Malawi - Demographic and Health Survey - 1994

Publication date: 1994

Mala i Demographic and Health Survey 1992 National Statistical Office ®DHS Demographic and Health Surveys Macro Internatio,~al Inc. A REPUBLIC OF MALAWI Mala i Demographic and Health Survey 1992 National Statistical Office Zomba, Mala~vi Macro International Inc. Calverton, Maryland USA January 1994 This report summarises the findings of the 1992 Malawi Demographic and Health Survey (MDHS) conducted by the National Statistical Office, Zomba, Malawi. Macro International Inc. provided technical assistance. Funding was provided by the United States Agency for International Development (USAID). Additional information about the MDHS may be obtained from the National Statistical Office, P.O. Box 333, Zomba, Malawi; Fax (265) 523-130. Additional information about the DHS programme may be obtained by writing to: DHS, Macro International Inc., 11785 Beltsville Drive, Calverton, MD 20705, USA (Telephone (301) 572-0200; Fax (301) 572-0999). CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Map of Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx CHAPTER 1 INTRODUCTION 1.1 Geography, History, and the Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Population and Family Planning Policies and Programmes . . . . . . . . . . . . . . . . . . 2 1.3 Health Priorities and Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.4 Objectives, Organisation, and Design of the Survey . . . . . . . . . . . . . . . . . . . . . . . 3 1.5 Data Collection and Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 CHAPTER 2 CHARALq'ERISTICS OF HOUSEHOLDS AND RESPONDENTS 2.1 Demographic Characteristics of Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.2 Economic and Environmental Characteristics of Households . . . . . . . . . . . . . . . 12 2.3 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHAPTER 3 FERTIL ITY 3.1 Current Fertility Levels and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.2 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.3 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.4 Age of the Mother at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.5 Adolescent Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 CHAPTER 4 FERTIL ITY REGULAT ION 4.1 Knowledge of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 4.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 4.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 4.4 Differentials in Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . 34 4.5 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . 36 4.6 Knowledge of the Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.7 Sources of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.8 Intention to Use Family Planning Among Nonusers . . . . . . . . . . . . . . . . . . . . . . 40 4.9 Reasons for Non-use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.10 Preferred Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 i i i Page 4.11 Exposure to Family Planning Messages on Radio . . . . . . . . . . . . . . . . . . . . . . . . 45 4.12 Approval of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 CHAPTER 5 PROXIMATE DETERMINANTS OF FERTILITY 5.1 Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5.2 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.3 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.4 Postpartum Amenorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 5.5 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 CHAPTER 6 FERTILITY PREFERENCES 6.1 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 6.2 Demand for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 6.3 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 6.4 Wanted and Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 CHAPTER 7 CHILDHOOD MORTALITY 7.1 Data Quality and Mortality Estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 7.2 Levels and Trends in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 7.3 Socioeconomic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . 72 7.4 Biodemographic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . 74 7.5 High-Risk Fertility Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 CHAPTER 8 MATERNAL AND CHILD HEALTH 8.1 Antenatal Care and Delivery Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 8.2 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 8.3 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 8.4 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 8.5 Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 CHAPTER 9 MATERNAL AND CHILD NUTRITION 9.1 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 9.2 Nutritional Status of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 9.3 Maternal Anthropometric Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 CHAPTER 10 KNOWLEDGE OF AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 iv CHAPTER 11 Page MATERNAL MORTAL ITY 11.1 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 11.2 Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 11.3 Direct Estimates of Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 11.4 Indirect Estimates of Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 CHAPTER 12 AVAILABIL ITY OF HEALTH SERVICES 12.1 Distance and Time to Nearest Health Facility . . . . . . . . . . . . . . . . . . . . . . . . . . 125 12.2 Services Provided at Nearest Health Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 12.3 Distance and Time to Nearest Hospit',d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 12.4 Distance and Time to Nearest Source of Family Planning and Source of Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 12.5 AIDS Education Campaigns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 APPENDICES Appendix A Interview Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Appendix B Estimates of Sampling Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Appendix C Data Quality Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Appendix D Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 .¢ Table 1.1 Table 1.2 Table 2.1 Table 2.2 Table 2.3 Table 2A. 1 Table 2.4.2 Table 2.5 Table 2.6 Table 2.7 Table 2.8.1 Table 2.8.2 Table 2.9 Table 2.10 Table 3.1 Table 3.2 Table 3.3 Table 3A Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 Table 4.1 Table 4.2 Table 4.3 Table 4A Table 4.5 Table 4.6 TABLES Page Selected demographic indices for Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Results oftbe household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Educational level of the household population - males . . . . . . . . . . . . . . . . . . . . . . . . . 10 Educational level of the household population - females . . . . . . . . . . . . . . . . . . . . . . . . 11 School enrolment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Background characteristics of respondents - males . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Background characteristics of respondents - females . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Children ever born and l iving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Adolescent pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Children ever born to adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Knowledge of contraceptive methods and source for methods . . . . . . . . . . . . . . . . . . . . 29 Knowledge of modern contraceptive methods and source for methods . . . . . . . . . . . . . 31 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Current method use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Current method use by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 vii Table 4.7 Table 4.8 Table 4.9 Table 4.10.1 Table 4.10.2 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16.1 Table 4.16.2 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 7.1 Table 7.2 Table 7.3 Page Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 T ime to source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . 40 Future use of contraception - females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Future use of contraception - males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Family planning messages on radio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Acceptability of the use of radio for disseminating family planning messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Discussion of family planning by couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Attitudes of couples towards family planning - female respondents . . . . . . . . . . . . . . . 48 Attitudes of couples towards family planning - male respondents . . . . . . . . . . . . . . . . . 49 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Number of co-wives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Number of wives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Postpartum amenorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Median duration of postpartum amenorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Fertility preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . . . . . . 66 Wanted and unwanted births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Neonatal deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Childhood mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Childhood mortality by socioeconomic charactcristics . . . . . . . . . . . . . . . . . . . . . . . . . 73 viii Table 7A Table 7.5 Table 8.1 Table 8.2 Table 8.3 Table 8A Table 8.5 Table 8,6 Table 8,7 Table 8,8 Table 8,9 Table 8,10 Table 8,11 Table 8.12 Table 8.13 Table 8.14 Table 8.15 Table 9.1 Table 9.2 Table 9.3 Table 9A Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 10.1.1 Table 10.1.2 Table 102 Table 10.3 Table 10.4 Table 10.5 Table 11.1 Table 11.2 Page Childhood mortality by biodemographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . 74 High-risk fertility behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Number of antenatal visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Characteristics of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Vaccinations in the first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . . . . . . . . 91 Prevalence and treatmcnt of fcver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Prevalence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Knowledge and use of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Treatment of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Feeding practices during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Initial breast feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Breastfeeding and supplementation by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Nutritional status by socioeconomic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Anthropometric indicalors of maternal nutritional status . . . . . . . . . . . . . . . . . . . . . . . 108 Differentials in maternal anthropometric indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Knowledge of AIDS - females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Knowledge of AIDS - males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Sources of AIDS information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Perceived modes of AIDS transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Perceptions about AIDS prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Attitudes towards AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Data on siblings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Estimates of age-specific adult female mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 ix Table 11.3 Table 11 A Table 11.5 Table 12.1 Table 12.2 Table 12.3 Table 12.4 Table 12.5 Table 12.6 Table 12.7 Table A. 1 Table B. 1 Table B.2 Table B.3 Table B.4 Table B.5 Table B.6 Table B.7 TabTe C.1 Table C.2 Table C.3 Table CA Table C.5 Table C.6 Page Estimates of age-specific female mortality, model life tables . . . . . . . . . . . . . . . . . . . 122 Direct estimates of maternal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Indirect estimates of matemal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Type of nearest health facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Distance and time to nearest health facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Available health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Distance and time to nearest hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Distance and time to nearest source for any family planning method . . . . . . . . . . . . . 129 Distance and time to nearest source of condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 AIDS awareness campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Sample implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 List of selected variables for sampling errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Sampling errors, entire sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Sampling errors, urban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Sampling errors, rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Sampling errors, Northem Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Sampling errors, Central Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Sampling errors, Southern Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Age distribution of eligible and interviewed women and men . . . . . . . . . . . . . . . . . . . 152 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Births by calendar year since birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 FIGURES Figure2.1 Figure 3.1 Figure3.2 Figure 3.3 Figure4.1 Figure 4.2 Figure 4.3 Figure 5.1 Figure 6.1 Figure6.2 Figure 6.3 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 8.1 Figure 8.2 Figure 8.3 Figure 8.4 Figure 9.1 Figure 10.1 Figure 10.2 Page Population pyramid of Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g Age-specific fertility rates, Malawi, 1984 FFS and 1992 MDHS . . . . . . . . . . . . . . . . . 20 Age-specific fertility rates, urban and rural Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Percentage of adolescents who have begun childbcaring, by age . . . . . . . . . . . . . . . . . 27 Percentages of currently married women who know specific contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Percentage of currently married women and men using a contraceptive method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Distribution of current female users of modem contraception by source of supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Percentage of currently married women whose husbands have at least one other wife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Fertility preferences among currently married women 15-49 . . . . . . . . . . . . . . . . . . . . 60 Fertility preferences among currently married women, by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Percentage of women with unmet need and met need for family planning services, by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Under-five mortality in cast and soud~em Africa, selected DHS surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Trends in neonatal, posmconatal, and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Under-five mortality by selected background characteristics . . . . . . . . . . . . . . . . . . . . . 73 Under-five mortality by selected biodcmographic characteristics . . . . . . . . . . . . . . . . . 75 Percent distribution of births by use of selected maternal health services . . . . . . . . . . . 80 Percentage of children age 12-23 months with certain vaccinations . . . . . . . . . . . . . . . 87 Percentage of children age 12-23 months who are fully vaccinated . . . . . . . . . . . . . . . 89 Prevalence of respiratory illness and diarrhoea in the last two weeks, by age of the child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Percentage of children stunted, by age of child and degree of stunting . . . . . . . . . . . . 106 AIDS awareness and knowledge of modes of HIV transmission . . . . . . . . . . . . . . . . . 113 Sources of information about AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 xi ABBREVIATIONS ANC ARI BCG BMI CBR CDC CDD CDR CEB DC DHS DPT EA EPI FFS GDP IEC ISSA IUCD MDHS NCHS NGO NPAC NSO OPC ORS ORT PHC SD TBA TFR UNICEF UN WHO Antenatal care Acute respiratory infections Bacille Bilid de Calmette et Gudrin (vaccine) Body mass index Crude birth rate Centers for Disease Control Control of Diarrhoeal Diseases Crude death rate Children ever born Delivery care Demographic and Health Surveys Diphtheria - poliomyelitis - tetanus (vaccine) Enumeration area Expanded Programme on Immunisation Family Formation Survey Gross domestic product Information, education and communication Integrated system for survey analysis Intra-uterine cervical device Malawi Demographic and Health Survey National Center for Health Statistics (USA) Non-governmental organisations National Population Advisory Committee National Statistical Office Office of the President and Cabinet Oral rehydration salts Oral rehydration therapy Primary health care Standard deviation Traditional birth attendant Total fertitity rate United Nations Children's Fund United Nations World Health Organisation xiii PREFACE This final report presents the major findings of the Malawi Demographic and Health Survey (MDHS). The MDHS fieldwork was carried out by the National Statistical Office (NSO) from September to November 1992; the data were processed and ready for analysis by January 1993. The First Report, which provided a more limited set of demographic and health indices, was published in March 1993. The primary objective of the Malawi Demographic and Health Survey was to provide up-to-date information for policymakers, planners and researchers that would allow guidance in the development and evaluation of bealth and population programmes. Specifically, the MDHS collected information on fertility levels, nuptiality, fertility preferences, knowledge and use of family planning methods, breastfocding practices, nutritional status of mothers and children, early childhood morbidity and mortality, use of maternal and child health services, maternal mortality, AIDS awareness, and availability of basic health services. The MDHS was a nationally representative sample survey designed to provide estimates of various demographic and health indices for the three regions of the country, urban and rural areas, and for the country as a whole. Three types of questionnaires were used: the Household Questionnaire, the Individual Female Questionnaire, and the Individual Male Questionnaire. The contents of these questionnaires were based on the DHS Model B Questionnaire, with modifications that were undertaken by the National Statistical Office in conjunction with the Ministry of Health and Macro International Inc. (Macro) of Columbia, Maryland (U.S.A). I would like to thank Macro for providing technical assistance for the preparation, planning, implementation, and processing of the survey and for the printing of the first and this final report. I would also like to thank USAID for contracting Macro to carry out the MDHS and for providing the funding. Finally, I would like to thank all the members of the MDHS team at NSO who participated in this survey, and a special thanks goes to all of the many respondents who gave their time to make the survey a great success. J. Nowa Actin ~Cnmmissioner for Census and Statistics XV SUMMARY OF FINDINGS The 1992 Malawi Demographic and Health Survey (MDHS) was a nationally representative sample survey designed to provide information on levels and trends in fertility, early childhood mortality and morbidity, family planning knowledge and use, and maternal and child health. The survey was implemented by the National Statistical Office during September to November 1992. In 5323 households, 4849 women age 15-49 years and 1151 men age 20-54 years were interviewed. The findings indicate that fertility in Malawi has been declining over the last decade; at current levels a woman will give birth to an average of 6.7 children during her lifetime. Fertility in rural areas is 6.9 children per woman compared to 5.5 children in urban areas. Fertility is higher in the Central Region (7.4 children per woman) than in the Northem Region (6.7) or Southern Region (6.2). Over the last decade, the average age at which a woman first gives birth has risen slightly over the last decade from 18.3 to 18.9 years. Still, over one third of women currently under 20 years of age have either already given birlh to at least one child or are currently pregnant. Although 58 percent of currently married women would like to have another child, only 19 percent want one within the next two years. Thirty-seven percent would prefer to walt two or more years. Nearly one quarter of married women want no more children than they already have. Thus, a majority of women (61 percent) want either to delay their next birth or end childbearing altogether. This represents the proportion of women who are potentially in need of family planning. Women reported an average ideal family size of 5.7 children (i.e., wanted fertility), one child less than the actual fertility level measured in the survey--further evidence of the need for family planning methods. Knowledge of contraceptive methods is high among all age groups and socioeconomic strata of women and men. Most women and men also know of a source to obtain a contraceptive method, although this varies by the type of method. The contraceptive pill is the most commonly cited method known by women; men are most familiar with condoms. Despite widespread knowledge of family planning, current use of contraception remains quite low. Only 7 percent of currently married women were using a modem method and another 6 percent were using a traditional method of family planning at the time of the survey. This does, however, represent an increase in the contraceptive prevalence rate (modem methods) from about 1 percent estimated from data collected in the 1984 Family Formation Survey. The modem methods most commonly used by women are the pill (2.2 percent), female sterilisation (1.7 percent), condoms (1.7 percent), and injections (1.5 percent). Men reported higher rates of contraceptive use (13 percent use of modem methods) than women. However, when comparing method-specific use rates, nearly all of the difference in use between men and women is explained by much higher condom use among men. Early childhood mortality remains high in Malawi; the under-five mortality rate currently stands at 234 deaths per 1000 live births. The infant mortality rate was estimated at 134 per 10130 live births. This means that nearly one in seven children dies before his first birthday, and nearly one in four children does not reach his fifth birthday. The probability of child death is linked to several factors, most strikingly, low levels of maternal education and short intervals between births. Children of uneducated women are twice as likely to die in the first five years of life as children of women with a secondary education. Similarly, the probablity of under-five mortality for children with a previous birth interval of less than 2 years is two times greater than for children with a birth interval of 4 or more years. Children living in rural areas have a higher rate ofunder-fwe mortality than urban children, and children in the Central Region have higher mortality than their counterparts in the Northem and Southem Regions. xvii Data were collected that allow estimation ofmatemalmortality. It is estimated that for every ! 00,000 live births, 620 women die due to causes related to pregnancy and childbearing. The height and weight of children under five years old and their mothers were collected in the survey. The results show that nearly one half of children under age five are stunted, i.e., too short for their age; about half of these are severely stunted. By age 3, two-thirds of children are stunted. As with childhood mortality, chronic undernutrition is more common in rural areas and among children of uneducated women. The duration of breastfeeding is relatively long in Malawi (median length, 21 months), but supplemental liquids and foods are introduced at an early age. By age 2-3 months, 76 percent of children are already receiving supplements. Mothers were asked to report on recent episodes ofilloess among their young children. The results indicate that children age 6-23 months are the most vulnerable to fever, acute respiratory infection (ARI), and diarrhoea. Over half of the children in this age group were reported to have had a fever, about 40 percent had a bout with diarrhoea, and 20 percent had symptoms indicating ARI in the two-week period before the survey. Less than hal fof recently sick children had been taken to a health facility for treatment. Sixty-three percent of children with diarrhoea were given rehydration therapy, using either prepackaged rehydration salts or a home-based preparation. However, one quarter of children with diarrhoea received less fluids than normal during the illness, and for 17 percent of children still being breastfed, breastfeeding of the sick child was reduced. Use o f basic, preventive maternal and child health services is generally high. For 90 pereent of recent births, mothers had received antenatal care from a trained medical person, most commonly a nurse or trained midwife. For 86 percent of births, mothers had received at least one dose of tetanus toxoid during pregnancy. Over half of recent births were delivered in a health facility. Child vaccination coverage is high; 82 percent of children age 12-23 months had received the full complement of recommended vaccines, 67 percent by exact age 12 months. BCG coverage and first dose coverage for DPT and polio vaccine were 97 percent. However, 9 percent of children age 12-23 months who received the first doses of DPT and polio vaccine failed to eventually receive the recommended third doses. Information was collected on knowledge and attitudes regarding AIDS. General knowledge of AIDS is nearly universal in Malawi; 98 percent of men and 95 percent of women said they had heard of AIDS. Further, the vast majority of men and women know that the disease is transmitted through sexual intercourse. Men tended to know more different ways of disease transmission than women, and were more likely to mention condom use as a means to prevent spread of AIDS. Women, especially those living in rural areas, are more likely to hold misconceptions about modes of disease transmission. Thirty percent of rural women believe that AIDS can not be prevented. xviii MALAWl TANZANIA NORTHERN REGION ZAMBIA • ii II :.% ¢. LAKE CENTRAL REGION ~ ~ • ; • • i l l •• SOUTHERN REGION MOZAMBIQUE ~CTED SAMPLE POtNTS • Rural and Small Urban Sample Points 2 in Zomba Municipality {~) 7 in Mzuzu City 1~ 15 in I-ilongwe City (capital) (~ 17 in Blantyre City • "| r" • QQ.m ~ XX CHAPTER 1 INTRODUCTION 1.1 Geography, History and the Economy Geography Malawi is a landlocked country bordered to the north and northeast by the United Republic of Tanzania, to the east, south and southwest by the People's Republic of Mozambique and to the west by the Republic of Zambia. It is 901 kilometres long and ranges in width from 80 to 161 kilometres. The country has a total area of 118,484 square kilometres, of which 94,276 square kilometres is land area. Fifty-six percent of the land area is arable. Malawi's most striking topographic feature is the Rift Valley which runs through the entire length of the country, passing through Lake Malawi in the northem and central part of the country to the Shire Valley in the south. To the west and south of the lake are fertile plains and high mountain ranges whose main peaks range from 1,698 to 3,002 metres. The country is divided into three administrative regions; Northern, Central and Southern. There are twenty-four districts, five in the Northern Region, nine in the Central Region and ten in the Southern Region. In each district there are Traditional Authorities (or chiefs) and the smallest administrative unit is the village. There are 43 Traditional Authorities in the Northcrn Region, 79 in the Central Region and 83 in the Southern Region. Malawi experiences a tropical continental climate with some maritime influences. Rainfall and temperature are greatly influenced by the lake and altitude, which varies from 37 to 3,050 meters above sea level. From May to August, the climate is cool and dry. From September to November, average temperatures rise and the rainy season begins towards the end of this period. The rainy season extends to April or May. History Based on the examination of earliest human remains and stone-aged tools, people who are known as Abathwa, Akafula or Mwandionerakuti lived in Malawi since around 8000 BC. During the 9th Century AD, a group of people known by the name of Pule, Lenda or Katanga from the shores of Lake Tanganyika settled in Malawi. Between the 13th and 16th Century AD, Bantu speakers known as Maravi settled in central and southern Malawi. Those who eventually settled in central Malawi are known as Chewa while those who settled in southern Malawi are known as Mang'anja or Nyanja. The Tumbuka, Tonga, Ngonde, and Lambya eventually came to settle in northem Malawi. Later, during the 19th Century AD, the Ngoni, Yao, Lomwe and Sena settled in Malawi. It was also during this period that Europeans arrived in Malawi. On 14th May 1891, the British declared the country a British Protectorate under the name of Nyasaland District Protectorate which was then changed to British Central African Protectorate in 1893. Opposition to colonial adminstration culminated in the uprising led by John Chilembwe in 1915. In 1953 the Federation of Rhodesia and Nyasaland, which was also known as the Centred African Federation, was instituted comprising three countries, namely, Zimbabwe (then Southern Rhodesia), Zambia (then Northern Rhodesia) and Malawi (then Nyasaland) despite protests from Africans in Malawi through the Nyasaland African Congress, which was a nationalist movement founded in 1944. On 3rd March 1959 a state of emergency was declared by the colonial government and the Nyasaland African Congress, whose leaders were arrested and detained, became a banned party. In September 1959 the Malawi Congress Party was formed and on 19th September 1959 the Malawi News was launched as the official organ of the Party. On 15th August 1961 the first multiparty general election was held wherein four political parties contested. The Malawi Congress Party won all twenty seats on the lower roll plus two which it contested on the higher roll. As a result of the general election, the country formed an internal self-government. In April 1964 another general election was held wherein all candidates of the Malawi Congress Party were returned unopposed. On 6th July 1964 Nyasaland became the independent state of Malawi under the monarchical constitution which was replaced by a republican constitution as of 6th July 1966 when Malawi bec~une a Republic and a one-party state. On 14th June 1993 a National Referendum was eonductcd which resulted in Malawi becoming a multiparty state. The Economy Malawi is predominantly an agricultural country. Agricultural produce accounts for 90 percent of Malawi's exports; tobacco, tea and cotton are the major export commodities. The country is largely self- sufficient in food. The economy of Malawi improved in 1991 over performance in the three preceding years. Real gross domestic product (GDP) grew at a rate of 7.8 percent in 1991 compared to growth of 4.8 percent, 4.1 percent and 3.3 percent recorded in 1990, 1989 and 1988, respectively. The agricultural and distribution sectors accounted for most of the increase in real GDP. 1.2 Population and Family Planning Policies and Programmes The major source of demographic data is the population census. Population censuses have been taken in Malawi during the years 1891, 1901, 1911, 1921, 1926, 1931, 1945, 1956, 1966, 1977 and 1987. Additional popula- tion data have been collected through nationwide demographic and other related surveys. These are the Malawi Population Change Survey in 1970-72, the Malawi Demographic Survey in 1982, the Malawi Labour Force Survey and the Survey of Handicapped Persons in 1983, and the Family Formation Survey in 1984. Table 1.1 provides some demographic indices for Malawi. The population of Malawi is growing at a rate of around 3.2 percent per year based on the 1987 census, up from 2.9 percent in 1977 (this considers only natural or intrinsic growth and does not include refugee populations, esti- mated at about 1 million persons in 1992). The total Malawian population in the 1987 census was enumerated at around 8 million persons, having roughly doubled since the 1966 census. Given current growth rate estimates, the 1994 population will reach approximately 10 million Table 1.1 Selected demographic indices fi~r Malawi Census year Index 1966 1977 1987 Population I 4039583 55474611 7988507 Intercensal growth rate 2 - 2.9 3.2 Total area (sq. kin.) 118484 118484 118484 Land area (sq. kin.) 94079 94276 94276 Density (pop./sq. kin.) 43 59 85 Percentage urban 5.0 8.5 10.7 Women of childbearing age as percentage of female population 47.6 45.1 44.2 Sex ratio 90 93 94 Crude birth rate 48.3 41.2 Total fertility rate 7.6 7.63 Crude death rate 25.0 14. I Infant mortality rate 165 1513 Life expectancy' Male 39.2 41 4 Female 42 4 44.6 IDe facto population 2Natural increase; excludes migration, refugees 3Based on the 1984 Family Formation Survey 2 persons. With a doubling of the size of Malawi's population over the last two decades has come a doubling of the population density from 43 to 85 persons per square kilometre during the period 1966 to 1987. By 1994, Malawi's population density will exceed 100 persons per square kilometre. A national population policy for Malawi has been prepared. The policy aims at achieving lower population growth rates compatible with attainment of the country's social and economic objectives in addition to reducing morbidity and mortality among mothers and children. It aims at improving the status of mothers and children in all spheres of development as well as improving information, education and communication on the use of contraceptives and benefits of small family sizes. In the education sector, the policy will enhance the relevance of formal and informal education. The policy stresses the importance of the creation of employment and food self-sufficiency especially for pregnant and lactating mothers as well as children. Last but not least, the policy aims at improving the collection, analysis and dissemination of demographic, environment and employment data, by gender, and the utilisation of these data for social and economic planning. A technical secretariat for the National Population Advisory Committee (NPAC) composed of all relevant ministries and non-government organisations (NGOs) was recently established in the Office of the President and Cabinet (OPC). The Secretariat's overall responsibility is to coordinate and monitor the implementation of population programmes and projects and to develop population guidelines for the country. 1.3 Health Priorities and Programmes Health services in Malawi are provided by the Ministry of Health, the Ministry of Local Government and the NGOs, particularly mission organisations. The Ministry of Health is responsible for planning and developing health policies and for providing health care in all government hospitals. The Ministry of Local Govemment is in charge of health care delivery at the district level and below. NGOs provide services to both hospitals and smaller medical units. In Malawi, the provision of curative services takes a large proportion of the total government funds allocated to the health sector. The lack of an effective outreach capacity in the system has been recognised by the Ministry of Health, and strategies for creating a community-based distribution system are being implemented despite a severe lack of trained medical personnel in the country. Currently, the government is developing a health policy with the goal of achieving health for all by the year 2(g30. 1.4 Objectives, Organisation, and Design of the Survey Objectives The Malawi Demographic and Health Survey (MDHS) was a national sample survey of women and men of reproductive age designed to provide, among other things, information on fertility, family planning, child survival, and health of mothers and children. Specifically, the main objectives of the survey were to: Collect up-to-date information on fertility, infant and child mortality, and family planning Collect information on health-related matters, including breastleeding, antenatal and maternity services, vaccinations, and childhood diseases and treatment Assess the nutritional status of mothers and children Collect information on knowledge and attitudes regarding AIDS • Collect information suitable for the estimation of mortality related to pregnancy and childbearing Assess the availability of health and family planning services. Organisation The MDHS was conducted by the National Statistical Office (NSO) from September to November 1992. Financial support for the survey was provided by the United States Agency for International Development (USAID) while technical assistance was provided by Macro International Inc. (Macro) of Columbia, Maryland (USA) through its contract with USAID. Survey Design Based on the 1987 Malawi Population and Housing Census, the country is demarcated into 8,652 enumeration areas (EAs) of roughly equal population size. This sampling frame of census EAs was stratified by urban and rural areas within each of the three administrative regions, making six sampling strata in total. Within each sampling stratum, districts were geographically ordered, thereby providing additional implicit stratification. The MDHS sample of households was selected in two stages. First, 225 EAs were selected from the 1987 census frame of EAs with probability proportional to population size. The distribution of selected sample points (EAs) is shown in the map of Malawi on page xx. The measure of EA size was based on the number of households enumerated during the 1987 census. NSO staff, after being trained in listing procedures and methods for updating maps, were sent to the selected EAs to list all households and produce maps which provided the orientation for later data collection teams in finding selected households. Households in refugee camps and institutional populations (army barracks, police camps, hospitals, etc.) were not listed. In the second stage, a systematic sample of households was selected from the above lists, with the sampling interval from each EA being proportional to its size based on the results of the household listing operation. In these households, all women age 15-49 years were eligible lot interview. Further, a one-in-tln'ce systematic subsample of households was drawn, within which both eligible men age 20-54 years and women age 15-49 years were interviewed. Because the objective of the survey was to produce region-level and urban/rural estimates of some indicators, an oversample of households in the Northern Region and in urban areas was necessary. Thus the MDHS sample is not self-weighting at the national level, but it is self-weighting within each ol the six region/urban-rural strata. Four types of questionnaires were used: the Household Questionnaire, the Individual Female Questionnaire, the Individual Male Questionnaire, and the Health Services Awfilability Questionnaire. The contents of these questionnaires were based on the DHS Model B Questionnaire, which is designed for use in countries with a low level of contraceptive use. Modification of the questionnaires was undertaken by NSO in consultation with the Ministry of Health and Macro. The questionnaires were pretested in April 1992. Approximately 250 interviews were conducted over a two-week period, and further adjustments to the questionnaires were made based on lessons drawn fi'om the interviews and analysis of the data. 4 The Household Questionnaire was used to list all the usual members and visitors of selected households. A household is defined as one that consists of one or more persons, related or unrelated, who make common provisions for food, or who regularly take all their food from the same pot or same grainstore (Nkhokwe), or who pool their incomes for the purpose of purchasing food. Persons in a household may live in one or more dwelling units. Information was collected on the characteristics of each person listed, including his/her age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women who were eligible for individual interview, namely, those age 15-49 years. For those women who were either absent or could not be interviewed during the first visit, a minimum of three visits were made before recording nonresponse. Women were interviewed with the individual female questionnaire. In the course of administering the household questionnaire, eligible men, namely, those age 20-54 were also identified. The individual male questionnaire was administered to all men age 20-54 living in every third household in the selected sample. The male questionnaire collected much of the same information found in the female questionnaire, but was considerably shorter because it did not contain questions on reproductive history, and maternal and child health. During the household listing operation (i.e., before the main survey), one Health Services Availability Questionnaire was completed in each of the 225 MDHS sample points. Leaders in the community provided information that allowed an assessment of the availability of health and family planning services to persons living in the respective localities. A three-week training course for the main survey was held in July and August of 1992. A total of 80 field staff was trained. The training course consisted of instruction in general interviewing techniques, field procedures, a detailed review of items on the questionnaires, instruction and practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews in areas outside MDHS sample points. Only trainees who performed satisfactorily in the training programme were selected for fieldwork. Team leaders were NSO staff who had previously participated in the MDHS pretest. 1.5 Data Collection and Data Processing The fieldwork for the MDHS was car- ried out by ten interviewing teams, each con- sisting of one team leader, one field editor, five female interviewers, one male interviewer and one driver. Additionally, senior NSO staff co- ordinated and supervised fieldwork activities. Data collection began 1 September and was completed on 10 November 1992. Table 1.2 shows the results of house- hold and individual interviews for the urban and rural sample and for Malawi as a whole. A more detailed presentation of interview results by re- gion and urban-rural residence is given in Appendix A. A total of 5,811 households was selected in the MDHS sample, of which 5,396 were currently occupied. Of the 5,396 occupied households, 5,323 were interviewed, yiclding a Table 1.2 Results of the household mad indivldua[ interviews Number of households, number of interviews, and response rates, Malawi 1992 ResuLt Urban Rural Malawl Households sampled 1413 4398 5811 Households occupied 1360 4036 5396 Households interviewed 1339 3984 5323 HOUSEIIOLD RESPONSE RATE 98 5 98.7 98.6 Eligible women 1359 3661 51120 Eligible women interviewed 1316 3533 4849 ELIGIIILE WOMEN RESPONSE RATE 96.8 96 5 96.6 Eligible men 416 872 1288 Eligible men lnlerviewed 364 787 1151 ELIGIBLE MEN RESPONSE RATE 87.5 903 89.4 household response rate of 98.6 percent. Rural and urban response rates at the household level did not differ significantly. Within the interviewed households, 5020 eligible women (15-49 years) were identified of which 4849 were interviewed, yielding an individual female response rate of 96.6 percent. In the one-in-three subsample of households, 1,288 eligible men were identified, of which 1,151 were successfully interviewed (89.4 percent response). The principal mason for nonresponse among both eligible men and women was the failure to find them at home despite repeated visits to the household. The lower response rate among men than women was due to more frequent and longer-term absence of men. The refusal rate in the MDHS was extremely low (0.1 percent). Response rates were marginally better in rural areas than in urban areas in the male survey (rural, 90.3 percent; urban, 87.5 percent), but nearly the same in the female survey (rural, 96.5 percent; urban, 96.8 percent). Completed questionnaires were retumed to NSO for data processing. The processing operation consisted of office editing, coding of open-ended questions, data entry and editing of errors found by the computer programs. Data entry, editing, and analysis were accomplished on personal computers, using a software program called ISSA (Integrated System for Survey Analysis). Data processing started on 14 September 1992 and was completed on 21 January 1993. 6 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 2.1 Introduction An understanding of the background characteristics of the households interviewed in the survey and the individual survey respondents is essential to the interpretation of the MDHS data and provides an indication of the representativeness of the survey sample. Information on age and educational level of household members, household composition, and household possessions and amenities was collected in the survey. This chapter presents this information in three parts: • Demographic characteristics of households Economic and environmental characteristics of households Characteristics of survey respondents. 2.1 Demographic Character ist ics of Households Age Structure The age distribution of the household population in the MDHS is shown in Table 2.1. The age structure, depicted by way of the population pyramid in Figure 2.1. is one typical of high-fertil ity populations, Table 2.1 Household population by ager residence and sex Percent distribution of the de facto household population by five-year age group, according to urban-rural residence and sex, Malawi 1992 Urban Rural Total Age group Male Female Total Male Female Total Male Female Total 0-4 14.8 15.3 15.0 17.3 15.7 16.5 17.0 15.7 16.3 5-9 15.1 15.3 15.2 16.4 15.6 16.0 16.2 15.5 15.9 10-14 12.3 19.0 15.5 15.0 15.0 15.0 14.7 15.5 15.1 15-19 12.6 9.7 11.2 10.6 9.4 10.0 10.9 9.4 10.2 20-24 9.9 10.1 10.0 7.5 7.8 7.6 7.8 8.0 7.9 25-29 8.8 9.0 8.9 5.9 6.3 6.1 6.3 6.6 6.4 30-34 7.7 6.3 7.0 4.7 5.3 5.0 5.1 5.4 5.3 35-39 4.9 4,7 4,8 3,9 4,4 4,2 4,0 4,5 4,2 40-44 4.5 3.0 3.7 4.3 4.4 4.3 4.3 4.2 4.3 45-49 2.8 1.9 2.4 2.7 3.1 2.9 2,7 2.9 2.8 50-54 2.5 2.2 2.3 2.7 3.7 3.2 2.7 3.5 3.1 55-59 1.3 1.1 1.2 2.1 2.6 2.4 2.0 2.4 2.2 60-64 1.4 0.9 1.2 2.3 2.3 2.3 2.2 2.1 2.2 65-69 0.4 0.6 0.5 1.4 1.4 1.4 1.3 1.3 1.3 70-74 0.4 0.3 0.3 1.4 1.3 1.4 1.2 1.2 1.2 75-79 0.2 0.4 0.3 0,6 0.8 0.7 0.6 0.7 0.7 80+ 0.4 0.3 0.4 0.9 0.9 0.9 0.8 0.8 0.8 Don't know/Missing 0.1 0.0 0.1 0.2 0.1 0.1 0.2 0.1 0.1 Total 100.0 I00.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1464 1334 2798 9770 10518 20288 11234 11853 23087 8(} ÷ , , ) t~ tt 2' ~'1 I L , 1 , I F gure 2 1 Populatio Pyramid ol ' qalawl , I , ! r r F',ID ~ I~ . 19!97 i.e., a very wide-based population pyramid indicating large numbers of recent births relative to the adult population. A comparison of urban and rural age distributions indicates an excess of adult males in the urban setting and an excess of adult females in the rural setting. Table 2.2 shows the percentage distribution of the de facto household population under age 15, 15 -64 years old, and 65 years and older indicated by the 1966, 1977 and 1987 national censuses, and the 1992 MDHS. The percentage of the population undcr age 15 years has risen from 43.9 percent in 1966 to 47.3 Table 2.2 Population by age from selected sources Percent distribution of the population by age group and dependency ratio, from 1992 MDHS and 1966. 1977, and 1987 censuses, Malawi 1992 MDItS 1992 Census Age group De jure l)e facto 1987 1977 1966 Less than 15 46.6 47.3 46.0 44.6 43.9 15-64 49.2 48.6 50.0 50.9 52.1 65+ 4.1 4.0 4.0 4.5 4.0 Don't know/Missing 0.1 0.1 Total 100.0 100.0 llX/.O 100.0 100.0 Dependency ratio 1.05 1.00 0.96 0.92 percent in 1992. Consequently, over the period 1966 to 1992, the dependency ratio ~ has risen from 0.92 in 1966, to 0.96 in 1977, to 1.00 in 1987, to 1.05 in 1992. There exists a substantial difference in the dependency ratio between urban and rural settings, due to a larger proportion of the population in rural areas at ages under 15 and ages over 64. For each person 15- 64 years old in rural areas, there are 1.08 dependents in the household; in urban areas the dependency ratio is 0.90. Size of Househo lds and Relat ionship Structure Table 2.3 gives the percentage distri- bution of households by sex of the household head, size of the household, relationship struc- ture within the household, and presence of fos- ter children 2 in the household. Three-quarters of Malawian households are headed by a man. Thirteen percent of urban households are head- ed by a woman compared to 26 percent of rural households. The average number of persons l iving in a household is 4.5. Urban households tend to be larger (4.8 persons) than rural households (4.4 persons). This pattern is typical of coun- tries in this region and is evidently due to a greater percentage of urban households having a very large number (9+) of members. The most common relationship structure was one where two adults of the opposite sex lived to- gether in the household (44 percent). Of the re- maining households, most had 3 adult mem- bers who were related (29 percent). Interesting- ly, rural households were nearly 50 percent more likely than urban households to have only one adult resident. Urban households, on the other hand, were twice as likely as rural households to have an "other" arrangement, which in large part represents households with large numbers of adult residents. The MDHS also found that a greater percentage of urban households than rural households contained foster children. Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, kinship structure, and presence of foster children, according k~ urban-rural residence, Malawi 1992 Residence Characteristic Urban Rural Total Household headship Male 87.4 73.9 75.4 Female 12.6 26.1 24.6 Number of usual members 1 9.1 7.9 8.1 2 14.2 15A 15.3 3 13.7 17,2 16.8 4 14.2 16,5 16.3 5 12.2 14,1 13.8 6 11.0 10,9 10.9 7 8.3 7,1 7.3 8 6.6 4,7 4.9 9+ 10.6 6,1 6.6 Mean size 4.8 4,4 4.5 Relatinnship structure One adult 12.8 18,8 18.1 Two related adults: Of opposite sex 41.5 44,8 44.4 Of same sex 4.5 4.2 4.2 Three ur more related adults 32.3 28,0 28.5 Oilier 8.6 4,0 4.6 With foster children 24.0 19.2 19.8 XThe dependency ratio is the ratio of persons 0-14 years and 65 years and older over persons 15-64 years. 2A foster child is a child under 15 years, neither of whose parents live in the same household as the child. Education Level of Household Members Tables 2.4.1 and 2.4.2 present the distribution of the de facto population of housebold members by level of education by sex and five-year age group. For Malawi as a whole, 30 percent of males and 48 percent of females had never been to school. Once having attended school, males also tended to stay in school longer than females; 6 percent of males had been to secondary school compared with only 2 percent for females. Looking at changes by age group in the percentage never attending school, male non-attendance starts to rise only after age 35-39, whereas the same occurs to females starting at age 15-19, indicating a more recent improvement in school attendance for females. In the youngest age groups, which better reflect the current situation, attendance among boys and girls is nearly equal. Table 2.4.1 Educational level of the household population - males Percent distribution of the de facto male household population age five and over by highest level of education auended, according to selected background characteristics, Malawi 1992 Level of education Number Median Background Primary Primary of number characteristic None 1-4 5-8 Secondary+ Total men of years Age 5-9 56.4 43.2 0.3 0.1 100.0 1815 0.0 10-14 22.3 65.0 12,6 0.2 100.0 1645 2,4 15-19 19.5 34,3 42.2 4.0 100.0 1224 4.6 20-24 23.0 26.2 36.2 14.6 100.0 876 5.1 25-29 20.1 20.8 43.6 15.5 100.0 702 5.9 30-34 20,2 21.2 43.6 15.0 100.0 566 6.2 35-39 20,1 23,2 41.6 15.0 100.0 448 5.8 40-44 24.0 29.4 35.8 10.8 100.0 488 4.6 45-49 22.1 25.3 45.2 7.3 100 0 305 5 3 50-54 26.2 35.8 29.9 8.1 100.0 303 4.2 55-59 34.7 36,4 26,6 2.3 100.0 224 3.2 60-64 40.0 30.0 26.4 3 5 100.0 247 2.6 65+ 42.3 35.11 21.4 1.3 100.0 435 2.4 Don't know/Missing 85.6 0.0 3.9 10.5 10(/.0 12 0.0 Residence Urban 14.3 28.6 36.4 20.7 100.0 1241 6.1 Rural 32.7 39.2 24.3 3.8 100.0 8050 2.4 Region Northern 13.0 38.1 38.1 10.8 100.0 1108 4.9 Central 33.2 36.8 25.1 4.9 100.0 3611 2.5 Southern 32.1 38.5 23.6 5.8 100.0 4572 2 5 Total 30.2 37.8 25.9 6.1 100.0 9291 2.8 Tables 2.4.1 and 2.4.2 also show school attendcnce by urban-rural residence and region. Three- quarters of females and 86 percent of males in the urban areas have been to school; 11 percent of females and 21 percent of males go to secondary school or beyond. But for the nearly 90 percent of Malawi's population that live in rural areas, educational attainment is much lower, with over hal f of females and nearly one third 10 Table 2.4,2 Educational level of the household population - females Percent distribution of the de facto female household population age five and over by highest level of education attended, according to selected background characteristics, Malawi 1992 Level of education Number Median Background Primary Primary of number characteristic None 1-4 5-8 Secondary+ Total women of years Age 5-9 52.7 46.9 0.3 0.0 100.0 1833 0.0 10-14 27.2 59.2 13.4 0.2 100.0 1832 2.2 15-19 30.3 32,1 33.5 4,1 100.0 1118 3,5 20-24 40.9 24.4 28.1 6.6 100.0 953 2.9 25-29 44.7 23.1 27.0 5.3 100.0 778 2.1 30-34 55.8 21.4 18.4 4.4 100.0 645 0.0 35-39 58.5 22.4 15.7 3.4 100.0 529 0.0 40~.4 57.3 25.6 14.9 2.1 100.0 498 0,0 45-49 69,5 18.2 11.2 1.1 100.0 347 0,0 50-54 69.5 24.3 5.8 0.4 100.0 417 0.0 55-59 73.2 21.5 5.3 0.0 100.0 283 0.0 60-64 68.3 27.0 4.7 0.0 10O.0 254 0.0 65+ 77.1 18.5 4.5 0.0 100.0 479 0,0 Don't know/Missing 64.3 35.7 0.0 0.0 100.0 8 0.0 Residence Urban 24.8 34.7 29.2 11.2 100.0 1130 3.7 Rural 50.9 35.0 13.1 1.0 100.0 8847 0.0 Region Northern 25.2 40.3 30.4 4.1 100.0 1153 3,1 Central 49.2 35.9 13.0 1.9 100,0 3953 0.9 Southern 52.3 32,9 12.9 1,9 100.0 4870 0.0 Total 47.9 34.9 15.0 2.2 100.0 9976 1.0 of males never having attended school. Only 1 percent of females and 4 percent of males have reached secondary school level in rural Malawi. The MDHS data show that the Northern Region has significantly higher levels of school attendance than the Central and Southern Regions, which have roughly similar levels. Northern residents are half as likely as persons who live in the rest of the country to have never been to school and twice as likely to have ever attended secondary school. This pattem is exhibited among both males and females. Current School Enrolment Table 2.5 shows the percentage distribution of the de facto household population 6-24 years of age currently enrolled in school by age, sex and urban-rural residence. According to the MDHS, 52 percent of children age 6-10 were enrolled in school at the survey date. The percentage enrolment rises to 66 percent in the age group 11-15 years and begins to fall thereafter, reaching 10 percent in the age group 21-24 years. About three-quarters of urban 6-10 ycar-olds are currently 11 Table 2.5 School enrolment Percentage of the de facto household population age 6-24 years enrolled in school, by age group, sex, and urban- rural residence, Malawi 1992 Age group Male Female Total Urban Rural Total Urban Rural Total Urban Rural Total 6-10 71,9 48.1 50.8 75.7 51.1 53.8 73.9 49.6 52.3 11-15 83.5 67.5 69.4 74.7 61.5 63.3 78.6 64.5 66.3 6-15 77.4 57.0 59.3 75.2 55.8 58.2 76.2 56.4 58.7 16-20 58.1 49.0 50.5 44,8 20,7 23.4 52.4 34.2 36.7 21-24 23.2 12.3 14.1 10.7 4.6 5.5 17.0 8.4 9.7 enrolled, compared with 50 percent in rural areas. Girls are only slightly less likely than boys to be enrolled in school in rural areas during ages 6-15. But for ages 16-20 and 21-24, percentage enrolment drops off much more sharply for females than males. In conclusion, while girls and boys apparently receive roughly the same opportunity to start school, boys have a greater chance to stay in school and reach more advanced levels. This gender-related differential is particularly marked in rural areas. 