Malawi - Demographic and Health Survey - 2005

Publication date: 2005

Malawi Demographic and Health Survey M alaw i 2004 D em ographic and H ealth S urvey 2004 Malawi Demographic and Health Survey 2004 National Statistical Office Zomba, Malawi ORC Macro Calverton, Maryland, USA December 2005 This report summarises the findings of the 2004 Malawi Demographic and Health Survey (MDHS), which was carried out by the Malawi National Statistical Office (NSO). Most of the funds for the local costs of the survey were provided by multiple donors through the National AIDS Commission. The Department for International Development (DfID) of the British Government, UNICEF, and UNFPA also provided funds for the survey. The United States Agency for International Development (USAID) provided technical assistance through ORC Macro. Technical assistance for the HIV testing was provided by the Centers for Disease Control and Prevention. The MDHS is part of the worldwide Demographic and Health Surveys (DHS) programme funded by the United States Agency for International Development (USAID). The programme is designed to collect data on fertility, family planning, maternal and child health, nutrition, and HIV/AIDS. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID. Additional information about the survey may be obtained from the Demography and Social Statistics Division (DSS), National Statistical Office, Chimbiya Road, P.O. Box 333, Zomba, Malawi (Telephone: 265-1-524-377, 265-1-524-111 (switchboard); Fax: 265-1-525-130, E-mail: demography@statistics.gov.mw; Internet: www.nso.malawi.net). Additional information about the DHS programme may be obtained from MEASURE DHS, ORC Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, U.S.A. (Telephone: 301.572.0200; Fax: 301.572.0999; E-mail: reports@orcmacro.com; Internet: www.measuredhs.com) Recommended citation: National Statistical Office (NSO) [Malawi], and ORC Macro. 2005. Malawi Demographic and Health Survey 2004. Calverton, Maryland: NSO and ORC Macro. Contents | iii CONTENTS Page TABLES AND FIGURES .ix FOREWORD . xvii SUMMARY OF FINDINGS . xix MAP OF MALAWI . xxviii CHAPTER 1 INTRODUCTION .1 1.1 Geography, History, and the Economy. 1 1.2 Population. 2 1.3 Objective of the Survey . 3 1.4 Organisation of the Survey. 4 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND HOUSEHOLD MEMBERS .9 2.1 Household Population by Age, Sex, and Residence . 9 2.2 Household Composition . 11 2.3 Fosterhood and Orphanhood . 11 2.4 Educational Level of Household Population . 13 2.5 School Attendance. 16 2.6 Child Labour . 20 2.7 Housing Characteristics. 21 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS AND WOMEN’S STATUS.25 3.1 Characteristics of Survey Respondents . 25 3.2 Educational Attainment. 27 3.3 Literacy. 29 3.4 Access to Mass Media . 31 3.5 Employment Status . 34 3.6 Women’s Occupation . 37 3.7 Type of Employment . 40 3.8 Measures of Women’s Empowerment. 41 CHAPTER 4 FERTILITY .55 4.1 Current Fertility Levels and Trends. 55 4.2 Children Ever Born and Children Surviving . 62 4.3 Birth Intervals . 63 4.4 Age of Mothers at First Birth. 65 4.5 Median Age at First Birth by Background Characteristics . 65 4.6 Adolescent Fertility . 66 iv | Contents CHAPTER 5 FERTILITY REGULATION.69 5.1 Knowledge of Contraceptive Methods . 69 5.2 Ever Use of Contraception . 73 5.3 Current Use of Contraceptive Methods. 74 5.4 Current Use of Contraception By Background Characteristics . 75 5.5 Trends in Contraceptive Use. 77 5.6 Current Use of Contraception By Woman's Status. 78 5.7 Number of Children At First Use of Contraception. 79 5.8 Knowledge of Fertile Period. 79 5.9 Timing of Sterilisation . 80 5.10 Source of Contraception. 81 5.11 Informed Choice . 82 5.12 Contraceptive Discontinuation. 83 5.13 Future Use of Contraception. 85 5.14 Reasons for Not Intending to Use Contraception . 86 5.15 Preferred Method of Contraception for Future Use . 87 5.16 Exposure to Family Planning Messages Through the Media . 87 5.17 Contact of Nonusers with Family Planning Providers. 89 5.18 Discussion of Family Planning with Husband . 91 5.19 Men's Attitude Toward Contraception. 92 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY .93 6.1 Marital Status. 93 6.2 Polygyny. 94 6.3 Age at First Marriage . 96 6.4 Age at First Sexual Intercourse . 99 6.5 Recent Sexual Activity. 101 6.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 105 6.7 Termination of Exposure to Pregnancy. 107 CHAPTER 7 FERTILITY PREFERENCES AND UNMET NEED FOR FAMILY PLANNING . 109 7.1 Desire For More Children . 109 7.2 Desire To Limit Childbearing by Background Characteristics . 110 7.3 Unmet Need For Family Planning . 112 7.4 Ideal Family Size. 115 7.5 Wanted and Unwanted Fertility. 119 CHAPTER 8 INFANT AND CHILD MORTALITY . 123 8.1 Definitions. 123 8.2 Methodological Considerations. 124 8.3 Assessment of Data Quality. 124 8.4 Levels and Trends of Early Childhood Mortality . 126 8.5 Socioeconomic Differentials in Childhood Mortality . 127 8.6 Biodemographic Differentials in Childhood Mortality. 128 Contents | v 8.7 Childhood Mortality by Women’s Status . 130 8.8 Perinatal Mortality . 131 8.9 High-Risk Fertility Behaviour. 132 CHAPTER 9 MATERNAL AND CHILD HEALTH . 133 9.1 Antenatal Care. 133 9.2 Assistance and Medical Care at Delivery . 140 9.3 Postnatal Care . 145 9.4 Women’s Participation in Decisionmaking. 148 9.5 Childhood Vaccinations. 149 9.6 Acute Respiratory Infection. 153 9.7 Diarrhoeal Disease . 155 9.8 Women’s Perceptions of Problems in Accessing Health Care . 158 CHAPTER 10 INFANT FEEDING AND CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS. 163 10.1 Breastfeeding. 163 10.2 Complementary Feeding. 169 10.3 Micronutrients . 171 10.4 Prevalence of Anaemia in Children. 175 10.5 Nutritional Status . 178 10.6 Nutritional Status of Women . 181 CHAPTER 11 HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS. 185 11.1 Introduction . 185 11.2 Knowledge of AIDS and HIV Transmission. 186 11.3 Accepting Attitudes Towards Those with HIV/AIDS. 193 11.4 Attitudes Towards Condom Education for Youth. 196 11.5 Attitudes Towards Negotiating Safer Sex . 197 11.6 Multiple Sexual Partnerships . 198 11.7 Higher-Risk Sex . 200 11.8 Paid Sex and Condom Use . 201 11.9 Counselling and Testing for HIV. 202 11.10 Self-Reporting of Sexually Transmitted Infections and Symptoms . 207 11.11 Prevalence of Injections . 209 11.12 HIV/AIDS-Related Knowledge and Behaviour among Youth. 210 11.13 Age at First Sex among Youth. 212 11.14 Condom Use at First Sex among Youth . 214 11.15 Premarital Sex . 216 11.16 Higher-Risk Sex and Condom Use among Youth. 217 11.17 HIV Testing among Youth . 221 11.18 Orphanhood and School Attendance. 222 11.19 Male Circumcision. 223 vi | Contents CHAPTER 12 HIV PREVALENCE AND ASSOCIATED FACTORS . 225 12.1 Coverage of HIV Testing . 226 12.2 HIV Prevalence. 230 12.3 Measuring the HIV Burden in Malawi . 241 CHAPTER 13 ADULT AND MATERNAL MORTALITY. 243 13.1 Data . 243 13.2 Direct Estimates of Adult Mortality. 245 13.3 Maternal Mortality . 247 CHAPTER 14 MALARIA . 249 14.1 Mosquito Nets . 250 14.2 Intermittent Preventive Treatment During Pregnancy. 257 14.3 Prevalence and Management of Malaria in Children . 259 CHAPTER 15 DOMESTIC VIOLENCE . 265 15.1 Introduction . 265 15.2 Physical Violence Since Age 15. 266 15.3 Perpetrators of Physical Violence . 267 15.4 Violence During Pregnancy. 268 15.5 Marital Control by Husband. 269 15.6 Forms of Marital Violence. 272 15.7 Frequency of Spousal Violence . 274 15.8 Onset of Spousal Violence . 275 15.9 Physical Consequences of Spousal Violence. 276 15.10 Violence by Spousal Characteristics and Women’s Indicators. 277 15.11 Help Seeking for Women Who Experience Violence . 279 CHAPTER 16 MEN’S PARTICIPATION IN HEALTH CARE. 281 16.1 Advice or Care Received by Mother During Pregnancy, Delivery, and After Delivery . 281 16.2 Main Provider During Pregnancy, Delivery, and After Delivery . 283 16.3 Reasons for Not Getting Care During Pregnancy, Delivery, and After Delivery 283 16.4 Decisionmaking on Child’s Health Care. 284 16.5 Men’s Knowledge of Pregnancy Complications . 286 REFERENCES . 289 APPENDIX A SAMPLE IMPLEMENTATION . 293 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 299 APPENDIX C DATA QUALITY . 321 Contents | vii APPENDIX D PERSONS INVOLVED IN THE 2004 MALAWI DEMOGRAPHIC AND HEALTH SURVEY . 327 APPENDIX E QUESTIONNAIRES . 331 APPENDIX F MILLENNIUM DEVELOPMENT GOAL INDICATORS . 449 APPENDIX G ANALYSIS OF RESPONSE BIAS AND ADJUSTMENT OF HIV PREVALENCE . 451 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Demographic indicators.2 Table 1.2 Results of the household and individual interviews .7 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 and orphanhood.12 Table 2.4.1 Educational attainment of household population: women .14 Table 2.4.2 Educational attainment of household population: men .15 Table 2.5.1 School attendance ratios: primary school.17 Table 2.5.2 School attendance ratios: secondary school .18 Table 2.6 Grade repetition and dropout rates.19 Table 2.7 Child labour .21 Table 2.8 Household characteristics .22 Table 2.9 Household durable goods.24 Figure 2.1 Population pyramid .10 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS AND WOMEN’S STATUS Table 3.1 Background characteristics of respondents .26 Table 3.2.1 Educational attainment by background characteristics: women.28 Table 3.2.2 Educational attainment by background characteristics: men.29 Table 3.3.1 Literacy: women.30 Table 3.3.2 Literacy: men .31 Table 3.4.1 Exposure to mass media: women.32 Table 3.4.2 Exposure to mass media: men .33 Table 3.5.1 Employment status: women.35 Table 3.5.2 Employment status: men .36 Table 3.6.1 Occupation: women.38 Table 3.6.2 Occupation: men .39 Table 3.7.1 Type of employment: women.40 Table 3.7.2 Type of employment: men .41 Table 3.8 Decision on use of earnings and contribution of earnings to household expenditures.43 Table 3.9 Women's control over earnings .44 Table 3.10 Women's participation in decisionmaking .45 x | Tables and Figures Table 3.11.1 Women's participation in decisionmaking by background characteristics: women .46 Table 3.11.2 Men’s attitudes towards women’s control of decisionmaking by background characteristics .47 Table 3.12.1 Women's attitude towards wife beating.49 Table 3.12.2 Men's attitude towards wife beating .50 Table 3.13.1 Women's attitude towards refusing sex with husband.52 Table 3.13.1 Men's attitude towards refusing sex with husband .53 Figure 3.1 Employment status of women age 15-49 .37 Figure 3.2 Type of earnings of women age 15-49 .41 CHAPTER 4 FERTILITY Table 4.1 Current fertility .56 Table 4.2 Fertility by background characteristics.58 Table 4.3 Trends in age-specific fertility rates .59 Table 4.4 Trends in fertility by background characteristics .61 Table 4.5 Trends in age-specific fertility rates .61 Table 4.6 Children ever born and living.62 Table 4.7 Birth intervals.64 Table 4.8 Age at first birth .65 Table 4.9 Median age at first birth by background characteristics.66 Table 4.10 Adolescent pregnancy and motherhood.67 Figure 4.1 Total fertility rates for selected sub-Saharan countries .57 Figure 4.2 Total fertility rate by background characteristics .59 Figure 4.3 Trends in the total fertility rate .60 Figure 4.4 Trends in age-specific fertility rates .60 CHAPTER 5 FERTILITY REGULATION Table 5.1.1 Knowledge of contraceptive method: women.70 Table 5.1.2 Knowledge of contraceptive method: men .71 Table 5.2 Knowledge of contraceptive methods by background characteristics.72 Table 5.3.1 Ever use of contraception: women.73 Table 5.3.2 Ever use of contraception: men .74 Table 5.4 Current use of contraception .75 Table 5.5 Current use of contraception by background characteristics .76 Table 5.6 Trends in contraceptive use .77 Table 5.7 Current use of contraception by women's status.78 Table 5.8 Number of children at first use of contraception .79 Table 5.9 Knowledge of fertile period.80 Table 5.10 Timing of sterilisation.80 Table 5.11 Source of contraception.81 Table 5.12 Informed choice .83 Table 5.13 First-year contraceptive discontinuation rates.84 Tables and Figures | xi Table 5.14 Reasons for discontinuation .85 Table 5.15 Future use of contraception .85 Table 5.16 Reason for not intending to use contraception .86 Table 5.17 Preferred method of contraception for future use .87 Table 5.18.1 Exposure to family planning messages: women .88 Table 5.18.2 Exposure to family planning messages: men.89 Table 5.19 Contact of nonusers with family planning providers .90 Table 5.20 Discussion of family planning with husband.91 Table 5.21 Men's attitudes towards contraception .92 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status.93 Table 6.2 Number of cowives and wives .95 Table 6.3 Age at first marriage .97 Table 6.4 Median age at first marriage.98 Table 6.5 Age at first sexual intercourse.99 Table 6.6.1 Median age at first intercourse: women . 100 Table 6.6.2 Median age at first intercourse: men. 101 Table 6.7.1 Recent sexual activity: women. 103 Table 6.7.2 Recent sexual activity: men . 104 Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility . 105 Table 6.9 Median duration of postpartum insusceptibility by background characteristics . 106 Table 6.10 Menopause . 107 Figure 6.1 Percentage of currently married men in a polygynous marriage, by background characteristics .96 CHAPTER 7 FERTILITY PREFERENCES AND UNMET NEED FOR FAMILY PLANNING Table 7.1.1 Fertility preferences by number of living children: women . 110 Table 7.1.2 Fertility preferences by number of living children: men. 110 Table 7.2 Desire to limit childbearing. 111 Table 7.3 Need for family planning . 113 Table 7.4 Ideal number of children . 116 Table 7.5.1 Mean ideal number of children by background characteristics: women . 118 Table 7.5.2 Mean ideal number of children by background characteristics: men . 119 Table 7.6 Fertility planning status . 120 Table 7.7 Wanted fertility rates . 121 Figure 7.1 Percentage of currently married women who have two children who want to end childbearing . 112 Figure 7.2 Trend in unmet need for family planning, total demand, and percentage of demand satisfied. 114 xii | Tables and Figures CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates. 126 Table 8.2 Early childhood mortality rates by background characteristics . 128 Table 8.3 Early childhood mortality rates by demographic characteristics . 129 Table 8.4 Early childhood mortality rates by women's status . 130 Table 8.5 Perinatal mortality . 131 Table 8.6 High-risk fertility behaviour. 132 CHAPTER 9 MATERNAL AND CHILD HEALTH Table 9.1 Antenatal care . 134 Table 9.2 Number of antenatal care visits and timing of first visit . 135 Table 9.3 Components of antenatal care . 136 Table 9.4 Tetanus toxoid injections . 137 Table 9.5 Complications during pregnancy. 138 Table 9.6 Treatment for complications during pregnancy . 140 Table 9.7 Place of delivery . 141 Table 9.8 Assistance during delivery . 142 Table 9.9 Delivery characteristics . 144 Table 9.10 Postnatal care . 146 Table 9.11 Complications after delivery. 147 Table 9.12 Reproductive health care by women's status . 148 Table 9.13 Vaccinations by source of information . 150 Table 9.14 Trends in vaccination coverage . 151 Table 9.15 Vaccinations by background characteristics. 152 Table 9.16 Prevalence and treatment of symptoms of ARI and fever. 154 Table 9.17 Prevalence of diarrhoea . 155 Table 9.18 Knowledge of ORS packets . 156 Table 9.19 Diarrhoea treatment . 157 Table 9.20 Feeding practices during diarrhoea . 158 Table 9.21 Problems in accessing health care . 159 Figure 9.1 Complications during pregnancy. 139 Figure 9.2 Assistance at delivery from a health professional, by residence and district . 143 Figure 9.3 Percentage of children age 12-23 months who were vaccinated by 12 months of age. 150 Figure 9.4 Percentage of women who reported they have big problems in accessing health care, by type of problem. 160 Figure 9.5 Percentage of women who reported the cost of transport as a big problem in accessing health care. 161 Tables and Figures | xiii CHAPTER 10 INFANT FEEDING AND CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS Table 10.1 Initial breastfeeding . 164 Table 10.2 Breastfeeding status by age . 166 Table 10.3 Median duration and frequency of breastfeeding. 168 Table 10.4 Foods consumed by children in the day or night preceding the interview . 170 Table 10.5 Frequency of foods consumed by children in the day or night preceding the interview . 171 Table 10.6 Micronutrient intake among children . 172 Table 10.7 Micronutrient intake among mothers . 174 Table 10.8 Prevalence of anaemia in children . 175 Table 10.9 Prevalence of anaemia in women . 177 Table 10.10 Prevalence of anaemia in children by anaemia status of mother. 178 Table 10.11 Nutritional status of children. 180 Table 10.12 Nutritional status of women . 183 Figure 10.1 Distribution of children by breastfeeding status, according to age. 167 Figure 10.2 Percentage of children with low height-for-age, weight-for-height, and weight-for-age, by age of child . 182 Figure 10.3 Prevalence of chronic energy deficiency (percent with BMI <18.5) among women age 15-49, for selected districts. 184 CHAPTER 11 HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS Table 11.1 Knowledge of AIDS. 186 Table 11.2 Knowledge of HIV prevention methods . 187 Table 11.3.1 Beliefs about AIDS: women . 189 Table 11.3.2 Beliefs about AIDS: men. 190 Table 11.4 Knowledge of prevention of mother-to-child transmission of HIV. 192 Table 11.5.1 Accepting attitudes towards people living with HIV: women. 194 Table 11.5.2 Accepting attitudes towards people living with HIV: men. 195 Table 11.6 Adult support of education about condom use to prevent AIDS. 196 Table 11.7 Attitudes toward negotiating safer sex with husband . 197 Table 11.8 Multiple sex partners among women and men. 199 Table 11.9 Higher-risk sex and condom use at last higher-risk sex in the past year. 200 Table 11.10 Paid sex in past year and condom use at last paid sex . 201 Table 11.11 HIV testing status and receipt of test results. 203 Table 11.12 Pregnant women counselled and tested for HIV. 205 Table 11.13 Knowledge of source for test. 206 Table 11.14 Self-reporting of sexually transmitted infection and STI symptoms. 208 Table 11.15 Injections by background characteristics . 210 Table 11.16 Comprehensive knowledge about AIDS and of a source of condoms among youth . 211 Table 11.17 Age at first sex among young women and men . 213 Table 11.18 Condom use at first sex among young women and men . 215 Table 11.19 Premarital sex and condom use during premarital sex. 216 xiv | Tables and Figures Table 11.20 Higher-risk sex and condom use at last higher-risk sex in the past year among young women and men . 218 Table 11.21 Age-mixing in sexual relationships. 220 Table 11.22 Recent HIV tests among youth . 221 Table 11.23 Schooling of children 10-14 by orphanhood and living arrangements . 222 Table 11. 24 Male circumcision . 223 Figure 11.1 Percentage of women and men reporting an STI or symptoms of an STI in the past 12 months who sought care, by source of advice or treatment. 209 Figure 11.2 Percentage of respondents age 15-19 who had sex before age 15 and percentage of respondents age 18-19 who had sex before age 18. 