Malawi - Demographic and Health Survey - 2001

Publication date: 2001

2000Demographic andHealth Survey M alaw i 2000 D em ographic and H ealth Survey Malawi Malawi Demographic and Health Survey 2000 National Statistical Office Zomba, Malawi ORC Macro Calverton, Maryland, USA August 2001 This report presents findings from the 2000 Malawi Dem ographic and Health Survey (2000 MDHS), which was implemented by the National Statistical Office. ORC Macro (DHS) furnished technical assistance in the design and implementation of the survey. Funding for the 2000 MDHS survey was provided by the United States Agency for International Development (USAID/Malawi), the Department for International Development (DfID/Malawi), and the United Nations Children’s Fund (UNICEF/Malawi). The 2000 MDHS is part of a worldwide MEASURE Demographic and Health Surveys (DHS+) Project, which is designed to collect, analyse, and disseminate data on fertility, family planning, maternal and child health, HIV/AIDS, and other topics in health and population. Additional information about the Malawi DHS may be obtained from: National Statistical Office P.O. 333 Zomba, Malawi Telephone: 524-377 Fax 525-130 E-mail: demography@statis tics.gov.mw Internet: www.nso.malawi.net Information about the MEASURE DHS+ project may be obtained from: ORC Macro 11785 Beltsville Drive Suite 300 Calverton, MD 20705 Telephone: 301-572-0200 Fax: 301-572-0999 E-mail: reports@macroint.com Internet: www.measuredhs.com Suggested citation: National Statistica l Office [Malawi] and ORC Macro. 2001. Malawi Demographic and Health Survey 2000. Zomba, Malawi and Calverton, Maryland, USA: National Statistical Office and ORC Macro. Contents * iii CONTENTS Page TABLES AND FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii MAP OF MALAWI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxii CHAPTER 1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Geography, History, and the Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.2 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.3 Objectives of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.4 Organisation of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5 Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.6 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.7 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.8 Data Collection and Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND HOUSEHOLD MEMBERS . . . 9 2.1 Household Population by Age, Sex, and Residence . . . . . . . . . . . . . . . . . . . . . . . 9 2.2 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.3 Fosterhood and Orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.4 Educational Level of Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.5 School Attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.6 Child Labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.7 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS AND WOMEN’S STATUS . . . . . . 21 3.1 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3.2 Educational Attainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.3 Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 3.4 Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 3.5 Women’s Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.6 Form of Women’s Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.7 Control over Women’s Earnings and Women’s Contribution to Household Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.8 Measures of Women’s Empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.9 Use of Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.10 Birth Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 iv * Contents Page CHAPTER 4 FERTILITY LEVELS AND TRENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.1 Current Fertility Levels and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.2 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 4.3 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 4.4 Age of Mothers at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 4.4.1 Adolescent Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 CHAPTER 5 FERTILITY REGULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 5.1 Knowledge of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 5.2 Knowledge of Contraceptive Methods by Background Characteristics . . . . . . . . 50 5.3 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.4 Current Use of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.5 Current Use of Contraception by Background Characteristics . . . . . . . . . . . . . . 57 5.6 Current Use of Contraceptives by Women’s Status . . . . . . . . . . . . . . . . . . . . . . 60 5.7 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . 60 5.8 Timing of Female Sterilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 5.9 Source of Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 5.10 Informed Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 5.11 Future Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 5.12 Reasons for Not Intending to Use Contraception . . . . . . . . . . . . . . . . . . . . . . . 65 5.13 Preferred Method of Contraception for Future Use . . . . . . . . . . . . . . . . . . . . . . 65 5.14 Exposure to Family Planning Messages on Radio and Television . . . . . . . . . . . 66 5.15 Exposure to Family Planning Messages in Print Media or Drama . . . . . . . . . . . 69 5.16 Exposure to Specific Health and Family Planning Radio Programmes . . . . . . . . 69 5.17 Contact of Nonusers with Family Planning Providers . . . . . . . . . . . . . . . . . . . . 69 5.18 Discussion about Family Planning with Husband . . . . . . . . . . . . . . . . . . . . . . . 73 5.19 Attitudes of Couples toward Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 73 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . . 75 6.1 Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.2 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 6.3 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 6.4 Age at First Sexual Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 6.5 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 6.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . . . . . . . . . . . . . . . 83 CHAPTER 7 FERTILITY PREFERENCES AND UNMET NEED FOR FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.1 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.2 Desire to Limit Childbearing by Background Characteristics . . . . . . . . . . . . . . . 88 7.3 Unmet Need for Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 7.4 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 7.5 Wanted and Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Contents * v Page CHAPTER 8 INFANT AND CHILD MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 8.1 Definitions, Methodology, and Assessment of Data Quality . . . . . . . . . . . . . . . 97 8.2 Early Childhood Mortality Rates: Levels and Trends . . . . . . . . . . . . . . . . . . . . . 98 8.3 Socioeconomic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . 100 8.4 Biodemographic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . 101 8.5 Perinatal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 CHAPTER 9 MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 9.1 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 9.2 Assistance and Medical Care at Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 9.3 Caesarean Section and Small Size at Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 9.4 Postnatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 9.5 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 9.6 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 9.7 Diarrhoeal Disease and Related Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 9.8 Women’s Perceptions of Problems in Accessing Health Care . . . . . . . . . . . . . . 122 CHAPTER 10 INFANT FEEDING, NUTRITIONAL PRACTISES, AND NUTRITIONAL STATUS AMONG YOUNG CHILDREN AND WOMEN . . . . . . . . . . . . . . 125 10.1 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 10.1.1 Initiation of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 10.1.2 Age Pattern of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 10.1.3 Types of Complementary Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 10.1.4 Frequency of Foods Consumed by Children . . . . . . . . . . . . . . . . . . . . 130 10.1.5 Micronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 10.2 Nutritional Status of Children under Age Five . . . . . . . . . . . . . . . . . . . . . . . . 136 10.2.1 Measures of Nutritional Status in Childhood . . . . . . . . . . . . . . . . . . . 136 10.2.2 Levels of Child Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 10.3 Nutritional Status of Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 CHAPTER 11 AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS . . . . . . . . . . 143 11.1 Knowledge of Ways to Prevent HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 11.2 Knowledge of Other AIDS-related Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 11.3 Stigma Associated with AIDS and Acceptability of AIDS-related Messages in the Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 11.4 Testing for HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 11.5 Reports on Recent Sexually Transmitted Infections . . . . . . . . . . . . . . . . . . . . 159 11.6 Treatment-seeking and Other Behaviours in Response to STIs . . . . . . . . . . . . 162 11.7 Number of Sexual Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 11.7.1 Married Men and Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 11.7.2 Unmarried Men and Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 vi * Contents Page 11.8 Payment for Sexual Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 11.9 Knowledge of a Source for Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 11.10 Chishango Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 11.11 Use of Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Condom Use during Commercial Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 CHAPTER 12 ADULT AND MATERNAL MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . 177 12.1 The Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 12.2 Adult Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 12.3 Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 CHAPTER 13 MALARIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 13.1 Bednets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 13.1.1 Possession of Bednets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 13.1.2 Use of Bednets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 13.1.3 Insecticide Treatment of Bednets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 13.2 Intermittent Treatment During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 13.3 Treatment of Children with Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 13.4 Timing of Antimalarial Response to Child’s Fever . . . . . . . . . . . . . . . . . . . . . . 192 13.5 Initial Response to Child’s Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 APPENDIX A SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 APPENDIX B SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 APPENDIX C DATA QUALITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 APPENDIX D SURVEY STAFF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 APPENDIX E QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 APPENDIX F UNICEF WORLD SUMMIT FOR CHILDREN: END-DECADE INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Tables and Figures * vii TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Demographic indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Table 1.2 Results of the household and individual interviews . . . . . . . . . . . . . . . . . 6 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND HOUSEHOLD MEMBERS Table 2.1 Household population by age, sex, and residence . . . . . . . . . . . . . . . . . 10 Table 2.2 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 2.3 Children’s living arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 2.4 Educational attainment of household population . . . . . . . . . . . . . . . . . 13 Table 2.5 School attendance ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Table 2.6 Grade repetition and dropout rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table 2.7 Child labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Table 2.8 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Table 2.9 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Figure 2.1 Population pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS AND WOMEN’S STATUS Table 3.1 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . 22 Table 3.2 Educational attainment by background characteristics . . . . . . . . . . . . . 23 Table 3.3 Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table 3.4 Exposure to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Table 3.5 Employment of women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Table 3.6 Employer and form of earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 3.7 Decision on use of earnings and contribution of earnings to household expenditures . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 3.8 Women’s participation in decisionmaking . . . . . . . . . . . . . . . . . . . . . . . 33 Table 3.9 Women’s participation in decisionmaking by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Table 3.10 Women’s attitude toward wife beating . . . . . . . . . . . . . . . . . . . . . . . . . 35 Table 3.11 Women’s attitude toward refusing sexual relations with husband . . . . . 36 Table 3.12 Use of smoking tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table 3.13 Knowledge of birth registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Figure 3.1 Percentage of Men and Women Who Have Had Any Exposure to Mass Media, by Background Characteristics . . . . . . . . . . . . . . . . . . . 27 Figure 3.2 Percent Distribution of Women Age 15-49 Employed in Agricultural Work and in Non-agricultural Work by Type of Earnings . . 30 viii * Tables and Figures Page CHAPTER 4 FERTILITY LEVELS AND TRENDS Table 4.1 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Table 4.2 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 41 Table 4.3 Trends in fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Table 4.4 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Table 4.5 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Table 4.6 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Table 4.7 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Table 4.8 Median age at first birth by background characteristics . . . . . . . . . . . . 47 Table 4.9 Teenage pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Figure 4.1 Total Fertility Rates, by Background Characteristics . . . . . . . . . . . . . . . 42 Figure 4.2 Trends in Age-specific Fertility Rates, 1984 FFS, 1992 MDHS, and 2000 MDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Figure 4.3 Percentage of Women Age 15-49 Who Are Mothers or Are Pregnant with Their First Child, by Level of Education . . . . . . . . . . . . . 48 CHAPTER 5 FERTILITY REGULATION Table 5.1 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Table 5.2 Knowledge of contraceptive methods by background characteristics . . . 51 Table 5.3.1 Ever use of contraception: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Table 5.3.2 Ever use of contraception: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Table 5.4.1 Current use of contraception: women . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Table 5.4.2 Current use of contraception: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Table 5.5.1 Current use of contraception by background characteristics: women . . 58 Table 5.5.2 Current use of contraception by background characteristics: men . . . . 59 Table 5.6 Current use of contraception by women’s status . . . . . . . . . . . . . . . . . . 61 Table 5.7 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . 61 Table 5.8 Timing of sterilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Table 5.9 Source of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Table 5.10 Informed choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Table 5.11 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Table 5.12 Reason for not intending to use contraception . . . . . . . . . . . . . . . . . . . 66 Table 5.13 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . 66 Table 5.14.1 Exposure to family planning messages on radio and television: women 67 Table 5.14.2 Exposure to family planning messages on radio and television: men . . 68 Table 5.15 Exposure to family planning messages in print media . . . . . . . . . . . . . . 70 Table 5.16.1 Exposure to radio programs on health and family planning: women . . . 71 Table 5.16.2 Exposure to radio programs on health and family planning: men . . . . . 71 Table 5.17 Contact of nonusers with family planning providers . . . . . . . . . . . . . . . 72 Table 5.18 Discussion of family planning with husband . . . . . . . . . . . . . . . . . . . . . 73 Table 5.19 Attitudes of couples toward family planning . . . . . . . . . . . . . . . . . . . . . 74 Figure 5.1 Percentage of Currently Married Women Using Contraception, by Method Type, 1992 MDHS, 1996 MKAPH, 2000 MDHS . . . . . . . . . . 57 Tables and Figures * ix Page CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Table 6.2 Number of co-wives and wives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Table 6.3 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Table 6.4 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Table 6.5 Age at first sexual intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table 6.6 Median age at first sexual intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Table 6.7 Recent sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility . . . . . . . . . . 84 Table 6.9 Median duration of postpartum insusceptibility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Figure 6.1 Percentage of Currently Married Men in a Polygynous Marriage, by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 CHAPTER 7 FERTILITY PREFERENCES AND UNMET NEED FOR FAMILY PLANNING Table 7.1 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . 88 Table 7.2 Desire to limit childbearing by background characteristics . . . . . . . . . . 90 Table 7.3 Need for family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Table 7.4 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Table 7.5 Mean ideal number of children by background characteristics . . . . . . . 94 Table 7.6 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Table 7.7 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Figure 7.1 Percentage of Currently Married Men and Women Who Have Had Two Children Who Want to End Childbearing . . . . . . . . . . . 89 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Table 8.2 Early childhood mortality by socioeconomic characteristics . . . . . . . . 100 Table 8.3 Early childhood mortality by demographic characteristics . . . . . . . . . 102 Table 8.4 Perinatal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Figure 8.1 Trends in Infant and Under-five Mortality, 1992 MDHS and 2000 MDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Figure 8.2 Under-five Mortality by Biodemographic Characteristics . . . . . . . . . . . 102 CHAPTER 9 MATERNAL AND CHILD HEALTH Table 9.1 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Table 9.2 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . 107 Table 9.3 Antenatal care content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 x * Tables and Figures Page Table 9.4 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Table 9.5 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Table 9.6 Delivery characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Table 9.7 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . 115 Table 9.8 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . 116 Table 9.9 Prevalence and treatment of acute respiratory infection . . . . . . . . . . 118 Table 9.10 Disposal of children’s stools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Table 9.11 Prevalence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Table 9.12 Knowledge of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Table 9.13 Diarrhoea treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Table 9.14 Feeding practices during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Table 9.15 Perceived problems in accessing women’s health care by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Figure 9.1 Percentage of Births for Which Women Received Medical Assistance at Delivery, by Urban-rural Residence and Selected Districts . . . . . . . 112 Figure 9.2 Percentage of Children Age 12-23 Months Who Are Fully Vaccinated, by Background Characteristics . . . . . . . . . . . . . . . . . . . . . 117 CHAPTER 10 INFANT FEEDING, NUTRITIONAL PRACTISES, AND NUTRITIONAL STATUS AMONG YOUNG CHILDREN AND WOMEN Table 10.1 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Table 10.2 Breastfeeding status by child’s age . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Table 10.3 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . 128 Table 10.4 Foods consumed by children in preceding 24 hours . . . . . . . . . . . . . . 129 Table 10.5 Frequency of foods consumed by children in preceding 24 hours . . . . 131 Table 10.6 Micronutrient intake of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Table 10.7 Micronutrient intake among mothers . . . . . . . . . . . . . . . . . . . . . . . . . 135 Table 10.8 Nutritional status of children by demographic characteristics . . . . . . . 138 Table 10.9 Nutritional status of women by background characteristics . . . . . . . . 141 Figure 10.1 Percentage of Children under Age 5 Who Live in Households That Use Adequately Iodised Salt . . . . . . . . . . . . . . . . . . . 134 Figure 10.2 Percentage of Children with Low Height-for-Age, Low Weight-for-Height, Low Weight-for-Age, by Age of Child . . . . . . . . . . 139 Figure 10.3 Prevalence of Chronic Energy Deficiency (Percent with BMI < 18.5) among Women Age 15-49, for Selected Districts . . . . . . 142 CHAPTER 11 AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS Table 11.1 Knowledge of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Table 11.2.1 Knowledge of ways to avoid HIV/AIDS: women . . . . . . . . . . . . . . . . . 146 Table 11.2.2 Knowledge of ways to avoid HIV/AIDS: men . . . . . . . . . . . . . . . . . . . 146 Table 11.3.1 Knowledge of programmatically important ways to avoid HIV/AIDS: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Tables and Figures * xi Page Table 11.3.2 Knowledge of programmatically important ways to avoid HIV/AIDS: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Table 11.4 Knowledge of HIV/AIDS-related issues . . . . . . . . . . . . . . . . . . . . . . . . 150 Table 11.5 Discussion of HIV/AIDS with spouse/partner . . . . . . . . . . . . . . . . . . . 