2.2 Economic and Environmental Characteristics of Households In order to assess the economic and environmental characteristics of households, a series of questions was asked of household respondents regarding features of their dwelling units. In addition to reflecting the socioeconomic status of a household, source of water, method of excreta disposal, mad crowding conditions are important determinants of the health status of household members. Table 2.6 shows that about 20 percent of urban households and 1 percent of rural households have access to electricity in the home. Overall, 3 percent of Malawian households have electricity. The vast majority of urban households (82 percent) have access to piped water, but most of these get water from a public tap (49 percent). Sixty-four percent of rural households, on the other hand, obtain their water from a well; 24 percent from a protected (covered) well, and 41 percent from an unprotected well. At the national level, over half (53 percent) of all households obtain their water from a source that can be considered unsafe (i.e., unprotected well or natural sources). Over two-thirds of households use a traditional pit latrine; 82 percent of urban households and 68 percent of rural households. In urban areas, the second most common method of excreta disposal is a flush toilet (14 percent), either in one's own household (12 percent) or shared with other households (2 percent). in rural areas, nearly all of the households that do not use a traditional pit latrine do not use any toilet or latrine facility (31 percent). The large majority of households live in dwellings with floors made of packed earth (87 percent). About 93 percent of rural households have mud/earth floors compared with 44 percent in urban households. Households having cement floors were much more common in urban areas (55 percent) than in rural areas (7.1 percent). 12 Table 2.6 Housing characteristics Percent disa'ibution of households by housing characteristics. aeoording to urban-rural residence, Malawi 1992 Residence Housing characteristic Ui'ben Rural Total Electricity Yes 19,8 1.1 3.2 No 80,1 98.9 96.8 Total 100,0 100.0 100.0 Source of drinking water Piped into reaidence 11,1 0.6 1.8 Piped into yardkplot 22,5 1.2 3.6 Public tap 48,5 16.2 19.8 Protected well 8,8 23.6 21.9 Unpmtected well 6,7 40.7 36.9 River/S a'eara/Spring 1,0 15.8 14.2 Lake/Pond/Dam 1,2 1.7 1.6 Don't know/Missing 0.2 0.1 0.1 Total 100,0 100.0 100.0 Sanitation facility Own flush 11,6 0.3 1.6 Shared flush 2,4 0.3 0.5 Traditional pit latrine 81,7 67,9 69.5 Vent. imp. pit latrine 1.2 0.6 0.7 No facility/Bush 3,1 30.8 27.7 Don't know/Missing 0,1 0.0 0.0 Total 100,0 100.0 100,0 Flooring Mud/Earth 43,7 92.6 87.1 Cement 54,7 7.1 12.5 Other 1.6 0.3 0.4 Total 100,0 100.0 100.0 Persons per sleeping room 1-2 57,3 55,6 55,8 3-4 34.4 33.4 33.5 5-6 5.8 8.0 7.7 7+ 1,5 2.5 2.3 Missing/Don't know 1.0 0.6 0.6 Total 100.0 100.0 100.0 Mean persons per room 2.7 2.8 2.8 Number of households 603 4720 5323 As a measure of household crowding and the potential for spread of infection among household members, the number of persons per the room used for sleeping was calculated. Crowding conditions varied little between urban and rural households. The mean number of household members per sleeping room was 2.8 in rural areas and 2.7 for urban areas. For the country as a whole, 56 percent of households sleep with 1 or2 persons per room and 34 percent with 34 persons per room. About 10 percent of households have 5 or more persons per sleeping room. 13 Household Durable Goods Table 2.7 gives the percentage of house- holds possessing a radio, a paraffin lamp, a bi- cycle, a motorcycle, a car, or an oxcart. For the country as a whole, about 33 percent of house- holds had radios in working condition; 65 per- cent in urban areas and 29 percent in rural areas. The majority of the households (83 per- cent) reported possessing a paraffin lamp; this percentage did not vary substantially by urban- rural residence. Possession of a bicycle was slightly more common in rural households (22 percent) than in urban households (17 percent), but was more than offset by the much more fre- quent possession of motorised vehicles (motor- cycles and cars) in urban households. Table 2.7 Household durable goods Percentage of households possessing specific durable consumer goods, by urban-rural residence, Malawi 1992 Residence Dureh~ goods Urban Rur~ Total Radio 65.1 28.6 32.8 Par alTm lamp 83.9 82.5 82.6 Bicycle 17.0 21.8 21.2 Motorcycle 2.6 0.7 0.9 Car 6.1 0.5 1.1 Oxc~t 0.8 3.0 2.8 Number of households 603 4720 5323 2.3 Characteristics of Survey Respondents A person's age, marital status, educational level, and residence have an important influence on decisions regarding health and family planning. Tables 2.8.1 and 2.8.2 show the percentage distribution of all women (15-49 years) and men (20-54 years) interviewed in the survey according to age group, marital status, education level, urban-rural residence, and region of the country. Nearly a quarter of male respondents are in the youngest age group interviewed, 20-24 years, while 22 percent of female respondents are 15-19 years of age. As expected, the percentage of men and women in each age group declines with increasing age. Despite the older average age of males interviewed, a larger percentage of male respondents reported never having been married (19 percent) than female respondents (16 percent). Similarly, more men (7 percent) are in an informal union than women (3 percent). On the other hand, women respondents are more likely than men to be widowed (3 versus 1 percent), divorced (7 versus 3 percent), or separated (3 versus 2 percen0. All women and men interviewed in the MDHS were asked if they attended school. Those who had auended were further asked the highest level that they achieved according to Malawi's formal education system, and at that level, how many years had they completed. Respondents were grouped into four education categories: those with no education, those with 1-4 years of primary education, those with 5-8 years of primary education and those with at least some secondary education or above. The distribution of respondents by educational attainment parallels that already reported using the household data) That is, male respondents have more commonly attended school at all and have progressed to more advanced educational levels than female respondents. Only 4 percent of female respondents and 14 percent of males have had some secondary education. ~l'he figures differ slightly from those presented using the household data because here the information comes directly from the respondent, whereas in the household data, information concerning the respondent's education may be reported by someone else (i.e., any competent household member). 14 Table 2.8.1 Background characteristics of respondents - males Percent distribution of men by selected background characteristics, Malawi 1992 Number of men Background Weighted Un- characteristic percent Weighted weighted Age 20-24 24.1 277 270 25-29 17.8 205 222 30-34 14.6 168 175 35-39 12.4 143 140 40-44 13.9 160 158 45-49 8.2 95 95 50-54 8.9 102 91 Marltalstatus Never married 18.5 213 229 Married 68.1 784 777 Living together 7.1 81 69 Widowed 0.9 10 12 Divorced 3.2 37 36 Separ~ed 2.2 26 28 Education No education 20.5 236 183 Primary 1-4 29.1 335 267 Primary5-8 36.7 423 460 Secondaa-y+ 13.6 157 241 Residence Urban 15.8 181 364 Rur~ 84.2 970 787 Region Northern 12.0 139 345 Centr~ 38.5 443 381 Southern 49.4 569 425 All men 100.0 1151 1151 Table 2.8.2 Background characteristics of respondents - females Percent distribution of women by selected back- ground characteristics, Malawi 1992 Number of women Background Weighted Un- characteristic percent Weighted weighted Age 15-19 22.3 1082 1105 20-24 19.5 944 990 25-29 16.0 777 804 30-34 13.5 656 664 35-39 11.1 537 517 40-44 10.5 510 458 45-49 7.1 343 311 Marital status Never married 15.7 761 839 Married 68.8 3335 3347 Living together 3.2 157 142 Widowed 2.5 121 121 Divorced 6.8 329 266 Separated 3.0 146 134 Education No education 47.2 2287 1834 Primary 1-4 24.6 1192 1117 Primary5-8 23.9 1157 1515 Secondary+ 4.4 212 382 Residence Urban 12.3 594 1316 Rur~ 87.7 4255 3533 Region Northern 11.9 578 1442 Centlal 38.6 1872 1606 Southern 49.5 2398 1801 All women 100.0 4849 4849 The data indicate that 12 percent of women age 15-49 years live in urban areas. There are slightly more men (16 percent) age 20-54 years that live in the urban areas, reflecting a pattern of rural-urban migration. About halfofwomenlive in the Southern Region, 39 percent in the Central Region, and 12 percent in the Northern Region. The distribution of interviewed men by region is the same as that for women. 15 Respondent Level of Education by Background Characteristics Table 2.9 presents the percentage distribution of interviewed women and men by educational level attained according to age, urban-rural residence, and region. Education is inversely related to age, that is, Table 2.9 Levelofeducation Pe~cnt distribution of women and men by highest level of education attended, according to selected background characteristics, Malawi 1992 Level of education Background Primary Primary characteristic None 1-4 5-8 Secondary+ Total Number MALES Age 20-24 18.1 26.0 39.6 16.3 100.0 277 25-29 19.9 25.4 39.5 15.1 100.0 205 30-34 18.8 28.4 36.0 16.8 100.0 168 35-39 14.0 26.2 44.9 14.8 100.0 143 40-,~1 21.2 37.1 32.2 9.5 100.0 160 45-49 27.1 26.6 37.1 9.3 100.0 95 50-54 33.1 40.2 19.9 6.9 100.0 102 Residence Urban 9.2 11.5 37.1 42.1 100.0 181 Rural 22.6 32.4 36.7 8.3 100.0 970 Region Northern 7.7 15.0 52.7 24.6 100.0 139 Central 23.2 25.7 41.4 9.8 100.0 443 Southern 21.6 35.3 29.2 13.9 100.0 569 Total 20.5 29.1 36.7 13.6 100.0 1151 FEMALES Age 15-19 28.9 32.8 33.8 4.5 100.0 1082 20-24 41.5 24.2 28.1 6.3 100.0 944 25-29 44.8 23.5 26.5 5.2 100.0 777 30-34 56.8 19.5 18.9 4.7 100.0 656 35-39 59.6 20.9 16.0 3.5 100.0 537 40-44 58.0 24.6 15.3 2.0 100.0 510 45-49 71.5 17.5 10.l 0.9 100.0 343 Residence Urban 22.7 17.6 38.8 20.9 100.0 594 Rural 50.6 25.6 21.8 2.1 I00.0 4255 Region Northern 20.2 23.2 48.7 7.9 100.0 578 Central 48.7 25.2 22.1 4.0 100.0 1872 Southern 52.4 24.5 19.3 3.8 100.0 2398 Total 47.2 24.6 23.9 4.4 100.0 4849 16 older women and men are typically less edu- cated than younger women and men. For ex- ample, 72 percent of women and 27 percent of men 45-49 years old have not been to school, compared to 42 percent and 18 percent for 20- 24 year-old women and men, respectively. Rural men and women are education- ally disadvantaged compared to those in urban areas. Whereas 42 percent ofurhan men and 21 percent of urban women have been to secon- dary school, only 8 percent of rural men and 2 percent of rural women have done so. Rural men and women are twice as likely to have never been to school than their urban counter- parts. Regional differentials also exist. North- em men and women tend to have much greater educational opportunities to attend school and then to be able to continue to more advanced levels than persons in other regions. Access to Mass Media Respondents were asked if they usual- ly read a newspaper or listen to a radio at least once a week. This information can be useful to programme planners seeking to reach men and women with media messages concerning fami- ly health. Table 2.10 shows the percentage of men and women who have access to mass me- dia by background characteristics. The MDHS shows that for Malawi as a whole, 75 percent of men and 52 percent of women listen to the radio and 41 percent of men and 19 percent of women read a newspaper at least once a week. Media contact is related to age of the respond- ent. Men and women in the older age groups tend to read the newspaper and listen to radio less frequently than younger men and women. This would be in part related to the fact that younger men and women in Malawi also tend to be better educated. Education leads to infor- marion-seeking behaviour, including following the media. Both radio listening and especially newspaper reading are highly correlated with education of the respondent. Men and women without education have, for obvious reasons, very limited access to messages sent through Table 2.10 Access to mass media Percentage of women and men who usually reed a newspaper once a week or listen to radio once a week, by selected background characteristics, Malawi 1992 Read Listen to Background newspaper redio characteristic weekly weekly Number MALES Age 20-24 47.2 77.7 277 25-29 37.9 72.5 205 30-34 43.6 79.5 168 35-39 49.4 81.2 143 40-44 34.1 69.2 160 45-49 35.0 68.5 95 50-54 26.4 65.9 102 Education No education 4.7 62.5 236 Primary 1-4 33.2 69.6 335 Primary 5-8 49.4 77.3 423 Secondary+ 86.8 95.5 157 Residence Urban 63.7 88.0 181 Rural 36.3 72.0 970 Region Northern 32.6 70.5 139 Cen~'al 32.1 67.7 443 Southern 49.2 80.8 569 Total 40.6 74.5 1151 FEMALES Age 15-19 25.6 58.4 1082 20-24 21.7 54.9 944 25-29 20.0 58.0 777 30-34 14.5 49.3 656 35-39 13.9 48.1 537 40-44 12.0 45.2 510 45-49 7.7 35.6 343 Education No education 0.7 37.4 2287 Primary 1-4 16.6 54.3 1192 Primary 5-8 43.8 72.1 1159 Secondary+ 81.9 92.8 212 Residence Urb~ 47.9 82.0 594 Rural 14.4 48.1 4255 Region Northern 26.8 55.9 578 Central 15.2 51.8 1872 Southern 19.0 51.7 2398 Total 18.5 52.3 4849 17 newspapers; only 5 percent of men and 1 percent of women without formal education reported reading the newspaper at least once a week. Yet over 80 percent of men and women who attended secondary school read the newspaper regularly. A similar, but less pronounced, relationship is observed between radio listening and education. In the interim before education is more nearly universal, important messages to the public will get widespread reception only through radio. Them are important geographic differences in media contact. Men and women in urban areas have vastly better use of newspapers and radios to receive information. This is especially true for women; for example, urban women am over three times more likely to read a newspaper weekly than women in rural areas. Of course, part of this association is due to differences in the educational level of rural and urban women. Women in the Northern Region have greater exposure to both printed media and radio messages than their counterparts in other regions. However, men in the Southern Region have greater access to radio and newspaper messages than men in the Northern and Central Regions. 18 CHAPTER 3 FERTILITY Measures of current and completed fertility presented in this chapter are based on the reported reproductive histories of women age 15-49 who were interviewed during the survey. Each woman was asked about the number of sons and daughters living with her, the number living elsewhere and the number who had died. She was then asked for a complete history of all of her live-born children, including month and year of birth, name, sex, and if dead, the age at death and if alive the current age and whether she/he was living with the respondent. Current fertility (age-specific and total fertility) and completed fertility (number of children ever born) are examined below, and then in connection with various background characteristics. 3.1 Current Fertility Levels and Trends The most widely used measures for cur- rent fertility are the total fertility rate and its component age-specific fertility rates. The total fertility rate is defined as the number of births a woman would have if she survived to age 50 and experienced the currently observed rates of age-specific fertility. To obtain the most recent estimate of fertility possible without compro- mising the statistical precision of estimates, the 3-year period immediately prior to the survey will be used. ~ For analysis of fertility trends, four-year rates will be used to avoid biases that could be introduced from birth date misreport- ing around the years 1986 and 1987 (Appendix C, Table C.4). Current total and age-specific fertility rates are presented in Table 3.1. If fertility were to remain constant at the current levels meas- ured in the MDHS (1-36 months before the sur- vey), a woman would bear an average of 6.7 children in her lifetime. This is lower than the rate of 7.6 estimated for the 1980-83 period from the 1984 Family Formation Survey (FFS), implying a decline of about 12 percent over the last decade. Figure 3.1 shows that much of the decline in total fertility between the two surveys occurred in the peak childbearing ages, 20-34 years. Table 3.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-rural residence for 1992 MDHS and 1984 Family Formation Survey (FFS). Malawi 1992 MDHS 1992 FFS Age group Urban Rural Total 1984 15-19 135 165 161 202 20-24 268 291 287 319 25-29 242 273 269 309 30-34 210 261 254 273 35-39 149 202 197 201 40-44 86 123 120 129 45-49 12 62 58 83 TFR 15-49 5.51 6.88 6.73 7.58 TFR 15-44 5.45 6.57 6.44 7.29 GFR 201 226 223 264 CBR 40.5 43.2 42.9 52.0 Note: MDHS rates are for the period 1-36 months preceding the survey, FFS rates are for the 4 years preceding the survey, Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate expressed as children per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1.000 woman CBR: Crude birth rate. expressed per 1,000 population 1Numerators of the age-specific fertility rates from the MDHS data in Table 3.1 are calculated by summing the number of live births that occurred in the period 1-36 months preceding the survey (determined by the date of interview and date of birth of the child), and classifying them by the age (in five-year groups) of the mother at the time of birth (determined by the mother's date of birth). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. 19 350 ASFR (110O0) Figure 3.1 Age-Specific Fertility Rates Malawi, 1984 FFS and 1992 MDHS 3OO 25O 20O 150 1 0O 5O 0 15-19 i i 25 29 30-34 Age Group of Women 45 49 MDHS 1992 ASFR (/1000) 350 30O 250 200 150, 0 Figure 3.2 Age-Specific Fertility Rates Urban and Rural Malawi 15 19 i 25 29 30 34 Age Group of Women 45 49 MDHS 1992 20 As expected, fertility among rural women is higher (6.9 children per woman) than among urban women (5.5 children per woman). Figure 3.2 shows that the urban-rural difference in total fertility is due to lower fertility in urban areas at all ages, but especially at age 30 years and above. Table 3.2 presents total fertility rates and completed fertility (average number of children ever born to women at the end of their childbearing period, age 45-49) by selected background characteristics. In addi- tion to the urban-rural difference, there exists notable variation in total fertility among the regions, ranging from 6.2 children per woman in the South, to 6.7 in the North, to 7.4 in the Centre. A woman's fertility is closely linked to her level of education. Women who have attended secondary school have 4.4 children compared to 7.2 for those without any education. The level of fertility among women with no education is about 0.5 children more than that among women with lower primary education, which is itself about 0.5 children more than that of women with higher primary education. Table 3.2 also allows a crude assessment ofdi fferential trends in fertility over time among population subgroups. The mean number of children ever bom to women age 45-49 years is a measure of fertility during the past. A comparison of current (total) fertility with past (completed) fertility shows that the largest differ- ences occur in urban areas and among women with more education, suggesting that these groups have experienced the largest recent decline in fertility. Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 45-49, by selected background characteristics, Malawi 1992 Mean number of children Total ever born Background fer til~ty to women characteristic rate age 45-49 Residence Urban 5.51 7.39 Rural 6.88 7.29 Region Northern 6.74 7.51 Central 7.44 8.09 Southern 6.17 6.55 Education No education 7.16 7.36 Primary 1-4 6.70 7.04 Primary 5-8 6.17 7.48 Secondary+ 4.37 * Total 6.73 7.30 IRate for women age 15-49 years * Based on less than 25 cases 21 More direct evidence of fertility decline is obtained by looking at changes in age-specific fertility rates across the three four-year calendar periods before the survey using data from the respondents' birth histories (Table 3.3). Within each age group of women, fertility has declined steadily over the 8-11 year period before the sur- vey to the 0-3 year period before the survey. Be- cause of truncated observation, fertility declines in the older age groups are difficult to ascertain with precision. Table 3.4 presents fertility rates forever- married women by duration since first marriage for four-year periods preceding the survey. Though the table is analogous to Table 3.3, it is confined to ever-married women and age is re- placed with duration since first marriage. Within Table 3.3 Age-specific fertility rates Age-specific fertility rates for four-year periods preceding the survey, by mother's age at the time of birth, Malawi 1992 Number of years preceding the survey Mother's age 0-3 4-7 8-11 12-15 15-19 159 180 193 201 20-24 285 302 319 339 25-29 264 292 323 329 30-34 252 253 287 285 35-39 190 228 [232] [270] 4044 121 [128] 45-49 [64] Note: Age-specific fertility rates are births pet 1,000 women- ye~s of exposure. Estimates enclosed in brackets ~e truncated. each marriage duration group, one observes a decline in fertility with increasing proximity to the survey date. These marriage duration-specific estimates of fertility confirm the decline in fertility, and that the decline has occurred within marriage. Table 3.4 Fertility by marital duration Fertility rates for ever-married women by duration since first marriage, in years, for four-year periods preceding the survey, Malawi 1992 Marriage Number of years preceding the survey duration at birth 0-3 4-7 8-11 12-15 0-4 333 351 364 376 5-9 286 308 338 348 10-14 256 281 296 314 15-19 235 225 260 259 20-24 143 190 [199] [231] 25-29 89 [99] Note: Duration-specific fertility rates are births per 1,000 women. Estimates enclosed in brackets are truncated. 3.2 Children Ever Born The distribution of women by number of children ever bom is presented in Table 3.5 for all women and for currently married women. The table also shows the mean number of children ever born (CEB) to women in each five-year age group. On average, women have given birth to three children by their late twenties, six children by their late thirties, and over seven children by the end of their childbearing years. Of the 7.3 children ever born to women 45-49, only 4.8 will have survived. 22 Table 3.5 Chi ldren ever born and living Percent distribution of all women and of currently married women age 15-49 by number of chi ldren ever born (CEB) and mean number ever born and living, according to five-year age groups, Malawi 1992 Number of children ever bona (CEB) Number Mean no. Mean no. Age of of of living group 0 1 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN Age 15-19 72.7 21.1 5.1 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1082 0.34 0.27 20-24 19.4 27.3 28.7 16.7 6.3 1.0 0.5 0.2 0.0 0.0 0.0 100.0 944 1.69 1.31 25-29 6.1 10.9 14.6 22.5 24.0 14.3 5.2 2.3 0.1 0.0 0.0 100.0 777 3.23 2.47 30-34 2.7 4.5 7.9 l l . l 14.3 17.5 19.8 12.1 7.0 2.9 0.3 100.0 656 4.87 3.68 35-39 2.7 2.9 4.6 8.8 9.9 13.8 13.0 15.6 14.1 7.2 7.3 10(3.0 537 5.90 4.39 40~14 1.8 2.6 3.8 4.4 6.7 9.6 13.7 15.2 12.1 9.5 20.6 100.0 510 6.93 4.92 45-49 1.1 2.3 5.2 5.6 6.1 7.2 10.1 10.9 12.3 14.0 25.1 100.0 343 7.30 4.80 Total 21.9 13.1 11.4 10.4 9.2 7.9 7.2 6.1 4.7 3.2 4.8 100.0 4849 3.48 2.55 CURRENTLY MARRIED WOMEN Age 15-19 43.0 41.5 13.0 2.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 I00.0 388 0.75 0.58 20-24 13.8 26.1 32.0 18.5 7.7 1.1 0.6 0.2 0.0 0.0 0.0 100.0 743 1.87 1.44 25-29 4.3 10.1 12.9 24.1 25.7 15.1 5.3 2.5 0.1 0.0 0.0 100.0 661 3.36 2.61 30-34 2.5 4.0 7.8 9.8 14.7 18.1 20.4 11.9 7.3 3.3 0.3 100.0 584 4.95 3.73 35-39 2.7 2.4 5.1 8.4 9.1 12.9 12.6 15.7 15.6 7.9 7.7 100.0 455 6.01 4.47 40~14 1.8 2.9 4.4 4.8 5.1 S.l 15.1 14.8 11.1 9.2 22.8 100.0 408 7.01 4.98 4549 1.5 1.4 4.6 3.8 5.4 Z7 8.8 10.4 10.7 16.0 29.7 lt~O.O 253 7.69 5.06 Total 9.6 13.5 13.5 12.4 11.1 9.3 8.6 7.0 5.3 3.8 5.9 100.0 3492 4.10 3.02 The distribution of women by number of births indicates that over one-quarter of women age 15-19 have already borne at least one child, and that one-quarter of women age 45-49 have borne ten or more children. The results for younger women who are currently married differ from those for the sample as a whole because of the large number of young unmarried women with minimal fertility. Differences at older ages, though minimal, generally reflect the impact of marital dissolution (either divorce or widowhood). Since desire for children is nearly universal in Malawi, the proportion of married women at 45-49 years who arc childless is a rough measure of primary infertility, or the inability to bear children. The MDHS results suggest that primary infertility is low, with ordy 1.5 percent of Malawian women unable to bear children. It should be emphasised that this estimate of primary infertility does not include women who may have had one or more births but who are unable to have more (secondary infertility). 3.3 Birth Intervals Research has shown that children born too soon after a previous birth are at increased risk of dying, particularly when the interval between births is less than 24 months, Table 3.6 shows the percent distribution of births in the five years before the survey by the number of months since the previous birth. More than one of every five births in Malawi occurs less than two years after the birth of the previous child. The overall median birth interval length is 32.7 months. 23 Table 3.6 Birth intervals Percent distribution of births in the five ye~s preceding the survey by number of months since previous birth, according to demographic and socioeconomic charact~istics, Malawi 1992 Number of months since previous birth Characteristic 7-17 18-23 24-35 36~,7 48+ Median number of Number months since of Total previous birth births Age of meth~r 15-19 26.5 23.1 34.1 12.5 3.9 100.0 24,2 78 20-29 8.8 15.6 43.8 18.0 13.8 100.0 30.7 1692 30-39 6.4 10.9 37.2 23.5 22.0 10O.0 34.6 1406 40+ 7.9 8.1 33.1 21.3 29.6 100.0 36.5 563 Birth erder 2-3 8.9 15.3 40.3 18.5 16.9 100.0 31.6 1360 4-6 7.1 12.0 39.4 22.1 19.3 100.0 33.4 1429 7+ 8.5 10.6 38.5 20.7 21.7 100.0 33.4 949 Sex of prier blrtlz Male 7.7 13.3 39.0 20.8 19.2 100.0 33.0 1875 Female 8.6 12.4 40.0 20.1 18.9 100.0 32.4 1864 Survival of prier birth Living 4.5 10.5 42.1 22.8 20.1 100.0 34.0 2861 Dc, ed 19.9 20.6 31.0 12.8 15.6 100.0 26.7 878 Residence Urban 9.7 12.7 37.9 19.8 19.8 100.0 32.1 404 Rural 7.9 12.9 39.7 20.5 19.0 100.0 32.8 3335 Region Northern 6.3 10.3 41.2 24.7 17.4 100.0 33.8 427 Central 9.5 14.5 38.6 18.7 18.6 100.0 31.2 1591 Southern 7.3 11.9 39.9 21.0 19.8 100.0 33.2 1720 FAItwatUoa No education 7.3 12.8 38.2 18.9 22.8 100.0 33.2 2005 Prima~ 1-4 10.4 13.2 40.3 22.3 13.8 100.0 31.7 863 Primary 5-8 8.0 11.8 43.0 22.8 14.4 100.0 32.2 774 Secondary+ 6.2 19.5 31.5 18.0 24.8 10O.0 34.8 97 Total 8.1 12.9 39.5 20.5 19.1 100.0 32.7 3739 Note: First-order lirthi are excluded. In Malawi, birth intervals tend to be shorter when the mother is young and at lower birth orders (second and third births). The median birth interval length is 7 months shorter when the previous child died than when the previous child survived. Whereas only 15 percent of children whose previous siblings were still alive were born after less than 24 months, 41 percent of children whose previous sibling was dead were born after less than 24 months. This is due to behavioural and biological mechanisms that operate to rapidly "replace" deceased children. 24 Although birth spacing varies little by urban-rural residence, regional differences do emerge in the MDHS data. On average, birth intervals in the Central Region are 2 months shorter than in the Southern region and 2.5 months shorter than in the Northern Region. Further, 24 percent of births follow a short interval in the Central Region versus 19 percent in the Southern and 17 percent in the Nor, hem Regions. Not coincidentally, this characteristic oftbe Central Region is consistent with its relatively lower level of fertility regulation (Chapter 4) and higher level of childhood mortality (Chapter 7). The relationship between birth interval length and maternal education follows a U-shaped pattern, with the longest interval length associated with both no education and higher education. The shortest intervals occur when the mother has had only some primary education. 3.4 Age of the Mother at First Birth The age at which women start childbearing is an important demographic and social indicator in society. Early childbearing generally leads to a large family size if not coupled with contraception, and is associated with increased health risks for the mother. It also tends to diminish a woman's educational and employment opportunities. A rise in the age at first birth is usually a reflection of a rise in the age at first marriage (see Chapter 6) and in many countries has contributed greatly to overall fertility decline. Table 3.7 presents the distribution of women 15-49 by age at first birth. Two pattems are evident in the data. First, there is fairly clear evidence of a displacement of first births of older women from a period further to a period closer to the survey date, the result of which is that an implausibly large percentage of older women appear to have had their first birth at 25 years or older. This, of course, inflates the median age at first birth. This problem apparently is focused on women 35 years and older. Second, among women currently under 35 years of age, there is clear evidence of an increase in the average age at first birth, from 18.3 years to 18.9 years over the last decade or so. In support of this, the percentage of births that occurred at a very young age (< 15 years) have decreased considerably from about 11 percent among women currently age 30-34 to 3 percent among women now age 15-19. Table 3.7 Age at first birth Percent distribution of women age 15-49 by age at first bkth, according to current age, Malawi 1992 Current age Women Median with Age at first birth Number age at no of first births <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 72.7 3.0 17.3 7.0 NA NA NA 100.0 1082 a 20-24 19.4 8.9 28.6 25.8 13.9 3.4 NA 100.0 944 18.9 25-29 6.1 9.3 31.2 25.3 16.4 9.5 2.3 100.0 777 18.7 30-34 2.7 10.8 34.5 25.0 13.0 8.6 5.5 100.0 656 18.3 35-39 2.7 9.7 24.0 26.0 14.4 11.7 11.6 100.0 537 19.3 40~M 1.8 10.7 23.3 22,6 13.8 15.1 12.8 100.0 510 19.4 45-49 1.1 7.6 22.5 16.7 12.4 21,7 18.0 100,0 343 20,5 NA = Not applicable aLess than 50 percx, nt of the women in the age group x to x+4 have had a birth by age 25 Table 3.8 shows the median age at first birth by background characteristics of the woman. There is very little variation in the median age at first birth between women by urban-rural residence or by region. Age at first birth does, however, varies significantly with a woman's level of education, from about 19 years for women with no education or primary education to 21 years among women with secondary education or higher. Table 3.8 Median age at first birth Median age at first birth among women age 20-49 years, by current age and selected background characteristics, Malawi 1992 Current age Background Ages Ages charactezisdc 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 Residence Urban 19.4 19.5 19.0 18.9 19.1 19.2 19.2" 19.2 Rural 18.8 18.6 18.2 19.3 19.5 20.7 18.9 18.9 Region Northern 19.0 18.9 18.5 18.9 19.1 18.8 18.9 18.8 Central 19.3 19.1 18.5 19.4 18.8 20.4 19.1 19.1 Southern 18.5 18.3 18.2 19.2 20.0 21.1 18.8 18.9 Education No education 18.3 18.0 18.0 19.6 19.8 21.2 18.8 18.9 Primary 1-4 18.8 18.8 18.1 18.6 18.8 20.7 18.8 18.8 Primary 5-8 19.1 19.2 18.8 18.5 19.3 (18.5) 19.0 18.9 Secondary+ a 22.8 (20.8) (20.7) (19.9) 21.4" a 21.4 Total 18.9 18.7 18.3 19.3 19.4 20.5 18.9 19.0 Note: The medians for cohort 15-19 could not be determined because half the women have not yet had a birth. aMedians were not calculated for these cohorts because less than 50 percent of women in the age group x to x+4 have had a birth by age x. ( ) Based on 25-49 cases * B~ad on less than 25 cases 3.5 Adolescent Fertility The issue of adolescent fertility is an important one on both health and social grounds. Children born to adolescent mothers are at increased risk of sickness and death. The young mothers themselves are more likely to experience adverse pregnancy outcomes and, in any case, are less able to pursue educational opportunities than their counterparts who delay childbearing. Table 3.9 shows the percentage of adolescents (under age 20) who are mothers or pregnant with their first child, by background characteristics. Among women under 20, over one-third have already entered the family formation pathway--and most are already mothers of at least one child. Motherhood increases sharply between ages 15 (6 percent) and 19 (55 percent). Two-thirds of 19-year-olds have either had a child or are pregnant with their first (Figure 3.3). 26 Table 3.9 Adolescent pregnancy and motherhood Percentage of adolescents (age 15-19) who are mothers or pregnant with their first child, by selected background characteristics, Malawi 1992 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of charactaristic Mothers child bearing adolescents Age 15 5.7 3.2 8.9 205 16 11.5 4.6 16.1 222 17 22.1 9.1 31.2 214 18 41.3 10.0 51.3 235 19 55.2 10.0 65.1 205 Residence Urban 23.4 5.2 28.6 127 Rural 27,8 7.7 35.5 956 Region Northern 18.9 8.6 27.5 148 Central 23.2 10.4 33.6 402 Southern 32.6 4.8 37.4 533 Education No education 36,0 6,8 42.8 313 Primary I-4 29.2 9.3 38.5 355 Primary 5-8 19.0 7.0 26.0 365 Secondary+ 18.6 1.0 19.6 49 Total 27.3 7.4 34.7 1082 Figure 3,3 Percentage of Adolescents (age 15-1 9) Who Have Begun Childbearing, by Age Percentage 7O 6O 50 4O 3O 2O 10 0 15 16 17 18 Age (years) 19 MDHS 1992 27 In rural areas, 36 percent of adolescents have begun childbearing as compared to 29 percent in urban areas. Regional differences also exist--37 percent of adolescents in the South are either mothers or are pregnant with their first child versus 34 percent in the Centre and 28 percent in the North. A strong link between a woman's education and early childbearing is evidenced here. Although 43 percent of adolescents (15-19 years) without any education have started childbearing, only 20 percent of those with some secondary education have done so. Table 3.10 shows the distribution of adolescents by number of children ever born. The MDHS shows that 21 percent of adolescents have had one child and 6 percent have had at least two children. About 18 percent of women age 19 years have had at least two children. The mean number of children ever born (CEB) to women 15-19 is 0.34. Table 3.10 Children ever born to adolescents Percent distribution of adolescents (age 15-19) by number of children ever born (CEB), Malawi 1992 Age 0 1 2+ Number of Mean children ever born number Number of of Total CEB adolescents 15 94.3 5.0 0.8 100.0 0.06 205 16 88.5 10.5 1.0 100.0 0.12 222 17 77.9 19.5 2.6 100.0 0.25 214 18 58.7 32.3 9.0 100.0 0.52 235 19 44.8 37.7 17.5 100.0 0.76 205 Total 72.7 21.1 6.1 100.0 0.34 1082 28 CHAPTER 4 FERTILITY REGULATION 4.1 Knowledge of Contraception Acquiring knowledge about fertility control is an important step to- wards gaining access to and then using a suitable method in a timely and effec- tive manner. Information about knowl- edge of contraceptive methods was col- lected by asking the respondent to name ways or methods by which a cou- ple could delay or avoid pregnancy. If the respondent failed to mention a par- ticular method spontaneously, the inter- viewer described the method and asked if she/he recognised it. Seven modem methods--the pill, IUCD, injection, vaginal methods (foaming tablets, jelly, sponge and diaphragm), condoms, fe- male sterilisation and male sterilisa- tiorv--were described, as well as two traditional methods--natural family planning (periodic abstinence or the rhythm method) and withdrawal. Any other methods mentioned by the re- spondent, such as herbs, strings or breastfeeding, were also recorded. For each method recognised, the respond- ent was asked if she/he knew where a person could go to get the method. If the respondent reported knowing about natural family planning, she/he was asked where a person could obtain the advice on how to use the method. Table 4.1 indicates that nine of ten women age 15-49 years know at least one method of family planning. Knowledge of methods is slightly high- er among currently married women than among all women. Since it is cur- rently married women who are at great- est risk of pregnancy, they are the pri- mary focus of this chapter. Table 4.1 Knowledge of comraceptive methods and source for methods Percentage of all women and men and currently married women and men who know specific contraceptive methods and who know a source (for services), by specific methods, Malawi 1992 Know method Know a source Currently Currently All married All married Contraceptive women/ women/ women/ women/ method men men men men FEMALES Any method 90.4 94.6 80.1 85.1 Any modern method 87.7 91.8 78.5 83.3 Modern method Pill 76.4 82.9 66.5 72.8 IUCD 41.5 46.3 35.3 39.6 Injection 61.6 68.3 54.8 61.1 Diaphragm/Foam/Jelly 42.6 47.8 35.5 39.9 Condom 70.1 73.2 58.6 61.9 Female sterilisation 58.0 63.1 48.9 53.5 Male sterilisation 17.3 18.8 14.0 15.3 Any traditional method 69.3 76.5 32.3 36.8 Natural method 43.9 49.1 32.3 36.8 Withdrawal 41.1 46.4 NA NA Other 46.0 52.0 NA NA Number of women 4849 3492 4849 3492 MALES Any method 95.8 97.3 85.6 86.8 Any modern method 93.7 94.6 84.0 85.1 Modern method Pill 70.0 72.1 56.0 58.6 IUCD 42.0 43.6 31.0 32.1 Injection 55.7 59.0 48.9 51.5 Diaphragm/Foam/Jelly 44.6 45.6 31.9 32.9 Condom 88.8 89.7 73.6 74.7 Female sterilisation 63.6 66.2 55.4 57.9 Male sterilisation 28.0 27.7 24.3 24 5 Any traditional method 78.7 80.7 45.6 46.7 Natural method 61.5 62.7 45.6 46.7 Withdrawal 54.1 55.7 NA NA Other 33.5 37.6 NA NA Number of men 1151 866 I 151 866 NA = Not applicable 29 A high proportion of married women reported knowing a modem method (92 percent) and 77 percent of them have some knowledge about a traditional method. The most widely known methods among married women are the pill (83 percen0, the condom (73 percent), injections (68 percent) and female sterilisation (63 percent) (Figure 4.1). Women are relatively unfamiliar with male sterilisation; only 19 percent said they knew of the method. Regarding traditional methods, about half of married women said they knew of natural family planning, withdrawal, and other traditional methods. Most of the other traditional methods cited by women were medicinal strings and herbal preparations of various types. Figure 4.1 Percentage of Currently Married Women Who Know Specific Contraceptive Methods Pill ,JI [ ] ~ 46 r' I, , 'li ir ~ 6~ L] dkih[,) I 'h'~carr/x,', I f ~ 48 Oir,J< m/" ii __~ . . , , .'' i i-i:" . " /'3 I rru /I,. _,'(/rlllC ~tl< ' 3 ~ (}3 k,1,~l,' :tr~ 'lilt ~'i, ,p ~ 19 \<:{,r<ll M < l h , , , l ~ 49 f, Ir!/i J' .+'/ .I ~ ~ 46 0 20 40 (lC 83 e]f; 1 (,) F~ rl f:r I P . I 1J.~ Knowledge of fertility regulation was also very high among men; 96 percent of all men and 97 percent of all married men knew of some method of family planning. Nearly all men who knew of a method knew of at least one modem method of contraception. Knowledge of specific family planning methods among men follows a pattem similar to that observed among women. Looking at modem methods, condoms and sterihsation are slightly better known by men than women; the other methods are better known by women. Regarding traditional methods, men reported knowing of natural family planning and withdrawal more commonly than women, but women tended to be more familiar with other traditional methods (i.e., strings and herbal preparations). Knowledge of sources for obtaining family planning methods is widespread in Malawi. Eighty-three percent of currently married women and 85 percent of currently married men knew of a source for obtaining a modem method of contraception. Women responded more commonly than men that they knew where to obtain pills, the IUCD, injections, and barrier methods, whereas men reported more frequently than women that they knew a source of condoms and sterilisation services. 30 Table 4.2 shows that women in their 20s and 30s are more likely to know of at least one method, at least one modem method, and a source to obtain a modem method than adolescent women and women age 40 years or older. In the same way, men between 25 and 39 years tend to be more familiar with meth- otls and method sources than young- er and older men. In particular, knowledge of a source of modem contraception goes down sharply with increasing age of men. As ex- pected, men and women living in ur- ban areas are more likely to know of family planning methods and to know where to obtain them than their rural counterparts. Regional differences in contraceptive knowl- edge are negligible. Formal education is related to a person's knowledge of contra- ception. About one-quarter of both men and women without any educa- tion do not know of a source of mod- em contraception, whereas source knowledge is nearly universal among men and women with at least some secondary eduction. 4.2 Ever Use of Contraception All women and men who said that they had heard era method of family planning were asked if they had ever used it. Forty-one per- cent of currently married women and 57 percent of men have used a meth- od of family planning at some time in the past (Table 4.3). Ever-use of modem methods was reported by 19 percent of women and 30 percent of men. The difference between male and female ever-use of modem con- traception is explained by far greater condom use among men. Table 4.2 Knowledge of modem contraceptive methods and source for methods Percentage of cuxrently married women and men who know at least one modem contraceptive method mad who know a source (for services), by selected background characteristics, Malawi 1992 Know a Number Know Know source for of Background any a modem modem women/ characteristic method method 1 method men FEMALES Age 15-19 88,0 84.2 72.5 388 20-24 95.9 94.2 86.3 743 25-29 96.7 95.1 89.8 661 30-34 96.3 93.8 87.5 584 35-39 95.4 93.4 83.2 455 40-44 93.2 88.3 77.2 408 45-49 91.7 86.3 74,6 253 Residence Urban 97.2 96.3 91.4 411 Rural 94.2 91.2 82.2 3081 Region Northern 93.7 89.6 80.8 430 Central 94.3 92.3 84.8 1402 Southern 95.0 92.0 82.7 1660 Education No education 92.2 88.2 77.3 1815 Primary I-4 95.4 93.7 85.5 819 Primary 5-8 98.5 97.5 93.3 750 Second~y+ 99.6 99.6 98.9 107 Total 94.6 91.8 83.3 3492 MALES Age 20-24 97.0 94.9 83.6 100 25-29 99.1 99.1 91.7 163 30-34 98.0 97.0 91.0 147 35-39 96.5 94.9 86.8 129 40-44 95.8 92.2 84.7 147 45-49 95.6 91.7 79.1 83 50-54 98.3 89.2 69.4 95 Residence Urban 98.9 98.7 90.4 126 Rural 97.0 93.9 84.2 739 Region Northern Central Southern Education No education 95.7 90.I 74.8 183 Primary 1-4 95.8 91.5 78.3 255 Primary 5-8 98.6 98.0 92,5 330 Secondary+ 100.0 100.0 97.1 97 Total 97.3 94.6 85,1 866 1Includes pill, IUCD, injection, vaginal methods (foaming tablets/diaphragm/ foam/jelly), condom, female sterilisation, and male sterilisation. 99.5 97.3 88.0 99 95.3 94.0 85.6 347 98.5 94.6 83.9 419 31 Table 4.3 Ever use of contraception Percentage of currently marr ied women and men who have ever used any contraceptive method, by specific method and age, Malawi 1992 Any naa- l'emale Male Number modem In phragm/ sten sten Any Natural of Any meth- jec- Foam/ hsa- hsa- trad meth- With women/ Age method od Pill IUCD tion Jelly Condom uon tion method od drawal Other men CURRENTLY MARRIED WOMEN 15-19 24.2 12.1 3.8 0.4 2 1 0.8 7,3 0.0 0.5 17 1 11 I 8,5 5.4 388 20-24 38.6 18.3 7.5 0.5 1.9 0.8 122 0.0 I).2 29.0 174 12.4 8.0 743 25-29 444 23.0 12.1 1.7 3.0 1.3 10,0 1.2 0.0 32.3 19.8 15.3 12.2 661 30-34 47.0 21.2 10.5 2.1 4.0 1.2 8.7 25 06 39.1 21.6 16.9 13.7 584 35-39 46.5 22.8 10.8 2 2 7.5 1.3 8.4 3.2 0.0 35.5 17.3 14.8 16.7 455 40-44 43.5 17.5 6.0 1.1 8.3 1 3 4.2 3 8 0.8 32.3 16.3 15 3 12 3 408 45-49 31.4 12.4 5.7 07 7.6 0,3 2.2 2.4 0.0 264 11 9 11,4 12.7 253 Total 40.6 191 8,6 1.3 4.4 1.0 85 1.7 113 31.1 173 13.9 114 3492 CURRIINTLY MARRII'D MEN 20-24 50.4 30.3 8.5 0.2 1.0 1.7 26.8 07 0.0 33.8 27 1 122 3 2 100 25-29 55.4 33.3 9.1 0.9 2.1 1 2 27.6 0.0 0.0 40.1 260 24.4 7.2 163 30-34 64.9 42.3 9 4 3.4 3.2 0.0 32 8 1.0 0.3 43.7 32 2 23 3 9,0 147 35-39 66.7 35.7 12.3 1.1 3 8 0.4 25.8 1.3 oo 498 27.6 33.4 16.8 129 40-44 55.2 226 8.0 1.3 6.0 0.5 15.6 2.3 0.0 42.2 34.0 18.7 12.3 147 45-49 57.0 23.8 7.6 2.9 8.3 0 8 111.0 5.4 0.9 45.2 33.4 24.1 12.2 83 50-54 45.0 18.3 9.1 1 6 10.6 0.7 6.6 2 0 0.7 42.1 311.7 16 4 15 2 95 Total 57.1 30.4 9.2 1,6 4.6 07 22 1 1 6 0.2 425 300 223 m,7 866 Ever-use of modem contraception peaks during ages 25-29 for women and during ages 30-34 for men. The most commonly reported modem methods ever used by women arc the pill (9 percent) and condom (9 percent) followed by injections (4 percent) and female sterilisation (2 percent). The mcthod-specific pattern reported by men follows a pattern very similar to women, except that condoms arc much more commonly reported by men (22 percent) than women. The age pattern of ever-use varies by the method used. Ever-use of injections and sterilisation increase steeply while condom use tends to decrease with increasing age. Ever-use of the pill is highest at ages 25-29 for married women and 35-39 for married men. 4.3 Current Use of Contraception Although 90 percent of married women in Malawi have heard of and 41 percent have ever used a family planning method, only 13 percent reported that they were currently using a method at the time of the survey (Table 4.4). Only 7 percent of married women arc using modem methods, whereas 6 percent are using traditional methods. The most popular modem methods are the pill, female sterilisation, condoms, and injections, each used by about 2 percent of women. Natural family planning is the most commonly used traditional method (2 percent). 32 Table 4.4 Current method use Percent disu'ibution of currently married women and men and all women and men by contraceptive method currently used, according to age, Malawi 1992 Any Dia- Female Male Number modem In phragm/ *teri- steri- Any Natural Not of Any meth- jec- Foam/ liza- lisa- trad. meth- With- currently women/ Age method od pill IUCD tion JeUy Condom tion tion method od drawal Other using To~al men CURRENTLY MARRIED WOMEN 15-19 7.3 3.4 0.9 0.0 0.5 0.0 2.0 0.0 0.0 3.9 1.4 0.4 2.1 92.7 I00.0 388 20-24 12,0 5.3 2.2 0,0 0.2 0.0 2,9 0.0 0,0 6.6 2.9 1.8 2.0 88.0 100.0 743 25-29 14.8 8.4 3.9 0.7 0.9 0.0 1.8 1.2 0.0 6.4 2.6 2.3 1.5 85.2 100.0 661 30-34 16.2 8.2 2.3 0.5 1.3 0.2 1.2 2.5 0.3 8.0 2.9 2.4 2.8 83.8 100.0 584 35-39 16.4 11.3 2.0 0.6 3.2 0.3 1.9 3.2 0.0 5.2 1.2 1.4 2.5 83.6 100.0 455 40-44 13.2 9.3 1.3 0.0 3.9 0.4 0.0 3,8 0.0 3.9 2.2 0.0 1.6 86.8 100.0 408 4549 6.4 4.6 0.6 0.0 L6 0.0 0.0 2.4 0.0 1.8 0,8 0.4 0,7 93.6 100.0 253 Total 13.0 7.4 2.2 0.3 1.5 0.1 1.6 1.7 0.0 5.6 2.2 1.5 2.0 87.0 10(3.0 3492 CURRENTLY MARRIED MEN 20-24 15.9 9.3 0.7 0.0 0.5 0.2 7.8 0.2 0.0 6.6 6.6 0.0 0.0 84.1 1(](3.0 100 25-29 23.4 13.5 2.8 0.0 0.0 0.0 10.7 0.0 0.0 9.9 7.7 1.3 0.9 76.6 1130.0 163 30-34 27.0 15.8 3.4 0.5 1.5 0.0 9.1 1.0 0.3 II.2 6.9 2.1 2.2 73.0 I00.0 147 35-39 33.2 14.3 4.6 0.0 0.8 0.0 7.7 1.2 0.0 19.0 8.2 5.1 5.6 66.8 I00.0 129 40-44 26.2 10.9 4.1 0.3 2.4 0.0 2.2 1.9 0.0 15.2 9.6 0.8 4.9 73.8 100.0 147 45-49 31.8 16.2 1.5 1.5 5.3 0.2 2.4 4.6 0.9 15.5 9.5 3.2 2.8 68.2 I00.0 83 50-54 15.9 5.3 2.5 1.6 0.0 0.0 0.5 0.0 0.7 10.6 7.0 3.6 0.0 84.1 10(3.0 95 Total 25.1 12.5 3.0 0.5 1.3 0.0 6.3 1.1 0.2 12.6 7.9 2.2 2.5 74.9 100.0 866 ALL WOMEN 15-19 3.5 1.8 0.5 0.0 0.3 0.0 1.0 0.0 0.0 1.7 0.6 0.1 0.9 96.5 100.0 1082 20-24 II.I 5.8 2.4 0.0 0.3 0.0 2.9 0.2 0.0 5.3 2.4 1.4 1.6 88.9 100.O 944 25-29 13.5 8.0 3.7 0.6 O.7 0.0 1.8 1.2 0.0 5.5 2.3 1.9 1.3 86.5 100.0 777 30-34 15.5 8.3 2.2 0.6 1.2 0.I 1.2 2.8 0.2 7.1 2.6 2.1 2.5 84.5 I00.0 656 35-39 15.3 10.1 1.9 0.5 3.0 0.3 1.6 2,7 0.0 5.2 1.3 1.2 2.7 84.7 100.0 537 40-44 11.5 8.4 1.3 0.0 3.1 0.3 0.0 33 0.0 3.1 1.8 0.0 1.3 88.5 100.0 510 4549 6.1 4.8 0.4 0.5 1.6 0.0 0.0 2.3 0.0 1.4 0.6 0.3 0.5 93.9 100.0 343 Total 10.5 6.3 1.8 0.3 1.2 0.I 1.4 1.5 0.0 4.3 1.7 1.1 1.5 89.5 100.0 4849 ALL MEN 20-24 ]4.8 H.5 0.9 0.0 0.2 0.1 10.3 0,I 0.0 3.3 3.3 0.0 0.0 85.2 ]00.0 277 25-29 23.0 12.6 2.5 0.0 0.0 0.0 10.1 0,0 0.0 10.4 8.6 1.0 0.7 77.0 100.0 205 30-34 26.3 16.5 3.3 0.4 1.3 0.0 10.3 0.9 0.3 9.8 6.0 1.8 2.0 73.7 100.0 168 35-39 30.0 12.9 4.2 0.0 0.7 0.0 6.9 1.0 0.0 17.1 7.4 4.7 5.1 70.0 100.0 143 40-44 24.0 10.1 3.8 0.3 2.2 0.0 2.0 1.8 0.0 14.0 8.8 0.7 4.5 76.0 100.0 160 4549 27.9 14.3 1.3 1.3 4.6 0.2 2.1 4,0 0.7 13.7 8.4 2.8 2.5 72.1 100.0 95 50-54 14.8 4.9 2.3 1.5 0.0 0.0 0.5 0,0 0.7 9.8 6.5 3.4 0.0 85.2 IO0.0 102 Total 22.2 12.0 2.5 0.3 1.0 0.0 7.2 0,9 0.2 10.2 6.6 1.7 1.9 77.8 100.0 1151 33 Reported current use among married men (25 percent) is higher than among married women (13 percent), largely because of much higher reported use of condoms (6 percent) and of natural family planning (8 percent). Otherwise, the method-specific pattern of use for men follows closely that observed for women. Contraceptive use is highest among married women age 35-39 and lowest among women age 15-19 and 45-49 years. Lower use among younger women is related to having just begun childbearing and thus having fewer than their desired number of children. For the same reason, younger women who do use family planning tend to use less effective methods such as withdrawal or temporary methods such as the condom, whereas older women are more likely to use more effective, long-term methods such as female sterilisation. About three percent of married women age 35 years or older have been sterilised. Use among the oldest women (i.e., 45-49) may be lower because they perceive themselves as unable to have more children and thus not in need of family planning. Among married men, current use of contraception is highest during ages 35-39 and lowest during ages 20-24 and 50-54. As among women, condom use is more frequent at younger ages, while more effective, longer-term methods such as sterilisation and injections are more commonly used at older ages. 4.4 Di f ferent ia ls in Cur rent Use of Fami ly P lann ing While overall use of family planning is quite low, the data indicate that some married women and men are more likely to be using contraception than others. Table 4.5 and Figure 4.2 show the percentages of currently married women and men using specific methods by background characteristics. The use of family planning increases with increasing parity of the woman, suggesting that demand for methods to space or limit births increases as a woman reaches her desired number of children. This pattern is especially pronounced regarding modem method use, presumably because modem methods are recognised by couples to be more effective in achieving their desired family size. Large differences are observed between urban and rural women in the current use of any method of family planning (23 percent in urban areas and 12 percent in rural areas). The difference is explained wholly by the much higher use of modem methods by urban women; current use of traditional methods varies little between urban and rural women. The largest urban-rural differentials occur regarding female sterilisation, the IUCD, and the pill. The most commonly used methods in rural areas are natural family planning and other traditional methods, whereas pills and female sterilisation are the most popular methods among urban women. Regional differences in use of modem contraception are negligible. However, traditional methods are more commonly practiced in the Northern Region. Interestingly, this pattern of relatively higher use of traditional methods in the North is explained by the much more common practice of withdrawal among couples in that Region. This finding is supported by an even more pronounced difference reported by males. Use of contraception, especially use of modem methods, is also related to a persons's level of education. Use of a modem method was reported by 5 percent of married women without schooling, 6 percent of women with 1-4 years of primary school, 11 percent of women with 5-8 years of primary school, and 38 percent of women with at least some secondary schooling. A very similar pattern of results was obtained when looking at information obtained from males. 34 Table 4.5 Current method use by background characteristics Percem distribution of currently married women and men by contraceptive method currently used, according to background characteristics, Malawi 1992 Any Dia- Female Male Number Background modem In phragnd steri- steri- Any Natural Not of characlet- Any meth- jec- Foam/ lisa- lisa- trad. meth- With- currently women/ is~c method od Pill JUCD lion Jelly Condom ticn tion melhod cd drawal Other using Tc4al men CURRENTLy MARRIED WOMEN Residence Urban 22.9 17,2 5.7 1,3 2,2 0.3 2.9 4.9 0,0 5.6 2.1 0.8 2.7 77,1 100,0 411 Rural 11.7 6.0 1,7 0,1 1.4 0.1 1.5 1.2 0.1 5,6 2,2 1.5 1.9 88.3 100,0 3081 Region Northern 17.9 6.9 1.1 0.0 0.7 0.0 3.9 1,1 0.0 11.0 2.5 7.2 1.3 82.1 100.0 430 Central 13,1 8.2 2.4 0.2 2,6 0.1 1.3 1.6 0.0 4.8 2.6 0.5 1,8 86.9 100.0 1402 Sc~athern 11.7 6.8 2,2 0,4 0,7 0.2 1.3 1.8 0,1 4.9 1,8 0.8 2,3 88.3 |00.0 1660 EducaUoh No education 10.0 4.8 1.3 0.0 1.4 0.1 0.6 1.4 0.0 5.2 2.0 1,2 2.0 90.0 100.0 1815 Primary I-4 11.1 6.0 1,6 0,0 1,6 0.0 1.7 1,1 0.0 5,1 2.3 1.0 1.8 88.9 100.0 819 Primary 5-8 18.0 10.6 3.4 0.6 1,3 0.1 3.3 1.9 0.0 7.4 2.6 2.6 2,2 82.0 100.0 750 Secondary+ 43.0 37.9 11.4 5.4 3.0 1,9 5.7 9.0 1,5 5.1 2.4 1.7 1.1 57.0 100.0 107 No, of living children None 3.0 1,6 0,1 0.0 0.0 0.0 1.1 0,3 0.0 1.5 0,5 0.4 0.6 97.0 100.0 464 1 10,9 5.3 1,9 0.3 0,2 0.0 2.3 0,6 0,0 5.6 2.5 1.3 1.9 89.1 100.0 6~0 2 11.4 6,3 2.1 0.2 0.9 0.0 2.4 0.7 0.0 5.1 1,5 1.1 2.5 88,6 100.0 615 3 14.9 7.8 2.5 0.4 0.8 0,0 1,6 2.0 0.3 7.1 3,6 1.8 1.7 85.1 100.0 494 4+ 17.5 10.7 2.9 0.4 3.0 0.3 1.1 2,9 0,O 6.8 2,5 2.0 2.4 82.5 100.0 1319 Total 13.0 7.4 2.2 0.3 1.5 0.1 1.6 1.7 0.0 5.6 2,2 1.5 2.0 87.0 100.0 3492 CURRENTLY MARRIED MEN R~dence Urban 38.9 23.8 7,6 1.9 3.3 0.3 8.0 1.3 1.5 15.0 9.4 2,3 3.3 61.1 100.0 126 Rural 22.7 10.5 2.2 0.2 1.0 0.0 6.0 1.1 0.0 12.2 7.7 2.2 2.3 77.3 100.0 739 Reglon Northern 31.6 12.0 2.3 0.0 0.2 0.4 8.3 0.9 0.0 19.6 8.1 11.1 0.4 68.4 I00.0 99 Central 28.8 13.0 2.3 0,7 2,9 0,0 5.5 1.4 0.1 15,8 11.7 1.7 2,4 71.2 100.0 347 Soutbem 20.4 12.1 3.7 0.3 0.3 0.0 6.5 1.0 0.3 8.3 4.8 0.5 3.0 79.6 100.0 419 Educatlott No education 15.1 5.1 0.0 0.0 1.9 0.0 1.7 0.8 0.7 10.0 6.8 1.5 1.7 84.9 100.0 183 Primary 1-4 17.4 7.7 1.9 0.2 0.6 0.0 4.2 0.9 0.0 9.7 7.4 0.2 2.1 82.6 100.0 255 Primary 5-8 30.9 15.7 4.1 0.5 1.2 0.I 8.0 1.8 0.2 15.1 8.7 3.4 3.0 69.1 100.0 330 Secondary+ 44.3 27.5 7.9 2.0 2.7 0.2 14.6 0.2 0.0 16.8 8.6 4.8 3.3 55.7 100.0 97 Total 25.1 12.5 3.0 0.5 1.3 0.0 6.3 1.1 0.2 12.6 7.9 2.2 2.5 74.9 100.0 866 35 Figure 4 2 Percentages of Currently Married Women and Men Using a Contraceptwe Method Females VL'~#< , MALAWI RESIDENCF Urban Rura~ REGION N, ,rtnerr C~nrra' Sou'herr] LbJCA7 ON No Educatlor] Prlmar¢ 1 -i Prm/ary 5 8 :-,eL or'dary + ,0 12 I ~ 11W '1:3 40 30 20 10 0 Per en', ll, r, 117 Is2 ]29 12o 10 MA[ AWl RESIDENCE Urban Rural REGION Ntlrtbern Central Soulherq EEbL( "A] !