214 Figure 11.3 Scale of risk for young women: abstinence, being faithful, and condom use. 219 Figure 11.4 Scale of risk for young men: abstinence, being faithful, and condom use . 219 CHAPTER 12 HIV PREVALENCE AND ASSOCIATED FACTORS Table 12.1 Coverage of HIV testing by residence and region . 227 Table 12.2.1 Coverage of HIV testing by background characteristics: women. 228 Table 12.2.2 Coverage of HIV testing by background characteristics: men. 229 Table 12.3 HIV prevalence by age. 230 Table 12.4 HIV prevalence by socioeconomic characteristics . 232 Table 12.5 Observed and adjusted HIV prevalence. 233 Table 12.6 HIV prevalence by sociodemographic characteristics . 234 Table 12.7 HIV prevalence by sexual behaviour characteristics . 236 Table 12.8 HIV prevalence by other characteristics . 237 Table 12.9 HIV prevalence among young people . 239 Table 12.10 HIV prevalence among couples . 240 Figure 12.1 Percentage HIV positive among women and men age 15-49 . 231 Figure 12.2 HIV Prevalence by prior testing status . 238 CHAPTER 13 ADULT AND MATERNAL MORTALITY Table 13.1 Data on siblings: completeness of reported data . 244 Table 13.2 Adult mortality rates . 245 Table 13.3 Direct estimates of maternal mortality. 247 Figure 13.1 Trends in age-specific mortality among women age 15-49 . 246 Figure 13.2 Trends in age-specific mortality among men age 15-49. 246 CHAPTER 14 MALARIA Table 14.1 Ownership of mosquito nets. 251 Table 14.2 Colour and shape of mosquito nets. 252 Table 14.3 Use of mosquito nets by children. 254 Table 14.4 Use of mosquito nets by pregnant women . 256 Tables and Figures | xv Table 14.5 Prophylactic use of antimalarial drugs and of Intermittent Preventive Treatment by women during pregnancy. 258 Table 14.6 Initial response to fever. 260 Table 14.7 Prevalence and prompt treatment of fever . 261 Table 14.8 Type and timing of antimalarial drugs taken by children with fever . 263 Figure 14.1 Preferred colour of mosquito nets, by residence . 253 Figure 14.2 Preferred shape of mosquito nets, by residence . 253 Figure 14.3 Percentage of children under age five who slept under a mosquito net the night before the survey . 255 Figure 14.4 Percentage of women age 15-49 who slept under a mosquito net on the night before the survey . 257 Figure 14.5 Percentage of pregnant women who took at least 2 doses of SP for IPT of malaria during pregnancy in the 5 years preceding the survey. 259 CHAPTER 15 DOMESTIC VIOLENCE Table 15.1 Experience of physical violence since age 15 . 267 Table 15.2 Perpetrators of physical violence. 268 Table 15.3 Violence during pregnancy . 269 Table 15.4 Degree of marital control by husband . 270 Table 15.5 Marital violence. 272 Table 15.6 Frequency of spousal violence . 275 Table 15.7 Onset of spousal violence . 276 Table 15.8 Physical consequences of spousal violence . 277 Table 15.9 Spousal violence by spousal characteristics . 278 Table 15.10: Spousal violence by women's status . 279 Table 15.11 Help seeking for women who experience violence . 280 Figure 15.1 Percentage of ever-married women who have experienced violence by their current or last husband . 273 Figure 15.2 Percentage of women who ever experienced sexual, physical, and/or emotional violence . 274 CHAPTER 16 MEN’S PARTICIPATION IN HEALTH CARE Table 16.1 Care received by mother during pregnancy, delivery, and after delivery . 282 Table 16.2 Main provider for payment for maternal care. 283 Table 16.3 Reason for not getting care during pregnancy, delivery, and after delivery. 284 Table 16.4 Decisionmaker in child's health care . 285 Table 16.5 Knowledge of pregnancy complications . 287 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Sample implementation: women . 295 Table A.2 Sample implementation: men. 296 xvi | Tables and Figures APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Malawi 2004. 302 Table B.2 Sampling errors: Total sample . 303 Table B.3 Sampling errors: Urban sample. 304 Table B.4 Sampling errors: Rural sample. 305 Table B.5 Sampling errors: Northern Region. 306 Table B.6 Sampling errors: Central Region. 307 Table B.7 Sampling errors: Southern Region. 308 Table B.8 Sampling errors: Blantyre District . 309 Table B.9 Sampling errors: Kasungu District. 310 Table B.10 Sampling errors: Machinga District. 311 Table B.11 Sampling errors: Mangochi District . 312 Table B.12 Sampling errors: Mzimba District . 313 Table B.13 Sampling errors: Salima District . 314 Table B.14 Sampling errors: Thyolo District . 315 Table B.15 Sampling errors: Zomba District. 316 Table B.16 Sampling errors: Lilongwe District. 317 Table B.17 Sampling errors: Mulanje District . 318 Table B.18 Sampling errors: Other Districts . 319 APPENDIX C DATA QUALITY Table C.1 Household age distribution. 321 Table C.2 Age distribution of eligible and interviewed women. 322 Table C.3 Completeness of reporting . 323 Table C.4 Births by calendar years . 324 Table C.5 Reporting of age at death in days . 325 Table C.6 Reporting of age at death in months . 326 APPENDIX D PERSONS INVOLVED IN THE 2004 MALAWI DEMOGRAPHIC AND HEALTH SURVEY . 327 APPENDIX E QUESTIONNAIRES . 331 APPENDIX F MILLENNIUM DEVELOPMENT GOAL INDICATORS . 449 APPENDIX G ANALYSIS OF RESPONSE BIAS AND ADJUSTMENT OF HIV PREVALENCE Table G.1 Observed and adjusted HIV prevalence among women and men age 15-49 . 453 Table G.2 Observed and adjusted HIV prevalence among women and men age 15-49 by selected background characteristics . 454 Foreword | xvii FOREWORD This final report presents the major findings of the 2004 Malawi Demographic and Health Survey (MDHS). The 2004 MDHS survey is the third survey of its kind to be conducted in Malawi; the first MDHS was in 1992 and the second was in 2000. The 2004 MDHS included, for the first time, testing of blood samples to provide national rates for anaemia and HIV. The fieldwork was carried out by the National Statistical Office (NSO) in collaboration with the Ministry of Health from October 2004 to January 2005. In 1996, a similar survey on Knowledge, Attitudes, and Practices in Health (MKAPH) was conducted. All four surveys were designed to provide information on indicators of maternal and child health in Malawi. The primary objective of the 2004 MDHS 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 2004 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, HIV/AIDS-related knowledge and behaviours. The survey will also provide the national level estimates of HIV prevalence for women age 15-49 and men age 15-54, and anaemia status of women age 15-49 and children age 6-59 months. The 2004 MDHS results present evidence of a decline in maternal mortality rate as compared to the 2000 MDHS; decrease in fertility rates, an increase in the use of family planning methods and a decline in infant and under-five mortality since the 1992 MDHS. 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. The NSO would like to acknowledge the efforts of a number of organisations and individuals who contributed immensely to the success of the survey. First, we would like to acknowledge the financial assistance from the National AIDS Commission (NAC), United States Agency for International Development (USAID), the Department for International Development (DFID), United Kingdom, and the United Nations Children’s Fund (UNICEF/Malawi), the Centers for Disease Control and Prevention (CDC), NORAD (Norway), CIDA (Canada), and UNFPA. We would also like to acknowledge ORC Macro for technical backstopping, and the assistance of the staff of the National Statistical Office, the Ministry of Health and Population, Department of Population Services in the Ministry of Economic Planning and Development, all members of the steering committee and various technical working groups. We also appreciate the work done by the Community Health Services Unit (CHSU), and especially commend the laboratory team assigned to work on the blood samples for their tireless efforts in getting the testing done successfully. xviii | Foreword Finally, we are 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 Statistics Summary of Findings | xix SUMMARY OF FINDINGS The 2004 Malawi Demographic and Health Survey (MDHS) is a nationally representative survey of 11,698 women age 15- 49 and 3,261 men age 15-54. The main purpose of the 2004 MDHS is to provide policymakers and programme managers with detailed information on fertility, family planning, childhood and adult mortality, maternal and child health, as well as knowledge of and attitudes related to HIV/AIDS and other sexually transmitted infections (STIs). The 2004 MDHS is designed to provide data to monitor the population and health situation in Malawi as a followup of the 1992 and 2000 MDHS surveys, and the 1996 Malawi Knowledge, Attitudes, and Practices in Health Survey. New features of the 2004 MDHS include the collection of information on use of mosquito nets, domestic violence, anaemia testing of women and children under 5, and HIV testing of adults. The 2004 MDHS survey was implemented by the National Statistical Office (NSO). The Ministry of Health and Population, the National AIDS Commission (NAC), the National Economic Council, and the Ministry of Gender contributed to the development of the questionnaires for the survey. Most of the funds for the local costs of the survey were provided by multiple donors through the NAC. The United States Agency for International Development (USAID) provided additional funds for the technical assistance through ORC Macro. The Department for International Development (DfID) of the British Government, the United Nations Children’s Fund (UNICEF), and the United Nations Population Fund (UNFPA) also provided funds for the survey. The Centers of Disease Control and Prevention provided technical assistance in HIV testing. The survey used a two-stage sample based on the 1998 Census of Population and Housing and was designed to produce estimates for key indicators for ten large districts in addition to estimates for national, regional, and urban-rural domains. Fieldwork for the 2004 MDHS was carried out by 22 mobile interviewing teams. Data collection commenced on 4 October 2004 and was completed on 31 January 2005. FERTILITY Fertility Levels and Trends. While there has been a significant decline in fertility in the past two decades from 7.6 children in the early 1980s to 6.0 children per woman in the early 2000s, compared with selected countries in Eastern and Southern Africa, such as Zambia, Tanzania, Mozambique, Kenya, and Uganda, the total fertility rate (TFR) in Malawi is high, lower only than Uganda (6.9). Fertility Differentials. Fertility varies substantially across residence. Urban women have, on average, more than two children fewer than rural women (4.2 and 6.4, respectively). While the TFR in the Central Region is 6.4, in the Southern and Northern Regions it is only 5.8 and 5.6 births per woman, respectively. Among the ten oversampled districts, TFR varies from 4.8 births per woman in Blantyre to 7.2 births per woman in Mangochi. As expected, fertility is strongly associated with education and wealth status. The TFR decreases dramatically from 6.9 for women with no education to 3.8 for women with at least some secondary education. The TFR for women in the lowest (poorest) quintile is 7.1 births per woman, compared with 4.1 births for women in the highest (richest) quintile. xx | Summary of Findings Unplanned Fertility. Despite increasing use of contraception, the 2004 MDHS data indicate that unplanned pregnancies are common in Malawi. Twenty percent of births in the five years preceding the survey are not wanted and 21 percent are mistimed (wanted later). The percentage of recent births that are not wanted increased from 14 percent in 1992 to 22 percent in 2000, and declined to 20 percent in 2004. Fertility Preferences. The 2004 MDHS finding indicates that 35 percent of women wanted no more children and therefore want to limit the family size at its current level, and 6 percent had already been sterilised. Thirty- eight percent of men also report wanting no more children. There has been a decline in fertility preferences among currently married women since 2000. The average ideal family size for all women was 5.0 children in 2000 and was 4.1 in 2004. For all men, ideal family size declined from 4.8 children in 2000 to 4.0 in 2004. FAMILY PLANNING Knowledge of Contraception. Know- ledge of family planning is nearly universal, with 97 percent of women age 15-49 and 97 percent of men age 15-54 knowing at least one modern method of family planning. The most widely known modern methods of contraception among all women are injectables (93 percent), the pill and male condom (90 percent each), and female sterilisation (83 percent). The male condom is the most widely known contraceptive method (72 percent) among women with no sexual experience. These findings are similar to those in the 2000 MDHS. Use of Contraception. One in three married women (33 percent) in Malawi is using a method of family planning. Most of these women are using a modern method (28 percent). Injectables, female sterilisation, and the pill are the most commonly used contraceptive methods, used by 18, 6, and 2 percent of married women, respectively. The most commonly used methods for sexually active unmarried women are injectables (11 percent) and male condoms (10 percent). Trends in Contraceptive Use. Contra- ceptive use among married women in Malawi has increased slightly from 31 percent in 2000 to 33 percent in 2004. This is a much slower increase than between 1992 and 2000 (13 and 31 percent, respectively). There is a notable rise in the use of modern methods from 7 percent in 1992 to 28 percent in 2004, mostly because of a sharp increase in the use of injectables and female sterilisation. The use of male condoms remained unchanged at 2 percent. Differentials in Contraceptive Use. Use of a modern contraceptive method is higher among currently married women in urban areas than women in rural areas (35 and 27 percent, respectively). The highest levels of use of modern family planning methods are in Lilongwe and Blantyre (each 34 percent), and the lowest levels are in Mangochi (17 percent) and Salima (20 percent). Use of modern family planning methods is slightly higher in the Central Region (30 percent) and the Northern Region (29 percent) than in the Southern Region (27 percent). The same pattern was seen in the 2000 MDHS. Use of traditional methods is more common in the Northern Region (13 percent) than in the other regions (3 percent or less). In the Northern Region, withdrawal is the traditional method most commonly used (10 percent). Modern contraceptive methods increase with the woman’s education and wealth status. Twenty-two percent of married women in the lowest wealth quintile use a modern family planning method, and the corresponding proportion for those in the highest wealth quintile is 38 percent. Summary of Findings | xxi Source of Modern Methods. In Malawi, 67 percent of current users of modern methods obtain their methods from a public facility. This is about the same proportion captured in the 2000 MDHS (68 percent). Thirteen percent of all current users get their methods from religious (mission) facilities, 4 percent from the private medical sector, and 17 percent from other sources including nongovernmental organizations (NGOs), where Banja La Mtsogolo is the most commonly used source (13 percent). Contraceptive Discontinuation Rates. Thirty-six percent of contraceptive users discontinue use of a method within a year after beginning to use the method. The 12-month discontinuation rate for modern contraceptives is highest for the male condom (62 percent), followed by the pill (52 percent) and injectables (33 percent). Eight percent of the users report that they stopped using a method because of the desire to get pregnant. Twenty percent gave other reasons for discontinuing. Unmet Need for Family Planning. Unmet need for family planning services is defined as the percentage of currently married women who either do not want any more children or want to wait before having their next birth, but are not using any method of family planning. The 2004 MDHS shows that 28 percent of married women have an unmet need for family planning services: 17 percent for spacing births and 10 percent for limiting births. The total demand for family planning among married women increased from 60 percent in 2000 to 62 percent in 2004. MATERNAL HEALTH Antenatal Care. There has been little change in the coverage of antenatal care (ANC) from a medical professional since 2000 (93 percent in 2004 compared with 91 percent in 2000). Most women receive ANC from a nurse or a midwife (82 percent), although 10 percent go to a doctor or a clinical officer. A small proportion (2 percent) receives ANC from a traditional birth attendant, and 5 percent do not receive any ANC. Only 8 percent of women initiated ANC before the fourth month of pregnancy, a marginal increase from 7 percent in the 2000 MDHS. Eighty-five percent of women received at least one tetanus toxoid injection during pregnancy for their most recent birth in the five years preceding the survey. The coverage of tetanus toxoid injection has not changed since 1992 (85-86 percent). Two in three women had two or more doses of tetanus toxoid injections. This figure is lower than that reported in the 1992 MDHS (73 percent). With regard to malaria prevention during pregnancy, the 2004 MDHS data show that 81 percent of pregnant women took an antimalarial drug and 43 percent of women received two or more doses of intermittent preventive treatment (IPT), at least once during an ANC visit. Delivery Care. The majority of births were attended by medical professionals, 50 percent by a nurse or midwife, 6 percent by a doctor/clinical officer, and only 1 percent by a patient attendant. There has been a slight increase in the proportion of births that are attended by a doctor/clinical officer from 4 percent in 2000 to 6 percent in 2004. The role of traditional birth attendants in assisting delivery also increased from 23 percent in 2000 to 26 percent in 2004. Similar to that recorded in the 2000 MDHS, 3 percent of births in the five years preceding the survey were delivered by C–section. Postnatal Care. Postnatal care is recommended to start immediately after the birth of the baby and placenta to 42 days after delivery. The 2004 MDHS shows that seven in ten women did not receive postnatal care. Among those who had postnatal care (31 percent), 21 percent received care within two days of delivery. Few women had a xxii | Summary of Findings checkup 3-6 days after delivery, and 8 percent received care between the first and sixth week after delivery. Adult and Maternal Mortality. Com- parison of data from the 2000 and 2004 MDHS surveys indicates that mortality for both women and men has remained at the same levels since 1997 (11-12 deaths per 1,000). Data on the survival of respondents’ sisters were used to calculate a maternal mortality ratio for the 7-year period before the survey, centered in mid-2001. Using direct estimation procedures, the maternal mortality ratio (MMR) is estimated to be 984 maternal deaths per 100,000 live births. The MMR based on