151 Table 11.6.1 Social aspects of HIV/AIDS prevention and mitigation: women . . . . . 152 Table 11.6.2 Social aspects of HIV/AIDS prevention and mitigation: men . . . . . . . . 153 Table 11.7 Discussion of HIV/AIDS in the media . . . . . . . . . . . . . . . . . . . . . . . . . 155 Table 11.8.1 Testing for HIV: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Table 11.8.2 Testing for HIV: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Table 11.9.1 Self-reporting of sexually transmitted infections and STI symptoms: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Table 11.9.2 Self-reporting of sexually transmitted infections and STI symptoms: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Table 11.10.1 Source of treatment of STIs: women . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Table 11.10.2 Source of treatment of STIs: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Table 11.11.1 Efforts to protect partners from infection: women with STIs . . . . . . . . 164 Table 11.11.2 Efforts to protect partners from infection: men with STIs . . . . . . . . . . 165 Table 11.12 Number of sexual partners: married women and men . . . . . . . . . . . . 166 Table 11.13 Number of sexual partners: unmarried women and men . . . . . . . . . . 167 Table 11.14 Payment for sexual relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Table 11.15 Knowledge of male condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Table 11.16 Knowledge of Chishango brand condom . . . . . . . . . . . . . . . . . . . . . . . 171 Table 11.17.1 Use of condoms: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Table 11.17.2 Use of condoms: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Table 11.18 Use of condoms during commercial sex . . . . . . . . . . . . . . . . . . . . . . . 175 Figure 11.1 Percentage of Women and Men Who Think That An HIV-positive Individual Who Works with Others in a Shop, Office, or Farm Should be Allowed to Continue Working, by Level of Education . . . . . 154 Figure 11.2 Percentage of Respondents with a Need (Met and Unmet) for HIV-Testing Services, by Sex and (among Women) by Level of Education . . . . . . . . . . . . . . 159 Figure 11.3 Percentage of Men and Women Who Could “Get a Condom If They Wanted To,” by Level of Education . . . . . . . . . . . . . . . . . . . . . 171 Figure 11.4 Percentage of Women and Men Who Used a Condom at Last Sex with a Noncohabitating (High Risk) Partner, by Urban-rural Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 CHAPTER 12 ADULT AND MATERNAL MORTALITY Table 12.1 Data on siblings: completeness of reported data . . . . . . . . . . . . . . . . . 178 Table 12.2 Adult mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Table 12.3 Direct estimates of maternal mortality . . . . . . . . . . . . . . . . . . . . . . . . 181 Figure 12.1 Trends in Age-specific Mortality among Women 15-49 . . . . . . . . . . . . 180 Figure 12.2 Trends in Age-specific Mortality among Men 15-49 . . . . . . . . . . . . . . 180 xii * Tables and Figures Page CHAPTER 13 MALARIA Table 13.1 Possession and use of bednets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Table 13.2 Bednet age and insecticide treatment for bednets . . . . . . . . . . . . . . . . 188 Table 13.3 Intermittent treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Table 13.4 Treatment of children with fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Table 13.5 Promptness of treatment of children with fever . . . . . . . . . . . . . . . . . 193 Table 13.6 Initial response to fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Figure 13.1 Percentage of Children Under Age 5 and Women Age 15-49 Who Slept under a Bednet on the Night Before the Survey . . . . . . . . . 187 Figure 13.2 Among Children under Age 5 with Fever in 2 Weeks Preceding Survey, the Percentage Who Were Treated with an Antimalarial Drug and the Percentage Who Were Taken to a Health Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 APPENDIX A SAMPLE DESIGN Table A.1 Sample implementation: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Table A.1 Sample implementation: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Figure A.1 Malawi GPS Data Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 APPENDIX B SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Malawi 2000 . . . . . . . . 206 Table B.2 Sampling errors: Total sample, Malawi 2000 . . . . . . . . . . . . . . . . . . . 207 Table B.3 Sampling errors: Urban sample, Malawi 2000 . . . . . . . . . . . . . . . . . . 208 Table B.4 Sampling errors: Rural sample, Malawi 2000 . . . . . . . . . . . . . . . . . . 209 Table B.5 Sampling errors: Northern sample, Malawi 2000 . . . . . . . . . . . . . . . . 210 Table B.6 Sampling errors: Central sample, Malawi 2000 . . . . . . . . . . . . . . . . . 211 Table B.7 Sampling errors: Southern sample, Malawi 2000 . . . . . . . . . . . . . . . . 212 Table B.8 Sampling errors: Blantyre sample, Malawi 2000 . . . . . . . . . . . . . . . . 213 Table B.9 Sampling errors: Karonga sample, Malawi 2000 . . . . . . . . . . . . . . . . 214 Table B.10 Sampling errors: Kasungu sample, Malawi 2000 . . . . . . . . . . . . . . . . 215 Table B.11 Sampling errors: Lilongwe sample, Malawi 2000 . . . . . . . . . . . . . . . . 216 Table B.12 Sampling errors: Machinga sample, Malawi 2000 . . . . . . . . . . . . . . . 217 Table B.13 Sampling errors: Mangochi sample, Malawi 2000 . . . . . . . . . . . . . . . 218 Table B.14 Sampling errors: Mulanje sample, Malawi 2000 . . . . . . . . . . . . . . . . 219 Table B.15 Sampling errors: Mzimba sample, Malawi 2000 . . . . . . . . . . . . . . . . 220 Table B.16 Sampling errors: Salima sample, Malawi 2000 . . . . . . . . . . . . . . . . . 221 Table B.17 Sampling errors: Thyolo sample, Malawi 2000 . . . . . . . . . . . . . . . . . 222 Table B.18 Sampling errors: Zomba sample, Malawi 2000 . . . . . . . . . . . . . . . . . 223 Tables and Figures * xiii Page APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Table C.2.1 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . 226 Table C.2.2 Age distribution of eligible and interviewed men . . . . . . . . . . . . . . . . 226 Table C.3 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Table C.4 Births by calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Table C.5 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Table C.6 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . 230 APPENDIX F UNICEF WORLD SUMMIT FOR CHILDREN: END-DECADE INDICATORS Table F.1 World Summit for Children: End-decade Indicators . . . . . . . . . . . . . . 327 Foreword * xv FOREWORD This final report presents the major findings of the 2000 Malawi Demographic and Health Survey (MDHS). The 2000 MDHS survey is the second survey of its kind to be conducted in Malawi; the first MDHS was in 1992. The fieldwork was carried out by the National Statistical Office (NSO) from July to November 2000. In 1996, a similar survey on Knowledge, Attitudes, and Practices in Health (MKAPH) was conducted. All three surveys were designed to provide information on indicators of maternal and child health in Malawi. The primary objective of the 2000 MDHS survey was to provide up-to-date information for policymakers, planners, researchers, and programme managers that would allow guidance in the development, monitoring, and evaluation of health programmes in Malawi. Specifically, the 2000 MDHS collected information on fertility levels, nuptiality, fertility preferences, knowledge and use of family planning methods, breastfeeding practices, nutritional status of mothers and children, childhood illnesses and mortality, use of maternal and child health services, malaria, maternal mortality, and HIV/AIDS-related knowledge and behaviours. The 2000 MDHS results present evidence of a decline in fertility, an increase in the use of family planning methods, a decline in infant and under-five mortality, and an increase in adult and maternal mortality since the 1992 MDHS survey. However, the disparity between knowledge and use of family planning remains high. Some of these are critical issues and need to be addressed without delay. I would like to acknowledge the efforts of a number of organisations and individuals who contributed immensely to the success of the survey. First, I would like to acknowledge the financial assistance from the United States Agency for International Development (USAID), the Department for International Development (DfID), United Kingdom, and the United Nations Children’s Fund (UNICEF/Malawi). I would also like to acknowledge ORC Macro for technical backstopping, and the assistance of the staff of the National Statistical Office and the Ministry of Health and Population. Finally, I am grateful to the survey respondents who generously gave their time to provide the information that forms the basis of this report. Charles Machinjili Commissioner for Census and Statistics xvi * Summary of Findings SUMMARY OF FINDINGS The 2000 Malawi Demographic and Health Survey (MDHS) is a nationally represen- tative sample survey covering 14,213 house- holds, 13,220 women age 15-49, and 3,092 men age 15-54. The 2000 MDHS is similar, but much expanded in size and scope, to the 1992 MDHS. The survey was designed to provide information on fertility trends, family planning knowledge and use, early childhood mortality, various indicators of maternal and child health and nutrition, HIV/AIDS, adult and maternal mortality, and malaria control programme indicators. Unlike earlier surveys in Malawi, the 2000 MDHS sample was sufficiently large to allow for estimates of certain indicators to be produced for 11 districts in addition to esti- mates for national, regional, and urban-rural domains. Twenty-two mobile survey teams, trained and supervised by the National Statisti- cal Office, conducted the survey from July to November 2000. FERTILITY Fertility Decline. The 2000 MDHS data indicate that there has been a modest decline in fertility since the 1992 MDHS. The total fertil- ity rate has dropped from 6.7 births per woman, in the period 1990-1992 to 6.3 births in the period 1998-2000. The fertility decline is concentrated amongst older women (age 30 and above); no decline was observed in women under age 30. Large Fertility Differentials. Fertility levels remain high in Malawi, especially in rural parts of the country. The total fertility rate among rural women is 6.7 births per woman compared with 4.5 births in urban areas. Fertil- ity levels are closely related to the socio-eco- nomic status of women. For example, women with no formal education give birth to an average of 7.3 children in their lifetime, com- pared with 3.0 for women who attended sec- ondary school or higher. Among districts over- sampled in the survey, fertility ranges from 4.3 births per woman in Blantyre District to 7.0 or more births in Kasungu, Machinga, and Mangochi districts. Unplanned Fertility. One reason for the persistently high fertility levels is that unplanned pregnancies are still common. Overall, 40 percent of births in the five years prior to the survey were reported to be un- planned; 18 percent were mistimed (wanted later) and 22 percent were unwanted. Un- wanted births are disproportionately high among older women who already have several children. If births associated with mistimed and unwanted pregnancies were avoided alto- gether, the total fertility rate in Malawi would be 5.2 births per woman instead of the actual level of 6.3. Ideal Family Size. Although a reduction in the number of unplanned births would reduce fertility substantially, the average mar- ried Malawian woman age 15-49 or man age 15-54 reports that they would like to have more than five children. Even among those who have yet to start family formation, the reported ideal family size exceeds four children. Childbearing at Young Ages. One-third of adolescent females (age 15-19) have either already had a child or are currently pregnant. This proportion has not changed significantly since the 1992 MDHS. The median age of women at first birth is 19.1 years, meaning that more than half of women have had a child by the time they reach age 20. FAMILY PLANNING Increasing Use of Contraception. A principle cause of the fertility decline in Malawi is the steady increase in contraceptive use over the last decade. The contraceptive prevalence rate (current use of a modern family planning method) has more than tripled since 1992, from 7 to 26 percent of all married women. Summary of Findings * xvii Less effective, traditional methods have become less frequently used during the 1990s. Changing Method Mix. Currently, the most widely used methods among married women are injectable contraceptives (16 per- cent), female sterilisation (5 percent), and the pill (3 percent). This method mix represents a shift in contraceptive use among Malawian women. The rapid increase in use of injectables (from 2 percent in 1992) has made it the predominant method. This, combined with small rises in the use of condoms and female sterilisation, have more than offset small drops in pill and IUD use. Thus, acceptance of new methods of contraception, as well as some method switching, have characterised the 1992- 2000 intersurvey period. Differentials in Family Planning Use. Differentials in current use of family planning are large. Urban women are nearly 60 percent more likely than rural women to be using a modern contraceptive method (38 versus 24 percent). Among districts oversampled in the 2000 MDHS, use of modern contraception is highest in Blantyre District (38 percent) and lowest in Salima District (16 percent). Source of Family Planning Methods. The survey results show that government-run facilities remain the major source for contra- ceptives in Malawi—providing family planning methods to 68 percent of the current users. This represents an increase from 59 percent based on the 1996 MKAPH survey results. The increase in public-sector participation is due in large part to the rapid increase in use of inject- ables, which are provided mostly at govern- ment health centres. Twenty-eight percent of users get their methods from private medical sources, and 4 percent get their methods from other private sources (mostly shops). Community-based distribution agents are involved in providing contraceptives to 2 per- cent of current users. Unmet Need for Family Planning. Women who are exposed to the risk of preg- nancy but who say they would like to delay or limit childbearing and are not using contracep- tion are considered to have an unmet need for family planning services. Unmet need for family planning services has declined from 36 to 30 percent of married women since 1992. Fifty- eight percent of the unmet need is composed of women who want to space their next birth, while the remainder is made up of women who do not want any more children. Although much progress has been made in satisfying women’s need for family planning, half of the total “demand” for contraception remains unmet. CHILD HEALTH AND SURVIVAL Progress in Reducing Early Childhood Mortality. The 2000 MDHS data indicate that mortality of children under age 5 has declined since the early 1990s. During the period 1988- 1992, the under-five mortality rate was 234 deaths per 1,000 live births, compared with 189 per 1,000 for the period 1996-2000. Al- though this represents important progress, the rate of the downward trend is modest and childhood mortality remains at a very high level. Factors discussed as potentially associ- ated with the improved child survival picture are better access to clean water sources, ma- laria control activities, and progress in the education of women (primary caregivers). The risk of child death is not spread evenly across Malawi’s geographic and social landscape. Low educational attainment, young age of mother at birth, and residence in a rural area are factors associated with higher child mortality. Childhood Vaccination Coverage Declines. The 2000 MDHS results show that 70 percent of children age 12-23 months are fully vaccinated. This represents a decline in coverage from 82 percent based on the 1992 MDHS. More detailed examination of the data indicates that the level of vaccination card retention has fallen from 86 to 81 percent suggesting lower levels of contact with child health care providers generally. Furthermore, dropout rates in the polio and DPT multi-dose schedules have worsened. Last, measles vaccine and BCG coverage have declined slightly from levels in the early 1990s. xviii * Summary of Findings Childhood Illnesses. The survey also provides data on some of the more common childhood illnesses and their treatment. A little more than 1 in 4 children under age five had a cough with short, rapid breathing, signs of acute respiratory infection (ARI), in the two weeks before the survey. Of these, 27 percent were taken to a health facility for treatment. In the 1992 MDHS, only 15 percent of children under five were reported to have had ARI in the preceding 2 weeks, and 49 percent of these were taken to health facilities for treatment. One explanation for the rise in reported mor- bidity and decline in use of health facilities for treatment is that caregivers (mostly mothers) are increasingly recognising and reporting less severe cases of ARI in their young children. Further in-depth study is required. Eighteen percent of children under age five were reported to have had diarrhoea in the two weeks preceding the survey, and of these, 62 percent received oral rehydration therapy (either solution prepared from oral rehydration salts (ORS) or increased fluids of some other kind). Most mothers (86 percent) know about the use of ORS packets. Improved Breastfeeding Practices. The 2000 MDHS results show that exclusive breast- feeding of children under 4 months of age has increased to 63 percent from only 3 percent in the 1992 MDHS. Further, the overall median duration of breastfeeding has risen from 21 to 24 months during the same period. Patterns of Feeding in Early Child- hood. After a child is weaned from the breast, which occurs for most children between 18 and 24 months of age, the daily diet tends to stabi- lize at the following pattern: virtually all chil- dren receive grain or cereal-based foods regu- larly; 80 to 85 percent of children receive some fruits or vegetables; 85 to 90 percent get foods rich in vitamin A; about 50 percent receive meats, poultry, fish or eggs; one-third of chil- dren receive beans or other legumes; and 50 to 55 percent get tubers, roots, or plantains. Only 10 to 15 percent of children get some oils or fats added to their daily diet. Micronutrient Supplements. The im- portance of adequate intake of vitamin A in mitigating the severity of childhood illnesses, and thereby reducing mortality, is well docu- mented. Supplementing young children and postpartum women with a capsule containing a high dose of vitamin A is an easy way to ensure adequate intake. The 2000 MDHS data show that 65 percent of children under age five received a vitamin A supplement in the six months preceding the survey, and 42 percent of women delivering a baby in the past five years received a vitamin A supplement within two months after the last birth. The iodine content of salt used in the household was measured in the 2000 MDHS. The results show that 49 percent of children under age five live in households that use salt containing an adequate level of iodine, but this varies from only 22 percent in Machinga District to over 62 percent in Kasungu, Blantyre and Thyolo districts. Nutritional Status of Children. The results show no appreciable change in the nutritional status of children in Malawi since 1992; still, nearly half (49 percent) of the children under age five are chronically mal- nourished or stunted in their growth. Malawi’s Central Region has especially high levels of stunting. Acute malnutrition or wasting re- mains at 5 to 6 percent of children under age five in Malawi. MALARIA CONTROL PROGRAMM E INDICATORS Bednets. The use of insecticide-treated bednets (mosquito nets) is a primary health intervention proven to reduce malaria transmis- sion. The 2000 MDHS found that 13 percent of households own at least 1 bednet, and among these households, the average number of bed- nets owned is 1.6. Bednet possession is more common in the Northern Region and in house- holds of higher socioeconomic status. The data also show that 8 percent of women age 15-49, 7 percent of pregnant Summary of Findings * xix women, 8 percent of children under age five, and 6 percent of men age 15-54 slept under a bednet on the night before the survey. (Note: Most of the survey was conducted during the dry season, when bednet use was probably lower than average.) Intermittent Antimalarial Treatment during Pregnancy. In Malawi, as a protective measure against various adverse outcomes of pregnancy, it is recommended that pregnant women receive a dose of sulpha-pyrimethamine (SP or Fansidar) in the second trimester and then again in the third trimester. The 2000 MDHS findings show that among women who recently gave birth, 68 percent received at least one dose of SP and 29 percent received two doses of SP during the last pregnancy. Treatment of Fever in Children Under Age Five. The survey found that 42 percent of children under age five had a fever in the two weeks preceding the survey. Among febrile children, 35 percent were reported to have been taken to a health facility for treatment and 27 percent of children were given an antimalarial, mostly SP (23 percent). Of those given an antimalarial, 83 percent were given the treatment within zero to one day of the onset of fever. WOMEN’S HEALTH Maternal Health Care. The survey findings indicate that use of antenatal services remains high in Malawi. Ninety-one percent of mothers with births in the last five years re- ceived antenatal care from a health profes- sional (doctor, trained nurse or midwife) at least once. In the 1992 MDHS, the figure was 90 percent. For 56 percent of births, mothers visited antenatal services four or more times. Antenatal care can be more effective in avoid- ing adverse pregnancy outcomes when it is sought early in pregnancy. By the start of the sixth month of pregnancy, 50 percent of preg- nant women have not had a single antenatal care visit. The 2000 MDHS also points to a wide disparity in the quality of antenatal ser- vices among Malawi’s districts and socioeco- nomic strata. Delivery under hygienic conditions and where medical assistance is available decreases the risk of maternal morbidity and mortality. At the national level, 55 percent of births in the five years before the survey were delivered in a health facility. This figure is identical to that reported from the 1992 data. For 7 percent of births occurring outside of a health facility, mothers received a postnatal check on their health. The survey results indicate that 3 percent of births were delivered by caesarean section (C-section). A C-section rate below 5 percent is generally