()N No Fct, oalk,rl Prmsary 1 4 J31 Primary ~ 8 ,1,1 St/.~ "/d/iy 20 30 40 50 MDH2, 19:~2 4.5 Number of Chi ldren at First Use of Contracept ion In many cultures, family planning is used only when couples have already had as many children as they want. However, as the concept of family planning gains more general acceptance, couples may choose to use contraception for spacing births as well as for limiting family size. In addition, unmarried young women may be particularly motivated to use family p!anning to avoid an unwanted pregnancy. By looking at differences in the number of living children at first use of family planning by current age of women, one can assess time trends in fertility control behaviour. Table 4.6 shows the number of children ever-married women had when they first used contraception, by age group. For the older cohorts (35-49 years), well over half of those women who have ever used a Table 4.6 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at the time of first use of contraception, according to current age, Malawi 1992 Number of living children at time Never of first use of contraception Number Current used of age contraception 0 1 2 3 4+ Missing Total women 15-19 75.5 10.7 11.8 1.5 0.0 0.0 0.5 100.0 446 20-24 62.0 5.9 22.7 6.3 1.7 0.9 0.4 100.0 850 25-29 57.3 3.1 15,8 12,9 7.0 3.3 0.6 100.0 759 30-34 53.8 1.4 11.7 12.2 8.1 12.3 0.5 100.0 651 35-39 54,3 1.7 9.0 8.9 5.6 20.2 0.3 100.0 531 40-44 56,7 0.8 7.5 8.7 6.2 19,6 0.6 100.0 507 4549 69.0 0.9 7.6 5.6 4.1 12.2 0.6 100.0 343 Total 60,2 3.6 13.5 8.5 4.8 8.8 0,5 100.0 4088 36 method started using only after they had three or more children. For the younger cohorts (15-29 years), women are more likely to have started using family planning after their first or second child. For instance, while 45 percent of ever-users currently age 25-29 first used a method before their second child was born, only 19 percent of ever-users age 40-44 had first used contraception by that point in their reproductive lives. Also, use of family planning before the first birth has risen sharply from 1 percent in the 4049 year-old cohort to 11 percent among 15-19 year-olds. These findings reflect a clear trend in Malawi towards earlier use of family planning for delaying childbearing and for spacing purposes. 4.6 Knowledge of Fertile Period A basic knowledge of reproductive physiology is useful for the successful practice of coitus-dependent methods such as withdrawal, the condom, or barrier methods, but itis especially important for users of natural family planning (periodic abstinence). The successful practice of natural family planning depends on an under- standing of when during the ovulatory cycle a woman is most likely to conceive. Table 4.7 presents the percent distributionofall female respondents and those who have ever used natural family planning by reported knowledge of the fertile period in the ovulatory cycle. Twenty-seven percent of the women interviewed said they did not know when a woman is most likely to conceive and an additional 39 percent said that there is no particular time when coitus is most likely to result in pregnancy. Only 12 percent of women gave the correct response: that a woman is most likely to conceive in the middle of her ovulatory cycle. Ever-users of natural family planning are only slightly more knowledgeable Table 4.7 Knowledge of fertile period Percent distribution of a/l women and of women who have ever used the natural method by knowledge of the fertile period during the ovulatory cycle, Malawi 1992 EVCT user5 of the Perceived All natural fertile period women method During menstrual period 0.4 0.7 Right after period has ended 13.7 17.4 In the middle of the cycle 12.1 14.4 Just before period begins 7.6 19.9 No particular time 38.9 30.3 Don't know 27.0 17.3 Missing 0.3 0.0 Total 100.0 100.0 Number 4849 708 about the ovulatory cycle than women in general. Although fewer ever-users of natural family planning responded "don't know" or "no particular time," still only 14 percent gave the correct response, i.e., "middle of the cycle." In conclusion, while these findings may understate genuine knowledge of the fertile period by Malawian women, it is also apparent that many women who claimed to be using natural family planning as a means to avoid pregnancy are either using it ineffectively or really do not understand what the method involves. 4.7 Sources of Family Planning Methods All current users of modem methods of family planning were asked to report the source from which they most recently obtained their methods. Since respondents often do not know exactly which category the source they use falls into (e.g., government hospital, primary health centre, etc.), interviewers were instructed to write the name of the source. Supervisors and field editors were instructed to verify that the reported name and the type of source were consistent, asking cluster informants for the names of local family planning sources if necessary. This practice was designed to improve the reporting of data on sources of family planning. 37 Table 4.8 and Figure 4.3 indicate that a large majority of female users of modem contraception (70 percent) obtained their methods from government sources d2 percent from government hospitals, 16 percent from government primary health centres, and 11 percent from govemment dispensaries/matemity clinics. Twenty-two percent of current users repotted the private medical sector as their source of current method. Half of these women obtained their method at a private hospital or clinic. Lastly, six percent of current users, mostly those using condoms, repotted their source as a shop, pharmacy, or friends and relatives. Table 4.8 Source of supply for modem contraceptive methods Percent distribution of current users of modern contraceptive methods by most recent source of supply or information, according to specific methods, Malawi 1992 Female Con- sterili- Source of supply Pill IUCD ilom sation Other Total FEMALES Public 77.7 75.9 62.1 62.8 69.0 69.9 Government hospital. 40.2 27.3 34.2 62.8 50.3 42.3 Primary health centre 25.4 30.5 6.8 0.0 11.8 15.5 Dispensary/Maternity climc 12.I 15.5 16.1 0.0 6.9 10.5 Mobde clinic 0.0 2.5 5.0 0.0 0.0 1.6 Private (medical) 18.8 24.1 12.8 32.0 31.0 22.3 Priv ate hc~pital/Cli nic 6.1 7.2 4.2 26.9 19.2 11.5 Private health centre 4.1 5.9 4.7 0.7 8.3 4.0 Dispensary/Maternity clinic 5.0 8.4 4.0 4.4 3.5 5.2 Mobile clinic 0.7 2.5 0.0 0.0 0.0 0.7 Private doctor 2.9 0.0 0.0 0.0 0.0 0.9 Other private 2.9 0.0 24.9 0.0 0.0 6.4 Shop/Phaxmacy 1.5 0.0 22.6 0.0 0.0 5.5 Friends/Relatives 1.5 0.0 2.3 0.0 0.0 0.9 Other 0.5 0.0 0.0 0.0 0.0 0.2 Don't know 0.0 0.0 0.3 0.0 0.0 0.1 Missing 0.0 0.0 0.0 5.2 0.0 1.2 Total 100.0 100.0 100.0 100.0 i00.0 100.0 Number 89 58 68 71 19 304 MALES Public 83.9 49.9 66.4 60.2 Government hospital 61.7 23.1 42.3 34.9 Primary health centre 5.2 10.3 13.4 9.9 Dispensary/Maternity chrac 17.0 12.8 5.4 12.2 Mobile chnic 0.0 3.6 29.2 3.2 Private (medical) 11.9 24.1 23.8 22.6 Private hospital/Clinic 0.0 3.9 0.0 7.1 Private health centre 3.4 8.6 5.4 5.8 Dispensary/Maternity clinic 8.5 10.4 0.0 9.0 Mobile clinic 0.0 0.6 0.0 0.4 Private doctor 0.0 0.6 0.0 0.4 Other private 4.2 24.2 0.0 15.3 Shop/Pharmacy 2.5 19.7 0.0 12.2 Friends/Relatives 1.7 4.5 0.0 3.0 Missing 0.0 1.8 4.4 2.0 Total 100.0 100.0 100.0 100.0 Number 29 82 28 139 38 Figure 4,3 Distribution of Current Female Users of Modern Contraception by Source of Supply Government Hospit~ 42% Govl Health Centre 16% Govt C]inic/Dispens/Mob Olinic Don't Know/Missing 1% Other 6% Private (medicaJ) 22% MDHS 1992 The distribution of male users by source of modern method shows a different pattern than that of female users, largely because over half of current male users report using the condom. Half of the condom users report having obtained their last supply in the public sector, most commonly at a government hospital. The remaining half are split equally between those who obtained their condoms from the medical private sector and those who obtained them from shops, pharmacies, and friends. The source a woman uses to obtain contraceptive methods depends on many things, one of which is the type of method she has chosen. About two-thirds of sterilisation procedures are done in government hospitals. The source of pills is much more varied, but government hospitals, health centres and clinics together account for over three-quarters of reported user sources. While condoms are also obtained from many sources, 38 percent of women users and 48 percent of male users report getting their condoms from non-governmental sources, the most common single source of which is shops. Women and men who were currently using a modern contraceptive method were asked how long it takes to travel from their home to the place where they obtain the method. Non-users were asked if they knew a place where they could obtain a modern method and, if so, how long it would take to travel there. The results are presented in Table 4.9. Among the women currently using a modem method, 19 percent are within 30 minutes (one-way travel time) of the place to which they go to get their method, while 13 percent are 30 minutes to one hour from their source. Fifty-nine percent of users of modem methods are one hour or more from their source of supply. Nearly 10 percent could not provide a quantitative estimate of time to their source. As expected, urban users are generally closer than rural users to their supply sources. Thirty-six percent of urban users are within 30 minutes of their supply sources as compared to only 12 percent of the rural users. Two-thirds of the latter have to travel for one hour or more to get their supplies. 39 Table 4.9 Time to source of supply for modem contraceptive methods Perc~mt distribution of women and men who are currently using a modern contraceptive method, who are not using a modern method, and who know a method, by time to reach a source of supply, according to urban-rural residence, Malawi 1992 Time (minutes) Currently using a modern method Not currently using a modem method Know a contraceptive method Urban Rural Total Urban Rural Total Urban Rural Total FEMALES 0-14 22.6 9.3 13.0 9.5 5.2 5.7 11.9 5.9 6.7 15-29 12.9 2.9 5.7 12.0 2.8 3.9 12.7 3.1 4.3 30-59 24.2 8.8 13.0 21.4 6.9 8.6 22.7 7.7 9.6 60 or more 35.2 67.2 58.5 39.3 53.8 52.2 40.3 59.4 56.9 Does not know time 4.4 10.2 8.6 2.9 5.2 4.9 3.3 5.9 5.6 Does not know source 0.0 0.0 0.0 14.6 25.7 24.5 8.8 17.6 16.4 Not stated 0.8 1.4 1.2 0.2 0.3 0.3 0.3 0.4 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 83 221 304 511 4033 4545 568 3817 4385 MALES 0-14 25.1 17.5 19.7 14.6 6.7 7.9 17.2 8.2 9.7 15-29 22.3 4.3 9.6 8.9 3.1 3.9 12.1 3.2 4.6 30-59 29.9 11.1 16.6 23.8 13.6 15.0 25.5 13.9 15.7 60 or more 18.6 63.9 50.8 27.1 50.1 46.9 25.3 53.2 48.7 Does not know time 1.8 1.0 1.2 1.4 1.l 1.1 1.5 1.1 1.2 Does not know source 0.0 0.0 0.0 22.5 25.1 24.7 16.6 19.9 19.4 Not stated 2.2 2.2 2.2 1.6 0.2 0.4 1.8 0.5 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of mext 40 98 139 141 871 1012 179 924 1103 Among women who are not using a modem method, almost one-quarter do not know a source for a modem contraceptive method. It should be noted that this question was asked of all nonusers and thus includes the 10 percent of women who do not know any method. Since these women presumably do not know of a source for family planning, they would account for almost half of those nonusers who do not know of a source. The last panel of Table 4.9 is based on all women who know a contraceptive method. Among women who know at least one family planning method, 11 percent are within 30 minutes of a source for a modem method, but 16 percent say they do not know of a place to get a modem method. 4.8 Intention to Use Family Planning Among Nonusers Women and men who were not us ing a cont racept ive method at the t ime o f the survey were asked i f they thought they wou ld do someth ing to prevent p regnancy at any t ime in the future. The resu l ts are shown in Tab les 4 .10.1 and 4 .10 .2 by whether or not the woman/man had ever used a method in the past. 40 Table 4.10.1 Future use of contraception - females Percent disVribution of currently married women who are not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living children, Malawi 1992 Past experience Number of living children t with contraception and future intentions 0 1 2 3 4+ Total Never used contraception Intends to use in next 12 months 13.8 28.6 25.3 29.0 25.7 25.4 Intends to use latex 19.2 13.5 7.7 6.7 5.0 8.8 Unsure as to timing 4.2 l , l 1.2 1.2 0.7 1.3 Unsure as to intention 7.9 8.7 8.1 4.6 6.1 6.9 Does not intend to use 38.6 26.6 23.5 21.9 24.2 25.7 Missing 0.0 0.0 0.3 0.3 0.0 0.1 Previously used contraception Intends to use in next 12 months 6.0 9.9 17.5 17.6 22.8 16.9 Intends to use later 4.8 4.0 5.9 5.5 3.9 4.6 Unsure as to timing 1.3 0.6 1.0 0.6 0.7 0.8 Unsure as to intention 0.6 1.6 2.3 2.5 1.3 1.6 Does not intend to use 3.5 5.0 7.1 9.9 9.7 7.7 Missing 0.0 0.3 0.0 0.l 0.0 0.1 Tota/ 100.0 100 .0 100 .0 100 .0 100.0 100.0 All currently married nonusers Intends to use in next 12 months 19,9 38.6 42,8 46.6 48.5 42.3 Intends to use later 24.0 17.5 13.6 12.2 8.8 13.4 Unsure as to timing 5.6 1.7 2.2 1.8 1.4 2.1 Unsure as to intention 8.5 10.3 10.5 7.1 7.4 8.6 Does not intend to use 42.1 31.6 30.6 31.7 33.9 33.4 Missing 0.0 0.3 0.3 0.4 0.0 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 330 558 542 456 1151 3038 tincludes current pregnancy Among all currently married female nonusers, 42 percent reported intending to use a method within the next 12 months, while another 13 percent intend to use family planning but only at a later time. Nine percent were not sure whether they would ever use a method, but a third of women said that they do not intend to ever use contraception. Intention to use family planning in the future is closely tied to the number of children a woman has. Intent to use in the next 12 months jumps from 20 percent among women with no living children to 49 percent among women with 4 or more living children. Also, while 42 percent of women without children say they will never use family planning, 34 percent of women with 4 or more children say the same. Sixty-one percent of women who intend to use contraception in the future have not used it in the past. If constraints to use (i.e., cost, access, etc.) are minimised, and thus intentions to use are manifest in future behaviour, the contraceptive prevalence rate in Malawi will increase substantially over the ensuing years. Overall, intent to use in the next twelve months is only slightly higher among men (46 percent) than women (42 percen0. More significant male-female differences do, however, emerge when looking at the relationship between reptvductJ ve history and intention to use. Whereas among women, one observes a fairly strong increase in intention to use associated with the current number of living children, this pattem is not observed among male respondents; in fact, the inverse may be true. The results for males however must be interpreted cautiously because they are based on small numbers. 41 Table 4.10.2 Future use of contraception - males Percent distribution of curreaatly married men who axe not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living childran, Malawi 1992 Past experience with contraception and future intentions Number of living children 0 1 2 3 4+ Total Never used contraception Intends to use in next 12 months 26.4 15.9 23.5 25.3 19.7 21.2 Intends to use later 17.3 15.9 8.6 8.8 8.5 10.7 Unsure ~ to timing 1.4 0.0 2.1 0.0 1.5 1.2 Unsure as to intention 9.4 2.9 0.4 7,0 4.1 4.2 Does not intend to use 10.4 16.7 18.4 20.6 23.0 19.5 Missing 0.0 0.0 1.7 0.8 0.0 0.4 Previously used contraception Intends to use in next 12 months 19.4 31.6 23.7 24.8 23.2 24.5 Intends to use latex 4.3 8.6 5.1 4.2 4.3 5.1 Unsure as to timing 4.5 2.0 4.3 0.6 1.8 2.4 Unsure as to intention 1.4 3.0 1.7 4.2 1.9 2.3 Does not intend to use 5.6 3.2 10.2 3.7 11.9 8.4 Missing 0.0 0.0 0.2 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 All currently married nonusers Intends to use in next 12 months 45.7 47.5 47.2 50.2 42.9 45.7 Intends to use later 21.6 24.5 13.7 13.0 12.8 15.8 Unsure as to timing 5.9 2.0 6.4 0.6 3.3 3.6 Unsure as m intention 10.8 5.9 2.2 11.2 6.0 6.5 Does not intend to use 15.9 20.0 28.7 24.3 34.9 28.0 Missing 0.0 0.0 1.9 0.8 0.0 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number ofmen 69 104 115 86 274 649 4.9 Reasons for Non-use Table 4.11 presents the main reasons for not using contraception given by married women and men who are not using any contraceptive method and do not intend to use it in the future. Thirty percent of women say they do not intend to use because they want children, while another 35 percent cite infecundity (either "difficult to get pregnant" or "menopausal") as the reason. Other reasons commonly given are concerns about side effects or other more serious health effects (10 percent) and lack of knowledge (9 percent). The younger cohort of women (under age 30) are much more likely to say they do not to intend to use contraception in the future because they want more children or because they lack knowledge, while those age 30 and over are more likely to cite reasons such as being menopausal or infecund. 42 Table 4.11 Reasons for not using contlaception Percent distribution of currently married women and men who are not using a contraceptive method and who do not intend to use in the future by main reason for not using, according to age, Malawi 1992 Age Less 30 Reason for not using than or more contraception 30 years years Total FEMALES Wants children Lack of knowledge Partner opposed Costs too much Side effects Health concerns Hard to get methods Religion Opposed to family planning Fatalistic Other people opposed Infrequent sex Difficult to get pregnant Menopausal/Had hysterectomy Inconvenient Not married Other Don't know 47.3 21.3 30.3 15.9 5.9 9,4 4.4 1.8 2.7 0.1 0.2 0.2 3.4 4.6 4.2 6.4 5.2 5.6 0.l 0.0 0.0 0,7 0.1 0.3 0,8 1.2 1.1 5.6 3,9 4.5 0,0 0.6 0.4 0,7 1.2 1.0 7,1 36.3 26,2 0.1 14.2 9.3 0.6 0.5 0,5 0.4 0.1 0.2 0.8 1.1 1.0 5.4 1.7 3.0 Total Number I00.0 100.0 100.0 352 664 1016 MALES Wants children 51.8 19,8 24.6 Lack of knowledge 24.9 8.6 11.1 Partner opposed 0.0 2,0 1.7 Side effects 0.0 3,9 3~3 Health concerns 1.8 2,5 2.4 Opposed to family planning 0.0 0.4 0.4 Fatalistic 0.0 3.2 2.8 Other people opposed 0.0 1.9 1.6 Infrequent sex 5.5 2,0 2,6 Difficult to get pregnant 5.5 36.8 32,1 Menopausal/Had hysterectomy 6.1 16.1 14,6 Inconvenient 1.8 0.1 0.4 Other 0.0 0,5 0.4 Don't know 2,6 1,9 2,0 Total 100.0 100.0 100.0 Number 27 154 181 The results for men are very similar to those obtained for women, except that men tend to cite desire for more children less often and infecundity and lack of knowledge more often than women do. The results for men should be viewed with caution since they are based on a small number of respondents. 43 4.10 Preferred Method Non-users who said that they d/d intend to use family planning in the future were asked which method they preferred to use. The results are presented in Table 4.12. Most women said they preferred to use the pill (51 percent), and injections were the next most preferred method ( 16 percent). The same pattern of method preference is noted among women regardless of whether they intend to use in the next 12 months or later. There is a tendency for women who are unsure about the timing of future use to also be unsure of which method they might use. The preferred method among men is the condom (40 percent) followed by the pill (28 percent). Table 4.12 Preferred method of contraception for future use Percent distribution of currently married women and men who are not using a contraceptive method but who intend to use in the future by prefea"red method, according to whether they intend to use in the next 12 months or later, Malawi 1992 Intondtouse In next After Unsure Preferred method 12 12 as to of contraception months months timing Total FEMALES Pill 51.9 51.8 41.2 51.4 IUCD 1.2 1.6 0.0 1.2 Injection 17.3 13.5 13.6 16.3 Diaphragm/Foam/Jelly 1.6 0.9 2.3 1.5 Condom 6.3 8.3 3.3 6.6 Female sterilisation 5.2 3.5 7.3 4.8 Male stetilisation 0.1 0.0 0.0 0.1 Natural method 6.1 4.2 4.8 5.6 Withdrawal 1.8 1.7 2.2 1.8 Other 4.3 4.1 5.6 4.3 Unsure 4.3 10.5 19.7 6.3 Total 100.0 100.0 100.0 100.0 Number 1284 408 65 1757 MALES Pill 27.4 32.9 15.5 28.0 IUCD 1.4 0.5 0.0 1.1 Injection 6.9 3.1 5.0 5.8 Diaphragm/Foam/Jelly 1.3 0.0 0.0 0.9 Condom 42.1 38.7 24.1 40.2 Female storilisation 7.3 0.0 19.3 6.2 Male sterilisation 0.0 1.6 0.0 0.4 Natural method 8.2 15.5 10.6 10.0 Withdrawal 0.5 1.1 10.5 1.2 Other 3.4 4.7 10.0 4.0 Unsure 1.6 1.9 5.0 2.1 Total 100.0 100.0 100.0 100.0 Number 296 103 23 422 44 4.11 Exposure to Family Planning Messages on Radio All respondents were asked if they had heard a message about family planning on radio in the month pre- ceding the interview. Only one-quarter of women and about half of men said that they had heard a message on the radio (Table 4.13). The percentage who had heard family planning messages in the month prior to the survey varied widely by background characteristics. Rural men and women and those with little orno education were less likely to have heard a family planning message. Table 4.14 presents the results from a question on whether women and men believe it is acceptable or not ac- ceptable to air family planning messages over the radio. Eighty-four percent of women and 93 percent of men said that such messages are acceptable to them. Young women (15-19 years) were much more likely than others to re- spond "don't know," and men and women 45 years of age or older were more likely to say that family planning messages on the radio were unacceptable. Patterns of ac- ceptability across region, urban-rural residence and educa- tion were small or negligible. 4.12 Approval of Family Planning An indication of the acceptability of family plan- ning is the extent to which couples discuss the topic with each other. Table 4.15 shows the results obtained by ask- ing married, non-sterilised women and men who know of a contraceptive method questions conceming communica- tion about family planning with their spouse. Fifty-seven percent of these women and 63 percent of these men said they had discussed family planning with their spouse in the year prior to the survey. Not only am men more likely to have said they have discussed family planning with their spouse, but they report having discussed it more often than women report. While 38 percent of men said they dis- cussed family planning three or more times over the last year, only 24 percent of women said the same. Men and women age 35-39 years were most likely to have recently discussed family planning with their spouse, with such communication becoming increasingly less common among the older and younger age groups. Table 4,13 Family planning messages on radio Percent distribution of all women and men by whether they have heard a family planning message on radio in the month preceding the survey, according to selected background characteristics, Malawi 1992 Heard family Number planning of Background message women/ characteristic on radio men FEMALES Residence Urban 48,3 594 Rur~ 23.7 4255 Region Northern 28.8 578 Centr~ 25.0 1872 Southem 27.6 2398 Education No education 19.0 2287 Primary 1-4 24,6 1192 Primary 5-8 38.2 1159 Secondary+ 60.1 212 Total 26.8 4849 MALES Residence Urban Rural Region Northern Centr~ Southexn 61.3 181 46.3 970 52.7 139 44.9 443 50.7 569 Education No education 42.8 236 Primary 1-4 36.3 335 Primary5-8 51.8 423 Secondary+ 75.8 157 Total 48.7 1151 45 Table 4.14 Acceptability of the use of radio for disseminating family planning messages Percentage of women and men who believe that it is acceptable to have messages about family planning on radio, by age and selected background characteristics, Malawl 1992 Number Not of Background Accept- acc t , - Don't know/ women/ characteristic able able Missing Total men FEMALES Age 15-19 76.8 13.2 10.0 100.0 1082 20-24 88.6 7.9 3.5 100.0 944 25-29 88.0 8.7 3.3 100.0 777 30-34 83.9 11.4 4.7 100.0 656 35-39 86.4 10.0 3.6 100.0 537 40~14 83.1 9.9 7.0 100.0 510 45-49 77.3 16.0 6.7 100.0 343 Residence Urban 88.3 9.0 2.7 1GO.0 594 Rural 83.0 10.9 6.1 100.0 4255 Region No~bem 80.4 10.0 9.6 100.0 578 Central 83.8 11.6 4.6 100.0 1872 Southern 84.3 10.1 5.6 100.0 2398 ~duc.&t Ion No education 78.7 14.7 6.5 100.0 2287 Primary 1-4 85.6 7.7 6.7 100.0 1192 Primary 5-8 89.8 6.3 3.8 100.0 1159 Secondary+ 91.2 8.0 0.8 100.0 212 Total 83.6 10.7 5,7 100.0 4849 MALES Age 20-24 93.4 3.2 3.3 100.0 277 25-29 94.9 2.4 2.6 100.0 205 30-34 94.6 3.6 1.8 100.0 168 35-39 93.9 3.4 2.7 100.0 143 40-44 94.4 3.7 1.8 1(30.0 160 45-49 86.7 10.3 3.0 100.0 95 50-54 87.7 10.3 1.9 100.0 102 Residence Urban 90.0 6.9 3.1 100.0 181 Rural 93.6 4.0 2.4 100.0 970 Region Nonhero 85.8 7.2 7.1 1(30.0 139 Central 95.1 3.5 1.4 100.0 443 Southern 93.1 4.5 2.4 100.0 569 Ec:l uc~itlon No education 92.8 2.9 4.4 100.0 236 Primary 1-4 93.9 4.0 2.2 100.0 335 Primary 5-8 93.8 3.9 2.3 100.0 423 Secondary+ 89.5 9.3 1.2 1130.0 157 Total 93.0 4.4 2.5 100.0 1151 46 Table 4.15 Discussion of family planning by couples Percent disla'ibution of currently married, non-st~ilised women and men who know a contraceptive method by the number of times family planning was discussed with spouse in the year preceding the survey, according to current age, Malawi 1992 Number of times family planning discussed Once or Three Age Never twice or more Missing Total Number FEMALES 15-19 50.4 37.2 11.9 0.6 100,0 341 20-24 42.3 33.8 23.3 0.7 100,0 713 25-29 37.7 34.0 28.0 0.2 100,0 632 30-34 39.1 34.2 25.7 0.9 1120,0 546 35-39 34.7 34.9 29.4 1.0 100,0 419 40-44 49.3 24.5 25.8 0.4 100.0 364 45-49 59.9 20.4 18.1 1.6 100,0 226 Total 42.7 32.4 24.1 0.7 100,0 3242 MALES 20-24 50.9 19.2 29.8 0.2 100.0 97 25 -29 34.2 30.4 35.2 0. t 100.0 162 30-34 26.3 26.1 46.6 1.0 100.0 144 35-39 24.2 22.6 52.0 1.2 100.0 125 40-44 36.6 24.6 36.8 2.0 100.0 141 45-49 31.5 25.6 37.9 5.0 100.0 79 50-54 58.1 18.5 23.4 0.0 100.0 92 Total 36.1 24.5 38.3 1.2 100.0 840 In order to obtain more direct information about the acceptability of family planning, respondents were asked if they approved or disapproved of couples using a method to avoid pregnancy. Although all women and men were asked this question, the data presented in Tables 4.16.1 and 4.16.2 are confined to currently married, non-sterilised respondents and exclude those who had never heard of a contraceptive method. Currently married, non-sterilised women and men were a/so asked if they thought that/heir spouse approved of the use of family planning. It should be noted that the respondent's opinions of their spouse's attitudes may be incorrect, either because they have misconstrued their spouse's attitudes or because of a tendency to report their spouse's attitudes as similar to their own. 47 Table 4.16.1 Attitudes of couples toward family planning - female respondents Among cttrreafly married, non-sterilised women who know a contiaceptive method, the percentage who approve of family planning, by their perception of their husband's attitude and selected background characteristics, Malawi 1992 Respondent approves Respondent disapproves Unstll-e Ul?dtffe Both Husband of Husband Husband of Respondent Characteristic approve disapproves husband approves disapproves husband unsure Percent Total Age 15-19 69.2 8.6 15.9 0.2 2.3 2.5 1.3 100.0 341 20-24 73.1 7.2 10.7 1.9 2.0 3.5 1.6 100.0 713 25-29 74.1 10.4 10.1 1.1 1.1 2.6 0.6 100.0 632 30-34 69.4 12.9 10.3 2.2 1.4 2.8 l. l 100.0 546 35-39 70.3 8.5 9.6 3.1 2.5 4.5 1.4 100.0 419 40-44 69.9 8.6 14.3 0.4 1.5 4.8 0.5 100.0 364 45-49 62.0 9.0 15.8 2.3 2.0 7.4 1.6 100.0 226 Residence Urban 74.8 9.9 9.5 1.5 0.8 2.6 1.0 100.0 380 Rural 70.2 9.3 12.0 1.6 1.9 3.8 1.2 100.0 2862 Region Northern 69.8 10.l 11.8 1.7 3.0 2.1 1.5 100.0 398 Central 72.5 9.6 10.2 1.7 1.4 3.8 0.8 100.0 1299 Southea-n 69.5 9.0 13.0 1.5 1.7 3.9 1.4 100.0 1545 Education No education 67.5 9.1 13.4 1.9 2.2 5.0 0.8 100.0 1648 Primary I-4 71.6 9.7 10.8 1.6 1.9 2.9 1.4 100.0 773 Primary 5-8 75.2 9.9 9.8 1.2 0.8 1.8 1.3 100.0 725 Secondary+ 86.2 7.0 3.0 0.5 0.0 0.0 3.3 100.0 96 Total 70.8 9.4 11.7 1.6 1.8 3.6 1.1 100.0 3242 Overall, 92 percent of married women and 96 percent of married men who know a contraceptive method approve of family planning. Women are more likely than men to report that they do not know their spouse's view on family planning or that their spouse disapproves. Less educated men and women are more likely to disapprove of family planning themselves, and are also more likely to say that their spouses disapprove or that they do not know their spouse's views. Comparison of results among regions and between urban and rural respondents suggest that only very small to negligible differences in attitudes towards family planning exist across these lines. Further, only very small differences exist in attitudes by age of the respondents, although there is a slight tendency for older men and women to disapprove of family planning. 48 Table 4.16.2 Attitudes of couples toward family planning - male respondents Among currendy married, non-sterilised men who know a conU'aceptive method, the percentage who approve of family planning, by their perception of their wife's attitude and selected background characteristics, Malawi 1992 Respondent approves Respondent disapproves Unsure Unsure Both Wife of Wife Wife of Respondent Characteristic approve disapproves wife approves disapproves wife unsure Percent Total Age 20-24 90.0 0.0 7.4 0.0 2.4 0.0 0.2 100.0 97 25-29 92.3 1.2 4.6 0.0 0.0 1.8 0.l 100.0 162 30-34 90.3 2.3 4.2 2.2 0.0 0.0 1.0 100.0 144 35-39 92.4 1.0 1.7 3.0 0.6 0.1 1.2 100.0 125 40-44 87.0 2.3 5.2 0.4 1.1 2.0 2.0 lO0.O 141 45-49 88.2 1.3 0.6 0.2 1.9 2.7 5.0 100.0 79 50-54 80.3 8.7 6.0 0.6 3.4 1.1 0.0 100.0 92 Residence Urban 85.1 2.8 5.2 1.7 1.2 2.4 1.6 100.0 123 Rural 89.8 2.2 4. I 0.8 1.1 0.9 1.2 100.0 717 Region Northern 89.2 2.5 5.0 0.4 0.0 1.7 1.2 100.0 98 Central 88.3 1.1 4.5 2.1 1.4 1.1 1.5 100.0 330 Southern 89.7 3.1 3.9 0.2 1.1 1.0 1.0 100.0 411 Education No education 85.7 6.1 4.0 0.9 1.7 0.7 0,9 100.0 174 Primary 1-4 84.1 2,0 7.5 1.4 2.0 2.2 1.0 100.0 244 Primary 5-8 93.0 0.4 2.9 0.8 0.2 0.7 1.8 100.0 325 Secondary+ 94.5 2.1 1.3 0.5 0.7 0.5 0.4 100.0 97 Total 89.1 2.2 4.3 1.0 1.1 1.1 1.2 100.0 840 49 CHAPTER 5 OTHER PROXIMATE DETERMINANTS OF FERTILITY This chapter addresses two of the principal factors other than contraception that affect a woman's risk of becoming pregnant: nuptiality and postpartum amenorrhoea. Nuptiality (marriage) is a primary factor influencing the exposure of a woman to the risk of pregnancy and therefore is important in understanding fertility dynamics. Populations in which age at first marriage is low tend to be populations with early childbearing and high fertility. One of the first signs of a transition from high to lower fertility levels is a rise in the age at first marriage. Postpartum amenorrhoea is another factor that directly influences exposure to the risk of pregnancy. A woman is normally amenorrhoeic for a few weeks or months following the termination of a pregnancy. During this time, she is less susceptible to the risk of pregnancy and, although the correlation is not an exact one, this period of amenorrhoea can be lengthened by breastfeediag. Inversely, by curtailing the length of breastfeeding without adopting other fertility control measures, a woman will become susceptible to the risk of pregnancy at an earlier postpartum date. 5.1 Marital Status Table 5.1 shows the distribution of women and men by age and marital status at the time of the survey. The term "married" refers to legal or formal marriage, whereas "living together" refers to informal unions. In this report, these two categories are combined and referred to collectively as "currently married" Table 5.1 Current marital status Percent distribution of women and men by current marital status, according to age. Malawi 1992 Marital status Number of Age Never Living Not living women/ (years) married Married together Widowed Divorced together Total men FEMALES 15-19 58.8 34.6 1.2 0.3 3.6 1.5 100.0 1082 20-24 10.0 74.4 4.3 1.2 7.9 2.3 100.0 944 25-29 2.2 82.2 3.0 2.4 7.1 3.2 100.0 777 30-34 0.6 84.8 4.3 2.9 4.9 2.5 100.0 656 35-39 1.1 80.6 4.1 3.8 6.1 4.4 100.0 537 40-44 0.6 76.3 3.7 3.9 11.4 4,2 100.0 510 45-49 0.0 70.4 3.4 8.6 11.2 6.4 100.0 343 Total 15.7 68.8 3.2 2.5 6.8 3.0 100.0 4849 MALES 20-24 60.8 32.8 3.4 0.0 1.2 1.8 100.0 277 25-29 14.5 72.5 7.3 0.9 3.5 1.3 100.0 205 30-34 5.5 77.0 10.3 1.0 4.0 2,2 100,0 168 35-39 1,8 77,4 13,0 1,0 1.2 5,6 100,0 143 40-44 0.6 85.2 6.7 2.3 4.5 0.7 100.0 160 45-49 0.0 79.8 8.1 0.5 8.1 3.5 100.0 95 50-54 1.6 90.4 2.3 1.0 3.1 1.6 100.0 102 Total 18.5 68.1 7.1 0.9 3.2 2.2 100.0 1151 51 or "currently in union." Along with the currently married, respondents who are widowed, divorced, or no longer living together (separated) make up the remainder of the "ever-married" or "ever in union" category. Marriage is almost universal in Malawi; in other words, nearly everyone is married at some time in his/her life, and the majority of people are currently married. By the time women reach ages 25-29 and men reach ages 35-39, 98 percent have been married. More women than men marry in their adolescent years (before 20 years), and more men than women remain married at older ages. Among women, the percentage currently married declines after age 35, so that approximately 7 out of 10 women are currently married by the age of 45-49. Among men, 90 percent are currently married in the age group 50-54. The percentage of respondents who are not currently married (but were at one time) is twice as high among women than among men. 5.2 Polygyny Married women were asked whether their husbands have other wives and, if so, how many other wives. Married men were asked whether they have more than one wife and, if so, how many other wives. Table 5.2 shows the percentage of currently married women and men who are in polygynous unions, by age Table 5.2 Polygyny Percentage of currently married women and men in a polygynous union, by age and selected background characteristics, Malawi 1992 Age of woman Background characteristic 15-19 20-24 25 29 30-34 35-39 40-44 45-49 Total Residence Urban 12.5 11.2 8.3 14.6 13.4 16 2 13.6 12 0 Rural i0.4 13.2 24.5 24.9 24.8 29 5 34.0 21.9 Region Northern 14.8 18.8 29.2 40.2 31.2 3/).0 46.5 28.3 Central 12.9 13.1 20.0 24.1 27.8 34.4 41.2 22.7 Southern 8,0 10.9 22,0 19,1 18.5 23,4 2(I,5 17 2 Education No education 10.9 14.6 21.5 25.7 23.8 30./I 32.8 22.7 Primary 1-4 12.0 12.9 22.1 19.5 19.0 27.5 31.3 18.9 Primary 5-8 8.6 10.2 24.9 25.3 30.1 24.5 (30 4) 19.5 Secondary+ * (13.1) 8.6 (7.9) (7.4) * * 10,2 Total 10.6 12.9 22.1 23.6 23.4 28.5 32.2 2(/.8 Age of man Background characteristic 20-24 25-29 30 34 35-39 40-44 45 49 50k54 Total Residence Urban * (0.9) 2.0 (3.9) (9.0) (10.4) * 4.3 Rural 4.0 2.1 9.9 17.6 10.6 15 2 13.9 9.8 Total 3.8 1.9 8 4 15.2 10.4 14.3 12 6 9.0 ( ) Based on 25-49 persons • Based on less than 25 persons 52 Figure Percentage of Currently Married Women Whose Husbands Have at least One Other Wife MALAW 21 RESIDENCE Urban 12 Rural 22 REGION Central Northern [ 23 [ 28 Soulherr J 1T EDUCATIOK No Educal~or Pnma~y 1-4 Primary 5 8 Secondary ~ ~ 20 5 10 15 20 Percent 25 30 MDHS 1992 and background characteristics. Figure 5.1 shows the polygyny prevalence data for married women. Overall, 21 percent of currently married women are in a polygynous union, and 9 percent of currently married men have more than one wife. Polygyny exists in all regions and among all socioeconomic groups, although the prevalence varies. Among women, polygyny increases with age, from 11 percent among women age 15-19 to 32 percent of women age 45-49. Women and men in rural areas are about twice as likely to be in a polygynous union as their urban counterparts. Polygyny is more common in the Northern Region (28 percent of women) than in the Central Region (23 percent) and Southern Region (17 percent). Education among women is associated with a lower prevalence of pelygyny; 23 percent of uneducated women arc in a polygynous union versus only 10 percent of women with some secondary education. Of those women in polygynous unions (21 percen0, 60 percent have a single co-wife (Table 5.3). This means that 8 percent of all currently married women have at least two other co-wives. The likelihood of a woman having more than one co-wife increases with age, from 2 percent among women age 15-19 to 16 percent of women age 45-49. Women living in urban areas, in the Southem Region, and those with secondary education are least likely to have multiple co-wives. Only two percent of men have more than two wives (Table 5.4). As among female respondents, pelygyny among males is much less common in urban areas, in the Southern Region, and among men with more formal education. 53 Table 5.3 Number of co-wives Percent distribution of currently married women by number of co-wives, according to selected background characteristics. Malawi 1992 Number of co-wives Number Background of characteristic 0 1 2+ Missing Total women Age 15-19 89.4 7.4 2.2 0.9 100.0 388 20-24 87.1 9.1 3.4 0.4 100.0 743 25-29 77.9 13.8 8.2 0.1 100.0 661 30-34 76.4 14.4 8.9 0.2 100.0 584 35-39 76,6 13.8 9.6 0.0 100.0 455 40-44 71.5 i9.0 9.4 0.0 100.0 408 45~.9 67.8 15.7 15.9 0.6 100.0 253 Residence Urban 88.0 7.1 4.5 0.4 100.0 411 Rural 78.1 13.7 7.9 0.3 100.0 3081 Region Northern 71.7 17,3 10,7 0,3 100.0 430 Central 77.3 11.4 11.0 0.3 100.0 1402 Southern 82.8 13.1 3.7 0.3 100.0 1660 Education No education 77.3 14.4 7.9 0.4 100.0 1815 Primary I-4 81.1 11.7 7.0 0.2 100,0 819 Primary 5-8 80.5 11.6 7.8 0.1 100.0 750 Secondary+ 89.8 6.6 2.6 1.1 100.0 107 Total 79.2 12.9 7.5 0.3 100.0 3492 Table 5.4 Number of wives Percent dista'ibution of currently married men by number of wives, according to selected background characteristics. Malawi 1992 Number of wives Number Background of characteristic 1 2 3+ Total men Age 20-24 96.2 3.8 0.0 100.0 100 25 29 98.1 1.9 0.0 100.0 163 30-34 91.6 7.1 1.2 100.0 147 35-39 84.8 13.7 1.5 100.0 129 40-44 89.6 6.0 4.4 100.0 147 45-49 85.7 9.8 4.5 100.0 83 50-54 87.4 9.4 3.2 100.0 95 Residence Urban 95.7 4.2 0.1 100.0 126 Rural 90.2 7.5 2.3 100.0 739 Region Northern 85.1 13.2 1.7 100.0 99 Central 87.4 9.6 3.0 100.0 347 Southern 95.3 3.5 1.2 100.0 419 Education No education 95,0 3.9 1.1 100.0 183 Primary 1-4 89.2 7.5 3.3 100.0 255 Primary 5-8 89.0 9.0 2.0 100.0 330 Secondary+ 94.6 5.2 0.2 100.0 97 Total 91.0 7.1 2.0 100.0 866 54 5.3 Age at First Marriage Women marry for the first time, on average, 5 to 6 years earlier in life than men (Table 5.5). The median age at first marriage is 18 years for women and about 24 years for men. By age 20, three-quarters of women are married, whereas fewer than one in five men are married by this age. Nearly all women are married by age 25. Table 5.5 Age at first marriage Percentage of women and men ever married by specific exact ages and median age at first marriage, according to ctwrent age, Malawi 1992 Percentage ever married Percentage by specific exact age: who had neve]" Current age 15 18 20 22 25 married Number Median aeat marriage FEMALES 15-19 7.8 NA NA NA NA 58.8 1082 a 20-24 14.8 54.8 76.6 NA NA 10.0 944 17.7 25-29 16.3 53.7 76.9 88.1 95.2 2.3 777 17.7 30-34 20.8 61.0 80.3 89.3 95.3 0.6 656 17.2 35~39 16.4 51.2 73.3 85.0 92.5 1.1 537 17.9 40.44 18.0 49.4 69.0 79.9 93.3 0.6 510 18.1 45-49 17.8 44.9 65.9 79.9 93.1 0.0 343 18.4 20-49 17.1 53.5 74.8 85.9 93.1 3.3 3767 17.7 MALES 20-24 1.3 4.8 13.7 NA NA 60.8 277 a 25-29 2.2 5.5 18.0 38.1 58.2 14.5 205 24.0 30-34 1.9 4.8 14.0 37.1 67.6 5.5 168 23.0 35-39 0.0 7.0 20.7 43.2 64.4 1.8 143 23.1 40-44 0.9 4.8 21.4 40.4 65.9 0.6 160 23.3 45-49 2.2 11.1 20.5 31.5 56.6 0.0 95 24.5 50-54 1.6 11.4 22.0 33.9 67.0 1.6 102 23.5 25-54 1.5 6.8 19.0 38.0 63.3 5.0 874 23.5 NA = Not applicable aOmiued because less than 50 percent of the women in the age group x to x+4 were first married by age x Trends in age at marriage can be described by comparing the cumulative distribution married for successive five-year age groups) The data show that there has been a decline in the proportion of women and men marrying at early ages. The proportion of women marrying before age 15 has declined from 21 percent of the 30-34 year-olds to 8 percent of the 15-19 year-olds. The decline in age at first marriage is not quite as marked among men; the percentage married by age 20 has dropped from 21 among men currently age 35-49 to 14 percent among men aged 20-24. ~For each age-group cohort, the accumulated percentages stop at the lower age boundary of the cohort to avoid censoring problems. For instance, for women currently age 15-19, accumulation stops with the percentage married by exact age 15. 55 Although the decline in marriage at early ages has not been sufficient to change substantially the national median age at first marriage, there are differentials between subgroups of the population. Table 5.6 presents median ages at first marriage by background characteristics. Only the results for women are presented due to the small male sample. Urban women under age 35 marry for the first time one year later than rural women. Regional differences in age at marriage arc small, although recent cohorts of women in the Southern Region are marrying at a slightly earlier age than women of the same age in the Northern and Central Regions. The association between greater education and later age at marriage, witnessed in countries around the world, is also seen among Malawian women. As an example, in the cohort age 25-29 years, women with secondary education have a median age at marriage of 22 compared to age 17 for women without education. Table 5.6 Median age at first marriage Median age at first marriage for women by current age and selected background characteristics, Malawi 1992 Age of woman Women Background age characteristic 20-24 25-29 30-34 35-39 40 44 45-49 20-49 Residence Urban 18.9 18.6 18.2 18.0 18.1 18.3 18,5 Rural 17 5 17.6 17.0 17.9 18.1 18.4 17.6 Region Northern 17.9 17.8 17.2 17.9 17.7 17 7 17.7 Central 17.9 18.0 17.4 17.8 17.9 18 1 17.8 Southern 17.3 17.4 16.9 18.0 18.4 18.7 1%6 Education No education 16.8 17.3 16.6 18.0 18.0 18.5 17,4 Primary 1-4 17.6 17.2 17.1 17.0 18.0 18 4 17.5 Primary 5-8 18.2 18.4 17.8 17.5 18.0 (17.4) 18.1 Secondary+ a 22.4 (20 5) (20.6) * * a Total 17.7 17.7 17.2 17.9 18.1 18.4 17.7 aOmitted because less than 50 percent in the age group were first married by age 20. ( ) Based on 25-49 cases • Based on less than 25 cases 5.4 Postpar tum Amenorrhoea Postpartum amenorrhoea is defined as the timc between the birth of a child and the return of the menstrual cycle. During this time without menses, a woman is normally not ovulating, and is therefore insusceptible to the risk of pregnancy. This period of insusceptibility can be prolonged by breastt~eding. Once her menses returns, a woman is once again susceptible to the risk of becoming pregnant. Table 5.7 shows the percentage of mothers who are postpartum amenorrhoeic at the time of the survey by number of months since birth. More than three-quarters of women remain amenorrhoeic lor at least six months following a birth. After six months, the percentage remaining amenorrhocic drops signilicantly, so that by the time a child is 18-19 months old, only 22 percent of mothers are still insusceptible. Overall, more than one-half of women become susceptible to the risk of pregnancy within one year of the birth of a child. 56 Table 5.7 Postpartum amenorrhoea Percentage of births whose mothers are postpartum amenorrhoeic, by number of months smce birth, and median and mean durazion~, Malawi 1992 Number Months Amenor- of since birth rhoeic births < 2 88.7 171 2-3 89.8 173 4-5 83.0 189 6-7 81.6 156 8-9 64.9 210 10-11 51.8 160 12-13 47.3 178 14-15 42.4 135 16-17 34.1 115 18-19 21.9 161 20-21 19.7 156 22-23 8.9 152 24-25 12.5 147 26-27 1.9 122 28-29 2.5 142 30-31 6.3 147 32-33 2.6 136 34-35 2.1 14 Total 39.7 2800 Median 11.9 Mean 13.5 Prevalence/Incidence Mean 14.1 Table 5.8 shows the median durations ofamenorrhoca by background characteristics of the mother. Mothers age 30 and over are amenorrhoeic 3.2 months longer than younger mothers. Urban mothers have shorter durations of amenorrhoea, reflecting in large part differences in breastfeeding durations and patterns. Regional differentials are negligible. The duration of amenor- rhoea decreases steadily with increasing education, from a length of 15 months among women with no education, to 7 months among women with secondary schooling. It is interesting to note that the differential by education is larger than the educational differential in duration of breast feeding (see Table 9.4). This sug- gests that a diminution in the frequency as well as the overall duration of breastfeeding is associated with higher education levels. 5.5 Termination of Exposure to Pregnancy Later in life, the risk of pregnancy begins to decline with age, typically beginning around age 30. While the onset of infe- cundity is difficult to determine for any individual woman, there are ways ofeslimating it for a population. Table 5.9 presents an indicator of decreasing exposure to the risk of pregnancy for women age 30 and above--the percentage of women who have entered menopause. Here, a woman is considered menopausal if Table 5.8 Median duration of postpartum amenorrhoea Median number of months of postpartum amenorrhoea, by selected background characteristics, Malawi 1992 Amenor- Number Background rhoeic of characteristics (months) births Age (years) <30 11.3 171)5 30+ 14.5 109 Residence Urban 10,0 315 Rural 12,3 2485 Region Northern 11,9 331 CenZral 11.5 1170 Southern 12.3 1299 Education No education 14.6 I410 Primary 1-4 11.5 675 Primary 5-8 9.2 628 Secondary+ 7.4 86 Total 11.9 2800 Note: Medians are based on current status. 57 she is not pregnant or postpartum amenorrhoeic, and she has not had a menstrual period in the six months preceding the survey. As expected, the percent of women who are menopausal (based on this definition) steadily increases with age, from 7 percent of women age 30-34 to nearly a third of women age 48-49. Table 5.9 Menopau~ Percentage of non-pregnant, non- amenorrhoeic married women age 30-49 whose last menstrual period occurred six or more months preceding the survey or who report that they axe menopausal, by age, M',dawi 1992 Number Percentage of Age menopausal women 30-34 7.2 314 35-39 5.2 272 40-41 14.9 113 42-43 16.1 134 44-45 20.3 99 46-47 31.5 84 48 49 32.5 84 Total 13.5 1101 58 CHAPTER 6 FERTILITY PREFERENCES Women and men were asked several questions in order to ascertain their fertility preferences: their desire to have another child, the length of time they wanted to walt before having a child, and the number of children they considered to be ideal. These data make the quantification of fertility preferences possible and, in combination with data on contraceptive use, allow an estimation of the demand for family planning, either to space or to limit births. 6.1 Desire for More Children Table 6.1 presents fertility desires among women and men by the number of living children. Although 58 percent of currently married women would like to have another child, only 19 percent want one within two years. T/tiny-seven percent would prefer to wait two or more years. Nearly a quarter of married women want no more children than they already have. Thus, a majority of women (61 percent) want either to space their next birth or end childbearing altogether (Figure 6.1). This represents the proportion of women who are potentially in need of some method of family planning. Table 6.1 Fertility preferences Percent distribution of currently married women and men by desire for more children, according to number of living children, Malawl 1992 Number of living children I Desire for children 0 1 2 3 4 5 6+ Total FEMALES Have anolher soon 2 58.9 23.4 22,4 12,7 11.6 6,6 3.2 18.5 Have another later 3 12.6 56.5 49.8 47.4 36.8 26.5 17,0 37,3 Have another, undecided when 11.6 3.3 1,8 2,0 1.8 0,2 0.1 2,6 Undecided 6.7 5.4 8.2 11,8 10.0 13,6 11.2 9,4 Wants no more 1.2 5.2 l 1.3 16.0 31.9 42.6 56,0 23,3 Sterilised 0.5 0.6 0.7 2,2 2.5 2,0 3.6 1,7 Declared infecund 8,5 5.4 5.8 7.9 5,4 8.5 8.6 7.1 Missing 0,0 0.2 0.0 0,0 0.0 0.0 0.3 0,1 Total 100.0 100.0 100,0 100.0 100,0 100.0 100.0 100.0 Number of women 344 623 613 530 403 396 584 3492 MALES Have aaaother soon 42.0 18.5 21.9 21.1 19.6 14.2 3.5 17.7 Have another later 45.1 66.2 52.9 42.8 37.5 35.8 27.7 43.3 Have another, undecided when 5.1 0.9 1.7 2.8 0.9 0.0 1.3 1.7 Undecided 4.8 3.0 3.8 5.2 3.6 3.6 3.8 3.9 Wants no more 2.9 6.7 12.5 20.4 29,1 35.2 50.8 25.1 S terilised 0.0 0.1 1.3 1,2 2.9 1.7 1.8 1.4 Declared infecund 0.0 4.6 5,8 6.6 6.5 9,6 11.2 6.9 Missing 0.0 0.0 0.0 0,0 0.0 0.0 0.1 0,0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 104).0 Number of women 75 127 149 121 110 82 202 866 llncludes current pregnancy 2Wants next birth within 2 years 3Wants to delay next birth for 2 or more years 59 Figure 6,1 Fertility Preferences among Currently Married Women 15-49 Undecided 9% Sterilised 2S~ Infeeund 7% Want child, undecided 3% Wants child soon 19% Wants no more 23% i ~n[sch~ldtater 37% Nole: Soon = wilhrn 2 years; la~er = atler 2 years. MDHS 1992 1 ^ ^ Figure 6,2 Fertility Preferences among Currently Married Women by Number of Living Children Percent 0 1 2 8 4 5 Number of Living Children 6+ MDHS 1992 60 As expected, the desire to discontinue childbearing increases sharply with increasing number of l iving children, from 1 percent among married women without a child to 56 percent among women with 6 or more children (Figure 6.2). A similar pattem of changing fertility desires with number of l iving children is also observed among men. Table 6.2 shows similar data according to the age of women and men. The desire to l imit births rises rapidly with age, from 4 percent of married women age 15-19 to 45 percent of those age 45-49. Conversely, the desire to space births declines with age. In other words, the potential need for family planning services is greatest among older women for l imiting childbearing and among younger women for spacing births. The net effect of these two opposing pattems is that the proportion of women falling into one of these two groups is roughly constant at between 50-60 percent. This pattern of a shift in spacing and l imiting desires with increasing age is also observed among men. However, the overall desire to space or l imit is greater among men than women. About one-third of both men and women at older ages (women 45-49, men 50-54) declared themselves infecund. Table 6.2 Fertility preferences by age Percent distribution of currently married women and men by desire for more children, according to age, Malawi 1992 Age of woman Desire for children 15-19 20-24 25-29 30-34 35-39 40-44 45-~9 Total Have another soon 1 26.7 25.7 21.6 15.7 14.6 7.8 7.0 18.5 Have another late~ 56.2 56,2 47.7 31.3 23,8 12.9 4.0 37.3 Have another, undecided when 7.3 2.6 2.9 2.1 1.5 1.0 0.0 2.6 Undecided 5.4 7.5 7.6 15.0 10.6 10.4 9.5 9.4 Wealts no more 4.0 7.6 17.1 28.8 37.5 43.3 45.1 23.3 S teailised 0.0 0.0 1.2 2.7 3.2 3.8 2.4 1.7 Declared infecund 0.4 0.5 2.0 4.3 8.8 20.6 31.3 7.1 Missing 0.0 0.0 0.0 0.0 0.0 0.4 0.6 0.1 Total 100.0 100.0 100.0 1{30.0 100.0 100.0 100.0 100.0 Number 388 743 661 584 455 408 253 3492 Age of man Desire for children 20-24 25-29 30-34 35-39 40~4 45-49 50-54 Total Have another soon I 27.1 23.0 23.5 18.8 12.0 10.5 3.2 17.7 Have another later 2 60.1 60.4 44.7 38.8 41.2 32.8 12.1 43.3 Have another, undecided when 1.6 2.4 1,0 1.3 1,6 2.0 1.7 1,7 Undecided 4.1 1.0 6.8 2.8 6.6 3.3 2.1 3.9 Wants no more 6.9 11.2 22.3 32.9 29.8 35.0 46.1 25.1 Sterilised 0.2 0.0 1.4 1.2 1.9 5.4 0.7 1.4 Declared infecund 0.0 2.0 0.3 4.0 6.8 10.8 33.9 6.9 Missing 0.0 0.0 0.0 0.1 0.0 0.2 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 100 163 147 129 147 83 95 866 XWants next birth within 2 years 2Wants to delay next birth for 2 or more years 61 Table 6.3 presents the percentage of currently married women and men who want no more children by number of living children and selected background characteristics. Women living in urban areas more frequently reported wanting no more children (32 percent) than did women in rural areas (24 percent). This difference becomes more pronounced as the number of living children increases; 80 percent of urban women with 6 or more living children want no more children, compared to 57 percent of rural women. Interestingly, the widening of the urban-rural differential at a higher number of living children is not as marked for men. Regional differences in the desire for no more children are not large, especially at lower parities. At higher parities, however, women from the Central Region more frequently report that they prefer no more children than women from the Northern and Southern Regions. The desire to have no more children is related to the education of the woman; however, only at the level of secondary education is a greater desire to limit births clearly observed. Table 6.3 Desire to limit (stop) childbearing Percentage of cta"rently married women and men who want no more children, by number of living children and selected background characteristics, Malawi 1992 Number of living children ~ Background char~t~ist ic 0 1 2 3 4 5 6+ Total FEMALES Residence Urban (1.2) 5.2 18.1 25.8 36.6 (59.9) 79.6 31.5 Rural 1.7 5.8 11.2 17.2 34.1 42.7 57.1 24.2 Region Northern (1.2) 3.9 10.9 20.7 28.0 (45.2) 61.9 25.5 Central 1.7 5.2 11.0 22.6 41.3 48.4 70.7 29.5 Southern 1.6 6.8 13.1 13.3 30.6 40.9 48.2 21.2 Education No education 3.5 5.7 11.7 18.1 35.8 41.4 54.9 25.7 Primary 14 0.0 7.2 10.9 16.2 30.9 39.3 61.3 22.4 Primary 5-8 0.0 4.3 12.6 16.1 27.2 54.6 66.8 23.6 Secondary+ 0.0" 6.2* 24.4* 45.8* 73.5* 80.7* 95.6* 44.6 Total 1.6 5.8 12.1 18.2 34.4 44.6 59.6 25.0 MALES Residence Urban (4.3) (4.9) (20.3) (17.9) (46.8) (43.5) 58.4 30.7 Rural 2.6 7.2 13.1 22.5 29.3 35.6 51.6 25.8 Total 2.9 6.8 13.9 21.7 31.9 36.9 52.5 26.5 Note: Women and men who have been sterilised are considered to want no more children. qncludes current pregnancy for women ( ) Based on 2.5 J,9 cases * B~ed on less than 25 cases 6.2 Demand 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 62 considered to have an unmet need for family planning, t Women who are using family planning methods are said to have a met need for family planning. Women with unmet and met need together constitute the total demand for family planning. Table 6.4 presents data on unmet need, met need and total demand for family planning, according to whether the need is for spacing or limiting births. Over one-third of married women have an unmet need for family planning services, 20 percent for spacing purposes and 17 percent for limiting births. Combined with the 13 percent of married women who are currently using a contraceptive method, the total demand for family planning comprises half the married women in Malawi. Thus, if all women who say they want to space or limit their children were to use methods, the contraceptive prevalence rate could be increased from 13 percent to 50 percent of married women. At present, only about one-quarter of the potential demand for family planning is being met (next-to- last column in Table 6.4). Table 6.4 Need for family planning services Percentage of currently married women with unmet need for family planning, met need for fanfily planning, and the total demand for family planning services, by selected background characteristics, Malawi 1992 Met need for Unmet need for family planning. Total demand for Percentage family planning I (currently ~ing)" family planning of demand Background For For For For For For satis- characteristic spacing limiting Total spacing limiting Total spacing limiting Total fled Total Age 15-19 20.1 6.4 26.5 6.9 0.4 7.3 27.0 6.8 33.8 21.5 388 20-24 27.5 4.6 32.1 10.9 1.1 12.0 38.4 5.7 44.0 27.2 743 25-29 24.2 12.3 36.5 11.3 3.5 14.8 35.5 15.8 51.3 28.8 661 30-34 19.8 17.1 37.0 7.8 8.4 16.2 27.6 25.5 53.2 30.4 584 35-39 18.2 24.0 42.2 5.2 11.2 16.4 23.4 35.3 58.7 28.0 455 40-44 10.6 32.8 43.5 1.2 11.9 13.2 11.9 44.8 56.6 23.3 408 45-49 3.2 36.6 39.8 0.0 6.4 6.4 3.2 43.1 46.2 13.9 253 Resldenee Urban 16.3 19.5 35.8 10.9 11.9 22.9 27.2 31.4 58.6 39.0 411 Rural 20.3 16.1 36.4 6.9 4.8 11.7 27.2 20.9 48.1 24.3 3081 Region Northern 18.6 12.4 31.1 10.6 7.2 17.9 29.3 19.6 48.9 36.5 430 Central 18.2 19.0 37.2 6.6 6.5 13.1 24.7 25.5 50.3 26.0 1402 Southern 21.5 15,4 37.0 7.2 4.5 11.7 28.7 20.0 48.7 24.0 1660 Education No education 19.1 17.4 36.5 5.5 4.5 10.0 24.6 21.9 46.5 21.6 1815 Primary 1-4 21.3 15.7 37.1 6.7 4.4 11.1 28.0 20.2 48.2 23.0 819 Primary 5-8 21.2 15.6 36.8 11.3 6.7 18.0 32.4 22.3 54.8 32.9 750 Secondary+ 11.4 13.6 25.0 16.2 26.8 43.0 27.5 40.5 68.0 63.2 107 Total 19.8 16.5 36.3 7.4 5.7 13.0 27.2 22.2 49.3 26.4 3492 IUnmet need for spacing refers to pregnant women wh~e pregnancy was mistimed, amenorrhoeic women whose last birth was mistimed, and women who are neither pregnant nor ata~norrhoeic and who are not using any method of family planning and say they want to wait two or more years for their next birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhoeic women whose last child was unwanted, and women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and who want no more children. Also excluded are menopausal women, defined in Table 5.9. 