testing (89 percent), followed by Western (85 percent) and Rift Valley Province (78 percent). Cen- tral Province (67 percent) and Nairobi (52 percent) had the lowest testing rates. In every province, women were more likely to be tested than men. Based on the reason for nonresponse, individuals who were not tested are divided into four cate- gories in Table 13.1: • those who refused testing when asked for informed consent by the health worker (14 percent overall) Table 13.1 Coverage of HIV testing by sex and urban-rural residence Percent distribution of women and men eligible for testing by testing status, according to sex and urban-rural residence, Kenya 2003 (unweighted) ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Province ––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Rift North Testing status Urban Rural Nairobi Central Coast Eastern Nyanza Valley Western Eastern Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Tested 66.2 81.7 54.5 70.7 80.1 76.1 91.1 81.1 88.0 75.6 76.3 Refused 19.2 11.9 21.5 18.8 14.5 15.1 5.4 11.7 8.7 19.9 14.4 Absent for testing 10.6 3.5 19.5 5.1 3.3 4.6 1.9 3.1 2.4 4.5 6.0 Interviewed in survey 5.9 1.7 11.8 3.0 0.8 2.2 1.4 1.3 1.0 0.0 3.1 Not interviewed 4.7 1.8 7.7 2.2 2.5 2.4 0.6 1.9 1.4 4.5 2.8 Other/missing 4.0 2.9 4.5 5.3 2.0 4.2 1.6 4.1 1.0 0.0 3.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,488 2,815 651 738 488 502 514 702 507 201 4,303 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Tested 58.4 76.7 50.2 62.9 66.2 74.5 87.1 75.7 82.7 74.9 70.3 Refused 16.5 11.2 15.3 16.2 21.4 14.0 3.3 10.0 9.9 13.8 13.0 Absent for testing 20.3 7.9 30.8 13.0 8.8 6.1 6.6 9.4 4.9 11.3 12.2 Interviewed in survey 5.8 2.6 9.8 5.4 3.8 2.8 0.8 1.5 1.1 0.5 3.7 Not interviewed 14.5 5.3 21.1 7.6 5.0 3.4 5.7 8.0 3.9 10.8 8.5 Other/missing 4.8 4.2 3.6 7.8 3.6 5.3 3.1 4.9 2.6 0.0 4.4 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,466 2,717 665 739 444 506 488 679 467 195 4,183 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– TOTAL ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Tested 62.3 79.3 52.4 66.8 73.5 75.3 89.1 78.4 85.4 75.3 73.4 Refused 17.8 11.5 18.4 17.5 17.8 14.6 4.4 10.9 9.2 16.9 13.7 Absent for testing 15.4 5.7 25.2 9.1 5.9 5.4 4.2 6.2 3.6 7.8 9.1 Interviewed in survey 5.9 2.1 10.8 4.2 2.3 2.5 1.1 1.4 1.0 0.3 3.4 Not interviewed 9.6 3.5 14.4 4.9 3.6 2.9 3.1 4.9 2.6 7.6 5.6 Other/missing 4.4 3.5 4.0 6.6 2.8 4.8 2.3 4.5 1.7 0.0 3.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,954 5,532 1,316 1,477 932 1,008 1,002 1,381 974 396 8,486 HIV Prevalence and Associated Factors | 219 • those who were interviewed in the survey, but who were not at home when the health worker arrived for testing and were not found on callbacks (3 percent) • those who were not at home for the testing and were never interviewed (6 percent), and • those who were missing test results for some other reason, such as they were incapable of giv- ing consent for testing, there was a mismatch between the questionnaire and the blood sam- ple, or there was a technical problem in taking blood (4 percent). Refusal is the most important reason for non-response on the HIV testing component among both women and men. Among men, absence accounts for almost as much non-response as refusal, while it is less important among women. The fact that some respondents were interviewed but not subsequently con- tacted by the health worker is partly due to having only one health worker per team, which contributed to delays in the time of arrival of the health worker after the interview. The proportions falling into the four non-response categories vary markedly by urban-rural resi- dence. Refusal rates are higher among urban women and men (19 percent for women and 17 percent for men) than among their rural counterparts (12 percent for women and 11 percent for men). Absence was the main reason for non-response among urban men. Fifteen percent of urban men were not interviewed nor tested, compared with 5 percent of urban women, while in rural areas, only 5 percent of men and 2 percent of women were neither interviewed nor tested. Similarly, higher proportions of urban women and men (6 percent among both sexes) were interviewed but were not at home when the health worker visited to collect the blood sample, compared to rural residents (2 percent of women and 3 percent of men). Looking at the provincial patterns, Nairobi had the highest rate of refusal in women (22 percent), the highest proportions absent for the interview (8 percent of women and 21 percent of men), and the highest level of those interviewed but absent for testing (12 percent of women and 10 percent of men). Nyanza had the lowest rates of refusal among both women (5 percent) and men (3 percent). Nyanza also had the lowest proportions of women absent for testing (under 2 percent), while men were least likely to be absent in Western (5 percent) and Eastern (6 percent) provinces. Table 13.2 shows coverage rates for HIV testing by age group, education and wealth. If HIV status influenced participation in the testing, coverage would be expected to rise with age since HIV lev- els increase sharply with age before leveling off or declining at the older ages. In fact, the coverage rate for testing among women is consistent across all age groups (range 74 percent to 79 percent). Response rates are somewhat more variable by age among men (range between 64 percent and 76 percent), but again they do not rise with age as would be expected if they were influenced by HIV status. Those with an incomplete primary education are the most likely to have been tested, while men and women with at least some secondary education were least likely to be tested. Similarly, those in the highest quintile of the wealth index were the least likely to be tested and had the highest levels of refusal (18 percent of women and 13 percent of men), absent after interview (6 percent for both men and women), and absent and not interviewed (5 percent of women and 15 percent of men). In order to further explore whether nonresponse might have an impact on the HIV seroprevalence results, an analysis also was undertaken of the relationships between participation in the HIV testing and a number of other characteristics related to HIV risk. The descriptive tables which were examined in that analysis are included in Appendix A. 220 | HIV Prevalence and Associated Factors Table 13.2 Coverage of HIV testing by age, education, and wealth quintile Percent distribution of women and men eligible for HIV testing by testing status, by age, education, and wealth quintile, Kenya 2003 (un- weighted) ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Testing status ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Tested Refused Absent Other/missing ––––––––––––– ––––––––––––– ––––––––––––– ––––––––––––– Not Not Not Not Age, education, and Inter- inter- Inter- inter- Inter- inter- Inter- inter- wealth quintile viewed viewed viewed viewed viewed viewed viewed viewed Total Number ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 75.1 0.2 13.4 1.2 3.8 3.4 1.6 1.2 100.0 975 20-24 77.2 0.5 11.7 1.7 2.4 2.3 2.4 1.9 100.0 886 25-29 76.1 0.3 11.2 1.7 3.4 3.3 2.4 1.6 100.0 704 30-34 76.1 0.5 13.3 0.8 4.0 1.3 2.1 1.9 100.0 618 35-39 78.9 0.0 11.8 1.8 1.8 3.5 1.3 0.9 100.0 451 40-44 74.2 0.0 15.7 1.5 2.8 3.5 1.0 1.3 100.0 395 45-49 73.7 0.4 16.8 1.8 3.3 2.9 0.4 0.7 100.0 274 Education No education 74.5 1.0 15.1 1.6 1.6 2.6 1.0 2.6 100.0 689 Primary incomplete 81.4 0.2 10.8 1.2 2.1 1.4 1.7 1.1 100.0 1,259 Primary complete 76.7 0.2 13.7 1.3 3.7 1.7 1.5 1.1 100.0 993 Secondary+ 72.0 0.0 13.4 1.5 4.4 5.0 2.5 1.3 100.0 1,352 Wealth quintile Lowest 84.3 0.6 10.0 0.2 0.9 2.1 0.9 1.1 100.0 661 Second 86.6 0.4 8.7 0.4 0.4 1.0 0.7 1.6 100.0 677 Middle 81.7 0.5 10.2 0.7 1.9 1.6 1.6 1.6 100.0 732 Fourth 77.9 0.1 12.4 1.6 3.2 1.6 2.1 1.2 100.0 822 Highest 63.2 0.0 18.1 2.9 6.1 5.4 2.7 1.6 100.0 1,411 Total 76.1 0.3 12.9 1.5 3.1 2.8 1.8 1.5 100.0 4,303 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 75.5 0.4 8.2 1.8 3.8 6.0 1.8 2.4 100.0 928 20-24 67.4 0.1 12.0 3.2 3.7 8.0 2.1 3.5 100.0 791 25-29 64.2 0.6 11.5 3.0 3.3 11.9 1.7 3.8 100.0 637 30-34 68.8 1.4 8.8 2.9 3.5 11.7 1.0 1.9 100.0 513 35-39 68.3 0.7 10.9 2.7 5.8 7.8 1.6 2.4 100.0 451 40-44 69.9 0.8 13.8 1.4 2.2 8.0 0.8 3.0 100.0 362 45-49 68.9 0.4 12.0 2.5 3.3 10.4 1.2 1.2 100.0 241 50-54 74.6 0.4 8.5 2.7 4.2 4.6 1.2 3.8 100.0 260 Education No education 69.3 0.8 10.7 2.5 2.0 7.3 1.4 5.9 100.0 355 Primary incomplete 75.1 0.7 8.9 2.1 3.0 6.2 1.8 2.2 100.0 1,250 Primary complete 70.2 0.2 10.9 3.5 3.9 7.5 1.6 2.2 100.0 939 Secondary+ 65.9 0.6 11.6 2.0 4.5 10.9 1.5 2.9 100.0 1,627 Wealth quintile Lowest 79.5 0.8 9.1 2.2 1.2 4.7 0.8 1.7 100.0 596 Second 79.3 1.1 7.1 1.0 1.4 5.6 1.3 3.2 100.0 624 Middle 74.1 0.3 9.0 3.0 3.1 6.4 1.3 2.8 100.0 703 Fourth 72.9 0.4 11.0 1.9 3.8 4.9 2.0 3.1 100.0 838 Highest 57.4 0.5 13.1 3.5 6.0 14.6 1.9 3.0 100.0 1,422 Total 69.7 0.6 10.5 2.5 3.7 8.5 1.6 2.8 100.0 4,183 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 10 women and 8 men not stated as to education. HIV Prevalence and Associated Factors | 221 The variation in response rates with these measures is again reassuring as coverage rates are fre- quently but not uniformly higher among those groups considered to be at higher risk for HIV (Tables A.3- A.6). For example, response rates are slightly higher among those who have ever had sex than among those who have not. Similarly, rates are higher among those in polygynous unions and lowest among those who are not currently in union. Among women, response rates are highest among those who are widowed, while among men they are highest among those who are divorced or separated. Coverage is higher among those who reported having had higher risk sex in the 12 months preceding the survey than among those who had sex but not higher risk sex and those who did not have sex at all in the prior 12 months. Among women, response rates are higher for the small number who report having multiple part- ners; however, coverage is lower among men with multiple partners. Among men, the coverage rate for HIV testing is higher among uncircumcised than circumcised men. Since HIV prevalence is higher among uncircumcised men (see next section), the higher response rates in the former group again are reassuring. However, men who sleep away from home—a characteris- tic assumed to be related to higher HIV risk—have lower rates of testing: 75 percent in those who sleep away more than 5 times a month and 77 percent for those who stay away for more than one month at a time compared to 81 percent or more among who were never absent or absent less frequently. Finally, in addition to the examination of the descriptive tables, a multivariate analysis of the de- terminants of non-response was conducted (ORC Macro, 2004). The results of that analysis confirm that eligible respondents who were not tested for HIV did not differ in meaningful ways from those tested. In fact, adjusted prevalence based on the regression analysis would lower prevalence among both women and men by a fraction of one percent because those not tested have slightly lower behavioural and socio- demographic risks for HIV. In summary, the initial descriptive and multivariate examinations of the HIV testing coverage levels provided no evidence of a consistent relationship between non-response rate and variables associ- ated with higher HIV risk. Although further analysis is required, this analysis supports the conclusion that the KDHS prevalence rates are a reasonable measure of the actual levels of HIV prevalence in the popula- tion. 13.2 HIV PREVALENCE HIV Prevalence by Socioeconomic Characteristics Results from the 2003 KDHS indicate that 7 percent of Kenyan adults are infected with HIV. (Table 13.3). HIV prevalence in women age 15-49 is nearly 9 percent, while for men 15-54, it is under 5 percent. This female-to-male ratio of 1.9 to 1 is higher than that found in most population-based studies in Africa and implies that young women are particularly vulnerable to HIV infection compared with young men. Figure 13.1 shows, for example, that 3 percent of women age 15-19 are HIV infected, compared with less than half of one percent of men 15-19, while HIV prevalence among women 20-24 is over three times that of men in the same age group (9 percent and 2 percent, respectively). The peak prevalence among women is at age 25-29 (13 percent), while prevalence rises gradually with age among men to peak at age 40-44 (9 percent). Only in the 45-49 year age group is HIV prevalence among men (5 percent) higher than that for women (4 percent). Since few HIV infected children survive into their teenage years, infected youth represent more recent cases of HIV infection and serve as an important indicator for detecting trends in both prevalence and incidence. Overall, prevalence among women age 15-24 in the KDHS is 6 percent, compared with slightly over 1 percent among men, for an overall prevalence in youth of under 4 percent. These preva- lence levels will provide a baseline for measuring progress toward the goals of the National HIV/AIDS Strategic Plan in future surveys. 