the 2000 MDHS is significantly higher than that calculated from the 1992 MDHS (620 maternal deaths per 100,000 live births), but lower than the rate from the 2000 MDHS survey of 1,120 maternal deaths per 100,000 live births. It is unlikely that maternal mortality has changed so dramatically up and then down again, especially because the reference periods for the estimates overlap each other. MMRs measured in this way are subject to very high sampling errors and cannot adequately indicate short-term trends. CHILD HEALTH Childhood Mortality. Data from the 2004 MDHS show that for the 2000-2004 period, the infant mortality rate is 76 per 1,000 live births, child mortality is 62 per 1,000, and the under-five mortality rate is 133 per 1,000 live births. This means that about one in every eight children born in Malawi dies before reaching their fifth birthday. The estimate of under-five mortality calculated from the 1992 MDHS data (for the period 1988-1992) is 234 and from the 2000 MDHS data (1996-2000) is 189 per 1,000 live births. These figures suggest that the decline between 2000 and 2004 is faster than between 1992 and 2000 (29 and 19 percent, respectively). During the 15-year period preceding the survey, the estimates of neonatal mortality show a decline of 36 percent (from 42 to 27 per 1,000 live births). Childhood Vaccination Coverage. In the 2004 MDHS, mothers were able to show a health card with immunisation data for 74 percent of children age 12-23 months. This is lower than that recorded in 1992 and 2000 (86 and 81 percent, respectively). Sixty-four percent of children 12-23 months are fully vaccinated against six major childhood illnesses (tuberculosis, diphtheria, pertussis, tetanus, polio, and measles). Nine in ten of these children have been vaccinated against tuberculosis, 95 percent received polio 1 and DPT 1. Comparison with estimates of coverage of specific vaccines based on the 1992 and 2000 MDHS data show that the immunisation coverage for children has declined over time. Child Illness and Treatment. Acute respiratory infections (ARI), diarrhoea, and malaria are common causes of child death. In the two weeks before the survey, 19 percent of children under five years of age were ill with a cough and short, rapid breathing, 37 percent of children had fever, and 22 percent of children experienced diarrhoea. Among children with symptoms of ARI and/or fever, 20 percent were taken to a health facility, as were 36 percent of children with diarrhoea. Cough and diarrhoea are highest among children age 6-11 months. More than half (61 percent) of children with diarrhoea were treated with ORS (solution prepared from oral rehydration salts), 70 percent were given either ORS or increased fluids, and 18 percent received no treatment. Among children with fever, 57 percent were given an antimalarial drug, and 46 percent were given the drug on the same day or the following day. One in five children under age five years slept under a mosquito net the night before the survey, and most of them (18 percent) slept under an insecticide-treated net. Summary of Findings | xxiii NUTRITION Breastfeeding Practices. Breastfeeding is nearly universal in Malawi. Ninety- eight percent of children are breastfed for some period of time. The median duration of breastfeeding in Malawi in 2004 is 23.2 months, one month shorter than in 2000. The median duration of exclusive breastfeeding is 2.5 months, whereas the median for predominant breastfeeding is 4.8 months, twice as long as that recorded in 2000. More than half (53 percent) of children under six months are exclusively breastfed compared with 45 percent in the 2000 MDHS. Bottle-feeding is uncommon in Malawi. Use of feeding bottles in children under age six months has remained at the same level as in the 2000 MDHS (3 percent). Intake of Vitamin A. The Ministry of Health’s policy is to supplement children age 6- 59 months with a dose of vitamin A capsules once every six months. The 2004 MDHS shows that 65 percent of children under age three had consumed foods rich in vitamin A in the seven days preceding the survey and 65 percent of children had received a vitamin A capsule in the last six months before the survey. Furthermore, 41 percent of women received a vitamin A supplement during the postnatal period. This is the same level as that recorded in the 2000 MDHS. Nutritional Status of Children. The 2004 MDHS shows that the nutritional status of children under five has not improved since 1992. At the national level, 48 percent of children under five in Malawi are stunted, or too short for their age, 5 percent of children are wasted or too thin, and 22 percent are underweight. For the first time in Malawi, the DHS collected blood samples to be tested for haemoglobin level, a measurement of anaemia. The survey found that 73 percent of children age 6-59 months are anaemic: 26 percent have mild anaemia, 42 percent have moderate anaemia, and 5 percent have severe anaemia. Nutritional Status of Women. The nutritional status of women in Malawi has remained constant since 2000; the mean height of mothers is 156 centimetres. The cut-off point, below which a woman is considered at risk, is between 140 and 150 centimetres. Three percent of women are less than 145 centimetres in height., The 2004 MDHS used the body mass index (BMI)—defined as weight in kilograms divided by height squared in metres, to assess thinness and obesity. A cut off point of 18.5 is used to define chronic energy deficiency. The mean BMI among the weighed and measured women in the 2004 MDHS is 22, with 77 percent of women classified as normal (BMI 18.5-24.9) and 9 percent are considered thin (BMI below 18.5). Fourteen percent of women in Malawi are classified as overweight or obese (BMI 25.0 or higher). The survey also found that 45 percent of women are anaemic: 33 percent have mild anaemia, 11 percent have moderate anaemia, and 2 percent have severe anaemia. HIV/AIDS Awareness of AIDS. Knowledge of AIDS among women and men in Malawi is almost universal. This is true across age group, urban-rural residence, marital status, wealth index, and education. Nearly half of women and six in ten men can identify the two most common misconceptions about the transmission of HIV—HIV can be transmitted by mosquito bites, and HIV can be transmitted by supernatural means—and know that a healthy-looking person can have the AIDS virus. Attitudes Towards Persons with HIV. To gauge stigma associated with AIDS, the 2004 MDHS asked respondents who had heard of HIV/AIDS about their attitudes towards people with HIV. These questions include whether respondents would be willing to take care of orphaned children of family member who died of HIV, whether they would buy fresh vegetables from a shopkeeper who is xxiv | Summary of Findings infected with HIV, and whether they believe an HIV-positive female teacher should be allowed to keep on teaching. Almost all women and men age 15-49 (94 and 97 percent, respectively) say that they are willing to take care of orphaned children of a family member who died of AIDS. About two in three women and 84 percent of men say they would buy fresh vegetables from a shopkeeper who is HIV- positive. Two in three women and 80 percent of men say that an HIV-positive female teacher should be allowed to keep teaching. Sixty- five percent of women and 48 percent of men say that they would not necessarily fear disclosure of a family member’s HIV-positive status. Looking at all of the stigmas attached to persons with AIDS, 31 percent of women age 15-49 and 30 percent of men age 15-49 expressed acceptance of all four measures of stigma. HIV-Related Behavioural Indicators. Three in four women agree that HIV can be transmitted by breastfeeding, while about four in ten said the risk of mother-to-child transmission (MTCT) can be reduced by the mother taking drugs during pregnancy, and 37 percent reported both, that HIV can be transmitted by breastfeeding and the risk of MTCT can be reduced by the mother taking special drugs during pregnancy. Sixty- seven percent of men say that HIV can be transmitted by breastfeeding, 35 percent say that the risk of MTCT can be reduced by the mother taking drugs during pregnancy, and 29 percent report that HIV can be transmitted by breastfeeding and that the risk of MTCT can be reduced by taking special drugs during pregnancy. Delaying the age at which young persons become sexually active is an important strategy for reducing the risk of contracting a sexually transmitted infection (STI). In Malawi, 15 percent of women age 15-24 and 14 percent of men age 15-24 have had sex by age 15. Sexual intercourse with a nonmarital or noncohabiting partner is associated with an increase in the risk of contracting an STI. Eight percent of women and 27 percent of men engaged in higher-risk sexual behaviour in the last 12 months. Higher-risk sexual behaviour is even more common among youth age 15-24. Fourteen percent of young women and 62 percent of young men age 15-24 engaged in higher-risk sexual activity in the 12 months preceding the survey. Only 39 percent of young women and 46 percent of young men reported using a condom at last higher-risk sexual intercourse. HIV Testing. To gauge the coverage of HIV testing, respondents in the 2004 MDHS were asked if they had ever been tested to see if they have the AIDS virus. Those who had been tested were asked when they were last tested, whether they had asked for the test or were required to take it, and whether they received their results. Thirteen percent of women age 15-49 and 15 percent of men age 15-49 have been tested for HIV and received the test results. Additionally, 2 percent of women and 2 percent of men were tested but never received the result. HIV Prevalence. One in three households in the 2004 MDHS sample was selected for individual interviews with male respondents. All men age 15-54 in these households were eligible for individual interview. In the same households, all women age 15-49 and all men age 15-54 were asked to voluntarily provide some drops of blood for HIV testing in the laboratory. Results indicate that 12 percent of adults age 15-49 in Malawi is infected with HIV. HIV prevalence is higher among women than among men (13 and 10 percent, respectively). Prevalence peaks at 19 percent for adults age 30-34, 18 percent for women, and 20 percent for men. Patterns of HIV Prevalence. Prevalence is higher in urban areas than in rural areas. While 18 percent of urban women are HIV Summary of Findings | xxv positive, the corresponding proportion for rural women is 13 percent. For men, the urban-rural difference in HIV prevalence is even greater; urban men are nearly twice as likely to be infected as rural men (16 and 9 percent, respectively). HIV prevalence among women is higher in the Southern Region (20 percent) than in the Northern (10 percent) or Central (7 percent) Regions. The same pattern is observed for men, HIV prevalence is higher in Southern Region (15 percent) than in Central (6 percent) and Northern (5 percent) Regions. In Malawi, circumcised men have a slightly higher HIV infection rate than men who are not circumcised (13 and 10 percent, respectively). Among couples, 83 percent are both HIV negative, and 7 percent are both HIV positive. Ten percent of the couples are discordant, that is, one partner is infected and the other not. GENDER-RELATED VIOLENCE Violence since Age 15. Gender-related violence refers to any act of violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women. Domestic violence has negative health consequences on the victims and on the reproductive health of women. In response to the international and regional instruments on women’s rights, the Malawi government and its stakeholders started to implement various initiatives aimed at creating awareness on the dangers of gender-based violence. In the 2004 MDHS, women were asked if they had experienced any physical violence since age 15. The data show that 28 percent of women experienced physical violence since age 15 and 15 percent experienced it in the 12 months preceding the survey. Marital Violence. Seventy-seven percent of ever-married women who ex- perienced physical violence report their husbands as the perpetrators of the violence. The survey further found that 13 percent of ever-married women report to have ever experienced emotional violence, 20 percent experienced physical violence, and 13 percent experienced sexual violence. About one-third of women (30 percent) experienced at least one of the three forms of violence, and 4 percent experience all three forms of violence. The common form of spousal violence is slapping and arm twisting (16 percent) and forced intercourse or marital rape (13 percent). The 2004 MDHS results show that 39 percent of women were physically or sexually violated once or twice in the 12 months preceding the survey, 21 percent three to five times, and 10 percent more than five times. The factor most strongly related to marital violence is husband’s alcohol and/or drug use. Violence is more than twice as prevalent among women who say their husband gets drunk very often as among those whose husbands do not drink. Help-seeking Behaviour among Wo- men who Experienced Violence. Less than half of women who experienced violence actually sought help (42 percent). Of these women, 44 percent sought help from relatives or friends, one in three sought help from their own family, and 11 percent sought help from their in-laws. MALARIA Mosquito Nets. The use of insecticide- treated mosquito nets (ITNs) is a primary health intervention proven to reduce malaria transmission. The 2004 MDHS found that 42 percent of households in Malawi own at least one mosquito net, 29 percent of households own at least one ever-treated mosquito net, and 12 percent of households own an ITN. In one in five households the interviewer observed the mosquito nets. Among the observed nets, 21 percent are blue, 74 percent are green, and 5 percent are white. Most nets (71 percent) are rectangular. About one in four of the observed nets had at least one hole. Of the households that have no mosquito nets, 38 percent prefer a blue net and 41 percent prefer a green net. Forty-five percent of households with no mosquito net prefer a xxvi | Summary of Findings conical net while 43 percent prefer a rectangular net. One in five children under five years in Malawi slept under a mosquito net the night before the survey. Most of these children (18 percent) slept under an ever-treated net and 15 percent slept under an ITN. There is a small difference in the use of mosquito nets between pregnant women (19 percent) and all women (21 percent). Intermittent Preventive Treatment during Pregnancy. In Malawi, as a protective measure against various adverse outcomes of pregnancy, it is recommended that pregnant women receive at least two doses of sulfadoxine- pyrimethamine (SP), one in the second trimester and one in the third trimester. The 2004 MDHS data show that 81 percent of pregnant women in Malawi take an antimalarial drug for prevention during pregnancy—almost all take SP/Fansidar (79 percent)—and most women receive the drug during an ANC visit. Less than half (47 percent) of the women receive the recommended two or more doses of SP/ Fansidar. Prevalence and Management of Malaria in Children. The survey found that 37 percent of children had fever and/or convulsions in the two weeks preceding the survey. Of the children that had fever, 57 percent were given an antimalaria drug and 46 percent were given the medication the same or the following day. Children with fever were given quinine (45 percent), amodiaquine (39 percent), or SP/Fansidar (23 percent). One in five children were given medication (modern pharmaceutical or traditional) that was obtained at home, 39 percent of the children were given medicine that was bought at a pharmacy or shop (without a prescription), and 31 percent were taken to a health centre. Six percent of children with fever were not treated. MEN’S PARTICIPATION IN HEALTH CARE Reproductive Health Care. The 2004 MDHS collected information on men’s participation in their wives and children’s health care. This information helps family planning and health programme managers in investigating men’s role in taking care of the health of their family. When asked about antenatal care, 96 percent of fathers reported that the mother of their last child born in the five years preceding the survey received care from a health professional. This was almost the same as the response given by women (93 percent). For delivery assistance by a health care provider, 74 percent of men reported this response compared with 57 percent of women. Differences in question wording may account for differences in reporting by men and women. It should also be noted that fathers and mothers may not necessarily be reporting on the same child. Main Provider during Pregnancy, Delivery and after Delivery. The majority of men with a child born in the past five years reported that free services were received for antenatal care for 76 percent of pregnancies, delivery care for 66 percent of births, and postnatal care for 86 percent of births. Fathers reported providing payment for antenatal care for 19 percent of pregnancies, delivery care for 27 percent of births, and postnatal care for 12 percent of births. Decisionmaker on Child’s Health Care. The 2004 MDHS also collected information from fathers on who usually decides about their children’s health care. Questions were specifically asked about the health care for their youngest child under five. In 87 percent of cases, fathers reported that they decide about the health care for their children; mothers do so in 64 percent of cases. Summary of Findings | xxvii Knowledge of Signs of Danger in Pregnancy. The results from the 2004 MDHS show that men’s knowledge of danger signs in pregnancy is limited. Two in three men have no knowledge of any danger signs or symptoms that indicate that a pregnancy may be at an elevated risk. The most often cited sign of pregnancy complication is vaginal bleeding, with 11 percent of men reporting this complication. xxviii | Map of Malawi Introduction | 1 INTRODUCTION 1 Derek Zanera 1.1 GEOGRAPHY, HISTORY, AND THE ECONOMY 1.1.1 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. The total area is 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, which 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 28 districts in the country. Six districts are in the Northern Region, nine are in the Central Region, and 13 are in the Southern Region. Administratively, the districts are subdivided into traditional authorities (TAs), presided over by chiefs. Each TA is 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. 1.1.2 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, Southern Rhodesia (now Zimbabwe), Northern Rhodesia (now Zambia), and Nyasaland (now Malawi). In July 1964 Nyasaland became the independent state of Malawi and gained republic status in 1966. In 1994 Malawi adopted a multiparty system and a strategy to eradicate poverty. Since then, it has 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 rural-to-urban migration. 