thought to be a reflection of limited access to maternal health services and poten- tially life-saving emergency obstetrical care. Constraints to Use of Health Services. Women in the 2000 MDHS were asked whether certain circumstances constrain their access to and use of health services for themselves. By far, the most serious problems women face regarding use of health services involve trans- portation and cost. Nutritional Status of Women. The 2000 MDHS collected information on the height and weight of all women age 15-49, which allows assessment of the body mass index (BMI), a measure of a woman’s weight relative to her height. The findings point to two important issues in women’s health. First, about 1 in 11 women have a low BMI (too thin), indicating chronic energy (calorie) deficiency, with rural women and women in the Southern Region having the highest prevalence of low BMI. Second, about 1 in 8 women have a very high BMI level, indicating these woman are over- weight or obese. Nearly 1 in 4 urban women are overweight or obese, which places them at increased risk of cardiovascular disease, pregnancy-related complications, and other health problems. Rising Maternal Mortality. The survey collected data allowing measurement of mater- xx * Summary of Findings nal mortality. For the period 1994-2000, the maternal mortality ratio was estimated at 1,120 maternal deaths per 100,000 live births. This represents a rise from 620 maternal deaths per 100,000 estimated from the 1992 MDHS for the period 1986-1992. HIV/AIDS Impact of the Epidemic on Adult Mortality. All-cause mortality has risen by 76 percent among men and 74 percent among women age 15-49 during the 1990s. The age patterns of the increase are consistent with causes related to HIV/AIDS. Improved Knowledge of AIDS Preven- tion Methods. The 2000 MDHS results indi- cate that practical AIDS prevention knowledge has improved since the 1996 MKAPH survey. For example, unprompted awareness that use of condoms prevents HIV transmission has risen from 23 to 55 percent among women and from 47 to 71 percent among men. Generally, knowl- edge of means to prevent HIV/AIDS is lowest in the young, sexually inexperienced, and rural population. Sexual Activity Outside of Marriage. Among married men, 18 percent reported having had sex with someone other than their wives in the last 12 months. Only 1 percent of married women reported having extramarital sex. Among unmarried men who have had sex in the last 12 months, about 1 in 4 reported two or more partners. In contrast, only 1 in 20 unmarried women who have had sex in the last 12 months reported more than 1 partner. First sexual activity continues to occur at a young age. The median age of girls at first sex is 17 years; for boys, first sex occurs at 18 years of age. Patterns in the MDHS data suggest that age at first sex is unchanged or slightly rising for girls but falling for boys. Men in the 2000 MDHS were asked whether they had paid for sex in the last 12 months. The findings indicate that 21 percent of men engage in this high-risk activity, with married men as likely as unmarried men to be involved. Condom Use. One of the main objectives of the National AIDS Control Programme is to encourage consistent and correct use of con- doms, especially in high-risk sexual encounters. The 2000 MDHS data show that condom use with extramarital partners has increased slight- ly since 1996, but that use within marriage has actually declined by a small margin. Among men reporting having had commercial sex (for cash) in the last 12 months, only 35 percent reported using a condom on the last occasion. HIV-testing Experience. The 2000 MDHS data show that 9 percent of women and 15 percent of men have been tested for HIV. However, more than 70 percent of both men and women, while not yet tested, said that they would like to be tested. This represents a very large pool of men and women with an unmet need for HIV-testing services. Knowledge of one’s own HIV status is considered crucial to the adoption of AIDS prevention behaviours and the appropriate responses to mitigate the impact of the epidemic. Map of Malawi * xxi Introduction * 1 INTRODUCTION 1 Louis M. Magombo 1.1 GEOGRAPHY, HISTORY, AND THE ECONOMY GEOGRAPHY Malawi is a landlocked country south of the equator in sub-Saharan Africa. It is 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 and northwest by the Republic of Zambia. The country is 901 kilometres long and ranges in width from 80 to 161 kilometres. It has a total area of 118,484 square kilometres of which 94,276 square kilometres is land area. The remaining area is mostly composed of Lake Malawi, which is about 475 kilometres long and runs down Malawi’s eastern boundary with Mozambique. Malawi’s most striking topographic feature is the Rift Valley that runs the entire length of the country, passing through Lake Malawi in the Northern and Central regions to the Shire Valley in the south. The Shire River drains the water from Lake Malawi into the Zambezi River in Mozambique. To the west and south of Lake Malawi lie fertile plains and mountain ranges whose peaks range from 1,700 to 3,000 metres above sea level. The country is divided into three regions: the Northern, Central, and Southern regions. There are 27 districts in the country. Six districts are in the Northern Region, nine are in the Central Region, and 12 are in the Southern Region. Administratively, the districts are subdivided into Traditional Authorities (TAs), presided over by chiefs. Traditional Authorities are composed of villages, which are the smallest administrative units and are presided over by village headmen. Malawi has a tropical, continental climate with maritime influences. Rainfall and temperature vary depending on altitude and proximity to the lake. From May to August, the weather is cool and dry. From September to November, the weather becomes hot. The rainy season begins in October or November and continues until April. HISTORY Malawi was under British rule from 1891 until July 1964 under the name of the Nyasaland Protectorate. In 1953, the Federation of Rhodesia and Nyasaland was created, which was composed of three countries, namely, Zimbabwe (then Southern Rhodesia), Zambia (then Northern Rhodesia) and Malawi (then Nyasaland). In July1964, the country became the independent state of Malawi, and it gained republic status in 1966. In 1994, the country became a multiparty state and adopted a strategy to eradicate poverty. Since then the following have been introduced: free primary school education, a free market economy, a bill of rights, and a parliament with three main parties. Over the past ten years, the country has experienced a considerable increase of migrants from rural to urban areas. 2 * Introduction Table 1.1 Demographic indicators Selected demographic indicators, Malawi, 1977, 1987 and 1998 national censuses_______________________________________________________________ Census year____________________________ Index 1977 1987 1998________________________________________________________________ Population Intercensal growth rate Total area (sq km) Land area (sq km) Density (population per sq km) Percentage of urban population Women of child bearing age as a percentage of female population Sex ratio Crude birth rate Total fertility rate Crude death rate Infant mortality rate Life expectancy: Male Female 5,547,460 7,988,507 9,933,868 2.9 3.2 2.0 118,484 118,484 118,484 94,276 94,276 94,276 59 85 105 8.5 10.7 14.0 45.1 44.2 47.2 93 94 96 48.3 41.2 37.9 7.6 7.4 6.2 25.0 14.1 21.1 165 159 121 39.2 41.4 40.0 42.4 44.6 44.0 ECONOMY Malawi has a predominantly agricultural economy. Agricultural produce accounted for 61 percent of Malawi’s exports in 1999: tobacco, tea, and sugar being the major export commodities. The country is largely self-sufficient for food. 1.2 POPULATION The major source of historical demographic data comes from the population censuses. Population censuses have been taken in Malawi during the years 1891, 1901, 1911, 1921, 1926, 1931, 1945, 1956, 1966, 1977, 1987, and 1998. Other sources of population data include nationwide surveys: 1968/69, 1980/81, and 1992/93 National Sample Surveys of Agriculture; the 1970-72 Malawi Population Change Survey; the 1982 Malawi Demographic Survey; the 1983 Malawi Labour Force Survey and Survey of Handicapped Persons; the 1984 Family Formation Survey; the 1992 Malawi Demographic and Health Survey (MDHS); the 1996 Malawi Knowledge, Attitudes, and Practises in Health Survey (MKAPH); and the 1997/98 Integrated Household Survey. Table 1.1 provides some demographic indicators for Malawi based on the previous three censuses. The 1998 Population and Housing Census enumerated a total population of 9.9 million. The population grew from 8.0 million in 1987 representing an increase of 24 percent or an intercensal population growth rate of 2.0 percent per year. Along with population growth has come increasing Introduction * 3 population density from 85 persons per square kilometre in 1987 to 105 persons per square kilometre in 1998. To address problems associated with rapid population growth, the Malawi government adopted a National Population Policy in 1994, which was designed to reduce population growth to a level compatible with Malawi’s social and economic goals (OPC, 1994). The policy’s objectives include the following: to improve family planning and health care programmes, to increase school enrolment with an emphasis on raising the proportion of female students to 50 percent of total enrolment, and to increase employment opportunities—particularly in the private sector. 1.3 OBJECTIVES OF THE SURVEY The principal aim of the 2000 MDHS project is to provide up-to-date information on fertility and childhood mortality levels, nuptiality, fertility preferences, awareness and use of family planning methods, use of maternal and child health services, and knowledge and behaviours related to HIV/AIDS and other sexually transmitted infections. It was designed as a follow-on to the 1992 MDHS survey, a national-level survey of similar scope. The 2000 MDHS survey also strived to collect data that would be comparable to those collected under the international Multiple Indicator Cluster Survey (MICS), sponsored by UNICEF. In broad terms, the 2000 MDHS survey aimed to— C Assess trends in Malawi’s demographic indicators—principally, fertility and mortality C Assist in the evaluation of Malawi’s health, population, and nutrition programmes C Advance survey methodology in Malawi and contribute to national and international databases. In more specific terms, the 2000 MDHS survey was designed to— C Provide data on the family planning and fertility behaviour of the Malawian population and to thereby enable policymakers to evaluate and enhance family planning initiatives in the country. C Measure changes in fertility and contraceptive prevalence and at the same time, study the factors that affect these changes, such as marriage patterns, desire for children, availability of contraception, breastfeeding habits, and important social and economic factors. C Examine basic indicators of maternal and child health and welfare in Malawi, including nutritional status, use of antenatal and maternity services, treatment of recent episodes of childhood illness, and use of immunisation services. A particular emphasis was placed on the area of malaria programmes, including prevention activities and treatment of episodes of fever. C Describe levels and patterns of knowledge and behaviour related to the prevention of HIV/AIDS and other sexually transmitted infections. C Measure the level of adult and maternal mortality at the national level. C Assess the status of women in the country. 4 * Introduction 1.4 ORGANISATION OF THE SURVEY The 2000 MDHS survey was a comprehensive survey that involved several agencies. The National Statistical Office (NSO) had the major responsibility for conducting the survey. The Ministry of Health and Population, the National AIDS Secretariat, the National Economic Council, and the Ministry of Gender also contributed to the development of the questionnaires for the survey. Financial support for the survey was provided by the United States Agency for International Development (USAID), the United Kingdom’s Department for International Development (DfID), and the United Nations Children’s Fund (UNICEF/Malawi). Technical assistance was provided by Macro International Inc., USAID-funded MEASURE DHS+ project (USA). 1.5 SAMPLE DESIGN The 2000 MDHS survey was designed to provide estimates of health and demographic indicators at the national and regional levels, for rural and urban areas, and for some districts that were designated for oversampling. The 2000 MDHS sample points (clusters) were systematically sampled from a list of enumeration areas (EAs) defined in the 1998 Malawi Census of Population and Housing. A total of 560 clusters were drawn from the census sample frame: 449 in rural areas and 111 in urban areas. Eleven districts were oversampled in the 2000 MDHS survey in order to produce reliable estimates for certain variables at the district level. The oversampled districts are: Lilongwe, Blantyre, Zomba, Mzimba, Mangochi, Kasungu, Salima, Machinga, Mulanje, Thyolo, and Karonga. Upon selecting the 560 clusters, NSO trained teams of personnel in MDHS procedures for the comprehensive listing of households and updating of maps in the selected clusters. Nine listing teams were deployed; each team was composed of ten members including a team leader and driver. Each team was provided with a Global Positioning System (GPS) unit to obtain geographic coordinates for the locality of each selected cluster. The listing of households was conducted from early April until early May 2000. After the listing operation was complete, households to be included in the MDHS survey were selected, with the number of households selected per cluster being inversely proportional to the size of the cluster. Within each selected household, all women age 15-49 were eligible for interview. Further, a one-in-four systematic subsample of households was drawn, within which all men age 15-54 were eligible for interview. 1.6 QUESTIONNAIRES Three types of questionnaires were used in the 2000 MDHS survey: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. The contents of the questionnaires were based on the MEASURE DHS+ model. A series of meetings were held with policy experts, programme managers, and other professionals in Malawi to review, adapt, and revise the questionnaires. This process culminated in English-version questionnaires that were then translated into Chichewa and Tumbuka. 1 A household is defined as one or more persons, related or unrelated, who live together, make common provisions for food, regularly take their food from the same pot or same grainstore (Nkhokwe), or pool their income for the purpose of purchasing food. Introduction * 5 The Household Questionnaire was used to list all of the usual members and visitors in the selected households1. Basic information on each person listed was collected, including age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify all of the eligible women (age 15-49) and men (age 15-54) for individual interviews. In addition, information was collected about characteristics of the household, such as the source of water, type of toilet facilities, materials used to construct the household’s dwelling, and ownership of various consumer goods. Data on child labour practises, use of bednets (mosquito nets), and nutritional status of children and women were also collected in the Household Questionnaire. The Women’s Questionnaire was used to collect information from women age 15-49 and included questions on the following topics: C Background characteristics (age, education, religion, etc.) C Reproductive history (to arrive at fertility and childhood mortality rates) C Knowledge and use of family planning methods C Antenatal and delivery care C Infant feeding practises, including patterns of breastfeeding C Childhood vaccinations C Recent episodes of childhood illness and responses to illness, especially recent fevers C Marriage and sexual activity C Fertility preferences C Woman’s status and decisionmaking C Mortality of adults, including maternal mortality C AIDS-related knowledge, attitudes, and behaviour The Men’s Questionnaire covered many of the same topics but excluded the detailed reproductive history and sections dealing with maternal and child health and adult and maternal mortality. The Men’s questionnaire is consequently much shorter than the Women’s Questionnaire. The questionnaires were pretested in February 2000 in Mzimba, Ntcheu, and Blantyre City. More than 200 interviews were conducted over a one-week period. The questionnaires were produced in three language versions: Chichewa, Tumbuka, and English. However, interviews could be conducted in any of the languages spoken in Malawi if the respondent was not fluent in one of these three languages. Adjustments in language and content were made to the questionnaires based on the lessons drawn from the pretest interviews. 1.7 TRAINING Training of field staff for the main survey was conducted over a three-week period in June and July 2000. The training took place at Chilema Ecumenical Lay Training Centre outside Zomba Municipality. A total of 200 field staff were trained. The training course consisted of instruction in general interviewing techniques, and field procedures, a detailed review of items on the questionnaires, instruction and practise in weighing and measuring children and women, mock interviews between participants, and practical interviews 6 * Introduction Table 1.2 Results of the household and individual interviews Number of households, number of interviews and response rates, according to urban-rural residence, Malawi 2000 _____________________________________________________ Residence _____________ Result Urban Rural Total _______________________________________________________ Household interviews Households sampled Households occupied Households interviewed Household response rate Individual interviews: women Number of eligible women Number of eligible women interviewed Eligible woman response rate 2,868 2,714 2,680 98.7 2,929 2,871 98.0 12,553 11,638 11,533 99.1 10,609 10,349 97.5 15,421 14,352 14,213 99.0 13,538 13,220 97.7 Individual interviews: men Number of eligible men Number of eligible men interviewed Eligible man response rate 812 721 88.8 2,566 2,371 92.4 3,377 3,092 91.6 in surrounding villages. In-depth discussions of the translations were an important part of the training programme. The trainees included 26 medically trained personnel who worked on the survey as health technicians. Of the trainees, 183 who performed satisfactorily in the training programme were selected to form the 22 teams for the fieldwork. The rest, if qualified, were employed as MDHS data entry and registry staff. 1.8 DATA COLLECTION AND DATA PROCESSING Twenty-two interviewing teams carried out the fieldwork for the MDHS survey, with each team consisting of one team leader, one field editor, four female interviewers, one health technician, one male interviewer, and one driver. On a few teams, an additional male interviewer was added. Additionally, six senior staff from NSO coordinated and supervised field activities. Data collection began on July 12 and was completed in early November 2000. Complete, field-edited questionnaires were brought to the NSO headquarters in Zomba after collection during supervisory visits by NSO senior staff. Data entry began one week after data collection started and was completed in December 2000. Office editing, coding of open-ended questions, and editing based on computer identified inconsistencies in the data continued into January 2001. The questionnaires were entered, verified, and edited using a new version of ISSA (Integrated System for Survey Analysis) adapted by ORC Macro and the U.S. Bureau of Census for integrated use in censuses and surveys. Table 1.2 shows the results of household and individual interviews for Malawi as a whole, and for urban and rural areas. A total of 15,421 households were selected in the MDHS sample, of which 14,352 were occupied. Of the occupied households, 14,213 were interviewed, yielding a household response rate of 99 percent. The household response rate was slightly higher in rural areas. Introduction * 7 Within the interviewed households, 13,538 eligible women age 15-49 were identified, of which 13,220 were interviewed. The individual women’s response rate to the 2000 MDHS survey was 98 percent. In the one-in-four subsample of households, 3,377 men age 15-54 were identified, of which 3,092 men were interviewed, giving a response rate of 92 percent. The main reason for nonresponse among both eligible men and women was the failure to find them at home despite repeated visits to the household. It is typical for male response rates to be lower than female response rates because men are more frequently absent from the household. Response rates for women were not influenced by urban-rural residence, but men’s response rates were significantly better in rural areas than in urban areas. In comparing response rates from the 1992 MDHS survey and the 2000 MDHS survey, the more recent survey performed slightly better. The women’s response rate rose from 97 to 98 percent, and the men’s response rate increased from 89 to 92 percent. Characteristics of Households * 9 CHARACTERISTICS OF HOUSEHOLDS AND HOUSEHOLD MEMBERS Richmond C. Chinula The purpose of this chapter is to provide a descriptive summary of some demographic and socioeconomic characteristics of the population in the sampled households. Also examined are environmental conditions, such as housing facilities and physical features of dwelling units. This information on the characteristics of the surveyed population is essential for the interpretation of survey findings and can provide an approximate indication of the representativeness of the MDHS survey. For the purpose of the 2000 MDHS survey, a household was defined as a person or a group of persons, related or unrelated, who live together in the same dwelling unit, who make common provisions for food and regularly take their food from the same pot or share the same grain store (nkhokwe), or who pool their income for the purpose of purchasing food. The Household Questionnaire was used to collect information on all usual residents and visitors who spent the night preceding the survey in the household. This allows the analysis of either de jure (usual residents) or de facto (those who are there at the time of the survey) populations. 