222 | HIV Prevalence and Associated Factors Figure 13.1 HIV Prevalence by Age Group and Sex , , , , , , , # # # # # # # . 15-19 20-24 25-29 30-34 35-39 40-44 45-49 . 0 2 4 6 8 10 12 14 Women Men# , KDHS 2003 Women Men Percent As Table 13.4 shows, urban residents have a significantly higher risk of HIV infection (10 per- cent) than rural residents (6 percent). Prevalence in urban women is 12 percent compared with less than 8 percent for rural women, for a 1.6 urban-rural relative risk of HIV infection. For men, the risk associated with urban residence is even greater; urban men are twice as likely to be infected as rural men (8 percent and 4 percent, respectively). Since 80 percent of Kenya’s population is categorised as rural, however, the greatest burden of HIV infection is in the rural population. The HIV epidemic shows regional heterogeneity. Nyanza Province has an overall prevalence of 15 percent, followed by Nairobi with 10 percent. All other provinces have levels between 4 percent and 6 percent overall, except North Eastern where no respondent tested positive, indicating that the rate is very low in this province. Gender differences persist in all the regions. Table 13.3 HIV prevalence by age Percentage HIV positive among women age 15-49 and men age 15-54 who were tested, by age, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men Total –––––––––––––––––– ––––––––––––––––– ––––––––––––––––– Percent Percent Percent HIV HIV HIV Age positive Number positive Number positive Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 3.0 711 0.4 745 1.6 1,456 20-24 9.0 658 2.4 566 6.0 1,224 25-29 12.9 522 7.3 428 10.4 950 30-34 11.7 438 6.6 368 9.4 806 35-39 11.8 345 8.4 321 10.1 666 40-44 9.5 276 8.8 260 9.1 535 45-49 3.9 202 5.2 163 4.4 364 50-54 na na 5.7 193 na na Total age 15-49 8.7 3,151 4.6 2,851 6.7 6,001 Total age 15-54 na na 4.6 3,043 na na –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable HIV Prevalence and Associated Factors | 223 Table 13.4 HIV prevalence by selected socioeconomic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by socioeconomic characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men Total –––––––––––––––––– ––––––––––––––––– ––––––––––––––––– Percent Percent Percent Socioeconomic HIV HIV HIV characteristic positive Number positive Number positive Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 12.3 779 7.5 716 10.0 1,495 Rural 7.5 2,372 3.6 2,135 5.6 4,507 Province Nairobi 11.9 332 7.8 314 9.9 646 Central 7.6 462 2.0 438 4.9 900 Coast 6.6 236 4.8 197 5.8 433 Eastern 6.1 514 1.5 464 4.0 978 Nyanza 18.3 432 11.6 376 15.1 808 Rift Valley 6.9 747 3.6 691 5.3 1,438 Western 5.8 368 3.8 323 4.9 690 North Eastern 0.0 60 0.0 48 0.0 108 Education No education 4.4 396 2.7 156 3.9 552 Primary incomplete 9.3 1,052 3.4 982 6.4 2,034 Primary complete 10.6 784 5.9 660 8.5 1,444 Secondary+ 8.2 918 5.2 1,053 6.6 1,972 Employment Currently working 9.6 1,844 5.9 2,007 7.6 3,851 Not currently working 7.4 1,307 1.5 844 5.1 2,151 Wealth quintile Lowest 3.9 505 3.4 431 3.6 937 Second 8.5 580 4.2 501 6.5 1,082 Middle 7.1 597 2.2 528 4.8 1,125 Fourth 9.7 663 4.3 624 7.1 1,287 Highest 12.2 806 7.3 765 9.8 1,571 Ethnicity Embu (2.8) 37 (3.7) 37 3.3 73 Kalenjin 4.9 346 2.0 366 3.4 712 Kamba 8.6 392 1.6 334 5.4 726 Kikuyu 6.6 742 2.8 621 4.9 1,363 Kisii 7.4 171 0.5 163 4.0 334 Luhya 7.9 481 5.1 438 6.6 919 Luo 25.8 361 17.5 341 21.8 702 Maasai 2.8 76 2.2 56 2.5 132 Meru 6.1 172 1.2 165 3.7 337 Mijikenda/Swahili 3.8 137 3.0 116 3.5 254 Somali 0.9 100 1.8 77 1.3 177 Taita/Taveta 11.7 41 7.1 30 9.7 71 Turkana 6.5 39 5.1 45 5.7 84 Kuria * 19 (5.2) 21 2.7 40 Other 6.7 38 5.6 41 6.1 79 Religion Roman Catholic 8.9 800 4.9 756 6.9 1,556 Protestant/Other Christian 9.2 2,087 4.5 1,729 7.0 3,816 Muslim 2.7 204 3.1 175 2.9 378 No religion 11.1 52 5.5 185 6.7 237 Total 8.7 3,151 4.6 2,851 6.7 6,001 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 224 | HIV Prevalence and Associated Factors Those who have completed primary school have higher infection levels than those with either less or more education. Work status is related to the HIV rate among both women and men. Ten percent of currently working women and 6 percent of currently working men are HIV infected, compared with 7 percent of women and 2 percent of men currently not working. Those in the highest quintile of the wealth index have the highest rates of HIV infection. HIV prevalence is substantially higher among the Luo ethnic group than other groups. More than one in four Luo women and 18 percent of men are HIV positive. The only other group with higher than average prevalence levels is Taita/Taveta. Women and men who identify themselves as Christian have rates similar to the national average for each gender, while Muslim women and men both have rates of 3 percent. HIV Prevalence by Other Sociodemographic Characteristics As expected, marital status is related to HIV prevalence (Table 13.5). Women currently in a mari- tal union have a prevalence of 8 percent, only slightly higher than the rate among men who are currently in union (7 percent). Women who are widowed, divorced, or separated have significantly higher rates (30 percent and 21 percent, respectively) than married women (8 percent). Table 13.5 HIV prevalence by selected sociodemographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by marital status, pregnancy status for women, and mobility status for men, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men Total –––––––––––––––––– ––––––––––––––––– ––––––––––––––––– Percent Percent Percent Sociodemographic HIV HIV HIV characteristic positive Number positive Number positive Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Marital status Currently in union 8.0 1,897 7.0 1,353 7.6 3,250 Widowed 30.2 133 * 18 31.8 151 Divorced/separated 20.9 126 6.4 96 14.6 222 Never in union 5.6 995 1.6 1,384 3.2 2,378 Ever had sex 9.9 480 1.9 932 4.6 1,413 Never had sex 1.6 515 0.9 451 1.3 966 Type of union In polygynous union 11.4 326 11.9 126 11.6 452 Not in polygynous union 7.2 1,571 6.5 1,227 6.9 2,798 Not currently in union 9.8 1,254 2.4 1,498 5.7 2,752 Currently pregnant Pregnant 7.3 260 na na na na Not pregnant/not sure 8.8 2,891 na na na na Numbers of times slept away None na na 3.2 1,421 na na 1-2 na na 4.2 655 na na 3-5 na na 5.1 386 na na 5+ na na 9.3 373 na na Away for more than one month Away for more than 1 month na na 3.4 470 na na Away always less than 1 month na na 7.3 944 na na Never away na na 3.2 1,421 na na Total 8.7 3,151 4.6 2,851 6.7 6,001 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes cases missing data on number of times slept away and whether away for more than one month. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable HIV Prevalence and Associated Factors | 225 Women who report they ever had sex but have never been in a union have a higher risk than men in the same category (10 percent and 2 percent, respectively); this and the higher proportion of men who have never been in a union compared to women accounts for much of the overall female-male difference in prevalence. Around one percent of individuals who report they have never been in a union and have never had sex are also HIV-infected, suggesting either reporting errors in the sexual behaviour or non- sexual transmission of HIV. Considering the type of current union, women in a polygynous union have a higher prevalence (11 percent) than those in non-polygynous unions (7 percent). Again the rates for men are similar (12 per- cent in polyygynous unions and 7 percent for non-polygynous unions). HIV prevalence among women who are currently pregnant is 7 percent, providing a useful bench- mark to compare with rates in pregnant women tested during sentinel surveillance. The survey results show that men who sleep away from home more frequently have higher HIV prevalence, 9 percent for those who slept away from home five or more times in the previous 12 months compared with 3 percent for those who did not sleep away from home. Those who are away from home for short periods of time (always less than one month) have double the risk of HIV infection (7 percent) than those who are never away and those who are away for more than one month at a time (3 percent for both groups). HIV Prevalence by Sexual Risk Behaviour Table 13.6 examines the prevalence of HIV infection by sexual behaviour indicators among re- spondents who have ever had sexual intercourse. In reviewing these results, it is important to remember that responses about sexual risk behaviours may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk. For women, there is a clear pattern of higher HIV prevalence with earlier sexual debut. This pat- tern is not evident among men, who have a prevalence of 5 to 6 percent regardless of age at first sex. Young women (15-24 years) whose first sex was with a man ten or more years older have a higher prevalence of HIV (10 percent) compared with those whose first partner was less than ten years older (8 percent). Women who said that a condom was used during their first sexual encounter have a higher prevalence of HIV (11 percent) than those who did not use a condom (8 percent). Among men, no significant difference in prevalence can be detected between those who used a condom at first sex and those who did not. Seventeen percent of women who had a higher-risk sexual partner (a non-marital, non-cohabiting partner) are HIV-infected, compared with 8 percent of those who were sexually active but did not have a higher risk partner. In contrast, men reporting a higher-risk partner in the last year have a lower HIV prevalence, compared with sexually active men who did not have a higher-risk partner (5 percent and 7 percent, respectively). Among women reporting no sex in the last year, 11 percent are HIV-positive, compared with 2 percent of men reporting no sex in the last 12 months. Among women, having more than one partner and having more than one higher-risk partner in the preceding 12 months are associated with higher HIV prevalence. Among men, however, these vari- ables are not consistently related to HIV prevalence. Women who exchanged sex for money, gifts, or fa- vours in the last 12 months have a slightly higher HIV infection level than those who have not (11 percent and 10 percent, respectively). Among men, those who paid for sex prior to the 12 months preceding the survey have higher HIV prevalence (8 percent) than either those who have never paid for sex (5 percent) and, surprisingly, those who paid for sex in the preceding 12 months (4 percent). 