2 | Introduction 1.1.3 Economy Malawi has a predominantly agricultural economy. Agricultural produce accounted for 70 percent of Malawi exports in 2004, tobacco, tea, and sugar being the major export commodities. The country is largely self-sufficient with regard to food, but due to the high cost of fertilizer, coupled with erratic rains for the past three years, Malawi is experiencing food insecurity, making it largely dependent on imported maize from South Africa. 1.2 POPULATION The major source of historical demographic data comes from the population census, which was taken every ten years from 1891 to 1931. Since World War II, population censuses were conducted in 1945, 1966, 1977, 1987, and 1998. Other sources of population data include nationwide surveys, such as the 1992 Malawi Demographic and Health Survey (MDHS); the 1996 Malawi Knowledge Attitudes, and Practices in Health survey (MKAPH); and the 2000 MDHS. Table 1.1 provides some demographic indicators for Malawi based on various data sources. The population of Malawi grew from 8.0 million in 1987 to 9.9 million in 1998, as enumerated by the 1998 Population and Housing census, representing an increase of 24 percent, or an intercensal population growth rate of 2 percent per year. Population density increased from 85 persons per square kilometre in 1987 to 105 persons per square kilometre in 1998. To address problems associated with rapid population growth, in 1994 the Malawi government adopted the National Population Policy, which was designed to reduce population growth to a level compatible with Malawi’s social and economic goals (OPC, 1994). The policy’s objectives are 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. Table 1.1 Demographic indicators Selected demographic indicators, Malawi 1998 national census and population projections 1999-2002 Census Year Projections Indicator 1998 1999 2000 2001 2002 Population (midyear population) 9,933,868 10,152,753 10,475,257 10,816,294 11,174,648 Intercensal growth rate 2.0 3.1 3.2 3.3 3.3 Total area (sq km) 118,484 118,484 118,484 118,484 118,484 Land area (sq km) 94,276 94,276 94,276 94,276 94,276 Density (population per sq km) 105 108 111 115 119 Percentage of urban population 14.0 14.3 14.8 15.2 15.7 Women of childbearing age as a percentage of female population 47.2 48.2 49.8 51.4 53.1 Sex ratio 96.0 96.2 96.3 96.4 96.4 Crude birth rate 37.9 52.3 51.9 51.4 50.8 Total fertility rate 6.2 6.7 6.7 6.6 6.5 Crude death rate 21.1 23.1 21.8 20.5 19.4 Infant mortality rate 121.0 91.4 89.5 87.6 85.7 Life expectancy: Male 40.0 41.1 41.7 42.3 42.8 Female 44.0 43.8 44.3 44.9 45.5 Source: National Statistical Office (NSO). 1998 Population Projections for Malawi 1999 to 2023 based on the Population and Housing Census. Introduction | 3 1.3 OBJECTIVE OF THE SURVEY The principal aim of the 2004 MDHS project was 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 2000 MDHS survey, a national-level survey of similar scope. The 2004 MDHS survey, unlike the 2000 MDHS, collected blood samples which were later tested for HIV in order to estimate HIV prevalence in Malawi. In broad terms, the 2004 MDHS survey aimed to: • Assess trends in Malawi’s demographic indicators, principally fertility and mortality • Assist in the monitoring and evaluation of Malawi’s health, population, and nutrition programmes • Advance survey methodology in Malawi and contribute to national and international databases • Provide national-level estimates of HIV prevalence for women age 15-49 and men age 15-54. In more specific terms, the 2004 MDHS survey was designed to: • Provide data on the family planning and fertility behaviour of the Malawian population and thereby enable policymakers to evaluate and enhance family planning initiatives in the country • Measure changes in fertility and contraceptive prevalence and analyse the factors that affect these changes, such as marriage patterns, desire for children, availability of contraception, breastfeeding habits, and important social and economic factors • Examine 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. Particular emphasis was placed on malaria programmes, including malaria prevention activities and treatment of episodes of fever. • Provide levels and patterns of knowledge and behaviour related to the prevention of HIV/AIDS and other sexually transmitted infections • Provide national estimates of HIV prevalence • Measure the level of infant and adult mortality including maternal mortality at the national level • Assess the status of women in the country. 4 | Introduction 1.4 ORGANISATION OF THE SURVEY The 2004 MDHS survey was a comprehensive survey that involved several agencies. The National Statistical Office (NSO) had primary responsibility for conducting the survey. The Ministry of Health and Population, the National AIDS Commission (NAC), the National Economic Council, and the Ministry of Gender also contributed to the development of the questionnaires for the survey. Most of the funds for the local costs of the survey were provided by multiple donors through NAC. Financial support for the survey was also provided by the United States Agency for International Development (USAID), the United Kingdom’s Department for International Development (DFID), the United Nations Children’s Fund (UNICEF/Malawi) and United Nations Population Fund (UNFPA). Technical assistance was provided by ORC Macro through the USAID-funded MEASURE DHS project based in Calverton, Maryland, USA. The Centers for Disease Control and Prevention provided technical assistance in HIV testing. 1.4.1 Sample Design The 2004 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 selected large districts that were oversampled. To meet this objective, 522 clusters were drawn from the 1998 census sample frame: 458 in rural areas and 64 in urban areas. The following districts were oversampled in the 2004 MDHS in order to produce reliable district level estimates; Mulanje, Thyolo, Kasungu, Salima, Machinga, Zomba, Mangochi, Mzimba, Blantyre, and Lilongwe. The National Statistical Office staff conducted an exhaustive listing of households in each of the MDHS clusters in August and September 2004. From these lists, a systematic sample of households was drawn for a total of 15,091 households. All women age 15-49 in the selected households were eligible for individual interview. Every third household in the 2004 MDHS sample was selected for the male survey. In these households, all men age 15-54 were eligible for individual interview and HIV testing. In the same households, all women age 15-49 were eligible for HIV testing. During data collection, field staff used global positioning system (GPS) receivers to establish and record geographic coordinates of each of the MDHS clusters. 1.4.2 Questionnaires Three types of questionnaires were used in the 2004 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 questionnaires, which were adapted for use in Malawi in collaboration with a wide range of stakeholders. The MDHS survey instruments were translated into and printed in Chichewa and Tumbuka for pretesting. The Household Questionnaire was used to list all of the usual members and visitors in the selected households. Basic information on each person listed was collected, including age, sex, education, and relationship to the head of the household. Height and weight measurements were taken for all women age 15-49 and all children under the age of five. Respondents to the Household Questionnaire were asked questions on child labour for each child ages 5-14 living in the household or who spent the preceding night in the household. In addition, information was collected about the dwelling itself such as the source of water, type of toilet facilities, materials used to construct the Introduction | 5 house, ownership of various consumer goods, and use of bed nets. The Household Questionnaire was also used to identify persons eligible for individual interview: women age 15-49 and men age 15- 54. One woman in each household was selected for the interview on domestic violence. The Women’s Questionnaire was used to collect information from women age 15-49 and included questions on the following topics: • Background characteristics (age, education, religion, etc.) • Reproductive history (to arrive at fertility and childhood mortality rates) • Knowledge and use of family planning methods • Antenatal, delivery, and postnatal care • Infant feeding practices, including patterns of breastfeeding • Vaccinations • Episodes of childhood illness and responses to illness, with a focus on treatment of fevers in the last two weeks • Marriage and sexual activity • Fertility preferences • Husband’s background and the woman’s work status • Woman’s status and decisionmaking • Mortality of adults, including maternal mortality • AIDS-related knowledge, attitudes, and behaviour • Domestic violence The Men’s Questionnaire was much shorter than the Women’s Questionnaire, but covered many of the same topics, excluding the detailed reproductive history and sections dealing with maternal and child health and adult and maternal mortality. 1.4.3 Pretest Twelve NSO permanent staff were recruited as interviewers for the DHS pretest of the questionnaires, which was conducted in June and July 2004. The 12 interviewers were trained in conducting interviews and taking blood samples for anaemia and HIV testing. The training took place at the NSO offices for a period of two weeks. The interviewers were split into three teams to conduct interviews in the Northern Region, Central Region, and Southern Region, respectively. During the pretest fieldwork, 206 Household Questionnaires, 160 Women’s Questionnaires, and 154 Men’s Questionnaires were completed. Based on the observations in the field and suggestions 6 | Introduction made by the pretest field teams, revisions were made in some skip patterns, wording, and translations of the questionnaires. 1.4.4 Training A total of 180 people were recruited by NSO for the main training. Training was held for five weeks at Magomero College, south of Zomba town. The first week of training was devoted to the collection of blood samples. Sixty persons were trained to collect blood samples, 34 of whom had medical training and 26 with no medical training. These participants were joined in subsequent weeks by 120 persons who were trained as interviewers only. The second phase of training focused on interviewing the respondents and taking height and weight measurements. Initially, training consisted of lectures on the underlying rationale of the questionnaires’ content and how to complete the questionnaires. Guest lecturers were invited to give talks on specific subjects such as family planning and gender issues, in particular domestic violence. Mock interviews were conducted between participants to allow practice in proper interviewing techniques and the use of local language questionnaires. Throughout the training, participants were given tests to evaluate their understanding and skills in the survey procedures. Toward the end of training, participants spent several days practicing interviews near the training centre. 1.4.5 Data Collection and Data Processing Fieldwork for the 2004 MDHS was carried out by 22 mobile teams, each consisting of one supervisor, one field editor, four or five female interviewers, and one male interviewer. Two or three of the interviewers on each team were trained in taking blood samples, and at least one of these was medically trained. Four senior NSO staff and one from Ministry of Health and Population supervised and coordinated fieldwork activities. In addition, three health technicians were assigned to supervise the blood collection for anaemia and HIV testing. Fieldwork commenced on 4 October 2004 and was completed by 31 January 2005. All questionnaires for the MDHS were returned to the NSO central office in Zomba for data processing. The processing operation consisted of office editing, coding of open-ended questions, data entry, double entry verification, and editing inconsistencies found by computer programs developed for the MDHS. The MDHS data entry and editing programs used CSPro, a computer software package specifically designed for processing survey data such as that produced by DHS surveys. Data processing commenced one month after fieldwork and was completed in May 2005. Testing of blood samples started in May 2005 and was completed in June 2005. 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 15,041 households were selected in the MDHS sample, of which 13,965 were occupied. Of the occupied households, 13,664 were interviewed, yielding a household response rate of 98 percent. The household response rate is higher in rural areas. In the 13,664 interviewed households, 12,229 women age 15-49 were identified as eligible for the individual interview, and interviews were completed for 11,698, for a 96 percent response rate. Of the 3,797 men age 15-54 who were identified as eligible for individual interview, 3,261 were interviewed, resulting in an 86 percent response rate. For both women and men, the main reason for nonresponse in the MDHS was failure to find the respondents despite repeated visits to the Introduction | 7 household. Compared with the 2000 MDHS, the response rate for women declined from 98 to 96 percent and the response rate for men declined from 97 to 95 percent. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence, Malawi 2004 Residence Result Urban Rural Total Household interviews Households selected 1,984 13,057 15,041 Households occupied 1,799 12,166 13,965 Households interviewed 1,724 11,940 13,664 Household response rate 95.8 98.1 97.8 Interviews with women Number of eligible women 1,733 10,496 12,229 Number of eligible women inter- viewed 1,640 10,058 11,698 Eligible woman response rate 94.6 95.8 95.7 Interviews with men Number of eligible men 632 3,165 3,797 Number of eligible men inter- viewed 507 2,754 3,261 Eligible man response rate 80.2 87.0 85.9 Characteristics of Households and Household Members | 9 CHARACTERISTICS OF HOUSEHOLDS AND HOUSEHOLD MEMBERS 2 Isaac Dambula and Ephraim N.B. Chibwana This chapter describes the demographic and socioeconomic characteristics of the population in the sampled households. It also examines 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 2004 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. One of the background characteristics used throughout this report is the wealth index, which is a proxy of socioeconomic status. The index was developed and tested in a large number of countries in relation to inequities in household income, use of health services, and health outcomes (Rutstein et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The index was constructed by applying principal components analysis to information on household assets. The asset information was collected in the Household Questionnaire of the 2004 MDHS and covers information on household ownership of a number of consumer items ranging from a paraffin lamp to a bicycle, motorcycle, or car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities, and construction material used for flooring. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardized in relation to a normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles—five groups with the same number of individuals in each—from one (lowest) to five (highest). A single asset index was developed for the whole sample; separate indices were not prepared for the urban and rural population separately. 2.1 HOUSEHOLD POPULATION BY AGE, SEX, AND RESIDENCE The distribution of the household population in the 2004 MDHS survey is shown in Table 2.1 by five-year age groups, according to sex and urban-rural residence. The 13,664 households successfully interviewed in the 2004 MDHS were composed of 58,886 persons; 30,163 were women, representing 51 percent of the population, and 28,722 were men, representing 49 percent. The age structure of the population indicates that a larger proportion of the population falls into the younger age groups for each sex in both rural and urban areas as a result of relatively high fertility. 10 | Characteristics of Households and Household Members This pattern mirrors that seen in the 1998 Population and Housing Census, and can be seen in Figure 2.1, which 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. Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Malawi 2004 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 13.9 16.7 15.3 19.0 17.9 18.4 18.1 17.7 17.9 5-9 12.9 13.1 13.0 16.5 15.8 16.1 15.9 15.4 15.6 10-14 13.2 15.2 14.1 14.9 14.8 14.9 14.6 14.9 14.8 15-19 10.5 11.0 10.7 9.7 8.1 8.9 9.8 8.5 9.2 20-24 11.8 14.6 13.1 7.7 9.3 8.5 8.4 10.1 9.2 25-29 13.2 9.3 11.3 6.8 7.1 7.0 7.9 7.5 7.7 30-34 7.3 4.6 6.0 5.4 5.1 5.3 5.7 5.0 5.4 35-39 3.9 4.0 4.0 3.8 3.7 3.7 3.8 3.7 3.8 40-44 3.8 2.9 3.4 3.2 3.3 3.2 3.3 3.2 3.2 45-49 2.4 2.2 2.3 2.3 2.5 2.4 2.3 2.5 2.4 50-54 1.9 2.7 2.3 2.3 3.4 2.9 2.3 3.3 2.8 55-59 2.6 1.5 2.1 2.5 2.6 2.5 2.5 2.4 2.5 60-64 0.9 0.7 0.8 2.0 2.0 2.0 1.8 1.8 1.8 65-69 0.6 0.5 0.5 1.4 1.5 1.4 1.2 1.4 1.3 70-74 0.7 0.4 0.6 1.2 1.3 1.2 1.1 1.2 1.1 75-79 0.2 0.3 0.2 0.6 0.8 0.7 0.5 0.7 0.6 80 + 0.3 0.4 0.3 0.7 0.8 0.7 0.6 0.7 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,880 4,496 9,376 23,843 25,667 49,510 28,722 30,163 58,886 Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 Age Male Percent Female Characteristics of Households and Household Members | 11 2.2 HOUSEHOLD COMPOSITION Information about the composition of households by sex of the household head and household size is presented in Table 2.2. The data show that 75 percent of households in Malawi are headed by men. This proportion has not changed since 1992 (75 percent) and 2000 (73 percent). Female-headed households are more common in rural areas (26 percent) than in urban areas (17 percent). The average household size in Malawi remains at 4.4 persons, the same size recorded in 2000. The household size in rural areas is slightly larger than in urban areas (4.4 compared with 4.2 persons, respectively). Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size, according to residence, Malawi 2004 Residence Characteristic Urban Rural Total Sex of head of household Male 83.5 73.7 75.3 Female 16.5 26.3 24.7 Total 100.0 100.0 100.0 Number of usual members 0 0.6 0.2 0.3 1 12.0 7.6 8.4 2 13.1 12.3 12.4 3 16.6 17.7 17.5 4 18.2 18.7 18.6 5 13.2 15.1 14.8 6 11.1 11.4 11.4 7 6.5 8.0 7.8 8 4.0 4.3 4.3 9+ 4.6 4.7 4.7 Total 100.0 100.0 100.0 Number of households 2,262 11,402 13,664 Mean size 4.2 4.4 4.4 Note: Table is based on de jure members, i.e., usual residents. 2.3 FOSTERHOOD AND ORPHANHOOD Information on the living arrangements of children under age 18 is presented in Table 2.3. Of the 31,981 children under age 18 recorded in the 2004 MDHS, only 58 percent currently live with both their biological parents; the remainder live with either their mother only (19 percent) or their father only (3 percent), or live with neither of their natural parents (20 percent). 