2.1 HOUSEHOLD POPULATION BY AGE, SEX, AND RESIDENCE The distribution of the household population in the 2000 MDHS survey is shown in Table 2.1 by five-year age groups, according to sex and urban-rural residence. The 2000 MDHS households constitute a population of 61,725 persons. Fifty-one percent of the population is females, and 49 percent is males. Because of relatively high levels of fertility in the past, Malawi has a larger proportion of its population in the younger age groups than in the older age groups for each sex in both rural and urban areas. This pattern mirrors those observed in the 1992 MDHS survey and the 1998 Population and Housing Census. Figure 2.1 shows that the population structure is much wider at the younger ages than at the older ages. There is no evidence of a tapering at the younger ages, which would be expected in a population with declining fertility rates (see Chapter 4). This indicates that Malawi’s fertility decline is very recent and is not yet evident in the population structure. 2.2 HOUSEHOLD COMPOSITION Information about the composition of households by sex of the head of the household and size of the household is presented in Table 2.2. The data show that men head 73 percent of households in Malawi, similar to the level observed in the 1992 MDHS survey (75 percent). Female-headed households are more common in rural areas (28 percent) than in urban areas (16 percent). The average household size in Malawi is 4.4 persons. The household size is roughly the same in rural (4.4) and urban (4.5) areas. 2 10 * Characteristics of Households Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age group, according to sex and residence, Malawi 2000____________________________________________________________________________________________________ Urban Rural Total_______________________ _______________________ _______________________ Age group Male Female Total Male Female Total Male Female Total____________________________________________________________________________________________________ 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Total Number 16.1 16.5 16.3 18.5 17.8 18.1 18.1 17.6 17.9 13.8 14.0 13.9 16.3 15.3 15.8 15.9 15.2 15.5 11.0 14.3 12.6 13.8 13.5 13.6 13.4 13.6 13.5 11.6 11.7 11.7 10.0 9.0 9.5 10.3 9.3 9.8 12.4 13.3 12.8 8.2 8.9 8.6 8.8 9.5 9.2 10.2 9.2 9.7 7.0 7.4 7.2 7.5 7.6 7.5 7.2 5.7 6.5 5.0 4.8 4.9 5.4 5.0 5.1 5.8 4.5 5.2 4.6 4.5 4.5 4.7 4.5 4.6 3.4 2.9 3.2 3.6 3.4 3.5 3.5 3.3 3.4 3.1 2.5 2.8 2.8 3.0 2.9 2.8 3.0 2.9 2.2 2.0 2.1 2.7 3.6 3.2 2.6 3.4 3.0 1.3 1.1 1.2 2.2 2.5 2.4 2.0 2.3 2.2 0.8 0.7 0.8 1.8 2.2 2.0 1.6 2.0 1.8 0.4 0.8 0.6 1.5 1.6 1.5 1.3 1.5 1.4 0.2 0.4 0.3 1.1 1.1 1.1 0.9 1.0 1.0 0.1 0.1 0.1 0.6 0.6 0.6 0.5 0.6 0.6 0.2 0.3 0.2 0.6 0.6 0.6 0.5 0.6 0.6 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 4,483 4,326 8,809 25,507 27,409 52,917 29,990 31,735 61,725 ____________________________________________________________________________________________________ Note: Table is based on the de facto population; i.e., persons who stayed in the household the night before the interview. Characteristics of Households * 11 Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size, according to residence, Malawi 2000________________________________________ Residence_____________ Characteristic Urban Rural Total________________________________________ Sex of head of household Male Female Total Number of usual members 1 2 3 4 5 6 7 8 9+ Total Mean size 84.1 71.7 73.4 15.9 28.3 26.6 100.0 100.0 100.0 8.1 8.0 8.0 12.6 13.5 13.4 18.2 18.7 18.6 17.2 17.0 17.0 14.2 14.5 14.5 10.5 11.4 11.3 7.8 7.3 7.4 4.6 4.3 4.3 6.7 5.2 5.4 100.0 100.0 100.0 4.5 4.4 4.4 _______________________________________ Note: Table is based on de jure members; i.e., usual residents. Table 2.3 Children’s living arrangements Percent distribution of de jure children under age 15 by survival status of parents and children's living arrangements, according to background characteristics, Malawi 2000______________________________________________________________________________________________________ Living Living with mother with father but not father but not mother Not living with either parent Missing Living ____________ _____________ ________________________ informa- with Only Only tion on Background both Father Father Mother Mother Both father mother Both father/ characteristic parents alive dead alive dead alive alive alive dead mother Total Number______________________________________________________________________________________________________ Age <2 2-4 5-9 10-14 Sex Male Female Residence Urban Rural Region Northern Central Southern Total 75.1 21.6 1.5 0.0 0.0 1.0 0.3 0.0 0.0 0.4 100.0 4,872 68.4 18.3 2.9 0.6 0.4 7.4 0.6 0.5 0.4 0.5 100.0 6,176 58.3 15.0 5.2 1.6 0.9 12.1 2.4 2.0 1.7 0.8 100.0 9,650 48.0 13.3 7.0 2.3 1.5 14.7 4.1 3.7 4.2 1.3 100.0 8,417 61.7 16.2 4.8 1.4 0.8 8.8 1.9 1.7 1.8 0.8 100.0 14,308 . 58.9 16.4 4.4 1.2 0.8 11.2 2.5 1.9 1.9 0.8 100.0 14,806 . 63.3 9.2 5.4 2.7 1.7 10.1 1.7 2.7 2.4 0.8 100.0 3,763 59.8 17.4 4.5 1.1 0.7 10.0 2.2 1.7 1.8 0.8 100.0 25,352 . 61.3 12.6 4.0 2.1 1.7 11.7 1.3 2.4 2.0 0.7 100.0 3,349 64.6 15.2 3.7 1.2 0.8 8.9 2.0 1.5 1.3 0.6 100.0 12,524 . 55.9 18.3 5.7 1.2 0.6 10.5 2.5 2.0 2.3 1.0 100.0 13,242 60.3 16.3 4.6 1.3 0.8 10.0 2.2 1.8 1.9 0.8 100.0 29,114 2.3 FOSTERHOOD AND ORPHANHOOD Information on fosterhood and orphanhood of children under age 15 is presented in Table 2.3. The MDHS survey shows that only 60 percent of children under age 15 currently live with both of their biological parents. Twenty-one percent of children under 15 are living with their mother (but not with their father), 2 percent are living with their father (but not with their mother), and 16 percent are living with neither of their natural parents. The table also provides data on the extent of orphanhood, that is, the proportion of children who have lost one or both parents. Of children under 15 years, 8 percent have lost their father and 5 percent have lost their mother. Two percent of children have lost both their natural parents. Eleven percent have lost one or both parents. With the rates of adult illness and mortality related to HIV/AIDS rising in Malawi (see Chapter 12), the percentage of households with orphaned and foster children is expected to rise in the near term. 12 * Characteristics of Households Differentials by background characteristics in fosterhood and orphanhood are not large. As expected, older children are more likely than younger children to be fostered and orphaned. A slightly larger proportion of urban children than rural children have lost their father or both parents. 2.4 EDUCATIONAL LEVEL OF HOUSEHOLD POPULATION Education is a key determinant of the lifestyle and status an individual enjoys in a society. It affects many aspects of life, including demographic and health behaviour. Studies have consistently shown that educational attainment has strong effects on reproductive behaviour, contraceptive use, fertility, infant and child mortality, morbidity, and attitudes and awareness related to family health and hygiene. In the 2000 MDHS survey, information on educational attainment was collected for every member of the household. Table 2.4 shows the percent distribution of the de facto male and female population age 6 and over, by the highest level of education attained, according to selected background characteristics. There is a strong differential in educational attainment between the sexes, especially as age increases. Twenty-eight percent of female household members in Malawi have never been to school, compared with 16 percent of males. The proportion with no education increases with age. For example, the proportion of women who have never attended any formal schooling increases from 19 percent at age group 20-24 to 70 percent among those age 65 and over. For men, the proportion increases from 9 percent at age group 20-24 to 38 percent at age group 65 and over. About 6 percent of women and 12 percent of men have attended some secondary school. The median number of years of schooling is 1.4 for women and 2.7 for men. Overall, educational attainment is higher in urban areas than in rural areas. The proportion of women and men with secondary education is much higher in urban than in rural areas. Conversely, the proportion with no education in urban areas is one-third that in rural areas. The proportion of the population age 6 and over that has achieved any education varies among Malawi’s regions and districts. The Northern Region has the highest proportions with some education for both males (92 percent) and females (85 percent). For females, the proportion is lowest in the Southern Region (68 percent); for males, it is lowest in the Central Region (82 percent). Of the oversampled districts, Blantyre has the highest median years of education at 6.1 years for men and 4.2 years for women. Mzimba and Karonga follow at 4.5 years for men and 3.1 and 2.8, respectively, for women. The lowest educational attainment for both men and women is observed in Mangochi, where the median years of education is 1 year for men and 0 years for women. Rates of school attendance have improved since the 1992 MDHS survey, especially among females. The percentages of girls and boys age 10-14 who had never been to school were 27 and 22 percent, respectively, based on the 1992 MDHS survey. The 2000 MDHS survey indicates that these figures have improved greatly, to just 7 percent for both girls and boys. This trend can be attributed at least in part to the government’s introduction in 1994 of tuition-free primary education. Characteristics of Households * 13 Table 2.4 Educational attainment of household population Percent distribution of the de facto female and male household populations age six and over by highest level of education attended, according to background characteristics, Malawi 2000_____________________________________________________________________________________________________ Level of education___________________________________________________ No 0-4 5-8 More Don't Median Background educa- years of years of Secon- than know/ number characteristic tion primary primary dary secondary missing Total Number of years_____________________________________________________________________________________________________ FEMALE____________________________________________________________________________________________________ Age 6-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Residence Urban Rural Region Northern Central Southern Districts Blantyre Karonga Kasungu Lilongwe Machinga Mangochi Mulanje Mzimba Salima Thyolo Zomba Other districts Total 25.7 73.6 0.2 0.0 0.0 0.5 100.0 4,029 0.0 6.8 76.3 15.9 0.8 0.0 0.3 100.0 4,311 2.1 8.0 33.7 44.4 13.9 0.0 0.0 100.0 2,961 4.6 18.8 32.8 30.5 17.7 0.1 0.0 100.0 3,013 3.8 30.2 28.9 30.4 10.1 0.3 0.1 100.0 2,417 2.7 34.5 29.0 29.5 7.0 0.1 0.0 100.0 1,572 2.1 39.5 28.9 25.1 6.4 0.1 0.0 100.0 1,439 1.6 46.9 27.2 20.9 4.8 0.1 0.0 100.0 1,057 0.4 48.9 30.5 16.6 3.8 0.1 0.0 100.0 939 0.0 55.0 30.1 11.5 2.4 0.1 1.0 100.0 1,082 0.0 60.4 30.7 6.6 1.3 0.0 0.9 100.0 742 0.0 65.0 31.5 2.9 0.3 0.0 0.4 100.0 644 0.0 70.0 25.8 3.5 0.2 0.0 0.5 100.0 1,158 0.0 11.7 33.3 31.1 23.3 0.4 0.2 100.0 3,519 4.7 31.1 47.0 18.3 3.3 0.0 0.2 100.0 21,843 1.0 14.9 39.9 36.7 8.1 0.0 0.3 100.0 2,843 3.4 27.7 48.8 18.3 5.0 0.1 0.2 100.0 10,368 1.3 32.2 43.2 17.7 6.6 0.1 0.2 100.0 12,152 1.1 11.2 37.5 28.6 22.3 0.4 0.1 100.0 2,169 4.2 18.0 42.7 33.2 5.7 0.0 0.3 100.0 500 2.8 19.8 49.0 25.9 5.2 0.1 0.0 100.0 928 2.1 25.5 48.5 18.3 7.3 0.1 0.2 100.0 3,595 1.4 41.8 43.6 11.8 2.3 0.0 0.3 100.0 952 0.3 48.0 39.5 9.6 2.6 0.0 0.3 100.0 1,335 0.0 29.2 52.2 15.3 2.7 0.0 0.6 100.0 1,201 1.0 16.1 40.9 35.9 6.8 0.1 0.3 100.0 1,190 3.1 37.9 43.1 14.3 4.5 0.1 0.1 100.0 607 0.6 31.0 47.7 18.2 3.1 0.0 0.1 100.0 1,340 1.0 31.8 44.7 19.7 3.6 0.0 0.2 100.0 1,547 1.3 30.5 45.7 19.2 4.3 0.0 0.2 100.0 9,999 1.2 28.4 45.1 20.1 6.1 0.1 0.2 100.0 25,363 1.4 ___________________________________________________________________________________________________ MALE____________________________________________________________________________________________________ Age 6-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Residence Urban Rural Region Northern Central Southern Districts Blantyre Karonga Kasungu Lilongwe Machinga Mangochi Mulanje Mzimba Salima Thyolo Zomba Other districts Total 28.5 70.8 0.2 0.0 0.0 0.5 100.0 3,952 0.0 7.4 78.5 13.4 0.6 0.0 0.2 100.0 4,011 1.8 5.4 35.0 46.9 12.6 0.0 0.1 100.0 3,080 4.7 9.4 23.7 34.3 32.0 0.5 0.1 100.0 2,645 6.3 12.4 24.5 35.9 26.3 0.7 0.1 100.0 2,242 5.6 16.5 22.3 40.5 19.5 1.0 0.1 100.0 1,606 5.5 18.3 22.3 40.9 17.3 1.0 0.3 100.0 1,424 5.4 17.9 22.3 43.3 14.5 1.2 0.8 100.0 1,064 5.0 20.3 27.8 38.8 11.6 1.0 0.3 100.0 849 4.2 22.1 33.2 34.0 9.5 0.7 0.4 100.0 782 3.4 27.1 32.8 30.6 7.3 1.0 1.2 100.0 609 2.6 34.6 41.7 17.6 5.0 0.5 0.6 100.0 486 1.6 38.3 42.6 16.1 2.3 0.2 0.6 100.0 998 1.2 5.5 27.8 31.8 32.8 2.0 0.2 100.0 3,642 6.8 18.4 46.9 26.2 8.1 0.1 0.3 100.0 20,104 2.3 8.0 36.7 37.9 16.7 0.6 0.1 100.0 2,656 4.7 18.2 45.9 25.2 10.2 0.2 0.3 100.0 10,143 2.4 16.8 43.9 26.1 12.3 0.5 0.4 100.0 10,947 2.6 5.9 30.4 30.2 31.1 2.2 0.1 100.0 2,181 6.1 8.2 38.1 38.6 14.6 0.1 0.5 100.0 475 4.5 13.1 42.7 32.3 11.5 0.2 0.1 100.0 957 3.3 16.4 44.5 24.6 13.9 0.4 0.2 100.0 3,705 2.7 24.7 47.2 20.8 6.6 0.3 0.5 100.0 792 1.8 29.3 45.3 18.8 5.9 0.1 0.6 100.0 1,172 1.0 15.5 50.4 26.9 6.3 0.2 0.6 100.0 991 2.3 8.4 37.4 39.4 14.1 0.7 0.1 100.0 1,076 4.5 25.2 41.6 22.4 10.4 0.1 0.3 100.0 540 1.8 15.4 47.0 28.9 8.4 0.1 0.3 100.0 1,089 2.6 16.5 44.6 29.0 9.5 0.1 0.3 100.0 1,396 2.6 17.9 46.6 26.1 9.0 0.2 0.3 100.0 9,372 2.3 16.4 44.0 27.0 11.9 0.4 0.3 100.0 23,747 2.7 ____________________________________________________________________________________________________ Note: Totals include 3 women and 6 men for whom information on age is not available. 14 * Characteristics of Households Table 2.5 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de jure household population by level of schooling and sex, according to background characteristics, Malawi 2000 ________________________________________________________________________________________ Net attendance ratio (NAR)1 Gross attendance ratio (GAR)2 Background ____________________________ ___________________________ characteristic Male Female Total Male Female Total ________________________________________________________________________________________ PRIMARY SCHOOL ________________________________________________________________________________________ Residence Urban Rural Region Northern Central Southern Total 90.1 87.5 88.7 123.9 107.8 115.4 75.2 77.9 76.6 109.6 101.5 105.5 86.3 89.9 88.2 128.5 116.4 122.2 74.7 78.5 76.6 107.0 100.9 103.9 77.0 77.2 77.1 111.3 100.1 105.6 77.0 79.2 78.2 111.4 102.4 106.8 ________________________________________________________________________________________ SECONDARY SCHOOL ________________________________________________________________________________________ Residence Urban Rural Region Northern Central Southern Total 23.4 30.0 26.6 75.5 61.8 69.0 3.7 5.0 4.3 24.9 13.0 19.2 8.0 15.0 11.6 46.1 25.3 35.5 5.8 7.0 6.4 30.8 17.4 24.5 7.3 8.5 7.8 30.9 21.6 26.4 6.7 8.8 7.7 32.6 20.4 26.8 ________________________________________________________________________________________ 1 The NAR for primary school is the percentage of the primary-school-age (6-13 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (14-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, among those of any age, expressed as the percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students (up to age 24), expressed as the percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 2.5 SCHOOL ATTENDANCE The 2000 MDHS collected information that allows calculation of net attendance ratios (NARs) and gross attendance ratios (GARs). The NAR for primary school is the percentage of the primary-school-age (6-13 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (14-17 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. The GAR for primary school is the total number of primary school students, of any age, expressed as the percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students up to an age limit of 24 years, expressed as the percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. Table 2.5 presents the NARs and GARs by urban-rural residence and region, according to sex for primary school and secondary school. Findings indicate that among children within the official age range for primary school, slightly more girls are attending school than boys (79 versus Characteristics of Households * 15 Table 2.6 Grade repetition and dropout rates Repetition and dropout rates for the de jure household population age 5-24 years by school standard, sex, residence, and region, Malawi 2000___________________________________________________________________________________________ Primary school standard______________________________________________________________________ Characteristic 1 2 3 4 5 6 7 8_________________________________________________________________________________________ REPETITION RATE1_________________________________________________________________________________________ Sex Male Female Residence Urban Rural Region Northern Central Southern Total 43.9 23.6 28.5 17.8 16.1 14.3 11.3 40.2 46.7 24.9 25.7 16.5 14.2 10.4 11.4 35.9 29.1 16.4 24.7 9.2 12.4 12.0 12.4 27.2 47.1 25.3 27.6 18.5 15.8 12.6 11.0 43.3 42.7 17.2 22.4 19.7 14.3 12.4 18.1 49.8 46.7 24.5 28.3 15.2 12.9 10.9 8.0 34.9 44.6 25.9 27.5 18.0 17.4 13.8 10.7 35.5 45.3 24.2 27.2 17.2 15.2 12.5 11.4 38.6 ___________________________________________________________________________________________ DROPOUT RATE2_________________________________________________________________________________________ Sex Male Female Residence Urban Rural Region Northern Central Southern Total 3.3 3.1 4.7 4.8 6.9 4.9 6.2 9.9 2.2 3.5 4.0 6.2 6.5 9.0 9.7 14.1 1.0 0.6 1.7 1.1 2.5 4.6 2.7 5.4 2.9 3.7 4.8 6.3 7.6 7.4 9.5 14.0 1.1 1.1 1.5 1.8 3.0 4.7 8.3 11.4 2.0 2.3 4.3 4.0 6.5 6.6 6.9 10.5 3.9 4.8 5.1 7.8 8.2 7.8 7.9 12.4 2.7 3.3 4.3 5.5 6.7 6.9 7.7 11.5 ___________________________________________________________________________________________ 1 The repetition rate is the percentage of students in a given standard who are repeating that standard. 2 The dropout rate is the percentage of students in a given standard in the previous school year who are not currently attending school. 77 percent). However the GAR shows that, overall, more boys are attending than girls. It is also shown that the primary net attendance ratio is highest for children in the Northern Region (88 percent), followed by the Central and Southern regions (both 77 percent). The NAR for primary school is also higher in urban areas (89 percent) than in rural areas (77 percent). Secondary school attendance ratios are much lower and differ substantially by background characteristics. The NAR in urban areas is six times higher than the NAR in rural areas. The same regional patterns exist for secondary school attendance ratios as for educational attainment: the Northern Region has the highest attendance ratios with the Central and Southern regions being slightly lower. Overall, the net attendance ratio is 8, indicating only 8 percent of secondary-school- age children are attending school at roughly the correct ages. The gross attendance ratio of 27 percent (secondary school) indicates that a substantial proportion of secondary school students are outside the official age range. By asking about the grade or standard that children were attending during the previous school year, it is possible to calculate dropout rates and repetition rates. Table 2.6 indicates that repetition rates are high in Standard 1 (45 percent), which may be related to the teachers’ decision 16 * Characteristics of Households to ensure a more uniform preparedness before promoting children to Standard 2. Repetition rates decline at higher standards, but increase at Standard 8, due to failed attempts at getting into a secondary school. The second panel of Table 2.6 shows a pattern of increasing dropout rates with increasing year in school. Only 3 percent of children drop out of school after having attended Standard 1 compared with a dropout rate of 12 percent at Standard 8. Notable is that the dropout rate at Standard 8 is higher for girls than for boys, while the repetition rate at Standard 8 is higher for boys than for girls (first panel of Table 2.6). This suggests that, despite initiatives to promote continuation of girls’ schooling, boys are still able (to a greater extent than girls) to persist in moving on past a primary education. Boys are more likely to repeat Standard 8, which allows repeat attempts at entry to secondary schools, while girls are more likely to leave school. Rural children are more likely to drop out at all standards than their urban counterparts. Children from the Southern Region are more likely to dropout than children in the Northern or Central regions, except in Standards 7 and 8. 