226 | HIV Prevalence and Associated Factors Table 13.6 HIV prevalence by sexual behaviour characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and were tested, by sexual behaviour characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men Total –––––––––––––––––– ––––––––––––––––– ––––––––––––––––– Percent Percent Percent Sexual behaviour HIV HIV HIV characteristic positive Number positive Number positive Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age at first sex <15 12.4 940 5.1 1,143 8.4 2,083 16-17 9.3 648 5.2 457 7.6 1,106 18-19 9.7 515 4.8 436 7.5 951 20+ 6.0 392 6.0 355 6.0 747 First sexual partner was:1 10 or more years older 10.4 66 na na na na Other/Doesn’t know 7.7 681 na na na na Condom use at first sex1 Used at first sexual sex 10.7 93 0.0 108 4.9 201 Did not use at first sex 7.5 654 1.0 674 4.2 1,328 Higher-risk sex in past 12 months Had higher-risk sex 17.2 392 4.7 812 8.7 1,204 Had sex, not higher risk 8.3 1,833 6.7 1,213 7.7 3,046 No sex in past 12 months 11.1 411 1.9 374 6.7 785 Number of partners in past 12 months 1 9.6 2,166 5.4 1,700 7.7 3,866 2 20.4 53 9.7 262 11.5 315 3+ * 6 3.3 64 5.3 70 Number of higher-risk partners in past 12 months 1 15.7 361 4.8 632 8.7 993 2+ 34.0 32 4.4 181 8.8 211 Received money/gifts/favours for sex in past 12 months Exchanged for sex 11.2 119 na na na na No exchange 9.8 2,106 na na na na Paid for sex In past 12 months na na 4.3 86 na na Prior to past 12 months na na 8.1 269 na na Never na na 4.9 2,045 na na Condom use at last paid sex Used na na 8.0 173 na na Did not use na na 6.4 181 na na Any condom use Ever used condom 12.9 410 5.0 1,230 7.0 1,640 Never used condom 9.5 2,226 5.5 1,170 8.1 3,396 Condom use at last sex in past 12 months Used condom at last sex 15.3 124 4.1 357 6.9 481 No condom at last sex 9.6 2,101 6.3 1,668 8.1 3,769 Total 10.1 2,636 5.2 2,399 7.8 5,036 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Totals include those with missing or inconsistent information on age at first sex. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Refers to those age 15-24 only. na = Not applicable HIV Prevalence and Associated Factors | 227 The relationship between condom use and HIV infection is not uniform. Among women, any condom use and condom use at the most recent sexual encounter are associated with higher levels of HIV infection, while for men, condom use is associated with a lower level of infection. Women who know or suspect they or their partner might be infected would be more likely to use condoms, thus reversing the expected direction of the relationship of lower HIV prevalence among those who use condoms. None of the results discussed above demonstrate a consistent relationship between HIV preva- lence and sexual behavioural risk, particularly among men. However, more detailed analysis will be re- quired to thoroughly examine these relationships since they may be complicated by other factors such as age, residence, and educational status that are associated with both the behavioral measures and HIV prevalence. HIV Prevalence by Other Characteristics Related to HIV Risk Table 13.7 presents the variation in HIV prevalence with a number of other characteristics related to HIV risk among men and women who have ever had sex. As expected, women and men with a history of a sexually transmitted infection (STI) or STI symptoms have higher rates of HIV infection than those with none. Among women who reported ever drinking alcohol, HIV prevalence is 19 percent, compared with 9 percent among those who have never drunk alcohol. Differences for men are much smaller, with a prevalence of HIV of 6 percent among those who have drunk alcohol compared with 4 percent for those who have never drunk alcohol. Table 13.7 HIV prevalence by selected other characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and who were tested, by whether had a sexually transmitted infection, drank alcohol, had an HIV test, and perceived risk of getting AIDS, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men Total –––––––––––––––––– ––––––––––––––––– ––––––––––––––––– Percent Percent Percent HIV HIV HIV Characteristic positive Number positive Number positive Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Sexually transmitted infection in past 12 months Had STI or STI symptom 19.0 108 14.8 78 17.2 186 No STI, no symptoms 9.7 2,529 4.9 2,322 7.4 4,850 Use of alcohol Drank alcohol 18.8 334 6.1 1,353 8.6 1,687 Last month 18.5 145 6.4 808 8.2 953 Ever, not in past month 18.9 189 5.7 545 9.1 734 Never drank alcohol 8.8 2,301 4.2 1,046 7.4 3,348 Perceived risk of getting AIDS No risk at all 7.0 764 4.3 728 5.7 1,492 Small risk 11.0 1,077 5.8 1,261 8.2 2,338 Moderate risk 11.0 487 4.6 284 8.6 771 Great risk 14.6 267 7.5 118 12.4 385 HIV testing status Ever tested 12.5 446 7.6 428 10.1 875 Never tested 9.7 2,155 4.8 1,965 7.4 4,119 Total 10.1 2,636 5.2 2,399 7.8 5,036 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 40 women and 6 men missing data on risk of getting AIDS 228 | HIV Prevalence and Associated Factors The relationship between perception of the risk of getting AIDS and actual HIV infection is not straightforward, especially among men. It is disconcerting to note that 7 percent of women and 4 percent of men who say they have no risk of getting AIDS are actually HIV positive. Both women and men who have been tested for HIV in the past are more likely to be HIV in- fected than those who have never been tested. Among women who have ever had sex, the level of HIV infection is 13 percent among those who have ever been tested for HIV in the past, compared with 10 per- cent among those who have never been tested. Among men, 8 percent of those previously tested are HIV positive, compared with 5 percent of those who have never been tested. Although the individual’s HIV status is associated with prior HIV testing, the above results indi- cate that many individuals who are HIV positive have not been tested. Overall, four out of five of those infected with HIV (82 percent of infected women and 77 percent of infected men) do not know their HIV status, either because they were never tested or because they were tested and did not receive their results (Table 13.8). For women, 18 percent of those who are HIV infected have been tested and know their re- sults for their last test, compared to 13 percent of those who are HIV-negative. For men, there is a similar pattern; 23 percent of those who are HIV-infected know their results for their last test, compared with 14 percent of those who are HIV negative. HIV Prevalence and Male Circumcision Lack of circumcision is considered a risk factor for HIV infection, in part because of physiologi- cal differences that increase the susceptibility to HIV infection among uncircumcised men. Several prior studies in Kenya have shown a significant relationship between male circumcision and HIV risk (Agot et al., 2004; Auvert et al., 2002; Baeten et al., 2002). The KDHS obtained information on male circumci- sion status, and these results can be used to examine the relationship between HIV prevalence and male circumcision status. As Table 13.9 shows, the majority of Kenyan men (83 percent) are circumcised. However, the proportion circumcised varies with province and ethnicity, being markedly lower among men in Nyanza Province (46 percent), and among the Luo (17 percent). Table 13.8 HIV prevalence by prior HIV testing Percent distribution of HIV positive and negative women and men age 15-49 by HIV testing status prior to the survey, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Women Men –––––––––––––––––– –––––––––––––––– HIV HIV HIV HIV HIV testing status positive negative positive negative ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Ever tested and know results of last test 18.2 12.9 22.8 13.9 Ever tested, does not know results 2.6 1.4 2.2 1.5 Never tested 79.2 85.7 75.0 84.7 Total 100.0 100.0 100.0 100.0 Number 274 2,877 130 2,720 HIV Prevalence and Associated Factors | 229 Table 13.9 HIV prevalence by male circumcision Among men age 15-54 who were tested for HIV, percentage who are circumcised and percentage HIV positive among circumcised and uncircumcised men, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– All men tested for HIV Circumcised men Uncircumcised men ––––––––––––––––––––– –––––––––––––––––––––– ––––––––––––––––––––– Number Percentage Number of Percentage Number of Background Percentage of men HIV circumcised HIV uncircumcised characteristic circumcised tested positive men positive men –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 70.3 745 0.5 524 0.0 221 20-24 89.4 566 1.0 506 14.1 60 25-29 87.3 428 5.2 374 21.7 54 30-34 89.3 368 5.5 329 (16.1) 39 35-39 89.4 321 5.4 287 (33.7) 34 40-44 84.3 260 4.2 219 (33.2) 41 45-49 81.9 163 2.9 133 (15.2) 29 50-54 86.4 193 1.9 167 (29.5) 26 Residence Urban 82.2 763 5.4 627 16.9 136 Rural 83.8 2,280 2.3 1,911 11.0 369 Province Nairobi 80.0 336 6.6 269 13.5 67 Central 89.4 476 2.4 425 * 50 Coast 95.6 210 4.1 201 13.4 9 Eastern 96.1 502 1.6 482 * 20 Nyanza 46.4 408 2.1 189 21.1 218 Rift Valley 86.7 718 2.9 623 6.8 95 Western 86.8 339 3.9 295 1.9 45 North Eastern 100.0 55 0.0 55 * 0 Education No education 86.2 187 2.6 162 (0.0) 26 Primary incomplete 75.7 1,038 2.6 785 7.2 252 Primary complete 84.2 706 3.0 594 21.1 111 Secondary+ 89.6 1,113 3.5 997 19.1 116 Wealth quintile Lowest 73.9 463 1.3 342 11.4 121 Second 82.9 531 2.8 440 9.6 91 Middle 88.9 558 1.3 496 11.8 62 Fourth 86.9 673 3.5 584 8.3 88 Highest 82.5 819 5.0 676 18.6 144 Ethnicity Embu 100.0 41 3.3 41 * 0 Kalenjin 90.3 379 2.1 342 (0.0) 37 Kamba 99.4 353 1.7 351 * 2 Kikuyu 92.7 669 3.0 620 0.0 49 Kisii 99.5 172 0.5 171 * 1 Luhya 92.8 460 5.6 427 (0.0) 33 Luo 16.9 367 9.8 62 20.1 305 Maasai 82.5 59 2.2 49 1.4 10 Meru 91.0 187 1.2 170 * 17 Mijikenda/Swahili 100.0 124 2.8 124 * 0 Somali 100.0 86 1.7 86 * 0 Taita/Taveta 96.9 30 7.3 29 * 1 Turkana 44.4 51 0.0 23 (8.1) 28 Kuria 77.3 22 6.2 17 * 5 Religion Roman Catholic 81.7 821 2.6 670 14.2 150 Protestant/other Christian 82.2 1,836 3.0 1,510 12.7 326 Muslim 100.0 188 2.9 188 * 0 No religion 86.4 192 5.6 166 (3.6) 26 Total 83.4 3,043 3.0 2,538 12.6 505 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes cases with “other” and missing religion and ethnicity. Figures in parentheses are based on 25-49 un- weighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 230 | HIV Prevalence and Associated Factors Looking at HIV prevalence levels by circumcision status, 13 percent of Kenyan men who are un- circumcised are HIV infected, compared with 3 percent of those who are circumcised. In Nyanza Prov- ince, men who are uncircumcised are ten times more likely to be HIV positive than men who are circum- cised (21 and 2 percent, respectively). Multivariate analysis of these patterns is needed to obtain a better understanding of the role that the lack of male circumcision may be playing in the susceptibility to HIV infection in Kenya. HIV Prevalence among Couples Over 1,000 cohabiting couples were both tested for HIV in the 2003 KDHS. Results shown in Table 13.10 indicate that, for 89 percent of cohabiting couples, both partners are HIV-negative while in 4 percent of couples, both partners are HIV positive. Seven percent of couples are discordant, that is, one partner is infected and the other not. The variation in the level of couple HIV infection by background characteristics generally conforms to the patterns observed with respect to the variation in individual se- roprevalence rates, e.g., the infection rate is highest among couples in Nyanza Province. Looking more specifically at discordant couples, among 3 percent of couples, the man is infected