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 18 years, 12 percent have lost their father, 6 percent have lost their mother, and 4 percent have lost both of their natural 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. Differentials in fosterhood and orphanhood by background characteristics are not large. As expected, older children are more likely than younger children to be fostered or orphaned. A slightly larger proportion of urban children than rural children have lost one or both parents. 12 | Characteristics of Households and Household Members Table 2.3 indicates that children’s living arrangements have no consistent pattern by household wealth index quintile. Among the oversampled districts, children in Kasungu are the most likely to live with both their parents (69 percent), while children in Mangochi are the least likely to live with both parents (50 percent). Table 2.3 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by children's living arrangements and survival status of parents, accord- ing to background characteristics, Malawi 2004 Living with mother but not father Living with father but not mother Not living with either parent Background characteristic Living with both parents Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing information on father/ mother Total Number of children Age <2 77.3 18.6 2.0 0.1 0.1 1.0 0.2 0.1 0.1 0.5 100.0 4,717 2-4 68.7 15.7 3.5 1.0 0.5 7.7 0.7 0.7 1.0 0.6 100.0 5,947 5-9 56.5 13.1 5.8 2.1 0.7 13.8 2.1 2.6 2.7 0.7 100.0 9,299 10-14 47.5 11.6 8.3 2.4 1.2 14.8 3.1 4.4 6.0 0.8 100.0 8,808 15-17 41.2 9.0 8.6 2.6 1.2 17.2 3.7 5.3 8.8 2.4 100.0 3,211 <15 59.7 14.1 5.5 1.6 0.7 10.7 1.8 2.3 2.9 0.7 100.0 28,770 Sex Male 58.3 13.8 5.8 1.9 0.8 10.3 1.9 2.6 3.6 0.9 100.0 15,902 Female 57.4 13.3 5.7 1.5 0.8 12.4 2.1 2.6 3.4 0.7 100.0 16,079 Residence Urban 58.8 7.7 5.9 3.6 1.4 10.9 2.2 3.8 4.9 0.8 100.0 4,566 Rural 57.7 14.6 5.8 1.4 0.7 11.4 2.0 2.4 3.3 0.8 100.0 27,416 Region Northern 59.1 11.1 5.7 2.3 1.1 11.8 1.5 3.0 3.7 0.6 100.0 4,193 Central 59.4 11.2 5.3 2.2 0.7 12.6 2.2 2.3 3.2 1.0 100.0 13,638 Southern 55.9 16.6 6.3 1.1 0.8 10.0 2.0 2.8 3.8 0.7 100.0 14,150 District Blantyre 61.2 10.7 5.1 2.2 1.2 9.0 2.3 2.9 4.8 0.4 100.0 2,188 Kasungu 68.9 6.0 2.4 1.8 0.8 12.3 2.1 2.7 2.7 0.2 100.0 1,488 Machinga 55.5 17.6 5.8 1.3 0.4 11.2 2.4 2.5 2.3 0.9 100.0 1,230 Mangochi 50.2 21.8 5.6 0.8 0.5 14.4 1.8 2.2 2.1 0.6 100.0 1,800 Mzimba 63.1 10.7 4.2 1.7 1.2 13.0 1.4 2.1 2.0 0.6 100.0 2,064 Salima 57.6 12.1 6.0 0.5 0.6 15.1 2.4 2.4 2.9 0.4 100.0 930 Thyolo 52.8 19.9 5.9 0.8 0.8 10.2 2.1 3.2 3.5 0.8 100.0 1,630 Zomba 51.4 17.1 8.4 0.8 1.0 10.9 2.4 3.5 4.4 0.3 100.0 1,566 Lilongwe 56.4 9.5 5.4 3.1 0.9 14.3 2.3 2.7 3.7 1.7 100.0 4,694 Mulanje 51.6 19.0 8.0 0.8 0.9 7.6 3.5 3.9 3.5 1.1 100.0 1,226 Other districts 58.9 13.7 6.1 1.6 0.6 10.2 1.7 2.4 3.8 0.8 100.0 13,164 Wealth quintile Lowest 41.5 21.8 9.4 0.5 0.4 15.9 2.7 3.2 4.1 0.6 100.0 6,545 Second 60.4 15.4 5.7 1.1 0.6 9.1 1.7 2.0 2.8 1.1 100.0 6,460 Middle 65.5 11.3 5.4 1.6 0.5 9.0 1.7 1.8 2.7 0.5 100.0 6,491 Fourth 63.2 10.0 4.0 1.8 1.0 11.1 1.7 2.8 3.4 1.0 100.0 6,459 Highest 58.9 8.9 4.4 3.7 1.3 11.6 2.2 3.5 4.6 0.8 100.0 6,026 Total 57.8 13.6 5.8 1.7 0.8 11.4 2.0 2.6 3.5 0.8 100.0 31,981 Characteristics of Households and Household Members | 13 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 2004 MDHS, information on educational attainment was collected for every member of the household. Tables 2.4.1 and 2.4.2 show the percent distribution of the de facto female and male population age six and over by the highest level of education attained, according to background characteristics. There is a strong differential in educational attainment between the sexes, especially as age increases. While 30 percent of female household members in Malawi have never been to school, the proportion among males is 20 percent. The proportion of persons with no education is high at the youngest ages, is lowest between the ages of 10 and 24, and then increases with age. For example, the proportion of women who have never attended any formal schooling increases from 14 percent from age 20-24 to 73 percent among those age 65 and over. For men, the corresponding proportion is 8 percent and 44 percent, respectively. Eight percent of women and 15 percent of men have attended some secondary school. The median number of years of schooling is 1.8 years for women and 3.1 years for men. Overall, educational attainment is higher in urban areas than in rural areas. The proportion with no education in urban areas is about one-third that in rural areas. The proportion of the population age six and over that has attained any education varies across regions and districts. The Northern Region has the highest proportion with some education for both males (90 percent) and females (84 percent). For females, the proportion is lowest in the Southern Region (67 percent); for males, it is lowest in the Central Region (77 percent). Of the oversampled districts, Blantyre has the highest median years of education at 5.6 years for men, while Mzimba has the highest for women (4.0). The lowest educational attainment for both men and women is observed in Mangochi, where the median years of education is 1.1 years for men and 0 years for women. The situation in Mangochi has remained the same since 2000. 14 | Characteristics of Households and Household Members Table 2.4.1 Educational attainment of household population: women Percent distribution of the de facto female household population age six and over by highest level of education attended, according to background characteristics, Malawi 2004 Education Background characteristic No education Primary 1-4 Primary 5-8 Secondary or higher Missing Total Number Median number of years Age 6-9 43.8 55.6 0.3 0.0 0.3 100.0 3,872 0.2 10-14 9.3 68.8 20.6 1.1 0.2 100.0 4,492 2.3 15-19 7.1 24.9 48.9 19.1 0.1 100.0 2,570 5.5 20-24 14.0 26.2 36.0 23.6 0.2 100.0 3,036 5.1 25-29 25.2 27.3 31.0 16.4 0.2 100.0 2,247 3.7 30-34 36.4 26.8 27.9 8.9 0.0 100.0 1,516 2.0 35-39 38.6 22.3 32.0 6.9 0.1 100.0 1,122 2.2 40-44 41.0 24.0 30.1 4.7 0.2 100.0 970 1.5 45-49 51.4 22.5 21.5 4.6 0.0 100.0 743 0.0 50-54 49.6 27.7 15.8 5.5 1.4 100.0 998 0.0 55-59 61.7 27.2 7.5 3.0 0.6 100.0 734 0.0 60-64 67.6 25.8 5.5 0.5 0.6 100.0 536 0.0 65+ 73.3 23.1 2.9 0.5 0.1 100.0 1,189 0.0 Residence Urban 11.8 29.8 31.7 26.7 0.1 100.0 3,651 5.2 Rural 33.4 40.0 21.3 5.0 0.3 100.0 20,388 1.4 Region Northern 16.3 34.9 36.5 12.2 0.1 100.0 3,091 3.8 Central 31.4 39.5 20.6 8.2 0.3 100.0 10,086 1.6 Southern 32.8 38.4 21.1 7.4 0.3 100.0 10,862 1.5 District Blantyre 19.0 33.6 29.4 17.8 0.2 100.0 1,720 3.7 Kasungu 23.8 44.9 23.8 7.5 0.0 100.0 1,011 1.9 Machinga 42.8 37.1 15.8 3.9 0.3 100.0 892 0.6 Mangochi 49.7 32.3 13.7 4.1 0.3 100.0 1,240 0.0 Mzimba 16.6 33.1 37.6 12.6 0.2 100.0 1,550 4.0 Salima 41.7 38.1 14.7 5.4 0.1 100.0 700 0.8 Thyolo 31.9 42.9 19.9 5.2 0.1 100.0 1,234 1.5 Zomba 22.6 42.6 25.3 9.2 0.2 100.0 1,235 2.3 Lilongwe 27.9 36.9 21.8 13.1 0.3 100.0 3,599 2.2 Mulanje 31.2 42.9 20.7 5.2 0.0 100.0 1,029 1.5 Other districts 31.8 39.4 22.3 6.1 0.3 100.0 9,828 1.6 Wealth quintile Lowest 46.3 38.9 12.6 1.9 0.3 100.0 5,220 0.3 Second 38.4 41.1 17.9 2.2 0.3 100.0 4,681 0.9 Middle 31.0 42.1 23.7 2.8 0.4 100.0 4,661 1.5 Fourth 23.7 41.0 27.9 7.3 0.1 100.0 4,719 2.4 Highest 9.7 29.1 33.2 27.8 0.1 100.0 4,758 5.6 Total 30.1 38.4 22.9 8.3 0.2 100.0 24,039 1.8 Characteristics of Households and Household Members | 15 Table 2.4.2 Educational attainment of household population: men Percent distribution of the de facto male household population age six and over by highest level of education at- tended, according to background characteristics, Malawi 2004 Education Background characteristic No education Primary 1-4 Primary 5-8 Secondary or higher Missing Total Number Median number of years Age 6-9 47.9 51.3 0.3 0.0 0.5 100.0 3,868 0.1 10-14 10.3 69.2 19.4 1.0 0.1 100.0 4,204 2.2 15-19 6.4 29.3 45.5 18.6 0.1 100.0 2,826 5.2 20-24 7.7 21.1 35.5 35.5 0.2 100.0 2,408 6.8 25-29 11.1 18.8 34.0 35.9 0.2 100.0 2,271 6.8 30-34 16.4 19.0 36.4 28.1 0.1 100.0 1,651 5.8 35-39 18.8 19.8 39.8 21.2 0.4 100.0 1,101 5.8 40-44 15.9 20.6 41.8 21.3 0.3 100.0 939 5.9 45-49 20.4 18.8 41.8 18.6 0.3 100.0 656 5.1 50-54 21.4 25.8 37.0 15.0 0.8 100.0 649 4.4 55-59 26.1 26.4 32.8 12.1 2.5 100.0 712 3.4 60-64 32.9 34.6 25.8 5.6 1.2 100.0 528 1.9 65+ 43.7 36.4 15.6 3.0 1.4 100.0 996 0.8 Residence Urban 7.8 23.5 30.2 37.9 0.6 100.0 4,100 6.9 Rural 22.9 39.8 26.6 10.4 0.4 100.0 18,719 2.5 Region Northern 10.1 33.7 37.2 18.8 0.2 100.0 2,952 4.8 Central 22.7 36.8 25.3 14.6 0.6 100.0 9,758 2.7 Southern 20.6 37.8 26.2 15.1 0.3 100.0 10,109 2.9 District Blantyre 11.7 27.9 30.3 30.1 0.0 100.0 1,891 5.6 Kasungu 16.2 39.2 32.6 12.0 0.1 100.0 1,034 3.4 Machinga 28.8 38.9 22.3 9.8 0.2 100.0 808 1.9 Mangochi 36.4 38.0 16.6 8.7 0.3 100.0 1,200 1.1 Mzimba 9.4 34.8 37.2 18.5 0.1 100.0 1,471 4.7 Salima 29.8 40.7 20.9 8.1 0.5 100.0 627 1.7 Thyolo 17.6 44.1 25.9 11.8 0.4 100.0 1,103 2.7 Zomba 15.5 39.5 28.3 16.3 0.4 100.0 1,118 3.3 Lilongwe 20.4 30.2 26.3 22.2 0.9 100.0 3,634 3.8 Mulanje 16.4 44.9 27.2 11.2 0.3 100.0 847 2.7 Other districts 21.7 38.9 27.1 12.0 0.4 100.0 9,088 2.7 Wealth quintile Lowest 31.9 43.5 20.0 4.2 0.4 100.0 4,067 1.4 Second 27.9 41.4 24.4 6.0 0.2 100.0 4,484 2.0 Middle 21.5 39.5 30.2 8.3 0.5 100.0 4,497 2.7 Fourth 16.3 36.5 32.5 14.3 0.4 100.0 4,648 3.6 Highest 6.5 25.5 28.1 39.5 0.4 100.0 5,124 7.0 Total 20.2 36.9 27.2 15.3 0.4 100.0 22,819 3.1 Overall, there has been progress in education since 2000, as the proportion of people with no education has decreased, while the proportion with secondary or higher education has increased. In the 2000 MDHS, 6 percent of women and 12 percent of men reported attaining secondary or higher education; these proportions have increased to 8 percent and 15 percent, respectively. The median number of years of schooling for men has increased from 2.7 years in 2000 to 3.1 years in 2004. For women, the median is 1.4 years and 1.8 years, respectively. The improvement is shown by almost all subgroups of the population. 16 | Characteristics of Households and Household Members 2.5 SCHOOL ATTENDANCE The 2004 MDHS collected information that allows the calculation of net attendance ratios (NAR) and gross attendance ratios (GAR). 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 or underage students at a given level of schooling, the GAR can exceed 100 percent. Tables 2.5.1 and 2.5.2 present the NARs and GARs by urban-rural residence, region, and wealth index, by sex, for primary school and secondary school. Findings indicate that among children within the official age range for primary school, slightly more girls (84 percent) are attending school than boys (80 percent), which is a slight improvement over the 2000 MDHS findings. The GAR shows, however, that overall, more boys are attending primary school than girls (109 compared with 103). The NAR at primary school is highest for children in the Northern Region (92 percent), followed by the Central and Southern Regions (both at 81 percent). The NAR for primary school is higher in urban areas (89 percent) than in rural areas (81 percent). Both the NAR and the GAR for primary school increase directly with wealth. Secondary school attendance ratios are much lower and differ substantially by background characteristics. Overall, the net attendance ratio is 11.4, indicating that only 11 percent of secondary-school-age children are attending school at roughly the correct ages. The secondary NAR in urban areas is over four 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. The gross attendance ratio of 30 percent for secondary school, though slightly higher than in the 2000 MDHS, indicates that a substantial proportion of secondary-school students are outside the official age range for secondary schooling. Characteristics of Households and Household Members | 17 Table 2.5.1 School attendance ratios: primary school Primary school 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 2004 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Male Female Total Gender Parity Index3 Residence Urban 89.0 89.4 89.2 112.7 104.8 108.7 0.93 Rural 78.7 83.0 80.9 108.3 102.4 105.3 0.95 Region Northern 91.4 93.0 92.2 129.1 117.2 123.2 0.91 Central 77.6 83.4 80.6 105.1 102.3 103.7 0.97 Southern 79.2 81.7 80.5 106.6 99.0 102.8 0.93 District Blantyre 83.7 89.5 86.5 110.7 110.1 110.4 0.99 Kasungu 86.2 88.6 87.5 123.5 107.3 114.9 0.87 Machinga 78.0 79.9 79.0 106.0 94.2 99.9 0.89 Mangochi 66.7 68.7 67.7 84.7 83.0 83.9 0.98 Mzimba 92.4 93.8 93.1 128.7 115.6 122.1 0.90 Salima 77.8 79.6 78.8 100.8 93.5 97.0 0.93 Thyolo 83.9 84.7 84.3 108.6 102.8 105.7 0.95 Zomba 87.8 89.8 88.8 115.3 108.6 111.9 0.94 Lilongwe 79.7 84.0 82.0 103.0 100.1 101.5 0.97 Mulanje 83.5 82.2 82.9 108.8 104.5 106.7 0.96 Other districts 77.8 82.8 80.4 109.9 103.3 106.5 0.94 Wealth quintile Lowest 71.8 75.0 73.5 97.1 89.3 93.1 0.92 Second 73.8 79.5 76.6 101.0 97.5 99.3 0.97 Middle 80.9 84.0 82.5 113.0 104.6 108.7 0.93 Fourth 83.1 88.2 85.7 114.6 110.8 112.6 0.97 Highest 92.2 93.8 93.0 120.5 113.2 116.8 0.94 Total 80.1 83.8 82.0 108.9 102.7 105.8 0.94 1 The NAR for primary school is the percentage of the primary-school-age (6-13 years) population that is attending primary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-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. 3 The Gender Parity Index for primary school is the ratio of the primary school GAR for females to the GAR for males. 18 | Characteristics of Households and Household Members Table 2.5.2 School attendance ratios: secondary school Secondary school net attendance ratios (NAR) and gross attendance ratios (GAR) for the de jure household population by sex, according to background characteristics, Malawi 2004 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Male Female Total Gender Parity Index3 Residence Urban 30.3 32.3 31.3 71.9 64.9 68.5 0.90 Rural 6.2 8.7 7.4 25.9 17.0 21.8 0.65 Region Northern 10.2 16.2 13.1 39.9 28.8 34.6 0.72 Central 10.1 10.4 10.3 31.3 21.9 26.9 0.70 Southern 10.3 14.0 12.0 33.6 27.4 30.8 0.81 District Blantyre 15.0 24.6 19.3 46.2 48.3 47.1 1.05 Kasungu 7.1 16.8 11.4 23.2 29.8 26.1 1.29 Machinga 6.5 11.6 8.7 22.0 17.7 20.1 0.80 Mangochi 10.2 5.2 7.9 26.6 14.4 21.2 0.54 Mzimba 10.8 18.7 14.5 41.3 34.1 38.0 0.82 Salima 2.9 9.9 6.0 18.0 17.6 17.8 0.98 Thyolo 10.8 9.6 10.2 36.4 20.3 28.2 0.56 Zomba 16.1 14.7 15.5 41.8 35.4 38.9 0.85 Lilongwe 18.8 14.8 17.0 44.7 29.5 37.8 0.66 Mulanje 7.5 14.1 11.0 27.2 20.4 23.6 0.75 Other districts 6.6 9.8 8.1 29.0 20.2 24.8 0.69 Wealth quintile Lowest 2.6 4.0 3.2 12.4 7.0 10.0 0.57 Second 3.4 3.1 3.3 19.5 7.1 13.7 0.36 Middle 3.5 4.9 4.1 17.9 9.4 14.0 0.53 Fourth 6.8 11.5 9.1 34.6 25.4 30.1 0.74 Highest 30.6 32.9 31.7 74.8 62.7 69.0 0.84 Total 10.2 12.7 11.4 33.5 25.2 29.6 0.75 1 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 secondary school is the total number of secondary school students, expressed as a percentage of the official secondary- school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can ex- ceed 100 percent. 3 The Gender Parity Index for secondary school is the ratio of the secondary school GAR for females to the GAR for males. Characteristics of Households and Household Members | 19 Repetition and Dropout 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 for primary school. Table 2.6 indicates that repetition rates are high in Standard 1 (45 percent), which may be related to the teachers’ decision 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. While the repetition rates at Standard 1 are about the same as those in 2000, the rates at Standard 8 have decreased from 39 to 29 percent. Table 2.6 Grade repetition and dropout rates Repetition and dropout rates for the de jure household population age 5-24 years by school grade, according to back- ground characteristics, Malawi 2004 Standard Background characteristic 1 2 3 4 5 6 7 8 REPETITION RATE Sex Male 45.3 25.4 29.5 23.3 19.8 11.8 13.3 30.8 Female 44.1 27.7 26.2 20.0 18.9 18.6 14.8 25.2 Residence Urban 33.5 23.4 22.7 12.2 19.0 17.0 9.8 13.3 Rural 46.1 27.2 28.7 23.6 19.4 14.4 15.1 34.6 Region Northern 30.3 15.3 16.1 13.4 11.5 8.3 10.0 45.7 Central 47.3 28.9 31.3 24.3 19.6 19.3 15.9 29.5 Southern 45.7 27.7 28.3 22.7 22.5 14.5 14.3 20.3 Wealth quintile Lowest 46.4 30.1 29.2 24.8 19.0 13.7 20.5 30.9 Second 46.3 25.6 33.4 20.8 24.7 16.4 14.4 31.9 Middle 47.5 26.7 26.4 24.5 18.9 13.0 16.3 48.1 Fourth 44.0 28.5 29.0 24.3 18.0 14.8 9.5 32.5 Highest 37.2 21.9 22.4 15.3 18.5 16.0 13.1 16.5 Total 44.7 26.6 27.8 21.7 19.4 15.0 14.0 28.6 DROPOUT RATE Sex Male 2.3 1.8 3.4 3.1 4.9 2.9 4.4 10.7 Female 1.9 2.3 2.4 3.5 5.4 4.3 8.6 8.6 Residence Urban 2.3 1.8 1.5 0.9 1.8 1.1 2.1 3.8 Rural 2.0 2.1 3.1 3.8 6.1 4.3 7.5 12.2 Region Northern 0.3 1.1 1.1 0.9 4.6 1.0 6.4 7.1 Central 1.4 2.0 3.2 3.3 5.9 5.3 8.1 10.9 Southern 3.1 2.4 3.3 4.3 4.6 3.3 4.9 10.2 Wealth quintile Lowest 3.5 3.7 5.5 4.2 7.0 7.3 7.9 21.4 Second 2.5 1.8 3.5 5.7 10.2 5.6 15.7 21.5 Middle 2.0 1.8 4.0 4.3 4.9 4.8 5.1 12.8 Fourth 1.4 2.8 1.9 2.2 4.7 2.6 8.4 11.1 Highest 0.3 0.3 0.8 1.3 2.7 1.3 2.1 2.1 Total 2.1 2.1 2.9 3.3 5.1 3.6 6.3 9.9 Note: The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school in the current school year. 20 | Characteristics of Households and Household Members The second panel of Table 2.6 shows the expected pattern of increasing dropout rates with increasing years in school. Only 2 percent of children drop out of school after attending Standard 1 compared with a dropout rate of 10 percent at Standard 8. It is notable that the dropout rate and the repetition rate at Standard 8 is higher for boys than for girls. Rural children are more likely than urban children to drop out at all grades except Standard 1. Children in the Northern Region are less likely to stop their education than children in the Central or Southern Regions (7 percent compared with 10-11 percent at Standard 8). 2.6 CHILD LABOUR The 2004 MDHS survey collected information on the work activities of children age 5-14 in the week prior to the survey. 