2.6 CHILD LABOUR In the 2000 MDHS survey, information was collected on the work activities of children age 5-14. Working children have less opportunity to attend school and are more susceptible than adults to unfair working environments, including low or no pay, poor working conditions, and physical abuse. Despite policies and laws designed to curtail exploitative child labour, the practise continues in many settings. The 2000 MDHS survey asked a series of questions about whether children age 5-14 were doing any kind of work for pay, whether children regularly did unpaid family work on the farm or in a family business, and whether and to what extent (number of hours) children helped with household chores. Table 2.7 shows that 9 percent of children age 5-14 are doing work for nonrelatives, about two-thirds of these without pay. Sixty-two percent are working in the family business or on the family farm, and 19 percent of children are doing four or more hours of domestic work per day. Overall, 27 percent of children are either working for a nonrelative (paid or unpaid) or spending four or more hours a day doing household chores. Older children are much more likely to be working than younger children. Although boys are more likely to be involved in four or more hours of domestic work per day, there is little difference in the overall percentage engaged in work (26 to 28 percent). Urban children are much less likely to be involved in work than urban children. Children in the Northern Region (13 percent) are more likely than those in the Central Region (5 percent) and Southern Region (4 percent) to be working without pay for nonrelatives. Children in the Northern Region are also more likely to be employed on the family farm or in the family business. Characteristics of Households * 17 2.7 HOUSING CHARACTERISTICS MDHS respondents were asked about their household environment, including questions on access to electricity, sources of drinking water, time to water sources, type of toilet facilities and floor materials, and possession of various durable goods. This information is summarised in Table 2.8. About 5 percent of households in Malawi have electricity. Electricity is much more common in urban areas (29 percent) than in rural areas (1 percent). A household’s source of drinking water is important because potentially fatal diseases, including typhoid, cholera, and dysentery, are prevalent in unprotected sources. Sources of water expected to be relatively free of these diseases are piped water and water drawn from protected wells and deep boreholes. Other sources, like unprotected wells and surface water (rivers, streams, ponds, and lakes), are more likely to carry disease-causing agents. Table 2.8 shows that overall, 65 percent of Malawian households have access to clean water sources (23 percent from piped water plus 42 percent from protected wells or boreholes). This represents a substantial increase since the 1992 MDHS survey when just 47 percent of households had access to similar water sources. Most of this gain is the result of a doubling in the percentage of rural households that now have access to water from protected wells or boreholes from 24 percent in 1992 to 47 percent in 2000. These findings describe one of the most important public health advances in Malawi during the 1990s and may be an important reason for the declines in mortality among young children (see Chapter 8). Table 2.7 Child labour Percentage of children age 5-14 years who are currently working, by type of work and background characteristics, Malawi 2000 _________________________________________________________________________________ Currently Currently doing doing domestic work for: work on _________________ Working for family Less 4 or non-relatives farm or than more Number Background ______________ family 4 hours hours Currently of characteristic Paid Unpaid business per day per day working1 children __________________________________________________________________________________ Age 5-9 1.3 4.2 49.2 1.7 8.1 13.8 9,573 10-14 5.1 7.3 76.6 6.3 30.6 42.1 8,321 Gender Male 3.2 4.4 53.8 2.6 21.1 27.6 8,775 Female 3.0 6.8 69.7 5.1 16.1 26.4 9,120 Residence Urban 1.6 3.7 63.2 4.4 10.6 17.7 2,334 Rural 3.3 6.0 61.8 3.8 19.8 28.4 15,560 Region Northern 2.2 12.9 70.8 4.0 20.2 31.8 2,099 Central 3.7 5.3 61.6 3.8 16.8 25.4 7,686 Southern 2.8 4.1 60.0 3.9 19.9 27.2 8,110 Total 3.1 5.7 61.9 3.9 18.6 27.0 17,894 __________________________________________________________________________________ 1Working means doing paid or unpaid work or doing domestic work for four or more hours a day. 18 * Characteristics of Households Table 2.8 Housing characteristics Percent distribution of households by housing characteristics, according to residence, Malawi 2000_____________________________________________________ Residence Housing ______________ characteristic Urban Rural Total_____________________________________________________ Electricity Yes No Missing Total Source of drinking water Piped into dwelling Piped into yard/plot Community stand pipe Protected well Borehole Unprotected well Surface water Total Time to water source (in minutes) Percentage <15 minutes Median time to source Sanitation facility Own flush toilet Pit latrine No facility/bush Missing Total Main floor material Earth/sand/dung Cement or other modern material Total Number 28.7 1.0 4.8 71.2 98.8 95.0 0.1 0.2 0.2 100.0 100.0 100.0 17.1 0.6 2.8 24.6 1.1 4.3 41.8 12.1 16.2 3.0 6.6 6.1 8.3 40.1 35.8 3.9 27.0 23.8 1.3 12.5 10.9 100.0 100.0 100.0 65.4 28.3 33.4 4.8 19.9 19.6 16.4 0.7 2.9 81.8 78.0 78.5 1.8 21.2 18.5 0.0 0.1 0.1 100.0 100.0 100.0 31.5 89.1 81.2 68.5 10.9 18.8 100.0 100.0 100.0 1,949 12,264 14,213 As expected, a far greater propor- tion of urban than rural households have access to piped water (84 versus 14 per- cent). In urban areas, 65 percent of the households have access to water within 15 minutes, compared with 28 percent of rural households. Modern sanitation facilities are not yet available to large proportions of Malawian households. The use of tradi- tional pit latrines is still common in both urban and rural areas, accounting for 79 percent of all households. Overall, about 19 percent of the households in Malawi have no toilet facilities. This problem is more common in rural areas, where 21 percent of the households have no toilet facilities, compared with 2 percent of households in urban areas. The type of material used for flooring is an indicator of the economic standing of the household as well as an indicator of potential exposure to disease-causing agents. Overall, 81 per- cent of all households in Malawi live in residences with floors made of earth, sand, or dung, while 19 percent live in houses with finished floors like those made of cement or wooden panels. Earth flooring is almost universal in rural areas (89 percent). Respondents were also asked about their household’s ownership of particular durable goods. In addition to providing an indicator of economic status, ownership of these goods provides measures of other aspects of life. Ownership of a radio and a television is a measure of access to mass media; ownership of a refrigerator indicates a capacity for more hygienic food storage; and ownership of a bicycle, motorcycle, or car reflects means of transport and thus employment opportunities available to households. Information on ownership of these items is presented in Table 2.9. Possession of the specific durable goods referenced in the MDHS survey is not common in Malawi, since many households simply cannot afford them. Nationally, 55 percent of households own a radio and only 2 percent of households own a television. Bicycles are the most common type of vehicle owned by households; 43 percent of households have a bicycle. Ownership of motorised transport is rare. Only 2 percent of households have cars and even fewer (only 1 percent) have motorcycles. As expected, urban households are more likely than rural households to own the items listed, except for bicycles, which are more commonly owned in rural areas. For example, 80 percent of urban households have radios, compared with 51 percent of rural households. Most households (91 percent) own a paraffin lamp. Characteristics of Households * 19 Table 2.9 Household durable goods Percentage of households possessing various durable consumer goods and means of transport, by residence, Malawi 2000 ____________________________________________________ Residence Durable ______________ consumer goods Urban Rural Total ____________________________________________________ Household possessions Radio Television Paraffin lamp Means of transport Bicycle Motorcycle/scooter Car/truck None of the above Number of households 79.5 50.8 54.8 13.7 0.5 2.3 83.6 91.9 90.7 28.4 45.8 43.4 1.3 0.9 1.0 6.4 0.8 1.6 1.8 5.9 5.3 1,949 12,264 14,213 Ownership of radios, televisions, and bicycles has increased substantially since 1992. For example, the proportion of households with radios has increased from 33 to 55 percent and the proportion with bicycles has increased from 21 to 43 percent. Characteristics of Respondents * 21 CHARACTERISTICS OF RESPONDENTS AND WOMEN’S STATUS Sophie Kang’oma This chapter provides a demographic and socioeconomic profile of the 2000 Malawi DHS sample of individual female and male respondents. The chapter begins by describing basic background characteristics of men and women, including age, martial status, educational level, and residential characteristics. Next, more detailed information on education, literacy, and exposure to mass media among men and women are provided. Last, data on the employment and earnings of women, decisionmaking in the household, and attitudes on women’s position in relation to others in the household are presented. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Background characteristics of women age 15-49 and men age 15-54 interviewed in the 2000 MDHS survey are presented in Table 3.1. Generally, the proportion of respondents in each age group declines as age increases. Seventy percent of women and 59 percent of men were currently married as of the survey date. An additional 1 percent of women and nearly 3 percent of men reported being in an informal marriage or living together. For purposes of the 2000 MDHS survey and in presentation of findings throughout later chapters of this report, informal marriages are typically grouped together with formalised marriages to form the group “currently married” or “in union”. Because men get married later in life than women, more than one-third (35 percent) of the surveyed men have never married, compared with just 17 percent of women. Women were three times more likely than men to be divorced, widowed, or separated. As expected, most of the interviewed women and men reside in rural areas (82 percent of males and 84 percent of females). The largest proportion of the male and female respondents live in the Southern Region (47 and 49 percent, respectively), while 42 and 40 percent of men and women live in the Central Region. Only 11 percent of both men and women live in the Northern Region. Table 3.1 also shows the distribution of men and women by district, including those districts that were oversampled to allow for the estimation of certain indicators presented later in the report. Notable is the large difference between the weighted number of men and women and the unweighted number in some districts. The unweighted number represents the number that were actually interviewed in the 2000 MDHS survey; whereas the weighted number represents that district’s proportional representation in the population based on the 1998 census population distribution. For instance, Karonga District has only 2 percent of the national population of women age 15-49 (as represented by 266 weighted cases), but 941 women were actually interviewed (or 7 percent of the total number of interviewed women). This is mentioned so that the reader will understand that while weighted numbers are presented throughout the report, the district estimates may be based on a significantly large number of unweighted male or female individual interviews. 3 22 * Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men by background characteristics, Malawi 2000__________________________________________________________________________________ Women Men__________________________ ___________________________ Un- Un- Background Weighted Weighted weighted Weighted Weighted weighted characteristic percent number number percent number number__________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 Marital status Never married Married Living together Divorced/separated/widowed Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary Higher District Blantyre Karonga Kasungu Lilongwe Machinga Mangochi Mulanje Mzimba Salima Thyolo Zomba Other districts Total 21.7 2,867 2,914 21.4 660 674 22.4 2,957 2,998 19.4 598 584 18.2 2,401 2,358 17.4 539 544 11.8 1,566 1,574 10.7 330 335 10.8 1,424 1,410 11.0 340 333 8.0 1,053 1,052 7.8 240 240 7.2 951 914 6.7 207 209 na na na 5.7 177 173 17.0 2,243 2,284 34.7 1,073 1,064 70.2 9,282 9,155 59.2 1,830 1,807 1.3 170 206 2.5 76 96 11.5 1,525 1,575 3.7 113 125 15.9 2,106 2,871 18.2 564 721 84.1 11,114 10,349 81.8 2,528 2,371 11.0 1,453 2,187 11.3 351 544 40.3 5,321 4,508 41.9 1,296 1,116 48.8 6,446 6,525 46.8 1,446 1,432 27.0 3,574 3,372 10.4 322 301 30.4 4,025 3,829 29.0 898 822 31.4 4,152 4,390 40.2 1,243 1,269 11.0 1,452 1,608 19.9 614 682 0.1 16 21 0.5 15 18 10.0 1,324 1,023 10.4 321 252 2.0 266 941 2.1 64 245 3.7 484 728 4.6 142 215 14.1 1,864 871 15.7 487 217 3.6 481 798 3.8 119 173 4.8 637 654 5.0 154 154 4.7 624 905 3.8 117 171 4.6 603 781 4.6 142 199 2.3 301 784 2.1 65 174 5.2 687 882 4.5 141 179 6.4 846 899 5.7 177 213 38.6 5,103 3,954 37.6 1,163 900 100.0 13,220 13,220 100.0 3,092 3,092 ___________________________________________________________________________________ Note: Education refers to the highest level ever attended whether or not that level was completed. na = Not applicable Characteristics of Respondents * 23 Table 3.2 Educational attainment by background characteristics Percent distribution of women and men by highest level of schooling attended, and median number of years of schooling completed, according to background characteristics, Malawi 2000 ____________________________________________________________________________________________ Highest level of schooling attended Median ________________________________________________________ years of Background No edu- Primary Primary Secon- More than schooling characteristic cation 1-4 5-8 dary secondary Total Number completed ____________________________________________________________________________________________ WOMEN ____________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Northern Central Southern Total 7.7 32.9 45.2 14.2 0.0 100.0 2,867 4.7 18.5 32.5 31.1 17.7 0.1 100.0 2,957 3.9 30.0 29.1 30.6 9.9 0.3 100.0 2,401 2.8 34.9 28.3 29.8 6.9 0.1 100.0 1,566 2.2 40.1 28.7 24.8 6.3 0.1 100.0 1,424 1.5 47.0 26.8 21.2 4.9 0.1 100.0 1,053 0.4 49.6 30.3 16.4 3.6 0.1 100.0 951 0.0 10.3 14.2 39.1 35.7 0.6 100.0 2,106 7.0 30.2 33.5 29.9 6.3 0.0 100.0 11,114 2.5 11.1 18.0 56.4 14.4 0.0 100.0 1,453 5.6 26.9 34.0 29.7 9.2 0.1 100.0 5,321 2.8 30.7 30.3 27.2 11.7 0.1 100.0 6,446 2.7 27.0 30.4 31.4 11.0 0.1 100.0 13,220 3.1 ___________________________________________________________________________________________ MEN ___________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 Residence Urban Rural Region Northern Central Southern Total 3.3 32.9 51.6 12.1 0.0 100.0 660 5.0 5.4 26.8 35.6 32.1 0.1 100.0 598 6.4 7.5 31.6 33.9 26.1 0.9 100.0 539 5.6 15.9 23.3 37.4 22.9 0.5 100.0 330 5.8 15.9 27.6 40.0 15.1 1.4 100.0 340 4.8 17.2 24.5 44.0 14.0 0.3 100.0 240 4.9 21.7 30.2 36.9 11.1 0.1 100.0 207 3.8 19.0 32.6 36.7 10.2 1.5 100.0 177 3.8 3.4 10.4 39.3 45.0 1.9 100.0 564 7.7 12.0 33.2 40.4 14.3 0.2 100.0 2,528 4.5 2.7 12.6 58.8 25.5 0.3 100.0 351 7.2 11.8 32.0 39.1 16.5 0.7 100.0 1,296 4.6 11.1 30.4 36.7 21.5 0.4 100.0 1,446 4.9 10.4 29.0 40.2 19.9 0.5 100.0 3,092 5.1 3.2 EDUCATIONAL ATTAINMENT Table 3.2 shows the percent distribution of respondents by highest level of schooling attained according to their age and place of residence. Young women and men are more likely to have attended school than the older generation. The distribution of respondents who have never attended school rises with increasing age. For example, 8 percent of women and 3 percent of men age 15-19 have no formal education, compared with 50 percent of women and 22 percent of men 24 * Characteristics of Respondents age 45-49. Similarly, 18 percent of women age 20-24 attended secondary school, compared with only 4 percent of women age 45-49. For the male respondents, 32 percent of men age 20-24 attended secondary school, compared with just 10 percent of men age 50-54. The MDHS data indicate that educational opportunities vary among the respondents according to their areas of residence. Urban women and men are more likely to go to school than their rural counterparts. Only 10 percent of urban women and 3 percent of urban men have not attended school, compared with 30 percent and 12 percent in rural areas, respectively. Comparing the median completed years of education shows a similar differential, with urban women having a median of seven years of schooling and rural respondents having only three years. At the regional level, the proportion of women who have no formal education is lower in the Northern Region (11 percent), compared with to the Central Region (27 percent) and the Southern Region (31 percent). Secondary education (or higher) is most common for men (26 percent) and women (14 percent) who reside in the Northern Region and is least common for men (17 percent) and women (9 percent) residing in the Central Region. 3.3 LITERACY The ability to read is an important personal asset allowing women and men increased opportunities in life. In the 2000 MDHS survey, persons were defined as literate based on the UNICEF definition: persons who are able to read a complete sentence or those with some secondary education. Knowing the distribution of the literate population can help planners, especially for health and family planning, know how to reach women and men with their messages. Table 3.3 shows that especially for women, there has been a marked increase in the percent literate over time. Only 25 percent of women age 45-49 are literate compared with 67 percent of women age 15-19. The level of literacy is higher among men (72 percent) than women (49 percent). Urban respondents have a higher level of literacy (75 percent for women and 88 percent for men) than rural respondents (44 and 69 percent, respectively). For both women and men, the Northern Region has the highest literacy rate: almost 15 percentage points higher than the other two regions. 3.4 ACCESS TO MASS MEDIA The 2000 MDHS survey collected information on the exposure of respondents to the various common print and electronic media. Respondents were asked how often they read a newspaper, listened to the radio, or watched television in a week. This information is useful to family planning and health programmers to enable them to know how to reach targeted groups. Although more than one-half of the women and men listen to the radio at least once a week, a much smaller proportion read newspapers or watch television. Data in Table 3.4 show that 52 percent of interviewed women and 70 percent of interviewed men listen to the radio at least once a week. Only 4 percent of women and 9 percent of men watch television at least once a week. About one in five men and one in ten women read a newspaper at least once a week. Less than half of the interviewed women (46 percent) and one-quarter of men (26 percent) have no access to any type of mass media. Characteristics of Respondents * 25 Table 3.3 Literacy Percent distribution of women and men by level of schooling attended, level of literacy, and percent literate, according to background characteristics, Malawi 2000_______________________________________________________________________________________________ No schooling or primary school ______________________________________ No card in Cannot Can read Can read respon- Secondary Background read part of a a whole dent’s school or Percent characteristic at all sentence sentence language1 higher Total Number literate_______________________________________________________________________________________________ WOMEN_______________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Northern Central Southern Total 24.2 8.4 52.9 0.2 14.2 100.0 2,867 67.2 36.5 7.8 37.8 0.1 17.8 100.0 2,957 55.7 46.4 7.7 35.6 0.1 10.2 100.0 2,401 45.8 49.8 8.9 34.2 0.2 6.9 100.0 1,566 41.1 53.1 7.7 32.8 0.0 6.4 100.0 1,424 39.2 63.3 6.4 25.2 0.1 5.0 100.0 1,053 30.2 68.1 7.1 21.0 0.1 3.7 100.0 951 24.5 17.5 7.1 38.8 0.2 36.4 100.0 2,106 75.1 48.3 8.0 37.3 0.1 6.3 100.0 11,114 43.6 28.7 8.5 47.8 0.5 14.5 100.0 1,453 62.5 43.5 7.9 39.1 0.1 9.4 100.0 5,321 48.5 46.6 7.7 33.9 0.0 11.8 100.0 6,446 45.7 43.4 7.9 37.5 0.1 11.1 100.0 13,220 48.6 _______________________________________________________________________________________________ MEN_______________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 Residence Urban Rural Region Northern Central Southern Total 17.2 8.5 61.6 0.6 12.1 100.0 660 73.5 15.9 7.5 44.3 0.1 32.2 100.0 598 76.5 20.5 5.5 46.9 0.2 26.9 100.0 539 74.0 21.8 5.1 49.7 0.0 23.4 100.0 330 73.1 25.9 4.4 53.3 0.0 16.5 100.0 340 69.7 23.9 11.6 50.1 0.1 14.3 100.0 240 64.5 28.3 5.6 54.1 0.7 11.2 100.0 207 65.5 22.8 8.4 57.2 0.0 11.7 100.0 177 68.9 5.4 6.3 40.9 0.4 46.9 100.0 564 87.6 23.9 7.1 54.3 0.2 14.4 100.0 2,528 68.6 9.5 3.6 60.5 0.5 25.8 100.0 351 86.5 24.4 6.5 51.7 0.3 17.2 100.0 1,296 68.6 19.7 8.3 49.9 0.1 21.9 100.0 1,446 71.7 20.5 7.0 51.9 0.2 20.4 100.0 3,092 72.1 _________________________________________________________________________________________________ Note: Percent literate includes those who have attended secondary school and those who can read a whole sentence. 1 Literacy cards for reading a sentence were available only in the major languages. Urban residents and in general younger respondents have more access to all three types of media than their rural or older counterparts. In the Northern Region, where the literacy rate is high, both women and men are more likely to read a newspaper weekly than in the Central or Southern regions. Respondents of both sexes in the Southern Region and urban areas have greater exposure to televisions and radios. Accessibility to all mass media is lower among the Central Region residents. 26 * Characteristics of Respondents Table 3.4 Exposure to mass media Percentage of women and men who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Malawi 2000 ___________________________________________________________________________________________ Reads a Watches Listens to newspaper television the radio No at least at least at least All Background mass once a once a once a three characteristic media week week week media Number ___________________________________________________________________________________________ WOMEN ___________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 44.1 14.6 4.7 52.4 2.5 2,867 43.6 10.8 4.2 54.3 2.7 2,957 45.5 9.6 3.5 53.6 2.3 2,401 46.4 8.1 3.5 52.3 2.0 1,566 45.9 6.8 3.2 53.2 2.0 1,424 51.6 5.2 3.1 47.3 1.2 1,053 52.4 4.6 2.4 46.5 1.0 951 20.7 28.4 18.0 76.2 11.2 2,106 50.7 6.2 1.1 47.8 0.5 11,114 43.7 23.4 3.6 50.7 2.6 1,453 49.5 7.6 2.7 49.0 1.3 5,321 43.4 8.5 4.7 55.4 2.8 6,446 59.7 0.2 0.5 40.1 0.0 3,574 52.0 2.7 0.9 47.1 0.1 4,025 38.8 12.7 2.8 58.2 1.1 4,152 15.7 44.4 22.2 79.9 16.4 1,468 45.9 9.8 3.8 52.3 2.2 13,220 ___________________________________________________________________________________________ MEN ___________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 24.8 22.2 10.9 69.0 3.8 660 28.2 24.0 13.1 66.8 7.2 598 26.4 21.9 10.3 70.5 5.8 539 20.4 26.3 6.5 75.2 3.9 330 31.2 18.2 5.8 65.4 3.5 340 23.7 18.5 2.4 74.6 2.0 240 25.4 20.6 3.6 72.9 2.2 207 29.2 11.2 1.4 67.3 0.6 177 10.4 53.8 25.6 82.8 17.2 564 29.7 14.3 4.7 66.7 1.5 2,528 33.2 34.7 6.4 54.5 3.3 351 29.0 16.1 6.1 67.8 2.3 1,296 21.9 23.1 11.1 75.0 6.5 1,446 44.4 1.6 1.8 53.1 0.0 322 34.2 5.6 3.4 64.3 0.9 898 23.9 21.7 6.8 70.3 1.9 1,243 9.9 54.0 22.4 84.6 16.5 629 26.2 21.5 8.5 69.7 4.4 3,092 Characteristics of Respondents * 27 Education is strongly associated with mass media exposure. For instance, about 16 percent of women and men with secondary or more education were likely to have access to all three types of media versus less than 2 percent for the other education categories. Men have greater exposure to the mass media than women. As Figure 3.1 presents, this differential applies within every population subgroup. 