and the woman uninfected, while in 5 percent of couples, the woman is infected and the man is not. Dis- cordance is more common among couples in which the woman is age 20-29 or the man age 20-39, cou- ples whose union is polygynous, urban couples, and couples in Nyanza. The fact that there are twice as many couples that are discordant for HIV as couples that are both infected represents an unmet HIV pre- vention need for the country, since the vast majority of these couples do not mutually know their HIV status. Couple-oriented voluntary counselling and testing (VCT) services, where partners (including those in polygynous marriages) go together and receive results together, is available throughout the country, but few VCT clients attend as a couple. HIV Prevalence among KDHS VCT Clients As described in the introductory chapter, voluntary counselling and testing (VCT) for HIV was provided to participants in the KDHS and others in the neighborhood (see Chapter 1). In all, 10,644 cli- ents came voluntarily for information or counselling and 10,089 chose to be tested for HIV. Those who came for VCT were self-selected and are not, therefore, representative of the adult population as a whole. For example, two-thirds of those tested in the VCT component were men. Among the 3,472 women who were part of the VCT component, 13 percent were HIV infected, compared with the national rate of 9 percent obtained for women 15-49 in the survey. The higher preva- lence among the women who came for VCT compared with those tested in the KDHS is consistent with the KDHS finding that those who are HIV infected are more likely to learn their HIV status than those who are negative. Five percent of the 6,617 men who were tested in the VCT component were HIV posi- tive, which is identical to the rate for men tested in the KDHS. The large number who came for the mo- bile VCT services is testimony to the desire for HIV testing and counselling, especially since the VCT component was mainly confined to rural areas, and for the importance of offering participants in surveys an opportunity to learn their HIV status. HIV Prevalence and Associated Factors | 231 Table 13.10 HIV prevalence among couples Among cohabiting couples both of whom were tested, percent distribution by HIV test results, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Male partner Female partner Both positive, positive, Background partners female partner male partner Both partners characteristic HIV positive negative negative HIV negative Total Number –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Woman’s age 15-19 2.1 0.0 4.4 93.5 100.0 76 20-29 3.9 3.8 6.4 85.9 100.0 457 30-39 4.1 2.6 3.5 89.8 100.0 353 40-49 2.7 2.0 1.6 93.8 100.0 155 Man’s age 15-19 * * * * 100.0 7 20-29 3.7 3.5 5.3 87.5 100.0 244 30-39 3.8 3.3 5.5 87.4 100.0 403 40-54 3.5 2.0 3.2 91.3 100.0 386 Marital status Married 3.3 3.1 4.4 89.2 100.0 948 Living together 7.7 0.5 6.0 85.8 100.0 92 Type of union Monogamous 3.1 3.1 3.9 89.9 100.0 913 Polygynous 7.5 1.4 9.0 82.1 100.0 128 Residence Urban 4.8 3.9 6.4 84.9 100.0 207 Rural 3.4 2.6 4.1 89.9 100.0 833 Province Nairobi 5.2 4.7 9.4 80.7 100.0 89 Central 1.6 2.1 1.4 94.9 100.0 134 Coast 1.1 3.5 8.8 86.6 100.0 71 Eastern 2.3 0.0 3.5 94.3 100.0 159 Nyanza 9.8 8.7 8.4 73.2 100.0 169 Rift Valley 2.8 0.6 2.8 93.8 100.0 275 Western 2.2 3.3 3.0 91.5 100.0 121 North Eastern 0.0 0.0 0.0 100.0 100.0 25 Woman’s education No education 1.8 1.2 0.9 96.1 100.0 143 Primary incomplete 4.5 4.7 7.2 83.6 100.0 373 Primary complete 4.3 0.9 2.9 91.8 100.0 273 Secondary+ 2.7 3.1 4.5 89.6 100.0 251 Man’s education No education 1.7 1.0 1.4 95.9 100.0 94 Primary incomplete 2.7 2.4 4.8 90.1 100.0 289 Primary complete 5.4 2.7 4.4 87.6 100.0 261 Secondary+ 3.7 3.8 5.3 87.3 100.0 397 Wealth quintile Lowest 2.3 2.2 3.5 91.9 100.0 210 Second 4.0 2.8 4.3 88.9 100.0 211 Middle 2.4 3.3 4.0 90.3 100.0 208 Fourth 2.8 1.5 5.7 90.0 100.0 203 Highest 6.6 4.4 5.3 83.6 100.0 209 Total 3.7 2.8 4.6 88.9 100.0 1,041 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 232 | HIV Prevalence and Associated Factors 13.3 DISTRIBUTION OF THE HIV BURDEN IN KENYA The inclusion of HIV testing in the KDHS provides the basis for a more precise estimate of the burden of HIV in Kenya and permits the calibration of estimates of HIV prevalence based on sentinel surveillance in pregnant women. Kenya has a heterogeneous HIV epidemic, with significant differences by region. Three provinces, containing half of Kenya’s population, have 65 percent of the HIV infections: Nyanza Province with nearly one-third, Rift Valley with around one-fifth, and Nairobi with one-sixth of HIV infections in Kenya. Urban residents represent 25 percent of the population age 15-49, but nearly 40 percent of those HIV infected are urban residents. Higher educational level does not protect one from HIV infection in Kenya; HIV has spread through all regions and strata of society. The linkage of biological and behavioural data in this survey has strengthened the validity of this survey by making multivariate analysis possible. The measurement of HIV prevalence in the KDHS has proven useful in calibrating HIV prevalence estimates of the general population from sentinel surveillance in pregnant women and has resulted in downward projections of the severity of the epidemic in Kenya. These adjustments arise from a better understanding of rural-urban population distribution, from a recog- nition that rural pregnant women who do not seek ANC care have lower rates than those who do, and, most importantly, from acknowledgement of the high ratio of 1.9 women infected for every man. This linkage between HIV test results and demographic and behavioural data also enhances the understanding of the distribution, patterns, risk factors for HIV in Kenya, with the potential for improved planning and implementation of programs as a result of this information. The higher rate of HIV in uncir- cumcised men supports the need to evaluate possible causal links between male circumcision and HIV. Finally, the prevalence of couples that are discordant for HIV underscores the need for knowledge of both one’s own HIV status and that of one’s partner in order to prevent the continued spread of the HIV epi- demic. Adult and Maternal Mortality | 233 ADULT AND MATERNAL MORTALITY 14 Christopher Omolo and Paul Kizito This chapter presents information on overall adult mortality and maternal mortality in Kenya. Mortality levels and trends provide a good measure of the health status of the population and thus an indi- cator for national development. Studies have shown that improvement in economic performance and a decline in mortality follow similar trends. Little is known about adult mortality in Kenya when compared with infant and child mortality, for a number of reasons. First, while early childhood mortality can be estimated through the birth history approach, there is no equivalent in adult mortality measurement. Second, death rates are much lower at adult ages than at childhood, and hence estimates for particular age groups can be distorted by sampling errors. Third, there is usually very limited information about the characteristics of those who have died. While the same can be said about data on childhood mortality, it is reasonable to expect the characteristics of parents to influence directly their children’s chances of survival. 14.1 DATA To estimate adult mortality, the 2003 KDHS included a sibling history in the Women’s Question- naire. A series of questions was asked about all of the respondent’s brothers and sisters and their survival status. These data allow direct estimation of overall adult mortality (by age and sex) and maternal mortal- ity. Survival of siblings (i.e., biological brothers and sisters) is a useful method for collecting infor- mation on adult mortality. Each female respondent was asked to record a list of all children born to her biological mother, including herself. These included all siblings who were still alive and those who had died. For brothers and sisters who were alive, only the age at the last birthday was asked. For brothers who had died, only the number of years since death and age at death were asked. For sisters who had died at age 12 years or older, three questions were asked to determine whether the death was maternity related: “Was [NAME OF SISTER] pregnant when she died?” and, if negative, “Did she die during childbirth?” and, if negative, “Did she die within two months after the end of a pregnancy or childbirth?” Adult and maternal mortality estimation by either direct or indirect methods requires accurate re- porting of the number of siblings the respondent ever had, the number who died and the number of sisters who have died of maternal-related causes (for maternal mortality). Although there is no definitive proce- dure for establishing the completeness of retrospective data on sibling survivorship, Table 14.1 presents several indicators that can be used to measure the quality of sibling survivorship data. The data do not show any obvious defects that would indicate poor data quality or significant un- derreporting. A total of 51,673 siblings was recorded in the maternal mortality section of the 2003 KDHS questionnaires. The sex ratio of the enumerated siblings (the ratio of brothers to sisters) is 1.03, which is the expected value. The survival status for only 21 (less than 1 percent) of the siblings was not reported. For the surviving siblings, current age was not reported for only 657 (less than 2 percent). Among de- ceased siblings, both the age at death and years since death were missing for 2 percent. Rather than ex- clude the siblings with missing data from further analysis, information on the birth order of siblings in 234 | Adult and Maternal Mortality conjunction with other information was used to impute the missing data.1 The sibling survivorship data, including cases with imputed values, have been used in the direct estimation of adult and maternal mortal- ity. 14.2 ESTIMATES OF ADULT MORTALITY One way to assess the quality of data used to estimate maternal mortality is to evaluate the plau- sibility and stability of overall adult mortality. It is reasoned that if rates of overall adult mortality are im- plausible, rates based on a subset on deaths—maternal mortality in particular—are likely to have serious problems. Also, levels and trends in overall adult mortality have important implications in their own right for health and social programmes in Kenya, especially with regard to the potential impact of the AIDS epidemic. The direct estimation of adult mortality uses the reported ages at death and years since death of respondents’ brothers and sisters. Because of the differentials in exposure to the risk of dying, age- and sex-specific death rates are presented in this report. The results are also compared with rates obtained from the 1998 KDHS and the 1989 and 1999 population censuses. Since the number of deaths on which the KDHS rates are based is not very large (759 female deaths and 701 male deaths in 2003 and 529 fe- male deaths and 500 male deaths in 1998), the estimated age-specific rates are subject to considerable sampling variation. 