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 practice continues in many settings. The 2004 MDHS 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 overall, 37 percent of children age 5-14 are currently engaged in some type of work. Eight percent of children age 5-14 are doing work for nonrelatives, about half of these without pay. Seven in ten children did daily household chores during the past week, most of them working for less than four hours per day. One in three children are engaged in family business or working on the family farm. Older children are much more likely to be working than younger children. Although girls are more likely to be involved in longer hours of domestic work per day than boys, there is little difference in the overall proportions of girls and boys who work (35 and 39 percent, respectively). Urban children (17 percent) are much less likely to be working than rural children (40 percent). Children in the Northern Region are more likely than those in the Central Region and Southern Region to be working without pay for nonrelatives (5 percent compared with 3 percent and 2 percent, respectively). Children in the Northern Region are less likely to be employed on the family farm or in the family business than children in the Southern and Central regions (29 percent compared with 33 percent and 34 percent, respectively). While 41 percent of children in the lowest quintile work, the corresponding proportion among children in the highest quintile is only 22 percent. Among the oversampled districts, almost half of children age 5-14 in Kasungu are working, compared to 30 percent in Blantyre. Characteristics of Households and Household Members | 21 Table 2.7 Child labour Percentage of children age 5-14 years who are currently working, by type of employment and selected background characteristics, Malawi 2004 Domestic work for: Work for nonrelatives Background characteristic Paid Unpaid Currently doing work on family farm or family business Less than 4 hours per day 4 hours or more per day Currently working1 Number of children Age 5-9 2.0 2.3 16.1 56.3 0.8 19.3 9,202 10-14 8.0 3.7 50.5 80.0 3.8 55.9 8,696 Sex Male 5.4 2.3 35.4 62.0 1.6 39.0 8,762 Female 4.5 3.6 30.3 73.4 2.9 35.2 9,137 Residence Urban 1.7 1.6 13.7 71.0 1.9 17.0 2,543 Rural 5.5 3.2 36.0 67.3 2.3 40.4 15,356 Region Northern 3.9 5.4 29.4 74.9 3.3 35.2 2,333 Central 4.7 3.0 33.7 65.9 2.2 37.8 7,711 Southern 5.5 2.3 32.9 67.6 2.1 36.9 7,855 District Blantyre 2.8 3.6 24.4 65.3 2.7 30.4 1,250 Kasungu 6.1 4.0 45.3 68.4 2.5 49.1 807 Machinga 8.4 3.5 38.9 65.1 2.8 43.1 673 Mangochi 6.4 1.5 29.9 58.1 2.2 33.9 1,014 Mzimba 4.6 6.7 39.2 73.7 3.6 44.5 1,146 Salima 5.3 2.7 33.2 68.1 1.9 36.8 541 Thyolo 6.3 3.1 33.2 70.0 2.1 37.7 917 Zomba 5.9 0.9 41.8 76.7 3.4 44.8 849 Lilongwe 2.9 1.8 30.3 65.8 2.4 33.3 2,710 Mulanje 5.9 2.3 30.6 69.2 0.9 34.3 689 Other districts 5.0 3.1 31.7 68.2 1.9 36.3 7,302 Wealth quintile Lowest 7.1 3.0 36.4 65.0 2.0 40.5 3,780 Second 5.8 3.1 38.8 67.6 2.2 43.0 3,544 Middle 5.5 3.3 39.1 67.4 2.2 43.6 3,464 Fourth 4.2 3.2 31.6 67.7 3.0 36.3 3,661 Highest 1.9 2.2 17.7 71.8 2.0 21.5 3,451 Total 4.9 3.0 32.8 67.8 2.3 37.1 17,899 1Working means doing paid or unpaid work or working on a family farm or for a family business. 2.7 HOUSING CHARACTERISTICS 2004 MDHS respondents were asked about their housing environment, including access to electricity, source of drinking water, time to water source, type of toilet facilities, house construction materials, and possession of various durable goods. This information is summarised in Table 2.8. Seven percent of households in Malawi have electricity. Electricity is much more common in urban areas (30 percent) than in rural areas (2 percent). 22 | Characteristics of Households and Household Members Table 2.8 Household characteristics Percent distribution of households by household characteristics, according to residence, Malawi 2004 Residence Household characteristic Urban Rural Total Electricity Yes 30.2 2.2 6.9 No 69.6 97.6 93.0 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Source of drinking water Piped into dwelling 14.1 0.6 2.9 Piped into yard/plot 15.1 1.0 3.4 Public tap 45.2 7.4 13.7 Open well in yard/plot 1.9 2.5 2.4 Open public well 5.4 26.1 22.6 Protected well in yard/plot 2.0 5.5 4.9 Protected public well 14.7 43.4 38.6 Spring 0.1 3.2 2.6 River, stream 1.3 9.4 8.0 Pond, lake 0.0 0.5 0.4 Dam 0.0 0.3 0.2 Tanker truck 0.0 0.1 0.1 Total 100.0 100.0 100.0 Time to water source Percentage <15 minutes 67.4 36.7 41.8 Median time to source 4.9 19.4 19.0 Sanitation facility Flush toilet 16.2 0.8 3.4 Traditional pit toilet 76.1 80.0 79.4 VIP latrine 2.3 0.9 1.1 No facility/bush, field 5.2 18.2 16.1 Missing 0.2 0.0 0.1 Total 100.0 100.0 100.0 Flooring material Earth, sand 35.5 87.1 78.5 Dung 0.6 0.7 0.7 Cement 62.3 12.0 20.3 Carpet 0.9 0.1 0.2 Missing 0.2 0.0 0.1 Total 100.0 100.0 100.0 Cooking fuel Electricity 10.6 0.3 2.0 Kerosene 0.2 0.0 0.1 Charcoal 41.4 2.0 8.5 Firewood, straw 47.1 97.5 89.2 Dung 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of households 2,262 11,402 13,664 Characteristics of Households and Household Members | 23 A household’s source of drinking water is important because potentially fatal diseases including typhoid, cholera, and dysentery are prevalent in unprotected sources. Piped water, water drawn from protected wells, and deep boreholes are expected to be relatively free of these diseases. Unprotected wells and surface water (rivers, streams, ponds, and lakes), are more likely to carry disease-causing agents. Table 2.8 shows that overall, 64 percent of Malawian households have access to clean water, 20 percent from piped water and 44 percent from protected wells. As expected, a far greater proportion of urban households have access to piped water than rural households (74 compared to 9 percent). In urban areas, 67 percent of the households have access to water within 15 minutes, compared with 37 percent of rural households. Modern sanitation facilities are not yet available to large proportions of Malawian households. The use of traditional pit latrines is still common in both urban and rural areas, accounting for 79 percent of all households. Overall, 16 percent of the households in Malawi have no toilet facilities. This problem is more common in rural areas, where 18 percent of the households have no toilet facilities, compared with 5 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, 79 percent of all households in Malawi live in residences with floors made of earth, sand, or dung, while 21 percent live in houses with finished floors like those made of cement or wooden panels. Earth flooring is almost universal in rural areas (87 percent). The type of cooking fuel used by a household reflects both economic status as well as exposure to varying types of pollutants. Most households (89 percent) use firewood or straw. Charcoal is also a popular fuel in urban areas. Eleven percent of urban households use electricity as their cooking fuel, whereas almost no rural residents do. 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 or 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, which can be important for seeking emergency medical care or taking advantage of employment opportunities. Ownership of a telephone opens up communication with other users. Information on ownership of these items is presented in Table 2.9. Four in ten households own a paraffin lamp. This item is slightly more common in urban households than in rural households. Nationally, 62 percent of households own a radio and only 5 percent of households own a television. Five percent of households in Malawi own a cell phone, and only 2 percent have a landline telephone. More than one in five households own a bed with a mattress (21 percent) or table and chairs (29 percent), while ownership of a sofa set (11 percent) or a refrigerator (3 percent) is uncommon. Bicycles are the most common type of vehicle owned by households; 40 percent of households have a bicycle. Ownership of motorised transport is rare: only 2 percent of households have cars, and fewer households (1 percent) have motorcycles. As expected, urban households are more likely than rural households to own each of the items listed, with the exception of the bicycle. Overall, one in four rural households own none of the listed items, while the same is true for only one in ten urban households. 24 | Characteristics of Households and Household Members Table 2.9 Household durable goods Percentage of households possessing various durable consumer goods, by resi- dence, Malawi 2004 Residence Durable consumer goods Urban Rural Total Household goods Paraffin lamp 47.1 36.5 38.2 Radio 79.2 58.5 61.9 Television 21.1 2.2 5.3 Cell phone 20.8 1.5 4.7 Landline telephone 8.3 0.5 1.8 Bed with mattress 54.5 14.7 21.3 Sofa set 35.5 5.7 10.6 Table and chairs 53.8 24.5 29.3 Refrigerator 14.7 0.7 3.0 Means of transport Bicycle 30.9 41.8 40.0 Motorcycle 1.9 0.8 1.0 Car/truck 8.1 0.8 2.0 None of the above 9.6 25.1 22.5 Number of households 2,262 11,402 13,664 Characteristics of Respondents and Women’s Status | 25 CHARACTERISTICS OF RESPONDENTS AND WOMEN’S STATUS 3 Mylen Mahowe This chapter provides a demographic and socioeconomic profile of the 2004 Malawi DHS sample of individual female and male respondents. It begins by describing basic background characteristics of men and women, including age at the time of the survey, marital status, educational level, and residential characteristics. It also provides detailed information on education, literacy, and exposure to mass media among men and women, data on employment and work status of women, decisionmaking in the household, and attitudes on women’s position in relation to others in the household. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Background characteristics of women age 15-49 and men age 15-54 interviewed in the 2004 MDHS survey are presented in Table 3.1. As expected, the percentage of women and men is highest in the younger age groups and the proportion of respondents in each age group declines with age. Sixty-seven percent of women and 63 percent of men are currently married; an additional 4 percent of women and 1 percent of men reported being in an informal marriage or living together. For purposes of the 2004 MDHS survey and in presentation of findings throughout later chapters of this report, informal marriages are grouped together with formalised marriages to form the group “currently married” or “in union.” One in three men had never been married, compared with only 17 percent of women, supporting the fact that men get married later in life than women. Women were more likely than men (12 and 2 percent, respectively) to be divorced, separated, or widowed. As expected, most of the interviewed women and men reside in rural areas (82 percent of women and 80 percent of men). The largest proportion of female and male respondents live in the Southern Region (46 and 45 percent, respectively), while 41 percent of women and 42 percent of men live in the Central Region. Only 13 percent of both women and men live in the Northern Region. Table 3.1 also shows the distribution of men and women by district, including districts that were oversampled in the survey to allow the presentation of estimates of certain indicators at the district level. Notable are the large differences between the weighted and unweighted numbers of men and women in some districts. The unweighted number represents the number of respondents who were actually interviewed in the 2004 MDHS survey, whereas the weighted number represents that district’s proportional representation in the population. For instance, Salima District has only 3 percent of the population of women age 15-49 (as represented by 303 weighted cases), but 703 women were actually interviewed (or 6 percent of the total number of interviewed women). 26 | Characteristics of Respondents and Women’s Status Table 3.1. Background characteristics of respondents Percent distribution of women and men by background characteristics, Malawi 2004 Women Men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 20.4 2,392 2,407 19.9 650 650 20-24 24.5 2,870 2,824 18.0 587 583 25-29 18.4 2,157 2,136 19.4 634 617 30-34 12.6 1,478 1,492 14.9 485 474 35-39 9.5 1,117 1,129 9.0 294 287 40-44 8.0 935 940 8.6 282 293 45-49 6.4 749 770 5.6 182 181 50-54 na 0 0 19.9 650 650 Marital status Never married 16.8 1,970 1,902 33.2 1,084 1,039 Married 66.8 7,810 7,831 62.9 2,050 2,078 Living together 4.3 503 554 0.9 29 36 Divorced/separated 8.4 979 991 2.5 81 93 Widowed 3.7 437 420 0.5 17 15 Residence Urban 17.8 2,076 1,640 20.5 669 507 Rural 82.2 9,621 10,058 79.5 2,593 2,754 Region Northern 13.3 1,552 1,597 13.0 423 456 Central 40.5 4,734 4,199 42.0 1,370 1,261 Southern 46.3 5,412 5,902 45.0 1,468 1,544 District Blantyre 7.8 914 703 9.7 316 208 Kasungu 4.2 497 897 4.8 156 313 Machinga 3.7 427 772 3.5 114 198 Mangochi 5.1 599 774 4.6 150 190 Mzimba 6.7 778 953 6.5 212 274 Salima 2.6 303 703 2.4 78 182 Thyolo 5.3 618 820 5.2 169 211 Zomba 5.4 637 806 4.9 159 209 Lilongwe 14.6 1,705 710 16.6 542 228 Mulanje 4.4 512 777 3.5 114 178 Other districts 40.2 4,708 3,783 38.3 1,250 1,070 Education No education 23.4 2,734 2,823 11.7 383 383 Primary 1-4 25.6 2,998 3,057 24.5 798 830 Primary 5-8 35.5 4,154 4,132 37.4 1,220 1,231 Secondary+ 15.5 1,811 1,685 26.3 859 814 Religion Catholic 23.1 2,698 2,575 21.2 690 683 Church of Central Africa Presbyterian (CCAP) 18.6 2,170 2,065 18.9 616 594 Anglican 2.5 292 252 2.3 76 68 Seventh Day Adventist/Baptist 6.3 731 755 6.5 213 186 Other Christian 36.4 4,257 4,103 36.2 1,179 1,189 Muslim 12.0 1,404 1,816 11.4 372 455 No religion 0.9 100 84 3.0 99 75 Other 0.3 34 35 0.4 13 10 Ethnic group Chewa 33.9 3,967 3,665 32.7 1,068 1,006 Tumbuka 9.7 1,136 1,205 9.6 314 331 Lomwe 16.9 1,976 2,211 17.1 559 638 Tonga 2.2 253 255 2.1 68 71 Yao 12.8 1,496 1,819 13.1 426 469 Sena 4.4 512 383 4.6 151 114 Nkonde 1.1 124 98 1.5 49 42 Ngoni 11.7 1,367 1,155 11.9 388 332 Other 7.3 859 897 7.3 238 258 Total 100.0 11,698 11,698 100.0 3,261 3,261 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Respondents and Women’s Status | 27 Table 3.1 further illustrates the distribution of men and women by religion and ethnic group, showing that most of the interviewed women and men are Catholics (23 percent of women and 21 percent of men). Only 1 percent of women and 3 percent of men report having no religion. The Chewa are the largest ethnic group, making up one-third of male and female respondents; the smallest ethnic group is the Nkonde, making up only 1 percent of women and 2 percent of men. 3.2 EDUCATIONAL ATTAINMENT Tables 3.2.1 and 3.2.2 show the percent distribution of respondents by the highest level of schooling attended according to their age, place of residence, region, and district. 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, 6 percent of women and 3 percent of men age 15-19 have no formal education, compared with 50 percent of women and 21 percent of men age 45-49. Similarly, 24 percent of women age 20-24 attended secondary school or higher, compared with only 5 percent of women age 45-49. For male respondents, the corresponding proportions for ages 20-24 and 45-49 are 38 percent and 15 percent, respectively. The 2004 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 8 percent of urban women and 5 percent of urban men have not attended school, compared with 27 percent and 13 percent in rural areas, respectively. The median number of years of education shows a similar differential, with urban women having a median of 6.9 years of schooling and rural women a median of 3.4 years. Overall, respondents in the Northern Region are better educated than those in other regions. For example, while 9 percent of women in the Northern Region have no formal education, the proportion in the Central Region is 25 percent and in the Southern Region it is 27 percent. While 22 percent of women in the Northern Region have secondary or higher education, the proportions in the Central Region and Southern Region are 16 percent or lower. Tables 3.2.1 and 3.2.2 show that wealth status has a positive relationship with a person’s education. Women and men in higher wealth quintiles are better educated than those with less education. For example, the median years of schooling for women in the highest quintile is 7.6 years compared with 1.7 years for women in the lowest quintile. Tables 3.2.1 and 3.2.2 also show the percent distribution of respondents by highest level of schooling and district. Among the oversampled districts, the proportion of women who have no formal education is lowest in Mzimba (8 percent) and highest in Mangochi (44 percent). Secondary education (or higher) is most common for men and women in Blantyre (43 percent and 28 percent, respectively). Mangochi has the lowest education for both women and men. 28 | Characteristics of Respondents and Women’s Status Table 3.2.1 Educational attainment by background characteristics: women Percent distribution of women by highest level of schooling attended, and median number of years of schooling, according to background characteristics, Malawi, 2004 Education Background characteristic No education Primary 1-4 Primary 5-8 Secondary or higher Total Number of respondents Median years of schooling Age 15-19 5.5 24.2 50.0 20.2 100.0 2,392 5.6 20-24 12.7 26.9 36.5 23.9 100.0 2,870 5.2 25-29 24.3 27.0 31.8 16.9 100.0 2,157 3.9 30-34 36.6 26.5 28.3 8.5 100.0 1,478 2.1 35-39 38.3 22.8 32.5 6.4 100.0 1,117 2.2 40-44 39.4 25.8 30.2 4.6 100.0 935 1.7 45-49 50.0 23.6 21.7 4.7 100.0 749 0.0 Residence Urban 8.2 14.2 37.2 40.2 100.0 2,076 6.9 Rural 26.6 28.1 35.1 10.1 100.0 9,621 3.4 Region Northern 8.7 13.7 55.5 22.1 100.0 1,552 6.3 Central 24.6 27.3 32.3 15.8 100.0 4,734 3.8 Southern 26.5 27.6 32.6 13.3 100.0 5,412 3.5 District Blantyre 12.9 20.5 38.3 28.3 100.0 914 6.0 Kasungu 20.3 29.1 36.7 13.9 100.0 497 4.1 Machinga 38.6 26.8 26.2 8.3 100.0 427 2.1 Mangochi 43.6 24.6 23.7 8.0 100.0 599 1.3 Mzimba 8.2 12.5 56.7 22.6 100.0 778 6.4 Salima 34.0 30.3 24.3 11.3 100.0 303 2.4 Thyolo 28.3 32.4 30.0 9.3 100.0 618 2.8 Zomba 15.3 30.0 37.8 17.0 100.0 637 4.4 Lilongwe 21.5 23.1 31.6 23.7 100.0 1,705 4.8 Mulanje 22.2 35.7 31.7 10.4 100.0 512 3.1 Other districts 24.8 26.5 36.7 12.0 100.0 4,708 3.8 Wealth quintile Lowest 37.5 33.3 24.9 4.4 100.0 2,037 1.7 Second 33.4 32.4 29.6 4.6 100.0 2,277 2.4 Middle 26.6 30.4 38.0 5.1 100.0 2,383 3.3 Fourth 16.9 24.9 44.5 13.7 100.0 2,361 4.8 Highest 6.7 10.3 38.6 44.4 100.0 2,639 7.6 Total 23.4 25.6 35.5 15.5 100.0 11,698 4.1 Characteristics of Respondents and Women’s Status | 29 Table 3.2.2 Educational attainment by background characteristics: men Percent distribution of men by highest level of schooling attended, and median number of years of schooling, accord- ing to background characteristics, Malawi 2004 Education Background characteristic No education Primary 1-4 Primary 5-8 Secondary or higher Total Number of respondents Median years of schooling Age 15-19 3.2 28.4 47.6 20.7 100.0 650 5.5 20-24 7.4 22.9 31.3 38.4 100.0 587 6.4 25-29 10.9 22.5 30.9 35.8 100.0 634 6.3 30-34 14.6 22.5 34.1 28.7 100.0 485 5.7 35-39 20.9 21.2 41.0 17.0 100.0 294 5.3 40-44 16.3 25.1 43.4 15.1 100.0 282 5.3 45-49 21.1 23.3 40.7 14.9 100.0 182 4.5 50-54 22.4 35.0 33.0 9.0 100.0 148 3.3 Residence Urban 5.2 12.2 31.7 50.9 100.0 669 7.3 Rural 13.4 27.6 38.9 20.0 100.0 2,593 5.1 Region Northern 3.1 14.2 53.1 29.6 100.0 423 6.8 Central 13.8 26.4 35.3 24.5 100.0 1,370 5.2 Southern 12.4 25.6 34.8 27.1 100.0 1,468 5.6 District Blantyre 5.0 10.0 41.7 43.2 100.0 316 7.3 Kasungu 10.3 21.6 49.7 18.3 100.0 156 5.3 Machinga 18.0 30.0 29.7 22.4 100.0 114 4.2 Mangochi 20.2 31.3 24.7 23.8 100.0 150 3.9 Mzimba 3.0 15.2 51.7 30.1 100.0 212 6.7 Salima 10.2 38.8 33.1 17.9 100.0 78 4.1 Thyolo 12.5 32.8 31.2 23.0 100.0 169 4.6 Zomba 14.2 25.8 33.8 26.2 100.0 159 4.9 Lilongwe 13.1 23.2 31.1 32.5 100.0 542 5.8 Mulanje 7.3 28.0 42.7 22.0 100.0 114 5.6 Other districts 13.0 26.8 38.4 21.8 100.0 1,250 5.2 Wealth quintile Lowest 18.6 39.2 32.3 10.0 100.0 412 3.3 Second 16.9 35.6 34.0 13.3 100.0 640 3.8 Middle 16.6 26.1 41.1 16.1 100.0 699 4.8 Fourth 7.7 23.0 48.9 20.4 100.0 709 5.9 Highest 3.5 7.9 29.3 59.3 100.0 802 7.6 Total 11.7 24.5 37.4 26.3 100.0 3,261 5.6 3.3 LITERACY The ability to read and write is an important personal asset enabling women and men to have increased opportunities in life. In the 2004 MDHS survey, persons were defined as literate based on the UNICEF definition: persons who are able to read a complete sentence or part of a sentence. Knowing the distribution of the literate population can help programme planners design effective family planning and health messages. Tables 3.3.1 and 3.3.2 show the level of literacy for women and men by background characteristics. There has been a marked increase in the literacy rate over time, especially for women. While 49 percent of women age 15-49 were literate in 2000, this rate has increased to 62 percent in 2004. For men, the increase is less substantial: 72 percent in 2000 compared with 79 percent in 2004. 