3.5 WOMEN’S EMPLOYMENT Respondents were asked a number of questions to elicit their employment status at the time of the survey and the continuity of their employment in the 12 months prior to the survey. The measurement of women’s employment is difficult because some of the activities that women do, especially work on family farms, family businesses, or in the informal sector are often not perceived by women themselves as employment and hence are not reported as such. To avoid underestimating women’s employment, the MDHS survey asked women several questions to ascertain their employment status. First women were asked, “Aside from your own housework, are you currently working?” Women who answered “no” to this question were then asked, “As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business, or work on the family farm or in the family business. Are your currently doing any of these things or any other work?” Women who answered “no” to this question were asked,“Have you done any work in the last 12 months?” Women are currently employed if they answered “yes” to either of the first two questions. Women who answered “yes” to the third question are not currently employed but have worked in the past 12 months. All employed women were asked their occupation; whether they were paid in cash, in kind, or not at all; and for whom they worked. 28 * Characteristics of Respondents Table 3.5 Employment of women Percent distribution of women by employment status and continuity of employment, according to background characteristics, Malawi 2000 ____________________________________________________________________________________ Not currently employed __________________ Did not Worked work in the in the Currently employed 12 mos. 12 mos. ______________________ preced- preced- Background ing the ing the All Season- Occasion- characteristic survey survey year ally ally Total Number ____________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Current marital status Never married Currently married/ living together Divorced, separated, widowed Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 54.7 5.5 10.7 24.6 4.4 100.0 2,867 42.0 4.4 16.7 31.8 5.1 100.0 2,957 37.0 3.7 20.8 33.6 4.8 100.0 2,401 31.0 4.4 23.7 34.8 6.2 100.0 1,566 28.8 4.6 23.7 38.0 4.8 100.0 1,424 28.2 4.4 24.4 38.2 4.9 100.0 1,053 27.8 5.3 21.4 40.0 5.6 100.0 951 58.2 4.9 12.7 19.8 4.4 100.0 2,243 36.7 4.5 18.8 35.4 4.6 100.0 9,452 25.2 5.1 26.9 34.6 8.2 100.0 1,525 52.7 4.7 14.0 24.0 4.6 100.0 3,216 38.4 4.6 19.4 32.7 4.9 100.0 4,628 33.4 3.8 20.7 36.7 5.2 100.0 2,877 28.9 5.3 21.0 39.3 5.6 100.0 2,499 55.1 2.3 27.3 10.5 4.8 100.0 2,106 35.9 5.0 17.0 36.9 5.1 100.0 11,114 27.1 8.1 20.5 38.4 5.7 100.0 1,453 39.1 5.3 19.1 31.8 4.7 100.0 5,321 41.6 3.2 17.9 32.1 5.1 100.0 6,446 36.3 4.0 16.7 38.6 4.4 100.0 3,574 35.9 4.7 17.1 37.0 5.3 100.0 4,025 41.5 5.2 17.2 30.4 5.6 100.0 4,152 47.0 4.1 32.1 13.0 3.9 100.0 1,468 39.0 4.6 18.7 32.7 5.0 100.0 13,220 Table 3.5 shows the percent distribution of female respondents by employment status and continuity of employment, according to background characteristics. Fifty-six percent of women reported being currently employed: 19 percent all year, 33 percent seasonally, and 5 percent occasionally. Forty-four percent of women are not currently working, but 5 percent did work at some time during the past 12 months. Characteristics of Respondents * 29 Table 3.6 Employer and form of earnings Percent distribution of currently employed women by employer and type of earnings (cash, in kind, no payment), according to background characteristics, Malawi 2000 _____________________________________________________________________________________________________ Employed by a Employed by Self-employed non-family member a family member _______________ ______________ _______________ Does Does Does Background Earns not earn Earns not earn Earns not earn characteristic cash1 cash2 cash1 cash2 cash1 cash2 Missing3 Total Number _____________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Occupation Agriculture Non-agriculture Total 18.0 32.9 6.2 2.9 7.7 32.0 0.3 100.0 1,139 27.0 43.1 8.1 0.6 5.6 15.2 0.4 100.0 1,585 25.7 40.8 10.3 0.5 8.0 14.3 0.4 100.0 1,424 30.7 39.3 12.8 0.3 4.8 11.8 0.3 100.0 1,012 25.5 43.2 10.3 0.9 5.6 14.4 0.0 100.0 948 27.1 46.2 9.6 0.2 4.4 12.3 0.3 100.0 710 28.6 47.1 4.9 0.4 3.3 15.6 0.0 100.0 636 38.1 16.1 35.3 0.3 4.8 5.3 0.1 100.0 898 24.2 44.7 5.4 1.0 6.1 18.4 0.3 100.0 6,557 30.6 38.0 6.6 0.5 9.3 14.8 0.1 100.0 940 26.9 38.6 7.4 1.1 9.4 16.4 0.2 100.0 2,958 23.7 44.3 11.0 0.8 2.2 17.7 0.4 100.0 3,558 23.2 49.5 4.9 0.5 4.6 17.1 0.3 100.0 2,133 23.9 45.4 5.0 0.8 6.5 18.1 0.3 100.0 2,390 29.2 37.6 6.1 1.5 7.2 18.2 0.2 100.0 2,215 29.7 14.1 43.7 0.6 4.4 7.1 0.4 100.0 718 15.1 52.1 3.3 0.9 5.9 22.6 0.1 100.0 4,962 47.1 19.6 20.5 0.9 6.1 5.2 0.6 100.0 2,494 25.8 41.2 9.0 0.9 6.0 16.8 0.3 100.0 7,455 __________________________________________________________________________________________________ 1 Includes both women who receive only cash and those who receive cash and in-kind payment. 2 Includes both women who receive only in-kind payment and those who receive no payment. 3 Missing information on employer or type of earnings. All-year current employment is highest in the urban, more educated population, whereas seasonal work is more prevalent among the rural, less educated women. Women who have more children are more likely to be currently employed. Respondents from the Northern Region were more likely to be currently employed than those from Southern and Central regions. 3.6 FORM OF WOMEN’S EARNINGS Table 3.6 shows the percent distribution of employed women by type of employer and the type of earnings according to background characteristics. Sixty-seven percent of the employed women are self-employed, 23 percent work for a family member, and only 10 percent work for a nonrelative. The majority of the working women in rural areas are either self-employed or work for a family member. Similarly, less educated women and women engaged in agricultural work are more likely to be self-employed or to work for a family member. Self-employment and work for family members in these less advantaged settings usually involves work without cash payment. 30 * Characteristics of Respondents Figure 3.2 presents data on the type of earnings for employed women in the agricultural sector versus the non-agricultural sector. The majority of agricultural workers (72 percent) reported they receive no pay. For those women in non-agricultural professions, only 24 percent reported no pay. 3.7 CONTROL OVER WOMEN’S EARNINGS AND WOMEN’S CONTRIBUTION TO HOUSEHOLD EXPENDITURES To assess women’s autonomy, MDHS respondents were asked who decided how their earnings were used. Further, the survey asked employed women who earned cash, “On average, how much of your household’s expenditure do your earnings pay for: Almost none, less than half, about half, more than half, or all?” This information not only allows an evaluation of the relative importance of women’s earnings in the household economy but also has implications for the empowerment of women. It is expected that employment and earnings are more likely to empower women if they perceive their earnings as important for meeting the needs of their household. Table 3.7 shows that 51 percent of women report that they alone decide how their earnings are used, while 32 percent do not take part in household expenditure decisions, and 18 percent decide jointly with someone else (mostly husbands). The data also indicate that 75 percent of women report that one-half to all of their household’s expenditures are covered by their earnings. Although women with more education are more likely to report having a role in deciding how their earnings are spent, these same women are not more likely to contribute in a major way to the household expenditures. As a woman ages and has more children, her decisionmaking influence and contribution to meeting household expenditures increase. Characteristics of Respondents * 31 Table 3.7 Decision on use of earnings and contribution of earnings to household expenditures Percent distribution of women receiving cash earnings by person who decides how earnings are used, and by proportion of household expenditures met by earnings, according to background characteristics, Malawi 2000 ____________________________________________________________________________________________________ Person who decides Proportion of household how earnings are used expenditures met by earnings __________________________ ________________________________ Some- Less Half/ Background Self one Almost than more characteristic only Jointly1 else2 Missing Total none half than half All Missing Total Number ____________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Current marital status Never married Currently married/ living together Divorced, separated, widowed Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 45.4 13.2 41.4 0.0 100.0 12.6 24.8 41.1 21.1 0.4 100.0 365 48.2 14.7 37.1 0.0 100.0 4.5 24.8 48.2 22.5 0.0 100.0 649 43.8 23.9 32.2 0.0 100.0 2.5 20.9 43.5 33.1 0.0 100.0 629 55.4 17.5 26.6 0.6 100.0 2.3 18.6 45.4 33.3 0.3 100.0 489 52.9 18.4 28.7 0.0 100.0 1.0 18.4 49.9 30.7 0.0 100.0 393 56.5 19.1 24.2 0.3 100.0 2.4 18.2 43.8 35.4 0.3 100.0 292 62.7 13.8 23.5 0.0 100.0 3.0 14.5 44.5 37.9 0.0 100.0 234 62.3 6.4 31.3 0.0 100.0 15.9 26.2 37.9 19.5 0.5 100.0 312 37.5 23.5 38.8 0.1 100.0 2.3 22.0 49.4 26.3 0.0 100.0 2,186 95.7 1.0 3.1 0.3 100.0 3.7 12.7 34.3 49.1 0.3 100.0 554 49.8 13.9 36.3 0.0 100.0 11.7 23.1 41.1 23.8 0.3 100.0 503 50.1 18.5 31.4 0.1 100.0 3.3 22.0 46.1 28.5 0.1 100.0 1,132 50.3 18.6 30.9 0.2 100.0 1.7 17.4 48.0 32.7 0.2 100.0 739 52.5 18.2 29.1 0.2 100.0 1.7 20.7 44.7 32.9 0.0 100.0 678 69.1 20.1 10.9 0.0 100.0 9.0 18.5 46.1 26.5 0.0 100.0 703 45.1 17.0 37.8 0.2 100.0 2.4 21.5 45.3 30.7 0.2 100.0 2,349 45.3 16.3 38.1 0.3 100.0 5.3 29.0 49.4 16.2 0.0 100.0 439 42.3 16.2 41.4 0.0 100.0 2.1 19.7 50.5 27.8 0.0 100.0 1,293 60.5 19.6 19.7 0.2 100.0 5.2 19.1 39.2 36.2 0.3 100.0 1,320 44.6 18.1 37.3 0.0 100.0 2.2 18.2 42.6 36.9 0.0 100.0 697 46.6 14.9 38.4 0.1 100.0 3.5 20.0 44.6 31.7 0.3 100.0 851 50.0 18.1 31.5 0.3 100.0 4.7 22.5 46.4 26.2 0.2 100.0 945 65.3 20.7 14.0 0.0 100.0 5.5 22.0 48.7 23.8 0.0 100.0 558 50.6 17.7 31.6 0.1 100.0 3.9 20.8 45.4 29.7 0.1 100.0 3,052 ____________________________________________________________________________________________________ 1 With husband or someone else 2 Includes predominantly the husband The proportion of women who make decisions on their own is higher among those who are divorced, separated, or widowed (96 percent); never-married women (62 percent); urban residents (69 percent); women with a secondary education (65 percent); and Southern Region residents (61 percent). 32 * Characteristics of Respondents 3.8 MEASURES OF WOMEN’S EMPOWERMENT In addition to information on women’s education, employment status, and earnings control, the 2000 MDHS survey also obtained information on some other measures of women’s status and empowerment. In particular, questions were asked on women’s participation in specific household decisions, on their degree of acceptance of wife beating, and on their opinions about when a wife should be able to refuse sex with her husband. These data provide insight into women’s control over their lives and their environment and their attitudes toward traditional gender roles, which are important aspects of women’s empowerment relevant for understanding demographic and health behaviours. These questions are used to define three different indicators of women’s empowerment: women’s participation in decisionmaking, women’s degree of acceptance of wife beating, and their degree of acceptance of a wife’s right to refuse sex with her husband. The first measure requires little explanation since the ability to make decisions about one’s own life is of obvious importance to practical empowerment. The other two measures derive from the notion that gender equity is essential to empowerment. Responses that indicate a view that the beating of wives by husbands is justified reflect a sanction in favour of lower women’s status, both absolutely and relative to men. Although such attitudes do not necessarily signify approval of men beating their wives, they do signify women’s acceptance of norms that give men the right, in this case, to discipline women with force. Similarly, beliefs about whether and when a woman can refuse sex with her husband, reflect issues of gender equity regarding sexual rights and bodily integrity. Besides yielding an important measure of empowerment, the information about women’s attitudes toward sexual rights will be useful for improving and monitoring reproductive health programmes that depend on women’s willingness and ability to control their own sexual lives. Table 3.8 shows the percent distribution of women by the person who makes specific decisions, according to current marital status. The data show that more than 65 percent of currently married women reported that they have no say in their own health care, large household purchases, and daily household purchases. The majority of unmarried women make these decisions jointly with someone else. Table 3.9 displays the percentage of women who report that they, alone or jointly, have the final say in specific household decisions according to background characteristics. Women who are urban residents; have secondary or higher education; earn cash; or are divorced, separated, or widowed are more likely to have a final say in all given decisions. To assess women’s degree of acceptance of wife beating, the MDHS survey asked ever- married women, “Sometimes a husband is annoyed or angered by things which his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations?” The five situations presented to women for their opinion were: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sex with him. The first five columns in Table 3.10 show how acceptance of wife beating varies for each reason. The last column gives the percentages of women who feel that a husband beating his wife is justified for at least one of the given reasons. Note that empowerment decreases as the value of this indicator increases. That is to say, the more reasons with which a respondent agrees, the more “disempowered” she is according to this indicator. Characteristics of Respondents * 33 Table 3.8 Women's participation in decisionmaking Percent distribution of women by person who makes specific household decisions, according to marital status and type of decision, Malawi 2000 ___________________________________________________________________________________ Jointly with Some- Jointly some- one Household Self with one Husband else decision only husband else only only Nobody Total ____________________________________________________________________________________ CURRENTLY MARRIED OR LIVING WITH A MAN____________________________________________________________________________________ Own health care 20.5 7.1 1.6 70.6 0.2 0.1 100.0 Large household purchases 6.1 10.8 1.5 81.3 0.2 0.0 100.0 Daily household purchases 20.3 12.1 1.6 65.7 0.3 0.0 100.0 Visits to family or relatives 17.7 44.4 1.2 36.2 0.3 0.1 100.0 What food to cook each day 44.9 10.9 1.6 42.2 0.2 0.0 100.0 Number of children to bear 8.3 45.1 0.2 42.4 0.4 3.6 100.0 ___________________________________________________________________________________ NOT CURRENTLY MARRIED___________________________________________________________________________________ Own health care 38.4 na 53.6 na 6.4 1.6 100.0 Large household purchases 31.6 na 60.2 na 5.2 3.0 100.0 Daily household purchases 32.1 na 60.1 na 5.5 2.2 100.0 Visits to family or relatives 40.1 na 48.8 na 9.0 2.1 100.0 What food to cook each day 33.8 na 58.1 na 6.1 2.0 100.0 Number of children to bear 42.0 na 4.2 na 17.6 36.0 100.0 ______________________________________________________________________________________ Note: Not currently married refers to never-married, divorced, separated, or widowed women. na = Not applicable Thirty-six percent of women agree with at least one of the selected reasons for wife beating. Differentials across respondents’ background characteristics are small although rural women, women with less than secondary education, and younger women tend to be more likely to accept justifications for beating wives. Thirty-eight percent of rural women agree with at least one reason for justifying wife beating, compared with only 22 percent of urban women. The extent of control women have over when and with whom they have sex has important implications for demographic and health outcomes. To measure women’s agreement with the idea that a woman has the right to refuse to have sex with her husband, the MDHS survey asked respondents whether a wife is justified in refusing to have sex with her husband under four circumstances: she is tired or not in the mood, she has recently given birth, she knows her husband has had sex with other women, and she knows her husband has a sexually transmitted disease. Table 3.11 shows the percentage of ever-married women who say that women are justified in refusing to have sex with their husband for specific reasons, by background characteristics. The table also shows how this indicator of women’s empowerment varies with the other two indicators, namely with women’s participation in decisionmaking and women’s attitudes toward wife beating. It is worth noting that, unlike the previous indicator of empowerment, this indicator is positively related to empowerment: the more reasons women agree with, the higher is their empowerment in terms of the belief in women’s sexual rights. 34 * Characteristics of Respondents Table 3.9 Women’s participation in decisionmaking by background characteristics Percentage of women who say that they alone or jointly have the final say in specific household decisions, by background characteristics, Malawi 2000 _____________________________________________________________________________________________________ Alone or jointly have final say in: __________________________________________________ Has Has no Visits to What Number final say final say Own Making Making family food of in all in all Background health large daily relatives/ to cook children specified specified characteristic care purchases purchases friends daily to bear decisions decisions Number _____________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Current marital status Never married Currently married/ living together Divorced, separated, widowed Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Current employment Work for cash Not work for cash Not employed Total 70.2 65.6 71.4 77.1 78.7 32.1 16.0 9.6 2,867 42.7 32.9 44.4 69.3 61.8 54.1 16.0 14.8 2,957 35.3 26.0 39.2 65.1 60.4 55.8 15.3 16.6 2,401 40.3 31.1 45.1 72.1 67.3 58.8 19.1 13.4 1,566 39.2 33.1 46.7 68.0 66.4 61.0 21.3 13.4 1,424 45.1 36.7 50.3 70.3 66.5 55.9 23.7 15.3 1,053 46.0 40.1 51.1 71.6 69.5 59.4 26.5 13.6 951 89.8 90.2 91.0 85.6 90.1 27.2 22.1 4.2 2,243 29.2 18.5 34.0 63.4 57.5 53.5 9.2 17.9 9,452 95.2 94.1 94.0 93.7 94.4 74.3 68.1 1.1 1,525 70.7 67.6 72.9 78.2 79.5 34.3 17.9 8.8 3,216 41.4 31.5 43.6 68.9 62.3 56.4 18.2 15.3 4,628 37.5 28.4 42.4 66.6 63.5 57.3 18.4 15.6 2,877 38.2 30.2 44.3 68.7 65.2 57.7 18.3 14.5 2,499 57.4 51.8 65.9 81.9 75.2 63.1 24.1 5.4 2,106 45.1 37.0 47.7 68.5 65.8 49.2 17.1 15.2 11,114 51.0 35.3 55.5 75.4 87.7 53.8 16.4 4.9 1,453 42.0 36.9 46.6 70.4 66.4 50.7 15.1 14.2 5,321 50.4 42.3 52.9 69.8 63.4 51.6 21.1 15.1 6,446 37.6 28.4 37.7 62.0 56.8 51.0 16.3 19.4 3,574 43.6 35.7 47.5 68.9 64.9 49.0 15.9 15.4 4,025 50.9 42.5 55.4 74.5 72.8 51.7 17.7 10.4 4,152 69.0 67.0 77.0 85.5 84.1 58.6 30.5 3.8 1,468 53.9 47.5 60.6 77.3 75.5 60.0 27.9 9.2 3,052 42.5 32.8 45.0 65.1 64.5 51.2 15.5 15.5 4,401 46.9 40.0 49.5 71.4 65.1 47.2 15.1 14.6 5,762 47.1 39.4 50.6 70.7 67.3 51.5 18.2 13.6 13,220 __________________________________________________________________________________________________ Note: Six respondents had missing values for current employment status. Characteristics of Respondents * 35 Table 3.10 Women's attitude toward wife beating Percentage of women who agree with specific reasons justifying a husband hitting or beating his wife and percentage who agree with at least one of the reasons, by background characteristics, Malawi 2000 __________________________________________________________________________________________ Reasons justifying a husband hitting or beating his wife ________________________________________________ Agrees Goes out with at Burns Argues without Neglects Refuses least one Background the with telling the sexual specified characteristic food him him children relations reason Number __________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Current marital status Never married Married or living together Divorced, separated, widowed Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Employment1 Employed for cash Employed not for cash Not employed Number of decisions in which woman has final say2 0-1 2-3 4-5 6 All women 18.9 20.7 19.2 25.2 16.9 38.5 2,867 18.9 20.9 17.1 23.9 19.0 38.4 2,957 15.3 17.1 15.9 20.4 17.7 33.7 2,401 14.5 17.7 15.8 21.0 18.1 36.1 1,566 12.9 14.9 12.8 18.0 16.6 29.7 1,424 15.8 17.7 16.1 19.7 17.6 34.4 1,053 14.9 17.1 15.9 17.5 19.3 33.1 951 17.5 18.6 16.2 23.5 15.1 35.3 2,243 16.6 18.8 16.8 21.6 18.2 36.0 9,452 15.0 17.2 15.4 19.9 19.6 34.2 1,525 18.1 19.6 17.9 23.5 16.8 37.0 3,216 17.2 19.6 16.8 22.7 19.2 37.2 4,628 15.5 17.6 16.2 20.9 17.9 34.5 2,877 14.5 16.7 14.8 18.6 16.5 32.4 2,499 7.9 10.8 11.4 13.7 11.0 22.4 2,106 18.2 20.1 17.5 23.3 19.1 38.2 11,114 19.3 25.8 22.9 28.9 23.2 43.7 1,453 18.5 18.9 16.5 22.4 20.6 37.9 5,321 14.3 16.8 15.2 19.6 14.4 32.0 6,446 15.7 17.2 15.3 19.3 18.9 34.3 3,574 19.7 20.5 17.5 23.7 19.3 38.9 4,025 16.8 20.4 18.8 23.8 18.2 37.5 4,152 9.2 11.7 10.5 16.4 10.3 25.0 1,468 17.0 19.2 15.6 22.6 19.7 36.8 3,052 17.1 19.6 19.3 23.3 18.5 38.1 4,401 15.9 17.6 15.0 20.1 16.3 33.1 5,762 18.2 18.7 16.7 21.9 18.5 34.6 3,271 17.3 20.5 17.7 22.6 19.4 39.2 3,596 15.8 18.0 16.5 22.5 16.8 35.6 3,949 14.3 16.8 14.7 19.1 16.3 32.0 2,405 16.5 18.6 16.6 21.8 17.8 35.7 13,220 ____________________________________________________________________________________________ 1 Six respondents had missing values for employment status. 2 Refers to decisions made by the woman alone or jointly with others (Table 3.9). 