1 The imputation procedure is based on the assumption that the reported birth order of siblings in the history is cor- rect. The first step is to calculate birth dates. For each living sibling with a reported age and each dead sibling with complete information on both age at death and years since death, the birth date was calculated. For a sibling missing these data, a birth date was imputed within the range defined by the birth dates of the bracketing siblings. In the case of living siblings, an age at the time of the survey was then calculated from the imputed birth date. In the case of dead siblings, if either the age at death or years since death was reported, that information was combined with the birth date to produce the missing information. If both pieces of information were missing, the distribution of the ages at death for siblings for whom the years since death was unreported, but age at death was reported, was used as a basis for imputing the age at death. Table 14.1 Data on siblings Number of siblings reported by survey respondents and completeness of the reported data on age, age at death (AD), and years since death (YSD), Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Sibling status Females Males Total and completeness –––––––––––––––––– –––––––––––––––––– –––––––––––––––––– of reporting Number Percentage Number Percentage Number Percentage ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– All siblings 25,508 100.0 26,165 100.0 51,673 100.0 Surviving 21,895 85.8 22,140 84.6 44,035 85.2 Deceased 3,603 14.1 4,014 15.3 7,617 14.7 Missing information 10 0.0 11 0.0 21 0.0 Surviving siblings 21,895 100.0 22,140 100.0 44,035 100.0 Age reported 21,591 98.6 21,787 98.4 43,378 98.5 Age missing 304 1.4 353 1.6 657 1.5 Deceased siblings 3,603 100.0 4,014 100.0 7,617 100.0 AD and YSD reported 3,417 94.8 3,722 92.7 7,139 93.7 Missing only AD 23 0.6 51 1.3 74 1.0 Missing only YSD 96 2.7 134 3.3 231 3.0 Missing both 67 1.9 107 2.7 173 2.3 Adult and Maternal Mortality | 235 Table 14.2 Adult mortality rates Age-specific mortality rates for women and men age 15-49 based on the survivorship of sisters and broth- ers of survey respondents for the seven-year period preceding the survey, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––– Mortality Age Deaths Exposure rates ––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––– 15-19 65 23,470 2.76 20-24 117 25,091 4.67 25-29 148 22,601 6.56 30-34 166 18,221 9.11 35-39 119 13,248 9.02 40-44 92 8,428 10.94 45-49 51 4,912 10.34 15-49 759 115,971 6.57a ––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––– 15-19 42 22,865 1.83 20-24 93 25,142 3.71 25-29 101 22,448 4.48 30-34 159 18,811 8.45 35-39 128 13,862 9.26 40-44 111 8,543 13.01 45-49 67 4,775 14.08 15-49 701 116,446 6.19a ––––––––––––––––––––––––––––––––––––––––– a Age standardised Table 14.2 presents age-specific mortality rates for women and men age 15-49 for the seven-year period preceding the survey. The rates are stable, showing expected increases for both sexes with increasing age. For age group 15-34, female mortality exceeds male mortality, with a wider difference being observed at age group 25- 29; the rates are nearly the same at age group 35-39. Above age 35, male mortality exceeds female mortality by wider margins as age advances. A comparison of the 2003 KDHS and the 1998 KDHS rates indicates a substantial increase in adult mortality rates for both males and females at all ages, with the exception of men age 15-19.2 The summary measure of mortality for age group 15-49 shows an increase of about 40 percent in female mortality rates and about 30 percent in male mortality rates from the 1998 KDHS rates. The overall mortality rates derived from the 2003 KDHS data are higher among females than males (6.6 and 6.2 deaths per 1,000 years of exposure, respectively), which is unusual since male mortality typically exceeds female mortality during these ages. However, AIDS is now a significant cause of death in Kenya, and its emergence has altered the age and sex pattern of mortality (see Chapter 13 for HIV prevalence rates by age and sex). Figure 14.1 shows the age-specific mortality rates for males and females aged 15-49 for the 7-year period preceding the 1998 KDHS and the 2003 KDHS. Each series of rates in the figure is somewhat erratic, most probably because of sampling variability. As ex- pected, the mortality rates rise as age advances. The rise is steeper for women at younger ages and steeper for men at older ages, probably because of the effects of HIV/AIDS. A comparison of the rates derived from the two KDHS surveys shows that the female mortality rates from the 2003 KDHS are higher than those derived from the 1998 KDHS, especially for those above age 20. The male rates based on the 2003 KDHS and 1998 KDHS are roughly the same at the younger ages, but the differences widen above age 25. Thus, the figure shows a sizeable rise in mortality rates for the more recent seven-year period (ap- proximately 1996 to 2002), as compared with the earlier period (approximately 1991 to 1997). 2 Exclusion of the northern part of Kenya from the 2003 KDHS data tends to increase the age-specific mortality rates very slightly from those reported in Table 14.2 but decreases the age-adjusted overall mortality very slightly. 236 | Adult and Maternal Mortality Figure 14.1 Trends in Adult Mortality, Kenya 1991-1997 and 1996-2002 , , , , , , , � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 . Age in Years 0 5 10 15 Deaths per 1,000 , , , , , , , � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 . Age in Years 0 5 10 15 Deaths per 1,000 1998 KDHS (1991-1997) 2003 KDHS (1996-2002)� , Females Males Note: Data refer to the seven-year period preceding the survey. Figure 14.1 Trends in Adult Mortality, Kenya 1991-1997 and 1996-2002 14.3 ESTIMATES OF MATERNAL MORTALITY Two survey methods are generally used to estimate maternal mortality in developing countries: the sisterhood method (Graham et al., 1989) and a direct variant of the sisterhood method (Rutenberg and Sullivan, 1991). In this report, the direct estimation procedure is applied. Age-specific mortality rates are calculated by dividing the number of maternal deaths by woman-years of exposure. To remove the effect of truncation bias (the upper boundary for eligibility for women interviewed in the KDHS is 49 years), the report standardised the overall rate for women age 15-49 by the age distribution of the survey respon- dents. Maternal deaths are defined as any death that occurred during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy.3 Estimates of maternal mortality are therefore based solely on the timing of the death in relationship with pregnancy. 3 This time-dependent definition includes all deaths that occurred during pregnancy and two months after preg- nancy, even if the death was due to nonmaternal causes. However, this definition is unlikely to result in overre- porting of maternal deaths because most deaths to women during the two-month period are due to maternal causes, and maternal deaths are more likely to be underreported than overreported. Adult and Maternal Mortality | 237 Table 14.3 presents direct estimates of maternal mortality for the ten-year period preceding the survey. The data indicate that the rate of mortality associated with pregnancy and childbearing is 0.69 maternal deaths per 1,000 woman-years of exposure. The estimated age-specific mortality rates display a plausible pattern, being higher at the peak of childbearing ages of the twenties and thirties than at the younger and older age groups. Maternal deaths represent 15 percent of all deaths to women age 15-49 (115/759), a figure that is slightly more than half of the proportion found in the 1998 KDHS (27 percent) and lower than the level found in other Demographic and Health Surveys, except for Haiti and Indonesia (Stanton et al., 1997; Cayemittes et al., 2001; Badan Pusat Statistic and ORC Macro, 2003). The low pro- portion of maternal deaths could be due to an increase in nonmaternal deaths (e.g., AIDS-related deaths) or to underreporting of maternal deaths in the 2003 KDHS. The maternal mortality rate can be converted to a maternal mortality ratio and expressed per 100,000 live births by dividing the rate by the general fertility rate of 0.166, which prevailed during the same time period. With this procedure, the maternal mortality ratio during the 10-year period before the survey is estimated as 414 maternal deaths per 100,000 live births. This figure should be viewed with cau- tion, since the number of female deaths occurring during pregnancy, at delivery, or within two months of delivery is small (115). As a result, the maternal mortality estimates are subject to larger sampling errors than the adult mortality estimates; the 95 percent confidence intervals indicate that the maternal mortality ratio varies from 328 to 501 (see Appendix Table B.2). At first glance, it would appear that the maternal mortality ratio has declined significantly over the last five years, from 590 maternal deaths per 100,000 live births for the ten-year period prior to the 1998 KDHS to 414 for the ten-year period before the 2003 KDHS (or 396, excluding the northern areas of Kenya). However, the methodology used and the sample size implemented in these two surveys do not allow for precise estimates of maternal mortality. The sampling errors around each of the estimates are large and, consequently, the two estimates are not significantly different; thus, it is impossible to say with confidence that maternal mortality has declined. A decline in the maternal mortality ratio is not supported by the trends in related indicators, such as antenatal care coverage, delivery in health facilities, and medi- cal assistance at delivery, all of which have remained more or less stable over the last five years. Table 14.3 Maternal mortality Maternal mortality rates for the ten-year period preceding the survey, based on the survivorship of sisters of survey respondents, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––– Mortality Maternal Exposure rates Age deaths (years) (1,000) ––––––––––––––––––––––––––––––––––––––––––––––– 15-19 12 34,536 0.34 20-24 29 35,037 0.82 25-29 26 30,744 0.84 30-34 27 24,133 1.10 35-39 17 17,016 1.00 40-44 3 10,610 0.32 45-49 1 5,794 0.25 Total 15-49 115 157,870 0.69a General fertility rate 0.166a Maternal mortality ratiob - - 414 ––––––––––––––––––––––––––––––––––––––––––––––– a Age standardised b Per 100,000 births; calculated as maternal mortality rate divided by the general fertility rate Gender Violence | 239 GENDER VIOLENCE 15 Betty Khasakhala-Mwenesi, Robert C.B. Buluma, Rosemary U. Kong’ani, and Vivian M. Nyarunda 15.1 INTRODUCTION In recent years, there has been increasing concern about violence against women in general and domestic violence in particular, in both developed and developing countries. Not only has domestic vio- lence against women been acknowledged worldwide as a violation of the basic human rights of women, but an increasing amount of research highlights the health burdens, intergenerational effects, and demo- graphic consequences of such violence (United Nations General Assembly, 1991; Heise et al., 1994, 1998; Jejeebhoy, 1998). Gender-based violence occurs across all socioeconomic and cultural back- grounds, and in many societies, including Kenya, women are socialised to accept, tolerate, and even ra- tionalise domestic violence and to remain silent about such experiences (Zimmerman, 1994). Violence of any kind has a serious impact on the economy of a country; because women bear the brunt of domestic violence, they bear the health and psychological burdens as well. Victims of domestic violence are abused inside what should be the most secure environment—their own homes. To stop this violence, which sometimes causes great physical harm, death, psychological abuse, separation, divorce, and a host of other social ills, the Kenyan government has enacted the National Commission on Gender and Development Act of 2003 to help in the coordination and mainstreaming of gender concerns in national development. The Children Act of 2001 also classifies children exposed to domestic violence and female circumcision as children in need of care and protection. 