30 | Characteristics of Respondents and Women’s Status Literacy is much higher among younger women than older women. For instance, only 37 percent of women age 45-49 are literate compared with 78 percent of women age 15-19. The level of literacy is higher among men (79 percent) than women (62 percent). Urban respondents have a higher level of literacy than rural respondents (84 percent and 58 percent for women and 92 percent and 76 percent for men). As indicated in the previous section, respondents in the Northern Region have the highest level of education and thus the highest literacy rate. Literacy rates rise with increasing wealth quintile; variations are more pronounced for females than for males. Table 3.3.1 Literacy: women Percent distribution of women by level of schooling attended and by level of literacy, and percent literate, according to background characteristics, Malawi 2004 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all Missing Total Number of women Percent literate1 Age 15-19 20.2 49.4 8.0 21.9 0.4 100.0 2,392 77.6 20-24 23.9 37.9 9.2 28.8 0.1 100.0 2,870 71.1 25-29 16.9 36.9 9.2 36.8 0.1 100.0 2,157 63.0 30-34 8.5 33.5 7.8 50.2 0.0 100.0 1,478 49.8 35-39 6.4 36.5 8.6 48.5 0.0 100.0 1,117 51.5 40-44 4.6 34.0 9.8 51.4 0.2 100.0 935 48.4 45-49 4.7 25.9 6.4 63.0 0.1 100.0 749 36.9 Residence Urban 40.2 33.6 10.2 15.8 0.0 100.0 2,076 84.0 Rural 10.1 39.3 8.3 42.1 0.2 100.0 9,621 57.7 Region Northern 22.1 45.3 10.8 21.6 0.1 100.0 1,552 78.2 Central 15.8 36.5 8.5 39.0 0.1 100.0 4,734 60.9 Southern 13.3 37.8 8.0 40.6 0.2 100.0 5,412 59.1 Wealth quintile Lowest 4.4 32.0 7.4 56.1 0.1 100.0 2,037 43.8 Second 4.6 34.8 8.8 51.6 0.2 100.0 2,277 48.2 Middle 5.1 41.9 10.3 42.5 0.1 100.0 2,383 57.4 Fourth 13.7 45.6 9.5 30.9 0.2 100.0 2,361 68.9 Highest 44.4 36.3 6.9 12.1 0.2 100.0 2,639 87.6 Total 15.5 38.3 8.6 37.4 0.2 100.0 11,698 62.4 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence. Characteristics of Respondents and Women’s Status | 31 Table 3.3.2 Literacy: men Percent distribution of men by level of schooling attended and by level of literacy, and percent literate, according to background characteristics, Malawi 2004 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all Missing Total Number of men Percent literate1 Age 15-19 20.7 53.0 7.0 18.9 0.3 100.0 650 80.7 20-24 38.4 39.4 5.1 17.1 0.0 100.0 587 82.9 25-29 35.8 39.8 4.2 19.4 0.9 100.0 634 79.8 30-34 28.7 45.1 3.9 22.3 0.0 100.0 485 77.7 35-39 17.0 55.6 4.2 22.6 0.7 100.0 294 76.7 40-44 15.1 59.8 5.9 18.8 0.4 100.0 282 80.8 45-49 14.9 53.4 6.4 25.3 0.0 100.0 182 74.7 50-54 9.0 56.5 4.9 29.7 0.0 100.0 148 70.3 Residence Urban 50.9 37.1 4.1 7.3 0.7 100.0 669 92.1 Rural 20.0 50.6 5.5 23.7 0.2 100.0 2,593 76.0 Region Northern 29.6 46.0 8.6 15.7 0.0 100.0 423 84.3 Central 24.5 50.3 3.3 21.7 0.3 100.0 1,370 78.1 Southern 27.1 46.0 5.9 20.5 0.5 100.0 1,468 79.1 Wealth quintile Lowest 10.0 47.7 7.2 34.9 0.2 100.0 412 64.9 Second 13.3 52.3 4.8 29.4 0.3 100.0 640 70.3 Middle 16.1 50.7 4.9 28.2 0.1 100.0 699 71.7 Fourth 20.4 58.8 7.3 13.0 0.4 100.0 709 86.6 Highest 59.3 32.0 2.8 5.4 0.5 100.0 802 94.1 Total 26.3 47.8 5.2 20.4 0.3 100.0 3,261 79.3 1 Refers to men who attended secondary school or higher and women who can read a whole sentence or part of a sentence. 3.4 ACCESS TO MASS MEDIA The 2004 MDHS survey collected information on the exposure of respondents to common print and electronic media. Respondents were asked how often they read a newspaper, listen to the radio, or watch television. This information helps family planning and health programme planners reach targeted groups. More than half of women and men listen to the radio at least once a week; the proportion who read newspapers or watch television is much smaller. Data in Tables 3.4.1 and 3.4.2 show that 67 percent of women and 85 percent of men listen to the radio at least once a week. Only 9 percent of women and 19 percent of men watch television at least once a week. Twenty-six percent of men and 13 percent of women read a newspaper at least once a week. In general, men are more likely than women to be exposed to mass media; while 12 percent of men have access to all three types of media, only 5 percent of women do. Furthermore, 13 percent of men have no access to any type of mass media compared to 31 percent of women. Urban residents and younger respondents have more access to all three types of media than other respondents. In the Northern Region, where the literacy rate is high, women and men are more likely to read a newspaper weekly than in the Central or Southern regions. Further, exposure to 32 | Characteristics of Respondents and Women’s Status all three media is highest in the Northern Region (6 percent of women and 14 percent of men) and lowest in the Southern Region (4 percent of women and 11 percent of men). Table 3.4.1 Exposure to mass media: women Percentage of women who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Malawi 2004 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media No media Number of women Age 15-19 17.2 11.6 67.0 6.2 29.8 2,392 20-24 15.5 8.3 68.0 5.0 29.0 2,870 25-29 13.0 9.3 68.3 5.5 30.0 2,157 30-34 8.6 6.5 66.3 2.7 32.6 1,478 35-39 9.3 8.6 64.3 3.8 34.7 1,117 40-44 8.6 6.8 64.4 2.9 35.0 935 45-49 7.9 6.8 60.0 3.0 38.3 749 Residence Urban 35.5 31.3 79.3 19.7 16.8 2,076 Rural 8.0 3.9 63.7 1.4 34.6 9,621 Region Northern 18.9 10.3 66.0 6.1 30.7 1,552 Central 13.3 9.1 66.7 4.9 31.2 4,734 Southern 10.8 7.9 66.4 3.9 31.8 5,412 District Blantyre 22.7 19.8 76.0 11.8 21.2 914 Kasungu 11.5 4.9 71.2 1.7 27.3 497 Machinga 7.0 3.8 64.2 0.6 34.4 427 Mangochi 7.7 7.7 61.6 2.0 36.5 599 Mzimba 19.1 11.6 68.1 7.0 29.1 778 Salima 10.3 4.7 63.0 2.3 34.9 303 Thyolo 11.4 5.6 60.0 2.4 38.6 618 Zomba 12.9 10.4 75.9 5.3 21.9 637 Lilongwe 21.8 18.6 66.7 11.3 30.7 1,705 Mulanje 6.7 4.8 60.4 1.4 37.8 512 Other districts 9.1 4.4 65.1 2.2 33.0 4,708 Education No education 0.4 2.1 53.5 0.0 46.0 2,734 Primary 1-4 3.6 2.6 61.5 0.1 37.0 2,998 Primary 5-8 13.6 7.4 70.8 2.6 26.6 4,154 Secondary+ 45.5 32.0 84.2 23.6 11.3 1,811 Wealth quintile Lowest 4.1 1.1 27.4 0.1 70.8 2,037 Second 4.8 1.5 61.9 0.3 36.4 2,277 Middle 5.4 1.3 70.7 0.2 27.8 2,383 Fourth 9.9 3.8 77.7 1.0 19.9 2,361 Highest 36.1 32.1 86.8 19.1 10.3 2,639 Total 12.9 8.7 66.5 4.6 31.4 11,698 Characteristics of Respondents and Women’s Status | 33 Table 3.4.2 Exposure to mass media: men Percentage of men who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Malawi 2004 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media No media Number of men Age 15-19 26.5 23.8 81.5 11.6 16.2 650 20-24 32.6 23.0 85.4 15.3 12.3 587 25-29 26.0 20.4 88.2 13.5 9.8 634 30-34 28.1 22.4 87.9 14.4 10.0 485 35-39 20.8 12.9 85.7 7.6 13.5 294 40-44 21.5 11.4 83.7 6.9 14.8 282 45-49 21.2 14.1 83.4 9.0 15.3 182 50-54 13.0 3.1 81.0 0.7 18.0 148 Residence Urban 51.3 44.5 92.9 35.0 6.0 669 Rural 19.3 12.7 83.1 5.6 14.8 2,593 Region Northern 40.0 21.6 82.2 13.9 13.5 423 Central 21.9 19.8 83.4 11.6 14.9 1,370 Southern 25.6 18.0 87.5 11.1 11.1 1,468 District Blantyre 36.5 20.8 92.7 16.4 7.3 316 Kasungu 26.3 9.0 75.8 4.3 19.5 156 Machinga 47.9 33.0 92.9 25.9 6.6 114 Mangochi 20.2 16.8 84.8 8.2 13.5 150 Mzimba 53.6 25.3 83.3 18.9 10.4 212 Salima 16.2 6.7 88.3 4.5 11.1 78 Thyolo 20.9 8.4 93.3 6.4 6.3 169 Zomba 18.6 23.2 80.9 10.6 16.4 159 Lilongwe 30.4 34.8 87.0 22.7 12.1 542 Mulanje 28.6 13.4 83.5 6.6 14.1 114 Other districts 17.1 13.7 82.5 6.2 15.5 1,250 Education No education 3.6 5.2 77.5 0.0 21.2 383 Primary 1-4 7.2 8.0 78.9 1.7 19.9 798 Primary 5-8 21.5 15.7 84.8 6.6 12.4 1,220 Secondary+ 59.5 41.1 94.8 33.4 3.8 859 Wealth quintile Lowest 9.9 4.7 57.5 1.8 39.1 412 Second 12.9 5.9 82.5 1.2 15.8 640 Middle 16.0 9.7 86.9 3.3 11.2 699 Fourth 23.2 15.7 90.0 6.0 7.6 709 Highest 55.4 48.8 95.5 37.3 3.8 802 Total 25.9 19.2 85.1 11.7 13.0 3,261 Overall, respondents have greater exposure to radio broadcasts than television or print media. Education and household wealth status are strongly associated with mass media exposure: about 24 percent of women and 33 percent of men with secondary or higher education have access to all three types of media, compared with 7 percent or less for respondents in lower education categories. While 19 percent of women in the highest wealth quintile enjoy all three media, the corresponding proportion for women in the lower quintiles is 1 percent or less. 34 | Characteristics of Respondents and Women’s Status At the district level, women in Thyolo, Mulanje, and Mangochi are the most likely not to have access to any type of media (37-39 percent), while those living Lilongwe and Blantyre are more likely to have exposure to all three types of media (11-12 percent). For men, the differences across districts are less striking; exposure to all three media ranges from 4 percent in Kasungu to 26 percent in Machinga. 3.5 EMPLOYMENT STATUS 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 considered 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. Table 3.5.1 and Table 3.5.2 show the percent distribution of female respondents and male respondents, respectively, by employment status and continuity of employment, according to background characteristics. Fifty-five percent of women reported being currently employed, 3 percent were employed in the 12 months preceding the survey but not working at the time of the survey, and 42 percent were not employed in the 12 months preceding the survey (Figure 3.1). The corresponding proportions for men are 56, 22, and 23 percent, respectively. Employment among women and men increases with age. Women who are formerly married are more likely than other women to be employed at the time of the survey. For men, those who are currently married are most likely to be employed. One in three never-married women and men are currently employed. While rural women are more likely than urban women to be employed, for men the pattern is reversed. Employment among women is highest in Mzimba and Thyolo (79 and 71 percent, respectively), while in Lilongwe the proportion is only 47 percent. For men, employment rates range from 82 percent in Salima to 52 percent in Thyolo. Characteristics of Respondents and Women’s Status | 35 Table 3.5.1 Employment status: women Percent distribution of women by employment status, according to background characteristics, Malawi, 2004 Employed in the 12 months preceding the survey Background characteristic Currently employed Not currently employed Not employed in the 12 months preceding the survey Missing/ don't know Total Number of women Age 15-19 37.1 3.0 59.9 0.0 100.0 2,392 20-24 53.3 3.8 42.9 0.0 100.0 2,870 25-29 57.6 2.9 39.5 0.0 100.0 2,157 30-34 63.6 2.9 33.5 0.0 100.0 1,478 35-39 64.3 2.1 33.6 0.0 100.0 1,117 40-44 67.5 4.2 28.3 0.0 100.0 935 45-49 67.8 2.8 29.3 0.1 100.0 749 Marital status Never married 32.5 2.4 65.1 0.0 100.0 1,970 Married or living together 58.4 3.3 38.3 0.0 100.0 8,312 Divorced/separated/widowed 68.0 3.2 28.8 0.0 100.0 1,416 Number of living children 0 38.9 2.9 58.1 0.0 100.0 2,655 1-2 56.2 3.6 40.2 0.0 100.0 4,092 3-4 60.9 2.7 36.4 0.0 100.0 2,726 5+ 65.8 3.1 31.1 0.1 100.0 2,225 Residence Urban 44.2 1.9 53.9 0.0 100.0 2,076 Rural 57.6 3.4 39.0 0.0 100.0 9,621 Region Northern 62.2 2.3 35.5 0.0 100.0 1,552 Central 48.8 3.5 47.7 0.0 100.0 4,734 Southern 58.8 3.0 38.2 0.0 100.0 5,412 District Blantyre 49.3 2.4 48.4 0.0 100.0 914 Kasungu 47.5 8.0 44.4 0.1 100.0 497 Machinga 54.1 3.8 42.1 0.0 100.0 427 Mangochi 55.3 2.4 42.4 0.0 100.0 599 Mzimba 78.7 3.3 18.0 0.0 100.0 778 Salima 52.4 1.8 45.7 0.1 100.0 303 Thyolo 70.5 2.8 26.7 0.0 100.0 618 Zomba 52.5 0.5 46.9 0.1 100.0 637 Lilongwe 46.6 2.3 51.1 0.0 100.0 1,705 Mulanje 62.0 2.5 35.4 0.0 100.0 512 Other districts 54.3 3.7 42.1 0.0 100.0 4,708 Education No education 63.1 3.0 33.9 0.0 100.0 2,734 Primary 1-4 58.2 3.7 38.1 0.0 100.0 2,998 Primary 5-8 52.5 3.1 44.4 0.0 100.0 4,154 Secondary+ 44.4 2.5 53.1 0.0 100.0 1,811 Wealth quintile Lowest 63.9 3.0 33.1 0.0 100.0 2,037 Second 58.3 3.9 37.8 0.0 100.0 2,277 Middle 56.5 3.6 39.9 0.0 100.0 2,383 Fourth 54.6 3.4 41.9 0.0 100.0 2,361 Highest 45.2 2.0 52.8 0.0 100.0 2,639 Total 55.2 3.1 41.6 0.0 100.0 11,698 36 | Characteristics of Respondents and Women’s Status Table 3.5.2 Employment status: men Percent distribution of men by employment status, according to background characteristics, Malawi 2004 Employed in the 12 months preceding the survey Background characteristic Currently employed Not currently employed Not employed in the 12 months preceding the survey Missing/ don't know Total Number of men Age 15-19 19.6 15.7 64.3 0.5 100.0 650 20-24 52.4 18.5 28.7 0.3 100.0 587 25-29 63.3 28.1 8.6 0.0 100.0 634 30-34 72.4 21.5 6.0 0.0 100.0 485 35-39 71.0 22.6 6.4 0.0 100.0 294 40-44 71.4 22.5 6.1 0.0 100.0 282 45-49 63.3 27.8 8.9 0.0 100.0 182 50-54 69.1 24.1 6.8 0.0 100.0 148 Marital status Never married 31.0 15.1 53.5 0.5 100.0 1,084 Married or living together 68.2 25.3 6.5 0.0 100.0 2,079 Divorced/separated/widowed 62.5 19.8 17.7 0.0 100.0 98 Number of living children 0 34.2 17.7 47.7 0.4 100.0 1,253 1-2 70.8 22.6 6.6 0.0 100.0 794 3-4 68.0 25.4 6.6 0.0 100.0 588 5+ 67.8 25.2 7.0 0.0 100.0 625 Residence Urban 64.9 7.1 28.0 0.0 100.0 669 Rural 53.2 25.5 21.1 0.2 100.0 2,593 Region Northern 55.4 21.1 23.0 0.5 100.0 423 Central 51.6 30.5 17.8 0.1 100.0 1,370 Southern 59.5 13.7 26.7 0.1 100.0 1,468 District Blantyre 61.8 11.4 26.7 0.0 100.0 316 Kasungu 53.2 26.5 20.3 0.0 100.0 156 Machinga 53.7 8.7 37.6 0.0 100.0 114 Mangochi 69.6 17.4 13.0 0.0 100.0 150 Mzimba 60.4 16.2 23.4 0.0 100.0 212 Salima 81.7 8.4 9.9 0.0 100.0 78 Thyolo 51.5 26.0 22.5 0.0 100.0 169 Zomba 61.4 17.0 21.6 0.0 100.0 159 Lilongwe 53.8 26.3 20.0 0.0 100.0 542 Mulanje 62.3 13.8 23.9 0.0 100.0 114 Other districts 50.5 26.0 23.1 0.4 100.0 1,250 Education No education 62.2 29.5 8.4 0.0 100.0 383 Primary 1-4 60.4 23.1 16.5 0.0 100.0 798 Primary 5-8 53.6 23.1 23.1 0.2 100.0 1,220 Secondary+ 51.2 15.2 33.3 0.2 100.0 859 Wealth quintile Lowest 52.1 27.7 19.8 0.5 100.0 412 Second 54.7 24.5 20.8 0.0 100.0 640 Middle 51.0 31.1 17.6 0.3 100.0 699 Fourth 59.0 20.0 20.9 0.1 100.0 709 Highest 59.3 9.8 30.9 0.0 100.0 802 Total 55.6 21.7 22.5 0.2 100.0 3,261 Characteristics of Respondents and Women’s Status | 37 3.6 WOMEN’S OCCUPATION Table 3.6.1 shows the percent distribution of employed women in the 12 months preceding the survey by occupation, according to background characteristics. Information on a woman’s occupation not only allows an evaluation of the woman’s source of income but also has implications for her empowerment. It is expected that occupation and earnings are more likely to empower women if they perceive their earnings as important for meeting the needs of their household. Seven in ten women work in agriculture. Only 3 percent of employed women are in professional, technical, or managerial positions, and 21 percent are employed in sales and services. There are small variations across subgroups of women. However, urban women, women with secondary or higher education, and women living in households in the highest wealth quintile are more likely to hold professional, technical, or managerial jobs. Table 3.6.2 shows that among employed men, 57 percent work in agriculture, 17 percent in sales and services, and 14 percent work as skilled manual laborers. Men show similar variations across subgroups as women. Figure 3.1 Employment Status of Women Age 15-49 Did not work in the 12 months preceding the survey (42%) Not currently employed (3%) Currently employed (55%) MDHS 2004 38 | Characteristics of Respondents and Women’s Status Table 3.6.1 Occupation: women Percent distribution of women employed in the 12 months preceding the survey by occupation, according to background characteristics, Malawi 2004 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agricul- ture Total Number of women Age 15-19 0.2 0.1 15.3 1.8 1.1 3.4 77.8 100.0 958 20-24 1.3 1.8 18.5 2.1 1.2 1.4 73.7 100.0 1,638 25-29 4.3 2.0 22.2 2.1 1.4 1.5 66.4 100.0 1,306 30-34 4.2 1.4 22.2 2.1 1.2 1.3 67.6 100.0 982 35-39 4.7 0.7 24.2 2.7 2.4 0.6 64.7 100.0 741 40-44 2.9 0.5 24.7 4.0 1.1 1.4 65.3 100.0 670 45-49 1.7 0.7 17.8 2.4 0.9 1.1 75.4 100.0 529 Marital status Never married 3.1 5.3 20.5 3.3 2.2 6.5 59.0 100.0 688 Married or living together 2.5 0.7 18.6 2.3 1.0 0.6 74.3 100.0 5,128 Divorced/separated/widowed 3.7 0.9 29.9 1.9 2.3 3.4 57.9 100.0 1,008 Number of living children 0 2.3 3.2 18.3 2.5 1.6 4.2 67.7 100.0 1,112 1-2 3.2 1.4 21.1 2.0 1.3 1.2 69.9 100.0 2,446 3-4 3.4 0.4 20.8 2.1 1.0 0.9 71.4 100.0 1,735 5+ 1.6 0.4 20.7 3.0 1.5 1.0 71.9 100.0 1,531 Residence Urban 8.2 5.7 45.9 4.7 1.9 8.1 25.5 100.0 957 Rural 1.8 0.5 16.3 2.0 1.2 0.5 77.7 100.0 5,867 Region Northern 3.5 0.5 28.4 3.1 1.1 1.5 61.9 100.0 1,001 Central 2.5 1.8 19.7 2.7 1.6 1.7 70.0 100.0 2,477 Southern 2.6 1.0 18.7 1.8 1.2 1.5 73.1 100.0 3,346 District Blantyre 6.5 4.2 35.0 4.3 1.0 4.1 44.8 100.0 472 Kasungu 2.2 0.8 12.7 2.3 2.9 0.8 78.2 100.0 276 Machinga 3.3 0.0 9.1 1.6 1.5 1.0 83.4 100.0 248 Mangochi 2.0 1.4 18.7 1.0 1.4 1.0 74.6 100.0 345 Mzimba 3.0 0.6 13.7 1.6 1.0 1.9 78.2 100.0 638 Salima 2.9 1.7 17.9 3.4 3.8 0.7 69.6 100.0 164 Thyolo 1.7 0.0 15.6 2.7 1.8 0.8 77.5 100.0 453 Zomba 4.0 0.9 17.7 2.2 0.2 3.2 71.8 100.0 337 Lilongwe 2.1 3.7 22.4 2.9 1.0 4.1 63.5 100.0 834 Mulanje 2.3 0.3 17.0 1.2 1.9 1.7 75.6 100.0 330 Other districts 2.3 0.5 22.7 2.3 1.2 0.5 70.5 100.0 2,727 Education No education 0.2 0.0 13.0 2.1 1.4 0.5 82.8 100.0 1,808 Primary 1-4 0.5 0.0 17.3 2.1 1.3 1.3 77.5 100.0 1,855 Primary 5-8 1.1 0.3 25.2 2.2 1.3 2.2 67.6 100.0 2,310 Secondary+ 17.4 8.9 30.2 3.6 1.4 2.7 35.7 100.0 849 Wealth quintile Lowest 0.6 0.1 11.2 1.8 1.7 0.4 84.2 100.0 1,363 Second 0.4 0.0 15.6 1.6 1.4 0.6 80.5 100.0 1,415 Middle 0.4 0.1 17.3 2.2 1.4 0.3 78.1 100.0 1,432 Fourth 1.6 0.7 22.2 2.1 0.9 0.8 71.8 100.0 1,370 Highest 11.6 5.7 37.9 4.2 1.3 6.3 33.1 100.0 1,244 Total 2.7 1.2 20.5 2.3 1.3 1.6 70.3 100.0 6,824 Note: Total includes 2 women with missing information on occupation. Characteristics of Respondents and Women’s Status | 39 Table 3.6.2 Occupation: men Percent distribution of men employed in the 12 months preceding the survey by occupation, according to background characteristics, Malawi 2004 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agricul- ture Total Number of men Age 15-19 0.8 0.2 16.8 7.6 7.3 4.7 62.5 100.0 229 20-24 2.8 2.5 13.7 15.3 6.5 4.3 54.8 100.0 416 25-29 6.1 1.2 19.8 13.1 3.3 1.4 55.1 100.0 579 30-34 8.3 1.8 21.4 16.4 2.4 1.1 48.7 100.0 456 35-39 5.2 3.7 16.0 15.3 4.1 2.0 53.8 100.0 275 40-44 5.4 2.0 14.3 12.9 2.1 0.8 62.6 100.0 265 45-49 2.5 1.2 15.5 13.1 3.8 1.2 62.7 100.0 165 50-54 4.0 0.5 4.9 8.3 1.0 0.8 80.6 100.0 138 Marital status Never married 4.5 2.7 17.6 10.6 7.3 5.7 51.5 100.0 500 Married or living