36 * Characteristics of Respondents Table 3.11 Women's attitude toward refusing sexual relations with husband Percentage of women who have ever been in union who agree with specific reasons justifying a wife refusing to have sexual relations with her husband and percentage who agree with all and with none of the reasons, by background characteristics, Malawi 2000 _______________________________________________________________________________________________ Reasons justifying a wife refusing sex with husband _________________________________________ Knows husband has sexual Agrees Agrees Gave relations Knows with all with no Background Tired, not birth with other husband specified specified characteristic in mood recently women has STI1 reasons reason Number ________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Current marital status Married or living together Divorced, separated, widowed Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Employment Employed for cash Employed not for cash Not employed Number of decisions in which women have final say2 0-1 2-3 4-5 6 Number of reasons for which wife beating is justified 0 1-3 4-5 Total 61.5 74.4 66.8 70.9 50.2 18.8 1,054 60.3 76.7 68.6 73.7 50.1 16.8 2,594 62.9 79.3 71.2 73.8 53.0 15.4 2,357 61.0 78.8 68.1 73.4 48.9 15.6 1,551 59.4 78.9 68.9 74.0 49.9 16.3 1,420 56.8 77.8 65.3 73.9 45.9 16.8 1,049 58.8 75.8 64.1 72.3 45.2 18.1 951 62.5 80.0 70.2 75.3 51.0 13.9 9,452 47.9 63.3 56.3 61.3 41.7 33.2 1,525 57.1 71.8 64.3 69.9 45.2 19.6 1,173 61.7 77.0 68.2 73.1 50.7 17.1 4,431 59.5 78.0 68.1 72.8 49.2 16.6 2,875 61.2 81.2 70.3 76.0 50.6 14.1 2,497 55.3 74.0 65.8 72.5 47.2 21.0 1,585 61.4 78.3 68.6 73.5 50.1 15.8 9,392 73.4 89.5 77.8 84.0 60.1 6.1 1,228 56.2 78.7 67.6 72.6 45.8 16.0 4,373 61.0 74.1 66.5 71.5 50.5 19.4 5,376 58.2 76.5 65.5 70.9 47.3 18.1 3,468 58.3 77.1 67.9 71.6 47.7 16.6 3,434 64.6 79.7 71.0 77.0 53.0 14.2 3,200 62.8 77.0 70.4 76.3 54.8 18.9 876 63.8 80.1 72.5 77.1 54.9 15.4 2,740 59.2 80.2 69.6 75.6 48.0 13.8 3,885 59.6 73.9 64.3 68.9 47.9 19.8 4,347 65.6 79.5 69.3 72.6 53.0 14.1 3,128 63.2 82.2 72.3 78.5 52.5 12.1 3,487 57.1 77.7 67.5 74.6 46.3 17.0 2,453 51.5 66.4 60.0 63.5 43.5 28.1 1,908 60.1 75.9 67.5 71.9 50.8 19.2 7,055 59.1 79.6 68.0 75.3 45.7 12.4 2,826 66.7 84.1 74.0 77.6 53.1 10.1 1,095 60.5 77.7 68.2 73.3 49.7 16.6 10,977 _______________________________________________________________________________________________ 1 Sexually transmitted infection 2 Refers to decisions made by the woman alone or jointly with others (Table 3.9). Characteristics of Respondents * 37 Fifty percent of women agree with all selected reasons and only 17 percent agree with no selected reasons. Women are most likely to agree with the right of women to refuse sex if the woman recently gave birth (78 percent). It is a cultural taboo in Malawi to have sex right after birth so this finding may not be so much a sign of empowerment as a sign of adherence to an important traditional belief. Women are least likely to agree with the right to refuse sex if the woman is tired or not in the mood (61 percent). There is little variation in this index by background characteristics. Married women are slightly more likely to agree with reasons to refuse sex than women who are divorced, separated, or widowed. Sixty percent of the women in the Northern Region agree with all reasons for a woman to refuse to have sex with her husband. This is higher than the national average of 50 percent. There is evidence for a small negative correlation between the number of decisions in which a woman has a final say and her likelihood of agreeing with the reasons for refusing sex. (i.e., women with the most decisionmaking influence are less likely to agree with justifications for refusing sex). If a woman believes in none of the mentioned justifications for wife beating, she is more likely to respond that there is no reason to refuse sex. These findings are contrary to expectations and suggest that the particular dimensions of sexual empowerment captured in the MDHS survey may not be suitable in the Malawian context. More in-depth, qualitative research would perhaps be more illuminating. 3.9 USE OF TOBACCO The use of tobacco in the household adversely affects the health status of all household members, including individuals who are not smoking. In the 2000 MDHS survey, questions were asked on whether the respondent smoked regularly and how much he or she smoked in the last 24 hours. The results revealed that the number of Malawian women age 15-49 who smoke is small, just 2 percent of those surveyed, one-half of whom are cigarette smokers. On the other hand, smoking is common among men. Table 3.12 shows that nearly one in five men age 15-54 are tobacco smokers; 19 percent smoke (pre-rolled) cigarettes and 6 percent smoke “other” types of tobacco including locally grown and rolled tobacco “cigarettes” and pipe tobacco. Smoking of pre- rolled cigarettes does not vary much by region or urban-rural residence, but smoking of “other” forms of tobacco is limited largely to rural areas of the country. Smoking is much more prevalent among men with less education. Among cigarette smokers, 31 percent smoke six or more cigarettes per day, 41 percent smoke three to five per day, 23 percent smoke one or two, and 5 percent had not smoked any cigarettes in the last 24 hours. 38 * Characteristics of Respondents Table 3.12 Use of smoking tobacco Percentage of men who smoke tobacco and percent distribution of cigarette smokers by number of cigarettes in preceding 24 hours, according to background characteristics, Malawi 2000 ___________________________________________________________________________________________________________ Number Does Number Number of cigarettes Don’t of Background not use Cigar- Other of __________________________ know/ cigarette characteristic tobacco ettes tobacco men 0 1-2 3-5 6+ missing Total smokers ___________________________________________________________________________________________________________ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 80.6 18.5 0.9 564 7.4 18.6 42.1 31.6 0.3 100.0 104 75.0 18.8 6.8 2,528 3.9 24.2 41.0 30.6 0.3 100.0 475 78.8 19.0 2.6 351 3.7 17.9 51.2 27.2 0.0 100.0 67 73.5 20.3 6.3 1,296 1.6 22.0 46.0 29.9 0.5 100.0 263 77.6 17.3 5.9 1,446 7.8 25.8 33.5 32.7 0.1 100.0 250 54.4 31.8 14.8 322 6.4 23.2 36.1 34.3 0.0 100.0 102 68.7 23.4 8.4 897 3.7 24.0 46.2 25.6 0.6 100.0 210 80.6 15.7 4.0 1,243 3.4 20.6 43.7 32.3 0.0 100.0 196 88.3 11.4 0.5 629 7.2 28.1 27.4 36.8 0.4 100.0 72 76.0 18.7 5.6 3,092 4.5 23.2 41.2 30.8 0.3 100.0 580 Table 3.13 Knowledge of birth registration Percentage of women age 15-49 and men age 15-54 who have heard that when a child is born they can register that child with the government and receive a birth certificate, by background characteristics, Malawi 2000 ___________________________________________ Heard that a child may be registered and receive a birth certificate Background ______________________ characteristic Women Men ____________________________________________ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 27.3 42.5 17.4 29.6 27.3 39.3 16.5 28.8 19.0 33.0 13.2 28.0 16.2 31.4 18.8 32.6 40.9 41.0 18.9 32.0 3.10 BIRTH REGISTRATION The Malawian government has recently launched a birth registration programme, where- by parents are urged to register all live births and obtain a birth certificate for their children. This is an important step in ensuring health care and education for all of Malawi’s children. Men and women in the MDHS survey were asked whether they knew that a child’s birth could be registered. As shown in Table 3.13, 19 percent of women and 32 percent of men know of the birth registra- tion programme. There are slight regional differ- ences in knowledge of the birth registration programme. Urban respondents and Northern respondents are more likely to know about the programme than other respondents. Similarly women and men with more education are more likely to know that a child’s birth can be regis- tered. Fertility Levels and Trends * 39 FERTILITY LEVELS AND TRENDS 4 Ladislas R. S. Mpando The assessment of the levels, trends, and differentials in fertility in Malawi is especially relevant at this time for two reasons. First, the national population policy is currently being reviewed and reevaluated for the first time since its adoption in 1994. Second, the last time a DHS survey was conducted was in 1992 and the demographic profile of the nation can no longer rely on outdated data. The 2000 Malawi Demographic and Health Survey findings will facilitate evaluation of the demographic impact of successes in the uptake of family planning in the country over the last decade. This chapter presents the 2000 MDHS results on levels, trends, and differentials in fertility based on the analysis of the reported birth histories of women age 15-49 who were interviewed during the survey. This information was collected by asking each woman to report the number of her own children living with her, the number living elsewhere, and the number who had died. She was then asked a complete history of each of her live births. The detailed information collected on each of her children included sex; year and month of birth; and if dead, age at death, or if alive, whether the child was living with the respondent. Current fertility (age-specific and total fertility) and completed fertility (number of children ever born alive to the woman) are examined in relation to various background characteristics such as urban-rural residence, educational level of the woman, and region and district of residence. 4.1 CURRENT FERTILITY LEVELS AND TRENDS The most widely used measures of current fertility are the total fertility rate (TFR) and its component age-specific fertility rates (ASFRs). The TFR is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed rates of age-specific fertility. To obtain the most recent estimates of fertility without compromising the statistical precision of estimates and also as an attempt to avoid possible displacement of births from five to six years before the survey, the three- year period just prior to the survey is used, which roughly corresponds to the calendar period 1998- 2000. Current total fertility and age-specific fertility rates for Malawi, by urban and rural area are presented in Table 4.1. The results indicate that if fertility were to remain constant at the current age-specific rates measured in the survey (within 36 months before the survey), a woman in Malawi would, on average, bear 6.3 children in her lifetime. The corresponding total fertility rates for urban and rural areas are 4.5 and 6.7 children per woman, respectively. The TFR measured in the 2000 MDHS survey is lower than the corresponding rate of 6.7 obtained in the 1992 MDHS survey (for the 1989-1992 period). The current TFR indicates that fertility in Malawi has declined by 6 percent during the past decade or so. Fertility has declined more rapidly in urban areas (18 percent) than in rural areas (3 percent) during this period. 40 * Fertility Levels and Trends Table 4.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by residence, Malawi 2000___________________________________________ Residence______________ Age group Urban Rural Total___________________________________________ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 TFR 15-49 TFR 15-44 GFR CBR 134 180 172 243 319 305 223 282 272 145 232 219 104 176 167 51 100 94 1 45 41 4.5 6.7 6.3 4.5 6.4 6.1 173 233 223 40.8 46.2 45.5 ___________________________________________ Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate for ages 15-49 expressed per woman GFR: General fertility rate (births ÷ no. of women 15-44) expressed per 1,000 women CBR: Crude birth rate expressed per 1,000 population A further examination of the patterns of fertility in urban and rural areas reveals that rural fertility is higher than urban fertility at every age. The peak of childbearing among women in both urban and rural areas is 20-24 as was also observed in past censuses and demographic surveys. How- ever, elevated childbearing in urban areas is rather limited to the peak at age 20-24, unlike in the rural areas where childbearing is elevated over the age range 20-34. Urban women thus tend to start limit- ing their family size (or spacing births) at an earlier age than rural women. Table 4.2 and Figure 4.1 show fertility differentials by background characteristics. In addi- tion to the urban-rural difference, there exist notable geographic and education-related variations in the TFR. Women with no formal education have a TFR of 7.3 children per woman, compared with 6.7 for those with one to four years of primary education, 6.0 for those with five to eight years of primary education, and 3.0 for those with secondary educa- tion or higher. Fertility variations across regions are not very large: women in the Southern Region have a TFR of 6.0 children per woman, about one child less than women from the Central Region who have the highest total fertility rate of 6.8. Women in the Northern Region have a TFR of 6.2 children per woman. District variation is more substantial, with TFRs ranging from 4.3 children per woman in Blantyre District to more than 7 children per woman in Mangochi, Machinga, and Kasungu districts. At the time of the survey, about 12 percent of the women interviewed reported that they were pregnant. This proportion is probably an underestimate because some women who are early in their pregnancy do not yet know that they are pregnant, and some women may not want to declare that they are pregnant. The proportions of pregnant women in urban areas (10 percent) and those with secondary education or higher (8 percent) are lower than those for the other populations subgroups. As expected, levels of current pregnancy prevalence correlate with the levels of current fertility in population subgroups. Table 4.2 also allows a crude assessment of differential trends in fertility over time among population subgroups. The mean number of children ever born alive to a women age 40-49 years is a measure of past completed fertility. A comparison of current fertility (total fertility rate) with past fertility (completed) shows, for example, that there has been a substantial decline (40 percent) in fertility in Malawi among women with secondary education or higher. There have been modest declines in fertility among women with five to eight years of primary education (9 percent), urban women (24 percent), and women in the Southern Region (8 percent). Fertility in the Northern Region and in rural areas has remained virtually constant, but fertility for women with no formal education may have actually increased by about 6 percent. Differential trends among districts are Fertility Levels and Trends * 41 Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage currently pregnant, and mean number of children ever born to women age 40-49 years, by background charac- teristics, Malawi 2000___________________________________________________ Mean number of children Total Percentage ever born Background fertility currently to women characteristic rate1 pregnant age 40-49___________________________________________________ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary and higher Districts Blantyre Karonga Kasungu Lilongwe Machinga Mangochi Mulanje Mzimba Salima Thyolo Zomba Other districts Total 4.5 9.8 5.9 6.7 12.3 6.9 6.2 11.8 6.4 6.8 12.8 7.3 6.0 11.1 6.5 7.3 11.9 6.9 6.7 12.9 7.0 6.0 12.4 6.6 3.0 7.5 5.0 4.3 9.6 6.3 5.6 11.7 6.1 7.0 14.1 7.6 6.5 13.3 6.8 7.0 14.6 6.7 7.4 10.8 6.9 5.5 9.0 6.3 6.7 10.9 6.7 6.7 14.0 7.1 5.3 10.2 6.0 6.2 11.2 6.1 6.8 12.3 7.2 6.3 11.9 6.8 ___________________________________________________ 1 Rate for women age 15-49 years. notable. In Blantyre, fertility has declined by about 2 children per woman and in Thyolo and Mulanje, declines of 0.7 to 0.8 children per women occurred. On the other hand, the data indicates that little decrease in fertility has taken place in Zomba, Lilongwe, Salima, and Mzimba. In the districts of Mangochi and Machinga, fertility levels may have risen slightly. More direct evidence of the declining trend in fertility is obtained by looking at changes in age-specific fertility rates across three surveys that were conducted in Malawi since the early 1980s: the 1984 Family Formation Survey, the 1992 MDHS survey, and the 2000 MDHS survey (Table 4.3 and Figure 4.2). The results show that fertility declined in all groups between the 1984 and 1992 surveys. Between the 1992 and 2000 surveys, fairly dramatic downturns in fertility were seen at age 30 and above, but under age 25, fertility may have slightly increased. Over the whole period covered by the surveys (early 1980s to late 1990s), the TFR decreased by 17 percent. 42 * Fertility Levels and Trends Table 4.3 Trends in fertility Age-specific fertility rates (per 1,000 women) and total fertility rates for the three years preceding the survey, Malawi 1984, 1992, and 2000____________________________________________ 1984 1992 2000 Age group FFS1 MDHS MDHS____________________________________________ 15-19 202 161 172 20-24 319 287 305 25-29 309 269 272 30-34 273 254 219 35-39 201 197 167 40-44 129 120 94 45-49 83 58 41 Total fertility rate 7.6 6.7 6.3 ____________________________________________ 1 Family Formation Survey. Based on four years prior to survey. Further evidence of a recent modest de- cline in fertility in Malawi comes from analysis of the fertility of age cohorts of women in the 2000 MDHS survey (i.e., by examining trends within age groups). Table 4.4 shows age-specific fertility rates for four-year periods preceding the survey. Because women age 50 and above were not interviewed in the survey, the rates for calendar periods preceding the survey will be increasingly truncated by the exclusion of the fertility experi- ence of older women. The table shows that, again, the reduction in total fertility rates is due principally to declines in the older age groups. There has been little or no change in fertility among women age 20-24, and a small recent rise in women age15-19. The rise in contraceptive use occurring over the last decade (see next chapter) is likely to explain, at least in part, the fertility trends documented here. Fertility Levels and Trends * 43 Table 4.4 Trends in age-specific fertility rates Age-specific fertility rates for four-year periods preceding the survey, by mother's age at the time of the birth, Malawi 2000 ______________________________________________________ Number of years preceding survey Mother's __________________________________________ age at birth 0-3 4-7 8-11 12-15 16-19 ______________________________________________________ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 167 151 161 180 188 307 304 305 308 302 276 275 286 308 [294] 219 237 264 [272] - 169 179 [209] - - 99 [116] - - - [50] - - - - _______________________________________________________ Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Figure 4.2 Trends in Age-Specific Fertility Rates 1984 FFS, 1992 MDHS, and 2000 MDHS , , , , , , , % % % % % % % ! ! ! ! ! ! ! 15-19 20-24 25-29 30-34 35-39 40-44 45-49 . Age Group (years) 0 50 100 150 200 250 300 350 Births per 1,000 Women MDHS 2000 MDHS 1992 FFS 1984! % , Note: FFS is the Family Formation Survey 44 * Fertility Levels and Trends Table 4.5 Children ever born and living Percent distribution of all women and currently married women by number of children ever born (CEB), and mean number of children ever born and mean number of living children, according to age group, Malawi 2000_____________________________________________________________________________________________________________ Mean Mean number Number of children ever born number of ___________________________________________________________________ of living Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number CEB children _____________________________________________________________________________________________________________ ALL WOMEN____________________________________________________________________________________________________________ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total 74.6 20.9 4.0 0.4 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,867 0.30 0.26 16.7 33.3 31.8 14.5 3.2 0.4 0.1 0.0 0.0 0.0 0.0 100.0 2,957 1.56 1.29 4.0 9.9 19.1 30.0 20.5 11.5 4.0 0.7 0.1 0.1 0.0 100.0 2,401 3.09 2.46 3.0 5.5 7.5 11.5 21.1 21.9 15.8 9.6 2.7 0.8 0.5 100.0 1,566 4.46 3.56 2.2 4.4 6.3 7.6 10.3 12.4 19.9 15.5 12.9 5.6 2.9 100.0 1,424 5.55 4.30 1.8 3.0 3.8 7.2 8.2 7.6 12.7 14.8 14.9 11.3 14.9 100.0 1,053 6.63 4.97 2.0 3.2 4.3 5.7 5.5 9.6 12.1 11.3 13.5 12.0 20.8 100.0 951 6.99 4.89 21.5 15.4 13.6 11.9 9.1 7.4 6.6 4.9 3.9 2.5 3.1 100.0 13,220 3.13 2.42 ___________________________________________________________________________________________________________ CURRENTLY MARRIED WOMEN____________________________________________________________________________________________________________ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total 39.8 48.3 10.7 0.9 0.3 0.0 0.0 0.0 0.0 0.0 0.0 100.0 934 0.74 0.62 8.8 34.0 35.6 17.3 3.7 0.5 0.1 0.0 0.0 0.0 0.0 100.0 2,324 1.75 1.44 2.4 9.0 18.7 31.0 21.1 12.3 4.3 0.8 0.2 0.1 0.0 100.0 2,102 3.19 2.56 2.8 4.5 6.1 10.0 21.4 23.2 17.0 10.7 2.8 0.9 0.5 100.0 1,312 4.62 3.69 2.2 3.8 5.6 7.1 9.9 12.4 20.1 15.7 13.5 6.5 3.3 100.0 1,192 5.69 4.42 1.6 2.7 3.2 6.9 8.0 6.4 12.0 14.8 15.2 12.8 16.5 100.0 848 6.84 5.16 2.0 3.6 3.5 6.0 5.5 8.6 10.4 10.5 14.5 13.0 22.4 100.0 739 7.11 4.98 7.6 16.8 16.1 14.6 11.0 8.9 7.8 5.8 4.6 3.1 3.7 100.0 9,452 3.74 2.91 4.2 CHILDREN EVER BORN The distribution of women by number of children ever born is presented in Table 4.5 for all women and 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 seven children by age 45-49. Of the 7 children ever born to women age 45-49, only 4.9, or about 70 percent, have survived. The distribution of women by children ever born indicates that about one-quarter of the women age 15-19 have already given birth to at least one child, and about one fifth of the women age 45-49 have had 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 modest, generally reflect the impact of marital dissolution althrough divorce or widowhood. The desire for children is nearly universal in Malawi and so the proportion of married women at 45-49 years who are still childless is a rough indicator of primary infertility, or the inability to bear children. The survey results suggest that primary infertility is low in Malawi, with only 2 percent of Malawian women unable to bear children. It should be pointed out here 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 children, or secondary infertility. Fertility Levels and Trends * 45 Table 4.6 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, according to demographic and background characteristics, Malawi 2000____________________________________________________________________________________________________ Median number of months Months since preceding birth since Background ____________________________________________ preceding characteristic 7-17 18-23 24-35 36-47 48+ Total birth Number____________________________________________________________________________________________________ Age 15-19 20-29 30-39 40-49 Birth order 2-3 4-6 7 + Sex of preceding birth Male Female Survival of preceding birth Living Dead Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 13.9 26.6 44.4 12.1 3.0 100.0 25.7 128 6.3 13.6 45.2 21.5 13.4 100.0 31.6 5,047 3.8 9.6 33.5 25.9 27.2 100.0 36.8 3,188 5.5 6.7 29.0 23.9 35.0 100.0 39.7 967 5.7 13.3 43.6 21.1 16.3 100.0 32.1 4,247 4.9 10.6 37.2 25.3 22.1 100.0 35.2 3,401 6.0 9.8 33.8 24.0 26.4 100.0 36.1 1,681 5.1 11.8 39.5 23.5 20.1 100.0 34.0 4,633 5.9 11.6 39.5 22.7 20.3 100.0 33.7 4,697 3.0 9.8 41.1 24.8 21.3 100.0 34.8 7,468 15.3 19.2 33.1 16.4 16.0 100.0 28.2 1,862 3.5 10.1 35.8 24.8 25.9 100.0 36.2 1,018 5.7 11.9 40.0 22.9 19.5 100.0 33.6 8,312 3.6 8.7 38.6 26.2 22.8 100.0 35.7 1,050 6.1 11.8 40.4 23.1 18.6 100.0 33.3 4,140 5.4 12.3 38.8 22.4 21.2 100.0 33.7 4,141 5.5 12.0 38.0 22.9 21.5 100.0 34.3 3,408 6.0 12.4 40.5 21.9 19.2 100.0 32.9 2,943 4.9 10.9 41.0 24.3 18.9 100.0 33.8 2,614 4.7 8.2 34.6 26.4 26.1 100.0 36.9 365 5.5 11.7 39.5 23.1 20.2 100.0 33.8 9,330 ____________________________________________________________________________________________________ Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 4.3 BIRTH INTERVALS Information on the length of birth intervals provides insight into birth spacing patterns. Research has shown that children born too soon after a previous birth are at an increased risk of poor health and consequently an increased risk of dying, particularly when the interval between births is less than 24 months. Maternal health is also jeopardised when births are closely spaced. Table 4.6 shows the distribution of births in the five-year period preceding the survey by the number of months since the previous birth, according to various selected demographic and socioeconomic variables. First births are excluded from the table. The survey results indicate that about one in every six births (17 percent) in Malawi occurs less than 24 months after the birth of the previous child. The overall median birth interval length is 33.8 months, which is about one month longer than it was in the 1992 MDHS survey. 