2Using for spacing refers to women who ate using some method of family planning and who say they want to walt two or mote years for their next child. Using for limiting refers to women who are using and who want no more children. Note that the specific methods used are not taken into aceounL For an exact description of the calculation, see footnote 1, Table 6.4. 63 The overall unmet need for family planning increases with age. As expected, unmet need for spacing purposes is higher among younger women, while unmet need for limiting childbearing is higher among older women. There is almost no difference in the level of unmet need among urban and rural women, although there is a slightly higher unmet need in the Southern and Central Regions than in the Northern Region. Unmet need is lower among women with some secondary education than among other women, even though there is a greater overall demand in this group of women. This is primarily due to the fact that a much larger proportion of secondary educated women are currently using family planning, leading to a larger percent of their demand being satisfied (i.e., met need), as shown in Figure 6.3. Figure 6,3 Percentage of Women with Unmet Need and Met Need for Family Planning Services by Background Characteristics RESIDENCE Urban Rural REGION Northern Central Southern MATERNAL EDUCATION No Education Primary 1-4 Primary 5-8 Secondary + 10 2O 3O 40 50 Percent 60 70 80 90 100 Note: Unmet need plus met need equals total demand (need) for contraceplion MDHS 1992 6.3 Ideal Family Size Information on what women and men feel is the ideal family size was elicited through two questions. Respondents who had no children were asked, "If you could choose exactly the number of children to have in your whole life, how many would that be?" For respondents who had 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 whole life, how many would that be?" Some respondents, especially those for whom fertility control is an unfamiliar concept, may have had some difficulty in answering this hypothetical question. The data in Table 6.5 indicate that the majority of women and men were able to give a numeric answer to this question; nevertheless, 13 percent of women and 8 percent of men gave a non-numeric answer, such as "it is up to God," "any number" or "do not know." Those who gave numeric responses generally want to have large families. Over one-quarter (29 percent) of all women said they would choose to have six or more children, with an average numeric response of 5.1 children. There is a possibility that some women may report their actual number of children as their ideal number, since they may find it difficult to admit that they would not choose to have so many children if they could start afresh. Indeed, women who have fewer 64 Table 6.5 Ideal and actual number of children Percent distribution of all women and men by ideal number of children and mema ideal number of children for all women and men and for currently married women and men, according to number of living children, Malawi 1992 Number of living children 1 Ideal number of chiidron None 1 2 3 4 5 6+ Total FEMALES 0 0.5 0.1 0.2 0.3 0. l 0.1 0.0 0.2 1 1.7 2.5 0.6 0.3 0.0 0.3 0.3 1.0 2 11.5 6.0 5.8 4.1 4.5 3.2 2.2 6.0 3 14.9 12.9 8.9 8.4 5.3 3.7 3.0 9.2 4 25.2 28.7 28.8 20.6 16.2 14.6 10.4 21.8 5 21.7 21.8 22.3 22.6 15.6 18.8 12.3 19.7 6+ 13.7 17.5 22.3 31.2 42.6 41.7 51.5 28.5 Non-numeric response 10.8 10.6 11.1 12.5 15.6 17.5 20.3 13.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1086 829 718 607 474 465 670 4849 Mean ideal number 4.2 4.5 4.8 5.2 5.6 6.0 6.4 5.1 Number of women 969 741 638 531 400 384 534 4197 Mean for married women 4,6 4.5 4.8 5.2 5.6 6.0 6.4 5.3 Number of ram-led women 313 552 541 462 334 323 461 2985 MALES 0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1 1.2 2.0 1.0 0.0 0.0 0.0 0.0 0.7 2 9.9 6.0 4.3 0.9 4.9 2.9 3.2 5.3 3 20.9 14.2 8.2 10.5 5.1 5.6 4.3 11.3 4 30.7 35.9 35.3 31.3 30.2 15.4 10.4 27.2 5 17.5 19.9 15.1 19.5 10.1 18.2 4.0 14.6 6+ 15.1 15.3 28.6 31.7 40.1 47.8 63.9 32.7 Non-numeric response 4.7 6.6 7.6 6.0 9.5 10.1 14.1 8.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 293 159 159 128 115 89 208 1151 Mean ideal number 4.1 4.3 4.9 5.0 5.3 6.2 7.3 5.2 Number of men 279 149 147 120 104 80 178 1057 Mean for married men 4.3 4.4 4.9 5.0 5.3 6.2 7.2 5.4 Number of married men 72 119 141 113 99 75 173 791 Note: The means exclude respondents who gave non-numeric responses. llncludes current pregnancy for women children do report smaller ideal family sizes than women with more children. For example, the average ideal family size is 4.5 among women with one child, compared to 6.4 among women with six or more children. Many of the women with fewer children are young and, to the extent that their fertility preferences do not increase over time and that they can realise their ideal number of children, fertility in Malawi may decline. The data show evidence of unwanted fertility; for example, more than one-quarter of the women with six or more children said that they would ideally like to have had fewer than 6 children. 65 Interviewed men reponed very similar family size ideals as women, with the ideal number ol children only slightly higher (5.2) than among women (5,1) Table 6.6 shows the mean ideal number of children for all women and men by age according to selected background characteristics. The mean ideal family size increases with age of the respondent from 4.3 to 6.4 children, from the youngest age group of women (15-19) and men (20-24) to the oldest age group of women (45-49) and men (50-54). At every age, rural womcn and men have higher family-size norms than urban women and men. Very little regional variation in ideal family size is observed. However, ideal family size is negatively related to education level attained; as the education of a woman increases, her desired family size decreases. Table 6.6 Mean ideal number of children by background characteristics Mean ideal number o[ children for all women and men, by age and selected background characteristics, Malawi 1992 Age of woman Background characteristic 15 19 20-24 25 29 30-34 35 39 40-44 45 49 Total Residence Urban 4.1 3.9 4.4 5.1 5 3 5.9 (5 5) d, fi Rural 4.3 4.5 5 0 5.6 5 7 6.3 6 5 5.1 Region Northern 4.3 4.6 5.0 5.7 5.8 6.4 6.8 5.1 Central 4.0 4.2 5.2 5.7 5.6 5 9 6.3 5.1) Southern 4.5 4.4 4.7 5.5 5.7 6 5 6.5 5 1 Education No education 4.5 4.6 5 0 5.8 5.5 6.5 6.4 5 4 Primary 1-4 4.4 4.5 5.1 5.8 6.[ 5.8 6.8 5.[ Primary 5-8 4.2 4.3 4.9 5.1 5.8 6.4 6 3 4.7 Secondary+ 4.1 3.5 4.1 (4.1) (4.5) * * 4 0 Total 4.3 4.4 4.9 5.6 5.6 6.3 6.4 5 1 Age of man Background characteristic 20-24 25 29 30-34 35 39 40 44 45 49 50 54 Total Residence Urban 3.9 3.9 4.3 (5.2) (5.2) (5 2) (5.9) -1 5 Rural 4 4 4.5 4.9 5.9 6.3 6.9 6.5 5 3 Total 4.3 4.4 4.8 5.8 6.2 6.6 6.4 5.2 ( ) Based on 25-49 cases * Based on less than 25 cases 6.4 Wanted and Unwanted Fertility There are two ways of estimating levels of unwanted fertility from MDHS data. One is based on responses to a question on whether each birth in the five years before the survey was planned (wanted then), mistimed (wanted, but at a later time), or unwanted (wanted no more children), These data arc likely to result in underestimates of unplanned childbearing, since women may rationalisc unplanned births and declare them as planned once they are born. The other method of measuring unwanted [i~rtility utilises the data on ideal 66 family size to calculate "wanted" fertility rates. These too may suffer from underestimation to the extent that women are reluctant to report an ideal family size lower than their actual family size. Table 6.7 shows the percent distribution of births in the five years before the survey (including current pregnancies) by whether a birth was wanted then, wanted later, or not wanted. Fourteen percent of recent births were reported to be unwanted and 27 percent were reported as mistimed (wanted later). The percentage of births that was mistimed or unwanted goes up with birth order, from 31 percent of first births to 52 percent of 6th and higher births. Similarly, a much larger proportion of births to older women are unwanted than are those to younger women. While less than 10 percent of births to women under age 25 are unwanted, one-third of births to women 40 and older are unwanted. Table 6.7 Wanted and unwanted births Percent distribution of births in the five years preceding the survey (including current pregnancies) by whether birth was wanted and when, according to birth order and mother's age. Malawi 1992 Planning status of birth Birth order Wanted Number and mother's Wanted Wanted no of age then later more Missing Total births Birth order 1 68.1 21.0 9.8 1.1 100.0 949 2 66.4 25.3 7.5 0.8 100.0 811 3 62.1 28.6 9.1 0.2 100.0 708 4 59.3 29.6 10.4 0.7 100.0 640 5 58.0 28.3 13.3 0.4 100.0 537 6+ 47.6 28.0 24.1 0.4 100.0 1523 Age of mother at birth <20 62.4 26.7 9.7 1.2 100.0 943 20-24 63.4 26.4 9.6 0.6 100.0 1372 25-29 61.7 26.2 11.5 0.6 100.0 1109 30-34 53.7 30.5 15.6 0.2 100.0 792 35-39 52.9 25.6 21.3 0.2 100.0 570 40-44 46.4 20.4 32.8 0.5 1(30.0 303 45-49 39.4 26.3 34.4 0.0 100.0 79 Total 58.8 26.6 14.0 0.6 100.0 5168 Note: Birth order includes current pregnancy. Table 6.8 presents wanted fertility rates. The wanted fertility rate is calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. (Note: Women who did not report a numeric ideal family size were assumed to want all their births.) This rate represents the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been prevented. A comparison of the total wanted fertility rate and the actual total fertility rate suggests the potential demographic impact of the elimination of unwanted births. 67 The wanted total fertility rate was 5.7 for Malawi as a whole, one child lower than the actual total fertility rate. Moreover, this difference of one child between the wanted and actual total fertility rates is uniformly exhibited across all population subgroups. Table 6.8 Wmated fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by selected background characteristics, Malawi 1992 Total wanted Total Background f~r tillty feztility characteristic rate rate Residence Urbma 4.38 5.51 Rural 5.92 6.88 Region Northern 5.76 6.74 Centlal 6.39 7.44 Southern 5.23 6.17 Education No education 6.19 7.16 Primary 1-4 5.75 6.70 Primary 5-8 5.12 6.17 Secondary+ 3.26 4.37 Total 5.74 6.73 Note: Rates are based on births to women 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 3.2. 68 CHAPTER 7 CHILDHOOD MORTALITY One of the major objectives of the survey was to estimate rates of childhood mortality. Information on past and current levels of childhood mortality is an integral part of an overall demographic assessment and crucial to the evaluation of health and population programmes. Furthemaore, through estimation of mortality by age group and across characteristics of households and women, this chapter alms to identify sectors of the population that are at high risk of poor health and survival. 7.1 Data Quality and Mortality Estimation The childhood mortality rates presented here were calculated using information collected in the birth histories of female respondents. For each child who died, the respondent was asked to provide an age at death. If the child died in the first month after birth, the age at death data was recorded in units of days. If the death was before the second birthday, the age at death was collected in units of months, in order to minimise age heaping at "1 year." If the death occurred at 24 months of age or later, the age at death was recorded in years. From these data, period-specific, age-specific probabilities of mortality were estimated using a conventional life-table approach. The rates, actually true probabilities, presented in this report are: Neonatal mortality rate--the probability of dying within the first month of life Post-neonatal mortality rate--the difference between infant and neonatal mortality Infant mortality rote the probability of dying before the first birthday Child mortality rate---the probability of dying between the first and fifth birthday Under-five mortality rate--the probability of dying between birth and the fifth birthday. The term childhood mortality is used here simply to speak generally of mortality during childhood and carries no specific meaning regarding age period of risk. Unreported birth dates are a potential problem in this type of data, hut were uncommon in the MDHS; only 0.1 percent of births lacked a year of birth. A further 3.7 percent of births had a year of birth but lacked a month of birth, thus requiring imputation of a birth date within a fairly short 12-month range. Furthermore, only 0.2 percent of deaths recorded in the birth histories lacked an age at death. In the case of missing age at death a "hot deck" procedure was used to impute this information. ~ Misreporting of age at death will bias estimates of the age pattem of mortality if the net result of the misreporting is the transference of deaths between age segments for which rates are calculated. For example, an overestimate of child mortality (1-4 years) and an underestimate of infant mortality may result if children dying during the first year of life (say, month 10 or 11) are reported as having died at 12 months of age or 1 year. This phenomenon of reporting preferred digits is called "heaping." There was surprisingly little heaping on particular months of death in the MDHS and, due to strong emphasis during training and field supervision, very few deaths were reported to have occurred at age one year (see Appendix C, Table C.6), making any adjustment in infant and child mortality rates unnecessary. Underreporting of childhood deaths is a potentially serious problem in data of this type and is thought most likely to occur for deaths during the first few days after birth. If early neonatal deaths are selectively IThis procedure assigns an age at death equal to that of the last death in the data file of the same birth order. 69 underreported, the result would be an abnormally low ratio of deaths under seven days to all neonatal deaths. Moreover, if such underreporting is more common for deaths occurring in less recent periods or is related to the sex of the child, then this ratio would also be differentially affected. It should, however, be borne in mind that this type of internal consistency check will be insensitive to all but large- scale underreporting. Table 7.1 shows the ratio of deaths in the first week after birth (0-6 days) to all neonatal deaths (0-30 days) by sex of the child and calendar period of death. There is only minor variation in the ratio among the three time periods and between males and females. The ratios for females tend to be more variable--still, the lowest (0.63) and highest (0.72) ratios are very similar and are at an acceptable overall level. This suggests that gross under- reporting of early neonatal deaths is not a problem in these data, and that selective underreporting, if it has occurred, is minor. Table 7.1 Neonatal deaths Ratio of deaths in the first week (0-6 days) to all neonatal deaths (0-30 days), by sex of child. Malawi 1992 Years before survey Sex of child 0-4 5-9 10-14 Male 0.67 0.66 0.68 Female 0.72 0.63 0.65 Both sexes 0.70 0.64 0.67 These checks on the quality of the MDHS mortali- ty data indicate that the data are of reasonably good quality and that there is no serious underreporting of deaths during the time periods for which the mortality rates are estimated. Although there is some evidence of beaping in age at death at certain ages, the bias in infant and child mortality rates arising from this heaping is negligible. Finally, it is important to note that any method of measuring childhood mortality that relies on mothers' reports (e.g., birth histories) rests on the assumption that adult female mortality is not very high or, if it is high, that there is little or no correlation between the mortality risks of mothers and their children. In countries with high female mortality rates, these assumptions do not hold and the resulting childhood mortality rates will be understated to some degree. 7.2 Levels and Trends in Chi ldhood Morta l i ty Table 7.2 presents childhood mortality rates for periods 0-4, 5-9, and 10-14 years before the survey. Under-five mortality has declined slowly over the last decade from 258 deaths per 1000 live births during the 1978-1982 period to 234 deaths per 1000 live births for the 1988-1992 period. This means that, currently, Table 7.2 Childhood mortality Childhood mortality rates by five-year periods preceding the survey, Malawi 1992 Years Approximate Neonatal Posmeonatal Infant Child Under-five preceding calendar mortality mortality mortality mortality mortality survey period (NN) (PNN) (tq0 Qq0 (sq0 0-4 1988-1992 40.8 93.5 134.3 114.9 233.8 5-9 1983-1987 57.5 80.0 137.5 126.1 246.3 10-14 1978-1982 62.1 74.3 136.4 140.8 258.0 0-9 1983-1992 48.8 86.9 135.7 120.I 239.5 Note: Month of interview excluded from analysis 70 about 1 in 4 Malawian children do not live to see their fifth birthday. Figure 7.1 shows that Malawi has the highest level of under-five mortality among the 11 countries of Eastern and Southern Africa where DHS surveys have been undertaken. During 1978-1982, roughly half of under-five mortality occurred during infancy and haifduring ages 1-4 years. A nearly constant infant mortality rate, combined with an 18 percent decline in child mortality since 1978-1982, has led to change in the age pattern of under-five mortality, so that in 1988-1992 60 percent occurs during infancy. Current infant mortality stands at 134 deaths per thousand, and child mortality (1-4 years) at 115 deaths per thousand. Figure 7.1 Under-five Mortality in East and Southern Africa, Selected DHS Surveys Madagascar Tanzania Zimbabwe Botswana Malawi Zambia Uganda B u r u n d i . R w a n d a i - i . . " K e n y a ~ Namibia 0 50 100 150 Deaths per 1000live bJrlhs 200 250 While the level of infant mortality has remained fairly constant over the last decade, the age pattern ofinfant mortality has undergone changes. Over the 1978-1982 to 1988-1992 period, neonatalmortality feU by one-third from 62 to 41 per 1000, but was effectively offset by a 25 percent increase in postneonatal mortality from 74 to 94 over the same period (Figure 7.2). The observed rise in posmeonatal rates signals a need for more detailed analysis of its cause(s). 71 160 140 ! 20 100 60 60 40 20 0 Figure 7,2 Trends in Neonatal (< 1 month), Postneonatal (1-11 months), and Child (12-59 months) Mortality Deaths per 1000 live births Neonatal Mortality Postneonatal Child Mortafity Marlality MDHS 1992 7.3 Socioeconomic Differentials in Childhood Mortality The following section presents information on differences in mortality risk across population subgroups. In order to maintain adequate numbers of events and thus ensure statistically reliable estimates, the calendar period on which covariate estimates are based is the 10-year period before the survey. Place of Residence Table 7.3 and Figure 7.3 show that childhood mortality rates in rural areas are generally higher than those in urban areas. The urban-rural difference is especially pronounced in the 1-4 year age period, when rural children are 24 percent more likely to die than their urban counterparts. During the neonatal period, mortality risk does not vary substantially between urban and rural areas. The MDHS demonstrates regional variation in childhood mortality. Under-five mortality in the Central Region is 262 per 1000 compared to 230 in the South and 202 in the Northern Region. Nearly all of the regional varation in under-five mortality is explained by variation during ages 1-4 years; infant rates do not vary as much regionally. Child mortality (1-4 years), on the other hand, is more than 50 percent higher in the Central Region than in the rest of the country. Mother's Education Table 7.3 shows that a mother's education is strongly related to her children's chances of survival. Under-five mortality is twice as high among children of women without any education than among children of mothers with some secondary education. This education-mortality link is clearly demonstrated during all age segments, but is most pronounced during ages I-4 years. 72 Table 7.3 Childhood mortality by socioeconomic characteristics Childhood mortality rates for the ten-year period ixeceding the survey, by selected socioeconomic characteristics, Malawi 1992 Neonatal Posmeonatal Infant Child Under-five Socioeconomic mortality mortality mortality mortality mortality eharacteaistic (NN) (PNN) (tqo) (4ql) (sqo) Residence Urban 50.9 67.3 I 18. I 98,9 205.4 Rural 48.6 89.4 138.0 122.9 243.9 Region Northern 47.7 73,0 120.7 92,3 201.9 Central 44.3 85.9 130,2 151.0 261.6 Southern 53,1 91.2 144.3 100,1 230.0 Education No education 51.5 91.3 142,8 130.8 254.9 Primary 1-4 49,7 85,9 135.6 124,9 243.6 Primary 5-8 43,1 80.4 123.6 97,1 208.7 Secondary+ (35.1) (61.2) (96.3) (34.2) (127.3) Total 48.8 86.9 135.7 120.1 239.5 Note: Month of interview excluded from analysis ( ) Based on 250-499 cases Figure 7.3 Under-five Mortality by Selected Background Characteristics MATERNAL EDUCATION Non(} Prm~ary 1 4 Primary 5 8 SecoPda,y + RESIDENCE Urban Rural REGICN Norlhem (:t:rqral {~Odbl~rr/ 50 1 O0 I 5,.0 200 250 L'( ,H']. I,~.r 19,,00 live blrEhs 300 MDHS 1992 73 7.4 Biodemographic Differentials in Childhood Mortality Due to heritable factors, mortality among male children tends to be higher than among females. Table 7.4 shows that under-five mortality is about 10 percent higher among boys than girls. The excess male mortality is observed during all age periods. Table 7.4 Childhood mortality by biodemographic characteristics Childhood mortality rates for the ten-year period preceding the survey, by selected biodemographic characteristics, Malawi 1992 Neonatal Postneonatal Infant Child Under-five Biodemographic mortality mortality mortality mortality mortality characteristic (NN) (PNN) (tqo) (4qI) (sq0) Sex of child Male 49.8 91.2 141,0 125.9 249.1 Female 47.9 82.5 130.4 114.4 229.8 Age of mother at birth < 20 79.1 100.2 I79.3 143.9 297.4 20-29 43.5 81.9 125.5 117.2 228.0 30-39 38.3 85.0 123.3 111.2 220.8 40-49 (38.2) (91,4) (129.6) 92.1" (20%7) Birth order 1 76.8 98.3 175.1 126.8 279.7 2-3 47.5 86.5 134.0 132.5 248.8 4-6 39.6 78.9 118.5 110.8 216.1 7+ 40.0 89.7 129.6 109.7 225.1 Previous birth interval < 2 yrs 65.9 116.0 181.9 161.4 313.9 2-3 yrs 35.1 75.5 110.6 108.5 207.1 4 yrs + 31.1 65.0 96.1 76.6 165.3 Size at birth t Very sinai1 188.1" 128.9" 317.0" 102.2" 386.8* Small 42.7 (I08.5) (151.2) (107.6) (242.5) Average or larger 30.2 91.1 121.4 106.2 214.7 Medical maternity care 1 No matenataYdelivery care (68.0) (127.0) (195.0) 193.3" (350,6) Either antenatal or delivery 42.3 111.6 154.0 (116.3) 252,4 Both antenatal & delivery 35.7 81.7 117.4 93.9 200,3 Total 48.8 86.9 135.7 120.I 23%5 Note: Month of interview excluded from analysis tRates for the five-year period preceding the survey. ( ) Based on 250-499 cases * Based on less than 250 cases 74 In Chapter 3, it was noted that a significant proportion of women in Malawi were entering childbearing at early ages, i.e., before age 20. Table 7.4 and Figure 7.4 show that this pattern of early childbearing is associated with significantly higher risks of childhood death. The neonatal period is especially sensitive to this effect. Children of mothers under age 20 are twice as likely to die in the first month of life as children of mothers age 30 or older. First births carry a higher risk of mortality due to both biological and social factors. The data show that first births are 92 percent more likely to die in the neonatal period than children of birth order 4 or more. The vulnerability of first births diminishes considerably after the neonatal period, so that during the 1-4 year age period first births are only 15 percent more likely to die than children of birth order 4 or more. Table 7.4 also shows that short birth intervals are associated with higher mortality during and after the first year of life. The harmful effects of short birth intervals are especially pronounced during the neonatal period and the 1-4 year age period; periods during which children bom within 24 months of a previous child are more than twice as likely to die as children born after an interval of 4 years or more. That the effect of short birth intervals on mortality risk remains so pronounced after infancy suggests that maternal depletion and poor pregnancy outcome are not the only factors mediating the birth interval/mortality relationship. The f'mding does point to the conclusion that intra-household competition between similar age children for scarce resources (time, food, etc.) also plays a very important role. In any case, the enormity of this relationship demonstrates the potential for mortality reduction that could result from successful efforts to better space children in Malawi. Figure 74 Under-five Mortality by Selected Biodemographic Characteristics AGE AT BIRTH OF CHILD < 20 years 20 29 years 30 39 years 40 + yea~s BIRTH INTERVAl LENGTH < 24 months 24 47 months 48 + monlhs MATERNITY SERVICES Ne~the~ ANC or DC ANC & DC ANC =Antenatal Care DC Delivery Care I ] 0 100 200 300 Deaths per 1000 Iwe births 400 MDHS 1992 75 For each child born in the last five years, mothers were asked whether they thought the child was "very large, large, average size, small, or very small" at birth. Previous studies have shown that "small" and "very small" responses to this question are highly correlated with the incidence of low birth weight, which is in turn highly related to infant mortality, especially during the neonatal period. The data demonstrate this association (Table 7.4). Neonatal mortality is six times higher among children who were "very small" at birth than those who were judged average or above average in size. "Small" size at birth was associated with a 41 percent excess neonatal mortality. This effect continues to prevail during the postneonatal period but at a weaker level, and vanishes altogether after the first birthday. These findings suggest an opportunity to bring down infant mortality associated with low birth weight through the targetting of high-risk pregnancies for close medical supervision. Table 7.4 fu~her shows the relationship between use of basic matemity services and childhood mortality. Under-five mortality is 75 percent higher among children whose mothers received neither antenatal care nor medically-supervised delivery services as compared to children whose mothers received both services. Maternity services are apparently most protective during the 1-4 year age period. This indicates that this variable is linked not only to pregnancy outcome (and thus neonatal mortality), but probably serves as a proxy for the use of other health services that would be expected to impact survival after the first birthday (e.g., vaccination services, treatment of childhood illnesses, etc.). 7.5 High-Risk Fertility Behaviour Numerous studies have demonstrated a strong relationship between a mother's pattern of fertility and her children's survival chances. Results presented in the previous section bear this out. Typically, infants and young children have a higher risk of dying if they are born to very young mothers or older mothers, if they are born after a short interval, or if their mothers have already had many children. In the following analysis, mothers are classified as too young if they are less than 18 years old at the time of birth, and too old if they are age 35 years or more at the time of birth. A short birth interval is defined as one less than 24 months, and a high birth order as one occurring after five or more previous births (i.e., birth order 6 or higher). Births are also cross-classified by combinations of these characteristics. Thus, a birth may have from zero to three potentially high-risk characteristics. Column one of Table 7.5 shows the percentage of births during the five years before the survey that fall into various risk categories. More than half of births fall into at least one risk category, with about 20 percent having multiple risk characteristics. Risk ratios are presented in column two; the risk ratio is the ratio of the proportion of live births in a risk category who have died to the proportion dead among those who do not fall into any risk category. Two points need emphasis. First, high birth order is not associated with higher mortality risk in Malawi unless coupled with older age and short interval length. Since such a large percentage of births are of high birth order in Malawi, this operates to reduce the risk ratios for "any single high-risk" category to 1.1 and "any multiple high-risk" category to 1.0. Second, the main factors leading to heightened mortality risk in Malawi are young age or old age at birth as single risk factors, and short birth interval length, especially when coupled with any other risk factor(s). The latter finding again underscores the need to reduce, through greater use of contraception, the number of closely spaced births in Malawi. Column three of Table 7.5 shows the distribution of currently married, non-sterilised women by the risk category into which a currently conceived birth would fall. A comparison of this percentage with the distribution of actual births in the last five years indicates that, without fertility control, the percentage of births falling into each of the multiple risk categories could rise. Overall, the percentage of births with multiple risk characteristics could rise from 20 to 34 percent. 76 Table 7.5 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey who are at elevated risk of mortality, and the percent distribution of currently married women at risk of conceiving a child with an elevated risk of mortality, by category of increa.~ed risk, Malawi 1992 Births in 5 years preceding the survey Percentage of currently Risk Percentage Risk married category of births ratio women a Not In any high-risk category 49.0 1.0 34.0 b Single high-risk category Mother's age < 18 7.5 1.3 I 2 Mother's age > 34 2.4 (1.3) 6.8 Birth interval < 24 10.6 1.1 18.0 Birth order > 5 11.1 0 8 6.3 Any single high-risk category Multiple high-risk category Age <18 & birth interval <24 c Age >34 & birth interval<24 Age >34 & birth order>5 Age >34 & birth interval <24 & birth order >5 Birth interval <24 & birth order >5 31.6 1.1 32.3 0.6 (1.8) 0.8 0.3 (1.2) 0.6 12.9 0.8 19.3 2.6 (1.5) 6.6 3.0 (I.2) 6.4 19.5 1.0 33.7 51.0 1.0 66.0 100.0 NA 100.0 4513 NA 3492 Any multiple high-risk category In any risk category Total Number Note: Risk ratio is the ratio of the prolx~rtion dead of bLrths in a specific risk category to the proportion dead of births not in any risk category. Figures in parentheses are ratios based on fewer than 200 cases. NA = Not applicable ( ) Based on 250-499 cases aWomen were assigned to risk categories according to the status dley would have at the birth of a child, if the child were concewed at the time of the survey: nge less than 17 years and 3 months, age older than 34 years and 2 months, latest birth less than 15 months ago, and latest btrth of order 5 or ~igher. Includes sterilised women Clncludes the combined category age <18 and birth order >5 77 CHAPTER 8 MATERNAL AND CHILD HEALTH TMs chapter presents the MDHS f'mdings in three areas of importance to maternal and child health: maternal care and characteristics of the newborn, childhood vaccinations, and common childhood illnesses and their treatment. Coupled with information on childhood morality, this information can be used to identify subgroups of women whose babies are "at risk" because of nonuse of maternal health services, and to provide information to assist in the planning of appropriate improvements in services. Data were obtained for all live births that occurred in the five years preceding the survey. 8.1 Antenatal Care and Delivery Assistance Table 8.1 shows the percem distribution of births in the five years preceding the survey by source of antenatal care received during pregnancy, according to maternal and background characteristics. Inter- Table 8,1 Antenatal care Percent distxibetion of live births in the five years preceding the su~ey, by source of antenatal care (ANC) during pregnaacy, according to maternal and selected background characteristics, Malawi 1992 Antenatal care provider ~ Trained Traditional Number Background nurse/ birth Relative/ Don't know/ of characteristic Doctor Midwife attendant Other No One Missing Total births Mother's age at birth < 20 5.8 85.6 0.5 2.8 4.6 0.7 100,0 834 20,34 7.0 83.7 0.5 1.9 6.7 0.3 100.0 2858 35+ 3.8 81.0 0.3 3.2 11.6 0.1 100,0 820 Birth order 1 5.8 85.8 0.5 2.5 4.6 0.8 100.0 825 2-3 7.7 84.4 0.7 1.7 5.4 0.1 100.0 1342 4-5 6.0 83.8 0.2 2.1 7.5 0.5 100.0 1009 6+ 4.9 81.1 0.4 3.0 10.4 0.2 100.0 1335 Residence Urban 16.5 79.8 0.3 0,3 2.8 0.3 I00.0 512 Rural 4.9 84.0 0.5 2.6 7,7 0.4 100.0 4000 Re#on Northern 3.9 89.0 0.1 0.9 6.0 0.1 100.0 521 Central 5.5 80.8 0.9 4.0 8.5 0.4 100.0 1890 Southern 7.4 84.6 0.2 1.2 6.3 0.4 100.0 2101 Mother's education No education 4.9 80.2 0.8 3.4 10.4 0.3 100,0 2308 Primary I-4 6.6 86.4 0.1 1.4 4.9 0.6 I(30.0 1071 Primary 5-8 6.8 89.2 0.0 0.9 2.9 0.2 I(30.0 997 Secondary+ 20.4 75.9 0.6 1.5 0.7 0.8 100.0 136 All blrths 6.2 83,5 0.5 2.3 7.2 014 I00,0 4512 Note: Figures are for births in the period 1-59 months preceding the survey. qf the respondent mentioned more thin1 one provider, only the most qualified provider is considered 79 viewers were instructed to record 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). For nine in ten births, mothers received antenatal care from a doctor, trained nurse or midwife, or trained clinical officer. Women received antenatal care from a traditional birth attendant (TBA) for less than 1 percent of births and no antenatal care at all for 7 percent of births (Figure 8.1). Thus, most women receive some antenatal care, relying largely on a nurse or midwife (84 percent) or a doctor (6 percent). It should be borne in mind, however, that the type and quality of care are not reflected in these figures. Figure 81 Percent Distribution of Births by Use of Selected Maternal Health Services ANTENATAL CARE l~l~ql Docfor 6 Nurse/Mid w~fe I ~ NO Onel~ 7 TETANUS None VACCINATION ° n e l/////////////z Two or Mo~e PLACE OF DELIVERY Health FaCdlly H om e V/////////////, DELVERY ABB,BT o gE N u r s e /M i a w i le k%.'~%.\N.~.~"~: Trad Birlh Attend I~.\'%.\'~.\'~.\'e. No Onem 5 Note Based on b~rths in !he five },ears preced,ng the survey ~ 6 84 I t4 113 173 '/IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII///III///A 56 Y////////////////////////////////////////Y////////d 43 ~X\\XXXX\X~I 18 20 40 iS(] 80 1 ()0 i'r,rc ( "It M[ I1 ' ] JO, ' Maternal age and the birth order of the child are related to use of antenatal care. Increasing age of the woman at birth and higher birth order of the child is associated with lower use of medically-trained personnel during pregnancy. For instance, women with 6 or more previous births are more than twice as likely as women with fewer previous births to have had no antenatal consultation. There are differences in the use of antenatal services between urban and rural areas. Whereas nearly all the births to urban women receive antenatal care from medically trained providers (96 percent), 8 percent of births to rural women receive no antenatal care at all. Also, urban women are four times more likely than rural women to have received antenatal care from a doctor. Regional differences in the use of antenatal services are small, although women in the Central Region are more likely than women in the rest of the country to have used a TBA and also more likely to have not seen anyone for care. The use o£ antenatal services is strongly associated with a mother's educmion. Women with no education are about 10 times more likely than women with some secondary education to have received no antenatal care and more than four times less likely to have received care from a doctor. 80 Antenatal care can be more effective in avoiding adverse pregnancy outcome when it is sought early in the pregnancy and continues through to delivery. Obstetricians generally recommend that antenatal visits be made on a monthly basis to the 28th week (7th month), fortnightly to the 36th week (8th month) and then weekly until the 40th week (until birth). If the first antenatal visit is made at the third month of pregnancy, this optimum schedule translates to a total of at least 12 to 13 visits during the pregnancy. Information about the number and timing of visits made by pregnant women is presented in Table 8.2. For 63 percent of births, mothers made four or more antenatal care visits, indicating that women are aware of the importance of regular attendance. For a large proportion of births (35 percent), mothers made fewer than four visits; the median number of antenatal care visits was 4.8, far fewer than the recommended number of 12. By the start of the sixth month of pregnancy, one half of Malawian women have not made a single antenatal visit (see Table 8.2). The median duration of gestation at which the first antenatal care visit was made was 5.8 months. This delayed use of services, whether because of poor access or poor knowledge by mothers, makes it difficult for the optimum benefits of antenatal cam to be reaiised. An important component of antenatal care in Malawi is ensuring that pregnant women are adequately protected against tetanus. Tetanus toxoid injections are given during pregnancy for prevention of neonatal tetanus, one of the principal causes of death among infants in many developing countries. For full protection, Table 8.2 Number of antenatal care visits and stage of pregnancy Percent dis~bution of live births in the five years preceding the smwey by number of antenatal care visits, and by the stage of pregnancy at the time of the f'trst visit, Malawi 1992 Characteristic Percent Number of ANC visits None 7.2 1 visit 2.0 2-3 visits 25.7 4+ visits 62.8 Don't know/Missing 2.3 Total 100.0 Median 4.8 Number of months pregnant at time of first ANC visit No antenatal care 7.2 <= 5 months 49.7 6-7 months 38.8 8+ months 3.4 Don't know/Missing 1.0 Total 100.0 Median 5.8 Total 4512 a pregnant woman should receive two doses of the toxoid. However, i fa woman has been vaccinated during a previous pregnancy, she may only require one dose for a current pregnancy. Table 8.3 presents data on tetanus toxoid coverage during pregnancy for all births in the five years preceding the MDHS. Nearly three-quarters of births received the protection of two or more doses of tetanus toxoid during pregnancy, 13 percent received protection from one dose and 14 percent were not protected by any tetanus toxoid vaccination. As was seen with use of antenatal care, tetanus toxoid coverage is related to age of the mother and birth order. Older women and women of higher parity are more likely not to have received any tetanus vaccination during the pregnancy. These latter Findings, however, may not represent genuine differentials in protection against tetanus since older, higher parity women might have received tetanus toxoid in previous pregnancies. Births occurring in rural areas are about twice as likely as those in urban areas to have received no protection by the vaccination. There are no marked regional differentials in tetanus toxoid coverage. Education of the woman, however, is linked to the use of tetanus toxoid. For example, women without formal education are 2.5 times more likely than women with some secondary schooling not to have received any vaccination. Educated women may have greater accessibility to modern medical care, may have a better understanding of the benefits of vaccinations, or may be better able to take advantage of the available services. 81 Table 8,3 Tetanus toxoid vaccination Percent distribution of live births in the five years preceding the survey, by number of tetanus toxoid injections given to the mother during pregnancy and whether the respondent received an antenatal card, according to selected background characteristics, Malawi 1992 Number of tetanus toxoid injections Percentage Two gwen Number Background One doses Don't know/ antenatal of characteristic None dose or more Missing Total card births Mother's age at birth < 20 11.6 14.8 73.2 0.4 100.0 91.1 834 20-34 12.4 12.9 74.2 0.5 100.0 90.8 2858 35+ 21.1 11.6 66.4 0.9 100.0 85.9 820 Birth order 1 12.0 13.2 74.1 0.7 100.0 91.9 825 2-3 10.2 14.9 74.5 0.4 100.0 92.2 1342 4-5 13.7 10.7 74.8 0.7 I00.0 89.5 1009 6+ 18.8 12.7 68.1 0.4 100.0 86.9 1335 Reshienee Urban 7.3 12.9 78.3 1.5 100.0 96.4 512 Rural 14.7 13.0 71.9 0.4 100.0 89.2 4000 Region Northern 13.2 13.0 73.5 0.3 100.0 92.3 521 Central 15.9 10.5 73.2 0.4 100.0 87.3 1890 Southern 12.2 15.3 71.8 0.7 100.0 91.8 2101 Mother's education No education 18.3 12.5 68.6 0.5 100.0 85.9 2308 Primary 1-4 10.3 15.1 74.5 0,2 100.0 92.5 1071 Primary 5-8 8.2 12.6 78.3 0.8 100.0 95.6 997 Secondary+ 7.1 8.7 83.4 0.8 100.0 97.6 136 All births 13.8 13.0 72.6 0.5 100.0 90.0 4512 Note: Figtwes are for births in the period 1-59 months preceding the survey. Mothers in Malawi received antenatal cards for nine in ten births in the five years preceding the survey. However, rural women, women living in the Central Region, and less educated women were less likely m possess an antenatal card. Another important component of efforts to reduce the health risks of mothers and children is increasing the proportion of babies that are delivered in medical facilities. Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that can cause the death or serious illness of either the mother or the baby. Respondents were asked to report the place of birth of all children bom in the five yeats before the survey (Table 8.4). At the national level, 43 percent of births are delivered at home, 41 percent at government health facilities, and 14 percent at private facilities. Women age 35 years or older are more likely than younger women to deliver at home. Similarly, higher birth order of the child is associated with a higher likelihood of having been delivered at home. A child born in a rural area is three times more likely than an urban child to have been delivered at home. Delivery in a health facility is more common in the Northern Region (68 percent) than in either the Southem Region (56 percent) or the Central Region (51 percent). 82 Table 8.4 Place of delivery Percent dislxibutim't of live births in the five yem's preceding the survey, by place of delivery, according to selected background characteristics, Malawi 1992 Government Private Number Background At health health Don't know/ of characteristic home facility facility Other Missing Total births Mother 's age at birth < 20 40.2 40,7 16.8 1.0 1.3 100.0 834 20-34 40.5 43,3 14.1 1.5 0.5 100.0 2858 35+ 52.4 34.6 11.5 1.3 0.1 100.0 820 Birth order 1 36.6 46,1 15.7 0.7 1.0 100.0 825 2-3 41.4 43.0 13,7 1.3 0.6 100.0 1342 4-5 44.0 39.0 14.9 1.4 0.6 100.0 1009 6+ 46.5 38.2 13.2 1.8 0.3 100.0 1335 Residence Urban 13.1 71.1 14.7 0.6 0.5 100.0 512 Rural 46.4 37.5 14.1 1.5 0.6 100.0 4000 Regina Northern 3I.I 50.3 17.2 1.2 0.2 I00.0 521 Central 47.0 40.4 10.8 1.2 0.6 100.0 1890 Southern 41.5 39.8 16.5 1.6 0.7 100.0 2101 Mother's education No education 53.4 33,9 10.8 1,4 0.4 I00.0 2308 Primary 1-4 38.7 42.5 15,8 2.0 1.0 100.0 1071 Primary 5-8 26.6 53.8 18.5 0.5 0.6 100.0 997 Secondary+ 6.7 64.5 26.0 2.0 0.8 100.0 136 Antenatal care visits None 91.7 5.1 1.9 1.1 0.1 100.0 324 1-3 visits 44.9 40.4 12.8 1.8 0.1 100.0 1250 4 or more visits 36.7 45.6 16.4 1.2 0.1 100.0 2835 Don't know/Missing 22.5 46.5 8.0 1.5 21.5 100.0 104 All births 42.6 41.3 14.2 1.4 0.6 Note: Figures are for births in the period 1-59 months preceding the survey. 100.0 4512 There is a marked relationship between education of the mother and place of delivery. The proportion of births delivered in a health facility increases from 45 percent among women with no education to 91 percent among women with secondary education or higher. Women who have visited health professionals during pregnancy are much more likely to deliver at a health facility than women who have no such contact. Only 7 percent of women who received no antenatal care delivered in a health facility compared to 62 percent of women with 4 or more antenatal visits. The type of assistance a woman receives during the birth of her child also has important health consequences for both mother and child. Births that are delivered at home are more likely to be delivered without assistance from anyone, whereas births delivered at a health facility are more likely to be delivered by trained medical personnel. Table 8.5 shows that 55 percent of births were delivered under the supervision of personnel with medical training, mostly nurses or trained midwives. Traditional birth attendants assisted in 18 percent of births, while relatives provided the primary assistance in 21 percent of births. Five percent of hitahs were delivered without any assistance. 83 Table 8.5 Assistsmce dining delivery Percent dislributin~ of live births in the five years preceding the survey, by type of assistance during delivery, according to selected background characteristics, Melawi 1992 Attendant during delivery ! Trained Traditional Don't Number Background nurse/ Clinical birth know/ of charactezlstic Doctor Midwife officer auendant Relative Other No one Missing Total births M~ther's age at birth • 20 5.5 51.0 0.6 16.9 22.9 0.0 2.1 0.9 100.0 834 20-34 4.6 52.2 0.2 17.7 19.8 0.5 4.5 0.5 100.0 2858 35+ 2.5 43.4 0.2 18.3 24.8 1.1 9.7 0.1 100.0 820 Birth m-tier 1 6.3 53.7 0.4 17,8 17.9 0.1 2.9 0.8 100.0 825 2-3 4.4 51,6 0,4 16,9 22,7 0.2 3,3 0,4 100.0 1342 4-5 4.4 49.3 0.1 17.7 22.6 0.8 4.3 0.8 100.0 1009 6+ 3.2 47.8 0.2 18.3 20.9 0.9 8.4 0.2 100.0 1335 Residence Urban 14.7 71.1 0.3 5,0 6.0 0.3 2.2 0.3 100.0 512 Rural 3.1 47.7 0.3 19.3 23.2 0.6 5.3 0.5 100.0 4000 Region Northern 4.3 63.3 0.1 11.8 14.0 0.2 6.3 0.1 100.0 521 Central 4.4 45.9 0.4 22.6 19.6 0.5 6.0 0.5 100.0 1890 Southern 4.4 51.2 0.2 14.6 24.6 0.6 3.7 0.7 100.0 2101 Mother's education No education 3.0 41.4 0.3 20.2 27.6 0.8 6.3 0,3 100.0 2308 Primary 1-4 4.8 52.3 0.4 18.1 18.2 0.5 4.9 0.8 100.0 1071 Primary 5-8 5.8 65.4 0.1 12.9 12.4 0.0 2.7 0.7 100.0 997 Secondary+ 14.0 77.1 0.0 5.2 2.9 0.0 0.0 0.8 1(30.0 136 Antenatal care visits None 0.2 6.2 0.0 17.5 59.0 1.3 15.8 0.0 100.0 324 1-3 visits 3.7 49.5 0.3 21.2 20.6 0.5 4.0 0.1 100.0 1250 4 or more visits 4.8 56.2 0.3 16.3 17.5 0.4 4.2 0.2 100.0 2835 Don't know/Missing 14.3 37.7 0.0 11.8 15.9 1.5 3.5 15.2 100.0 104 Total 4.4 50.4 0.3 17.7 21.3 0.5 5.0 0.5 100.0 4512 No~: Figtues are for births in the period 1-59 months preceding the survey. llf the tespoodent mentioned ~ than one attendant, only the most qualified attendant is considered. Age of the woman and birth order of the child is associated with type of assistance at delivery. Older women and women who have already had many births are more likely to have received no assistance at delivery, whereas first births and births to younger women tend to receive better care during delivery, including more frequent supervision by a physician. Urban women are more likely than rural women and women living in the Northern Region are more likely than women living in the Central and Southern Regions to have received assistance from a medically- trained person during delivery. Maternal education is closely tied to better supervision at delivery. Women with some secondary education are 2 times more likely to receive medical assistance and nearly 5 times more likely to receive assistance from a doctor than women without any education. 84 I fa woman received antenatal care during pregnancy, she will more commonly deliver with medical assistance. Strikingly, only 6 percent of women not receiving antenatal care delivered their babies under medical supervision, compared with 61 percent of women with at least 4 antenatal visits. The combination of poor antenatal care and inadequate medical supervision at delivery pla- ces children and mothers at high risk of serious illness and death. Three percent of babies born in Malawi are delivered by caesarean section and 4 percent are reported by their mothers to have been born prematurely (Table 8.6). Respondents were asked if their baby had been weighed at birth and, if so, how much the baby weighed. In addition, the mother was asked for her own sub- jective assessment of whether the baby was very large, larger than average, average, smaller than average, or very small size at birda. For almost two-thirds of births, a birth weight was not reported. Of those births for whom a birth weight was reported, 10 percent (3.6 percent of all births) were reported to be less than 2.5 kilograms. Eighteen percent of all births were reported by their mothers to be either small (14 percent) or very small (4 percent). 8.2 Vaccinations In order to assist in the evaluation of the Expanded Pro- gramme of lmmunisation (EP1), the MDHS collected information on vaccination coverage for all children born in the five years pre- ceding the survey, although the data presented here are restricted to children who were alive at the time of the survey. The EPI fol- lows the World Health Organisation (WHO) guidelines for vacci- nating children. In order to be considered fully vaccinated, a child should receive the following vaccinations: BCG, measles and three doses each of DPT and polio. BCG is for protection against tu- berculosis and DPT is for protection against diphtheria, pertussis, and tetanus; both DPT and polio require three vaccinations at inter- vals of several weeks. Currently, a dose of polio vaccine may be given right after birth. WHO recommends that children receive the complete schedule of vaccinations by 12 months of age. Table 8.6 Characteristics of delivery Percent distribution of live births in the five years preceding the survey by whether the delivery was by caesarean section, whether premature, and by birth weight and the mother's estimate of baby's size at birth, Malawi 1992 Characteristic Percent C-zectlon Yes 3.4 No 95.3 Missing 1.3 Total 100.0 Premature birth Yes 3.7 No 95.6 Don't know/Missing 0.7 Total 100.0 Birth weight Less than 2.5 kg 3.6 2.5 kg or more 31.8 Not weighed/Missing 64.6 Total 100.0 Size at birth Very large 3.4 Larger than average 15.2 Average 61.8 Smaller than average 13.5 Very small 4.3 Don't know/Missing 1.8 Total 100.0 Number 4512 Note: Figures are for births in the period 1-59 months preceding the survey. Information on vaccination coverage was collected in two ways: from vaccination cards shown to the interviewer and from mothers' verbal reports. The majority of health eentres and clinics in Malawi pro- vide cards on which vaccinations are recorded. If a mother was able to present such a card to the interviewer, it was used as the source of information, with the interviewer recording vaccination dates directly from the card. In addition to collecting vaccination information from cards, there were two ways of collecting the information from the mother herself. If a vaccination card had been presented, but a vaccine had not been recorded on the card as being given, the mother was asked to recall whether that particular vaccine had been given, l fthe mother was not able to provide a card for the child at all, she was asked to recall whether the child had received BCG, polio (including the number of doses for polio), or measles vaccinations. DPT coverage was not asked for children without a written record as it was assumed to be the same as the mother's report for polio vaccine (polio and DPT are usually given at the same time). 85 Inform ation on vaccination coverage is presented in Table 8.7, according to the source of inform ation used to determine coverage, i.e., the vaccination card or mother's report. Data are presented for children age 12-23 months, thereby including only those children who have reached the age by which they should be fully vaccinated. According to the information from vaccination cards, 86 percent of children received a BCG vaccination. However, not all children who are vaccinated have cards available; 11 percent of children did not have a card but were reported by their mothers to have received the BCG vaccine. Thus, overall, 97 percent of children age 12-23 months are estimated to have been vaccinated against tuberculosis. Vaccinations are most effective when given at the proper age; according to the card information, 95 percent of children receive the BCG vaccine by 12 months of age. Figure 8.2 presents coverage figures as assessed from both vaccination cards and mothers' reports. Table 8.7 Vaccinations by som'ce of information Percentage of ehilthen 12-23 months who had re, c4~ved spocific vaccinea at any time before the survey and the pexcentagc vaccinated by 12 months of age, by wbethet the inforrmtion was from a vaccination card or from the mother, Malawi 1992 percentage of children who received: Polio DPT Number Source of of information BCG 1 2 3+ 1 2 3+ Measles All I None children Vaoelnated at any time before the survey Vaccination card 85.9 86.1 84.2 80.2 86.1 84.4 80.6 77.1 74.9 0.0 772 Mother's report 11.2 10.8 10.0 8.0 10.8 10.0 8.0 8.8 7.0 2.5 772 Either source 97,0 96.9 94.2 88.1 96.9 94.3 88.6 85.8 81.8 2.5 772 Vacr, thated by 12 months of age 94.7 94.9 91.5 83.7 94.8 91.3 83.6 70.,1 67.1 4.8 772 Note: The DPT coverage rate for ehildlen without a written record is assumed to be the same as that for polio vaccine since mothers were specifically asked whether the child had received polio vaccine. For children whose information was based on the mother's report, the prolm~on of vaccinations given during the fLrst year of life was assumed to be the same as for cinld~en with a written record of vaccination. 1Children who me fully vaccinated (i.e., those who have received BCG, measles and three doses of DPT and polio). Coverage for the first dose of polio and the first dose of DPT is virtually the same as for BCG; 97 percent received the first dose, with 95 percent receiving it by 12 months of age. Coverage declines after the first dose, with about 94 and 88 percent receiving the second and third doses, respectively. This yields a dropout rate 1 of about 9 percent for DPT and polio vaccine. The proportion vaccinated by 12 months of age also falls to about 92 percent at the second dose and 84 percent at the third dose. Eighty-six percent of children age 12-23 months were vaccinated against measles; 70 percent before their first birthday. Overall, 82 percent of all children age 12-23 months had all the recommended vaccinations; 67 percent before their first birthday. Less than 3 percent of children age 12-23 months have never received any vaccinations. I The dropout rate (%) is calculated as (DPTI-DPT3)/(DPTI) x 100. 