15.2 DATA COLLECTION Although gender-based violence is usually defined to include any physical, sexual, or psychologi- cal violence occurring not only in the family, but also within the general community (such as sexual har- assment at the workplace and trafficking in women for prostitution), this survey only covers domestic violence occurring within the household. This was the first time in the history of Demographic and Health Surveys in Kenya that questions on domestic violence were included. Data on female genital cutting, however, were collected as part of the 1998 Kenya Demographic and Health Survey (KDHS). There is a culture of silence surrounding gender-based violence, which makes collection of data on this sensitive topic particularly challenging. Even women who want to speak about their experiences of domestic violence may find it difficult because of feelings of shame or fear. The need for establishing rapport with the respondent and ensuring confidentiality and privacy during the interview are important for the entire survey, but are critical in ensuring the validity of the data on domestic violence. Complete privacy is also essential for ensuring the security of the respondent and the interviewer. Asking about or reporting violence, especially in households where the perpetrator may be present at the time of interview, carries the risk of further violence. Given these concerns related to the collection of data on violence, organisers of the 2003 KDHS took the following steps to ensure the validity of the data and the security of respondents and interview- ers: 240 | Gender Violence • The module was specially designed to allow the interviewer to continue the interview only if privacy was ensured. If privacy could not be obtained, the interviewer was instructed to skip the module, thank the respondent, and end the interview. In Kenya, less than 2 percent of women selected for interview with the module could not be interviewed because of secu- rity considerations. • Only one eligible woman in each selected household was administered the questions on domestic violence. In households with more than one eligible woman, the woman adminis- tered the module was randomly selected through a specially designed simple selection pro- cedure. By interviewing only one woman in each household with the module, any security breach due to other persons in the household knowing that information on domestic vio- lence was given was minimised. • Informed consent of the respondent was obtained for the survey at the start of the individual interview. In addition, at the start of the domestic violence section, each respondent was read a statement informing her that she was now going to be asked questions that could be personal in nature because they explored different aspects of the relationship between cou- ples. The statement assured her that her answers were completely confidential and would not be told to anyone else and that no one else in the household would be asked these ques- tions. Research on violence suggests that the most common form of domestic violence for adults is spousal violence. Thus, spousal violence was measured using a modified and greatly shortened Conflict Tactics Scale (CTS) (Strauss, 1990). The CTS scale has been found to be effective in measuring domestic violence and can be easily adapted for use in different cultural situations. In the 2003 KDHS, spousal vio- lence was measured using the following set of questions: Does/Did your (last) husband/partner ever— a) Push you, shake you, or throw something at you? b) Slap you or twist your arm? c) Punch you with his fist or with something that could hurt you? d) Kick you or drag you? e) Try to strangle you or burn you? f) Threaten you with a knife, gun, or other type of weapon? g) Attack you with a knife, gun, or other type of weapon? h) Physically force you to have sexual intercourse even when you did not want to? i) Force you to perform types of other sexual acts you did not want to? The questions were asked with reference to the current husband for women currently married and the last husband for women not currently married. Women could answer with “yes” or “no” to each item, and in cases when the answer was “yes,” women were asked about the frequency of the act in the 12 months preceding the survey. A “yes” answer to one or more of items a to g constitutes evidence of physical violence, while a “yes” answer to items h or i constitutes evidence of sexual violence. A similar approach was used to measure the prevalence of emotional violence. Respondents were asked the question— Does/Did your last husband ever: a) Say or do something to humiliate you in front of others? b) Threaten you or someone close to you with harm? Gender Violence | 241 Women could answer “yes” or “no” to each item, and for items they answered “yes” to, they were asked about frequency of occurrence in the 12 months preceding the survey. This approach of asking separately about specific acts has the advantage of not being affected by different understandings of what constitutes violence. A woman has to say whether she has, for example, ever been slapped, not whether she has ever experienced any violence. All women would probably agree on what constitutes a slap, but what constitutes a violent act or is understood as violence may vary across women as it does across cultures. In fact, summary terms such as “abuse” or “violence” were avoided in training and not used at all in the title, design, or implementation of the module. This approach has the advantage of giving the respondent multiple opportunities to disclose any experience of violence and, if the different violent acts included in the list are chosen carefully, also allows the assessment of the sever- ity of violence. In addition to spousal violence, women were asked whether they had experienced violence at the hands of anyone other than their current or last husband: “From the time you were 15 years old, has any- one other than your (current/last) husband hit, slapped, kicked, or done anything else to hurt you physi- cally?” Women who responded “yes” to this question were asked who had done this and the frequency of such violence during the 12 months preceding the survey. Although this approach to questioning is widely considered to be optimal, the possibility of some underreporting of violence cannot be entirely ruled out in any survey. Caution should always be exercised in interpreting not only the overall prevalence of violence data, but also differentials in prevalence be- tween subgroups of the population. Although a large part of any substantial difference in prevalence of violence between subgroups undoubtedly reflects actual differences in prevalence, differential underre- porting by women in the different subgroups can also contribute to exaggerating or narrowing differences in prevalence to an unknown extent. In the 2003 KDHS, men were not asked about their experience of violence because of security reasons. However, women were asked whether they had ever hit, slapped, kicked, or done anything else to physically hurt their husband or partner at any time when he was not already beating or physically hurt- ing them. They were further asked whether their husband/partner drinks alcohol or takes illegal drugs, which is often associated with violence. 15.3 VIOLENCE SINCE AGE 15 Table 15.1 shows the distribution of women who have experienced violence since age 15—ever and in the previous 12 months—by background characteristics. The data show that half of all women have experienced violence since they were 15 and one in four experienced violence in the 12 months pre- ceding the survey. The social and economic background of a woman has a bearing on her chances of experiencing domestic violence. Over half of all women in their thirties have experienced violence since age 15, with one-quarter experiencing violence in the 12 months preceding the survey. Those age 15-19 have the low- est proportion of women who ever experienced violence (42 percent). Data from the 2003 KDHS imply that domestic violence may contribute to separation and di- vorce. Almost two-thirds (64 percent) of divorced or separated women report having experienced vio- lence since age 15, compared with 53 percent of married women and 30 percent of those widowed. A sur- prisingly high proportion (40 percent) of women who have never been married report having experienced physical violence since age 15. Violence in the 12 months preceding the survey is high among currently married women, with three in ten reporting violence in the past year. 242 | Gender Violence Table 15.1 Experience of physical mistreatment Percentage of women who have experienced violence since age 15 and percentage who have experienced violence during the 12 months preceding the survey, by background character- istics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––– Percentage who have experienced violence ––––––––––––––––– Number Background Since In past of characteristic age 15 12 months women –––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 41.8 26.3 1,335 20-29 49.8 25.1 2,197 30-39 53.0 26.2 1,424 40-49 49.4 21.8 922 Marital status In union 52.9 31.0 3,508 Separated/divorced 64.4 19.6 348 Widowed 29.5 2.9 260 Never married 40.1 17.7 1,762 Residence Urban 48.1 18.1 1,423 Rural 48.9 27.3 4,455 Province Nairobi 50.7 19.0 559 Central 44.0 16.6 838 Coast 30.2 13.8 481 Eastern 36.5 20.0 938 Nyanza 59.6 35.9 902 Rift Valley 46.4 28.1 1,369 Western 72.8 35.9 675 North Eastern 50.8 22.5 116 Education No education 43.9 24.5 736. Primary incomplete 53.8 33.8 1,933. Primary complete 46.3 24.9 1,445. Secondary+ 47.0 15.9 1,765. Employment status Employed for cash 52.8 25.2 2,577 Employed, but not for cash 52.3 28.2 898 Not employed 43.0 23.9 2,401 Wealth quintile Lowest 51.9 31.5 986 Second 50.3 29.0 1,091 Middle 48.6 29.0 1,085 Fourth 46.0 22.3 1,218 Highest 47.7 17.5 1,499 Total 48.7 25.1 5,878 There is no urban-rural differential in the proportion of women who ever experienced violence since age 15, although recent violence is more prevalent among rural women. Women in Western Prov- ince are most likely to have experienced violence since age 15 (73 percent), followed by women in Ny- anza Province (60 percent); women in Coast Province are least likely to have experienced violence (30 percent). Violence in the 12 months preceding the survey is highest in Nyanza and Western provinces (both 36 percent) and lowest in Coast Province (14 percent). Gender Violence | 243 Table 15.2 Perpetrators of violence Percentage of women who have experi- enced physical violence since age 15 and who report specific perpetrators, Kenya 2003 ––––––––––––––––––––––––––––––––– Perpetrator Percentage ––––––––––––––––––––––––––––––––– Husband 57.8 Mother 23.8 Father 14.5 Stepmother 0.7 Stepfather 0.3 Sister 2.3 Brother 8.2 Daughter 0.2 Son 0.1 Late/ex-partner 1.5 Current boyfriend 0.0 Former boyfriend 1.5 Mother-in-law 0.2 Father-in-law 0.1 Other female relative/in-law 0.9 Other male relative/in-law 2.6 Female friend/acquaintance 3.6 Male friend/acquaintance 1.4 Teacher 25.7 Employer 0.4 Stranger 1.7 Number of women 2,863 Experience of violence does not vary consistently with education level, except that women who have at least some secondary education are less likely to have experienced domestic violence in the preceding 12 months than less educated women. Women who are not employed (43 percent) are less likely to have experienced violence than those who are employed (52 to 53 percent). There is a slight negative relationship between domestic violence and the wealth quintile. Table 15.2 shows that the main perpetrators are husbands and, to a lesser extent, teachers, mothers, fathers, and brothers. It is notable that one-quarter of women who experienced physical violence since they were age 15 report teachers as the perpetrators. 