46 * Fertility Levels and Trends Table 4.7 Age at first birth Percentage of women who had their first birth by specific exact ages and median age at first birth, by current age, Malawi 2000 ___________________________________________________________________________________ Percentage who have Median Percentage who had first birth by exact age: never age at ____________________________________ given first Current age 15 18 20 22 25 birth Number birth ___________________________________________________________________________________ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 1.3 na na na na 74.6 2,867 a 4.2 30.3 61.7 na na 16.7 2,957 19.3 5.8 32.7 60.9 82.0 92.9 4.0 2,401 19.2 7.8 38.5 65.3 83.2 92.7 3.0 1,566 18.8 7.4 36.5 62.4 78.1 90.1 2.2 1,424 19.0 10.6 39.6 62.6 79.8 91.6 1.8 1,053 19.0 7.0 33.6 60.0 73.2 85.1 2.0 951 19.2 ____________________________________________________________________________________ na = Not applicable a Omitted in populations where less than 50 percent of the women in the age group × to × + 4 have had a birth by age × In Malawi, birth intervals tend to be shorter for younger mothers and for births occurring after the preceding sibling has died. The latter relationship is the result largely of replacement fertility, whereby a mother will get pregnant again soon after the death of a child. The median birth interval length is shortened by about seven months when the preceding sibling dies. The results also show that only 13 percent of the births to women with secondary education or higher were born after less than 24 months, compared to 18 percent of the births to women with less than 5 years of primary education. 4.4 AGE OF MOTHERS AT FIRST BIRTH One of the factors that determines the level of current fertility in a population is the average age at first birth. Early childbearing generally leads to a large family size and is often associated with increased health risks for the mother and potential health hazards for the children. A rise in the median age at first birth is typically a sign of transition to lower fertility levels. Table 4.7 presents the percentage of women who have given birth by specified ages and the median age at first birth, according to current age. The results show that the median age at first birth for the youngest cohort of women is 19.3 years, a modest increase of 0.4 years over the median age measured in the 1992 MDHS survey. However, there is also evidence of a modest increase in the median age at first birth for all the women age 20-49. In the 1992 MDHS survey, the median age at first birth was 18.9 years, 0.2 years lower than the median age of 19.1 observed in 2000 MDHS survey. This interpretation is supported by the decrease in the percentage of births that occurred at a very young age (less than 15 years) from 8 percent among women currently age 30-34 to only 1 percent among the women now age 15-19. Further, the percentage of births occurring at very young ages has declined from about 3 percent as observed in the 1992 MDHS survey to the current level of 1 percent. Fertility Levels and Trends * 47 Table 4.8 Median age at first birth by background characteristics Median age at first birth among women age 20-49 years, by current age and background characteristics, Malawi 2000__________________________________________________________________________________________________ Current age Women Women Background _____________________________________________________ age age characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49__________________________________________________________________________________________________ Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ All women 20.1 19.8 19.0 19.5 19.3 18.9 19.7 19.4 19.1 19.2 18.8 18.9 18.9 19.3 19.0 19.0 19.0 18.6 18.9 18.4 18.6 18.4 18.7 18.6 19.6 19.4 19.0 19.3 19.4 19.4 19.4 19.3 19.0 19.2 18.6 18.9 18.7 19.3 19.0 18.9 18.4 18.9 18.3 19.3 18.8 19.6 18.8 18.9 18.9 19.1 18.7 18.3 18.3 19.1 18.8 18.8 19.1 19.1 19.1 19.1 19.3 18.5 19.1 19.1 20+a 22.3 21.3 21.1 21.3 19.6 20+a 21.6 19.3 19.2 18.8 19.0 19.0 19.2 19.1 19.1 _________________________________________________________________________________________________ a Less than 50 percent of respondents have had a birth by age 20; median is at least 20 years. Table 4.8 shows the median age at first birth for different age cohorts of women across urban-rural residence, regional, and educational subgroups. There is a small difference in the median age at first birth between urban women (19.7 years) and rural women (19.0 years). At the regional level, first births occur later, on average, in the Central Region than in the Northern and Southern regions. Age at first birth varies significantly with a woman’s level of education, ranging from 19 years for women with no education or primary education to 22 years among women with secondary education or higher. 4.4.1 ADOLESCENT FERTILITY The issue of adolescent fertility is important for both health and social reasons. Children born to very young mothers face an increased risk of illness and death. Adolescent mothers themselves are more likely to experience adverse pregnancy outcomes and maternity-related mortality than more mature women, and they are more constrained in their ability to pursue educational opportunities than their counterparts who delay childbearing. Table 4.9 shows the percentage of adolescent women (age 15-19) who were mothers or pregnant with their first child by selected background characteristics. About one-quarter of adolescent women in Malawi are already mothers with at least one child, and a further 8 percent are currently pregnant. The proportion of teenagers already on the family formation pathway rises very rapidly with age. Only about 4 percent of women age 15 have started childbearing, but by age 19, about two-thirds are pregnant or have had a baby. Overall, 33 percent of adolescents have begun childbearing, compared with 35 percent based on the 1992 MDHS survey. In rural areas, 34 percent of the adolescents have already begun childbearing, compared with 27 percent in urban areas. Regional variations also exist: 36 percent of the adolescents in the Southern Region are either mothers or are pregnant with their first child, compared with 33 percent and 30 percent of their counterparts in the Northern and Central regions, respectively. 48 * Fertility Levels and Trends Table 4.9 Teenage pregnancy and motherhood Percentage of women age 15-19 who are mothers or pregnant with their first child, by background characteristics, Malawi 2000_______________________________________________________________ Percentage who are: Percentage_________________ who have Pregnant begun Background with first child- characteristic Mothers child bearing Number_______________________________________________________________ Age 15 16 17 18 19 Residence Urban Rural Region Northern Central Southern Education No education Primary 1-4 Primary 5-8 Secondary+ Total 2.0 2.3 4.2 541 7.6 5.6 13.2 577 21.5 8.0 29.5 501 37.0 11.5 48.5 723 56.6 9.8 66.4 524 20.1 7.0 27.1 490 26.4 7.8 34.2 2,377 23.8 9.0 32.8 332 22.3 7.4 29.7 1,122 28.1 7.5 35.7 1,413 46.6 9.4 56.1 219 27.5 7.6 35.1 943 23.5 8.2 31.7 1,297 14.8 4.9 19.7 408 25.4 7.6 33.0 2,867 A strong link between continuing education and early motherhood is clear from the survey results (Figure 4.3). Whereas 56 percent of adolescents with no formal education have started childbearing, only 20 percent of their counterparts with secondary education or higher have done so. Fertility Regulation * 49 FERTILITY REGULATION 5 George J. Mandere This chapter presents the 2000 MDHS results on contraceptive knowledge, attitudes, and behaviour. Although the focus is on women, some results from the male survey will also be presented since men play an important role in the realisation of reproductive goals. Comparisons are also made, where feasible, with findings from previous surveys in order to evaluate trends occurring in Malawi over the last decade. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Acquiring knowledge about fertility control is an important step toward gaining access to and then using a suitable contraceptive method in a timely and effective manner. Information on knowledge of contraception was collected by asking the respondent to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent recognised it. Modern family planning methods—the pill, the IUD, injectables, vaginal methods (jelly, sponge, and diaphragm), male and female condoms, female and male sterilisation, the lactational amenorrhoea method (LAM), implants, and emergency contraception—were described, as well as two methods categorised as traditional (periodic abstinence and withdrawal). All other traditional or “folk” methods mentioned by the respondent, such as using herbs and tying strings around the waist, were recorded as well. In Table 5.1, knowledge of contraceptive methods is presented for all women and men, for currently married women and men, for sexually active unmarried women and men, for sexually inactive unmarried women and men, and for women and men with no sexual experience, by specific method. The 2000 MDHS survey finds that 97 percent of all women age 15-49 know at least one method of family planning. Knowledge of a modern method is higher for currently married women and sexually active unmarried women than among women with no sexual experience. The most widely known modern contraceptive methods among all women are injection (92 percent), pill (91 percent), male condom (90 percent), and female sterilisation (83 percent). Nearly all currently married men and sexually actively unmarried men know about fertility regulation. Even among men with no sexual experience, knowledge of any method is high (88 percent). The male condom (96 percent), female sterilisation (88 percent), injectables (87 percent), the pill (87 percent), and male sterilisation (68 percent) were the most widely known modern contraceptive methods among men. It is important to note that both unmarried male and female respondents who have never had sex possess a much more limited base of contraceptive knowledge than their sexually active counterparts. Programmes aimed at reducing adolescent pregnancy may see this as a challenge to improve educational interventions on knowledge and appropriate use of family planning methods. 50 * Fertility Regulation Table 5.1 Knowledge of contraceptive methods Percentage of all women and men, of currently married women and men, of sexually active unmarried women and men, of sexually inactive unmarried women and men, and of women and men with no sexual experience who know any contraceptive method, by specific method, Malawi 2000 ______________________________________________________________________________________________________________ Women Men ________________________________________ _______________________________________ Unmarried women: Unmarried men: ever had sex Un- ever had sex Un- Cur- ______________ married Cur- ______________ married rently Not women: rently Not men: Contraceptive All married Sexually sexually never All married Sexually sexually never method women women active1 active2 had sex men men active1 active2 had sex _____________________________________________________________________________________________________________ Any method Any modern method Pill IUD Injectables Diaphragm/Foam/Jelly Female condom Male condom Female sterilisation Male sterilisation Implants Emergency contraception Lactational amenorrhoea (LAM) Any traditional method Periodic abstinence Withdrawal Other methods3 Mean no. of methods known Number 96.8 98.6 98.2 97.2 82.9 98.3 99.7 99.0 98.7 88.2 96.5 98.4 98.2 96.7 82.7 98.2 99.5 99.0 98.7 88.2 91.0 94.9 91.2 90.7 65.1 86.8 93.0 82.6 81.8 61.7 64.7 70.4 64.2 61.7 30.3 49.9 60.4 38.7 37.7 18.9 92.2 95.5 93.0 91.6 69.6 86.6 93.0 84.2 80.5 61.2 35.8 39.9 34.3 34.7 9.8 26.7 31.2 24.2 21.9 10.5 47.7 51.6 53.1 48.0 19.7 52.3 57.2 49.8 47.6 33.3 89.8 92.2 94.3 89.7 71.9 96.3 97.7 96.9 96.2 86.5 82.8 87.5 78.7 82.2 52.6 87.7 92.5 88.0 85.7 61.5 55.4 60.2 54.4 51.7 28.2 67.8 72.9 64.0 65.7 43.8 48.0 52.4 48.4 45.8 20.9 27.8 32.9 22.9 21.3 13.1 20.4 22.2 28.9 20.4 6.1 19.8 22.7 16.8 17.9 7.9 38.7 43.2 37.8 35.7 11.9 37.3 45.4 31.2 28.2 10.1 65.5 73.0 65.2 63.0 17.3 74.2 86.8 67.5 60.9 27.7 42.0 46.4 48.1 41.0 12.3 57.3 68.7 50.6 45.3 15.7 40.4 46.0 42.2 37.5 6.2 51.8 61.1 48.4 41.5 17.4 35.2 39.9 37.4 33.2 4.6 23.1 32.3 11.2 9.8 2.7 8.4 9.0 8.6 8.1 4.2 8.0 9.0 7.3 7.0 4.5 13,220 9,452 317 2,076 1,375 3,092 1,906 281 599 306 ______________________________________________________________________________________________________________ 1 Unmarried women/men who have had sexual intercourse in the month preceding the survey 2 Unmarried women/men who have ever had sexual intercourse but have not had sexual intercourse in the month preceding the survey 3 Includes mostly folk methods such as tying strings around waist and taking herbs. 5.2 KNOWLEDGE OF CONTRACEPTIVE METHODS BY BACKGROUND CHARACTERISTICS Table 5.2 shows that knowledge of at least one modern family planning method is universally high (95 percent or more) among all subgroups of the currently married women and men in Malawi. Women age 15-19 and 45-49 and women with no education had slightly lower awareness levels. Also, women from Salima, Karonga, and Machinga were less likely to know of modern methods than women from other districts. The pattern of results for men is similar, with knowledge of contraceptive methods being uniformly high in all population subgroups. The youngest married men, however, do possess a more limited knowledge of contraception than both older men and their same-age female counterparts. Fertility Regulation * 51 Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and men who know at least one contraceptive method and who know at least one modern method, by background characteristics, Malawi 2000 _____________________________________________________________________________________________________ Women Men ____________________________________ _______________________________________ Knows Knows Knows three Knows three Knows any or more Knows any or more Background any modern modern any modern modern characteristic method method1 methods1 Number method method1 methods1 Number _____________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 Residence Urban Rural Region Northern Central Southern Districts Blantyre Karonga Kasungu Lilongwe Machinga Mangochi Mulanje Mzimba Salima Thyolo Zomba Other districts Education No education Primary 1-4 Primary 5-8 Secondary+ Total 96.4 96.3 89.7 934 (100.0) (94.9) (74.8) 23 99.1 98.9 95.9 2,324 100.0 99.9 94.2 236 98.9 98.7 96.3 2,102 99.7 99.7 98.9 441 99.1 99.1 97.2 1,312 100.0 100.0 98.7 308 99.3 99.2 95.4 1,192 100.0 100.0 98.2 314 98.6 98.3 95.5 848 99.0 99.0 96.1 228 97.4 96.8 93.1 739 98.8 98.8 97.1 195 na na na na 100.0 99.1 94.3 161 99.9 99.8 99.2 1,362 100.0 99.9 99.0 307 98.4 98.2 94.6 8,089 99.6 99.5 96.6 1,599 98.1 97.7 95.2 1,075 100.0 99.9 94.4 217 98.5 98.3 94.7 3,919 99.8 99.8 97.3 775 98.9 98.7 95.7 4,458 99.5 99.2 97.3 914 100.0 100.0 98.0 837 100.0 100.0 99.4 184 95.1 94.8 90.0 191 100.0 99.3 92.9 40 99.3 99.1 96.4 367 100.0 100.0 98.1 84 99.7 99.7 97.2 1,402 100.0 100.0 97.3 279 96.4 96.2 91.1 374 98.9 98.9 97.7 75 98.6 98.3 93.9 467 98.6 98.6 97.2 92 100.0 100.0 99.1 429 100.0 100.0 99.0 75 98.8 98.6 96.3 458 100.0 100.0 94.3 95 95.4 95.2 89.0 223 100.0 100.0 94.1 43 100.0 99.8 97.2 456 100.0 100.0 99.1 94 98.9 98.5 95.8 564 100.0 99.7 98.3 105 98.1 97.8 94.1 3,683 99.5 99.2 96.1 739 97.7 97.4 92.6 2,975 99.2 99.2 94.5 265 98.7 98.4 95.0 2,980 99.5 99.2 96.0 565 99.2 99.2 97.2 2,784 99.8 99.6 97.4 737 100.0 100.0 99.7 713 100.0 100.0 99.7 338 98.6 98.4 95.2 9,452.0 99.7 99.5 97.0 1,906 ______________________________________________________________________________________________________ na = Not applicable 1 Pill, IUD, injectables, diaphragm/foam/jelly, condom, female sterilisation, male sterilisation, implants, LAM or emergency contraception. ( ) Estimate based on 25-49 unweighted cases. 52 * Fertility Regulation 5.3 EVER USE OF CONTRACEPTION All women and men interviewed in the survey who said they had heard of a method of family planning were asked whether they had ever used that method. Tables 5.3.1 and 5.3.2 show the percent distribution of women and men who have ever used family planning by specific method and age. Forty-five percent of women and 65 percent of men reported having used a method at some time. Thirty-nine percent of women and 56 percent of men reported having used a modern method at some time. Of those currently married, 52 percent of women and 79 percent of men had used a method in the past; 45 percent of women and 66 percent of men used a modern method. Among currently married women, the most commonly used modern methods were injectables (30 percent), the pill (11 percent), male condoms (8 percent), and LAM (6 percent). For currently married men, use of the male condom (35 percent) was highest, followed by injectables (28 percent), the pill (20 percent), LAM (18 percent), and female sterilisation (6 percent). The large difference between men and women in ever use of contraception is due to the greater use of the male condom among men. For the sexually active unmarried population, ever use of any contraceptive method was 49 percent for women and 62 percent for men; modern method use was 44 percent for women and 59 percent for men. The most commonly used methods among women were the male condom (22 percent) and injectables (16 percent); among men, the male condom (57 percent) was by far the predominant method, with much lower use of the pill (5 percent) and injectables (3 percent). 5.4 CURRENT USE OF CONTRACEPTIVE METHODS In the 2000 MDHS, women and men were asked about the contraceptive method they were currently using. For women, current use was elicited from the question, “Are you currently doing something or using any method to delay or avoid getting pregnant?” However, for men the question was asked slightly differently. Men were first asked, “When was the last time you had sex?”—then they were asked, “On that occasion, did you or your partner do something to avoid pregnancy?” This means that for men, the current contraceptive method refers to the method employed at last sexual encounter. Table 5.4 shows the percent distribution of women and men who are currently using specific family planning methods by age. The 2000 MDHS indicates that 31 percent of currently married women are using a method of family planning. The 26 percent using a modern method represents a dramatic increase in the use of modern methods from 7 percent in the 1992 MDHS and 14 percent in the 1996 MKAPH—an approximate doubling of use every four years (see Figure 5.1). The increase in the use of modern contraceptive methods is due to a sharp rise in use of injectables and a small increase in female sterilisation. The use of injectables has more than doubled in four years, from 6 percent in 1996 to 16 percent in 2000, while the percentage of currently married women who have been sterilised grew from 3 to 5 percent. Use of other modern methods is lower: the pill (3 percent), the condom (2 percent), and the IUD, male sterilisation, implants, and LAM (each less than 0.5 percent). Contraceptive use varies by age. Current use of a modern contraceptive method is 13 percent for married women age 15-19, rises to 32 percent among women age 35-44, and then drops sharply to 20 percent at age 45-49. Most of the women who are sterilised are age 35 and over; injectables are predominant in the peak childbearing ages (20-39); and under age 20, condoms are favoured (i.e., especially among the unmarried). Fertility Regulation * 53 Ta bl e 5. 3. 1 E ve r u se o f c on tra ce pt io n: w om en Pe rc en ta ge o f a ll w om en , o f c ur re nt ly m ar rie d w om en , a nd o f s ex ua lly a ct iv e un m ar rie d w om en w ho h av e ev er u se d a co nt ra ce pt iv e m et ho d, b y sp ec ifi c m et ho d an d ag e, M al aw i 2 00 0 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ M od er n m et ho d Tr ad iti on al m et ho d __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ An y An y D ia ph ra gm / Fe m al e M al e Em er ge nc y tra di - Pe rio di c An y m od er n In je ct - Fo am / Fe m al e M al e st er ili - st er ili - Im - co nt ra - tio na l ab st i- W ith - Ag e m et ho d m et ho d Pi ll IU D ab le s Je lly co nd om co nd om sa tio n sa tio n pl an t ce pt io n LA M m et ho d ne nc e dr aw al O th er 1 N um be r __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ AL L W O M EN __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 15 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 Al l a ge s 15 .1 13 .5 1 .7 0. 0 4 .5 0. 1 0. 1 7 .2 0 .0 0. 0 0. 0 0. 3 1 .5 3 .9 2 .5 1 .7 0 .6 2, 86 7 45 .4 39 .4 7 .7 0. 2 24 .9 0. 4 0. 2 11 .4 0 .5 0. 0 0. 2 0. 7 5 .5 14 .5 6 .2 6 .7 4 .8 2, 95 7 59 .1 52 .3 12 .1 0. 9 35 .4 0. 4 0. 1 11 .5 1 .9 0. 1 0. 3 0. 4 7 .3 19 .6 7 .6 8 .4 7 .6 2, 40 1 59 .4 51 .0 16 .7 1. 1 36 .2 0. 3 0. 2 8 .1 4 .6 0. 3 0. 6 0. 4 6 .5 22 .6 7 .4 10 .5 9 .9 1, 56 6 56 .2 49 .4 15 .0 1. 3 31 .1 0. 8 0. 1 6 .0 10 .0 0. 0 0. 4 0. 2 6 .1 19 .1 6 .0 8 .4 8 .4 1, 42 4 55 .4 45 .5 13 .8 1. 2 28 .6 0. 7 0. 3 5 .2 13 .0 0. 0 0. 2 0. 2 5 .3 21 .6 7 .5 7 .8 12 .2 1, 05 3 44 .7 32 .5 9 .2 1. 4 17 .2 0. 4 0. 0 2 .6 9 .6 0. 3 0. 2 0. 9 4 .7 22 .0 6 .7 6 .4 13 .5 9 51 44 .9 38 .6 9 .7 0. 7 24 .1 0. 4 0. 2 8 .4 3 .8 0. 1 0. 2 0. 4 5 .1 15 .7 5 .9 6 .6 6 .6 13 ,2 20 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ C U RR EN TL Y M AR RI ED W O M EN __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _

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