86 Figure 8.2 Percentage of Children Age 12-23 Months With Certain Vaccinations Pe'cehl 1CO 80 60 49 20 C 97 94 / 1,1 / 88 BOG 1 3 Measles Poho Ng'e ~asec )~1 neal'~'l L,x'JS arc To'hers 'e',,rt 82 / 3 " r! All No,/~. ~ , © cc~ bOH,_, 199, Table 8.8 presents vaccination coverage (according to card information and mothers' reports) of children 12-23 months old at the time of the survey by selected background characteristics. The differentials in coverage are very similar irrespective of vaccine type. Thus, the focus here is on differentials in complete coverage (i.e., all vaccines received). There is virtually no difference in coverage between boys and girls. First births and lower birth order children have better coverage than higher birth order children. Children from urban areas have a slightly better coverage rate (87 percent) than rural children (81 percent). Regional differentials are negligible. Completecoverage increases with increasingmatemal education, from 76percent among children of uneducated mothers to 96 percent among children of mothers with some secondary education. Figure 8.3 shows the percentage of children age 12-23 months who are fully vaccinated by selected background characteristics of the mother. 87 Table 8.8 Vaccinations by background characteristics Percentege of childa~n 12-23 months who had received specific vaccines by the time of the survey (according to the vaccination card or the mother's report) and the percentage with a vaccination card, by selected background characteristics, Malawi 1992 Percentage of children who received: Per- Number Polio DPT eentage of Background with chil- characteristic BCG I 2 3+ I 2 3+ Measles All I None a card drcn Sex Male 95.8 95.8 93.6 87.7 95.8 93.7 88.2 86.2 81.7 3.4 84.6 404 Female 98.3 98.2 94.8 88.6 98.2 95.0 89.0 85.4 81.9 1.5 88.2 368 Birth order 1 99.6 99.6 97.2 91.1 99.6 97.2 92.6 96.5 89.8 0.4 88.7 127 2-3 98.5 98.5 96.5 91.6 98.5 96.5 92.2 88.5 85.3 1.5 86.9 228 4-5 96.3 96.3 95.5 89.9 96.3 95.8 90.1 83.3 81.3 3.7 85.6 176 6+ 94.8 94.6 89.5 82.1 94.6 89.7 81.9 79.6 74.6 3.7 85.0 241 Residence Urban 97.9 97.9 96.5 93.9 97.9 96.5 93.3 90.7 87.2 1.3 81.9 84 Rural 96.9 96.8 93.9 87.4 96.8 94.0 88.0 85.3 81.1 2.7 86.9 688 Region Northern 98.2 97.7 95.2 87.2 97.7 96.1 88.1 83.8 80.1 1.8 82.8 104 Central 95.7 95.7 90.9 85.4 95.7 90.9 85.7 83.6 80.5 3.8 89.2 320 Southern 97.8 97.8 96.9 90.9 97.8 96.9 91.4 88.6 83.5 1.5 84.7 348 Mother's education No education 95.4 94.8 89.7 83.7 94.8 89.8 84.2 79.7 76.3 4.3 86.5 393 Primary 1-4 98.7 98.8 98.8 89.3 98.8 98.8 90.2 92.1 84.5 0.9 82.2 175 Primm-y 5-8 98.5 99.4 98.7 95.1 99.4 99.0 95.4 91.5 89.2 0.6 89.7 178 Secondary+ 100.0 100.0 100.0 100.0 100.0 100.0 98.2 98.2 96.3 0.0 88.2 26 All children 97.0 96.9 94.2 88.1 96.9 94.3 88.6 85.8 81.8 2.5 86.3 772 Note: The DPT coverage rate for chilcken without a written record is assumed to be the same as that for polio vaccine since mothers were specifically asked whether the child had received polio vaccine. IChildren who are fully vaccinated (i.e., those who have received BCG, measles and three doses of DPT and polio). 88 Figure 8.3 Percentage of Children 12-23 Months Who Are Fully Vaccinated MALAWI RESIDENCE Urban Rural REGION Northern Central Southern MATERNAL EDUCATION No Education Pnmary 1 4 Pnmary 5-8 Secondary + _ ~ 82 ~Y/~/ / / / / / / / / / / / / , / / / / / / / / / / / / / / / / / /~ l 87 Y// / / / / / / / / / / / / / / / / / / / /~// / / / J / / / / / / / / / / , , '/////////, '/,////////////~ 81 18o 181 184 76 ~ 8 5 ~ 8 9 96 20 40 60 80 100 Percent MD,tS 1992 Thus far, the discussion has focused on children age 12-23 months. Information on the proportion of children age 12-59 months who had been vaccinated by 12 months of age, by their current age is presented in Table 8.9 and can be used to assess trends; the table also shows the percentage with a vaccination card shown to the interviewer. The coverage figures are based on both card information and mothers' reports. Cards were shown to interviewers by mothers for 65 percent of the children age 12-59 months. The percentage of children with vaccination cards decreases with increasing age, from 86 percent for children age 12-23 months to 45 percent among those age 48-59 months. A large part of the decrease in card possession is probably due to greater card loss among the older cohorts. Mothers may be inclined to retain cards only as long as they need them to present to health staff; once children are fully vaccinated and/or reach a certain age, there may be a tendency to discard the cards. By comparing vaccination coverage among the various age cohorts of children, it is possible to obtain a picture of changes in the success of the vaccination programme over time. The proportion vaccinated by 12 months of age among children 12-23 months old refers, on average, to the EPi performance during late 1991 to late 1992, coverage among the 24-35 month old children refers to performance during late 1990 to late 1991, etc. This analysis suggests that the EPI programme has improved vaccination coverage during the period 1988-1992. The improvement is especially pronounced when considering third dose coverage by the first birthday, e.g., polio3 coverage has increased from 66 to 84 percent. Further, whereas 15 percent of children had received not a single vaccination by the first birthday in the 48-59 month cohort, only 5 percent of the 12-23 month cohort is so chamcterised. 89 Table 8.9 Vaccinations in the first ye~ of life Percentage of children one to four years of age for whom a vaccination card was shown to the interview~ Jmd the percentage vaccinated for BCG, DPT, polio, and measles during the first year of life, by current age of the child, Malawi 1992 Vaccine Current age of child in months All children 12-59 12-23 24-35 36-47 48-59 months Vaccinat ion card shown to Interviewer 86.3 71.3 56.5 44.8 65.3 Percent vaccinated at 0-11 months a BCG 94.7 92.3 87.2 84.7 89.8 Polio 1 94.9 91.7 85.9 83,0 89.0 Polio 2 91.5 88.3 82.3 77.4 85.0 Polio ~. 83.7 79.8 70.7 65.6 75.2 DPT l ° 94.8 91.8 85.9 82.8 89.0 DPT 2 91.3 87.9 81.3 77.7 84.7 DPT 3 83.6 81.3 70.9 68.7 76.3 Measles 70.1 65.5 58.0 60.3 63.7 All vaccinations c 67.1 60.4 51.9 52.2 58.2 No vaccinations 4.8 6.8 12.3 14.6 9.5 Number of children 772 679 667 701 2819 alnl'ormation was obtained either from a vaccination card or from the mother if there was no written record. 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 ~e the same as that for children with a written vaccination record. 'q'he DPT coverage rate for childreul without a written record is assumed to be the same as that for polio vaccine, since mothers were specifically asked whether the child had received polio vaccine, CChildren who have received BCG, measles and three doses of DPT and polio vaccines. 8.3 Acute Respiratory Infection Pneumonia is aleading cause of childhood mortality in Malawi. The prevalence of severe respiratory infection was estimated by asking mothers if their children under age five had been ill with coughing accompanied by short, rapid breathing, in the two weeks preceding the survey. These symptoms are compatible with pneumonia. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths due to pneumonia. It should be borne in mind that morbidity data collected in surveys are subjective--i.e., mother's perception of illness---and are not validated by medical personnel. Similarly, accuracy in reporting of treatment practices depends on how much a mother knows about the medicines that her children may receive. For instance, a mother may not know whether the pills or syrups that her children receive contain antibiotics or not. Thus, reporting may vary within the country due to sociocultural differences. Table 8.10 shows that 15 percent of children under five years of age were ill with a cough and rapid breathing at some time in the two weeks preceding the survey. Prevalence of respiratory illness varied by age of the child; older children were less commonly ill than younger children. Regional and urban-rural differences were small or negligible. Children of women with secondary education were less frequently ill than other children, but the number of children on which this estimate is based is small. 90 Table 8,10 Prevalence and treatment of acute respiratory infection Percentage of children under five years who were ill with a cough accompanied by rapid breathing during the two weeks preceding the survey, and the percentage of ill children who were treated with specific remedies, by selected background characteristics, Malawi 1992 Among children with cough and rapid breathing Percentage percentage Percentage treated with: of children taken to with cough a health Antibiotic Number Background and rapid facility or pill or Cough Home No of characteristic breathing provider I syrup Injection syrup remedy Other treatment children Child's age < 6 months 18.4 54.2 16.6 5.2 35.4 2.5 52.7 9.5 449 6-11 months 22,7 46.9 21.1 10.4 17.9 2.9 59.1 11.6 462 12-23 months 17.7 48.4 25.3 4.6 17.8 13.0 55.8 13.4 772 24-35 months 14.0 55.8 25.5 6.1 19.6 6.0 56.5 13.5 679 36-47 months 9.5 49.3 27.3 6.2 17.7 3.0 57.2 14.8 667 48-59 months 8.6 35.3 28.0 0.8 20.0 5.0 41.1 15 4 701 Sex Male 14.2 47,2 21.6 6.0 19.9 6.7 55.1 14.6 1869 Female 14.9 50.6 25.8 5 6 22.2 5.7 54. I I 1.2 1862 Blrlh order l 16.5 43.5 22.8 3.8 16.8 5.8 57.9 14.0 629 2-3 13.8 57.6 30.7 5.4 23.5 4.2 57 0 11.7 1118 4-5 14.5 47.8 23.6 5 1 24.6 3.2 57.8 8.4 856 6+ 14.2 44.9 17.7 8.1 18.7 10.6 47 7 16.7 1127 Residence Urban 14.9 54.8 37.9 4.6 31.1 1.8 57 4 1.3 422 Rural 14.5 48.2 21.9 6.0 19.7 6.7 54.3 14.4 3308 Region Northern 14.3 51.2 28.6 8.2 20.6 9.9 48.6 10.4 442 Cent~l 12.8 43.9 20.8 8 3 14.9 3.9 47.8 20.1 1552 Southern 16.2 52.0 24.7 3 6 25.5 6.9 60.8 8.3 1736 Mother's education No edueatton 14.4 50.9 23.0 5.0 14.4 7.7 53.5 16.0 1912 Primary 1-4 15.1 36.6 20.9 2,6 23.4 6.3 62.3 I 1.7 880 Pfirn~y 5-8 15.1 57.4 28.1 10.4 30.9 3.1 48.8 8.4 819 Secondary+ 9.8 53.3 27.4 13 3 46.7 0.0 53.8 0.0 120 All children 14.6 48.9 23.7 5.8 21.1 6.2 54 6 12.9 3730 Note: Figures are for children born in the period 1-59 months preceding the survey. tlncludes health post, health centre, hospital, and private doctor. Forty-nine percent of children with respiratory illness visited a health facility of some kind. Differentials in use of health facilities are small, although children in rural areas and in the Central Region are less frequently taken to a health facility when sick. Twenty-four percent of children received an antibiotic treatment, 6 percent received an injection, 21 percent received cough syrup, and 6 percent received some type of home remedy. Over one half of sick children also received "other" treatment, which most often consisted of Panadol, aspirin, etc. purchased at pharmacies. Thirteen pcrccnt of ill children, however, received no treatment at all. A much larger percentage of children in rural areas than in urban areas and in the Central Region than in the Southern and Northern Regions received no treatment at all. 91 8.4 Fever Malaria is endemic throughout Malawi and is by far the most common cause of hospital admission for all age groups. Since the major manifestation of malaria is fever, mothers were asked whether thcir children under age five had a fever in the two weeks preceding the survey, and what type of treatment was sought, if any. Table 8.11 shows that 41 percent of children under five years of age were reported to have had fever in the two weeks prior to the survey. Fever is more common at the younger ages, especially during 6-23 months. Children in the Northern Region have a higher prevalence of fever (48 percent) than children in the Central Region (43 percent) or Southern Region (37 percent). Other diffcrentials in fever prevalence are small or negligible. Table 8.11 Prevalence and treatment of fever Percentage of children under five years who had a fever during the two weeks preceding the survey, and the percentage of children v, ath a fever who were treated with specific remedies, by selected background charactenstics, Malaw~ 1992 Among children with fever m Percentage Percentage Percentage treated wtth' of taken children a health Antibiotic Don't Number Background with facility or Anti- pill or Home No know/ of characteristic fever provider I malarial syrup Injection remedy Other treatment Missing children Child's age < 6 months 42.8 45.3 26.4 17.3 4 0 5.0 47.0 18 8 0.8 449 6-11 months 59.0 47.2 27.1 16.4 5.3 3.4 489 13.9 0.5 462 12-23 months 52.1 46.9 28.3 21.0 3.5 4.2 46 0 12.8 0.5 772 24-35 months 42.1 51.0 31.6 16.1 5.6 4 2 49 5 11.6 0.8 679 36-47 months 30.1 40.4 29.7 18.2 3.9 6 5 38 4 17.9 1.6 667 48-59 months 22.5 42.0 30.5 20.3 0 9 5 8 36.2 15.7 2 9 70] Sex Male 40.8 46.7 29.1 19.0 3 8 4.9 44.0 14.7 0.9 1869 Female 40.2 45.6 28.7 17.7 4 3 4.3 46 5 14.4 1.1 1862 Birth order 1 38.4 42,2 25.4 16.0 4 0 6 5 48 3 14.6 0.8 629 2-3 39.9 48.1 29.2 20.8 4.8 4.2 45.5 14 1 1.2 1118 4-5 42.6 46.8 31.9 17.9 3 1 2 8 46 9 12.5 1 I 856 6+ 40.8 45.9 28.0 17.5 4.2 5 5 42 2 16 5 0.8 1127 Residence Urban 37.0 54 5 45.1 22.0 4.2 2 3 47 8 5.5 1 7 422 Rural 41 0 45.2 27.0 17.9 4 0 4 9 45 0 15.6 1).9 33118 Region Northern 48.0 50.4 25.2 21.8 3.6 7.4 48.1) 12.6 00 442 Cen~al 42.9 40 4 23.4 16.5 5.0 3.9 45 5 19 2 (I 7 1552 Southern 36.5 50.8 35.9 19.1 3.3 4.5 44.11 103 I 7 1736 Mother ' s education No education 41.0 44.0 29.0 15.4 3.5 4.8 40.0 19 1 1.5 1912 Ptamary 1-4 41.8 43.4 27.9 17.8 2.7 5 7 52.5 10.9 0.9 880 Primary 5-8 39.5 53.7 28.0 24 9 6 0 3 6 49.8 9.11 0. I 8 ] 9 Secondary+ 30.5 53.7 44.0 27.4 11.3 0 0 46 3 I 3 0.0 1211 All children 40.5 46.2 28.9 18.3 4.1 4,6 45.3 14.5 1.0 37311 Note: Figures are for children born in the period 1-59 months preceding the survey llncludes health post, health centre, hospital, and private doctor. 92 Among children with fever, 46 percent were taken to a health facility; 29 percent were reported to have received an antimalarial treatment, 18 percent received an antibiotic, 4 percent an injection, and 5 percent some sort of home remedy. Forty-five percent of febrile children received treatment classified as "other" (aspirin, Panadol, etc.), and nearly 15 percent received no treatment at all. Differentials in treatment pattems were not very pronounced. Febrile children were less likely to be taken to a health facility in rural areas than in urban areas and in the Central Region compared to the Southern and Northern Regions. These same children were also more likely to have received no trealmcnt at all tot fever. These patterns may well reflect general patterns of access to health services. In addition to having fever more frequently, children of less educated mothers were less likely to be taken to a health facility and much more likely to have received no treatment at all for the fever. Children with fever are treated with antimalarial pills and symps more commonly in urban areas than in rural areas, and more in the Southern Region than in the Northern and Central Re- gions. 8.5 Diarrhoea Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children. One treatment for dehydration is oral rehydration therapy tORT). In Malawi, ORT is promoted by way of three inter- ventions: through preparation and use of oral rehydration solution (ORS) made in the home from commercially packaged packets of oral rehydration salts (sold in shops) and water, through health facility-based provision of pro- mixed ORS, and through preparation and use in the home of various grain- based rehydration fluids (i.e., rice wa- ter, maize water, etc.). ORT has been actively promoted in Malawi since the mid-1980s. Table 8.12 presents the preva- lence of diarrhoea in children under five years of age. Twenty-two percent of children had experienced diarrhoea at some time in the two weeks preced- ing the survey; 4 percent of children had experienced bloody diarrhoea. Seven percent of children were still having an episode of diarrhoea at the time of the survey (i.e., within the last 24 hours). Table 8.12 Prevalence of diarrhoea Percentage of chddren under five years who had diarrhoea and dxarrhoea w~th blood in the two weeks preceding the survey, and the lx~rcentage ol children who had diarrhoea in the preceding 24 hours, by selected background characteristics, Malawl 1992 Diarrhoea m the All preceding 2 weeks I diarrhoea m the Number Background All Diarrhoea precedm~ of characteristic diarrhoea with blood 24 hours children Chi ld 's age (months) < 6 17.4 2.6 7.8 449 6-11 41.7 6.1 13 5 462 12-23 36.2 5.8 13.2 772 24-35 21.2 4.8 7.0 679 36-47 10 I 3.2 3 0 667 48-59 8 I 2.2 1 4 701 Sex Male 23.6 4.2 S 6 1869 Female 20 2 4.1 6 2 1862 Birth order 1 22.3 3.1 8.5 629 2-3 20.8 3.4 7 8 1118 4-5 20.5 4.2 6.7 856 6+ 23.9 5 4 6.9 1127 Residence Urban 19.3 3 1 5.6 422 Rural 22 3 4.3 7 6 3308 Region Northern 25 1 4.9 8 5 442 Central 24 0 4.5 8 9 1552 Southern 19.2 3.6 5.S 1736 Mother's educatlnn No education 23.0 4.1 7.8 1912 Pr imly 1-4 21.7 5.6 6 9 880 Primary 5-8 20.1 3.0 7.4 819 Secondary+ 19. I 1.7 4.2 121) All children 21.9 4.1 7.4 3730 Note. Figures are for chddren born m file penod 1-59 months preceding the survey. llncludes diarrhcrea in the past 24 hours Zlncludes diarrhoea wxth blood 93 There are pronounced differences in diarrhoeal prevalence by age of the child. Figure 8.4 shows the remarkable peak in reported diarflaoea during ages 6-23 months and the subsequent fall with increasing age of the child, in comparison with reported respiratory illness, which varies much less by age. Bloody diarrhoea also peaks at ages 6-23 months. Diarrhoea is more common among children in rural areas, among children in the Central and Northern Regions, and among children whose mothers are less educated. Figure 8.4 Prevalence of Respiratory Illness and Diarrhoea in the Last Two Weeks, by Age of the Child Percentage 5O 4O 3O 2O 10 0 i i I I "~ ~. , . i i i . . . . . . . . i . . . . i . . . . , . i i . . . . i . , 6 10 15 20 25 30 35 40 45 50 55 60 Age of the Ch i ld (months) MDHS 1992 94 Knowledge of ORS is widespread in Malawi; 90 percent of women who had births in the five years preceding the survey had heard of ORS packets (see Table 8.13). However, only 62 percent of these mothers had ever used an ORS packet. There are no marked differences in the level of ORS knowledge by background characteristics of the mothers, except that uneducated mothers are slightly less likely to know about it. However, actual use of ORS packets differs more widely by background characteristics of the mother. Mothers most commonly using ORS are those living in urban areas, and those living in the Northern and Central Regions, as well as mothers with more education. The youngest cohort of women (i.e., age 15- 19) are least likely to have used ORS packets. Table 8.13 Knowledge and use of ORS packets P~tage of mothers with births in the five years preceding the survey who Imow about and have ever used ORS packets, by selected background characteristics, Malawi 1992 Know about Have ever Number Background ORS used ORS of characteristic packets packets mothers Age 15-19 82.5 45.6 294 20-24 89.4 58.2 713 25-29 94.0 66.4 616 30-34 90.9 66.4 506 35+ 88.7 65.6 726 Residence Urban 93.2 68.7 335 Rural 89.3 61.1 2519 Region Northern 93.9 71.1 341 Central 88.4 63.4 1166 Southern 89.9 58.5 1348 Education No education 86.2 55.1 1463 Prima~ I-4 91.5 64.6 656 Primary 5-8 95.4 72.2 641 Secondary+ 95.3 82.3 94 All mothers 89.8 62.0 2854 95 Table 8.14 shows the percentage of children with recent bouts of diarrhoea who were given various treatments. Among children with diarrhoea, 45 percent were taken to a health facility. A child with diarrhoea is more commonly taken to a health facility if he lives in an urban area, if hc lives in the Northern Region, or if his mother is better educated. Table 8.14 Treatment of diarrhoea Percentage of chi ldren under five years who had diarrhoea in the two weeks preceding the survey who were tztken for treatment to a health facility or provider, the percentage who received oral rehydration therapy tORT), the percentage who received increased fluids, the percentage who received neither ORT nor increased fluids, and thc percentage recc iwng other treatments, according to selected background characteristics, Malawi 1992 Oral rchydrauon Percentage Percentage receiving Number P~cenmge the=apy tORT) recetvmg other treatments' of Uiken to Pt=centage neither chddren a health ORS florae Either recetvmg ORT n<:¢ H(nne No with Background fncthty or ORS premlxed solutton ORS increased increased Anti Inje~ remedy/ treat dJ~- characteristic provider I packets bottle (1IS) or ns flmds flutds b]ot]cs tJon Ottler mcl~t M~ssmg rhoea 2 Chi ld 's age (months) <6 45.0 283 9.2 28.9 55.8 35.4 31.4 5.1 0.0 25.7 18.0 0.0 78 6-11 48.1 38.7 10.8 44.6 70.2 409 17.1 35 05 210 88 {).8 193 12-23 44.0 29.9 10.0 41.7 64.6 41.0 25,3 7 7 0,3 18.2 16 7 0 3 279 24-35 50.1 30.5 14.6 35.0 62 2 36 2 25 9 10.3 0 3 23 1 12.9 1,1 144 36-47 40.9 34.6 10 g 49.0 65 6 39 3 27 3 14.0 0 0 13.6 25,8 0.0 67 48-59 37.3 26.2 11.1 18.4 426 245 410 11.1 00 25.1 21/.8 0.0 57 Sex Male 49.1 33.7 12.1 40.3 64.3 366 245 8.0 02 20.1 14.5 0.5 441 Female 41.1 30.1 9.8 37.3 62.0 40.4 26.2 7 2 0 4 21.0 16 3 0 4 377 Birth order 1 42.9 31.8 1L9 41.0 64.5 39.8 26.1 3.7 0.3 19.0 18.9 0.3 141 2-3 43.5 330 12.1 44.1 66.2 37.8 22.5 6.3 0.11 22.8 14.1 06 232 4-5 50 0 31 9 9.4 39.6 62.2 37.6 25.2 I 1.3 0,8 23.0 13 9 0.0 176 6+ 45 4 31 5 10.8 33.1 60.6 38.5 27 5 8.5 0 2 17 7 15.5 {),8 2711 Residence Urban 49.3 37.9 8.0 54.0 74.8 55.1 12.6 8.4 0,0 19.1 8.1 0.0 82 Rural 45.0 31.4 11.4 37.3 61.9 36.4 26.7 7.6 0,3 20.7 16.1 115 737 Region Northern 54.3 42.8 11.3 43.0 72 8 40 3 18 3 7.9 2 2 31J 5 8.2 0 9 1 ] ] Central 44.5 31.5 11.7 33.1 58.4 32.5 31 0 9.6 00 14.6 20.6 04 373 Southern 43.4 29.1 10.3 44.2 65.4 44.1 21.3 5,4 0.0 23.9 11 8 115 334 Educat ion No education 40.8 27.6 9.9 34 4 57 4 33.9 31.0 7 8 0.0 20 7 19 2 (J 4 440 Primary 1-4 46.4 34.0 12.2 396 649 42.1 22.3 7 1 0.3 186 135 1 (J 191 Primary 5-8 53.7 37.0 14.0 47.9 74.2 43.7 16.8 6.2 1,2 22.7 9.1 0.3 165 Secondary+ 65.11 66.1 2.8 56 6 81 6 52 1 3 6 21 1 0 0 16 6 0 8 0 f) 23 Total 45.4 32.1 11.1 38.9 632 383 253 7.7 03 2115 15.3 05 818 Note: Oral rehydration therapy tORT) includes soluuon prepared from ORS packets and home solution (ncc water or mal/c water) llncludes health post, health centre, hospital and private doctor 21ncludes children born in the period 1-59 months preceding the survey who were reported to have diarrhoea in the last two weeks 96 Nearly two in three (63 percent) children with diarrhoea in the last two weeks were treated with some form of OPT. Thirty-two percent received ORS prepared in the home from packets, 11 percent received ORT from pre-mixed ORS packets, and 39 percent received home-based solutions prepared from rice and water or maize and water. Thirty-eight percent of sick chil- dren were reported to have received increased fluids during the bout of diarrhoea. Despite these encouraging statistics, still a quarter of children did not receive any rehydration therapy during the recent episode. Other therapies offered to the child included treatment with antibiotics (8 percent) and home remedies (21 percent). Fifteen percent of children were given no treatment at all. Use of rehydration therapy is most common for children aged 6-11 months, and least common for younger children and children 48-59 months old. Gender differentials in treatment pat- terns are not evident, nor are differentials by birth order of the child. Use of ORT is, however, related to socioeconomic factors. ORT use is more common in urban than rural areas, in the North- em Region than in the Southern or Central Regions, and among children of more educated women than children of less educated women. Rural children, children from the Central Region, and children of less educated women are most likely to have received no treatment whatsoever. Table 8.15 shows that 61 percent of children who had diarrhoea and who were still being breastfed continued to be breastfed as usual, without increasing the frequency of feeds. About one in six children who had diarrhoea were breastfed less than usual during the episode. Forty percent of all children with Table 8.15 Feeding practices during diarrhoea Feeding practices among children under five years who had diarrhoea in the two weeks preceding the storey, Malawi 1992 Feeding practices Percent Breastfeedlng frequency 1 Same as usual 61,1 Increased 20.1 Reduced 17.0 Stopped 0.0 Don't know/Missing 1.8 Total 100.0 Number of breastfeeding children with diarrhoea 644 Amount of Ilulds given Same as usual 40.0 More 33.6 Less 25.4 Don't know/Missing 1.0 Total 100.0 Number of children with diarrhoea 2 818 tApplies only to children who are still breasffod. 2Children born in the period 1-59 months preceding the survey. diarrhoea were given the same amount of fluid as usual, 34 percent were given more fluids, and 25 percent were given less fluids. That a quarter of sick children are being given less fluids is troubling because it indicates that many mothers' knowledge of the effects of diarrhoea on the child needs to be improved. 97 CHAPTER 9 MATERNAL AND CHILD NUTRITION This chapter presents the findings on two related topics: (1) infant feeding, including breastfeeding practices, introduction of supplementary weaning foods, and use of feeding bottles; and (2) nutritional status of young children and their mothers. 9.1 Breastfeeding and Supplementation Patterns of infant feeding have important influences on both the child and the mother. Feeding practices are important determinants of the child's nutritional status, which in turn influences the risk of dying, The mother is affected by breasffeeding through its biological suppression of the return to fertile status, therefore impacting the length of the birth interval and health outcome. These effects are influenced by both the duration and intensity of breastfeeding, and by the age at which the child receives foods and liquids. The data presented in Table 9.1 show that almost all children (97 percent) are breastfed for some period of time. Fifly-seven percent of children were put to the breast within an hour of birth and 90 percent within the first day. Little orno difference exists in breastfeeding patterns between male and female children or among children in different regions of the country. Urban children are less likely than rural children to be put to the breast soon after birth. Children of more educated mothers are similarly less likely to be breastfed within an hour of birth than children of less educated mothers. If the child was delivered at a health facility or by a medically-trained person, breastfeeding within an hour of birth is slightly less common than if the delivery was at home or not assisted by a medically trained person. Breast milk is uncontaminated and contains all the nutrients needed by children in the first few months of life. In addition, it provides some immunity to disease through transference of the mother's antibodies. The percent distribution of children under age three years by breastfeeding status at the time of the survey is presented in Table 9.2, based on information about feeding practices in the 24 hours preceding the survey. By 12-13 months of age, 94 percent of children are still breastfed; and even by 18-19 months 86 percent are being breastfed. By 24-25 months of age, only 27 percent are still receiving some breastmilk, and by the end of the third year almost all children have been completely weaned. Exclusive breastfeeding is uncommon; only 5 percent of children under 2 months of age are fed only breast milk. Most children are given water in addition to breast milk (56 percent of children under 2 months of age). By 2-3 months, three-quarters of children are given some form of food supplement; by 4-5 months, 96 percent of children have received supplements. Solid or mushy food is introduced into the diet as early as one month after birth, when a quarter of breastfeeding children are given food (see Table 9.3). By age 4-5 months, nearly nine of ten breastfeeding children have food introduced into their diets. Bottle feeding is not common; only 5 percent of babies age 0-1 months are being given a bottle and teat (nipple) in addition to being breastfed. These findings are encouraging, since neonates are particularly vulnerable to infections and use of unsterilised bottles with nipples is a prime source of infection. 99 Table 9,1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and the percentage of last-born children who started breastfeeding within one hour of birth and within one day of birth, by selected background characteristics, Malawi 1992 Among all children: Among last-born children, percentage who started breasffoeding: Percentage Number Within Within Number Background ever of 1 hour 1 day of characteristic breastfed children of birth of birth children Sex Male 97.0 2307 55.4 88.6 1499 Female 96.7 2267 58.7 91.1 1411 Residence Urban 95.8 515 48.2 85.8 343 Rural 97.0 4058 58.2 90.3 2567 Region Northern 97.7 527 55,3 92.9 348 Central 97.1 1912 56.5 89.3 1191 Southern 96.4 2134 57.8 89.5 1371 Mother's education No education 97.6 2343 60.3 91.9 1493 Primary 1-4 96.0 1085 56.3 87.5 669 Primary 5-8 96.2 1008 52.3 88.5 653 Secondary+ 96.1 137 43.4 81.4 96 Asslstance at delivery Medically trained person 97.7 2513 54.0 89.3 1568 Traditional birth attendant 96.8 805 60.1 91.4 519 Other or none 96.3 1232 61.1 90.2 817 Place of delivery Health facility 97.8 2530 54.1 89.3 1584 At berne 96.9 1915 61.2 90.6 1244 Other 97.7 65 42.7 95.9 50 All childron 96.9 4574 57.0 89.8 2910 Note: Table is based on all children born in the five years preceding the survey, whether living or dead at the time of the interview. There were 7 cases with missing information on assistmace at delivery and 33 eases with missing information on place of delivery. 100 Table 9.2 Breastfeeding status Percent distribution of living children by breasffeeding status, according to child's age in months, Malawi 1992 Age in months Percentage of riving childreaa who are: Breasffeeding and: Number Not Exclusively Plain of breast- breast- water Supple- living feeding fed only ments Total children 0-1 0.9 4.8 56.1 38.2 100.0 162 2-3 0.0 1.7 23,9 74.4 100.0 168 4-5 1.1 0.0 2.8 96.1 100.0 178 6-7 1.7 2.1 3,0 93.2 100.0 144 8-9 0.8 0.0 5.3 93,9 100.0 183 10-11 1.3 0.0 2.2 96.5 100.0 135 12-13 6.2 0.6 6.1 87.1 100.0 154 14-15 8.7 0.0 1.2 90.0 100.0 117 16-17 13.0 0.0 3.1 83.9 100.0 97 18-19 13.5 0.3 2.5 83.7 100.0 142 20-21 31.6 0.0 2.1 66.3 100.0 141 22-23 58.6 0.0 2.9 38.5 100.0 121 24-25 72.9 0.0 0.0 27.1 100.0 126 26-27 87.8 0.0 1.5 10.6 100.0 103 28-29 86.1 0.0 1.3 12.6 100.0 116 30-31 84.3 0.0 1.4 14.3 100.0 115 32-33 98.0 0.0 0.0 2.0 100.0 105 34-35 96.0 0.0 0.0 4.0 100.0 114 Note: Breastfeeding status refers to preceding 24 hours. Children cl~sified as breastfeeding and plain water only receive no supplements. 101 Table 9.3 Breastfeeding and supplementation by age Percentage of breasffeeding children who are receiving specific types of food supplementation, and the percentage who are using a boule with a nipple, by age in months, Malawi 1992 Percentage of breasffeeding children who are: Receiving supplemem Using a bottle Number Infant Other Other Solid/ with a of Age in months formula milk liquid mushy nipple children 0-1 1.3 1.9 18.4 25,1 4.5 161 2-3 6.5 6.0 22.5 59.7 3.4 168 4-5 9.8 13.6 29.0 88.7 9.5 176 6-7 5.1 3.3 31.6 87.1 6.6 142 8-9 3.8 7.7 35.3 89.4 3.7 182 10-11 4.0 7.7 31.1 94.2 3.5 133 12-13 3.3 7.3 41.9 90.2 1.7 145 14-15 4.7 13.8 44.3 95.3 4.3 107 16-17 4.2 14.1 47.3 96.4 5.4 85 18-19 2.7 11.7 50.4 93.5 0.5 123 20-21 1.7 12.9 31.6 94.4 1.5 96 22-23 1.9 9.3 43.1 93.0 1.3 50 24-25 1.9 4.8 65.5 90.0 1.4 34 26-27 0.0 0.0 24.0 75.1 0.0 13 28-29 0.0 15.1 18.8 81.8 0.0 16 30-31 0.0 1.0 26.4 83.2 0.0 18 32-33 0.0 0.0 8.3 100.0 0.0 2 34-35 0.0 0.0 34.1 100.0 0.0 5 Note: Breasffeedlng status refers to pre,ced'mg 24 horns. Percents by type of supplement among breastfeeding children may sum to more than 100 percent since children may have received more than one type of supplement. The median duration of breastfeeding is 21 months (Table 9.4). The duration of brcastfeeding is longest for the children in the Southern Region, in rural areas, and among mothers of lower educational level, although these differentials are not large. Breastfeeding duration does not vary significantly between male and female children, nor does it depend on type of person assisting at delivery of the child. The median duration of exclusive breasO~eeding (only breast milk) is less than 1 month. Children arc classified as fully breas!fed if they are receiving only breast milk or if water is the only addition to their diet of brcast milk. The median duration of full breastfeeding is only 1.2 months. The frequency of breasffeeding influences the nutritional status of the baby by affecting the overall amount of milk he or she receives. It also affects the mother by influencing the retum of her menstrual period after the birth. Medical research has shown that mothers who nurse their babies more frequently have longer durations of postpartum amenorrhoea than mothers whose infants suckle less often. The data indicate that 93 percent of children under 6 months of age were breastfed six or more times in the 24 hours preceding the interview. The percentage is slightly higher in the rural areas (93 percent) than in the urban areas (90 percen0, but varies little by other characteristics. 102 Table 9.4 Median duration and frequency of breastfeeding Median duration of may breastfeeding and full breasffeeding, end the percentage of children under six months of age who were breasffed six or more times in the 24 hours preceding the survey, by selected background characteristics, Malawi 1992 Median duration in months x Children under 6 months Breastfed Any Exclusive Full Number 6+ times Number Background breast- breast- breast- of in preceding of characteristic feeding feeding feeding ~" children 24 hours children Residence Urban 19.6 0.4 0.7 322 90.4 53 Rural 21.4 0.4 1.3 2532 93.0 455 Region Northern 20.5 0.4 0.6 339 93.6 56 Central 20.1 0.4 0.8 1190 93.1 196 Southern 21.9 0.4 1.6 1325 92.3 255 Mother's education No education 22.2 0.4 1.4 1436 91.6 263 Primary I-4 20.5 0.4 0.9 687 98.0 129 Primary 5-8 19.9 0.4 1.4 641 94.1 101 Secondary+ 20.6 0.4 0.5 89 a a Assistance at delivery Medically trained person 20.9 0.4 1.4 1508 92.8 273 Traditional birth attendant 23.0 0.4 0.7 538 91.4 100 Other or none 21.0 0.4 1.3 808 93.8 134 Sex of child Male Female 21.0 0.4 1.2 1447 92.5 278 21.3 0.4 1.3 1407 93.0 230 All children 21.2 0.4 1.2 2854 92.8 508 Mean 20.2 0.9 3.0 96.8 Prevalence/Incidence mean 20.6 0.2 2.4 IMediens and means are based on current status of children born less then 36 months before the survey. 2Eith~ exclusively h'easffed or received plain water only in addition to breastfeeding. tLess than 25 cases 103 9.2 Nutr i t iona l Status of Ch i ld ren A significant contribution of the MDHS to an understanding of child health in Malawi was the collection of anthropometric data (height and weight) on children under 5 years of age. Measures of poor nutritional status are important as they allow evaluation of the susceptibility of children in the population to disease, impaired mental development, and untimely death. Evaluation of nutritional status is based on the rationale that in a wefl-nourished population, one observes a statistically predictable distribution of children of a given age with respect to height and weight of the child. Use of a standard reference population facilitates analysis of any given population over time or comparisons among subgroups of a population. One of the most commonly used reference populations, and the one used in this report, is the NCHS (U.S. National Center for Health Statistics) standard, which is recommended by the World Health Organisation (WHO). Three standard indices of physical growth that describe the nutritional status of children are presented in this report: height-for-age, weight-for-height, and weight-for-age. Height-for-age is a measure of linear growth. A child who is more than two standard deviations below the mean of the NCHS reference population (i.e., <-2 SD) in terms of height-for-age is considered short for his/her age, or stunted, a condition that would reflect the cumulative effect of chronic underoutrition. If the child is more than three standard deviations below the reference mean (i.e., <-3 SD), then the child is considered to be severely stunted. A child between -2SD and -3 SD is considered moderately stunted. Weight-for-height describes current nutritional status. A child who is more than two standard deviations below the reference mean weight-for-height is considered too thin for his/her height, or wasted, a condition reflecting acute or recent nutritional deficit. As with stunting, wasting is considered severe if the child is more than three standard deviations below the reference mean. Severe wasting is closely linked to mortality risk. Weight-for-age is a composite index of weight-for-height and height-for-age and, thus, provides little information beyond that embodied in the two indices described above. A child can be underweight for his age because he is stunted, because he is wasted, or because he is wasted and stunted. In the survey, all surviving children born to interviewed women since January 1987 were eligible for height and weight measurement. Of the 3789 children (1-59 months old at the survey date) eligible for measurement, 3403 (or 90 percent) were weighed and measured. The most common reason for not being measured was that the child was not home at the time of the survey. Of the children who were both weighed and measured, 168 (5 percent) were considered to have implausibly low or high values for height-for-age or weight-for-height. The following analysis focuses on the 3235 children, age 1-59 months, for whom complete and plausible anthropometric data were collected. Table 9.5 shows the percentage of children under five years of age classified as undernourished according to height-for-age, weight-for-height and weight-for-age indices, by the child's age and selected demographic characteristics. Nearly one half of children under five are classified as stunted, and about one quarter are severely stunted. The prevalence of stunting increases with increasing age, peaking at 36-47 months (66 percent) and then falling slightly among children 48-59 months of age (Figure 9.1). The prevalence of stunting varies very little by sex or birth order. However, stunting occurs more frequently among children born after a short birth interval (less than 24 months) than among those born after a long interval (4 years or more). 104 Table 9.5 Nutritional status by deanographic charaete~istles Percentage of children under five years who are classified as undemourlshed according to three anthropometric indices of nutritional statm: beight-for-age, weight-for-heighi, mad weight-for-age, by selected demographic characteristics, Malawi 1992 Demographic characteristic Height-for-age Weight-for-height Weight-for-age Percentage Percentage Percentage Percentage Percentage Percentage Number below below below below below below of -3 SD -2 SD* -3 SD -2 SD l -3 SD - 2 SD 1 children Child's age (months) <6 2.1 10.4 0.8 2.4 0.5 2.2 418 6-11 8,5 26,9 3.1 7,0 8.6 23.4 409 12-23 24.1 52.0 2.2 11.2 11.4 37.5 692 24-35 28.7 59.5 1.2 3.9 10,2 35.5 586 36-47 35.0 66.3 0.4 2.6 7.0 30.3 553 48-59 29.4 60.1 1.0 3.9 5.4 24.2 577 S~x Male 24.5 50.9 2.0 6.0 8.5 28.3 1615 Female 21.4 46.5 0.9 4.9 6.7 26.1 1620 Birth order 1 23,9 49.8 2.7 6.2 9.8 24.7 511 2-3 21.9 46.7 1.8 6.1 6,8 27.8 959 4-5 23.9 52.3 1.4 3.9 7.8 27.8 762 6+ 22.7 47.3 0.5 5.5 7.1 27.4 1003 Previous birth Interval <2 years 24.3 53.1 1.2 6.6 8.9 26.6 538 2-3 years 23.9 48.2 1.2 5.3 7.0 28.8 1658 4 or more years 17.5 44.7 1.1 4.0 5.8 25.4 527 All children 22.9 48.7 1.4 5.4 7,6 27.2 3235 Note: Figures are for children born in the period 1-59 months preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/~DC/WHO inteamational reference population. Children are classified as undernourished if their z-scores are below minus two or minus three standard deviations (-2 SD or -3 SD) from the median of the reference population. 1Includes children who are below -3 SD. The weight-for-height index gives information about children's recent nutritional status. Severe wasting represents failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of recent illness or of seasonal variations in food supply. Five percent of children in Malawi are wasted, i.e., below minus two standard deviations (-2 SD) from the median of the reference population; one percent are severely wasted (-3 SD). Wasting is most common during ages 6-23 months, suggesting that food supplementation during weaning is inadequate. Male children and children of lower birth order are at higher risk of severe wasting than girls and children of higher birth order. 105 100 80 60 40 20 0 Figure 9,1 Percentage of Children Stunted, by Age of Child and Degree of Stunting Percentage stun~ed 1 5 6 11 12 23 24 35 36 4? 48 59 Age ofchlid Irrlonlhs} MF)H~ ILl(I? Over one-quarter of children in Malawi are underweight, whichmay reflect stunting, wasting orboth. Children in their second and third year of life are particularly susceptible to undemutrition. One in ten children between 12 and 35 months of age are severely undemourished. Table 9.6 shows the variation in undernutrition indices by urban-rural residence, region, and education of the mother. Rural children are more poorly nourished, both acutely and chronically, than their urban counterparts. Severely low height-for-age is more than twice as common in rural Malawi than in towns. Regarding regional variation, acute undemutrition is most prevalent in the Southern Region, but chronic tmdemuUition is most prevalent in the Central Region. The former may reflect drought conditions and food shortages occurring in the South during the period of data collection. During late 1992, 7 percent of children under five in the Southem Region were wasted; 2 percent severely so. A mother's education is strongly associated with her child's risk of poor nutritional status. Children of women with no education are 4 times more likely to be severely stunted and more than twice as likely to be severely wasted than children of women with at least some secondary schooling. 106 Table 9.6 Nutritional status by socioeconomic characteristics Pen:.entage of children under five years who axe classified as undernourished according to three anthropometric indices of nutritional status: height-for-age, welght-for-heigin and weighi-for-age, by selected socioeconomic characteristics, Malawi 1992 Socioeconomic chBzaeteristic Height-for-age Weight-for-height Weight-for-age Percentage Percentage Percentage Percentage Percentage Percentage Number below below below below below below of -3 SD -2 SD 1 -3 SD -2 SD 1 -3 SD -2 SD l children Residence Urban l l .1 35.0 1.0 2.6 3.6 15.4 345 Rural 24.3 50.3 1.5 5.8 8.1 28.6 2890 Region Northern 17.5 44.7 0.4 3.5 5.0 20.3 390 Central 25.0 50.5 1.0 4.5 6.8 25.0 1314 Southeazn 22.5 48.1 2.1 6.7 8.9 30.8 1531 Mother's education No education 26.4 51.7 1.9 6.2 9.0 30.7 1669 Primary 1-4 23.1 51.7 1.2 4.9 7.9 27.1 775 Primary 5-8 16.5 42.1 0.7 4.5 4.9 21.1 696 Second,a3'+ 6.1 19.3 0.7 3.4 1.2 10.7 95 All children 22.9 48.7 1.4 5.4 7.6 27.2 3235 Note: Hgmes are for children born in the period 1-59 months preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international reference population. Children are classified as undernourished if their z-scores are below minus two or minus three standard deviations (-2 SD or -3 SD) from the median of the reference population. llnchides children who are below -3 SD 9.3 Maternal Anthropometric Status Several indicators can be used to assess the nutritional status of women (Krasovec and Anderson, 1991). In the MDHS, data were collected on the height and weight of women who had had at least one birth since January 1987. This sample of women will thus underrepresent lower fertility age groups; for example, women 15-19 years and women 40-49 years old. Table 9.7 shows the percentage distribution of mothers for three anthropometric indicators: height; body mass index (BMI), an indicator combining height and weight data; and upper ann circumference, along with means and standard deviations. Height of a woman is associated with past socioeconomic status and with nutrition during her childhood and adolescence. In addition, maternal height is used to predict the risk of difficult delivery, since small stature is often associated with small pelvis size. The risk of low birth weight also seems to be higher for short women. The optimal cut-offpoint, below which a woman can be identified as at risk, is in the range of 140-150 centimetres. The mean height of mothers measured in the MDHS was 156 cm. About 3 percent of mothers were less than 145 cm. in height and 14 percent were less than 150 cm. 107 Body mass indices are used to assess thinness and obesi- ty. The most commonly used index is the BMI, which is defined as the weight in kilograms divided by the squared height in metres. A cut-off point of 18.5 has been recommended for defining chronic energy deficiency among non-pregnant women. The mean BMI among the weighed and measured mothers was 21.7; 9 percent had a B MI below 18.5, reflecting a chronic nutri- tional deficit. Ann circumference can be used as an indicator of nutri- tional status in both pregnant and non-pregnant women. Because ann circumference is relatively easy to measure, it has oRen been used as a tool during pregnancy to screen for risk of low birth weight and late foetal and infant mortality. The recommended cut-offpoint for assessing these risks is on the order of 21-23 era. In Malawi, the mean arm circumference of women with a recent birth was 26.2 cm. Over 2 percent of mothers had an ann circum- ference below 22 cm. and 6 percent had an arm circumference below 23 cm. Table 9.8 presents differentials in maternal nutritional status indicators by background characteristics. The MDHS data indicate that the height of a woman is associated with educational status. Women with some secondary school are almost 4 cm. tall- er, on average, than their uneducated counterparts. The percent- age of women under 145 cm. in height decreases with increasing level ofmatemal education. There is little variation in the average height of women by urban-rural residence or regions of the coun- try. A woman's age and number of children are not closely as- sociated with maternal height. The BMI of Malawian mothers varies considerably across background characteristics. Whereas 12 percent of uneducated (non-pregnant) mothers have a BM1 indicating chronic nutritional deficit (< 18.5), only 7 percent of mothers with at least 5 years of school fall into the same risk category. Rural mothers are 42 per- cent more likely than urban mothers to have a BMI less than 18,5, and mothers in the Southern Region are 70 percent more likely to have a low BMI than women in the Centre or North. The latter observation is consistent with the relatively poor nutritional status of children under five years in the South, and with the severe drought in that part of Malawi before and during the MDHS field- work. Older mothers (35 years or more) and very young mothers (less than 20 years) are more likely than other women to have BMI values that indicate nutritional risk. Table 9.7 Anthropomc~'ic indicmors of maternal nutritional status Petc¢~ distribution of womtm who delivered • chlkl in the fly© yem pcecedlng the ~ey w.cording to amhropomea'in indicators, and mean hciglg, weight and body mass index (BMD, Malawt 1992 Variables percent ndght (cn~) <140 0.3 140-144 2.4 145-149 I0.8 150-159 60.3 160-169 22.8 170-179 0.8 >~ 180 0.1 Missing 2.3 Total 100.0 Mean 156.0 Standard deviation 6,4 Number of women 2854 Weight (kgs.) <40 2.6 40-49 35.4 50-59 46.9 6069 10 7 >= 70 1.9 Missing 2.5 Total 100.0 Mean 52.4 Standard deviation 7.7 Number of women I 2259 BMI <16,0 0.5 16.0-18.4 8.5 18.5-19.9 20.3 20.0-22.9 43.4 23.0-25.9 19.6 26.0-28,9 3.5 >=29.0 1.4 Mis~ing 2.6 Total ItX).O Mean 21.7 Standard deviation 6.3 Number of women I 2259 Arm circun~'erence (cnm.) <21.0 1.3 21.0-21.9 1.0 22.0-22.9 4.0 23.0-23.9 10.4 24.0-24,9 13,6 25.0-25.9 14.9 26.0-26.9 18.4 27.0-27.9 10.8 28.0-28.9 10.4 29.0-29.9 6.7 ~30.0 6.5 Missing 1.9 To~I I00.0 Mean 26.2 Standard dev~on 2.7 Number of women 2854 IExcludes pregnant women and those who gave bbth in the two months preceding the m~ey. 108 Differentials in upper arm circumference generally are less pronounced than for height and BMI. Education, urban-rural, and regional differentials are small or negligible. However, nutritional risk as measured by ann circumference less than 23 cm. decreases significantly with age of the mother and with increasing number of children ever born. Table 9.8 Differentials in mammal anthropomelxic indicators Mean height end the percentage of women shorter than 145 centimetres, mean body mass index (BMI) and the percentage of women whose BMI is less then 18.5. according to selected background characteristics, Malawi 1992 Height Body mass index (BM1) Arm circumference Percent Percent Background <145 Number Percent Number <23.0 Number characteristic Mean (cms.) of women Mean <18.5 of women Mean (cms.) of women Age < 20 154.8 3.0 291 21.0 13.4 226 25.2 11.5 289 20-34 156.1 2,9 1784 21.8 8,6 1391 26.2 6.6 1795 >=35 156.0 2.5 713 21.8 11,0 583 26.8 4.2 714 Residence Urban 157.0 1.1 323 22.5 7.1 260 27.1 5.9 322 Rural 155.8 3.0 2465 21.6 10.1 1941 26.1 6.6 2477 Region Northern 155.5 3.2 335 22.2 7.2 266 26.1 8,5 335 Cen~al 156.4 2.2 1137 22.2 7.3 879 26.4 5.2 1144 Southern 155.7 3.2 1316 21.1 12.4 1055 26.1 7.1 1319 Education No education 155,5 3.5 1432 21.3 11.9 1132 26.1 6,1 1438 Primary 1-4 155.7 3.4 634 22.0 8.4 499 26.1 7.1 640 Primary 5-8 156.8 1.1 630 21.9 6.6 489 26.5 6,8 629 Secondary+ 159.3 0.5 91 24.0 7.2 80 28.0 5.7 90 Children ever born 1 155.7 2,5 503 21.3 10.4 395 25.4 11,5 502 2-3 155.9 2.9 771 21.5 10.0 595 26.2 6.7 774 4-5 155.9 3.2 618 21.9 9.8 484 26.1 6.3 623 6+ 156.1 2.6 897 21.9 9.1 728 26.8 3.7 901 Total 156.0 2.8 2788 21.7 9.8 2200 26.2 6,5 2799 Nora: Excluded from the BMI index are pregnant women and those who gave birth in the two months preceding the survey. Education values missing for two cases. 109 CHAPTER 10 KNOWLEDGE OF AIDS A series of nine questions, asked of both women and men, was aimed at assessing the level of general and specific knowledge concerning the modes of HIV/AIDS transmission and prevention of AIDS in the country. Tables 10.1.1 and 10.1.2 and Figure 10.1 present the distribution of women and men respondents by awareness of AIDS, knowledge of specific modes of AIDS transmission, and background characteristics. General knowledge of AIDS is almost universal in Malawi among males (98 percen0 and females (95 percent). Among both women and men, sexual intercourse was the most frequently reported mode of HIV/AIDS transmission (86 and 93 percent, respectively), followed by needles and blades, and blood transfusions. General/y, men could cite more specilic modes of transmission than could women. Table 10.1.1 Knowledge of AIDS - females Percentage of women age 15-49 who have ever heard of AIDS and percentage reporting various modes of AIDS transmission, by selected background characteristics, Malawi 1992 Mode of AIDS transmission Ever Needles, heard Sexua l blades, Mother Blood Number Background of inter- skin to trans- Don't of characteristic AIDS course punctures child fusion Other know women Age 15-19 94.5 85.7 44.8 1.4 6.9 6.4 8.8 1082 20-24 95.4 87.9 51.1 2.3 8.5 5.4 7.3 944 25-29 95.7 88.9 48.5 1.9 8.7 4.3 5.6 777 30-34 96.8 87.1 48.1 1.3 7.9 5.0 6.1 656 35-39 96.0 86.1 43.1 1.5 8.2 5.3 6.3 537 40-44 93.7 84.0 32.7 2.1 8.1 2.9 13.1 510 45-49 93.9 79.2 29.8 0.9 2.8 2.7 17.3 343 Residence Urbma 98.8 90.8 54.3 2.3 15.6 6.0 4.6 594 Rural 94.7 85.6 43.2 1.6 6.5 4.8 8.9 4255 Region Northern 94.5 82.0 56.2 2.2 9.0 5.9 9.8 578 Central 93.6 83.6 41.1 1.7 6.5 4.9 10.3 1872 Southern 96.7 89.3 44.5 1.6 8.2 4.8 6.6 2398 Education No education 93.1 80.8 33.0 0.9 4.0 3.7 13.6 2287 Primary 1-4 94.8 89.0 43.1 1.2 6.0 5.5 5.5 1191 Primary 5-8 99.1 91.5 61.9 2.7 11.3 6.1 2.8 1157 Secondary+ 99.9 97.9 75.3 7.6 33.3 8.2 1.4 212 Total 95.2 86.3 44.6 1.7 7.6 5.0 8.4 4849 111 Table I0.1.2 Knowledge of AIDS - males Percentage of men age 20-54 who have ever heard of AIDS mad percentage reporting various modes of AIDS transmission, by selected background characteristics, Malawi 1992 Mode of AIDS transmission Ever Needle.s, heard Sexual blades, Mother Blood Number Background of inter- skin to trans- Don't of characteristic AIDS course punctures child fusion Other know women A~e 20-24 98.0 94.4 70.5 1.3 II.8 3.5 2.2 277 25-29 I00.0 94.5 68.0 3.2 13.7 4.7 1.2 205 30-34 98.2 93.7 68.0 1.4 15.3 5.8 3.3 168 35-39 97.8 95.6 65,4 t.2 17.1 4.0 2.0 143 40~t4 IO0.O 93.0 58.1 1.7 9.2 2.7 5.4 160 45-49 99.3 89.7 62.7 0.8 3.5 1.5 5.2 95 50-54 94.0 86.5 50.1 0.0 8.3 1.5 9.8 102 Residence Urbma 99.9 97.3 71.4 2.9 20.7 7.1 1.6 181 Rural 98.1 92.4 63.7 1.3 10.3 3.0 3.9 970 Region Northern 98,8 89.1 68.9 1.0 19.0 14.4 5.2 139 Central 97.3 93.8 59.5 0.7 7.0 1.4 2.1 443 Southern 99.1 93.8 68.1 2.3 14.1 2.8 4.2 569 Education No education 95.9 89.5 46.8 0.3 4.2 2.7 6.4 236 Primary 1-4 98.5 90.0 57.6 0.5 3.9 1.5 4.2 335 primary 5-8 99.1 95.4 74.1 1.7 13.4 4.4 2.5 423 Secondary+ 100.0 99.4 82.0 5.4 36.3 7.7 0.3 157 Total 98.4 93.2 64.9 1.5 12.0 3.7 3.5 1151 The results show that AIDS awareness and knowledge of specific mode of transmission are very high among young men and women and decrease slightly at older ages. Only small differences exist between urban and rural areas in both general and specific A IDS knowledge. Rural women in particular are less knowledgeable about HIV/AIDS; 14 percent did not mention sexual encounter as a mode of transmission versus less than 3 percent among urban men. Only 2 percent of men and women mentioned (spontaneously) mother-to-child transmission of HIV/AIDS. Education of the respondent is strongly related to AIDS knowledge, especially when looking at specific knowledge of modes of H IV transmission, and especially when the respondent is female. For example, secondary education more than doubles the probability that a women knows the virus can be transmitted through contaminated needles/blades and through blood transfusion as compared with women without any education. 