15.4 MARITAL VIOLENCE Marital violence refers to violence perpetrated by partners in a marital union. Table 15.3 shows the percentage of married women, divorced or separated women who have ever experienced emotional, physical, or sexual violence by their current or last hus- band or partner, according to selected background characteristics. Note that the different types of violence are not mutually exclusive; therefore, women may report experiencing multiple forms of violence. Twenty-six percent of ever-married women report having experienced emotional violence by husbands, 40 percent report physical violence, and 16 percent report sexual violence. Almost half (47 percent) of ever-married women report suffering emotional, physical, or sexual violence, while 8 percent have experienced all three forms of violence by their current or most recent husband. The experience of all forms of spousal violence rises with age. The table further shows that di- vorced or separated women are most likely to have been abused emotionally, physically, and sexually, giving the impression that the violence might have been a factor in the termination of their marriages, though older age could also be a factor. On the other hand, women who are married and those who have no living children report less emotional, physical, and sexual violence, perhaps because they are more likely to be newly married and still in their courtship. The relationship between education and spousal violence is not straightforward. Ever-married women with incomplete primary education are more likely than those with less or more education to re- port all three types of violence. Women who are employed, whether they are paid in cash or not, are more likely to have experienced spousal violence than unemployed women. One might expect a correlation between spousal violence and poverty. However differences in spousal violence by wealth index are not strong; only the wealthiest women are less likely to experience violence from a husband or partner. It may seem that domestic violence is not related to socioeconomic status. 244 | Gender Violence The proportions of married women and divorced or separated women who have experienced dif- ferent forms of violence by their current or last husbands, ever and during the 12 months preceding the survey are presented in Figure 15.1. The most common form of spousal violence is slapping or arm twist- ing, which has been experienced by one-third of women. Almost one-quarter (23 percent) of ever-married women have ever been pushed, shaken, or thrown by a husband; 17 percent have been punched; 15 per- cent have been forced to have intercourse; and 11 percent have been kicked or dragged. The least com- monly reported forms of marital violence against women are attacking with a weapon (3 percent), forced sexual acts other than intercourse (4 percent), strangling or burning (4 percent), and threatening with a weapon (6 percent). Marital rape appears to be common, with 15 percent of married women and sepa- rated or divorced women reporting having experienced forced sexual intercourse; 12 percent report this experience in the 12 months preceding the survey. Table 15.3 Marital violence Percentage of married women and divorced or separated women who have ever experienced emotional, physical, or sexual violence by their current or most recent husband, according to selected background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Type of violence ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Emotional, Physical Emotional, physical, Number Background or physical, and of characteristic Emotional Physical Sexual sexual or sexual sexual women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 15.9 26.1 12.0 29.7 33.3 4.7 274 20-29 23.3 37.1 14.5 40.5 44.6 7.5 1,565 30-39 25.8 43.6 15.9 46.3 50.9 8.4 1,248 40-49 33.1 44.0 19.2 47.2 51.9 11.3 769 Marital status Currently married 23.4 38.3 14.8 41.5 45.8 7.4 3,508 Once 22.8 37.4 14.4 40.7 45.0 6.9 3,267 More than once 31.8 50.0 21.4 52.3 56.8 13.5 240 Divorced/separated 47.1 54.9 24.5 57.2 62.4 18.3 348 Number of living children 0 13.6 20.9 9.3 24.6 27.2 3.8 283 1-2 22.9 35.3 14.4 39.1 44.1 6.9 1,372 3-4 27.5 41.8 16.2 44.9 49.6 8.8 1,132 5 or more 30.0 48.5 18.5 50.7 54.3 10.9 1,067 Education No education 26.6 39.7 11.3 40.9 44.1 7.2 592 Primary incomplete 29.9 47.9 19.8 51.5 55.9 10.4 1,250 Primary complete 22.1 36.1 14.7 39.3 43.5 7.5 1,022 Secondary+ 23.0 33.4 14.2 37.1 42.2 7.3 992 Employment status Employed for cash 27.2 42.3 19.6 46.4 50.6 10.2 1,886 Employed, but not for cash 25.8 44.6 16.6 47.8 51.1 8.5 666 Not employed 23.0 33.8 9.6 35.5 40.6 5.6 1,303 Wealth quintile Lowest 28.1 43.4 16.4 45.6 50.2 9.1 706 Second 26.8 43.0 18.4 47.1 50.9 9.5 751 Middle 27.2 43.5 17.5 46.9 50.5 9.2 722 Fourth 25.6 38.3 14.9 42.0 47.0 7.6 781 Highest 21.1 32.5 12.1 35.0 39.6 6.8 895 Total 25.5 39.8 15.7 42.9 47.3 8.3 3,856 Gender Violence | 245 Figure 15.1 Percentage of Women Who Have Experienced Different Forms of Spousal Violence Ever (Since Age 15) and in the 12 Months Preceding the Survey KDHS 2003 Pushed/shaken/thrown Slapped/arm twisted Punched Kicked/dragged Strangled/burned Threatened with weapon Attacked with weapon Forced to have intercourse Forced to perform other sexual acts 0 5 10 15 20 25 30 35 Ever Last 12 months 15.5 FREQUENCY OF SPOUSAL VIOLENCE Frequency of spousal violence is an indication of the extent to which domestic violence is a cur- rent or recurring problem for Kenyan women. Table 15.4 shows the percent distribution of currently mar- ried women and divorced or separated women who report physical or sexual violence by current or last husband by the maximum frequency of any form of such violence in the 12 months preceding the survey, by selected background characteristics. This table shows that 65 percent of women who have experienced physical or sexual violence by their husbands have experienced such violence in the 12 months preceding the survey. One-quarter of ever-abused women (26 percent) have experienced spousal violence three or more times in the last 12 months. Among those who have ever experienced spousal violence, those who are younger are likely to experience violence somewhat more frequently than older women; 30 percent of women age 15-19 report experiencing spousal violence three or more times in the 12 months preceding the survey, compared with 24 percent of women age 40-49. Women who have been married more than once are most likely (35 per- cent) to have experienced violence three or more times in the 12 months preceding the survey, while those divorced or separated are less likely (15 percent) than other women to have reported frequent violence in the recent past. Differences in the frequency of violence against women in the recent past by the number of living children, employment status, and wealth index do not show a clear pattern. Abused women with no education are more likely to experience more frequent spousal violence, compared with women who have secondary or higher education. 246 | Gender Violence 15.6 ONSET OF SPOUSAL VIOLENCE AGAINST WOMEN To study the timing of the onset of marital violence, the 2003 KDHS asked ever-married women who reported physical or sexual violence by their spouse how long after they got married the violence first occurred. Table 15.5 shows the percent distribution of married women and divorced or separated women by the number of years between marriage and the first time they experienced physical or sexual violence by their current or most recent husband, according to duration since marriage. The percentages who have not experienced spousal violence are shown as well. Table 15.4 Frequency of spousal violence Percent distribution of currently married women and divorced or separated women reporting physical or sexual violence by current or last husband by maximum frequency of any form of such violence in the 12 months pre- ceding the survey, according to background characteristics, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Maximum frequency of any type of physical or sexual violence in the 12 months preceding the survey ––––––––––––––––––––––––––––––––––––––––––––––– Don’t Number Background know/ of characteristic 0 times 1-2 times 3-5 times >5 times missing Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 8.4 61.3 22.6 7.7 0.0 100.0 81 20-29 23.1 50.8 14.1 11.8 0.2 100.0 634 30-39 41.3 30.9 13.2 13.8 0.9 100.0 578 40-49 48.9 25.9 11.4 12.3 1.5 100.0 363 Marital status Currently married 29.7 42.1 14.6 13.0 0.6 100.0 1,457 Once 30.7 42.0 14.2 12.7 0.4 100.0 1,331 More than once 20.0 42.8 18.3 16.5 2.4 100.0 126 Divorced/separated 68.4 15.5 6.5 8.3 1.3 100.0 199 Number of living children 0 24.1 45.3 11.5 19.1 0.0 100.0 70 1-2 29.2 47.0 12.7 10.8 0.2 100.0 536 3-4 33.2 40.0 14.3 11.4 1.0 100.0 509 5 or more 41.9 28.9 14.1 14.1 0.9 100.0 541 Education No education 37.3 29.6 13.2 19.7 0.2 100.0 242 Primary incomplete 28.6 43.9 14.7 11.9 0.9 100.0 644 Primary complete 29.4 41.7 14.3 13.9 0.7 100.0 402 Secondary+ 48.1 33.1 11.1 7.0 0.6 100.0 368 Employment status Employed for cash 35.6 36.5 14.8 12.7 0.5 100.0 875 Employed, but not for cash 36.1 38.0 13.2 11.7 0.9 100.0 319 Not employed 31.0 44.1 11.6 12.4 0.9 100.0 462 Wealth quintile Lowest 25.6 40.9 18.8 14.1 0.6 100.0 322 Second 30.1 46.2 11.2 11.4 1.2 100.0 354 Middle 32.6 41.8 12.0 13.4 0.3 100.0 339 Fourth 43.3 28.5 13.3 13.8 1.1 100.0 328 Highest 40.9 36.3 13.0 9.5 0.3 100.0 313 Total 34.4 38.9 13.6 12.4 0.7 100.0 1,656 Gender Violence | 247 Table 15.5 shows that in the majority of cases, initiation of violence takes place early in the mar- riage. Almost one-fifth (19 percent) of women experience spousal violence within the first two years of marriage, and one-third (32 percent) experience violence in the first five years of marriage. Women who are currently married but married more than once and women who are currently di- vorced or separated are more likely to have experienced violence early in their marriages than women who married only once. 15.7 PHYSICAL CONSEQUENCES OF SPOUSAL VIOLENCE Table 15.6 shows the percentage of married, divorced, or separated women reporting different types of physical consequences resulting from something the current or last husband or partner did to them, by type of violence. Among all married, divorced, or separated women, 13 percent reported ever having had bruises or aches and 9 percent reported having bruises or aches in the past year because of something their husband did to them. Injuries and broken bones are far less common consequences of spousal violence, reported by 4 percent of women as ever occurring and by 2 percent as occurring in the 12 months preceding the survey. Six percent of all married, divorced or separated women reported ever visiting a health facility, and 4 percent reported visiting a health facility in the 12 months before the sur- vey because of something their husband did to them. Among women who report having ever experienced physical violence, one-third (32 percent) also report having ever had bruises or aches, 9 percent report having had a broken bone or injury, and 15 per- cent report having visited a health facility because of something their husband or partner did. Although the question was asked of all married, divorced, or separated women as another means of encouraging them to report any spousal violence that they may not have reported in prior questions, the data in Table 15.6 indicate that almost no women who had not previously reported spousal violence said “yes” to these questions on physical consequences. Table 15.5 Onset of spousal violence Percent distribution of married women and divorced or separated women by number of years between marriage and first experience of physi- cal or sexual violence by current or last husband