112 Figure 10.1 AIDS Awareness and Knowledge of Modes of HIV Transmission EVER HEARD OF AIDS MODES OF TRANSMISSIOK Sexual Intercourse Needles/Blades Mothe{ to Chtld~ Blood Transluston Olt~ef Don't Kno'a I 20 40 60 80 100 MDHS 1992 113 Table 10.2 and Figure 10.2 present the proportion of respondents who reported that they heard of A IDS during the month before the survey by source of information. The results indicate that most men and women have been exposed to some type of AIDS information. Less than 1 percent of male and about 4 per- eent of female respondents did not receive any AIDS messages. However, the sources of information about AIDS tend to differ between men and women and between urban and rural residents. Men are much more likely to be exposed to messages through the major media, i.e,, radio and newspapers, whereas women are more likely to have received information from health workers, friends and relatives. This finding has important implications for the design of gender-specific programmes to spread the word on AIDS prevention. Similarly, rural residents have received messages through fewer different sources and, specifically, are not as exposed to messages through the media as frequently as urban residents. Table 10.2 Sources of AIDS information Percentage of women age 15-49 and men 20-54 who report hearing of AIDS from various sources in the month before the sur~ey, by urban-rural residence, Malawi 1992 Source of information Urban Rural Total FEMALES Radio 87.5 59.6 63.1 Newspaper 13.5 4.2 5.4 Health worker 45.7 42.3 42.8 MosqueK~httrch 6.3 5.8 5.8 Friend/Relative 28.1 43.8 41.8 School/leacher 5.3 3.7 3.9 Booklet/Poster 5.5 3.0 3.3 Community meeting 6.1 6.9 6.8 Other 0.8 0.0 0.1 None 0.6 4.2 3.8 Number of women 587 4031 4618 MALES Radio 93.2 85.7 86.9 Newspaper 34.8 22.2 24.2 Health worker 41.6 34.8 35.9 MosqueK2hurch 8.0 6.0 6.3 Friend/Relative 23.8 35.3 33.5 School/Teacher 7.9 2.8 3.6 Booklet/Poster 12.4 6.0 7.0 Community meeting 13.5 17.7 17.0 Other 2.5 0.3 0.7 None 0.3 0.4 0.4 Number of men 181 951 1132 Note: Includes only men and women who ~etmrtad to ha'~e heard of AIDS. 114 Figure 10,2 Sources of Information about AIDS Radto E" Newspaper ~, x Health workers L Mosques/Churches I Frlends,/~elalwes School/Teachers Booklets/Posters Cornmun W Meetings Other None I I I m I [ ] 10 20 30 40 50 60 70 80 90 MDHS 1992 Information was also collected on the respondents' perception of possible means of transmission of the HIV/AIDS. More than 80 percent of men and women who had heard of AIDS knew that it is possible for a mother with AIDS to give birth to an infected child (Table 10.3). Further, 69 percent of women and 83 per- cent of men were aware that healthy-looking persons can be infected with HIV/AIDS. To assess potential misconceptions about methods of transmission of HIV/AIDS, respondents were asked whether they thought they could contract AIDS through handshaking, hugging, kissing, sharing clothes or eating utensils, stepping on urine or stool, and mosquito bites. More than half the men and women believed that kissing, stepping on urine/stool and mosquito bites are risk factors for HIV/AIDS transmission. Misconceptions about modes of transmission tended to be more common in rural areas and among women. Over one quarter of rural women believe that HIV/AIDS can be transmitted through handshaking, 115 Table 10.3 Perceived modes of AIDS tzansmission Percentage of women age 15-49 and men age 20-54 who think it is possible to get AIDS by various means, according to urban-rural residence, Malawi 1992 Urban Rural Total FEMALES Possible to get AIDS by: Shaking hands with someone who has AIDS Hugging someone who has AIDS Kissing sometme who has AIDS Sharing the clothes of someone who has AIDS Sharing eating utensils with someone who has AIDS Stepping on the urine or stool of someone who has AIDS Mosquito, flies or bedbug bites 12.0 26.9 25.0 19.7 39.1 36.6 39.7 53.9 52.1 24.6 43.6 41.2 25.4 42.5 40.3 42.5 58.1 56.1 45.3 63.9 61.6 Possible for a healthy-looking person to carry AIDS? Yes 84.6 66.1 68.5 No II.I 24.0 22.3 Don't know 4.3 9.8 9.1 Missing 0.1 0.1 0.1 Pe~lble for a woman with AIDS to give birth to a child with AIDS virus? Yes 90.3 80.3 81.6 No 5.6 11.8 11 .fl Don't know 3.9 7.6 7.1 Missing 0.1 0.3 0.3 N,araber of women 587 4031 4618 MALES Possible to get AIDS by: Shaking hands with someone who has AIDS 9.5 22.2 Hugging someone who has AIDS 16.6 29.2 Kissing someone who has AIDS 44.2 56.g Sharing the clothea of someone who has AIDS 27.1 45.2 Sharing eating utensils with someone who has AIDS 22.9 40.5 Stepping on the urine or stool of someone who has AIDS 34.4 55.7 Mosquito, flies or bedbug bites 43.0 59.3 20.2 27.1 54.7 42.3 37.7 52.3 56.7 Possible for a healthy-looking person to carry AIDS? Yes 93.2 80.5 82.6 No 4.9 13.8 12.4 Don't know 1.9 5.6 5.1 Missing 0.0 0.0 0.0 Possible for a woman with AIDS to give birth to a child with AIDS virus? Yes 94.7 86.2 No 2.4 6.5 Don't know 2.8 7.1 Missing 0,0 0.2 87.6 5,8 6.4 0.2 Number of men 181 951 1132 116 Table 10.4 shows the distribution of respondents by their awareness of means of AIDS prevention. Again, the results show that women and rural residents have less information available to them than men and urban residents. Nearly 30 percent of rural women do not think that AIDS can be prevented compared to 18 percent of urban women, 13 percent of rural men, and 8 percent of urban men. In general, men know of more different ways of preventing the disease, and cited condom use and needle sterilisation more commonly than women as ways to avoid the disease. In urban areas, men are more likely than women to report avoidance of prostitutes as a way of disease prevention, whereas in rural areas women are more likely than men to report the same. Table 10.4 Perceptions about AIDS prevention Percent distribution of women age 15-49 mad men age 20-54 by whether they believe AIDS can be prevented and. of those who believe it can be prevented, the percentage reporting various means of prevention, according to urban-rural residence. Malawi 1992 Urban Rural Total FEMALES Can AIDS be prevented? Yes 82.4 70.9 72.4 No 17.5 28.9 27.5 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Number of women 587 4031 4618 Among those who believe AIDS Is preventahle, percentage reporting means: Have no sex at all 41.5 35.4 36.2 Limit number of parmers 42.4 40.7 40.9 Use condoms 16.0 11.1 11.8 Sterilise needles 39.6 29.9 31.3 Avoid prostitutes 25.7 30.5 29.8 Other 7.5 9.0 8.8 MALES Can AIDS be prevented? Yes 92.4 87.2 88.0 No 7.6 12.6 11.8 Missing 0.0 0.2 0.1 Total 100.6 100.0 100.0 Number of men 181 951 1132 Among these who believe AIDS Is preventable, percentage reporting means: Have no sex at a// 25.7 39.3 37.0 Limit number of parmers 43.5 59.2 56.5 Use condoms 31.4 30.2 30.4 Sterilise needles 55.9 38.8 41.7 Avoid prostitutes 37.4 15.4 19.1 Other 6.5 4.7 5.0 117 Table 10.5 prescntstheopinionsofthe respondentsonwhoshouldtakecareofAIDSpatients. Most men and women think that friends and relatives should bear primary responsibility for care of the afflicted. However, men---especially those in rural areas---tended to suggest more often that the government be involved (35 percent) than did women (20 percent). Table 10.5 Attitudes towards AIDS Percent distribution of women age 15-49 and men age 20-54 by preferred caretakers for a relative with AIDS, according to urban-rural residence, Malawi 1992 Urban Rural Total FEMALES Preferred caretaker Relatives/Friends 76.8 72.7 73.3 Govarnment facility 18.4 19.8 19.6 Religious or ganisation 0.2 0.2 0.2 Nobody/Abandon 3.5 6.6 6.2 Other 1.0 0.7 0.7 Number of women 587 4031 4618 MALES Preferred caretaker Relatlves/Friends 76.2 61.2 63.6 Government facility 22.7 37.5 35.1 Religious organisation 0.1 0.4 0.3 Nobody/Abandon 0.9 0.7 0.8 Other 0.1 0.2 0.2 Number of men 181 951 1132 118 CHAPTER 11 MATERNAL MORTALITY Data were collected in the MDHS which are suitable for estimating maternal mortality using either direct or indirect estimation procedures (Rutenberg et al., 1990; Graham et al., 1989). The information concerns the survivorship of all live births of the female respondent's natural mother. For each of the woman's siblings, questions were asked on current age or, if deceased, the age at death and years ago the death occurred. For sisters who died at age 10 years or older, questions were asked to determine if the death was maternity-related, i.e., did the death occur during pregnancy, during delivery, or within six weeks of delivery or pregnancy termination. The direct approach for estimating maternal mortality maximises use of the available data, using information on age of surviving sisters, the age at death of sisters who died, and the number of years ago the sister died. This allows the data to be aggregated to determine the number of person-years of exposure to mortality and the number of matemal deaths occurring in defined calendar periods. Rates of maternal mortality are obtained by dividing maternal deaths by person-years of exposure. The indirect approach to estimation of maternal mortality, i.e., the sisterhood method, has simpler data requirements than the direct method. None of the information on dates and ages related to sisters is used, and data on all sisters are used to estimate the life-time risk of matemal death. Since the estimates pertain to the life-time experience of respondents' sisters, a well-defined calendar reference period is not derived and the estimates represent mortality conditions over the past 50 years or so. Assuming changes in mortality over time are linear, the reference period can be said to be centered about 12-13 years before the survey date. 11.1 Data Collection Each respondent was first asked to give the total number of her mother's live births. Then the respondent was asked to provide a list of all of the children born to her mother starting with the first-boro, and whether or not each of these siblings was still alive at the survey date. For living siblings, current age was collected; for deceased siblings, age at death and years since death were collected. Interviewers were instructed that when a respondent could not provide precise information on ages or years ago, approximate but still quantitative answers were acceptable. For sisters who died at age 10 years or older, three questions were asked to determine if 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 six weeks of the birth of a child or pregnancy termination?" 11.2 Data Quality The estimation of maternal mortality by either direct or indirect means requires reasonably accurate reporting of the number of sisters the respondent ever had, the number that have died, and the number who have died of maternity-related causes. There is no defnitive procedure for establishing the completeness or accuracy of retrospective data on sibling survivorship. Table 11.1 shows the number of siblings reported by the respondents and the completeness of the reported data on current age, age at death, and years since death. 119 Table l l . l Dataon siblings Number of siblings reported by survey respondents and completeness of the reported data on age, age at death and years since death, weighted, Malawi 1992 Sisters Brothers Unknown sex Total Number Percent Number Percent Number Percent number Total siblings 15107 100.0 14792 100.0 270 100.0 30169 Alive 10467 69.3 10279 69.5 58 21.7 20804 Dead 4624 30.6 4486 30.3 80 29.5 9190 Status unknown 17 0.1 27 0.2 132 48.8 176 Living siblings 10467 100.0 10279 100.0 58 100.0 20804 Age reported 10460 99.9 10272 99.1 58 100.0 20791 Missing age 7 0.1 7 0.1 0 0.0 13 Dead siblings 4624 100.0 4486 100.0 80 100.0 9190 Age at death and years since death reported 4590 99.3 4454 99.3 65 81.8 9109 Missing any age-at-death information 34 0.7 32 0.7 15 19.8 81 The respondents did not report the sex of 0.9 percent of their siblings. The sex ratio of siblings (the ratio of brothers to sisters) enumerated was 0.98, which is low ~ and may indicate underreporting of male births by the respondent. In very few cases (< 0.1 percent) was current age not reported by the respondent. In the case of deceased siblings, reporting of age at death and years since death was also nearly universal. Ninety-nine percent of deceased siblings have both age at death and years since death reported. Rather than exclude the siblings with age or age at death missing from further analysis, information on the birth order of siblings in conjunction with other information were used to impute the missing data. 2 The sibling survivorship data, including cases with imputed values, were used in the direct estimation of maternal mortality. Another way to assess the quality of data used to estimate matemal mortality is to evaluate the plausibility and stability of estimates of adult female mortality. It is reasoned that if estimated rates of overall adult female mortality are implausible, rates based on a subset of these deaths--i.e., maternal deaths in particular--are unlikely to be free of serious problems. Table 11.2 presents the age-specific rates of female mortality (15-49 years) for 0-6 and 7-13 years before the survey, calculated by direct procedures. Overall female mortality (15-49 years) during the period 0-6 years before the survey, taken at face value, is more that 1However, previous censuses and surveys in Malawi have found a similarly low sex ratio at birth. 2The imputation procedure is based on the assumption that the reported birth ordering of siblings in the history is correct. 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 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. 120 Table 11.2 Estimates of age-specific female mortality Direct estimates of age-specific female mortality based on the survivorship of sisters of survey respondents, Malawi 1979-85 and 1986-92 1979-1985 1986-1992 Exposure Ram Exposure Rate Age Deaths years (000) Deaths years (000) 15-19 24 11144 2.18 54 10241 5.27 20-24 22 9618 2.34 40 10890 3.64 25-29 21 7443 2.78 70 10217 6.83 30-34 18 5647 3.24 57 7932 7.24 35-39 8 3532 2.31 55 6148 8.96 40-44 l0 1754 5.86 38 4232 8.91 4549 0 665 0.00 22 2291 9.58 1549 104 39804 2.62 335 51951 6.46 twice as high as mortality during the 7-13 year period before the survey. The difference is apparent at all age groups, which would be difficult to explain on epidemiological grounds alone. Further, the data indicate a shift in the proportion of all female deaths attributable to non-maternal causes, from 64 percent in the less recent period to 79 percent in the more recent period (not shown). Either female mortality (and especially non-maternal mort,ality) is genuinely on the rise or there exists gross underreporting of deaths for the 7-13 year period before the survey. One way to examine the quality of adult mortality estimates is through comparison against model or reference mortality schedules. Embodied in a model life table is a relationship between mortality during childhood and mortality during later years. Some models posit high child relative to adult mortality levels; others describe low child relative to adult mortality. In this exercise we ask the question, "Given an under- five (female) mortality rate of 230 per thousand (taken from Table 7.3), are the estimated rates of adult female mortality plausible?" Table 11.3 shows the adult female mortality rates described in three model mortality schedules when under-five mortality (female) is 230 per thousand live births. The table presents adult female mortality rates implied by the Coale-Demeny South and North model families and the United Nations West African model alongside rates calculated from the MDHS data (0-6 and 7-13 years before the survey). For the 0-6 year period before the survey, MDHS rates increase smoothly between ages 20-24 and 40-44, and fit fairly well the level and pattern described in the South Model, while being somewhat lower than the patterns described in the North and significantly higher than those described in the West African model. On the other hand, for the 7-13 year period before the survey, MDHS adult female rates are lower than those embodied in all three models, although only slightly lower than the West African pattern. The most plausible conclusion to be drawn from this analysis is that the data for the 0-6 year period before the survey are reasonably complete and that the data for previous calendar periods are incomplete. If correct, this means that rates calculated using less recent data or rates derived from data drawn from all calendar periods combined (i.e., sisterhood method) will be underestimated. However, this conclusion does not rule out the possibility than adult mortality has indeed risen recently. 121 Table 11.3 Estimates of age-specific female adult mortality Direct estimates of age-specific female mortality based on the survivorship of sisters of survey respondents, Malawi 1986-92 and 1979-85, and model life table rates, by age Estimated rates Mixlel life table rates I South North W. African Age 1979-85 1986-92 (47.5) (45.0) (55.0) 15-19 2.18 5.27 4.34 5.55 2.18 20-24 2.34 3.63 5.52 6.46 2 96 25-29 2.78 6.83 6.09 7.50 3.39 30-34 3.24 7.24 6.41 8.72 4.22 35-39 2.31 8.96 6.99 10.00 5.04 40-44 5.86 8.91 7.65 11.09 5.39 45-49 0.00 9.58 8.68 12.15 6.35 Total (15-49) 2.62 6.46 6.42 8.59 4.16 tModel life tables were selected at a level of mortality approximately corresponding to a probability of dying between birth and exact age 5 estimated for the period 1983-92 (i.e., 5o.0 of 230 per 1,000 female births). Life expectancies at birth are given in parentheses It is speculative to use this one data source to infer trends in either adult female mortality or maternal mortality. The main objective of the MDHS in this area is to produce a "best estimate" of recent maternal mortality level. In this vein, the direct estimation of maternal mortality that follows will fncus on producing one point estimate of maternal mortality for the 0-6 year period before survey. 11.3 Direct Estimates of Maternal Mortality Direct, age-specific estimates of maternal mortality from the rcportcd survivorship of sistcrs are shown in Table 11.4 for the 0-6 year period before the survey. The number of deaths (71 ) is rather sm all, and the age-pattern of rates is somewhat erratic, but there is the expected trend.of higher rates at older ages. Given the small number of deaths, age-specific rates should not be overinterpreted--the preferred approach is to calculate one estimate for all childbearing ages (15-49 years). For the period 0-6 years belore the survey (1986-1992), the rate of maternal mortality during the childbearing years is 1.36 matemal deaths per 1000 women-years of exposure. The matemal mortality rate can be converted to a maternal mortality ratio and expressed per 100,000 live births by dividing the rate by the period-specific general fertility rate of 0.220 operating during this time period. In this way, the obstetrical risk of pregnancy and childbearing is underlined. By direct estimation procedures, the maternal mortality ratio is estimated at 620 maternal deaths per 100,000 live births during 1986-1992. 3 3The maternal mortality ratio for the period 7-13 years before the survey was calculated to be 347 per 100,000 births. Even after standardizing the rates for the differences in exposure by age, the ratio rose only 0.8 percent to 350 per 100,000. As indicated earlier, this estimate should not be taken to represent the true maternal mortality conditions prevailing at that time. Rather, the estimate is unreasonably low and is interpreted to be due to underreperting of female and maternal deaths prior to the 0-6 year period before the survey. 122 Table 11.4 Direct estimates of matemal mortality Direct estimates of maternal mortality based on the survivorship of sisters of survey respondents, Malawi 1986-92 Exposure Rate Age Deaths years (000) 15-19 13 10241 1,271 20-24 5 10890 0.472 25-29 15 10217 1.485 30-34 14 7932 1.822 35-39 12 6148 1.947 40-44 3 4233 0.827 45-49 8 2299 3.365 Total (15-49) 71 51960 1.362 GFR .220 MMR 1 620 GFR = General fertility rate MMR = Maternal mortality ratio IPer 100,000 llve births; calculated as maternal mortality rate divided by general fertility rate Twenty-one percent offem ale deaths at ages 15-49 were associated with pregnancy and childbearing. Of the 71 matemal deaths during the 0-6 years period before the survey, 29 (41 percent) occurred during pregnancy, 22 (31 percent) during childbirth, and 20 (28 percent) in the six-week period following pregnancy termination or childbirth. 11.4 Indirect Estimates of Maternal Mortality The data on the survivorship of sisters can also be used to estimate matemal mortality by the indirect method, i.e., the sisterhood method. In this method, the data are aggregated by five-year age groups of respondents. For each age group, information on the number of maternal deaths among all sisters of respondents and on the number of "sister units" of risk is used to estimate the lifetime risk of dying from maternal causes. The method also provides an overall estimate of matemal mortality for sisters of all respondents combined, which refers to a period in time centered 12-13 years prior to the survey. The indirect estimatesofmatemal mortality are giveninTable 11.5. Whenaggregating thedataover all respondents, the lifetime risk of matemal death is 0.035, a risk of dying of maternal causes of about 1 in 29. As shown earlier, there is evidence here of more complete reporting in the recent period (i.e., by younger women). The highest estimates of risk come from reports of young women. The lifetime risk of maternal mortality can be converted to an estimate of the maternal mortality ratio (see formula in Table 11.5): 434 maternal deaths per 100,000 live births, applicable to a period around 1980. In conclusion, the maternal mortality ratio was estimated to be 620 per 100,000 by direct means, applicable to a 1986-1992 time period, and 434 per 100,000 by the sisterhood (indirect) method referring to a time period centered around the year 1980. Why the large discrepancy between direct and indirect estimates of matemal mortality? As was shown earlier, it seems likely that maternal deaths (indeed all adult female deaths) were underreported in the periods before 6 years prior to the survey, and that to interpret these data as indicating a rise in female adult mortality and matemal mortality could be misleading. (This may be true, 123 Table 11.5 Indirect estimates of matemal mortality Estimates of maternal mortality using the indirect method, Malawx 1992 Age Lifetime Number Number a Sister units risk of of of Maternal Adjustment of risk maternal respondents sisters 15+ deaths factor exposure death (a) (b) (c) (d) (e)=(b)*(d) (f)=(c)/(e) 15-19 1082 2304 16 .107 246 .066 20-24 944 2010 20 .206 414 .048 25-29 777 1654 26 .343 567 .045 30-34 656 1380 20 .503 694 .029 35-39 537 1245 20 .664 826 .024 40-44 510 1015 21 .802 814 .026 45-49 342 714 23 .900 643 .035 Total (15-49) 4849 8975 145 4205 .[135 TFR 1978-82 8.0 MMR 435 TFR = Total fertility rate MMR = Maternal mortality ratio (1 - [1 - Lifetime risk]t/TFR) * 100,000, where TFR represents the total fertility rate 10-14 years preceding the survey aAdjustod for tile age distribution of respondents' sisters (see Graham et at., 1989). but the data are inadequate to support this.) Since the indirect estimate is essentially a weighted average of reported maternal mortality conditions occurring over the last 50 years or so, the lower indirect estimate may be attributed to the effect ofthe underreporting indicated in less recent periods. Therefore, the direct estimate (620 maternal deaths per 100,000 live births) should be taken as the best national-level estimate of the maternal mortality ratio. 124 CHAPTER 12 AVAILABILITY OF HEALTH SERVICES The use of health services is determined by supply as well as demand. Before the household interviews, community leaders were asked to provide information regarding the availability to local residents of basic health services (see Health Services Availability Questionnaire in Appendix D). In each of the 225 sample points, questions were posed to leaders in the communities about the nearest health facilities, the nearest hospital, the nearest place where methods of family planning could be obtained, and where residents could obtain condoms. The distance and time to these service points were asked and whether specific health services---antenatal care, delivery care, immunisation, provision of methods of family planning, and specifically provision of condoms---were available in each health facility. Where possible, data collection personnel were instructed to ascertain or verify distances and times to facilities themselves. Distances and times were ascertained as an average for persons residing in the sample segment (i.e., selected enumeration area). Before proceeding to the results, it is important to emphasise three points regarding the interpretation of these data. First, although the results in this chapter are presented in terms of the percentage distribution of women age 15-49, the data were collected at the level of the cluster, or sample point. Therefore, from a statistical standpoint, there are only 223 independent observationsL--one for each cluster-level questionnaire completed. Second, the responses to questions regarding time and distances should be regarded only as that perceived by knowledgeable community residents. There is bound to be an important level of imprecision in data collected like this, and no systematic effort was made at external validation of these estimates. Third, the time and distance data are severely heaped, i.e., travel time has been reported in "convenient" increments of 30 minutes, and distance has been reported most commonly in increments of 5 km. This causes the estimated median values to most frequently fall on a heaped value. 12.1 Distance and Time to Nearest Health Facility Table 12.1 shows that for 38 percent of women age 15-49, the nearest health facility is a primary health centre, most commonly government-run. For 24 percent of women, the nearest facility was a dispensary; for 19 percent of women, a hospital was the nearest facility; for 11 percent of women, a manned health post or mobile clinic was the nearest facility; for 4 percent of women, a dispensary/maternity clinic was nearest; and for another 4 percent of women, a maternity clinic was the nearest facility. The data conceming distance and travel time to the nearest health facility are shown in Table 12.2. For the country as a whole, 51 percent of women are within 5 km. of a health facility and 18 percent are 10 or more kin. away from a facility. The median distance to the nearest health facility is 5 km. As expected, urban dwellers are nearer to facilities (median = 2.7 km.) than rural residents (median = 6.2 km.). Women living in the North are, on average, 7.2 km. from the nearest facility compared to 5.9 km. in the Central Region and 4.4 kin. in the South. This is consistent with the greater dispersion of the population in the North. l The MDHS included 225 sample points. However, the data on service availability for two sample points (0.9 percent) are missing. 125 Table 12.1 Type of nearest health facility Percent distribution of all women 15-49 by type of nearest health facility, according to urban-rural residence and region, Malawi 1992 Reddeace/ Re~ion Manned Primary health Dispensary/ Matemity health post/ Hospital centre Malcmity c, lJni¢ clinic Dispensary Mobile clinic Number Govern- Govern- Govern- Govern- Govern- Govern- of meat Private merit Private meat Private ment Private meat private meat Private Total women R~dence Urban 33.7 4.4 30.1 0.0 1.8 0,0 0.0 0.0 20.5 6.8 2.7 0.0 100.0 573 Rural 12.1 4.7 31.0 8.1 3.4 0,5 1.7 2.4 15.4 8.3 6.0 6.4 100.0 4255 n~oe Northern 7.2 4.4 12.8 4.7 25.3 3,6 6.7 0.0 14.2 9.9 7.5 3,7 100.0 578 CcnUal 14.9 5.0 32.8 10.6 0.6 13,0 0.0 0.0 13.0 10.7 5.6 6.9 100.0 1851 Southern 16.3 4.6 33.8 5,1 0.0 0,0 1.4 4.2 18.7 5.6 5.1 5.2 11)0.0 2398 Total 14.7 4.7 30.9 7.2 3.2 0,4 1.5 2.1 16.0 8.1 5.6 5.7 100.0 4828 Table 12.2 Distance and time m nearest health facility Percent distribution of all women 15-49 by distance and time to nearest health facility, according to urban-tufa] residence and region, Malawi 1992 DISTANCE TO NEAREST FACILITY Unde~ I~. 5-9 10-14 15-29 30+ 1 km km km km km km Total Median Total Residence Urban 21.3 64.9 13.8 0.0 0.0 0.0 100.0 23 573 Rural 6.3 39.7 33.5 13,3 6.5 0.8 100.0 6.2 4255 Region Northern 6.5 35.8 29.2 17.9 10.6 0.0 100.0 7.2 578 Central 4.6 42.4 36.7 10.6 5.7 0.0 I00.0 5.9 1851 Southesn 11.1 44.5 27.4 11.1 4.5 1.4 100.0 4.4 2398 Total 8.1 42.7 31.1 11.7 5.7 0.7 100.0 4.9 4828 T IME TO NEAREST FACILITY (MINUTES) Under Median 15 15-29 30-59 60-119 120+ Total time Total Residence Urban 17.2 24.7 39.2 11.7 7.1 100.0 30.3 573 Rural 10.6 2.4 15.9 25,2 45.9 100,0 90.4 4255 Region Northea'n 6.4 7.0 22.6 26.9 37.2 100.0 60.8 578 Central 4.8 7.5 13.9 19.5 54.3 100.0 120.2 1851 South~a-n 17.6 2.7 21.4 26.1 32.2 100.0 60.8 2398 Total 11.4 5.1 18.7 23.6 41,3 100.0 75.7 4828 126 The median estimated time to the nearest health facility for a women is one and a quarter hours. One- fifth of women are within half an hour from a facility, but nearly two-thirds are more than an hour away, and two of five women are at least two hours away. It takes women living in rural areas, on average, an hour longer to reach the nearest health facility than those living in urban areas. Unlike the distance information, the estimated time to the nearest facility is greatest for Central Region (2 hours) compared with only one hour in the Northern and Southern Regions. In all three regions, the predominant means to reach the nearest health facility is by walking. 12.2 Serv ices P rov ided at Nearest Hea l th Fac i l i ty Community respondents were asked whether specific services were pro- vided atthe health facilities nearest to them. The services included antenatal care, ma- ternity care, vaccinations, family planning services, and condom provision. The use- fulness of the recalled data to assess availa- bility of services depends on the respond- ents' knowledge of the services available. In the optimum case, the respondents know whether the service is available or not, and the data can be considered as an indicator of service availability. In a more realistic scenario, the community respondents will provide inaccurate information in a certain, but unknown, fraction of cases. For in- stance, the respondent may report that there were no family planning services but, actu- ally, such services were available at the nearest clinic. In this case, availability of family planning services will be underesti- mated. Table 12.3 presents data on the community respondents' knowledge of the services available at the nearest health fa- cility. The results are reported in terms of the percentage of women age 15-49 whose nearest health facility had the relevant ser- vice available. Table 12.3 Available health services Percent distribution of all women age 15-49 by availability of various health services at the nearest health facility, according to region, Malawi 1992 Region Service available Northern Central Southern Total Antenatal care Yes 90.1 89.9 89.1 89.5 No 9.9 10.1 10.9 10.5 Total 100.0 100.0 100.0 100.0 Delivery care Yes 87.9 84.0 76.2 80.6 No 12.1 16.0 23.8 19.4 Total 100.0 100.0 100.0 100.0 Vaccinations Yes 97.8 99.2 92.4 95.7 No 2.2 0.8 6.7 3.9 Don't know 0.0 0.0 0.9 0.5 Total lO0.O 100.0 100.0 100.0 Family planning Yes 68.6 98.5 79.0 85.2 No 29.5 1.5 14.1 11.1 Don't know 1.8 0.0 6.9 3.7 Total 100.0 100.0 100.0 100.0 Condom provision Yes 73.8 70.1 68.2 69.6 No 16.9 16.5 15.9 16.3 Don't know 9.3 13.4 15.9 14.1 Total 100.0 100.0 100.0 100.0 Number of women 578 1851 2398 4828 Regarding antenatal care, most women reside in communities where the nearest facility provides antenatal care (90 percent of women), maternity services (81 percent), vaccination services (96 percent), and some sort of family planning services (85 percent). The availability of condoms at the nearest facility was unknown by the community respondents in 14 percent of cases. Of those cases where the availability was reported, 81 percent of women are reported to have condoms available at the nearest facility. Regional differences in the services available at the nearest facility depends on the particular service being considered. Availability of antenatal services is nearly the same in all regions, but maternity services and vaccination services are less available at the nearest facility in the Southem Region than in the Central and Northern 127 Regions. The nearest facility for women in the Northern Region is less likely to have family planning services available than in the Southern and Central Regions. Availability of condoms at the nearest facility is similar in the three regions. 12.3 Distance and Time to Nearest Hospital Table 12.4 shows that the median distance to the nearest hospital is about 20 km.; 5 kin. for urban residents and 21 km. for rural residents. Two-thirds of rural women live more than 15 km. from the nearest hospital. On average, Northern Region residents live farther away from a hospital (30 kin.) than those in the Centre (24 kin.) and South (18 km.). The median time to the nearest hospital is 2 hours, though only 45 minutes for urban residents, and an hour and a half for residents of the Northern Region. Northern residents have a greater distance to hospital being covered within a shorter travel time than in the Centre and South. Fifty-seven percent of women--63 percent in rural areas---live two or more hours from the nearest hospital. Table 12.4 Distance and time to nearest hospital Percent distribution of all women age 15-49 by distance and time to nearest hospital, according to urban-rural residence and region. Malawi 1992 DISTANCE TO NEAREST HOSPITAL Number Under 1-4 5-9 10-14 15-29 30+ Distance of 1 km km km km km km unknown Total Median women Residence Urban 7.1 47.0 21.0 11.8 9.6 3.5 0.0 100.0 4.7 573 Rural 0.0 5.4 12.1 13.4 32.7 33.5 2.8 100.0 20.9 4255 Region Northern 1.2 8.1 11.1 4.8 17.6 53.7 3,5 100.0 30.1 578 Central 0.5 7.9 11.2 14.7 32.8 32.8 0.0 100.0 24.0 1851 Southern 1.0 12.8 15.2 14.0 30.8 22.0 4.1 100.0 17.7 2398 Total 0.8 10.4 13.2 13.2 30.0 30.0 2.5 100.0 20.2 4828 T IME TO NEAREST HOSPITAL (MINUTES) Number Under Time Median of 15 15-29 30-59 60-119 120+ unlmown Total time women Residence Urban 10.6 14.7 31.0 28.0 15.7 0.0 100.0 45.9 573 Rural 0.0 2.4 10.4 23.1 63.0 1.2 100.0 120.7 42.55 Region Northexn I.I 1.9 20.I 26.0 47.4 3.5 I00.0 90,9 578 Central 0,0 4.3 7.6 17.9 68.6 1.6 100.0 120.9 1851 Southe~m 2.3 3.9 15.1 27.6 51.1 0.0 I00.0 120.I 2398 Total 1.3 3.8 12.8 23.7 57.4 1.0 I00.0 120.4 4828 128 12.4 Distance and Time to Nearest Source of Family Planning and Source of Condoms A source o f family planning is on average less physically accessible than a health facility (of any type), but is more accessible than a hospital specifically (Table 12.5). The median distance to the nearest source of family planning for a Malawian woman is 6 kin. and takes an hour and a quarter to reach. In rural areas, women are about 7 km. from the nearest source, which represents about 2 hours travel time; in urban areas, women are much closer, on average about 3 km. and an half hour of travel time. As with general health services, the Nortbem population tends to be farther from a source of family planning, but it takes less travel time to reach the source than that for the populations in the Centre and South. About one-third of women in the North and South, but over half of women in the Central Region are 2 hours or more from a family planning source. Yet, on average, women in the Centre are only 5 kin. from a source compared with 7 km. in the other regions. Travel to facilities is perceived to be more difficult in the Central region. Table 12.5 Distance and time to nearest source for any family planning method Percent distribution of all women age 15-49 by distance and time to nearest source for any family planning method, according to urban-rural residence and region. Malawi 1992 DISTANCE TO NEAREST SOURCE Number Under 1-4 5-9 10-14 15-29 30+ Mobile of 1 km km km km km km facility Total Median women Residence Urban 17.7 67.2 11.6 0.5 0.0 0.0 3.0 100.0 2.8 573 Rural 4.2 34.0 33.4 10.4 10.8 2.8 4.4 100.0 6.8 4255 Region Northern 5.0 35.4 19.0 19.4 10.2 4.8 6.2 100.0 7.0 578 Central 4.1 42.8 34.4 5,8 8.2 0.0 4.7 100.0 5.1 1851 Southern 7.3 34.8 31.0 9.5 10.4 3.7 3.3 100.0 6.7 2398 Total 5.8 37.9 30.9 9.2 9.6 2.4 4.2 100.0 6.3 4828 TIME TO NEAREST SOURCE (MINUTES) Number Under Mobile Median of 15 15-29 30-59 60-119 120+ facility Total time women Residence Urban 15.7 29.4 38.1 10.5 3.4 3.0 100.0 30.1 573 Rural 8.5 4.3 13.5 22.2 47.1 4.4 I00.0 120.0 4255 Region North~'n 4.7 8.7 22.2 25.2 33.0 6.2 100.0 60.9 578 Central 3.7 9.2 18.1 12.7 51.6 4.7 100.0 120.2 1851 Southern 14.8 5.5 13.7 26.1 36.5 3.3 100.0 75.7 2398 Total 9.3 7.3 16.4 20.8 41.9 4.2 100.0 90.1 4828 Access to a supply o f condoms is only slightly more difficult for the average Malawian than is access to any method of family planning (Table 12.6). A supply of condoms is, on average, 7 km. away and takes an hour and a half to reach. 129 Table 12.6 Distance and time to nearest source of condoms Percent distribution of all women age 15-49 by distance and time to nearest source of condoms, according to urban-rural residence and region. Malawi 1992 DISTANCE TO NEAREST SOURCE Number Under 1-4 5-9 10-14 15-29 30+ Distance Mobile of 1 km km km km km km urdmown facility Total Median women Residence Urban 17.7 60.9 9.6 0.0 4.3 0.0 0.5 7.0 100.0 3.1 573 Rural 1.5 24.8 28.2 13.1 10.5 9.4 4.0 8.4 100.0 7.9 4255 Region Northern 2.3 28.3 23.9 18.7 10.2 8.0 4.2 4.3 100.0 8.4 578 Central 2.5 28.0 31.3 7.4 7.6 11.4 3.0 8.8 100.0 6.8 1851 Southexn 4.4 30.1 22.5 13.0 11.3 5.9 4.0 8.8 100.0 7.1 2398 Total 3.4 29.1 26.0 11.6 9.7 8.3 3.6 8.2 100.0 7.0 4828 TIME TO NEAREST SOURCE (MINUTES) Number Under Time Mobile Median of 15 15-29 30-59 60-119 120+ uv.imowa facUi.ty Total time women Residence Urban 15.7 29.4 28.4 10.5 6.6 2.5 7.0 100.0 30.0 573 Rural 4.3 4.0 11.7 20.5 49.8 1.3 8.4 100.0 120.2 4255 Region Nor thea"n 1.2 8.7 20.2 23.3 38.1 4.2 4.3 100.0 80.8 578 Cen~al 2.1 8.0 13.9 10.0 55.5 1.7 8.8 100.0 120.5 1851 Southern 9.5 5.9 11.9 25.6 37.8 0.5 8.8 100.0 75.9 2398 Total 5.7 7.0 13.7 19.4 44.6 1.4 8.2 100.0 90.9 4828 12.5 A IDS Education Campaigns Efforts to reduce the spread of the AIDS virus in Malawi rely in large part on educating the public about the virus, how it is transmitted, and how one can prevent its spread. Community lead- ers were asked whether, over the last 12 months, a special program to educate people in the community had been implemented. Table 12.7 shows that only about one-third of women lived in communi- ties where such community education had been implemented. Ur- ban communit ies and communit ies in the Southern Region were much less l ikely to have had a community-based AIDS education program in the last 12 months. It should be remembered that this indicator does not necessarily represent knowledge imparted to community residents. Indeed, we know nothing about the specific content of the messages put forward in these community-based ef- forts. Also, it may be true that persons l iving in those areas with lower estimates of A IDS education coverage (i.e., towns and the Southern Region) have greater exposure to alternative information sources and thus may be in less need of this type of community- based action. Table 12.7 AIDS awareness campaign Percent of all women age 15-49 in communldes with special educational campaign over past 12 months intended to increase awareness of AIDS, by urban- rt~al residence and region, Malawi 1992 Number of Percent women Resltience Urban 13.2 573 Rural 38.3 4255 Region Northern 48.9 578 Centlal 47.4 1851 Southern 22.8 2398 Total 35.4 4828 130 REFERENCES Graham, Wendy, WiUiam Brass and Robert W. Snow. 1989. Estimating Maternal Mortality: The Sisterhood Method. Studies in Family Planning 20(3): 125-35. Krasovec, Katherine and Mary-Ann Anderson, eds. 1991. Maternal Nutrition and Pregnancy Outcomes: Anthropometric Assessment. PAHO Scientific Publication No. 259, Washington, D.C.: Pan American Health Organisation. National Statistical Office. [Malawi]. 1980. Malawi Population Census 1977: Final Report, Volume I, Zomba: Govemment Printer. National Statistical Office. [Malawi]. 1984. MalawiFamily Formation Survey. Zomba: Government Printer. National Statistical Office. [Malawi]. 1991. MalawiPopulation andHousing Census 1987: Summary of Final Results, Volume I, Zomba: Government Printer. Rutenberg, Naomi and Jeremiah M. Sullivan. 1991. Direct and Indirect Estimates of Maternal Mortality from the Sisterhood Method. In Proceedings of D H S World Conference, Washington, D.C. August 5-7, 1991, Vol. 3, 1669-1696. Columbia, Maryland: IRD/Macro International Inc. 131 APPENDIX A INTERVIEW RESULTS Table A . I Sarnple imphmentat ion Percent d isu ibudon of households and eligible women and men by result of the intecview mid household response rates, el igible woman and man response rates, and ov~al l response rates, according to sample domain and ttrban-rura/residence, Malawi 1992 Reset Region Total Urban Rural N~them Central Southern Selected households Completed 91.6 94.8 90.6 91.7 91.9 91.3 Ho*asehold present but no competent respondent at home 1.2 1.4 1.2 1,3 1.3 1.2 Refused 0.0 0.1 0.0 0.0 0.1 0.0 Dwelling not found 0.2 0.3 0.2 0.2 0.2 0.2 Hc~sehold absem 1.7 1.1 2.0 2.2 1.0 2.1 Dwelling vacant/address not a dwelling 4.1 2.1 4.8 4.1 4.2 4.1 Dwe/lin 8 dearoyed 0.4 0.3 0.5 0.2 0.7 0.4 Other 0.6 0.0 0.8 0.3 0.7 0.8 Total percent 100.0 100.0 100.0 100.0 IGO.0 100.0 Number 5811 1413 4398 1626 1919 2266 Household response rate 98.6 98.5 98.7 98.6 98.6 98.7 Eligible women Completed 96.6 96.8 96.5 96.5 96.7 96.6 Net at home 2.4 2.6 2.3 2.4 2.4 2.4 Postponed 0.0 0.0 0.I 0.0 0.I 0.0 Refused 0.1 0.1 0.1 0.2 0.1 0.0 Partly completed 0.1 0.0 0.1 0.1 0.0 0.2 Incapacitated 0.6 0.4 0.7 0.7 0.5 0.5 Other 0.2 0.1 0.2 0.1 0.1 0.3 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 Number eligible 5020 1359 3661 1495 1661 1864 Eligible woman response rate 96.6 96.8 96.5 96.5 96,7 96.6 Overall response rate (women) 95.3 95.3 95.3 95.1 95.3 95.4 Eligible men Completed 89.4 87.5 90.3 90.8 89.9 87.8 Not at home 9.2 11.3 8.1 7.6 8.7 10.7 Postponed 0.2 0.0 0.2 0.0 0.2 0.2 Refused 0.2 0.7 0.0 0.3 0.0 0.4 Partly completed 0.2 0.2 0.1 0.3 0.2 0.0 lncapadtated 0.5 0.0 0.7 0.5 0.5 0.4 Other 0.5 0.2 0.6 0.5 0.5 0.4 Total percent 100.0 100,0 100.0 100.0 100.0 100.0 Number eligible 1288 416 872 380 424 484 Eligible man response rate 89.4 87.5 90.3 90.8 89.9 87.8 Overall response rate (men) 86.5 85.2 87.2 87.5 87.7 84.8 Note: The household response rate is calculated for completed households as a proportion of the sum of those completed, those with no competent reslxmdent , and those refused. The eligible woman response rate is calculated for completed interviews as a proportion of all eligible women. The overall response rate (women) is the product of the household and woman response rates. Response rates for men are calculated in the same way as for women. 135 APPENDIX B SAMPLING ERRORS APPENDIX B ESTIMATES OF SAMPLING ERRORS The estimates from sample surveys are affected by two types of errors, nonsampling error and sampling error. Nonsampling error is the result of mistakes made in implementing data collection and data processing procedures, such as failure to locate and interview the correct household, errors in the way the questions are asked, misunderstanding on the part of either the interviewer or the respondent, data entry errors, etc. Although numerous efforts were made during the design and implementation of the MDHS to minimise this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be measured statistically. The sample of women selected in the MDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each one would have yielded results that differed somewhat from the actual sample selected. The sampling error is a measure of the variability between all possible samples; although it is not known exactly, it can be estimated from the survey results. Sampling error is usually measured in terms of standard error of a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which one can be reasonably assured that, apart from nonsampling errors, the true value of the variable for the whole population falls. For example, for any given statistic calculated from a sample survey, the value of that same statistic as measured in 95 percent of all possible samples with the same design (and expected size) will fall within a range of plus or minus two times the standard error of that statistic. If the sample of women had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the MDHS sample design depended on stratification, stages and clusters. Consequently, it was necessary to utilise more complex formulas. The computer package CLUSTERS, developed by the International Statistical Institute for the World Fertility Survey, was used to assist in computing the sampling errors with the proper statistical methodology. The CLUSTERS program treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: 1- f H~ mh 2 Zh var(r) ~=1 mh in which Z~ -- y~- r .x la and z h -- yn - r .x h 139 where h ra~ Y~ x~ / represents the stratum which varies from 1 to H, is the total number of EAs selected in the h t~ stratum, is the sum of the values of variable y in EA i in the h th stratum, is the sum of the number of cases (women) in EA i in the h th stratum, and is the overall sampling fraction, which is so small that CLUSTERS ignores it. In addition to the standard errors, CLUSTERS computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. CLUSTERS also computes the relative error and confidence limits for the estimates. In addition to the standard errors, CLUSTERS program also computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample; a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. Sampling errors are presented in Tables B.2-B.7 for variables considered to be of major interest. Results are presented for the whole country, for urban and rural areas, and for regions. For each variable, the type of statistic (mean or proportion) and the base population are given in Table B.1. For each variable, Tables B.2-B.7 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted cases (WN), the design effect (DEBT), the relative standard error (SE/R), and the 95 percent confidence limits (R:I:2SE). The confidence limits have the following interpretation. For the mean number of children ever bom (EVBORN), the overall average from the sample is 3.482 and its standard error is 0.049. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 3.482 + (2 x 0.049), which means that there is a high probability (95 percent) that the true average number of children ever born is between 3.383 and 3.580. The relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions. The magnitude of the error increases as estimates for subpopulations such as geographical areas are considered. For the variable children ever born (EVBORN), for instance, the relative standard error (as a percentage of the estimated mean) for the entire country and its regional divisions are 1.4 percent, 2.5 percent, 1.9 percent and 2.4 percent, respectively. 140 Table B.I List of selected variables for sampling errors~ Malawi 1992 Variable Description Estimate Base population URBAN SECOND CURMAR AGEM20 PREGNT EVBORN EVB40 SURVIV KMETHO KMDMET KSOURC EVUSE CUSE CUMODE CUPILL CUIUD CUSTER CUCOND CUPABS PSOURC NOMORE DELAY IDEAL TETANU MEDELI DIARR1 DIARR2 ORSTRE HCARD BCG DPT3 POL3 MEASLE FULLIM WGTAGE Urban Proportion With secondary education or more Proportion Currently married Proportion MmTiad before age 20 Proportion Currently pregnant Proportion Children ever horn Mean Children ever horn to women over 40 Mean Children sm'viving Mean Knowing any eontr~ptive method Proportion Knowing modern method Proportion Knowing soua'ce for method Proportion Ever use any method Proportion Currently using any method Proportion Currently using a modem method Proportion Currently using pill Proportion Currently using IUD Proportion Currently using female sterilisation Proportion Currently using condom Proportion Currently using perindie abstinence Proportion Using public sector source Proportion Want no more children Proportion Want to delay at least 2 years Proportion Ideal number of children Mean Mothers received w.tanus injection Proportion Received medical care at birth Proportion Had diarrhoea in last 2 weeks Proportion Had diarrhoea in last 24 hours Proportion Treated with ORS packets Proportion Having health card Proportion Received BCG vaccination Proportion Received DPT vaccination 0 doses) Proportion Received polio vsc.clnaClon (3 doses) Proportion Received measles vaccination Proportion Fully inamunised Proportion Weight-for-age below-2*SD Proportion All women 15-49 All womm 15-49 All women 15-49 Ever mwried 20-49 Currently tam'tied women All women 15-49 All women 40-49 All womert 15-49 Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women CurrenCy married women Currently married women Currently married women Current users of modem methods Cunenfly married women Cu~enfly married women All women 15-49 Births in last 5 years Births in lest 5 years Cbd/dren under five Children under five Children under five with diarrhoea in lest 2 weeks Children 12-23 months Children 12-23 months Children 12-23 months Childron 12-23 months Children 12-23 months Children 12-23 months Children under five with anthrophometrl¢ measure 141 Table B.2 Sampling errors - Entire sample T Malawi 1992 Variable Standard Value error (R) (SE) Number of cases Design Relative Confidence limiLs Unweighted Weighted effect error (N) (WN) (DEFT) (SE/R) R-2SE R+2SE URBAN .123 .006 4849 4849 1.212 .047 .III .134 SECOND .044 .004 4849 4849 1.438 .097 .035 .052 CURMAR .720 .009 4849 4849 1.359 .012 .703 .738 AGEM20 .748 .009 3744 3767 1.207 ,011 .731 .765 PREGNT .156 .007 3489 3492 1.121 .044 .143 .170 EVBORN 3.482 .049 4849 4849 1.097 ,014 3.383 3.580 EVB40 %082 .126 769 853 1.164 .018 6.830 7.334 SURVIV 2.552 .038 4849 4849 1,123 .015 2.476 2.627 KMETHO .946 .005 3489 3492 1.300 .005 ,936 .955 KMDMET .918 .007 3489 3492 1.602 .008 .903 .933 KSOURC .833 .010 3489 3492 1,523 ,012 .814 .852 EVUSE ,406 .011 3489 3492 1.341 .027 .384 .428 CUSE .130 .007 3489 3492 1.246 .055 . 116 .144 CUMODE .074 .005 3489 3492 1.166 .070 .063 ,084 CUPlLL .022 .003 3489 3492 1.280 ,146 .015 .028 CUIUD .003 .000 3489 3492 NP .000 .003 .003 CUSTER .017 .003 3489 3492 1.257 .163 .011 .022 CUCOND .016 .002 3489 3492 1.101 .145 .011 .021 CUPABS .037 .004 3489 3492 1,236 .107 .029 .045 PSOURC .699 .031 355 304 1.253 .044 .637 .760 NOMORE .233 .007 3489 3492 1.022 .031 ,219 .248 DELAY .372 .009 3489 3492 1.114 .025 .353 .390 IDEAL 5.061 .044 4167 4197 1.310 .009 4.974 5.149 TETANU .856 .010 4439 4512 1.564 .011 .837 .875 MEDELI .550 .018 4439 4512 2.033 ,033 .514 .586 DIARR1 .074 .005 3690 3730 1,068 .062 .065 .083 DIARR2 .219 .008 3690 3730 1.148 .036 .204 .235 ORSTRE .321 .020 812 818 1.149 .061 .281 .360 HCARD .863 .015 779 772 1.206 ,017 .833 .893 BCG .970 .006 779 772 .978 .006 .958 .982 DPT3 .886 .013 779 772 I.I03 .014 .860 .911 POL3 .881 .013 779 772 1.138 .015 .855 .908 MEASLE .858 ,016 779 772 1.304 .019 ,826 .891 FULLIM .818 .018 779 772 1.273 .022 .783 .854 WGTAGE .272 .010 3196 3235 1.240 .037 .252 .292 NP = Not possible to calculate 142 Table B.3 Sampling errors - Urban, Malawi 1992 Variable Standard Value error (R) (SE) Number of cases Design Relative Confidence limits Unweighted Weighted effect error (N) (WN) (DEFT) (SE/R) R-2SE R+2SE URBAN 1.000 .000 1316 594 NP .000 1.000 1.000 SECOND .209 .023 1316 594 2.066 .111 .163 .255 CURMAR .692 .016 1316 594 1.219 .022 .661 .723 AGEM20 .662 .019 1029 468 1.271 .028 .624 .699 PREGNT .153 .010 908 411 .866 .068 .132 .173 EVBORN 3.018 .100 1316 594 1.242 ,033 2.818 3.219 EVB40 7,230 .227 145 66 .833 .031 6.776 7.684 SURVIV 2.384 .078 1316 594 1.184 .033 2.229 2.539 KMETHO .972 .006 908 411 1.068 .006 .960 .983 KMDMET .963 .007 908 411 1.139 .007 .949 .978 KSOURC .914 .010 908 411 1.077 .011 .894 .934 EVUSE .562 .020 908 411 1.195 .035 .523 .602 CUSE .229 .016 908 411 1.131 .069 .197 .260 CUMODE .172 .016 908 411 1.266 .092 .141 .204 CUPILL .057 .009 908 411 1.118 .151 .039 .074 CUIUD .013 .005 908 411 1.326 .377 .003 .024 CUSTER .049 .009 908 411 1.249 .183 .031 .067 CUCOND .029 .006 908 411 1.049 .203 .017 .040 CUPABS .029 .006 908 411 1.132 .217 .016 .042 PSOURC .772 .026 173 83 .803 .033 .720 .823 NOMORE .266 .014 908 411 .942 .052 .238 .293 DELAY ,348 ,016 908 411 ,988 .045 ,317 ,380 IDEAL 4.557 .103 1185 538 1.704 .023 4,352 4.763 TETANU .912 ,013 1137 512 1.398 .014 .886 .939 MEDELI .862 ,020 1137 512 1.644 .023 .82l .902 DIARRI .056 .007 946 423 .941 .124 .043 .070 DIARR2 .193 ,011 946 423 .867 .058 .171 .216 ORSTRE .379 .039 178 82 1,041 .103 .301 .457 HCARD .819 ,029 192 84 1,023 .035 .762 .877 BCG .979 ,012 192 84 1.178 .013 .954 1.004 DPT3 .933 ,019 192 84 1.057 .021 .894 .972 POL3 .939 ,021 192 84 1.177 .022 .897 .980 MEASLE .907 ,027 192 84 1.282 .030 .852 .962 FULLIM .872 .031 192 84 1.271 .036 .810 .935 WGTAGE .154 ,014 797 345 .996 .091 .126 .182 NP : Not possible to calculate 143 Table B.4 Sampling errors - Rural, Malawi 1992 Variable Standard Value error (R) (SE) Number of cases Design Relative Confidence limits Unweighted Weighted effect error (N) (WN) (DEFr) (SFJR) R-2SE R+2SE URBAN .000 ,000 3533 4255 NP .000 .000 .000 SECOND .021 .004 3533 4255 1.491 .173 .013 .028 CURMAR .724 .010 3533 4255 1.299 .013 .704 .744 AGEM20 .761 .009 2715 3299 1.152 .012 .742 .779 PREGNT .157 .008 2581 3081 1.074 .049 .142 .172 EVBORN 3.546 .055 3533 4255 1.035 .015 3.437 3.656 EVB40 7.070 .135 624 787 1.133 .019 6.800 7.340 SURVIV 2.575 .042 3533 4255 1.063 .016 2.492 2.659 KMETHO .942 .006 2581 3081 1.216 .006 .931 .953 KMDMET .912 .008 2581 3081 1.497 .009 .896 .929 KSOURC .822 .011 2581 3081 1.434 .013 .801 .844 EVUSE .385 .012 2581 3081 1.276 .032 .361 .409 CUSE .117 ,008 2581 3081 1,215 .066 .102 .132 CUMODE .060 .005 2581 3081 1.155 .090 .050 .071 CUP ILL .017 ,003 2581 3081 1.327 .200 .010 ,024 CUIUD .001 .000 2581 3081 NP .000 ,001 .G01 CUSTER .012 .003 2581 3081 1,298 .227 .007 .018 CUCOND .015 .003 2581 3081 1,083 .176 .009 .020 CUPABS .038 .004 2581 3081 1,167 ,116 .029 .047 PSOURC .671 .041 182 221 1.171 .061 .589 .753 NOMORE .229 .008 2581 3081 ,973 .035 .213 .245 DELAY .375 .010 2581 3081 1.059 .027 .354 .395 IDEAL 5.135 .048 2982 3660 1.216 .009 5.040 5.231 TETANU .849 ,011 3302 4000 1.458 .013 .828 .870 MEDELI .510 .020 3302 4000 1.897 .039 ,471 .550 DIARRI .076 .005 2744 3308 1.003 .067 ,066 .087 DIARR2 .223 .009 2744 3308 1.093 .039 .205 .240 ORSTRE ,314 .021 634 737 1.084 .067 .272 .356 HCARD ,869 ,016 587 688 1,153 ,019 .836 ,901 BCG .969 .007 587 688 .906 .007 .956 .982 DIrr3 .880 .014 587 688 1.032 .016 .852 .908 POL3 .874 .015 587 688 1.060 .017 .845 .904 MEASLE .853 .018 587 688 1.220 .021 .816 .889 FULLIM .811 .020 587 688 1.192 .024 .772 .851 WGTAGE .286 .011 2399 2890 1.156 .039 .264 .308 NP = Not possible to calculate 144 Table B.5 Sarnpling errors - Northern Region, Malawi 1992 Variable Standard Value error (R) (SE) Number of cases Design Relative Confidence limits Unweighted Weighted effect error (N) (WN) (DEFT) (8E/R) R-2SE R+2SE URBAN SECOND CURMAR AGEM20 PREGNT EVBORN EVB40 SURVIV KMETHO KIVlDMET KSOURC EVUSE CUSE CUMODE CUPILL CUIUD CUSTER CUCOND CUPABS PSOURC NOMORE DELAY IDEAL TETANU MEDELI DIARR 1 DIARR2 ORSTRE HCARD BCG DPT3 POL3 MEASLE FULLIM WGTAGE .114 .007 .079 .011 343 .015 .768 .014 .177 .015 3.249 .080 7.300 .187 2.528 .062 .937 .008 ,896 .010 .808 .014 .534 ,024 .179 .016 .069 .011 .011 .004 .000 .000 .011 .003 .039 .007 .097 .011 .709 .062 .244 .013 .393 .011 5.102 .088 .865 .013 .677 .034 .085 :~09 .251 .019 .428 .034 .828 .021 .982 .009 .881 .029 .872 .031 .838 .037 .801 .038 .203 .012 1442 579 .804 ,059 .100 .127 1442 579 1.537 .138 .057 .101 1442 579 1.315 .020 .713 .774 1081 431 1.107 .019 .739 .796 1056 430 1.245 .083 .147 .206 1442 579 1.000 .025 3.089 3.409 194 81 1.027 .026 6.926 7.675 1442 579 .968 .025 2.404 2.652 1056 430 1.078 .009 .921 .953 1056 430 1.082 .011 .876 .916 1056 430 1.123 .017 .781 .835 1056 430 1.551 .045 ,486 .581 1056 430 1.376 .091 .146 .211 1056 430 1.382 .156 .047 .091 1056 430 1.304 .374 .003 .020 1056 430 NP .000 .000 .000 1056 430 1.061 .303 .005 .018 1056 430 1.105 .169 .026 .052 1056 430 1.179 .111 .076 .119 92 32 1.297 .087 .586 .832 1056 430 1,018 .055 .217 .271 1056 430 .752 .029 .370 .415 1167 461 1.467 .017 4,926 5,279 1289 521 1.188 .015 .839 .891 1289 521 2.259 .051 .608 .745 1096 442 1.104 .110 .066 .104 1096 442 1.431 .076 .213 .289 261 111 1.086 .080 .360 .497 258 104 .893 .025 .786 .870 258 104 1.077 .009 .964 .000 258 104 1,390 .033 .823 .939 258 104 1.439 .035 ,810 .934 258 104 1.595 .044 .764 .911 258 104 1.516 .048 .724 .877 970 390 .900 .059 .179 .227 NP = Not possible to calculate 145 Table B.6 Sampling ea-rors - Central Region t Malawi 1992 Variable Standard Value error (R) (SE) Number of cases Design Relative Confidence limits Unweighted Weighted effect error (N) (WN) (DEFT) (SE/R) R-2SE R+2SE URBAN SECOND CURMAR AGEM20 PREGNT EVBORN EVB40 SURVIV KMETHO KMDMET KSOURC EVUSE CUSE CUMODE CUPILL CUIUD CUSTER CUCOND CUPABS PSOURC NOMORE DELAY IDEAL TETANU MEDELI DIARR 1 DIARR2 ORSTRE HCARD BCG DPT3 POL3 MEASLE FULLIM WGTAGE .122 .010 .040 .007 .749 .011 .759 .014 .180 .013 3.716 .072 7.812 .189 2.631 .053 .943 .009 .923 .011 .848 .016 .372 .018 .131 .014 .082 .010 .024 .006 .002 .001 .016 .004 .013 .004 .031 .007 .772 .048 .278 .012 .391 .016 4.953 .060 .837 .018 .507 .027 .089 .008 .240 .012 .315 .033 .892 .022 ,957 .010 .857 ,021 .854 .022 .836 .027 .805 .029 .250 .014 1606 1872 1.207 .081 .102 .142 1606 1872 1.398 .170 .027 .054 1606 1872 1.058 .015 .726 .772 1254 1471 1.150 .018 .731 .787 1188 1402 1.176 .073 .154 .207 1606 1872 .865 .019 3.572 3.860 268 339 1.043 .024 7.435 8.189 1606 1872 .895 .020 2.524 2.737 1188 1402 1.280 .009 .926 .960 1188 1402 1.391 .012 .902 .945 1188 1402 1.497 .018 .817 .880 1188 1402 1.277 .(MS .336 .408 1188 1402 1.398 .105 .103 .158 1188 1402 1.250 .121 .062 .102 1188 1402 1.435 .268 .011 .036 1188 1402 .909 .581 -.000 .004 1188 1402 1.181 .265 .008 .025 1188 1402 1.239 .308 .005 .022 1188 1402 1.307 .213 .018 .044 129 127 1.293 .062 .676 .868 1188 1402 .945 .044 .254 .303 1188 1402 1.105 .040 .360 .422 1364 1550 1.017 .012 4.833 5.073 1581 1890 1.636 .022 .801 .873 1581 1890 1.811 .054 .452 .562 1299 1552 1.094 .095 .072 .105 1299 1552 1.071 .052 .216 .265 300 373 1.228 .105 .249 .381 258 320 1.184 .025 .848 .937 258 320 .847 .011 .937 .978 258 320 1.000 .025 .815 .899 258 320 1.047 .026 .809 .899 258 320 1.190 .032 .782 .889 258 320 1.195 .036 .748 .863 1112 1315 1.062 .056 .222 .278 146 Table B.7 Sampling errors - Southern Region, Malawi 1992 Number of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE URBAN .125 .008 1801 2398 1.087 .068 .108 .142 SECOND .038 .006 1801 2398 1.355 .162 .025 .050 CURMAR .692 .015 1801 2398 1.362 .021 .663 .722 AGEM20 .735 .013 1409 1865 1.107 .018 ,709 .761 PREGNT .131 .009 1245 1660 .906 .066 .114 .148 EVBORN 3,355 .079 1801 2398 1,128 .024 3,197 3.513 EVB40 6.469 .186 307 433 1,093 .029 6,097 6.842 SURVIV 2.496 .062 1801 2398 1,152 .025 2,372 2.620 K/dE-WHO .950 .007 1245 1660 1.178 .008 .935 .964 KMDMET ,920 ,012 1245 1660 1,620 .014 ,895 .945 KSOURC .827 .015 1245 1660 1.391 .018 .797 .857 EVUSE .401 .017 1245 1660 1.198 .042 .368 .434 CUSE .117 .008 1245 1660 .927 .072 .100 .134 CUMODE .068 .006 1245 1660 .872 .092 .055 .080 CUPILL .022 .004 1245 1660 .900 .168 .015 .030 CUIUD .004 .002 1245 1660 .941 .408 .001 .008 CUSTER .018 ,004 1245 1660 1.134 .235 .010 .027 CUCOND ,013 ,003 1245 1660 ,960 ,241 ,007 .019 CUPABS .026 .006 1245 1660 1.223 .212 .015 .037 PSOURC .632 .045 134 145 1.076 .071 .542 .722 NOMORE .192 .011 1245 1660 .969 .056 .171 .214 DELAY .350 .013 1245 1660 ,994 .038 .323 .377 IDEAL 5,130 .069 1636 2187 1.296 .013 4.992 5,268 TETANU .872 .012 1569 2101 1.219 .014 .848 .896 MEDELI .558 .028 1569 2101 1.893 .051 .501 .614 D IARRI .058 .006 1295 1736 .824 .095 .047 .I)69 D IARR2 .192 .012 1295 1736 1.043 .060 .169 .216 ORSTRE .291 .028 251 334 .936 .095 .236 .346 HCARD .847 .025 263 348 1.125 .030 .797 .897 BCG .978 .009 263 348 .969 .009 .961 .996 DF]'3 .914 .018 263 348 1.063 .020 .877 .951 POL3 .909 .019 263 348 1.072 .021 .871 .947 MEASLE .886 .024 263 348 1.232 .027 .837 .934 FULLIM ,835 ,027 263 348 1,168 .032 .781 ,889 WGTAGE .308 .017 1114 1531 1.158 .054 .275 .342 147 APPENDIX C DATA QUALITY TABLES TableC.1 Household agedislribution Single-year age distribution of the de facto household population by sex (weighted), Malawi 1992 Males Females Males Females Age Number Percent Number Pe~ent Age Number Percent Number Percent <1 501 4.5 473 4.0 36 89 0.8 103 0.9 1 394 3.5 327 2.8 37 59 0.5 84 0.7 2 330 2.9 343 2.9 38 105 0.9 111 0.9 3 339 3.0 351 3.0 39 89 0.8 116 1.0 4 346 3.1 365 3.1 40 122 1.1 129 1.1 5 319 2.8 319 2.7 41 78 0.7 67 0.6 6 407 3.6 381 3.2 42 116 1.0 103 0.9 7 363 3.2 407 3.4 43 104 0.9 114 1.0 8 381 3.4 368 3.1 44 70 0.6 85 0.7 9 349 3.1 366 3.1 45 89 0.8 73 0.6 10 374 3.3 406 3.4 46 47 0.4 83 0.7 11 226 2.0 305 2.6 47 52 0.5 56 0.5 12 441 3.9 420 3.5 48 56 0.5 71 0.6 13 296 2,6 363 3.1 49 63 0.6 64 0,5 14 311 2.8 339 2.9 50 78 0.7 83 0.7 15 310 2.8 210 1.8 51 36 0.3 83 0.7 16 258 2.3 248 2.1 52 91 0.8 107 0.9 17 254 2.3 211 1.8 53 54 0.5 80 0.7 18 208 1,9 249 2.1 54 44 0.4 64 0.5 19 195 1,7 202 1,7 55 35 0.3 54 0,5 20 173 1.5 222 1.9 56 60 0.5 58 0.5 21 188 1.7 188 1.6 57 34 0.3 66 0.6 22 198 1.8 182 1.5 58 43 0.4 52 0.4 23 165 1.5 162 1.4 59 53 0.5 57 0.5 24 154 1.4 200 1.7 60 68 0.6 79 0.7 25 127 1.1 158 1.3 61 34 0.3 39 0.3 26 133 1.2 163 1.4 62 75 0.7 53 0.4 27 117 1.0 141 1.2 63 37 0.3 41 0.3 28 203 1.8 198 1.7 64 35 0.3 41 0.3 29 123 1.1 118 1.0 65 35 0.3 32 0.3 30 187 1.7 202 1.7 66 22 0.2 25 0.2 31 73 0.6 77 0.7 67 15 0.1 28 0.2 32 141 1.3 141 1.2 68 37 0.3 32 0.3 33 64 0.6 100 0.8 69 34 0.3 34 0.3 34 105 0.9 125 1.1 70+ 298 2.7 329 2.8 35 107 0.9 115 1.0 Don't know/ Missing 18 0.2 9 0.1 Total 11234 100.0 11853 100.0 Note: The de facto population includes all resideaats and nonresidents who slept in the household the night before the interview. 151 Table C.2 Age distribution of eligible and interviewed women and men Five-year age distribution of the de facto household population of women age 10-54 and men age 15-59, flve-year age distribution of interviewed women age 15-49 and men age 20-54, and percentage of eligible women and men who were interviewed (weighted), Malawi 1992 Household population Interviewed of women women age 15-49 Age Number Percent Number Percent Percentage interviewed (weighted) FEMALES 10-14 1832 NA NA NA NA 15-19 1120 23.0 1050 22.3 93.7 20-24 953 19.6 916 19.5 96.1 25-29 778 16.0 753 16.0 96.8 30-34 645 13.2 636 13.5 98.6 35-39 529 10.9 521 11.1 98.5 40-44 498 10.2 495 10.5 99.2 45-49 347 7.1 332 7.1 95.7 50-54 417 NA NA NA NA 15-49 4871 NA 4702 NA 96.5 MALES 15-19 421 NA NA NA NA 20-24 276 23.0 258 24.1 93.8 25-29 220 18.4 191 17.8 86.5 30-34 182 15.2 157 14.6 86.0 35-39 141 11.8 133 12.4 94.1 40-44 182 15.2 150 14.0 82.3 45-49 97 8.1 88 8.2 90.7 50-54 100 8.3 95 8.9 95.2 54-59 71 NA NA NA NA 20-54 1198 100.0 1071 100.0 89.4 Note: The de facto population includes all residents and nonresidents who slept in the household the "night befoTe inte~iew. Weights for both households and interviewed women and men are household weights. NA = Not applicable 152 Table C.3 Completeness of reporting Percentage of obseawations missing information for selected demographic and health questions (weighted), Malawi 1992 Pereenlage Number missing of Subject Reference group information c- u . Birth date Births in last 15 years Menath only 3.4 12310 M~tth and ye~ 0.0 12310 Age at death Deaths to b'trths in last 15 years 0.2 2785 Age/date at first union I Ever-ram-tied women 1.8 4088 Respondent's education All women 0.1 4849 Child's size at birth Births in last 59 months 0.7 4574 Anthropometry 2 Living children age 0-59 months Height 9.9 3789 Weight 8.6 3789 Height or weight missing 10.2 3789 Dim'rhoea in last 2 weeks Living children age 0-59 months 2.0 3789 lBoth year ~d age missing 2Child not measured 153 Table C.4 Births by calendar year since birth Dimibution of births by calendar yeus since birth for living (L), dead (D), and all (T) children, according to reporting completeness, sex ratio at birth, and ratio of bh'ths by calendar year, Malawi 1992 Percentage with Sex ratio Number ~ births complete birth date I at birth 2 Calendar rado ~ Male Female Year L D T L D T L D T L D T L D T L D T 92 792 66 859 99,4 100,0 99.5 110.0 166.4 113.5 NA NA NA 415 41 456 377 25 402 91 798 142 940 99.7 96,5 99,2 104.7 75.8 99.7 106.7 113.5 107.7 408 61 469 390 81 471 90 703 184 887 99,5 93.8 98.3 96.3 87,3 94,4 95.5 112.4 98.6 345 86 431 358 98 457 89 674 185 859 98.8 92.3 97.4 104.0 122.5 107.7 97.1 104.4 98.6 344 102 446 330 83 414 88 685 171 856 98.5 92.5 97.3 86.9 119.7 92.7 104.2 99.3 103.2 319 93 412 367 78 444 87 641 159 800 99.3 95.7 98.5 111.2 152,2 118.2 93.1 70.9 87.7 338 96 433 304 63 367 86 691 277 968 97.1 91,2 95.4 98.3 122.5 104.7 106.4 152.0 116,4 343 152 495 349 124 473 85 658 206 864 98.4 91.1 96.6 94.5 104.8 96.8 98,4 78.7 92.9 320 105 425 339 100 439 84 647 246 892 96.6 88.4 94,4 1O0.0 93.7 98.2 104.0 124.9 109.0 323 119 442 323 127 450 83 586 188 774 97.2 88.5 95.1 99.7 109.5 102.0 NA NA NA 292 98 391 293 90 383 88-92 3652 749 4402 99,2 94.2 98.4 100.4 105.1 101.2 NA NA NA 1830 384 2214 1822 365 2188 83-87 3223 1075 4298 97,7 90.7 96.0 100.5 113.1 103,5 NA NA NA 1616 571 2186 1608 504 2112 78-g2 2596 932 3528 96.2 g7.5 93.9 88.3 97.4 90.6 NA NA NA 1217 460 1677 1378 472 1851 73-77 1572 787 2359 94.5 88.1 92.4 104.9 98.2 102.6 NA NA NA 805 390 1195 767 397 1164 <73 1330 965 2295 91.1 81.7 87.2 104.2 109.2 106.3 NA NA NA 679 504 1182 651 461 1112 All 12374 450g 16882 96.7 88.2 94.5 98.7 104.9 100.3 NA NA NA 6147 230~ 8455 6227 2200 8427 NA = Not applicable tBo/h year and mo~th of b/nh given ~'B,,/Br) 100, where B, and BI are the numbers of male and female births, respecti ely 312B,/(B, I+B,+l)l* 100, where B, is the number of births in calendar year x 154 Table C.5 Reporting of age at death in days Distribution of reported deaths tmd~ 1 month of age by age at death in days and the percentage ofneonata/deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the sta'vey, Malawi 1992 Number of years preceding the survey Age at death Total (in days) 04 5-9 10-14 15-19 0-19 <1 47 37 45 37 166 1 22 57 25 20 124 2 24 15 30 9 79 3 15 27 15 13 69 4 11 8 16 7 43 5 5 5 7 0 18 6 8 8 6 2 23 7 22 31 23 21 97 8 3 3 4 4 14 9 0 6 6 2 14 10 2 4 4 0 10 11 0 0 0 2 2 12 0 0 0 2 3 13 1 0 2 0 3 14 8 17 12 20 56 15 2 2 3 0 6 16 0 1 3 0 4 17 1 0 0 0 1 18 0 2 0 0 2 19 0 0 0 1 1 20 2 1 2 1 7 21 6 6 9 2 22 22 3 6 0 2 11 23 1 0 0 0 2 24 0 0 0 1 1 25 1 0 0 2 3 26 0 0 0 2 2 28 0 4 2 0 6 29 0 0 0 1 2 30 4 0 2 1 7 31+ 3 0 0 0 3 Total 0-30 188 242 217 154 801 Percent early lleonatal I 70.4 65.4 66.0 57.5 65.2 1(0-6 days/O-30 days) * 100 155 Table C.6 Reporting of age at death in months Distribution of reported deaths under 2 years of age by age at death in months and the percentage of infant deaths reported to occur at ages under one month, for five-year periods of birth preceding the survey, Malawi 1992 Reported Number of years preceding the survey age at death (in months) 0-4 5-9 10-14 15-19 To~l 0-19 <1 a 188 242 217 154 801 1 36 25 20 21 102 2 36 34 24 24 119 3 42 40 27 20 129 4 35 32 35 21 124 5 49 27 24 23 123 6 54 42 31 22 148 7 36 33 25 8 101 8 27 33 18 18 97 9 32 38 24 13 107 10 21 17 10 16 64 11 13 15 15 13 56 12 32 62 39 41 174 13 13 35 17 16 81 14 17 21 11 14 62 15 11 8 13 9 41 16 8 11 13 8 40 17 7 3 4 4 17 18 19 15 22 12 67 19 5 1 6 7 18 20 1 11 0 0 12 21 5 2 0 2 9 22 0 4 7 3 14 23 2 4 1 3 9 24+ 3 2 ! 8 15 1 year 8 16 15 12 51 Total 0-11 569 579 472 351 1971 Percent neonatal b 33.1 41.9 46.0 43.7 40.7 alncludes deaths under 1 month reported in days b(Under 1 month/under 1 year) * 100 156 APPENDIX D SURVEY INSTRUMENTS Household Questionnaire Individual Female Questionnaire Individual Male Questionnaire Health Services Availability Questionnaire MALAWI DEMOGRAPHIC AND HEALTH SURVEY MALAWI GOVERNMENT - NAT IONAL STAT IST ICAL OFF ICE HOUSEHOLD SCHEDULE FORM MDHS-H/92 IDENTIF ICAT ION REGION/DISTR ICT I TA /STA/TOWN ENUMERATION AREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V ILLAGE OR PLACE MDHS CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (u rban=l , ru ra l=2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NUMBER OF DWELL ING UNITS USED BY HOUSEHOLD . . . . . . . . . . . . . . . . . DATE INTERVIEWER'S NAME RESULT*** NEXT VISIT: DATE T IME ***RESULT CODES: 1 COMPLETED INTERVIEWER VIS ITS i 2 2 NO HOUSEHOLD MEMBER AT HOME AT T IME OF V IS IT OR NO COMPETENT RESPONDENT AT HOME AT T IME OF V IS IT 3 i F INAL V IS IT ii DAY MONTH YEAR NAME '11 RESULT "11 i' TOTAL NUMBER OF VISITS TOTAL IN 3 ENT IRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 4 POSTPONED 5 REFUSED 6 DWELL ING VACANT OR ADDRESS NOT A DWELL ING 7 DWELL ING DESTROYED 8 DWELL ING NOT FOUND 9 OTHER (SPECIFY) HOUSEHOLD TOTAL NO. -EL IG IBLE WOMEN -EL IG IBLE ~--~ MEN LINE NO. ~- -~ OF HH RESP. 'F O ICE OITEDB I H1 159 HOUSEHOLD SCHEDULE NOW we would Like some information about the people ~ho usually live in your household or who are staying with you ~ou. U~LRESIDENTS. ISERI R~ i ED~?,ON.LIFERACT I RARENTA~R¥,~SN,~.RES(DEN~ VISITORS FOR PERS~qS LESS THAN 15 YEARS OLD*** LINE NO. ?lease give me the names of the persons aho usually Live in your household and guests of the house- ~lotd who stayed here last night, starting ~ith the head of the ~ehotd. (1) (2) 01 O2 O3 O4 O5 O6 O7 O8 09 10 i RELATIONSHIP RESIDENCE TO HEAD OF HOUSEHOLD* ~/nat is the Does Did Is HOU old Has relationship (NN4E) (NAME) INANE) is -(NAIE) of (NAME) to usuatt sleep mate (MANE)? ever the head live here or of the here? Last ;~ le to hcxaseho t d? night? ? ;chool? (3) (4) (5) (6) (7) (8) I I I I YES 140 fES NO 14 E iN YEARS FES NO [ ~ 12 12 12 ~ 12 ,2 12 12[~,2 ~ ,2 12 ,2 ~.12 F-~ ,2 , , , , r - l - l12 I 2 ! 1 2 1 2 I 2 J ~-] ,21 ,2 ,2 [ -~ .1 , ~ , , 12 12 rF l l , F-R 1.__2_ ~ ' ' " " IF AGED 5 YEARS OR OLDER I i IF ATTENDED SC~ ASK Is , O~LT IF- (NAME)~S ~lhat is %F AGED LESS natural the hlgJlest LESS THAN mother Level of THAN SECOND. ~ alive? school 25 SCHO~. (WUE) YEARS - - attended? Is (NN4E) BOW many able to years did Is read and (NAME) (NAHE) urite in complete ;till in English at that schoo|? or I eve t ?** Ch i cheua ? , (9) (10) L ( 1 2 ) IF ALIVE Is IF ALIVE (NANE)'s Does natural Does (NNCE)4s father (RNCE) ~s natural alive? ratursl LEVEL "fEARS YES NO YES NO ~ I -T - , 2 , , i - i i -T - , 2 1 , I~ I-r- , , 12 Ill-T-,,, 12 @~i-11, i12 YES RO DK 28 28 28 28 28 28 28 28 28 28 mother live in this h~se- hold? IF YES: ~at is her name? RECORD HOTHERJS LINE NUMBER (13) F-~ father live in this house- hold?. IF YES: ~at is his name? RECORD FATHER'S LINE NUMBER (14) (15) F i YES NO DK 1 2 8 1 2 8 i i ~ [ -~ i i i 2 8 ~- - ] I I I I 2 8 H2 I HOUSEHOLD SCHEDULE CONTINUED r - - - ! t~,-~-~,~-- (6) (T) (8) (9) i (111 I (11 I (Zl 1 (31 Ilil (41 I (51 m m m m m m m YES NO fEB NO g F [N YEARS IES NO LEVEL YEARS YES NO L YES NO • ,2 ~ ~ 2 I - i - [ ' , • i i ~, . ~ ~__~ ~ i i ~ . ~ . , ~ . ~ iT . ~ 1" • • • I I I i I L I I I I I: I I II T|CK HERE IF CONTINUATION SHEET USED ~ TOTAL NUMBER OF ELIGIBLE ~OgEN (1%/.9 years) ~ 1 (fZ) YES NO DIE 2 8 2 8 2 8 2 8 2 8 2 8 2 8 2 8 2 8 2 8 (131 mmamm i (141 ilmalm I _ _ (15) (16) YES NO DK i | 1 2 8 ~ / 1 1 L 1 2 8 ~-~ 12 t • 1 2 8 ~-~ 13 I • 1 2 8 ~ 14 I • i • 1 2 8 ~'~ 16 1 2 8 ~-~ 17 I • 1 2 8 ~ 18 I • 1 2 8 ~- - ] t9 I • 1 2 8 ~ 20 TOTAL NUMBER OF ELIGIBLE MEN (ZO-~ years1 JUSt to ntske sure that I have a c~plete Listing: 1) Are there any other persons such as scull chiLdre~or infants thlt ~e have not listed? 2) In additio% are there =my other people Wno maynot be members of your family, such as domestic servants, lodgers, or friends u~o usually tire here, bet that were not already listed? 3) anyone else who slept here test night that veh * CODES FO~ 0.3 RELATIONSHIP TO HEAD OF H~USEHOLD: 01= HEAD 05= GRANDCHILD 02= ~IFE ON HUSBAND 06= PARENT 03= SON ON DAUGHTER 07 = PARENT'iN-LAW 04= SON ON DALIGHTER-IN-LAM 08 = BROTHER OR SISTER Do you have any guests or temporary visitors stoyiog here, or vehave not already listed? 09=- OTHER RELATIVE 10=ADOPTED/FCGTER CHILD 11= NOT RELATED 98= DO NOT KMOW YES ~ • ENTER EACH )B TABLE NO (-~ YES [---1 YES [~1 ~ CODES FIll Q,9 LEVEL OF EDUCATICq: 1= pR IHARY 2= SECOIIOARy 3= HIGHER 8 = DO NOT I(MOJ b ENTER EACH IN TABLE NO • ENTER EACH IN TABLE NO ~-~ YEARS: DO:LESS THAN 1 TEAR COHPLETED *** These questio¢-4 refer to the biological parents of the child. Record O~ if parent not member of household. H ] BIRTHS AND DEATHS IN LAST 12 MONTHS Mow we uc~Jld (ike scr~e inforrr~Btion about oft of the births and deaths that occured in this household to usual First, tells talk ibout all of the I HA/dE OF CHILD I SEX Please give me the Was names of at( the (NAME) children born in , born in this household ! a boy over the past 12 or a months, that is, girt? since (MONTH OF INTERVIEW) 1991. PRO6E: Have you included at( births, even if the child Lived only a few moments, days, or weeks? (17) (18) I I M F 1 2 1 2 1 2 1 2 5 I I 1 2 B TOTAL BIRTHS IN HOUSEHOLD I I residents during the Last 12 months. births. DATE OF BIRTH J SURVIVAL w • I YEAR CHILD I~THER in In Is Is what ~at (NAME) the ~th year st i ( L ~ther was was alive? of (NAME) (NAME) (NAME) born? bornT stilt at Ive? PROBE : PROBE : In this what year? season? or last year? (19) (20) (21) (225 I I I I MOHTH YEAR YES NO YES NO | • - - m | | • 1 2 12 ,= FZ]FF] , ,, 2 ,, 2 Now we would Like some information about all household to usual residents during the Last I NAME OF PERSON I SEX B Please give me the Was names of all the [NAME5 persons who were born usual residents of a this household end n~[e died (luring the last or 12 me4~ths, that is, Female since (KONTH OF ? INTERVIEW) 1991. CHECK CONSISTENCY UITH O. 21 i | (23) | (24) MF 1 1 2 I 2 1 2 3 1 2 4 1 2 AGE AT DEATH Bow o ld was (NAME) when he/she died? RECORD IR C~4- PLETED YEARS (255 YEARS F-N, of the deaths that occured in this 12 months. DATE OF DEATH PLACE ~; l~ i~_ I oT DERTR In In Where dld (NAME) what what [die? month year did did HOUSEHOLD • I (NAME) (NAME) die~ die ? HOSPITAL/ CLIB]C = 2 PRONE: PROBE: ON WAY TO During this HOSPITAL/ what year? CLINIC = 3 season? or Last OUTSIDE = 4 year? HOUSEHOLD (26) l (27) l (28) MONTH YEAR J2 . A2. TOTAL DEATHS IN HOUSEHOLD B4 162 MO, 29 NDUSEHOLD AMENITIES G~JESTIONS AND FILTERS Wttat Is the maln source of water your household uses for hsnd=aehlng and dishweahing? SKIP CODING CATEGORIES I TO M PIPED HATER | PIPED INSIDE DUELLING UNIT .11 -31 PIPED INTO YARD/PLOT . 12 *]1 PUBLIC TAP . 1] WELL WATER PROFECTEO WELL/BOREHOLE . 21 UNPROTECTED WELL . 22 SURFACE MATER SPRING . ]1 RIVER/STREAM . ]2 POND/DAM . 3] LAKE . 34 RAINWATER . 41 "31 OTHER 71 (SPECIFY) I I 30 Ho~ long does I t take to go there, get water, | MINUTES . I l J l | and come back? I I I I I I PREMISES . DK . . . . . . . . . . Ho . .¢ /9~ 31 Does your household get drinking water I YES . ° . .° . 1 | P33 fr~ this same source? I I NO . 2 ]2 What is the main source of drinking water for members of your household? PIPED RATER PIPED INSIDE DWELLING UNIT .11 PIPED INTO YARD/PLOT . 12 PUBLIC TAP . 1] WELL WATER PROTECTED ~HELL/BCRENOLE . 21 UNPROTECTED WELL . 22 SURFACE WATER SPRING . 31 RIVER/STREAM . ]2 POND/DAM . 33 LAKE . 34 RAINNATER . 41 OTHER 71 (SPECIFY) ]3 What kind of toilet facility does your household have? FLUSH TOILET OWN FLUSH TOILET . 11 SHARED FLUSH TOILET . 12 PIT LATRINE YRADITIONAL P IT LATH|ME . . . . . . . 21 VENTILATED IMPROVED PIT (VIP) LATRINE . 22 NO FACILITY . 31 OTHCR 41 (SPECIFY) 3~ I oes your househoLd have: ELectricity? A rDdio? A parrafin tanqp? J YES NO I ELECTRICITY . 1 2 RADIO . . . . . . . . . . . . . . . . . . . . . . 1 2 PARRAFIH LAMP . 1 2 h~sehotd are ~ for sloping? ROCIMS . Does any member of your household o~: YES NO A bicycle? BICYCLE . ! 2 A ~torcycle? MOTORCYCLE . 1 2 A car? CAR . 1 2 An oxcart? OXCABT . I 2 H5 163 37A PLAIN MATERIAL OF THE FLO(~. RECORD OBSERVATION. MOTE: IF THE HOUSEHOLD LIVES IN MORE THAN ONE DWELLING Lk~IT ANO THE DUELLING UNITS DIFFER IN FLOOR MATERIALS, RECORD YOUR OBSERVATION ON THE FLOOR OF THE DUIELLING OF THE HEAD OF HOUSEHOLD. MUO/EARTH FLOOR . 11 FINISHED FLO(3~ CEMENT . 31 SRICKS . 32 ;~(X) . 33 TILES . 34 OTHER 41 (SPECIFY) 37B MAIN MATERIAL OF THE ROOF. GRASS THATCH . 1 IRON SHEETS . 2 RECORD OBSERVATION. IRON AND TIKES . 3 ASBESTOS . 4 BOTE: IF THE HOUSEHOLD LIVES IN MORE THAN ONE DS~LLING CEMENT . 5 LICIT AMD THE DUELLING UNITS DIFFER IN ROOF bJCQD . 6 MATERIALS, RECORD YOUR OGSERVATION ON THE ROOF OF THE DUELLING OF THE READ OF HOUSEHOLD. OTHER ? (SPECIFY) H6 164 MALAWI DEMOGRAPHIC AND HEALTH SURVEY MALAWI GOVERNMENT - NAT IONAL STAT IST ICAL OFFICE INDIV IDUAL OUESTIONNAIRE FEMALE FORM MDHS-F/92 IDENTIF ICATION REGION/DISTRICT TA/STA/TOWN ENUMERATION AREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V ILLAGE OR PLACE MDHS CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (urban=l, rural=2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME AND LINE NUMBER OF WOMAN NAME AND LINE NUMBER OF HUSBAND (CODE 98 IF NO HUSBAND OR HUSBAND NOT IN HOUSEHOLD) INTERVIEWER VIS ITS i , 2 3 F INAL V IS IT DATE INTERVIEWER'S NAME RESULT * NEXT VISIT: DATE T IME DAY MONTH YEAR NAME RESULT TOTAL NUMBER OF VIS ITS * RESULT CODES: 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER (SPECIFY) NAME DATE OFFICE EDITED BY I[ KEYED BY KEYED BY F I 165 SECTION I. RESPONDENT'S BACKGROUND SKIP 102 I First I wo~td like to •sk some q~estloo~ about you and your household. For most of the time until you were Ibout 12 year8 old, did you Live in • city, in a tow, or in • village? CITY . 1 TOWN . 2 VILLAGE . 3 ALWAYS . ~.m] VISITOR . 96 P105 10A ~ Just before you moved here, did you Live in a city, CITY . 1 I in • town, or in • village? TOWN . 2 VILLAGE . 3 105 In k~•t month s~l year Were yOU born? MONTH . OK MONTH . 98 YEAR . ~--~ DK YEA~ . 98 COtton.RE ~1/0 CORRECT 105 kl40/Oi{ 106 IF Lt4COI4SLSTE~Y. 01- - - i . i NO . 2 b111 I - . I primBry, Gecorldmry, or higher? SECONDARY . 2 HIGHER . ] I I09 | Hou utlny year• of schOOl did you complete at that I Level? SECONDARY OR HIGHER ~] ]YEA. . FT1] I I / 111 | Are you •bte to relld at¢l understar¢l English or Chichewa | EASILY . 1 | I easily, with difficulty, or not at all? J WITH DIFFICULTY . 2 L NOT AT ALL . ] 11] I °° ° ' - ' ' - - I . . I '" I I ,o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '1 F2 166 SKIP 115 I Now I ~o~Jtd Like to ask about the place in uhich you usually Live. Do you usually Live in a city, in a ton, or in a village? I CITY . . . . . . . . . . . . . . . . . . . . . . . . 1 { TC~ . ,. . .o.~ VILLAGE . 3 I n ch I . I CENFRAL . Z SOUTH . 3 OUTSIDE HALAWi . 4 117 Whet is the source of water your household uses for harclaashing and dlshwashing? PIPED WATER | PIPED INSIDE DWELLING UNIT .,11 Pl19 PIPED INTO YARD/PLOT . 12 ,119 PUBLIC TAP . 13 WELL WATER PROTECTED WELL/BOREHOLE . 21 UNPROFECTED WELL . 22 SURFACE MATER SPRING . 31 RIVER/STREAM . 32 POND/DAM . 33 LAKE . 34 RAINWATER . 41 ,119 OTHER 71 I (SPECIFY) ,,, i co ck, I M'NuTESOKo . PREM,SE . . 119 Does your household get drinking water YES . 1 P121 from this same source? NO . 2 120 Mhat is the source of drinkin9 water for members of your household? PIPED MATER PIPED INSIDE DUELLING UNIT ,.11 PIPED INTO YARD/PLOT . 12 PUBLIC TAP . 13 WELL WATER PROTECTED WELL/gOREHOLE . 21 UNPROTECTED WELL . 22 SURFACE WATER SPRING . 31 RIVER/STREAM . 32 POND/DAM . 33 LAKE . 34 RAINWATER . 41 OTHER 71 (SPECIFY) 121 ghat kind of toilet facility does your household have? FLUSH TOILET O~R FLUSH TOILET . 11 SHARED FLUSH TOILET . 12 PIT LATRINE TRADITIONAL PiT LATRINE . 21 VENTILATED IMPROVED PIT (V IP) LATRINE . 22 NO FACILITY . ]1 OTHER 41 (SPECIFY) 122 I oes your household have: EtectrLcity? A redio? A parrafin Lamp? I YES gO I ELECTN]C[TY . 1 2 RADIO . 1 2 PARRAFIN LAMp . 1 2 F3 167 NO. ~ QUESTIONS AND FILTERS i 123 I fl~ many roam In aLL of the dweLLing units of your I household are used for steeplng? SKIP I COOIRG CATEGORIES I TO I 124 I Does any member of your household ow~: I A bicycle? A ~otorcycLe? A car? OXCmFt? 125A At your o~1 house, what is the lain material that the floor is made from7 ROTE: IF HER BCUSEHOLD LIVES IN MORE THAN ONE DWELL]NO UNIT AND THE DWELLING UNITS DIFFER ]N FLOOR MATERIALS, ASK FOR THE FLOOR MATERIAL OF THE THE OMELLING OF THE READ OF HOUSEHOLD. L25B At ycNJr own house, ~at is the main n~steriat that The roof is made from? ROTE: IF HER HOUSEHOLD LIVES IN MORE THAN ONE D~ELL[MG UNIT AND THE OI,,IELL]NG ON[TS DIFFER IN ROOF MATERIALS, ASK FOR THE ROOF MATERIAL OF THE THE DUIELL]NG OF THE HEAD OF HOUSEHOLD. I YES NO BICYCLE . 1 2 MOTORCYCLE . 1 2 CAR . 1 2 OXCART . 1 2 V~O/EARTH FLOOR . 11 FINISHED FLOOR CEMENT . 31 BRICKS . 32 ~aouO . 33 TILES . OTHER kt (SPECIFY) GRASS THATCH . 1 IROR SHEETS . 2 IRON AND TILES . ] ASBESTOS . . . . . . . . . . . . . . . . . . . . . . . . 4 CEMENT . S . 6 OTHER 7 (SPECIFY) 168 ~[~TIOR 2. REPRODV~TI(~ SKLP NO. I QUESTIONS AND FILTERS I CODING CATEGORIES I TO NO . 2 •206 2021 IYEs . '1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2~204 01 n . I . And hou many daughters Live with you? DAUGHTERS AT HO~ . IF HONE RECORD '00 I . given birth td)o ere alive but do not live uith you? #0 . 2 -206 ° l ° I . And how many daughters ere alive but do not live with you? DAUGHTERS ELSEWHERE . IF gONE RECORD IOOI, i - r - - r ° ° ° n r o--o I . I baby ~o cried or should any sign of Life but NO . 2 P208 only survived a few hours or days? I I I . . ,oo. I . 209 210 CHECK 208: Just to make sure that I have this right: you have had In TOTAL births during your Life. Is that correct? PROBE AND YES E~ NO [~ • CORRECT 201-208 AS NECESSARY Y CHECK Z08: I ORE OR goRE [~ NO BIRTHS ~-~ P223 BIRTHS v E5 169 211 H¢~ I bmt~ld Itke to talk to you alo~t ILl of your bLrths, whether atilt alive or rmt, startir)g with the First o~ yo*J hid. RECORD NNd4ES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES, 212 213 What n~e kills RECORD given to y~Jr SINGLE (first,next) iOn MULTIPLE B[RTH STATUS. 11 SING.1 NULT.2 (MANE) 21 SING.1 NULT.2 (WO4E) O~J SING,,,1 MULT.2 (WANE) 041 SING.1 MULT.2 (WANE) 5J SING.1 14JLT.2 (WANE) ~j SING.1 NULT.2 ( Winkle ) SING.1 WJLT.2 (NAMdE) 81 SING.1 I4ULT.2 (WANE) 214 215 216 Is In what month Is (NAME) (NAME) ertdyear WaS stiLL • boy or (NAME) born? alive? I girL? PROBE: W11at Is his/ her birthday? ~: In what seas(]41 Was he/she born? BOY.1 K~NTH.[~ YES.1 GIRL.2 YEAR. NO.,.2 I v 220 60Y.1 MONTH.~ YES.1 GIRL.2 YEAR. NO.2 I v 220 BOY.1 M~44TH.~ YES.1 GIRL.2 YEAR. NO.2 I V 220 BOY.1 MONYH,.[~ YES.1 GIRL.2 YEAR,. NO,.,.2 I v 2ZQ BOY.1 ~r~)NTH. [ ~ YES.,,1 GIRL.2 YEAR. NO.2 I V 220 BOY.,,1 k~NTH.~ YES.1 G%RL.2 YEAR., NO,.,2 v 220 BOY.1 NONTH,,~ YES.,1 GIRL.2 YEAR. HO,.,,2 I V 220 DOY.1 ~TH,,~ YES,,.1 GIRL.2 YEAR. NO.2 I v 22O 217 IF ALIVE: How old was (NAME) at his/her last birthday? RECORD AGE IN COMPLETED YEARS. AGE IN YEARS FT1 AGE IN YEARS AGE IN YEARS AGE IN YEARS AGE IN YEARS AGE IN YEARS AGE IN YEARS AGE IN YEARS ]70 218 IF ALIVE: IS (NAHE) Living with you? YES . 1 (GO TO NEXT BIRTH)4] NO . 2 YES . 1- (~ TO NEXT BIRTH)4. NO . 2 YES . I (GO 10 NEXT BIRTH)- 1 NO . 2 YES . 1 (GO TO NEXT BIRTH)TJ NO . 2 YES . . . . . . . I (GO TO NEXI B]RTH)~ NO . 2 YES . 1 (GO TO NEX~ BERTH) NO . 2 YES . 1 (GO TO NEXT] DIRTH), NO . 2 YES . 1- (GO TO NEXT BIRTH)q- NO . 2 219 IF LESS THAN 15 YRS. OF AGE: With wh~ does he/she (ire? %F 15+: GO TO NEXT B%RTH. FATHER . 1 OTHER RELAT]VE.2 SOMEONE ELSE.S (GO NEXT B[RTH) FATHER . 1 OTHER RELATIVE.2 SC~4EO~IE ELSE.3 (GO NEXT BIRTH) FATHER . 1 OTHER RELATIVE.2 S[~4EONE ELSE.3 (CO NEXT BIRTH) FATHER . 1 OTHER RELATIVE.2 SOHEONE ELSE.3 (GO NEXT BIRTH) FATHER . 1 OTHER RELATIVE.2 sOtlEONE ELSE.3 (GO NEXT BIRTH) FATHER . 1 OTHER RELAHVE,2 SO~4EONE ELSE.,3 (GO NEXT BIRTH) FATHER . . . . . . . . . 1 OTHER HELATWE.2 S~4EONE ELSE.3 (GO NEXT BERTH) FATHER . 1 OTHER RELATIVE.2 SCItEONE ELSE.] (GO NEXT BIRTH) 220 IF DEAD: HO~ old wai he/she ~dleflhe/ehe died? IF "1 YR,', PROBE: HO~ ~ wO~lths old was (VALe)? RECORD DAYS ]F LESS THAN 1 ~TH~THS [F LESS TKAN T~O YEARS, OR YEARS. DAYS.1 ~ MONTHS.2 YEARS.] DAYS.,1 140NTHS.2 YEARS.3 DAYS.1 NONTHS.2 YEARS.] DAYS.1 M(SNTHS.2 YEARS.,.] DAYS.1 NONTHS.2 YEARS.] DAYS.,.,1 MONTHS.2 YEARS,.,3 DAYS.,.1 140WTH$.2 YEARS.,,3 DAYS.1 H~MTHS.2 YEARS.,.3 212 213 214 Vhet name US RECORD Is glvm tO your SINGLE (NAME) next b~by? OR • boy or MULTIPLE • glr(? BIRTH STATUS, I-°.11 MOLT. ,2 (iA/4E) 215 In what month year ~das (NAME) born? pROBE: what ts his/ her birthday? Ol: )nwhat season? 216 Is (NAME) stttt alive? 217 IF ALIVE: HO~ old ~os (NAME) ~t his/her tsst birthday? RECORD AGE %N COMPLETER TEARS. 218 IF ALZ~: IS (HA/4E) living with you? 219 IF LESS TBAB 15 YRB, OF ACE: Uith whom do~i he/sht /lYe? IF 15+: GO TO NEXT BIRTH, OE'N IYES NO . . . . . . . . . . . . . . . ,0 NEXT 2 - - - -ELSE . . .3 OTHE ELA"V .2 . . . . . . . . . " " " ' 220 IF DEAD: RO~ old ws he/she when he/qlh| died? IF "1YR. ' , PROeE: BOW qlanymotlths old v4s {BAalS)? RECORD DAYS IF LESS THAN 1F((ilTB,iaiONTHS IF LESS THAN TWO TEARS. OR YEARS. (NAME) IN ) N (NAME) (RAMIE) (~NE) AGE IN YES . 1 FATHER . 11 YEARS (GO TO NEXT i l l ~] ; BIRTH) OTHER RELAT[VE. 2': NO . 2 SOMEONE ELSE.3 (GO NEXT BIRTH) AGEyEARs~IN YES(GO . BIRTH) 4TO NEXT1 ] ~:i OTHERFATHER RELATIVE.211 NO . 2 SONEOHE ELSE.] (GO NEXT BIRTH) ; AGE IN YES . 1 FATHER . 1 YEARS (GO TO NEXT BIRTH) OTHER RELAT]VE.2 NO . . . . . . . . 2 SDNEORE ELSE,. . ] (GO NEXT BIRTH). AGE IN YES . 1 FATHER . 1 YEARS 1 (GO TO NEXT BIRTH) 4 OTHER RELATIVE.2 NO . 2 SOMEONE ELSE.3 ! (GO NEXT BERTH) I i A~E iN YES . 1 FATHER . 1 I YEARS T] (GO 10 NEXT i BIRTH) OTHER RELATIVE.~' [ ~ NO . 2 SOMEONE ELSE.3 (GO TO 221) COMPARE 208 UITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARX: ~r48[RB ~ #BJI4BER~ ARE ARE SAME DIFFERENT [~ ~ (PROBE AND RECONCILE) / ¥ CHECK: FOR EACH BIRTH: TEAR OF BIRTH IS RECORDED. [] D FOR EACH LIVING CHILD: CURRENT ACE IS REGOROED. FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED. FOR AGE AT DEATH 12 MONTHS: PROSE TO DETERMINE EXACT NUMBER OF MONTHS. CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1987. IF N(3~E~ RECG~D O. F7 171 .o. I ~sT,oRs AND FILTERS 2231 Are you pregnant now? I SKIP CODING CATEGORIES I TO YES. . .1 I :::::::::::::::::::::::::::::::::::: 22, I I - s . . . . . . . . . . . . . . . . . . . . . 225 I pillsOUringreguLartythis pregnancy't° prevent you are you from getting taking bitter'tastingmataria? OK. . . . .8 NO" .1 226 I At°p~egnadntyouhtnen°nt d~ndtY~°the t Line yo4J bec-- pregnant,wantbecom e pregnant at aL uaJt unti L dId yo~ want~t~r,tO become MOT AT . . A~.L . .3 THEN" .2 227 When did your Last menstrual period start? DAYS AGO . .1 WEEKS AGO . . . . . . . . . . . . . . . .2 NON/HS AGO. . . . . . . . . . . . . . .3 YEARS AGO. . ,6 IN NENOPAUSE . 99/* BEFORE LAST BIRTH. . 995 NEVER NENSTRUATED . 996 228 I "'a'''g'T'e"t"" other"""*" 0' h°rth''t~.?F'"Sth''';" D'e'T''ber"~'°' "'''n's°h.'" o,' . . .~ pr.,~n, at" 'h""per'~ ''d'rEa~r'the YES. . ::::::::::::::::::::::::::::::::::::: Z29 During which tiaves of the monthly cycle does a woman have the greatest chance of becoming pregnant? DURING HER PER]O0 . 1 RIGHT AFTER HER PERIOD HAS ENDED . ,2 IN THE MIDDLE OF THE DYDLE,,,.,.~ JUST BEFORE HER PERIOD BEGINS.6 OTHER S (SPECIFY) DK. . .8 F8 172 SECTION ]. METHODS OF CHILOSPACIHG 301 | Mow [ would tikl to talk ibout childapacing - the varJoL~l Wtyg or methods that I coup(I can u•e to I delay or Ivo(d • pregnancy+ Which ways or methoda hive you heard adDiCT CIRCLE CODE t IN 302 FOR EACH NETHO0 NEMT](Xt4ED $PO~TANECUSLY. THEN PHOCEED OOON THE C04~UMN, READING THE NAME AND OESCRIPFION OF EACH METHOD NOT MENTIONED SPONTAMECUSLY. CIRCLE CQDE 2 IF MET~ ]R HECOONiZED, AND CODE 3 IF NOT RECOGNIZEO. THEN, FOD EACH 14~THOD NITH CODE 1 ON 2 CIRCLED IN 302, ASK 303-304 6EEODE PROCEEDING TO THE NEXT NETHO0. 01 PILL WO~ can tahe a pitt O~ every day. 0021 IUOD gamin can have i loop or .J coil placed inside them by • doctor or a r~Jrae. ]1 INJECTIONS WcC~'ncan have an injectioe by a doctor or nurse which stops th~ frG41tbeCO~lng pregrant for several mo~ths, 41DIAPHRACd4,FON4,JELLY I ~ can place • spof~ge, s~sltory, diaphragm, jelly or cream in- side them before Intercourse. 0• COtiDGN Lien can u~e a rcd3bet" sheath during sexual Inter- tour•e, 61 FEMALE STERILIZATION women can hlve In oper•t lon to avoid hiving ~more children. 07 MALE STERILIZATION Men can O~ have an operati~ to lvold having any more children. 81 NATURAL NETHO0 Couples can avoid having sexual intercourse o~ certain days of the month when the ~omsn is more (ikeLy to become pregnant. _•J WITHDRAMAL Nen can be careful and dull out before climax. 01 Nave you heard of may other ~•ys or methods that kmmen or mle can use to delay or 302 Have you ever I 303 Hive you ever heard of (METHOD)? I ulled (METHOD)? READ OESCRIPTIOM OF EACH METHOD. YES/SPO~T . 1 YES . 1 YES/PROBED . 2 NO . 31 NO . 2 v . 304 OoyOu kno~ uhere a person could 9o to get (METHOD)? YES . 1 NO . . . 2 TES/SPONT . 1 YES . 1 TEE . 1 YES/PR(~EO . 2 NO . 31 NO . 2 NO . E v YES/SPONT . 1 YES/PROBED . 2 NO . v YES/SPOIlT . 1 YES/PRiED . 2 NO . '31 v YES/SPO~T . . . . . . . . . . . . . . . . . . . 1 YES/PRO6EO . 2 NO . .H , .~ I v YES . 1 NO . 2 YES . 1 NO . 2 YES . . . . . . . . . . . . . . . 1 HO . . . . . . . . . . . . . . . . 2 Have you ever had ir operation to •void having any more children? YES . 1 NO . 2 v YES/SPONT . YES/PROSED . NO . . . . . . . . . . . . . . . . . . . . . . . . . . YES . 1 NO . 2 YES/SPO#IT . 1 YEE/PRQ6EO . 2 NO . 31 V YES . 1 NO . 2 YES . 1 NO . E YES/SPONT . 1 YES/PROBED . 2 NO . YES . 1 NO. . . . . . . . . . . . . . . . . . . • . . . . . 2 YES . 1 NO, , , , , . . . . . . . . . . .H . . . . . . . YES . .,, . 1 NO . 2 YES . 1 NO. . 2 0o you know where •person can obtain advice on ham to use the natural method? YES . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . 2 v YES . I NO . 2 YES/SPONT . 1 YES/PROBEO . 2 NO . V - YES/SPONT . 1 HO . . . mvoid pregnancy? I (SPECIFY) 2 (SPECIFY) 3 (SPECIFY) YES . 1 NO . 2 YES . . . . . . . . . . . . . . . 1 NO . 2 YES . 1 NO . 2 v AT LEAST ONE 'aYES" (EVER USED) I I ~" SKIP TO 308 E9 173 NO. QUESTIONS AND FILTERS Have yo~ ever used anything or tried in any way to delay or avoid getting pregnant? SKIP I COOING CATEGORIES I '0 I TEE . n I NO . ~ ,324 I I 307 What have you used or done? I I CORRECT 303-305 (AND 302 IF NECESSARY). 308 309 310 311 NOW I would like to ask you about the time when you first did something or used a method to avoid getting pregnant. HOW many living children did you have at that time, if any? IF NORE, RECORD tO0', CHECK 223: MOT PREGNANT PREGNANT OR UR~RE [ -l CHECK 303: ~t4AN NOT STERILIZED I~MAN STERILIZED ~--~ Are you currently doing something or using any method to delay or avoid getting pregnant? NUMBER OF CHILDRER . ~-~ ,324 I P312A I YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' l NO . 2 P324 312 312A ~ich method are you using? 00 NOT ASK Q.312A IF THE ~N IS HOT STERILIZED yOU have said that yo~ had an operation that keeps you from getting pregnant, ]$ that correct? iF RESPONDENT SAYS "NO", CORRECT 303"305 (AND 302 iF RECCESSARY). IF RESPONDENT CONFIRMS WZTH A "YES", CIRCLE '06' FOR FEHALE STERZL[ZATiON. I PILL . 01 I IUCD . O2~ INJECTIONS . 03 DIAPHRAGM/FOAM/JELLY . 04 CONDOI4 . 05 318 FEMALE STERILIZATION . 06 MALE STERILIZATION . 07 OTHERNATURAL HETHCO . 01~ WITHDRAWAL . 09 323 (SPECIFY) I I I ]~3 A'L the t~e~e yOU first starte~ usi~ the piLL, did yo~.l | YES . 1 | consult a doctor, nurse or other me~icat parsorl? I [ NO . 2 DK . 8 , i o o r --. I . . . I 315 Nay I see the package of pills you are using now? RECORD N~E OF BRAND. PACKAGE SEEN . 1 317 BRAND NAME PACKAGE NOT SEEN . 2 I 316 Do you kno~ the brand name of the pills you are now using? I BRARONAHE [~1 DK . 98 RECORD NAME OF BRAND. FREE . 996 OK . 998 | 174 e lo 318 QUESTIONS AiD FILTERS CHECK 31E: SHE/HE STERILIZED ¥ ~ere did the sterilization take ptace? USING ANOTHER METRO0 (NAME OF PLACE) Where did you obtain (NETHOD) the last time? NOTE: PRIVATE SECTOQ INCLUDES NISSION FACILITIES SKIP CODING CATEGORIES J TO POBL ] CO [ SPERSARY/14ATERR i T Y . CL ] N i C . . , 13~VERRHERTpR ]I4ARySECT(~irtHEALTH HOSPITAL" . " 11CENTRE 12 [ ~]LE CLINIC. . 1~. ~321 NED ] CALD i SPERSARY/14ATERN ] E Y CL ] N i C . , , 2 3 P R I VATEpR I VATEPR [ VATEBEALTHHOSP I TALSECTORcENTRE • . , 2 I MOBILE CLINIC., . .24 "321 OTHERsBoP/PHARMACY . . . 3 1 P R I VATEpR [ VATE DOCTOR' " 25SECTOR J 319 OTRERk/ISE,fromH°WIF lESSl°ngyour home to EhISTHAN 2d°eSREcORDitHOURS,takeHouRs.t°RECGRDPlOceTtrOvetNINUTES. J DR. . . . 9998 HOUND .2MINUTES. .I ~ J 320 ,22 r J s it easy or difficu|t to get there? USING AROTHERNETRO0 [~ In what month and year wait the sterilization operation performed? I D] FFICULT . . .2 EASY" .1 I 3Z5 krnat is the main reason you do not intend to use a method? ~ANTS CHILDREN . .01- LACK OF KNOWLEDGE . .02 PARTNER OPPOSED. . .03 OTHER RELATIVES OPPOSED . 04 SIDE EFFECTS . .05 HEALTH C(~ICERNS. . . . . . . . . . . . . . . . 06 SOURCE TOO FAR A~AY. . ,07 NETHOOS ARE UNAVAILABLE . 08 OPPOSED TO FAMILY PLANNING . 09 FATAL % ST ] C/GOD °$ WILL. . 10 COSTS TO() MUCH . . . . . . . . . . . . . . . . 11 INFREQUENT SEX, . 12 CAN HOT GET PREGNANT . 13 MENOPAUSAL/HAD HYSTERECTDMY, . . . 14 INCONVENIENT, . .15 NOT HJ~RR IEO. . 16 OTHER 17 (SPECIFY) OK. . 98- - - ~'330 261 oo o . ou.o h 2 hOl o YE I F 11 1"75 NO. OUESTIORS AND F[LTERS 327 When you start u~ing • Bethod, which method aoutd you prefer To use? SKIP COOING CATEGORIES TO PILL. . ,01 IUED . .02 INJECTIONS. . .03 DIAPHRAGM~FOAM/ JELLY . . . . . . . . . . . 04* CO~OOM . .05 FEMALE ETERIL [ZAT [OM . 06 ~LkLE STERI LIZAT ]OR . .07 328 329 330 Where Ben yo~ get (NETHO0 MENTIONED IN 327)? (NN4E OF PLACE) NOTE: PRIVATE SECTOR INCLUOES MISSION FACILITIES CHECK 312: USING NATURALTRADITIC~A L METHOD WITHDRAI4AL' OR OTHER METHCO' vm Do you know of a place uhere yo~ can obtain a mtthod of childspecing? PUBLIC SECTOR I iTs !i ii: i;iiii iiii;i!!!i ,,2 MOBILE CLINIC . 1/. =.334 u MEDICAL PRIVATE SECTOR MOBILE CLINIC . 2~ ".334 PRIVATE DOCTOR. . .25 ".332 l OTHER PRIVATE SECTOR I SHOP/PHARNACY, . 31 "332 (SPECIFY) I OK. . 98 ".330 US 1NGMETHcoA MOOERN I---] ".334 I YES. . 1 I NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 J '3~ 331 ghere is that? (NAME OF PLACE) NOTE: PRIVATE SECTOR INCLUDES MISSION FACILITIES PUBLIC SECTOR GOVERNMENT HOSPITAL . 11 PRIMARY HEALTH CEHTRE . 12 DISPENSARY/MATERNITY CLINIC.13 MOBILE CLINIC . ,1£ P3~ MEDICAL PRIVATE SECTOR PRIVATE HOSPITAL . .21 PRIVATE HEALTH CENTRE . . . . . . . . . 22 DISPENSARY/MATERNI TY CL%NIC.23 NOB I LE CLINIC . 2/, ~334 OT HE RSHOP/PHARMACY . . 3 1 P R I VATEpR I VATE SEBTORDOCTOR .25 r (SPEC]FY) I 332 I OTHERI~ISE, IFfr°m Y°~rH°MLESS TNANI°ng d°eSh°meRECORD2itNCURS't°takeHouRs.thiSREcORot°pLece?travetMiNUYES" J MINUTES. . . . . 1 H O , JRS 9998~ I F 12 176 RO. I 3- I QUESTIONS AND FILTERS IS It easy or difficult to get there? I CODING CATEGORIES I EASY . 1 DIFFICULT . 2 SKIP I To I I 3~ I In the last mo~th, have you heard a messaRe I YES . 1 I abo~t chfldspacfng on the radfo7 I NO . * . . . ,2 335 I Is it acceptable or not acceptable to you for child- I ACCEPTABLE . 1 I spacing information to be provided on the radio? I NOT ACCEPTABLE . 2 OK, . ,,. . ., . .,,o,8 337 NEVER HEARD OF THE LORDLY4 I Have you seen or heard any advertisement in the last month about the cc~m? I I p4011 I YES . 1 ] NO . 2 ,339 3]8 tdhere did you see or hear the advertisement? CIRCLE ALL NENTIONED ~0 Where can someone go to get condo~s? (RARE OF PLACE) ROTE: PRIVATE SECTOR IRCLUOES HISSION FACILITIES RA~IO . A NEWSPAPER . . . . . . . . . . . . . . . . . . . . . . . B NAGAZIHE . C POSTERS . D CAN NOT RENEHBER . E OTHER F (SPECIFY) I pUDLIC SECTOR GOVERNMENT HOSPITAL . 11 PRIHARY HEALTH CENTRE . 12 DISPEHSARY/NATEHRITY CLINIC.13 ROSILE CL[N]C . . . . . . . . . . . . . . . . . 14 NEDICAL PRIVATE SECTOR PRIVATE HOSPITAL . 21 PRIVATE HEALTH CENTRE . 22 DISPENSARY/NATERNITY CLINIC.,23 MOBILE CLINIC . 24 PRIVATE DOCTOR . 25 OTHER PRIVATE SECTOR SHOP/PHARNACY . 31 CHURCH . 32 FRIENDS/RELATIVES . 33 OTHER ~I (SPECIFY) DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 F 13 177 SECTioN 4A. PREGNANCY AND ~R[A~TFEEDZNG 402 403 CHECK 222: ONE ON MORE NO BIRTHS ~ v ~ SINCE JAN. 1987 ['-~ . (SKIP TO ,01) I ENTER THE LINE MONGER AND NAME OF EACH BIRTH SINCE JANUARY 1987 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE 14~RE THAN ] BIRTRSa USE ADDITIONAL FORES). NOW I would Like to ask you some more questi~ about the health of all your children born in the pest five years. (We will tetk about one child at a time.) I LINE WJI4BER FROM O. 212 I FROM O. 212 m At the time yo~ became pregnant with (NAME), did you want to become pregnant ~hen, did you J wmnt to wait until tater or did you want ~ (more) I children at all? M IF] LAST BIRTH NEXT-TO-LAST BIRTH gAME NAHE SECOND" FROM- LAST BIRTH NANE (SKIP TO 405), ] THEN . 1 I THEN 1 THEN . 1 ~kib%~6~; ; . . . . 1 (SKIP ?o 405). I i LATEg . . . . . . . . . . . . . . . . . . . . z311 LATER . 2 LATER . 2 NO MORE . NO MORE . ~, NO RO~E . 3 1 (SKIP TO 405)' J (SKIP TO 405), l (SKIP TO 405)' (,04 | ROd mJch longer wo~ld yc~ I like to have waited? ~]~ MONTHS . 1 ~ ~ ] ROHTHS . 1 MONTHS . 1 YEARS . 2 YEARS . 2 YEARS . 2 ON . 998 DK . 998 DK . 9~)8 m 405 Whe~ you were pregnant with (MAME), did you see anyone for antenatal care for this pregnancy? IF YES, [~hom did you see? knyo~Ye else? RECORD ALL PERSONS SEEN. HEALTH PROFESSIONAL DOCTOR . A NURSE/MIDWIFE . . . . . . . . . . . B CLININAL DFICER/ MEDICAL ASSISTANT . C tRADITIONAL BIRTH ATTENDANT TRAINED . O UNTRAINED . E TRAINING UNCERTAIN . F OTHER G HEALTH PROFESSIONAL DOCTOR . A NURSE/MIDWIFE . B CLININAL OFICER/ HEDICAL ASSISTANT . C TRADITIONAL BIRTH ATTENDANT TRAINED . D UNTRAINED . E TRAINING UNCERTAZH . F 3THER G HEALTH PROFESSiONAL DOCTOR . A NURSE/MIDWIFE . B CLININAL OFICER/ MEDICAL ASSISTANT . E TRADITIONAL BIRTH ATTENDANT TRAINED . D UNTRAINED . . . . . . . . . . . . . . . E TRAINING UNCERTAIN . F OTHER G (SPECIFY) (SPECIFY) (SPECIFY) NO ONE . H qO ORE . H NO ONE . R- (SKIP TO 409)q (SKIP TO 409)4 (SKIP TO 409)* I ~te~tB( card f~r ] this pregnancy? NO . . . . . . . . . . . . . . . . . . . . . . . ~ NO . . . . . . . . . . . . . . . . . . . . . . . ~ NO . . . . . . . . . . . . . . . . . . . . . . . OK . 8 DK . 8 DK . 8 check m this pregnancy? DK . 98 OK . 98 OK . 98 m OOF . . . . . . . . . . . . . . o o v . . . . . . . thia pregnancy? DK . 98 OK . 98 DK . 98 m with (NAME) were you given YES . 1 YES . 1 YES . 1 an injectio~ in the buttock to prevent the baby Frown NO . 21 NO . 21 NO . 2 I getting tetanus, that is, (SKIP TO 411)* (SKIP TO 411]4 (SKIP TO 411)* convulsions after birth? DE . DK . OK . ''OlDo"n'thispreDnancYho'--oyt'.,d'd,ou.t TI"EE . 13 . ' ' = . sl th i s in j~t i~? OK . . . . . . . . . . . . . . . . . . . . . . . 8 oK . . . . . . . . . . . . . . . . . . . . . . . 8 DN . . . . . . . . . . . . . . . . . . . . . . . . , F 14 178 &11 Where did you give birth to (NAME)? NOTE: PRIVATE SECTOR INCLUDES MISSION FACIL I r IES LAST BIRTH NAME YOUR HONE . 11 HONE OF TBA . 12 OTHER HOME . 13 ~UBLIC BECTOR GVT. HOSPITAL . . . . . . . . . . 21 PRIMARY HEALTH CEMFEE.22 MATERNITY FACILITY . 23 PRIVATE SECTOR PVT. HOSPITAL . 31 PVT. HEALTH CEHFSE . 32 MATERNITY FACILITY . 33 3THER 41 (SPECIFY) NEXT'TO'LAST BIRTH NAME HONE YOUR HOME . 11 HONE OF TBA . 12 OTHER HONE . 13 PUBLIC HECTOR GVT. HOSPITAL . 21 PRIMARY HEALTH CENTRE.22 MATERNITY FACILITY . 23 PRIVATE SECTON PVT. HOSPITAL . 31 PVT. HEALTH CENTRE . . . . . 32 MATERNITY FACILITY . ]3 OTHER /.1 (SPECIFY) SECOWD'FRON'LAST BIRTH NAME NONE YOUR HONE . 11 NONE OF TEA . 12 OTHER HOME . 13 PUBLIC SECTOR GVT. HOSPITAL . 21 PRIMARY HEALTH CENTRE.22 MATERNITY FACILITY . 23 PRIVATE SECTCE PVT. HOSPITAL . 31 PVT. HEALTH CENTRE . 32 MATERNITY FACILITY . 33 OTHER 41 (SPECIFY) 412 Who assistod with the ~e(ivery af (NAME)? Anyo<le else? PROBE FOR THE TYPE OF PERSOM AND RECORD ALL PERSONS ASSZSTING. dEALTH PROFESSIONAL DOCTOR . A HURSE/NIDM; FE . O CL ININAL OF lEER/ MEDICAL ASS] STANT . C tRADITIONAL BIRTH ATTENDANT TRAINED . D UNTRAINED . E TRAINING ONCERTAI N . F RELATIVE . G OTHER H (SPECIFY) NO ONE . I HEALTH PROFESS IONAL DOCTOR . A NURSE/MIDW[ FE . H CL]NINAL OFICEH/ MED]CAL ASSISTANT . C TRADITIONAL BIRTH ATTENDANT TRAINED . D UNTRAINED . E TRAIN ING UNCERTA|R . . . . . . F RELATIVE . G OTHER H (SPECIFY) NO ONE . ] HEALTH PROFESSIONAL DOCTC~ . A NURSE/MIDUIFE . 8 CL|NiNAL OF|DEN/ NEDICAL ASSISTANT . C RADITIONAL BIRTH ATTENDANY TRAINED . D UNTRAINED . E TRAINING UMCERTAIN . . . . . . F :ELATIVE . G OTHER N (SPECIFY) NO ONE . i 413 m .- (NAME) born on tim ON TIME . 1 ON TXME . 1 ON TiME . 1 I or prer~,aturety? PRE~t4FUREL Y . 2 PREMATURELY . . . . . . . . . . . . . . 2 PREHkTURELY . 2 DK . B DK . 8 DK . B 414 | Has (NAME) delivered YES . 1 YES . 1 YES . 1 I I by caesarian section? I NO . . . . . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . . . . . . Z NO . . . . . . . . . . . . . . . . . . . . . . . 2 615 | When (MANE) was born, uas he/she: very forge, VERY LARGE . 1 VERY LARGE . 1 VERY LARGE . 1 Larger than average, LARGER THAN AVERAGE . 2 LARGER THAN AVERAGE . 2 LARGER THAN AVERAGE . 2 average, AVERAGE . 3 AVERAGE . 3 AVERAGE . ] miter than average, SMALLER THAN AVERAGE . 4 SMALLER THAN AVERAGE . 4 SMALLER THAN AVERAGE . ; or very stoat l? VERY SMALL . S VERY SHALL . 5 VERY SMALL . 5 OK . B DK . 8 DK . 8 I NO . 2] (SR.P TO 419). 1 YES . 1 I 416 t/as (M/LNE) weiBhed YES . 1 YES . 1 at birth? NO . 2 NO . 2 (SKP TO 418 4 • (SKIP TO 419)* 1 "' I N'=h+i°(N','igh? NE L RAMG I -1D KiL*RAMS C] K I LDGRAMS . K I . . OK . 98 DK . 9B DK . 98 1 YEs . '11 418 Has your period returned sine the birth of (HAME)? (SKIP TO 420)9 1 NO . Z (SKIP TO 421 )" i YES . 1 . 1 619 Did your period return between (SKIP TO 421)4 1 YES the birth of (NAME) and your NO . . . . . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . . . . . . 21 next pregnancy? (SKIP TO 421)1 I '2° I F°r h'--Y='h'"tar [--N the birth of (NAME) did MONTHS . MONTHS . MO~THS . you not have a period? GK . . . . . . . . . . . . . . . . . . . . . . 98 DK . . . . . . . . . . . . . . . . . . . . . . 98 DK . . . . . . . . . . . . . . . . . . . . . . 9B I (SKIP TO 423)~_ , YES . 1 I YES . 1 (SKIP TO 410)~ 1 YES . 1 k21 Did you ever breestfeed (NAME)? (SKIP TO 430) '1 J NO . . . . 2 NO . 2 HO . 2 ]79 F 15 422 ~y did you not breastfeed (MANE)? LAST BIRTH NANE NOTHER ILL/MEAK . 01 CHILD ILL/VEAK . 02 CHILD DIED . 03 NIPPLE/BREAST PR~LEN.04 INSUFFICIENT MILK . 05 NOTHER MORKING . 06 CHILD REFUSED . 07 OTHER 08 (SPECIFY) (SKIP TO 432)" NEXT'TO'LAST BIRTH HANE NOTHER ILL/WEAK . 01 CHILD ILL/WEAK . 02 CHILD DIED . 03 NIPPLE/BREAST PRODLEN.04 INSUFFICIENT MILK . 05 MOTHER WORKIHG . 06 CHILD REFUSED . 07 OTHER 08 (SPECIFY) (SKIP TO 432)- SECOND'FROM'LAST BIRTH NAME MOTHER ILL/MEAK . 01 CHILD ILL/~EAK . 02 CHILD DIED . 03 NIPPLE/BREAST PROBLEM.04 INSUFFICIENT NILK . 05 NOTSER MORKING . 06 CHZLD REFUSED . 07 OTHER 08 (SPECIFY) (SKIP TO 432)4 423 425 HOW Long after birth did yo~ first put (NAME) to the breast? IF LESS THAN I HOUR, RECORD I O0' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERMISE, RECORD DAYS. INI4EDIATELY . ODD HOURS . 1 ~ DAYS . 2L~ ~ ~v DEAD v~ (SKIP TO 4 3 0 ) YES . 1 NO . 2] (SKIP TO 430)4 426 | HOW many times did you NUMBER OF I breastfeed Lest Night NIGHTT%NE bstv~en sunset and sunrise? FEEDINGS If ANSMEB IS NOT NUMERIC, PROBE FOR APPROXIMATE NU~DER. 427 | HOW many times did you NU~4BER OF I breastfeed yesterday DAYLIGHT during the daylight hours? FEEDINGS IF ANSMER IS NOT HUNERIC, PRC~E FOR APPROXIMATE NUNBER. 428 At eny ti~e yesterday or last night was (NAME) given any of the following?: Plain water? Mater with herbs or roots? Juice? Baby formula? Fresh miLk? Tinned or powdered milk? Other Iic~Jida? Any solid or mushy food? CHECK 428: FO00 OR LIOUID GIVEN YESTERDAY? YES NO PLAIN I~ATER . 1 2 MATER WITH HRBS/RTS.1 2 JUICE . 1 2 BABY FORMULA . 1 2 FRESH MILK . 1 2 TINNED/PO~OEHED NILK.1 2 OTHER LIQUIDS . 1 2 SOLID/NUSHY FO00 . 1 2 "YES" TO (~E OR "NO" TO ALL v (SKIP TO 433 (SKIP TO 434) F 16 180 430 For how many month! did yo~ breastfeed (NAME)? NNdE LAST BIRTH I I MONTHS . , ~ . . . . . NEXT-TO'LAST BIRTH NAME MONTHS . " " ' M UNTIL DIED . 961 (SKIP TO 433), / SECOND - FRON- LAST BIRTH I NAME 431 433 I~hy did you stop breastfeeding (NAME)? CHECK 216: CHILD ALIVE? Was (NAME) ever given weter or 4~ythir41 else to drink or eat (other than breaatmiLk)? MOTHER ILL/WEAK . 01 CHILD ILL/~EAK . 02 CHILD DIED . 05 NIPPLE/BREAS$ PRONLEN.,.04 ]~SUFEJCIENT MILK . 05 MOTHER I~O~KIRG . 06 CHILD REFUSED . 07 WEANING AGE . 08 BECAME PREGNANT . 09 STARTED USING CONTRACEPT%ON . 10 OTHER 11 (SPECIFY) ,LIVE @v (SKIP TO 434) YES . 1 NO . 2] (SKIP TO 4571q MOTHER ILL/~EAK . 01 CHILD ILL/WEAK . OZ CHILD DIED . . . . . . . . . . . . . . O] NIPPLE/BREAST PROBLEN.Ok ]N$~JFE]CIENT MILK . 05 MOTHER N~)RXING . 06 CHILD REFUSED . 07 ~IEANING AGE . 08 BECAME PREGNANT . 09 STARTED USING CONTRACEPTION . 10 OTHER 11 (SPECIFY) (SKIP TO 434) YES . 1 NO . 2 (SXIP TO 437)" / MOTHER ILL/UEAK . 01 CHILD ILL/WEAK . 02 CHILD DIED . 03 NIPPLE/BREAST PROBLEN.Ok INSUFEJC|E~T MILK . 05 MOTHER ~JO~KING . 06 CHILD REFUSED . 07 WEANING AGE . 08 BECAME PREGNANT . 09 STARTED USING CONTRACEPTIOq . 10 OTHER 11 (SPECIFY) AL,VE DEAD (SKIP TO 434) imm YES . 1 NO.*. . . . 2 1 (SKIP TO 437) 9 I /434 /*36 How manymo~th$ old was (NAME) ~em you ztarted giving the foLtouing on a regular basis?: FormuLa or milk other than braastmitk? PLain water? Other Liquids? AGE IN MONTHS . IJJ NOT GIVEN . 96 AGE IN NONTHS . ~--~J NOT GIVEN . 96 I AGE IN MONTHS . JJl NOT GIVEN . 96 I AGE IN MC~THS . [ [ J NOT GIVEN . 96 AGE IN MONTHS . i l ] NOT GIVEN . 96 AGE IN MONTHS . i ] ] NOT GIVEN . . . . . . . . . . . . . . . 96 Any solid or mushy food? iF LESS THAN I 14O~TH, RECORD *DO'. AGE IN MONTHS . I [ NOT GIVEN . 96 AGE IN MONTHS . I I J NOT GIVEN . . . . . . . . . . . . . . . 96 (SKIP TO 437) Did (N~IE) d r ink z~qyth ing from a bottle with a n ix ie yesterday or last nlght? DEAD (SKIP TO /,37I YES . 1 NO . 2 DX . . . . . . . . . . . . . . .,.8 GO BACK TO 403 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO FIRST COLUHN OF /*38 AGE IN NONTHS . l J l NOT GIVEN . 96 AGE IN MONTHS . I J l NOT GIVEN . 96 AGE IN MONTHS . I l l NOT GIVER . 96 AGE IN HONTHS . I I I NOT GIVEN . 96 (SKIP TO 437) F 17 181 SECTION 4B. IMMU~IZATIOR AND HEALTH J ENTER THE LIME BUM~CA AND MANE OF EACH S%RTH SINCE JANUARY 1987 IN THE TABLE. ASK THE OUESTIUMS A4OUT ALL OE THESE BIRTHS. BEGIN MITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS USE ADD]T]UMAL ECRMS). I LINE MUllER FRGq O. 212 I I lH~ yc~J hive a card ~herl (M'S) v~cclrmtlom ere urltten do~n? If YES: May I see It, please? LAST BIRTH YES, SEEN . 1 1 (SKIP TO 441)~ / YES, MOT SEEM . 2 (SKIP TO 443)" ] NO CARD . 3 NEXT'tO'LAST BIRTH MANE YES, SEEN . 1 (SKIP TO 441)~ YES, NOT SEEN . 2 (SKIP TO 44S)~ N0 CARD . 3 I SECOMD-FRGq-LAST S[STK I kUU4E TEE. ~Y;'i~".~;;: . '11 TES, . . . . . . NO CARD . 3 I | Bid you ever have a i ~q~clnetlon card for (IIN~)T & 4~1 (1) COPY VACCIIU~TION DATES FOR EACH VACC]NE FROR 1HE CIRD. (~) kqRLTE n46' IN 'DAY t COLUMN IF CARO SHOMS THAT A VACC]BATIOR UAS GIVEN, BUT k~DATE RECORDED. ECG POLIO 1 P~]O 2 POLIO 3 OPT 1 DPT 2 OPT 3 MEASLES YES . 1 YES . I (SKIP TO ~43)~ (SKIP TO ~63)~ J (SKIP TO 6/~) • NO . 2 NO . 2 NO . 2 I DAY BCG PZ P] D1 D2 03 MEA 140 YR DAY MD YR BCG Pl . I P2 P3 D1 02 i -~ i D3 ~ . . . . ~EA DAY SCG l Pl P2 P3 oi 02 03 HEAl W) TB ~Z Nms (NAME) received vaccirmtfocu~ that Ire not recorded on this card? RECORD 'YES ~ (Sally LF RESPOHOENT MENTIC~S BCG, OPT 1-3, POLIO 1-3 ANO/~ MEASLES VACCINE(S). YES . 1 YES . 1 AND ~/RITE ~66' IN THE AND WRITS 166' IN THE CORRESPONOING DAY CORRESPONDING DAY COLUMN ;N 461) ~ COLL~N IN 441) MS . i " '~2 NO . . . . . . . . . . . . . . . . . . . . . . . ~2 OK . OK . (SKIP TO 445 (SKIP TO 445) • YES . ~ ] (PRORE FOR VAGCINATIORS AND MEITE t66' IN THE CO'RE SP~4dD [ XG DAY COLUqR IN 441) ~ NO . 2 oK.illi;.i;-ii;;.; . /~] Bid (MANE) ever receive YES . 1 YES . . . . . . . . . . . . . . . . . . . . . . 1 YES . 1 | I~y v~c¢ir~t iotas to NO . "'~72 NO . 2] NO . ~]2 I prevent him/hit from (SKIP TO 445), ~ (SKIP TO 445) 4 8] (SKIP TO ~S) q letting diseases? OK . .,~ OK . OK . kk4 445 PLease tell me if (MAJ4E) (ha) received any of the EoLLoNiP41 vaccinatior~s: A SCG vlccinatlo¢1 aBaJnst t~d)ercu~ts, that is w (njKti~ in the rlght ulcer am thIt ¢lvJSed a scar? Polio vlcclne, that is e dr~ in the mouth? IF YES: S(wRar~ times? An injection igslr~t lea~[l$? CHECK 216: CHILD ALIVE? YES . 1 110 . . . . . . . . . . . . . . . . . . . . . . . DK . S YES . I MO . 2 DK . 8 NLMBER OF TINES . . . . . . . . YES . 1 NO . 2 DK . 8 YES . 1 IDK . 8 ~ ~1 BACK TO 439 FOR NEXT BIRTH; OR, YES . 1 NO . 2 OK . S NUMBER OF TINES . [~ YES . 1 NO . 2 DK . S (SKIP TO 447) (SKIP 10 647) V I V [F NO HORE BIRTHS, SK[P TO 478. YES . 1 MO . . . . . . . . . . . . . . . . . . . . . . . DK . S YES . 1 XO . 2 DK . S NU/4SER OF TIMES . ~'~ YES . 1 NO . 2 DK . S ALZVE ~ DE~ ~ v (SKIP TO ~?) v E 18 I LAST BIRTH NEXT'TO'LAST BIRTH HANE NAHE "T lfl. (WAHE) been '(I w(th YES . 1J YES . l J • fever it ~ tJlIQ tn NO . 2 NO . 2 the lilt 2 weeklT DK . D DK . 8 SECOND- FROq-LAST gIRTH J HANE YES . 1 | NO, . , * , . * . . . . . . . . . . . . . . . . I DK . . . . . . . . . . . . . . . . . . . . . . . 0 --l',.,--'".,,h ,.S . i'" . i'" . il • cough at eny tim In NO . 2 NO . 2 NO . 2 the last 2 WeeksT (SKIP TO /,52)* (SKIP TO ~*S2)q (SKIP TO 452)~ DE . . . . . . . . . . . . . . . . . . . . . . . DK . DK . #*J*9 J Hag (~) beei~ ilL with YES . I YES . 1 YES . 1 I I • c ~ in the Last RO . 2 HO . 2 HO . 2 I 24 h~ra? OK . 8 DR . 8 DE . 8 ¢o~h tasted/did the cough DAYS . DAYS . DAYS . List)? IF LESS THAN 1 DAY, RECORD *DO'. YES . 1 YES . 1 YES . 1 HO . 2 NO . 2 NO . 2 OK . . . . . . . . . . . . . . . . . . . . . . . 8 OK . 8 "YES" IN EITHER 4~7 OR 448 ~TOIHER ! ~THER ) TO 451) YES . 1 YES . 1 NO . 2 NO . 2 (SKIPT04S5). ~ (SKIP TO ~,55)" ~ DK . DK . 451J~1~ (MANE) had the illness with = co~;Oh, did he/she breathe faster than •=l with 8borE, r4p id breaths? $55 | Was anything given to treet I the fever/cough? OK . 8 "YES'* IN EITHER 447OR 448 OTHER TO 4571 YES . 1 NO . (SKIP TO A~5)4 DK . 454 ~1~at Was given to treBt the fever/cough? Anything else? RECORD ALL HEETIOWED. INJECTION . A ANTIBIOTIC (PILL (~ SYRUP) . . . . . . . . . B ANTEHALARIAL (PILL OR SYRUP) . E COdGH SYRUP . D OTHER PILL OR SYRUP . E UNKNOWN PILL OR SYRUP,,,.F H~AE REMEDY/ HERBAL MEDICinE . G OTHER H INJECTION . A ANTIBIOTIC (PILL OK SYRUP) . . . . . . . . . B ANTIMALARIAL (PILL OR SYRUP) . C COUGH SYRUP . D OTHER PILL OR SYRUP . E UNKNOWN PILL OR SYRUP,,,.F HI~IE REMEDY/ HERBAL MEDICINE . O OTHER H INJECTIOP . A ANTIBIOTIC (PILL OR SYRUP) . . . . . . . . . R ANTIMALARIAL (PILL OR SYRUP) . C COUGH SYRUP . D OTHER PILL OR SYRUP . E UHHNONN PILL OR SYRUP.F HCI4E REMEDY/ BERRAL MEDICINE . G OTHER H (SPECIFY) (SPECIFY) (SPEC%FY) 655 I Did you seek advice or YES . 1 I YES . I YES . I I treatment for the I feverlcouQh? NO . 2 1 1 (SKIP TO 4S7)- (SKIP TO 457)q / (SKIP TO 457)q NO . 2 NO . 2 656 Where did you seek i~lvice or treatment? AnYwhere else? RECORD ALL MENTI~¢ED, PUBLIC SECTOR GVT. HOSPITAL . . . . . . . . . . . A PRIMARy HEALIH CENTRE.B DISPENSARY . C OTHER FIXED FAC[L]TY,,.D MOBILE CLINIC . E MEDICAL PRIVATE SECTOR PVT. HOSPITAL . F PVT. HEALTH CENTRE . G DISPEHSARY . H PRIVATE DOCTOR . I PHARMACY . d MOBILE CLINIC . K OTHER PRIVATE SECTOR SHOP . L TRADITIONAL PRACT]TIONER . M OTHER N (SPECIFY) ~USLIC SECTOR CVT. HOSPITAL . A PRIMARY HEALTH CENTRE,.,H DISPENSARY . C OTHER FIXED FACILITY.D MOBILE CLINIC . E HEDICAL PRIVATE SECTOR PVT. HOSPITAL . F PVT, HEALTH CENTRE . S DISPENSARY . B PRIVATE DOCTOR . I PHARMACY . J MOBILE CLINIC . K 3THER PRIVATE SECTOR SHOP . L TRADITIONAL PRACTITIONER . M 3THER N (SPECIFY) PUBLIC SECTOR GVT. HOSPITAL . A PRIHARY HEALTH CENTRE.B DISPENSARY . C OTHER FIXED FACILITY.O MOBILE CLINIC . E MEDICAL PRIVATE SECTOR PVT. HOSPITAL . F PVT. HEALTH CENTRE . O DISPENSARY . H PRIVATE D~TOR . I PHAR~CY . J MOBILE CLINIC . K OTHER PRIVATE SECTOR SHOP . L TRAI}[TIONAL PRACTITI(~WER . M OTHER g (SPECIFY) E 19 183 45? I I Hal (IA~) hid diarrhea In the (mat tw i~eks? LAST BIRTH NEXT-TO-LAST BIRTH NAI4~ NANE I YEs . . . . . . . . . . . . . . . . . . . . . . h T . . ~ (SKIP TO 459)q (SKIP TO 459)q ~ ~--.-- ~ ~ ~2 NO . 2 NO . 2 GO 9ACX YO 439 FOR NEXT t,)ST~; 91, |f NO MOAE SIST~S, SXIP TO ~.78 SECOND-FROM-LAST BIRTH I YES . 1 I I DK . . . . . . . . . . . . . . . . . . . . . . . ~ , . IH . . - - ,h .d , . **h . . YES . . . . . . . . . . . . . . . . . . . . . . ' YES . . . . . . . . . . . . . . . . . . . . . . , IYES . '1 in the laot 2k houri? NO . 2 NO . 2 NO . Z OK . 8 OK . 8 DK . B dlmrrhem tmated/dld DAYS . DAYS . DAYS . the dimrrhea last)? IF LESS THAN 1 DAY, RECO~ '00'. YES T OK . 8 . I /.61 ~l~ thtlrt ~ bLoOd YES . 1 YES . ( in the stoot=7 NO . 2 NO . 2 NO . Z OK . B DK . B (SKIP TO &6S) (SKIP TO 46~) I CHECK 421/E25: YES ~ NO [~ LAST CHILD STILL SREASTFED? v (SKXP TO 465) 463 During (S~IE)'a dimrrhea, did you change the frecNef~y of breastfeeding? YES . 1 (SKIP TO 465)q NO . [~CREASED . 1 or reduce th,, I ~, m (Asl. from brnstmitk) I Was he/she give~ the same SAME . 1 SANE . . . . . . . . . . . . . . . . . . . . . 1 SANE . 1 ~ t to drink as before NORE . 2 MORE . 2 MORE . 2 the diarrhem~ or more, or LESS . 3 LESS . 3 LESS . 3 [eBl? OK . S DK . 8 OK . 