if ever, according to marital status and number of unions, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Years between union and first experience of violence –––––––––––––––––––––––––––––––––––––– Experienced 10 or Don’t Number Duration since no Before 1-2 3-5 6-9 more know/ of marriage violence marriage <1 year years years years years missing Total women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Currently married 58.4 0.3 5.4 12.1 12.2 5.8 5.4 0.4 100.0 3,508 Married only once 59.2 0.3 4.9 11.8 12.3 6.0 5.1 0.4 100.0 3,267 <1 year 88.7 0.0 10.1 na na na na 1.2 100.0 164 1-5 years 68.0 0.1 8.2 16.7 6.8 na na 0.3 100.0 878 6-9 years 56.3 0.3 3.5 13.0 19.2 7.2 na 0.5 100.0 545 10 or more years 52.8 0.4 3.2 9.9 14.1 9.3 9.7 0.6 100.0 1,681 Married more than once 47.7 0.4 11.8 16.3 10.7 3.2 9.8 0.1 100.0 240 Divorced/separated 42.9 0.7 16.7 17.8 16.4 2.4 2.3 0.8 100.0 348 Total 57.1 0.3 6.4 12.6 12.6 5.5 5.1 0.4 100.0 3,856 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 248 | Gender Violence 15.8 VIOLENCE INITIATED BY WOMEN AGAINST HUSBANDS Violence by husbands against wives is not the only form of spousal violence; women may some- times be the perpetrators of violence. In most cultures, however, the level of spousal violence initiated by wives is only a fraction of the level of spousal violence initiated by husbands. To measure spousal vio- lence by women, the 2003 KDHS asked married, divorced, or separated women, “Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you?” This line of questioning may result in some underreport- ing if women find it difficult to admit that they themselves initiated violence. Results show that only 3 percent of married, divorced, or separated women report initiating vio- lence against their husbands (data not shown). Of the women who have experienced violence from their husband, 5 percent report initiating violence; of the women who have not experienced violence from their husband, less than 1 percent report initiating violence. 15.9 VIOLENCE BY SPOUSAL CHARACTERISTICS AND WOMEN’S STATUS INDICATORS Since the perpetrators of spousal violence are usually husbands, it is important to understand the characteristics of husbands. It is also useful to examine whether spousal violence varies with indicators of women’s status. Table 15.7 shows the percentage of married, divorced, or separated women who have experienced different forms of spousal violence by the current or last husband ever and in the year pre- ceding the survey, as well as the percentage of women who have initiated violence against their husbands, by spousal characteristics and selected women’s status variables. Table 15.6 Physical consequences of spousal violence Percentage of married, divorced, or separated women who report specific physical consequences resulting from something their current or last husband or partner did to them, according to type of violence reported, Kenya 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Had bruises Had injury or Had to visit or aches broken bone health personnel –––––––––––––– –––––––––––––– –––––––––––––– Number Type of violence Last Last Last of experienced Ever year Ever year Ever year women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Emotional violence Ever 36.7 24.2 11.5 5.6 19.1 11.1 985 At least once in last year 37.9 32.6 10.7 7.7 17.9 14.1 701 Physical violence Ever 31.7 21.0 8.9 4.7 15.2 9.3 1,534 At least once in last year 35.6 32.4 9.4 7.5 17.1 14.7 924 Sexual violence Ever 36.6 25.4 10.7 6.6 18.0 11.3 605 At least once in last year 36.0 31.5 9.9 7.9 16.0 13.1 466 Physical or sexual violence Ever 29.7 19.7 8.3 4.3 14.2 8.8 1,656 At least once in last year 32.9 28.8 8.4 6.4 15.3 12.5 1,087 Experienced no violence 0.2 0.2 0.0 0.0 0.1 0.1 2,032 Total 12.9 8.6 3.6 1.9 6.2 3.8 3,856 Gender Violence | 249 Table 15.7 Spousal violence, women’s status, and husband’s characteristics Percentage of married, divorced, or separated women who experienced different types of spousal violence by the current or last husband ever and in the last year, and percentage who have been violent to their husbands, by spousal characteristics and women's status vari- ables, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Violence Physical against Emotional Physical Sexual or sexual husband by violence violence violence violence Never respondent ––––––––––– ––––––––––– ––––––––––– ––––––––––– experi- –––––––––––– Spousal characteristic/ Last Last Last Last enced Last women’s status variable Ever year Ever year Ever year Ever year violence Ever year Number ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Husband’s education No education 22.7 19.6 39.1 27.6 9.5 8.7 39.7 28.4 57.1 3.1 2.0 369 Primary incomplete 29.0 24.6 47.5 32.5 21.2 18.6 51.2 38.2 44.4 2.3 1.3 733 Primary complete 25.8 19.6 39.2 25.4 15.2 13.2 42.7 30.8 52.4 1.1 0.9 996 Secondary+ 19.1 14.5 33.0 19.5 12.7 9.5 36.4 23.5 59.5 2.5 1.2 1,362 Age difference Wife older than husband 26.4 20.9 41.4 29.0 14.0 12.5 41.4 31.0 53.8 0.9 0.9 84 Husband older by <2 years 22.5 16.8 36.8 22.3 14.9 11.8 41.6 26.6 53.5 1.2 0.2 275 2-4 years 22.2 18.4 34.7 21.3 13.7 11.1 38.5 26.8 56.2 1.6 1.1 895 5-9 years 23.6 18.1 39.7 26.2 16.1 13.4 42.8 30.7 53.8 2.4 1.2 1,375 10+ years 24.7 20.1 40.2 26.4 13.9 12.1 42.8 29.9 52.8 2.6 1.8 864 Differences in education Husband has more education 26.8 19.1 41.5 24.7 16.6 12.8 44.6 29.4 51.8 2.6 1.3 1,972 Wife has more education 26.6 19.6 41.5 25.3 17.7 14.7 45.3 30.4 49.0 2.7 1.6 817 Both have equal education 21.8 14.4 35.0 20.9 13.9 9.4 38.1 23.9 56.5 1.7 0.9 677 Neither educated 22.8 18.2 37.4 24.5 8.2 7.0 37.9 24.9 59.3 3.6 1.1 300 Alcohol/illegal drug consumption of husband Does not drink/take drugs 17.2 13.6 29.8 18.4 10.5 8.8 32.6 21.9 63.1 1.5 0.6 2,300 Never gets drunk/takes drugs 18.9 8.9 58.7 39.1 4.5 4.5 58.7 39.1 38.4 0.0 0.0 21 Gets drunk/takes drugs sometimes 28.3 19.4 44.4 26.3 16.9 12.9 48.3 31.6 46.4 2.3 1.4 957 Gets drunk/takes drugs very often 55.6 36.2 73.3 43.2 36.1 24.8 76.7 48.8 19.8 7.5 3.6 551 Woman can refuse sex to husband1 Yes for all reasons 26.3 18.8 39.9 24.8 17.4 13.9 43.2 29.4 52.5 3.1 1.5 2,001 No for one or more reasons 24.7 17.6 39.7 23.1 13.9 10.1 42.6 26.8 53.0 2.1 1.0 1,854 Number of household decisions respondent participates in2 0 decisions 24.2 15.2 33.3 21.0 9.1 7.0 34.6 22.2 60.4 3.2 0.8 344 1-2 decisions 26.4 20.3 41.7 28.6 15.3 13.8 44.9 33.4 51.1 2.8 1.3 1,182 3-4 decisions 24.1 19.6 39.1 23.4 16.6 13.4 42.4 28.2 53.1 2.1 1.4 1,304 5+ decisions 26.8 14.9 40.6 20.3 17.2 10.1 44.2 24.1 51.6 3.0 1.3 1,025 Family structure Nuclear 26.2 19.1 42.7 27.0 15.9 12.7 45.5 30.9 50.4 2.4 1.2 2,562 Non-nuclear 24.3 16.3 34.1 17.9 15.2 11.0 37.8 22.9 57.3 3.1 1.5 1,294 Total 25.5 18.2 39.8 24.0 15.7 12.1 42.9 28.2 52.7 2.7 1.3 3,856 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 396 women for whom husband’s education is missing, 15 women for whom the age difference between spouses is missing, 90 women for whom education differences are missing, and 27 women for whom alcohol consumption of the husband is miss- ing. 1 For reasons, see Table 3.13. 2 For decisions, see Table 3.11. 250 | Gender Violence As mentioned above, 26 percent of married, separated, or divorced women have ever experienced emotional violence, 40 percent have ever experienced physical violence, and 16 percent have ever experi- enced sexual violence. Women whose husbands have at least some secondary education are less likely to have experienced emotional or physical violence than women whose husbands are less educated. All three types of violence—emotional, physical, and sexual—are more common for women whose husbands have incomplete primary education. Contrary to expectations that age and education discrepancies between spouses would exacerbate spousal violence, the data show only minor variations in the level of spousal violence by age or education differences between spouses. Women’s experience of violence varies strongly with the extent of alcohol and/or illegal drug consumption by their husbands or partners. All three forms of violence are two to three times more preva- lent among women who say their husbands get drunk or take illegal drugs very often than among those whose husbands do not drink or take illegal drugs. Differences in spousal violence by women’s status in- dicators and by family structure are minimal. 15.10 FEMALE GENITAL CUTTING Female genital cutting or circumcision is widely practised in many Kenyan communities. It in- volves the partial or total removal of the external female genitalia or other injury to the female organs for cultural or other nontherapeutic reasons (World Health Organisation, 1997). The practice is widely con- demned as harmful, because it poses a potentially great risk to the health and well-being of the women and girls who are subjected to it and it violates internationally accepted human rights. The United Nations Convention on the Rights of the Child recognises this as one of the cultural practices that violate the rights of the child. The Children Act of 2001 also describes girls who are likely to be forced into circum- cision as children in need of special care and protection. The act further provides for courts to take action against the perpetrators. In the 2003 KDHS, women were asked whether they were circumcised. They were also asked whether their eldest daughters were circumcised and, for those who were not circum- cised, whether they had plans of having them circumcised. Table 15.8 shows that 32 percent of surveyed women are circumcised. This represents a decline from 38 percent recorded in the 1998 KDHS to 31 percent in 2003, excluding the northern districts so as to be comparable. The proportion of women circumcised increases with age, from 20 percent of women age 15-19 to 48 percent of those age 45-49. This implies a steep decline by about half in the practice of female circumcision over the past two decades. A higher proportion of rural women (36 percent) than urban women (21 percent) have been cir- cumcised. North Eastern Province, which was included for the first time in the 2003 KDHS sample, has the largest proportion of women who are circumcised (99 percent). Western Province, which is mainly occupied by the Luhya ethnic group, has the lowest proportion of women who have undergone genital cutting (4 percent). There is a strong relationship between education level and circumcision status. Fifty-eight percent of women with no education report that they are circumcised, compared with only 21 percent of those with at least some secondary education. The survey results indicate that one-half of Muslim women (50 percent) are circumcised, compared with about one-third of non-Muslim women. Gender Violence | 251 Table 15.8 Female circumcision Percentage of women circumcised and percentage of eldest daughters age 15 and older who have been circumcisesd, by background characteristics, Kenya 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Percentage Percentage Number of eldest Number Background of women of daughters of eldest characteristic circumcised women circumcised daughters ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 20.3 1,856 * 0 20-24 24.8 1,691 * 0 25-29 33.0 1,382 * 6 30-34 38.1 1,086 12.7 138 35-39 39.7 871 16.9 399 40-44 47.5 788 24.2 591 45-49 47.7 521 22.7 442 Residence Urban 21.3 2,056 14.5 281 Rural 35.8 6,139 22.3 1,296 Province Nairobi 18.6 835 7.9 100 Central 36.3 1,181 12.8 244 Coast 20.2 667 15.4 115 Eastern 36.4 1,325 13.6 260 Nyanza 35.1 1,222 34.8 257 Rift Valley 42.8 1,872 30.8 370 Western 4.1 927 2.0 200 North Eastern 98.8 168 98.8 31 Education No education 58.2 1,039 37.3 388 Primary incomplete 32.8 2,685 18.5 464 Primary complete 31.0 2,069 17.4 373 Secondary+ 21.1 2,403 9.9 351 Religion Roman Catholic 33.2