8 . i . . i the diarrhea? #0 . 2 NO . 2 MO . 2 (SKIP TO 468)~ (SKIP TO 468)q (SKIP TO 668)q DK . DK . • DK . 467 ~at ~s given to treat the diarrhea? Arqthir~ etse? RECORD ALL MENTIONED. FLUID PREPARED AT HONE FRCI4 ORS PACKET . A ORS PREN%XED IN BOTTLE.B RECOI4NENDED HOME FLU%D.C 'ANTIBIOTIC (PILL OR SYRUP) . D OTHER PILL OR SYRUP . E INJECTION . F (].V.) INTRAVENOUS . G HOKE REMED%ES/ HERBAL MEDICINES . H OTHER ] (SPEC%FY) FLUID PREPARED AT NONE FROM ORS PACKET . A ORS PREMIXED %N BDTTLE.S RECOIqEENDED HONE FLU%D.C ANTIBIOTIC (PIll OR SYRUP) . D OTHER PILL OR SYRUP . . . . . . . . . . . . . . . . . . . E ]NJEET%ON . . . . . . . . . . . . . . . . F (].V.) INTRAVENOUS . . . . . . . G NONE REMEDIES/ HERBAL NED]DINES . H OTHER I FLUID PREPARED AT HOME FROM ORS PACKET . A ORS PREMIXED [B BOTTLE.B RECQk~EEk~ED HONE FLUIO.C ANTIBIOTIC (Pill OR SYRUP) . D OTHER PKLL OR SYRUP . E INJECT(ON . F (I.V.) iNTRAVENOUS . G HONE REHEDIES/ HERBAL NEDiEINES . H OTHER I (SPECIFY) (SPECIFY) I Did you seek advice or YES . 1 YES . 1 YES . 1 I treatment for the . (SKIP TO 470)4 diarrhea? NO 2 NO Z- NO 21, (SKIP TO 470) 4 (SKIP TO 470)~ F ZO 184 1 4P'O 471 Where did you seek advice or treatment? Anyvhere eLse? RECCliIO ALL MENTIONED. CHECK 667: ORS FLUIO FROM PACKET (PREPARED AT HOME OR PRERIXEO IN I~TTLE) MENTIONED? Mas (NAME) given ORS fluid ~de st home from I packet or premtxad in I bottle ~e~ he/she had diarrhea? LAST BIRTH NAME :~JBL I C SECTOR GVT. HOSP]TAL . A PRIMARY HEALTR CER'fRE.B DISPENSARY . C OTHER FIXED EACILITY.D MOBILE CLINIC . E 4EDIONL PRIVATE SECTOR PVT. HOSP]TAL . F PVT, HEALTH CENTRE . G D]SPEMSART . H PR ] VATE DOCTOR . I CHEMIST . J 14061LB CLINIC . E 3THER PRIVATE $ECT~ SHOP . L TRAD [ T IONAL PRACTITIONER . N 3TNER M (SPECIFY) NO, YES, ORS FLUID ORS FLUID NOT MENTIGOED MENTIONED E~ (SKIP TV~0472) V YES . 1 NO . (SHIP TO 473)q | DH . eJ NEXT'TO'LAST BIRTH NAME PUBLIC SECTOR GVT. HOSPITAL . A PRIMARY HEALTR CERTRE.B DISPENSARY . C OTHER FIXED FACILITY.,.D MOBILE CLINIC . E MEDICAL PRIVATE SECTOR PVT. HOSPITAL . F PVT. HEALTH CEHTRE . G DISPENSARY . R PRIVATE DOCTOR . ] CHEMIST . J MOBILE CLINIC . K OTHER PRIVATE SECTOR SHOP . L TRADITIONAL i PRACTITIORER . M 'OTHER R (SPECIFY) NO, YES, ORS FLUID ORS FLUID HOT MENTIONED RENTIONED (SKIP TO 47"~1 v YES . 1 NO . (SKIP TO 4T3)4 / DK . . 5J SEC(X~D'FR~'EAST BIRTH NAME PUBLIC SECTOR GVT. HOSPITAL . A PRIMARy HEALTR CERTRE.B DISPENSARY . C OTHER FIXED FACILITY.O NOB]LE CLINIC . E MEDICAL PRIVATE SECTOR PVT. HOSPITAL . F PVT. HEALTH CENTRE . G DISPENSARY . H PRIVATE DOCTOR . I CHEMIST . J MCQILE CLINIC . K OTHER PRIVATE SECTOR SHOP . L TRADITIONAL i PRACTITIOSER . M OTHER N (SPECIFY) NO, YES, ORS FLUID ORS FLUID HOT flENTIORED 14ENTIORED E~ CSKIP TV[~04721 v YES . 1 NO . 2 (SKIP TO 4T~)~- - - | DH . . . . . . . . . . . . . . . . . . . , . , . 8J 472 For ho~ many days ~as (liAI4£) gLven ORS fluid ? IF LESS THAN ( DAY, RECORD JO0'. I A73 I CHECK 467: RECOJII4ENDED HOME FLUID NENT]ORED? II m 674 ~ MBS (NAME) Q/yen any [ recaNtended home fluid rude from ~atec and rice or from uatar arid mQ/ze meat when he/she had diarrhea? O.B . . . . . . . . . . . . . . . . OAYB . . . . . . . . . . . . . . . . OATH . . . . . . . . . . . . . . . . DK . 98 DK . 98 DK . 98 NO, YES, NO, YES, NO, YES, HOHE FLUID HOME FLUID flO~lE FLUID HOME FLUID HOME FLUID HOlE FLUID NOT MENTIONED MENTIONED HOT MEN]IONED MEMTIONED HOT NENTIORED MEMT]ORED V (SK'P ~[~0 4~' V ~ (SKIP Tv~o 47~) ~ v {SK I P TV[~o '7'5 ) YES . 1 YES . 1 YES . 1 NO . 2 NO . 2 NO . 2 (SKIP TO 477)" ~ (SKIP TO4;XT)" ~ (SKIP TO 4~)4-- ~ OK . DK . OK . 475 Ul~at uaa the main reco~m~er~$ed | he/she had diarrhea? RICE WATER . 1 RICE WATER . 1 RICE MATER~ . 1 hc~ f(uJd That you gave (NAME] DILUTE MAIZE PORRIDGE.2 DILUTE MAIZE PORRIDGE.,.2 DILUTE MAIZE PORRIDGE.,.2 I when FERMENTED MAIZE FERMENTED MAIZE FERMENTED MAIZE PORRIDGE . 3 PORRIDCE . 3 PORRIOGE . 3 OTHER 4 OTHER 4 OTHER 4 ('76 | For how many days ~as (NAME) I gJv~ (THE FLUID MENTIONED IX 4;'5 J? IF LESS THAN 1 DAY, RECORD '00'. DAYS . . . . . . . . . . . . . . . . AYS . . . . . . . . . . . . . . . . OAFS . . . . . . . . . . . . . . . . DK . 98 K . 98 DK . 98 GO BACK TO 439 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 47B F 21 185 SKIP NO. QUESTIORS AND FILTERS CO01RG CATEGORIES TO 47 CHECK 467 AHO 471 (ALL COLU~S): ERS COOING CATEGOR]ES I TO CHILD (EITHER PREPARED ORS FLUID FR[~4 A PACKET AT HONE OR PRENIXED IN BOTTLE) HOT GIVEN TO ANY CHILD R TLE) (El A ED) (EITHER PREPAID OR PREMIXED) T v 479 HaVefLuidYOUyoueVercan getheardfor°f thea specialtreatmentProdUCtof diarrhea?CatLedoRS I| NOTES . . 21 1,481 i HIVe you ever Been a packet Like thLs before? ~ YES . 1 I I I g SHOM PACKEE. NO . 2 *485 /.81 I Have you ever pre#~ared = $olutio~ with o¢1e of these YES . 1 I packets to treat diarrhea tn y~rseLf or s~e else7 m I NO . 2 .4fl4 SHO~PACKET. m i The Last til you prepared the ORS fluid, did you WHOLE PACKET AT ONCE . 1 m I prepare the whole packet at o~e or only part of I the pocket? PART OF PACKET . 2 ~484 I HOW much ~ter did you ~e to prepare ORS fluid the Last time you made it? 1\2 LITER . 01 1 LITER . 02 1 1\2 LITERS . 03 1 COKE BOTTLE . 04 2 COKE BOTTLES . 05 3 COKE BOTTLES . 06 1 ORS CUP . 07 2 ORS CUPS . OD 3 ORS CUPS . 09 FOLLOWED PACKAGE INSTRUCT[ONS.lO OTHER lJ (SPECIFY) OK . 98 484 ~Jhara can you get the ORS packet? PRO6E: Anywhere else? RECORD ALL PLACES NENTIORED. PUBLIC SECT(~ GVT. HOSPITAL . A PRIMARY HEALTH CENTRE . B DISPENSARY . C OTHER FIXED FACILITY . D HOSILE CLINIC . E MEDICAL PRIVATE SECTOR PVT. HOSPITAL . F PRIMARY HEALTH CENTRE . G DISPENSARY . H PRIVATE DOCTOR . [ CHEMIST . J MOBILE CLINIC . K OTHER PRIVATE SECTOR SHOP . L TRADITIORAL PRACTITIOREH . N OTHER N (SPECIFY) OK . 0 F 22 186 CHECK 467 ANO 474 (ALL COLUMNS): RECOHMENDED HOME FLUID EECOI~4ENDED Lr-J NOT GIVEN TO AMY CHILD HCME FLUID GIVEN / OR TO ANY CHILD 467 AND 474 NOT ASKED ~501 486 WIlere did you Learn to prepare (FLUID MENTIONED ]N 47"5) given to (NAME) when he/she had diarrhea? RECORD ALL PLACES MENTIONED PUBLIC SECTON GVT. HOSPITAL . A PRIMARY HEALTH CENTRE . $ DISPENSARY . C OTHER FIXED FACILITY . D MOBILE CLINIC . E HEDICAL PRIVATE SECTI3~ PVF. HOSPITAL . . . . . . . . . . . . . . . . . F PRIMARY HEALTH CENTRE . G DISPENSARY . H PRIVATE DOCTOR . I CHEMIST . J MOBILE CLINIC . K OTHER PRIVATE SECTOR St~3P . t TRADIT%OHAL PRACTIT]ONER . N OTHER N F Z3 i87 SECTION 5. MARRIAGE NO. I (~JEST'ONS AND FILTERS I m J I I SKIP COOING CATEGORIES I TO m YES . 1 I | NO . 2 •601 I- . . " widowed, divorced, or no tonger living together? LIVING TOGETHER . 2 U] DOe~ED . 3 / DI VGRCED 4 ~507 SEPARATED . . . . . . . . . . . . . . . . . . . . . . 5 / °1 I _ . . I ~ I o - ,~ ~°--"r"~'"'°~°'~'~"""~" I '" ,~ . . , , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' l NO . 2 P507 DK . 98 •507 ~1 .e~ ~ j I ''~' . ~1 I . . '1 . . . . I I . . 510 I YES NO r--1 I I CHECK 508 AND 5D9: YEaR AWO ~_~ AGE GIVEN? 511 CHECK CONSISTENCY OF 508 AND 509: YEAR OF BIRTH (105) PLUS + AGE AT MARRIAGE (509) ~-~ CALCULATED ~-~ YEAR OF MARRIAGE IF NECESSARY, CALCULATE YEAR OF BIRTH CURRENT YEAR MINUS CURRENT AGE (106) CALCULATED ~-~ YEAR OF BIRTH KS THE CALCULATED YEAR OF MARRIAGE WITHIN ONE YEAR OF THE REPORTED YEAR OF MARRIAGE (508) ? YES N • CONTINUE TO 601 7 v NO PPROBE AND CORRECT 508 AND 509. 188 e 24 ~i[CT~ON 6. FEATII,|TY PReFeRENCES SKIP 602 CHECK 223: MOT PREGNANT OR UNSURE [~ go~ I have some questions about the future. ~ould you l ike to have (a/another) child or would you prefer not to PREGNANT [~] I V NOW I have soene questions about the future, After the child you are expecting, would you Like to have another chl|d or have any (more) children? wOULd you prefer not to have anymore children? HAVE A (ANOTHER) CHILD . 1 NON ORE/goRE . . . . . . . . . . . . . . . . . . . . 2 - - SAYS SHE CANmT GET PREGNANT . 3 UNDECIDED OR OK . 60.] CHECK 223: NOT PREGHANTORUNSURE [~] HO,,+ long wOULd you like to uait from now before the birth of (a/another) child? 604 CHECK 216 ANg 223: HAS LIV[NG CHILO(REN) YES OR PREGNANT? E~ v 605 CHECK 223: gOT PREGNANT OR UNSURE [~ / Hou old would you Like your youngest child to be when your next child i# born? PEEGNA%T How long would you like to wait after the birth of the child you are expecting before the birth of another child? NO F7 PREGNANT [~ How oLd v~uLd you Like the child you are expecting to be uhen your next child is born? MONTHS . 1 J ] J~ YEARS . 2 609 OTHER 996 I (SPECIFY) DK . 998 I p~9 I AGE OF CH#LD I-'-I--7 I :::::::::::::::::::::::::::::::: I °[ °'++"+'c+r--'s' +'++'°+i' I*Es . '1 over again, do you think (you/your husband] would make the same decision to have an operatlon not to have NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ny more children? + i oo++ +++r-- + +r" I * + , o ++ + + + + + . I NO . 2 P614 608 E#hy do you regret it? RESPONDENT ~ARTS ANOTHER CHILD.1 PARTNER I~AMTS ANOTHER CHILD . SIDE EFFECTS . 3 614 OTHER REASOI~., (SPECIFY) I F 2S 189 SKIP I I 610 I Do you think that your husband/partner approves or I APPROVES . 1 I disapproves of couples using a method to avoid I D[SAPPROVES . 2 pr~y? OK . 8 611 I How often have yo~J talked to your husband/partner about I NEVER . 1 I chftdopaclng in the past year? I {~CE OR TWICE . 2 140RE OFTEN . 3 612 I Have you and your hud:and/pertner ever discussed I YES . 1 I the rumber of children you bm~Jtd Like to have? I BO . 2 RUlffDer of children that you want, or does he want more MORE CHILDREN . 2 or f~,~r than you want? FEWER CHILDREN . 3 DK . .,.,,, . I 614 I How Long should a couple wait before starting sexual I intercourse after the birth of a baby'/ HONTHS . 1 YEARS . Z OTHER 996 (SPECIFY) I I 6,s I should • .Eher wait =t i t she has c~leteLy s to~d I . , , T . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 I breaitfeeding before starting to have sexual relations I again, or doesntt it matter? DOESN'T MATTER . 2 616 I Xn general, do you approve or disapprove of couples I APPROVE . 1 I using a method to avoid Retting pregnant? I DISAPPROVE . 2 617 CHECK 216: HAS LIVXNG CHILD(HEN) [~ / If you could go beck to the time you did not have any children and could choose exactly the num~r of children to have in your whole Life, how many ~.~Jtd that be? NO LIVING CH1LDREN[~ If you could choose exactly the number of children to have in your whole life, how a.any wo~td that be? RECORD SINGLE NLINBER OR OTHER ANSgER. NUMBER . OTHER ANSMER 96 (SPECIFY) I 618 | ghat do you think iz the best number of months or ] years between the birth of DOte child and The birth of the next child? I MONTHS . 1 YEARS . Z OTHER 996 (SPECIFY) F 26 190 SECTION 7. HUSBAMD*SDACKGROGND ANO I~I4AN'SWORK SKIP 140. QUESTIOgs AND FILTERS I COD ENG CATEGORIES TO 701 CHECK 501: EVER MARRIED NEVER )tARRIED/ C~ LIVED NEVER LIVED TOGETHER E~ TOGETHER ¥ ASK QUESTIONS ABOUT CURRENT OR frOST RECENT HUSBAND/PARTNER. D710 I 702 Did your (last) h=band/bartner ever attend school? J YES . 1 J I I NO . 2 P707 703 I/nat was the highest Level of school he attended: I PRIMARy . 1 primary, secondary, or hLgher? I SECONDARY . 2 HIGHER . OK . 8 "707 704 I How many yesrs °f sch°°L dLd he c°mpLete at that teveLT [YEARS DK . . ~-~ I 98 706 CHECK 703: J SECONDARY PRIMARY []] = HIGHER C--] .r07 Is your husbend/bartr~=r able to read and understand Er~ilLish or Chichewa easily, with difficulty, or not et all? I EASILY . 1 WITH DIFFICULTY . 2 NOT AT ALL . I 707 | llhat kind of work does (did) your J (Last) husband/bartr~r mainly do? 708 709 CHECK 707: WORKS (WORKED) E~ IN AGRICULTURE V DOES (OIO) NOT WORK [~ (g AGRICULTURE (Does/did) your husband/partner work mainly on his own Land or family Lend, or (does/did) he rent Land, or (does/dLd) he work on someone eLse'e Land? I HIS/FAJ41LY LAND . 1 RENTED LAND . 2 SOMEONE ELSE=S LAND . ] ,710 I 710 Aside from yOUr OWn hou4;ework, are you currently working? I ; YES . 1 ,`712 711 As you know, some Women take up jobs for which they nre baid in cash or kind. Others sell things, have a small business or work <~ the fatnlly farm or in the fa~i ty business. Are you currently doing any of these things or any other work? I YES . 1 I I HO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 P801 E 27 191 NO. J OUESYIORS AMO FILTERS i 712 J llhat is your occupation, that |s, I what kind of work do you do? I COOING CATEGORIES I SKIP m TO I I ++'LY- . '1 famLty, for somm~t~ else, or ere you self-employed? FOR SOHEONE ELSE . 2 SELF-EMPLOYED . I ° °++°++++ I + . I PROBE: Do you make money for working? NO . 2 715 I DO you do this wOrk at home or a~ay From home? I 717 | UhLte you ere working, do you usually I have (NAME OF YOUNGEST CHILD AT HOME) with you+ sometimes have him/her with you, or ~vffr have him/her with you? I HOME . 1 i AWAY . 2 NO [-7 I USUALLY . 1 SOMEFIMES . 2 NEVER . ] iI .BOl i I P801 I 718 Uho usually tskes care of (NAME OF YOUNGEST CHILD AT HOME) ~|te you are working? HUSBAND/PARTNER . 01 OLDER CHILD(SEN) . 02 CH]LDIS GRANDPARENT(S) . 03 OTHER RELATIVES . 04 REIGHDOURS . OS FRIENDS . 06 SERVANTS/HIRED HELP . 07 CHILD IS ]N SCH~L . 08 INSTITUTIONAL CHILDCARE . 09 OTHER 10 (SPECIFY) F 28 192 SECTION B, AIDS KNONLEDGE "" I QUESTIONS AND FILTERS I 801 I NOtJ I h,va , fetA q~estio~ about a very important topic. I Nave you heard of an illness catted AIDS? SKJP COOING CATEGORIES ~ TO YES . 1 J T. NO . 2 S~ 802 FrOm which s~rces of |nformtion or persons have yo~ heard about AIDS in the last month? CIRCLE ALL MENTIONED. RADIO . A NEWSPAPERS . B HEALTH WORKERS . C MOSQUES/CHURCHES . D FRIENDS/RELATIVES . E SCHOULS/QURAN TEACHERS . F BOOKLETS/PAMPHLETS/POSTERS . G COHMUN]TY MEETINGS . N OTHER I (SPECIFY) NOHE . J 803 NOW Is AIDS t r~ I t t~ CIRCLE ALL ~GENTIONED. SEXUAL INTERCOURSE . A NEEDLES/BLADES/SKIN PUWCTURES.B MOTHER TO CHILD . C TRANSFUSIOR OF INFECTED BLOQD.,D OTHER E (SPECIFY) DOn'T KN~ . . . . . . . . . . . . . . . . . . . . . . F 804 Do you think that you can get AIDS fr~ shaking hands with someone who has AIDS? h~gfng someone who has AIDS? kissing s~'~or~ w~o has AIDS? ~arinQ the clothes of someone who has AIDS? sheri~ eating utensils with someone who has AIDS? stepping on the urine or stool of s~neone with AIDS? mosq~Jito, flea Or ~ bites? YES NO DE HANDSHAKING . 1 2 8 HUGGING . 1 2 8 KISSING . 1 2 8 SHARING CLOTHES . I 2 S SHARING EATING UTENSILS.,.1 2 8 STEPPING ON URINE/STOOL,.,1 2 8 MOSQUiTO/FLEA/BEDBUG BITES.1 2 8 ' ' ' ' I . '1 to be infected with the AIDS virus? NO . 2 DK . S Rive birth to a child with the AIDS virus? NO . 2 DE . . . o . S 80, ) DaD, ~r= ~ro cot her.,If or hL--If f r ~ . t t i ~ AIDS? I TEa . J NO . 2~8(Y~ BOB NO~ can a person protect herself or himGe[f from gettir~ AIDS? CIRCLE ALL NENTI(X~ED DO NOT HAVE SEX AT ALL . A LIMIT NO. SEXUAL PARTNERS . S USE CONDOMS DURING SEX . C STERILIZE SYRINGES/NEEDLES . O AVOID PROSTITUTES . E OTHER F (SPECIFY) 8O9 If your relative is suffering with AIDS, who wouLd | RELATIVES/FRIENDS . 1 yo~J prefer to care for him or her? I GOVERNHEHT FACILITY . 2 RELIGIOUS ORG./MISSION . ] NOBODY/ABANDON . G OTHER S (SPECIFY) F~ 193 901 SECTION 9. MATERNAL HORTA~ITY Wow I would Like to ask you some questions ebout your brothers iwld sisters, that is, aLL of the children born to yo~Jr natural mther, IncLuding those who ere living with you, those tivieg elsewhere, end those who have died. How ~ children did your mother give birth to, including yo~Jrsetf? CNEC~ 901: TWO OR MC~E BIRTHS ONLY ONE BIRTH (RESPONDENT ONLY) I I • SKIP TO SECTI(~ 10 90] HOW nmny of these births did your mother have before you were NUMBER OF born? PRECEDING BIRTHS . L I J [1 ] J [Z ] I3] 14) [5 ] (6 ] I7] 904 I~at Was the neme given to your oldest I (next oldest) brother or . sister? i i = i i i 905 [i (MANE) HALE . 1 HALE . 1 HALE . 1 MALE . 1 MALE . 1 MALE . 1 MALE . 1 male or female? FEMALE . 2 FEMALE . 2 FEMALE . 2 FEMALE . ~' FEMALE . 2 FEMALE . 2 FEMALE . 2 i [ [ i i i i i 906 Is (NAME) YES . 1 YES . 1 YES . 1 YES . 1 YES . I YES . 1 YES . 1 stilt alive? NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 GO TO 90e<] 60 TO 908< ] GO TO 908<] GO TO 908< ] GO TO 908< ] GO TO 908<] GO TO 908<] DK . DK . OK . DK . 8 DK . DK . GO TO [2]< 8] GO TO [3]< 8~ GO TO 14] (~] GO TO [5]'] GO TO I6]< 8] BK~'iO'i~( ~] GO tO [0]< 8] GO TO [2] GO TO [3] GO TO [4] GO TO [5] GO TO [6] GO TO [7] GO TO [0] 908 HOW many INANE ) die? 909 Hoe old eas (k~ME) When she/he died? ==¢======~==== 910 Was (BANE) pregnant when i she died7 I IF HALE OR DIED BEFORE 10 YEARS OF AGE GO TO 12] = = == =_- YES . 1 GO TO 913~ ~] NO . 2 rT3 IF HALE OR DIED BEFORE 10 YEARS OF AGE GO TO I3) =z= == == YES . 1 GO TO 913< '] NO . 2 I IF HALE OR IF HALE OR DIED BEFORE lC ~[ED BEFORE 10 YEARS OF AGE YEARS OF AGE GO TO [4] GO TO [53 ==========~=== ============~ YES . 1 YES . 1 GO TO 913~ ~ GO TO 913( ~] i NO . 2 NO . 2 I F HALE OR DIED BEFORE 10 YEARS OF AGE GO TO 16] =========_-=_-== YES . 1 GO TO 913< ~] WO . 2 IF HALE OR DIED BEFORE 10 YEARS OF AGE GO TO [7] ===~== = YES . 1 GO TO 913< '~ NO . 2 IF NALE OR DiED BEFORE 10 YEARS OF AGE GO TO [B] _- _-= _- = YES . 1 GO TO 913< ~ WO . 2 911 Did (BANE) YES . 1 YES . 1 YES . 1 I YES . 1 YES . 1 Yes . 1 YES . 1 die during GO TO 913~ ~] GO TO 913~ ~ GO TO 913~ ~ GO TO 913< ~] GO To 913< ~] GO TO 913< ~ GO TO 913< '1 childbirth? i I NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 MO . 2 i 912 Did (NAME) die within six YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 weeks after the ~ of a i NO . 2 NO . 2 NO . 2] NO . 2 NO . 2 NO . 2 NO . 2 pregnancy or GO TO [21, ~] GO TO [31< ~ GO TO I41< ~ GO TO [51< ~] GO TO 161< ~-] GO TO [~J<~] GO TO [B), ~-] cbi tdbi rth? 913 Bow rainy chiidren had I birth to before that pr egr~)ncy? F 3O 194 (8] [93 (103 [11] [12] [13] (14] 90& Uhat war the name given to your oldest I (next otdeit) I lister?bY°theY or . . . . . . . . . . . . . . . . . . . . . . . . . . . . l . . . . . . . . . . . . . . ! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . is (RN4E) MALE . 1 MALE . 1 I MALE . 1 I MALE . 1 MALE . 1 MALE . 1 MALE . 1 ~Le or I i file? FEMALE . 2 FEMALE . 2 / FEMALE . 2 I FEMALE . 2 FEKALE . 2 FEMALE . 2 FEMALE . . . . . 2 L i li (DAME) YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 sti[[ i|(ve? NO . 2 NO . 2 I NO . 2 ! NO . 2 NO . 2 NO . 2] NO . 2 GO TO ~a,] GO TO 908< ] GO TO ~Oe, ] GO TO 908< ] GO TO ~Oe<] GO TO 90a~J GO TO ~Oe<] I DK . OK . DK . D~ . . . . . . . . . os . . . . . . . . . ~ ' ia ' i i~ i~ Go Yo [1~]5 GOYo [1 , ]~ GoYo [1 .~ D~ia i i i~ Go To (10]~ GO ,o [11]~ o~ i 907 Ro~ old Is GO TO [93 GO TO [10J GO TO [11] I GO TO [12] GO TO [133 ~ TO Ilk] CO TO [151 908 HO~ m~ny (NAME) die? L , i 909 R~ Did I i I-r-i she/he diecr~ , ~I0 UeS (NA/~) preDnant when she died? IF MALE OR DIED BEFORE 10 YEARS OF AGE GO TO [93 ilsslliwzlxsw= YES . I GO TO 913< '] SO . 2 children had [NAME) glveh birth to before that pregnRrcy? IF MALE OR DiED BEFORE 10 I YEARS OF AGE GO TO [10] =:SSS=Z:IUSSt ZZSX YES . [ GO TO 913< '~ NO . 2 IF MALE OR I 3lED BEFORE 101 YEARS OF AGE GO TO [11] x=szI===i=====l YES . 1 GO Yo ~1~;1! NO . 2 I ] F MALE OR DIED BEFORE 10 YEARS OF AGE GO TO [12] = = = = --== = s == = =~ YES . 1 GO TO 913< '] NO . 2 IF MALE OR DIED BEFORE 10 YEARS OF AGE GO TO [13] === === == = YES . I TO 913< ~] NO . 2 IF MALE OR DiED BEFORE 10 YEARS OF AGE GO TO [14] =====~====w=.s YES . I GO TO 913< ~1 NO . 2 IF HALE OR DIED BEFORE 10 YEARS OF AGE GO TO (15) ==l==z=u====== YES . 1 GO TO 913< ~ NO . 2 , , p ;)11 Did (NAME) YES . ,~1 YES . ,~1 I YEEGo . TO 913<, ]_1 GO TO 913( '~- GO TO 913< '~- GO TO 913< ''~- YES . 1 YES . 1 YES . 1 YES . 1 die during GO TO 913( -4 GO TO 913< ~ GO TO 913<~]l [hi [dbfrth? I GO . 2 NO . 2 NO . 2 I NO . 2 NO . 2 NO . 2 NO . 2 I i i [ 1 912 Did (NAME) I die within six YES . 1 YES . 1 YES . 1 I YES . 1 YES . 1 YES . 1 YES . 1 ~eeks after the end of a NO . Z NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 pregnancy or GO TO [9]<~ GO TO [IO]<~ GO TO [1U< ~ GO To [Iz]< -~] Go TO [13]< ~ GO ro (14]<~ GO ro [151< -`] chi [dbi rth? h P13 HO~ litany RECORD THE TJME, F 3~ 195 SECTION 1O. NEIGN~ AR~ ~EIGHT CHECK 222: ORe OR MONE OIRTNS NO DZRTHS SINCE JAN. 1987 [~ SINCE JAN, 1987 • END INTERVIEWER: IN 1002 (COLUMNS 2-4) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE JANUARY 1987 AND STILL ALIVE. IN 1003 AND 1004 REOORD THE MAJlE AND BIRTH DATE FOR THE RESPONDENT AND FOR ALL LIVING CHILDREN BO~N SINCE JANUARY 19B7. IN 1006 AND 1008 RECORD HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN. IN 1009 RECORD THE ARM CIRCUMFERENCE OF THE RESPONDENT AND LIVING CHILDREN. (MOTE: ALL RESI~3NDENTS WITH ONE ON NONE BIRTHS SINCE JANUARY 1987 SHOULD BE UEIGHED AND MEASURED EVEN IF ALL OF THE CHILDREN HAVE DIED. IF THERE ANE MORE THAN 3 LIVING CHILDREN BORN SINCE JANUARY 1987, USE ADDITIONAL FONMS). 1002 LINE NO. FRON 0.212 1003 IUU4E FRON O.212 FON CHILDREN ~004 DATE OF BIRTH FROM O,lO5 FOR RESPONDENT FROM Q.215 FOR CNILDRENj AND ASK FON DAY OF BIRTH 1005 BCG SCAR ON THE RIGHT UPPER ARM 1006 HEIGHT (in centimeters) 1007 WAS HEIGHT/LENGTH OF CHILD MEASURED LYING O0~W OR STAMDING UP? 100,8 WE IGNT (in ki tooramm) 1009 ARM CIRCUMFERENCE (~n centimeters) 1010 DATE WE IGHED AND MEASURED L~] RESPONDENT L2J YOUNGEST LIVING CHILD ( NAME ) (NANE) DAY . k~)NTH,,.~ MONTH . YEAR . YEAR . NT1N K RS DAY . MONTH . YEAR . 1011 RESULT 1012 MANE OF MEASURER: MEASURED . 1 NOT PRESENT.3 REFUSED . 4 OTHER . 6 (SPECIFY) SCAR SEEN . 1 NO SCAR . 2 LYING . 1 STANDING . 2 DAY . MONNTH . YEAR . CHILD MEASURED.1 CHILD SICK . 2 CHILD NOT PRESENT . 3 CHilD REFUGED.4 MOTHER REFUSED.S OTHER . 6 (SPECIFY) NAME OF ASSISTANT: NEXT-TO- ~ SECOND - TO- YOUNGEST Y~NGEST LIVING CHILD LIVING CHILD (NAME) (NAME) MONTH . ~TH . TEAR . YEAR . SCAN SEEN . 1 SCAR SEEN . 1 NO SCAR . 2 NO SCAR . 2 LYING . 1 LYING . 1 STANDING . 2 STANDING . 2 KT.D DAY . MONTH . MONTH . YEAR . YEAR . CHILD MEASURED.1 CHILD MEASURED.1 CHILD SICK . 2 CHZLD SICK . 2 CHILD NOT CHILD NOT PRESENT . 3 PRESENT . 3 CHILD REFUSED.4 CHILD REFUSe.4 MOTHER REFUSED,5 MOTHER REFUSED,5 OTHER . 6 OTHER . 6 (SPECIFY) (SPECIFY) K7 T 32 196 INTERVIEWER'S OBSERVATIONS (To be filled in after completing interview) Comments About Respondent: Comments on Specific Questions: Any Other Comments: SUPERVISOR'S OBSERVATIONS Name of Supervisor: Date: EDITORIS OBSERVATIONS F 33 197 MALAWI DEMOGRAPHIC AND HEALTH SURVEY MALAWI GOVERNMENT - NAT IONAL STAT IST ICAL OFF ICE INDIV IDUAL OUEST IONNAIRE MALE FORM MDHS-M/9 2 IDENT IF ICAT ION REGION/DISTR ICT TA/STA/TOWN ENUMERATION AREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V ILLAGE OR PLACE MDHS CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i URBAN~RURAL (urban=l, rural=2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME AND L INE NUMBER OF MAN NAME AND LINE NUMBER OF WIFE # 1 NAME AND LINE NUMBER OF WIFE # 2 NAME AND L INE NUMBER OF WIFE # 3 (NOTE: inc lude on ly w ives in household) INTERVIEWER VIS ITS 1 2 3 F INAL V IS IT DATE INTERVIEWER'S NAME RESULT* NEXT VISIT: DATE T IME * RESULT CODES: 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER DAY MONTH YEAR NAME RESULT TOTAL NUMBER OF V IS ITS (SPECIFY) NAME DATE II F IELD EDITED BY OFF ICE EDITED BY KEYED BY 199 N1 wo. I I 101 I RECORD THE FINE. 102 103 104 SECTION 1. RESPONDENT'S BACKGROUND ~JESTIONS AND FILTERS First I would Like to ask $~ questions at~t you and your household. FOr nK)st of the tinge until you were ab~Jt 12 years old, did you live in a city, in a town, or in a vttlage? SKIP C~lNS CATE~LE$ I ,o 1 CITY . I TOaN . 2 VILLAGE . 3 HOW l o~g have you been tiring co~tlr~ously in (NAME OF CURRENT PLACE OF RESIDENCE)? Just before yoJJ moved here, did you live in a city, in a town, or in a village? I l YEARS . [--~ ALWAYS . 9~ VISITOR . 96~105 CITY . 1 T(JWN . VILLAGE . 3 105 In what month ar=:J year were you born~ MONIH . ~ ] DK MONTH . . . . . . . . . . . . . . . . . . . . . . . 98 YEAR . [ ~ DK YEAR . 98 I 106 I Now old were you at your last birthday~ I C~PARE AND CORRECT 105 AND~OR 106 IF INCONSISTENT. 107 J Have you ever attended school? I AGL IN COMPLETED YEARS . ~]~ I YES . 1 I NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 P111 I I 108 I ~nat is the highest level of school you atterhded; | PRIMARY . 1 I primary, secondary, or higher~ j SECONDARY . 2 HIGHER . 3 109 I How many years of school d~d you con~)lete at that J I level? I SECONDARY OR HIGHER [~ I I 111 J Are you able to read and understand English or Chichewa | I easily, with difftculty, or not at all7 I I 112 | DO you usually read a newspaper or magazine at least I once a week? YEA S . I'''' I I EASILY . 1 I I WITH DIFFICULTY . 2 NOT AT ALL . 3 .113 NO . 2 113 I DO you usually listen tO a radio at Least once a weok 9 J YES . I NO . 2 M2 200 116 [ .o. I QUESTIONS AND FILTERS 114 I#nat kind of work do you nmmly do? 118 E• DOES NOT WORK IN [~ AGR I CULTURE v I COOING CATEGORIES I SKIP I To Do you work mainly on your own land or f~ily's [and, ~ O W N / F A H I L Y LAND . 1 or on land that you rent, or o~ sor~one e[se's land? RENIED LAND . 2 SOMEONE ELSE=S LAND . ] CHECK O.4 IN THE HOUSEHOLD QUESTIONNAIRE I I THE MAN INTERVIEWED IS NOT A THE NANN~ED IS A USUAL RESIDENT I ~ I N T E R V I E W E D A USUAL -- USUAL RESIDENT ~---~_ ,201 ROW I would like to ask about the place i n which yOU usually live. Do you usually Live in a city, in a town, or in a CITY . 1 v i L tage? TOUN . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 VILLAGE . 3 I 119 1 In which region is that Located? NORTH . 1 I CENTRAL . Z SOUTH . 3 OUTSIDE MALAW[ . . . . . . . . . . . . . . . . . 4 I 120 What is the source of water your household uses ,122 for handwash~ng and dishwashing~ ~122 PIPED WATER PIPED INSIDE DWELLING UNIT .,11 PIPED INTO YARD/PLOT . 12 PUGLIC TAP . . . . . . . . . . . . . . . . . . . . ~] WELL WATER PROrEEIED WELL/BOREHOLE . 21 UNPROTECTED NELL . 22 SURFACE WATER SPR ING . . . . . . . . . . . . . . . . . . . . . . . . 31 R IVER/STREAM . . . . . . . . . . . . . . . . . . 32 POND/DAM . . . . . . . . . . . . . . . . . . . . . 33 LAKE . 34 RAINNATER . 41 OTHER 71 (SPECIFY) ,122 I I 121 | HOW tong does i t take to go there, get water, I and c~e back~ ) I 122 I Does your household get drinking water I fr~n this same source? J MINUTES . [ ~ ON PREMISES . 996 OK . . . . . . . . . . . . . . . . . . . . . . . . . . . . 998 I ; Y~S . 1 ~'124 NO . N3 201 NO. QUESTIONS AND FILTERS 123 What is the source of drinking water for n~nloers of your household? COOING CATEGORIES PIPED WATER PIPED INSIDE DWELLING UNIT .11 PIPED INTO YARD/PLOT . 12 PUBLIC TAP . 13 WELL WATER PROIECTEO WELL/BOREHOLE . 21 UNPROTECTED WELL . 22 SURFACE WATER SPRING . 31 RIVER/STREAJ4 . 32 POND/DAM . 33 LAKE . 34 RAINWATER . 41 OTHER ~T (SPECIFY) SKIP TO 124 What klnd of toltet facitity does your househotd have? I 125 I D~s your household have: I Etectriclty? A radio? A parrafin tamp? 126 I Row many roo¢~ in at( of the dwe(llng units of your I household are used for sleeping? I 127 ~ Does any member of your househotd own: I A bicycte? A motorcycte? A Car? An oxcart? 28A At your own house, What is the wain material that the Floor Is made from? NOTE: IF HIS HOUSEHOLD LIVES IN MORE THAN ONE DWELLING UNIT AND THE DWELLING UNITS DIFFER IN FLOUR MATERIALS, ASK FOR THE FLOOR MATERIAL OF THE THE DWELLING OF THE HEAD OF HOUSEHOLD. 28B At your own house, what is the rnaln material that the roof is made from? MOTE: IF HIS HOUSEHOLD LIVES IN MORE THAN ONE DWELLING UNIT AND THE DWELLING UNITS DIFFER IN ROOF MATERIALS, ASK FOR THE ROOF MATERIAL Of THE THE DWELLING OF THE HEAD OF HOUSEHOLD. FLUSH TOILET O~N FLUSH TOILET . 11 SHARED FLUSH TOILET . 12 PIT LATRINE TNADIEIONAL PIE LATRINE . 21 VENTILAIED IMPROVED PIT (VIP) LATRINE . 22 RO FACILITY . 31 OTHER 41 (SPECIFY) ELLCIRICITY . 1 2 RADIO . I 2 PARRAFIN LAMP . I 2 ROOMS . r ~ I YES NO I BICYCLE . T 2 MOTORCYCLE . T 2 CAR . 1 2 OXCART . I 2 I MUO/EARTH FLOOR . 11 i FINISHED FLOOR i CEMENT . 31 i BRICKS . 32 ] wood . 33 TILES . 34 OTHER 41 (SPECIFY) GRASS THATCH . I IRON SHEETS . 2 IRON AND TILES . ] ASBESTOS . 4 CEMENT . 5 . 6 OTHER 7 (SPECIFY) N4 202 SECTION 2 MARRIAGE ~dO. ~ O~ESTIOblB AND FILTERS 201 l Have you ever 1oeen married or Lived with a woe~n? I SKIP I CODIBG CATEGORIES I TO i . m NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 P3Ol 202 I Are y~ now ~rried or tivin~ with a w~n, or are you m I nou widowed, divorced, or no Longer livir~l to9ether? I I MARRIED . 1 | I LIVING TOGETHER . . . . . . . . . . . . . . . . . 2 WIDOWED . DIVORCED . ~204 SEPARATED . 5 I 203 I Row mny wives ® you have? I CHECK CONSISTENCY WITH COVER PAGE 2O4 2O5 I 2~ 207 In what ~nth arid year did y~ start [lying with your (first) wife/~rtner? Now old were yo~J when you starte(I living with her? CHECK 204 AND 205: YEAR AND AGE YES GIVEN 9 ? v CHECK CONSISTENCY OF 204 AND 205; NO D YEAR OF BIRTH (105) PLUS AGE AT MARRIAGE (205) CALCULATED ~ ] YEAR OF MARRIAGE RUHBER . . . . . . . . . . . . . . . . . . . . . ~ '~ MON,. . . . . . . . . . . . . . . . . . . . . . . 113 DK MONTH . 98 YEAR . 117 OK YEAR . 98 A~E . . . . . . . . . . . . . . . . . . . . . . . . DK AGE . . . . . . . . . . . . . . . . . . . . . . . . . 98 IF NECESSARY, CALCULATE YEAR OF BIRTH EORRENTYEAR F~A MINUS CURRENT AGE (106) [ ~ CALCULATED ~-~ YEAR OF BIRTH IS THE CALCULATED YEAR OF MARRIAGE WITHIN ONE YEAR OF THE REPORTED YEAR OF MARRIAGE (204) ? YES NO [--~ "PROBE AND CORRECT 204 AND 205. CONTINUE TO 301 J 301 M5 203 $[CTION }. N~TH~S OF CHILDSPACING I 301 NOW I would like to talk about chiLdspacing - the varic, Js ways or methods that a couple can use to beLay or avoid a pregnancy. Which ways or methads have you heard about? CIRCLE CODE 1 IN 302 FOB EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DaRN THE COLONN, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT NENTIONED SPONTANEOUSLY. CIRCLE CODE 2 [F NETNOD IS RECOGNIZED, AND CODE 3 ZF NOT RECOGN[ZED. THEN~ FOR EACH NETHOD WITH CODE 1 OR 2 CIRCLED IN 302, ASK 303-304 BEFORE PROCEEDING TO THE NEXT NETNCO. 11 PILL Wo*nen can take a pill every day. 21 IUCD WO~ can have a [cop or coil placed inside them by a doctor or a rvJrse. O• INJECTIONS Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months. ~] DIAPHRAC~4,F~,JELLY W~n can place a Sl:q~ge, s%~oository, diaphrsgm, jetty or cream in- side them before interc(~Jrse. .• CONDOM Men can use a ruk~er sheath duri~B sexual inter- course. ~_J FE~LE STERILIZATION WOrn can have an operation to avoid havir)g any more children. ~LE STERILIZATION Hen can have an operation to avoid having any ~re children. 0 8 j NATURAL METHOD CoupLes can avoid having sexual intercourse c~1 certain days of the month when the woman is more Likely to becoa~e pregnant. WITHDRAWAL Men can be careful arx:l p~ll out before clin~ax, 01 Nave you heard of any other ways or methods that women or ¢nen can use to delay or avoid pregnancy? (SPECIFY) 2 (SPECIFY) 3 (SPECIFY) 302 Have you ever heard of (NETHCO)? READ DESCRIPTION OF EACH METHOD. YES/SPONT . 1 YES/PROBED . 2 NO . 31 v YES/SPORT . 1 YES/PROBED . 2 NO . 31 v YES/SPORT . 1 YES/PROBED . . . . . . . . . . . . . . . . . . 2 NO . 3] YESISPONT . 1 YES/PROBED . 2 NO . 3] v YES/SPOBT . 1 YES/PROBED . . . . . . . . . . . . . . . . . . 2 BO . 31 v YES/SPOBT . 1 YES/PROBED . 2 NO . 31 V YES/SPOBT . 1 YES/PROBED . 2 NO . YES/SPORT . I YES/PROBED . 2 NO . 3- m-- y YES/SPORT . 1 YES/PRODED . 2 NO . ]1 v YES/SPONT . 1 NO . 3- 303 Have you ever usad (METHOD) with any partner ? 304 DO you know kCere • person co4JLd go to get (NETHOD)? YES . 1 NO . 2 YES . 1 NO . 2 YES . . . . . . . . . . . . . . . 1 NO . 2 YES . 1 NO . 2 YES . 1 NO . 2 YES . I NO . 2 YES . 1 YES . 1 NO . 2 NO . 2 YES . 1 YES . 1 NO . 2 NO . 2 YES . 1 YES . 1 NO . 2 NO . 2 Have you ever had an YES . 1 OE:~ratlon to avoid having any more NO . 2 children7 YES . 1 NO . 2 YES . 1 DO you know mere a person can obtain advice on how to NO . 2 use the rmturaL methad? YES . 1 NO . 2 YES . 1 NO . 2 YES . 1 NO . 2 YES . 1 NO . Z YES . 1 NO . 2 AT LEAST ONE "YES" (EVER USED) ~[ • SKIP TO ]08 204 .6 NO. ~ QUESTIONS AND FILTERS i 306 I Have you or (your wife/partner) ever tried in any way m I to detay or avoid having a baby? SWIP CORING CATEGORIES I TO YES . [~ I NO . [~-'~317 I 307 309 Are you or your rife (or par t r~r ) current ly doing something or using any method to delay or avoid having a baby ? 310 310A, Which method are you using? DO NOT ASK THE QUESTION BELO~ IF HAM NOT STERILIZED. YOU have said that you fl~d an operatiot~ that keep~ you from ever mking a ~on~n pregnant. Is that correct? IF RESPORDENT SAYS HNO", CORRECT 303"305 (AND 302 IF NECCESSARY). IF RESPONDENT SAYS "YES", CIRCLE '07~ FOR HALE STER]LIZAT[OR. PILL . O1 IUCO . . . . . . . . . . . . . . . . . . . . . . . . . . . 02 INJECTIONS . 03 DIAPHRAC.M/FOAN/JELLY . 0/* CORDC$4 . 05 FEMALE STERIL[ZAT[OR . 06 JU~LE STERILIZATION . OT NATURAL HETHO0 . NITHDRAWAL . 09 OTHER 10~ (SPECIFY) ,316 311 CHECK 310: SHE/HE STERILIZED i ~ USING ANOTHER METHO0 [~ [ i v v Where did The Where did you obtain sterilization take (NETHODI the last t ime? ptace? (NAME OF PLACE) PUBLIC SECTOR I GOVERNMENT HOSPITAL . 11 PRIMARY HEALTH CENTRE . 12 DISPENSARY/HA, TERHITY CLINIC.13 MOBILE CLINIC . 14 ~314 | MEDICAL PRIVATE SECTOR I PRIVATE HOSPITAL . 21 I PRIVATE HEALTH CENTRE . 22 DISPENSARY/MATERNiTY CLINIC.2] MOBILE CLINIC . 24 ~314 PRIVATE DOCTOR . 25 I I OTHER PRIVATE SECTOR SHOP/PHARMACY . 31 CHURCH . 32 OTHER FRIENDS/RELATIVES . 4131~314 iDK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 32] OT--SE How oesit ketotraveL rF LESS y rT - - ECO 2 S o ths - -S ECO pace MIUES I M UT S O--S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - - I '''' I 0o . . I N7 205 315 CHECK 310: USING SHE/HE ANOTHER STERILIZED E~ METHOD r~ In what month and year was the sterilization operation performed? SKIP TO MONTH . 327 YEAR . 316 For how nwny months have you been using (CURRENT METHOD) continuously? IF LESS THAN 1 NORTH, RECORD 'O0'. l MONTHS . I 322 B YEARS OR LONGER . 317 318 DO you )nteod to use a method to delay or avoid pregna~y at any time ~n the future? ~Jhat Is the main reason you do not intend to use a method? 3"1 I DO you intend to use a method within the next 12 months~ 320 321 When you start using a method, which method woutd you prefer to use? Where can you get (METHOD MENTIONED IN 320) 0 (NAME OF PLACE) J I YES . 1 -319 NO . 2 l DK . B *323 WANTS CHILDREN . 01- LACK OF KNOWLEDGE . 02 PARTNER OPPOSED . 03 OTHER RELATIVES OPPOSED . 04 SIDE EFFECTS . 05 HEALTH CONCERNS . 06 SOURCE TOO FAR AWAY . 07 METHOOS ARE UNAVAILABLE . 08 OPPOSED TO FAMILY PLANNING . . . . . 09 FATALISTIC/GOD'S UILL . 10 COSTS TOO MUCH . 11 INFREQUENT SEX . 12 CAN NOT GET WIFE PREGNANT . 13 WIFE INFEDUND . 14 INCONVENIENT . 15 NOT MARRIED . 16 OTHER 17 (SPECIFY) DK . 9 ~ ~323 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 m I NO . DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PILL . 01 [UCD . 02 INJECTIONS . 03 DIAPHRAGM/FOAM/JELLY . 04 CONDO#4 . 05 FEMALE STERIL IZAT ION . . . . . . . . . . . 06 MALE STERILIZATION . 07 NAIURAL MEIHO0 . 08-=-- z WITHDRAWAL . 09 OTHER 10 323 UNSURE . 9 PUBLIC SECTOR l GOVERNMENT HOSPITAL . 11 PRIMARY HEALTH CENTRE . 12 325 DISPENSARY/MATERNITY CLINIC.,.13 ~ MOBILE CLINIC . 14 ,327 I MEDICAL PRIVATE SECTOR l PHIVAIE HOSPITAL . 21 PRIVATE HEALTH CENTRE . 22 325 DISPENSARY/MATERNITY CLINIC.2~ MOBILE CLINIC . 24 P327 PRIVATE DOCTOR . 25 P325 I OTHER PRIVATE SECTOR J SHOP/PHARMACY . 31 ~325 CHURCH . 32 FRIENDS/RELATIVES . 33 327 OTHER 61 ~ (SPECIFY) J DR . 98 ,323 M8 206 CHECK 310: USING I~ATURAL 14ETHOD, 'dITIIDRA~/AL, 011 OTHER TRAD I T IONAL NETHO0 323 I bOmethodYC~J knOWof childspacing? °f =ptace where you can obtein US I NGNETHGOA PlCOE R N J YES. . . . 1 N O " .2 SKIP TO P327 L_ -327 324 ~Jhere is that7 (NA14E OF PLACE) PUBLIC SECTOR GOVERN14ENT HOSPITAL . .11 PRIMARY HEALTH CENTRE . 12 DISPENSARY/14ATERN[TY CLINIC.1] 140B I LE CLINIC. . . . . . . . . . . . . . . . .1~. MEDICAL PRIVATE SECTOR PR]VATE HUSP[ TAL . . . . . . . . . . . . . 21 PRIVATE HEALTH CENTRE . 22 DISPENSARY/14ATERN%TY CLINIC.23 140BI LE CLINIC . .2/. OTHERPR I VAT ESHOP/PHARNAC Y . . 31 PRIVATE SECToRDOCTOR 25 *327 ~327 [ (SPECIFY) 326 1 Is it easy or difficult to get there? I EASY . . , 1 D I F F I E U L T .2 - 1,0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' 3 81 _,og, s , , . cc - °r he'°r INOT AccEpTABLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 NEVER HEARD OF THE [~ vE~ CONDO~4 | 330 I reonthHaVe youal0outSeen OrcondomTanyheardth e advertisement in the last I I -o,I J YES. . . . 1 N O " .2 J *332 331 ~Where did you see or hear the advertisement? CIRCLE ALL 14EHTIO~iED RADIO. . .A NEWSPAPER . . . . . . . . . . . . . . . . . . . . . . . B MAGAZINE . .C POSTERS . .D CAN NOT RE14EMBER . E OTHER F (SPECIFY) 149 207 SKIP TO 333 Where can someone So to get condoms? (NAME OF PLACE) PUBLIC SECTOR GOVERNMENT HOSPITAL . .'11 PRIMARY HEALTH CENTRE . 12 D ] SPENSARY/MATERN I TY CLINIC.13 MOBILE CLINIC . 14 MEDICAL PRIVATE SECTOR PRIVATE HOSPITAL . .21 PRIVATE HEALTH CENTRE . 22 DISPENSARY/MATERNITY CLINIC.23 MOBILE CLINIC. . .24 PRIVATE DOCTOR . . . . . . . . . . . . . . . . 25 OTHER PRIVATE SECTOR SHO~/PHARMACY . . . . . . . . . . . . . . . . . 31 CHURCH. . .32 FR [ ENDS/RELAT %VES . 33 OTHER ~1 (SPECIFY) OK . 98 M 10 208 ~ECTION 4. FERTILITY PREFERENCES SKIP ,o I g4JESTIOMS ARD FILTERS J CODING CATEGORIES J TO NUMBER OF ~ SONS . . . . . . . IF NONE, RECORD '00' 402 404 How many own doughters do you have who are still alive? IF NONE, RECORD '00' NUMBER OF OWN OAUGHTERS.FI-- 1 CHECK 310: I NEITHER HE OR SHE STERILIZED (~ STERILIZED P406 NO MORE/NONE . 2 Would you like to have another (a) child or would you NO MORE AFTER THIS PREGNANCY.3 409 prefer to have (no more children/no children) ? SAYS WIFE CAR,T GET PREGNANT.4 UNDECIDED OR DK . 5 405 HOW long would you Like to wait before the birth of another (a) child ? MONIHS . 1 I I ~ YEARS . 2 SOON/NOW . 994 SAYS WIFE CAN~T GET PREGNANT.995 OTHER 996 (SPEC%FY) OK . 998-- ~,409 ' lovn----cr--e you lYE . over again, do you think (you/your wife or partner) would make the se~e decision to have an operation not NO . 2 to have any more children? 407 I Do you regret that (you/your wife or partner) had The I YES . 1 I I operation not to have any (more) children? I I NO . 2 P414 408 Why do you reoret it? 409 CHECK 202: CURRENTLY MARRIED NOT MARRIED/ (%~ LIVING ~ NOT LIVING TOGETHER TOGETHER r--] ! v 410 Do you think that your (wife/partner) eTxproves or disapproves of couples using a method to avoid pregnancy? RESPONDENT WANTS ANOTHER CHILD*.I-- PARTNER WANTS ANOTHER CHILD . 2 SIDE EFFECTS . ] P414 OTHER REASON 4-- (SPECIFY) PIo14 I I APPROVES . . . . . . . . . . . . . . . . . . . . . . . . 1 I OISAPPROVES . . . . . . . . . . . . . . . . . . . . . 2 DK . H Mll 209 NO. I QUESTIONS AND FILTERS I 411 J Now often have you toLLed to your (wife/partner) about I chiLdspecing in the bast year? SKIP I COOING CATEGORIES I TO J NEVER . , I ONCE OR TWICE . 2 MORE OFTEN . 3 ,,21 H.v. yoo. o, c,,,.n ,,,.,o,., I Es.o . . 2'1 I . 1 number of chi[dren that yo~J want, or does she want more MORE CHILDREN . 2 or fewer than you want? FEWER CHILDREN . ] DK . I 414 1 Now Long should a coc~ole walt before startlng sexua( 1 Intercourse after the birth of a baby? I MONIHS . I ~ 1 TEARS . 2 OTHER ~6 (SPECIFY) I c°'""' I AIT . 'I breastfeecling before starting to have sexual re|atlons again, or doesn't it matter? DOESN'T MATTER . 2 I 416 I In general, do you aplorove or disapprove of couples I using a method to avoid gettlng pregnant ? 417 CHECK 401 ar)d 402: HAS LIVING CHILD(REN) ~ NO LIVING CHILDREN~ v V If you coutd go back to the If you could choose time you did not have any exact(y the number of children and could choose children to have In exactly the r~Jn~:er of children your whole life, how to have in your whole life, r~any would that be~ how many would that be? RECORD SINGLE HUMBER OR OTHER ANSWER, I 418 | b~hat do you think is the best number of months or I years between the birth of one child ar<J the birth of the next child ~ I APPROVE . ) I DISAPPROVE . 2 NUMBER . I~} OTHER ANSWER 96 (SPECIFY) J MONTHS . 1 ~ J YEARS . 2 OTHER 996 (SPECIFY) M 12 210 ~{~TION 5. AIP~ KNOWLEDGE No. i ~ESTtoNS AND FZLTERS I I Now 1 have a few questions ebeut a very important topic. ~OF I Rave you heard of 8n iltnes$ celled AIDS? I SKIP COOING CATEGORIES m TO m YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I NO . 2~ 601 50Z Front which sources of inform(ion or persons have yo~ heard abc~t AIDS in the last month? CIRCLE ALL MENTIONED. RADIO . A NEWSPAPERS . B REALT~ ~ORKERS . . . . . . . . . . . . . . . . . . C NOSQUES/CHURCHES . D FRIENDS/RELATIVES . E SCHOOLS/QURAN TEACHERS . . . . . . . . . . F BOOKLETS/PAMPHLETS/POSTERS . G COMM, UNITY MEETINGS . X OTHER I (SPECIFY) NONE . J 583 50/* HOW is AIDS transmitted? CIRCLE ALL NENTIQNED. Do you think that you can get AIDS from shaking hands with someone who has AIDS? h~ging someone who has AIDS? kissm9 sc~neone Who has AIDS? wearing the clothes of someone who has AIDS 9 sharing eating utensils with s~eone who has AIDS? stepping on the urine or stool of sc~neone with AIDS? nKas~ito, flea or ~ bites? SEXUAL INTERCOURSE . A NEEDLES/BLADES/SKIN PUNCTURES.,B MOTHER TO CHILD . C TRANSFUSIOR OF INFECTED BLOOD. , ,D OTHER E (SPECIFY) DON~T KNO~4 . F YES NO OK HANDSHAKING . . . . . . . . . . . . . . . . 1 2 8 RUGG]HG . 1 2 B KISSING . 1 2 8 SHARING CLOTHES . I 2 8 SNARING EATING UIENSILS.I 2 8 STEPPING ON URINE/STOOL.I 2 8 MOSOUITO/FLEA/BEDDUG BITES.1 2 8 so, i ,s,, s,b,e,or. I'e . 11 to be infected with the AIDS virus? NO . 2 DN . 8 506 | Is i t possible for a ~n who has the AIDS virus to | YES . 1 ' I Rive birth to a child with the AIDS virus? I NO . 2 I D• . 8 587 Dan a person protect himself or herself from gettin 9 I YES . I l AIDS7 I I NO . 2 ,SO9 508 How can a person1 protect himself of herself from getting AIDS? CIRCLE ALL MENTIONED DO NOT HAVE SEX AT ALL . A LIMIT NO. SEXUAL PARTNERS . B USE CONDOMS DURING SEX . C STERILIZE SYRINGES/NEEDLES . D AVO[D PROSTITUTES . E OTHER F (SPECIFY) 509 If yc~Jr retatlve is sufferiwJ with AIDS, who would yo~J prefer to care for him or her? I RELATIVES/FRIENDS . 1 I GOVERNMENT FACILITY . 2 RELIGICCJS ORG./MISSION . 3 NOBOOY/ABARDON . 4 OTHER S (SPECIFY) N 13 211 601 SECTIOR 6. MATERNAL MORTALITY Now I v~J(d tike to ask yc~J some questions about your brothers and sisters, that Is, a{( of the ch~tdren bern to your natura{ mother, inctuding those who are living with you, those living elsewhere, and those who have died, HOW many children did your mother give birth to, including yoursetf? CHECK 601: TWO OR N(~RE BIRTHS ONLY ORE BIRTH F~ (RESPONDENT ONLY) II • SK IP TO END I 603 J HOW many of these births did your ~ther have before you were I born? NUMBER OF r ~ PRECEDING BIRTHS . I l l I I I [1] [23 [3] [4] IS] [6] [7] 604 Whet was the name given to your oldest (next oldest) i brother or . . i . s~ster? 605 Is (NAME) MALE . 1 MALE . 1 HALE . 1 MALE . 1 MALl . 1 MALE . 1 MALE . 1 i1w~le or female? FEHALE . 2 FEMALE . 2 FEMALE . 2 FEMALE . 2 FENs LE . 2 FEMALE . 2 FEMALE . 2 IS (NAME) YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 YES . 1 still alive? NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 GO TO 608< ] GO TO 608<] GO TO 608< ] GO TO 608< ] G( TO 608< ] GO TO 608<] GO TO 608<] DE . DK . DK . . . . . . . . . DR . . . . . . . . . DR . . . . . . . . . DK . . . . . . . . . GO , o {7],h_ Go ,o GO TO {2]~ GO TO (3]< B] GO TO [,]8] DO '0 iS]( &] G[ FT-I I-I-1 L ]2 FF1 1 GO TO [23 GO TO (]] DO TO {4] GO TO [St D( TO {6] GO TO [7] I GO TO [B] HOW many .r. aBo0,o F I I ]21 I--T] (NAME) die? 609 How old was (NAME) When she/he died? 610 Was {MANE) pregnant when she died? IF HALE OR DIED BEFORE 10 YEARS OF AGE GO TO (2] YES . 1 GO TO 613<'] IF MALE OR DIED BEFORE YEARS OF AGE GO TO (3] YES . 1 GO TO 613< '~ IF MALE OR IF MALE OR DIED BEFORE IO DIED BEFORE 10 YEARS OF AGE YEARS OF AGE GO TO [43 GO TO IS] YES . 1 YES . I GO TO 613< ~ DO TO 613< -~ IF )ALE OR DIED BEFORE 10 YEAF S OF AGE GO TO {61 ====: ===~.--=== YESGo ;o "L;i:~ IF MALE OR DIED BEFORE 10 YEARS OF AGE GO TO [7] ========~===== YES . 1 GO TO 613< 'I IF MALE OR IDLED BEFORE 1C I YEARS OF AGE i GO TO [8 ] =¢====©=¢====: YES . 1 GO TO 613~'] NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 NO . 2 i 611 Did (NAME) YES . '11 YES . ,]I i YES . '11 YES C~ ~ I 1 YESGo . TO 613( '~I YESGo . TO 613< ']I d ie dur l r~ GO TO 613<~ GO TO 613<- - GO TO 613<- - GO ,u 'o , .<- - childbirth? NO . 2 NO . 2 NO . 2 NO . 2 NO . . . . . . . . . 2 NO . 2 NO . 2 612 Did {NAME) die withm six weeks after the end of a pregnancy or childbirth? YES . 1 NO . 2 GO TO [3]< ~] YES . I GO TO 613<-] YES . 1 YES . 1 NO . 2 MO . 2 GO TO [4]< ~] GO TO [51< ~] [-II YES . 1 NO . 2 GO TO [2]< ~] FES . 1 YES . 1 NO . 2 GO TO [71< ~] YES . 1 NO . 2 GO TO [81< ~] 613 Sow many children had {NAME) given birth to before that pregnancy? Ell M 14 212 604 What was the name given to y~r oldest (next oldest) brother or sister? 605 Is (NAME) nWlle 01" female? 606 Is (NAME) still alfve? 607 How old is (NAME)? 608 HOW many years ago did (NAME) die? 609 How Did was (MAME) when she/he died? 610 Was (NAME) pregnant whet~ she died? 611 Did (NAME) d~e ~rir~ ch i ldb i r th? 612 Did (NAME) die within six weeks after the end of a pregnancy or childbirth? [8] HALE . 1 FEMALE . 2 YES . 1 NO . 2 GO TO 608J DK . GO TO [91< ~] GO TO 193 IF HALE OR )lED BEFORE 10 YEARS OF AGE GO TO [9] == ©======== ~ == YES . I GO TO 613<~ NO . 2 YES . 1 GO TO 613<~ NO . 2 YES . 1 NO . 2 GO TO [91< ~ [9] HALE . 1 FEMALE . 2 YES . I NO . E GO TO 608<] OK . GO TO [103< ~ GO TO [103 rll IF HALE OR DIED BEFORE 10 YEARS OF AGE GO TO [10] ========== ~= == YES . 1 GO TO 613< ~ NO . 2 YES . 1 GO TO 613< ~] NO . 2 YES . 1 NO . 2 GO TO [10]< =l [10] HALE . 1 FEMALE . 2 YES . 1 RO . 2 Go TO ~] DK . 6 GO to [111~] GO TO II13 IF MALE OR DIED BEFORE 10 YEARS OF AGE GO TO [11] ========= === YES . 1 GO TO 613< '~ NO . 2 YES . I DO TO 613~] NO . 2 YES . 1 NO . 2 GO TO [11]< ~] [11] HALE . 1 FEMALE . 2 YES . 1 NO . 2 GO TO 608<] DK . GO TO [12i <8] GO TO [12I FII IF MALE OR DIED BEFORE 10 YEARS OF AGE GO TO [12] ============== YES . 1 GO TO 613~ ~ NO . 2 YES . 1 GO TO 613~ ~ NO . 2 YES . 1 NO . 2 GO TO [12]< ~] [12] HALE . 1 FEMALE . 2 YES . 1 NO . 2 GO 10 608<] GO TO [131~ GO TO 113] IF MALE OR DIED BEFORE I(] YEARS OF AGE GO TO [13] ==~=:==== ~= =_-== YES . I GO TO 613< ~] No . . . . . . . . . 2 YES . 1 GO TO 613< ~] NO . . . . . . . . . 2 YES . 1 NO . 2 GO TO [131< ~] [13] HALE . I FEMALE . 2 YES . 1 MO E DE . GO To [14] (~j GO TO [14J n-F] IF MALE OR DIED BEFORE 10 I YEARS OF AGE GO TO [14] =====_-=====--=.~ YES . 1 GO TO 613 ~:J I NO . 2 YES . 1 GO TO 613< '~ NO . 2 YES . 1 NO . 2 GO TO [141< ~ [14] MALE . I FEMALE . 2 YES . 1 NO . Z GO TO ~SJ OK . GO TO [151< 8] GO TO [153 IF MALE OR IED BEFORE 10 YEARS OF AGE GO TO [15] ============= YES . 1 GO TO 613( '~ NO . 2 YES . 1 GO TO 613< ~] NO . 2 YES . 1 NO . 2 GO TO [151c~ 613 HOW many , :::hotr:DoTn:; l RECORD THE TIME. M 15 213 Comments About Respondent: INTERVIEWER'S OBSERVATIONS (To be filled in after completing interview) Comments on Specific Questions: Any Other Comments: SUPERVISOR'S OBSERVATIONS Name of Supervisor: Date: EDITOR'S OBSERVATIONS M 16 214 MALAWI DEMOGRAPHIC AND HEALTH SURVEY MALAWI GOVERNMENT - NAT IONAL STAT IST ICAL OFF ICE HEALTH SERVICES AVAILABIL ITY QUEST IONNAIRE FORM MDHS-S/92 IDENT IF ICAT ION REGION/DISTR ICT TA/STA/TOWN ENUMERATION AREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CENTRAL V ILLAGE OR PLACE MDHS CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (urban=l , ru ra l=2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTERVIEWER NAME AND NUMBER DATE OF V IS IT . . . . . . . . . . . . . . DAY MONTH YEAR NAME DATE F IELD EDITED BY OFF ICE EDITED BY KEYED BY KEYED BY $1 215 No. I OuEs?i~s AND TILTERS I 1 | nat fs the name of the nearest hea(th fac i ( f ty That | I provides health services to (VILLAGE/PLACE)? ] (NAME) CODING CATEGORIES SKIP I TO I 2 I U~r what authority is the facility operated? I GOVERNMENT . . . . . . . . . . . . . . . . . . . . . . . I I MISSION/CHURCH . . . . . . . . . . . . . . . . . . . 2 PRIVATE EMPLOYER . 3 OTHER PRIVATE . 4 OTHER 5 ' l .ow far is the facility from here (in kms or miles) ? I RECORD 'DO' IF LESS THAN I KM, IF 97 KM O~ MORE RECORD '97% IF UNKNOWN RECORD '98' 4 How do most persons in this c~ity get from here to (HEALTH FACILITY NAME) ? IISE IIIIIII:I' F-F7 J I CAR / MOTORCYCLE . 1 ~S PUBLIC TRANSPORT (BUS,TAXI) . 2 I BICYCLE . ] ANIMAL / ANIMAL CART . 4 J WALKING . 5 ~5 OTHER 6 (SPECIFY) | CLUSTERS LY: How°''en'r I ,r.n--, motorized available to residents to to NO. Of TIMES PER WEEK.,.~ the facility ? I I J RECORLD '00' IF LESS THAN ONCE PER ~EEK. IF UNKNOWN RECORD '98'. 5 Row tong does it take to get from here to ] (HEALTH FACILITY NA~E) using (MEANS MENYIOLNED IN 4) ? HOURS . I Fill I RECORD IN MINUTES IF LESS THAN 2 HOURS AND IN HOURS IF 2 HOURS OR MORE. MINUTES . . . . . . . . . . . . 2 I J l J { t t t 6 Does (HEALTH FACILITY NAME) provide: antenatal care? delivery care? child ~zat i~? childspacing services? cor~? CHECK I: IS THE NEAREST NO YES FACILITY A "OSPITAL? ~, ~at is the n~ of the nearest hosplta[ that p rov1~s health serv(ces to (VILLAGE/PLACE)? (NAME OF HOSPITAL) YES NO DK ANTENATAL CARE . I 2 8 DELIVERY CARE . 1 2 8 CHILD IMMUNIZATION . 1 2 8 CHILDSPACING SERVICES.1 2 8 CONDOHS . I 2 8 1~14 I S2 217 NO. OUESTIONS AND FILTERS 9 Under what authority is the hospital operated~ SKIP I COOING CATEGORIES I TO I- . 1 MISSION/CHURCH . 2 PRIVATE EMPLOYER . 3 OTHER PRIVATE . 6 OTHER 5 10 11 HOW far i$ the hospital from here (in kms or miles) RECORD 'OO' IF LESS THAN 1 NM, I f 97 KM OR I~ORE RECORD '97% IF UNKNOWN RECORD =98' HOW do most persons in this comity get from here to (HOSPITAL NAME) ? I | CAR / MOTORCYCLE . . . . . . . . . . . . . . . . 1 ~ 1 2 PUBLIC IRABSPOhT (BUS,TAXI1 . 2 | BICYCLE . 3 ANIMAL / ANIMAL CART . 4 | WALKING . $ ~12 OTHER 6 (SPECIFY) | 'IAI' U ALCLUSTE S LY: I,r,ns r, go ,,, I motorized avaikabte to residents to to NO. OF TIMES PER ~JEEK.~ the facility ? RECORD =DO = IF LESS THAN ONCE PER WEEK. IF UNKNOWN RECORD 198'. ,21 H , es,t,aketoge fr 'ere ° I (HOSPITAL NAME) using (MEANS MENTIONED IN 11) 7 RECORh IN MINUTES IF LESS THAN 2 HOURS AND IN HOURS IF 2 HOURS OR MORE. 13 Does (HOSPITAL NAME) provide; antenata[ care? delivery care? child ~mmunizat ~ on? ch = Idspacing services? c c¢~doms~ 14 IS (NAME OF VILLAGE/PLACE) served by mobile outreach, that is, by a health unit that arrives regularly nearby to provide health services to persons In this coJllnUnlty~ IF YES: What is the name of the outreach point? (NAME) IF NO: RECORD 'OOO'. 15 I Under what authority is this service operated? 16 | HOW far is the outreach point from here (in kms or I miles)? RECORD '00 = tF LESS TBAN I KM, IF 97 KM OR MORE RECORD ~97', IF UMKNOi4M RECORD '98' NOURS . . . . . . . . . . . . . . . . . . . . . . . . . . '~1~ MINUTES 2 l l l l YES NO OK ANTENATAL CARE . I 2 8 DELIVERY CARE . I 2 8 CHILD IMMUNIZATION . I 2 8 CHILDSPACING SERVICES.I 2 8 CONDOMS . 1 2 D NO MUffLE OUTREACH . OOO ~21 I I . 1 MISSION/CHURCH . 2 PRIVATE EMPLOYER . 3 OTHER PRIVATE . 4 OTHER 5 $3 218 RO. 17 QUESTIONS AND FILTERS HOW many times per month does the mobile outreach come to provide services ? RECORD I00' ]F LESS THAN 1 TIME PER MONTH, IF UNKNOWN, RECORD 1981 SKIP I COOING CATEGORIES iT0 18 HOW do most persons in this con~]ty get frown here to the o~treach point? I CAR / MOIORCYCLE . 1 ~19 PUBLIC TRANSPORT (BUS,TAXI) . 2 | BICYCLE . ] ANIMAL / ANIMAL CART . 4 | WALKING . 5 ~ 19 OTHER 6 (SPECIFY) I I 'I'O u "LCLUS'E'S LY= °'°f'en r eek's I,r.r. or, ,,' I motorized avaitabLe tO residents to to NO. OF TINES PER 'WEEK.,,.~] the out reach point ? RECORD '00 t IF LESS THAN ONCE PER WEEK. IF UNKNOWN RECORD =98 °. 19 20 Now tong does it take to get fr~n here to I (NAME OF OUTREACH POINT) using (MEANS MENTIONED IN 18)9 ] RECORD IN MINUTES ]F LESS THAN Z HOURS AND IN HOURS IF 2 HOURS OR MORE. Does the c~Jtreach post provide: antenat at care? child immunization? chi [dspacing services? c Onc~T~ • H RS . ,FFF I MINUTES . 2 ~ YES NO OK I ANTENATAL CANE . 1 2 B CHILD IMMUNIZATION . 1 2 8 CH[LDSPACING SERVICES.( 2 8 COWDORS . 1 2 B 21 Z2 Whet Is the n~wIze of the nearest place where a person from (NAME Of VILLAGE~PLACE) can obtain condoms~ (NAME OF PLACE) HOW far IS (PLACE MENTIONED IN 21) from here (in kms or miLes) ? RECORD POD' IF LESS THAN 1 RE, ]F 97 KM OR MORE RECORD '97 ' , IF UNKNOWN RECORD '98 L PUNLIC SECTOR I GOVERNMENT HOSPITAL . 11 PRIMARY HEALTH CENTRE . . . . . . . . . 12 DISPENSARY/MATERNITY CliNiC.13 MOBILE CLINIC . 14 P25 | MEDICAL PRIVATE SECTOR [ I PRIVATE HOSPITAL . 21 PRIVAFE HEALTH CENTRE . 22 DISPENSARY/MATERNITY CLINIC,.*23 MOBILE CLINIC . 24 P25 PRIVATE DOCTOR . 25 I OTHER PRIVATE SECTOR SHOP . 31 CHURCH . 32 OTHERFR]ENBS/RELAFIVES~_413~25 DK . 9 N,LOREFERS . 'FF I MILES . 2 ~ St* 219 NO, ~ESTIONS AND FILTERS 23 HOW do most persons in this community get from here to (PLACE MENTIONED IN 21)7 SKIP COOING CATEGORIES I TO I CAR / MOTORCYCLE . 1 -~--~24 PUBLIC TRANSPORT (BUS,TAXI) . 2 | BICYCLE . . . . . . . . . . . . . . . . . . . . . . . . . 3 ANIMAL / ANIMAL CART . 4 m WALKING . 5 ~24 OTHER 6 (SPECIFY) | 23A m FOR RURAL CLUSTERS ONLY: HOW often per week is I motorizad transport av=itabie to residents to go to (PLACE MENTIONED IN 21) ? RECOND 'GO' IF LESS THAN ONCE PER WEEK. IF UNXNOl~Id REC(X~D '90% 24 | Now I ordt does it take to get from here to I (PLACE MENTIORED IN 21) using (MEANS MENTIONED IN 23)? RECORD IN MINUTES IF LESS THAN 2 HC~RS AND IN HOURS IF 2 HOURS ON MORE, 25 What Is the ~ of the nearest place where a person from (NAME OF VILLAGE/PLACE) can obtain a modern* method of chitdspacing other than condoms? (NAME OF PLACE) * NOTE: This excludes t rad i t iona l methods such as herbot medicines, strings, etc. l N°" °E TIMEs PEN WEEX''''Fr l I . MINUTES . 2 PUBLIC SECTOR I GOVERNMENT HOSPITAL . 11 PRIMARY HEALTH CENIBE . 12 DISPENSARY/MATERNITY CLINIC.,.13 MOBILE CLINIC . 14 ,29 i MEDICAL PRIVATE SECTOR I I PRIVATE HOSPITAL . 21 PRIVATE HEALTH CENTRE . 22 DISPENSARY/MATERNITY CLINIC.23 MOBILE CLINIC . 24 ,29 PRIVATE DOCTOR . 2S I I OTHER PRIVATE SECTOR SHOP . 31 CHURCH . 32 OTHERFR[ENDS/RELATIVES~. . 4131~ 29 DK . 9 26 | Bow far is (PLACE MENTIONED IN 25) from here I (in kn~ or mites) ? RECORD 'OS' IF LESS THAN 1XM, IF 97 KM OR MORE RECORD '97% ]F UNKNOWN RECORD ~98' 27 BOW do most persons in this ccmmunity get fr~ here to (PLACE MENTIONED IN 25)? [ZTTIIIIIIIIIIII [ ! CAR / MOTORCYCLE . . . . . . . . . . . . . . . . 1 ~ 2 8 PUBLIC TRANSPORT (BUS,TAXI) . 2 | BICYCLE . 3 ANIMAL / ANIMAL CART . 4 / WALKING . . . . . . . . . . . . . . . . . . . . . . . . . 5 ~ 2~ OTHER 6 (SPECIFY) I SS 220 NO. I OUESTIORS AND FILTERS 1 27A| FOR RURAL CLUSTERS ORLY: How often per week is I motorized transport evaltabte to residents to go to (PLACE MENTIONED IN 25) ? RECORD *OO' IF LESS THAN ONCE PER WEEK. IF UNKNOi,JN RECORD ~98', CODING CATEGORIES NO. OF TIMES PER ~/EEK.,.~ I I J SKIP I TO I 28 HOW t~9 does it take to get from here to ~ m (PLACE MENTIONED IN 25) ush~ (MEANS MENTIONED IN 2717 HOLJRS . 1 I°111 I RECORD IN M%RUEES IF LESS THAN 2 HOURS AND IN HOURS ]F 2 HOURS OR P4ORE, MINUTES . 2 IIII 29 Has there been any specie| educational camp~zgns in | (NAME OF VILLAGE/PLACE) over the past 12 r~onths that YES . 1 I ~ere lnterded to i nc rease ~wareness 8bout the problem of AIDS ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 S6 221 Front Matter Title Page Survey Information Table of Contents List of Tables List of Figures Abbreviations Preface Summary of Findings Map of Malawi Chapter 1 - Introduction Chapter 2 - Characteristics of Households and Respondents Chapter 3 - Fertility Chapter 4 - Fertility Regulation Chapter 5 - Other Proximate Determinants of Fertility Chapter 6 - Fertility Preferences Chapter 7 - Childhood Mortality Chapter 8 - Maternal and Child Health Chapter 9 - Maternal and Child Nutrition Chapter 10 - Knowledge of AIDS Chapter 11 - Maternal Mortality Chapter 12 - Availability of Health Services References Appendix A - Interview Results Appendix B - Sampling Errors Appendix C - Data Quality Tables Appendix D - Survey Instruments - Questionnaires Household Questionnaire Individual Questionnaire - Female Individual Questionnaire - Male Health Services Availability Questionnaire

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