together 4.9 1.6 16.5 14.2 3.2 1.1 58.5 100.0 1,943 Divorced/separated/widowed 7.9 0.0 15.7 16.7 0.6 2.4 56.7 100.0 81 Number of living children 0 4.1 2.1 16.8 11.3 6.3 4.1 55.3 100.0 651 1-2 6.6 1.5 18.1 15.0 3.5 2.2 53.1 100.0 742 3-4 5.8 2.0 15.7 15.0 3.0 0.8 57.7 100.0 550 5+ 3.0 1.4 15.8 12.8 2.5 0.9 63.6 100.0 581 Residence Urban 11.5 5.2 39.7 21.9 4.3 7.1 10.2 100.0 482 Rural 3.4 0.9 11.3 11.6 3.8 0.9 68.2 100.0 2,042 Region Northern 5.1 1.4 9.4 11.3 2.8 1.9 68.2 100.0 324 Central 3.9 1.8 14.3 9.1 3.4 1.9 65.7 100.0 1,126 Southern 6.0 1.8 21.5 18.9 4.8 2.3 44.7 100.0 1,074 District Blantyre 9.5 2.5 34.1 26.1 4.8 3.6 19.4 100.0 232 Kasungu 3.6 0.0 5.2 5.5 8.6 0.0 77.2 100.0 124 Machinga 6.8 2.0 20.2 14.3 2.2 0.7 53.9 100.0 71 Mangochi 3.2 0.0 17.6 12.5 1.4 0.0 65.3 100.0 131 Mzimba 4.6 1.5 5.9 8.3 2.2 2.0 75.4 100.0 163 Salima 2.6 1.0 18.2 9.2 4.9 1.6 62.6 100.0 71 Thyolo 3.7 2.0 17.8 20.6 12.7 1.0 42.2 100.0 131 Zomba 7.0 1.6 22.2 18.4 1.9 3.2 45.7 100.0 125 Lilongwe 5.3 2.5 22.1 8.7 2.6 4.7 54.1 100.0 434 Mulanje 8.2 2.5 17.3 22.3 5.7 1.9 42.2 100.0 87 Other Districts 3.8 1.7 12.0 12.7 3.2 1.2 65.4 100.0 956 Education No education 0.3 0.2 10.5 8.8 4.8 1.7 73.8 100.0 351 Primary 1-4 0.8 0.1 10.6 12.2 4.5 2.6 69.1 100.0 666 Primary 5-8 1.4 1.4 18.2 15.2 3.6 2.1 58.1 100.0 935 Secondary+ 18.3 5.1 25.3 15.3 3.2 1.6 31.1 100.0 571 Wealth quintile Lowest 1.4 0.7 5.4 8.9 2.2 1.6 79.8 100.0 328 Second 0.8 0.4 6.8 14.0 4.3 0.4 73.3 100.0 507 Middle 1.9 1.0 11.7 11.5 3.9 0.8 69.3 100.0 575 Fourth 3.0 0.9 18.0 14.3 4.1 0.5 59.1 100.0 560 Highest 15.9 5.3 36.5 17.1 4.4 6.8 14.0 100.0 554 Total 4.9 1.7 16.7 13.5 3.9 2.1 57.1 100.0 2,523 40 | Characteristics of Respondents and Women’s Status 3.7 TYPE OF EMPLOYMENT Table 3.7.1 shows the percent distribution of women who have worked at any time during the 12 months preceding the survey by type of employment (agricultural or nonagricultural). All employed women were asked whether they were paid in cash, in kind, or not at all. Two in three women receive no payment for their work (Figure 3.2). Women who work in agricultural jobs are much more likely not to be paid than women who work in nonagricultural jobs (80 percent compared with 32 percent). Ten percent of women engaged in agricultural work were paid in cash only, compared with 63 percent of women in nonagricultural jobs. Overall, three in four women who were employed in the 12 months prior to the survey were self-employed. Small differences are found between agriculture and nonagriculture occupations. Two in three women work seasonally. Women in agricultural jobs are more likely to work seasonally (82 percent) than women in nonagricultural jobs (29 percent). Fifteen percent of women who work in agriculture work all year, compared with 53 percent of women in nonagricultural jobs. Table 3.7.1 Type of employment: women Percent distribution of women employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Malawi 2004 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 10.2 62.6 25.7 Cash and in-kind 6.2 3.6 5.4 In-kind only 3.6 1.4 2.9 Not paid 80.0 32.2 65.8 Missing 0.0 0.3 0.1 Total 100.0 100.0 100.0 Type of employer Employed by family member 17.5 7.1 14.4 Employed by nonfamily member 3.7 23.5 9.6 Self-employed 78.7 69.2 75.9 Missing 0.1 0.3 0.1 Total 100.0 100.0 100.0 Continuity of employment All year 15.2 52.6 26.3 Seasonal 81.9 28.5 66.0 Occasional 2.6 18.8 7.4 Missing 0.4 0.2 0.3 Total 100.0 100.0 100.0 Number of women 4,800 2,022 6,824 Total includes two women with missing information on type of employment. Characteristics of Respondents and Women’s Status | 41 Table 3.7.2 shows the percent distribution of men who were employed in the 12 months preceding the survey by occupation and type of earnings. One in three men are not paid for their work and 54 percent receive cash payment only. Men who work in agriculture are less likely to be paid than men who work in nonagricultural jobs. Among those who are paid for their work, the largest proportion are paid in cash (32 percent), while 10 percent are paid in cash and in-kind and 6 percent are paid in in-kind only. Table 3.7.2 Type of employment: men Percent distribution of men employed in the 12 months preceding the survey by type of earnings, according to type of employment (agricultural or nonagricultural), Malawi 2004 Type of earnings Agricultural work Nonagricultural work Total Cash only 32.4 82.3 53.8 Cash and in-kind 10.4 3.4 7.4 In-kind only 6.1 1.0 3.9 Not paid 49.8 10.1 32.8 Missing 1.3 3.2 2.2 Total 100.0 100.0 100.0 Number of men 1,441 1,083 2,523 3.8 MEASURES OF WOMEN’S EMPOWERMENT In addition to information on women’s education, employment status, and control of earnings, the 2004 MDHS also obtained information on 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 Figure 3.2 Type of Earnings of Women Age 15-49 Not paid (66%) In-kind only (3%) Cash and in-kind (5%) Cash only (26%) MDHS 2004 42 | Characteristics of Respondents and Women’s Status important aspects of women’s empowerment relevant for understanding demographic and health behaviours. These questions are used to define three indicators of women’s empowerment: women’s participation in decision making, 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 of women’s lower 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 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. Employed women who earn cash for their work were asked who the main decisionmaker is with regard to the use of their earnings. This information allows the assessment of women’s control over their own earnings. In addition, they were asked about the proportion of household expenditures met by their earnings, in order to assess the relative importance of women’s earnings. This information not only allows an evaluation of the relative importance of women’s earnings in the household economy, but has implications for the empowerment of women. It is expected that employment and earnings are more likely to empower women if women perceive their earnings to be important for meeting the needs of their households. Table 3.8 shows how respondents’ degree of control over the use of their earnings and the extent to which earnings of women meet household expenditures varies by background characteristics. The data show that more than half (52 percent) of women decide for themselves on how their earnings are used, 20 percent make the decisions jointly with someone else, and 27 percent reported that someone else decides for them. Respondents’ degree of control over the use of their earnings varies by background characteristics. Older women, more educated women, and women who live in households in the higher wealth quintiles are more likely to have control over their earnings. For example, while 64 percent of women with secondary or higher education decide how their earnings are used, the proportion among women with no education is only 48 percent. Table 3.8 also shows the proportion of household expenditures that are met by the women’s cash earnings. More than half (57 percent) of women reported that their earnings support half or more of their household’s expenditures. Twenty percent of women say their earnings support all of their households’ expenditures, and 37 percent reported that their earnings support half or more of their households’ financial needs. Across subgroups of women, the data show that women who are more likely to meet all of their household’s expenditures are those over age 30, those who are widowed, separated, or divorced; rural women; and those who are less educated. Characteristics of Respondents and Women’s Status | 43 Table 3.8 Decision on use of earnings and contribution of earnings to household expenditures Percent distribution of women employed in the 12 months preceding the survey receiving cash earnings by person who decides how earnings are to be used and by proportion of household expenditures met by earnings, according to background characteristics, Malawi 2004 Person who decides how earnings are used Proportion of household expenditures met by earnings Background characteristic Self only Jointly Someone else only Missing Total Almost none/ none Less than half Half or more All Missing Total Number of women Age 15-19 44.2 13.2 42.6 0.0 100.0 21.3 31.8 33.0 13.9 0.0 100.0 225 20-24 46.0 17.8 35.8 0.4 100.0 12.5 36.6 31.2 19.2 0.5 100.0 467 25-29 52.0 21.4 25.4 1.3 100.0 8.1 33.0 43.6 14.7 0.6 100.0 455 30-34 54.3 22.2 23.6 0.0 100.0 11.6 27.8 31.9 28.3 0.4 100.0 316 35-39 58.5 22.9 18.3 0.2 100.0 5.4 34.2 38.5 21.6 0.2 100.0 273 40-44 56.5 21.6 21.0 0.9 100.0 7.9 32.4 35.3 24.3 0.0 100.0 234 45-49 63.6 19.2 17.3 0.0 100.0 3.7 30.7 44.9 20.6 0.0 100.0 155 Marital status Never married 70.0 4.1 25.8 0.0 100.0 19.6 29.6 31.4 19.4 0.0 100.0 250 Married or living together 37.5 27.9 34.1 0.5 100.0 9.0 35.5 39.4 15.7 0.4 100.0 1,468 Divorced/separated/widowed 95.2 0.7 3.4 0.6 100.0 9.3 25.0 29.4 35.9 0.4 100.0 407 Number of living children 0 55.9 12.3 31.5 0.3 100.0 19.8 34.0 29.0 16.9 0.3 100.0 364 1-2 49.8 21.3 28.0 0.8 100.0 7.7 31.6 40.0 20.2 0.5 100.0 771 3-4 51.4 21.8 26.3 0.5 100.0 9.9 32.9 36.1 20.8 0.4 100.0 531 5+ 55.0 21.4 23.6 0.0 100.0 7.7 33.8 37.2 21.3 0.0 100.0 459 Residence Urban 67.7 22.4 9.1 0.8 100.0 15.8 32.4 34.1 17.7 0.0 100.0 557 Rural 46.9 19.0 33.7 0.4 100.0 8.3 32.9 37.4 20.9 0.4 100.0 1,568 Region Northern 61.2 23.3 14.7 0.8 100.0 7.8 37.2 43.9 10.4 0.8 100.0 385 Central 43.1 13.7 42.9 0.4 100.0 14.9 39.1 31.8 13.8 0.2 100.0 894 Southern 58.2 24.9 16.4 0.5 100.0 6.6 24.1 38.2 30.9 0.2 100.0 847 District Blantyre 63.3 27.6 8.1 1.1 100.0 9.8 25.8 38.8 25.7 0.0 100.0 225 Kasungu 38.9 20.7 40.3 0.0 100.0 8.5 38.2 37.3 16.0 0.0 100.0 65 Machinga (73.5) (10.9) (15.7) (0.0) 100.0 (6.7) (28.3) (35.3) (29.7) (0.0) 100.0 33 Mangochi 68.4 12.2 19.4 0.0 100.0 3.9 19.7 21.8 54.6 0.0 100.0 65 Mzimba 57.7 21.6 20.7 0.0 100.0 11.4 36.1 42.3 10.2 0.0 100.0 121 Salima 34.2 19.3 46.5 0.0 100.0 15.0 56.0 17.4 11.6 0.0 100.0 63 Thyolo 61.4 25.7 11.2 1.8 100.0 8.8 16.4 35.4 37.6 1.8 100.0 106 Zomba 54.4 29.5 16.1 0.0 100.0 3.9 19.6 41.7 34.8 0.0 100.0 109 Lilongwe 54.6 12.4 32.4 0.6 100.0 21.2 35.0 27.1 16.8 0.0 100.0 341 Mulanje 60.1 19.9 20.0 0.0 100.0 2.3 27.1 43.3 27.3 0.0 100.0 119 Other districts 45.9 19.6 34.0 0.5 100.0 8.5 36.8 39.9 14.2 0.6 100.0 877 Education No education 48.2 12.9 38.3 0.6 100.0 9.6 33.3 31.4 24.9 0.9 100.0 411 Primary 1-4 45.8 21.2 33.0 0.0 100.0 11.0 33.3 35.2 20.3 0.2 100.0 487 Primary 5-8 51.8 20.5 27.1 0.5 100.0 11.8 32.6 37.3 18.2 0.1 100.0 755 Secondary+ 63.7 23.7 11.8 0.8 100.0 7.8 32.3 41.2 18.5 0.2 100.0 472 Wealth quintile Lowest 54.7 13.7 31.4 0.2 100.0 9.2 33.1 30.7 27.0 0.0 100.0 329 Second 45.5 18.2 35.3 1.0 100.0 6.2 37.9 31.4 22.9 1.7 100.0 351 Middle 42.1 18.9 39.1 0.0 100.0 11.4 31.5 36.2 20.9 0.0 100.0 367 Fourth 47.0 22.3 30.2 0.6 100.0 11.0 33.0 41.9 14.0 0.0 100.0 392 Highest 63.3 23.0 13.1 0.6 100.0 11.9 30.6 39.1 18.2 0.2 100.0 686 Total 52.4 19.9 27.2 0.5 100.0 10.3 32.8 36.5 20.0 0.3 100.0 2,125 Note: Figures in parentheses are based on 25-49 unweighted cases. 44 | Characteristics of Respondents and Women’s Status Table 3.9 shows working women’s control over their own earnings within marital and non- marital contexts, and how it varies by the extent to which their earnings help to meet household expenditures. Overall, 38 percent of married women have complete control over their earnings, 27 percent share control with their husband or partner, and for 34 percent of married women, their husband/partner controls their earnings. Many married women do not have control over their cash income even if their earnings do not contribute to the household expenditures. For example, husbands decide how their wives’ earnings are used for 43 percent of women whose income does not substantially contribute to household expenditures. Women who are divorced, separated, widowed, or never married are more likely to have control over their earnings than married women (86 percent compared with 38 percent). Table 3.9 Women's control over earnings Percent distribution of women who received cash earnings for work in the past 12 months by person who decides how earnings are used and current marital status, according to the proportion of household expenditures met by earnings, Malawi 2004 Currently married or living together Not married1 Contribution to household expenditures Self only Jointly with husband Jointly with some- one else Hus- band only Someone else only Miss- ing Total Number of women Self only Jointly with some- one else Someone else only Missing Total Number of women Almost none/none 40.8 10.9 3.9 42.9 1.5 0.0 100.0 132 84.6 1.8 13.6 0.0 100.0 87 Less than half 40.2 22.7 1.1 34.8 0.4 0.9 100.0 521 82.3 2.9 14.7 0.0 100.0 176 Half or more 34.5 32.9 0.4 31.9 0.3 0.0 100.0 578 83.6 2.7 13.7 0.0 100.0 198 All 37.7 31.6 0.5 30.0 0.0 0.3 100.0 231 92.0 0.6 7.1 0.3 100.0 195 Total 37.5 27.0 1.0 33.5 0.6 0.5 100.0 1,468 85.6 2.0 12.0 0.4 100.0 657 Note: Total includes women with missing information on contribution to household expenditures. 1Never married, divorced, separated or widowed women The ability of women to take decisions that affect the circumstances of their own lives is an essential aspect of empowerment. In order to assess women’s decisionmaking autonomy, information was collected on women’s participation in five different types of decisions: on the respondent’s own health care, on making large household purchases, on making household purchases for daily needs, on visits to family friends or relatives, and on what food should be cooked each day. Table 3.10 shows the percent distribution of women according to who in the household usually has the final say on each of these decisions. The data show that for 65 percent or more of married women, their husbands make decisions for their wives’ health care, and large and daily household purchases. Decisions to visit family or relatives are more likely to be made together with their husbands (41 percent). The only one of these decisions that a majority of married women make on their own is the type of food to cook daily. The pattern is different for nonmarried women. Nonmarried women are more likely than married women to make four of the five decisions by themselves. However, for about half of women all five of these decisions are made by someone other than the woman herself: someone else decides on visiting family and relatives for 47 percent of nonmarried women and on large household purchases for 56 percent of nonmarried women. Characteristics of Respondents and Women’s Status | 45 Table 3.10 Women's participation in decisionmaking Percent distribution of women by person who has the final say in making specific decisions and current marital status, according to type of decision, Malawi 2004 Currently married or living together Not married1 Decision Self only Jointly with husband Jointly with someone else Hus- band only Some- one else only Decision not made/not applicable Total Number of women Self only Jointly with someone else Some- one else only Decision not made/not applicable Total Num- ber of women Own health care 17.8 9.9 0.1 70.4 1.5 0.3 100.0 8,312 40.7 3.0 51.9 4.4 100.0 3,385 Large household purchases 6.4 11.5 0.1 80.3 1.2 0.5 100.0 8,312 34.2 3.4 55.7 6.7 100.0 3,385 Daily household purchases 18.8 13.8 0.1 65.4 1.5 0.2 100.0 8,312 35.4 3.8 54.8 5.9 100.0 3,385 Visits to family or relatives 18.8 41.3 0.2 38.4 1.1 0.2 100.0 8,312 40.9 6.8 46.5 5.7 100.0 3,385 What food to cook each day 64.3 9.5 0.4 24.2 1.3 0.1 100.0 8,312 38.6 5.9 49.5 5.9 100.0 3,385 1Never married, divorced, separated or widowed women Table 3.11.1 shows the percentage of women who report that they alone or jointly have the final say in specific household decisions, according to background characteristics. Divorced, separated, or widowed women are far more likely than married or never-married women to have the final say in all the specified decisions. Degree of independence in making household decisions increases with age and number of children. Urban women, women who earn cash, and the least educated women are more likely to have a final say in all given decisions. Regardless of background characteristic, ever-married women and those over age 20 have the final say on what food to cook every day. Table 3.11.2 shows similar data from a man’s perspective. Contrary to the women’s report, the majority of men say that in a couple, a wife has an equal or greater say in making decisions on visiting family or friends, control over the money she earns, and how many children she wants to have and when she wants to have them (73 percent, 69 percent, and 64 percent, respectively). Men are less likely to agree on a wife’s role in making decisions on large household purchases and small daily purchases (44 percent and 53 percent, respectively). Twenty-seven percent of men say that a wife has an equal or greater say in all five decisions listed. There are no significant differences by the man’s age, except that men age 15-19 are less likely than older men to agree that a wife has an equal or greater share in making specific decisions. Rural men are much less likely than urban men to agree to the five decisions (23 percent compared with 44 percent). Men in the Northern Region are less likely than men in other regions to agree to the specific decisions (21 percent compared with 27-28 percent). Education and wealth index have a positive relationship with the likelihood that men agree to the role of women in making specific decisions. Better educated men and men in higher wealth quintile are more likely than other men to say that a wife has an equal or greater say in all five decisions. Across oversampled districts, men in Blantyre and Machinga are most likely to say that a wife has an equal or greater say in making specific decisions. On the other hand, men in Salima are the least likely to agree to these decisions. 46 | Characteristics of Respondents and Women’s Status Table 3.11.1 Women's participation in decisionmaking by background characteristics: women Percentage of women who say that they alone or jointly have the final say in specific decisions, by background characteristics, Malawi 2004 Alone or jointly have final say in: Background characteristic Own health care Making large purchases Making daily purchases Visits to family or relatives What food to cook each day All specified decisions None of the specified decisions Number of women Age 15-19 17.8 8.7 13.1 30.3 31.2 6.3 56.4 2,392 20-24 28.2 18.0 30.5 55.5 65.7 13.3 23.6 2,870 25-29 33.8 25.0 39.0 62.2 74.2 19.9 17.9 2,157 30-34 38.5 30.6 43.7 68.1 78.0 24.7 13.6 1,478 35-39 42.4 34.8 44.8 65.3 78.4 27.9 13.6 1,117 40-44 43.4 35.5 49.4 70.9 83.6 28.9 10.8 935 45-49 50.0 43.9 54.7 76.1 85.0 37.8 10.5 749 Marital status Never married 17.1 9.3 10.2 20.6 16.3 7.9 71.3 1,970 Married or living together 27.8 18.0 32.8 60.3 74.3 12.1 16.7 8,312 Divorced/separated/widowed 80.6 76.9 79.5 85.6 83.8 73.2 10.7 1,416 Number of living children 0 19.7 10.9 15.6 30.7 31.3 8.4 56.5 2,655 1-2 33.4 24.8 36.6 61.6 71.8 19.6 18.4 4,092 3-4 37.0 28.9 42.0 65.3 78.0 22.9 14.6 2,726 5+ 40.1 30.4 44.5 67.9 80.4 24.6 13.3 2,225 Residence Urban 34.1 28.2 42.9 53.2 61.2 23.6 31.1 2,076 Rural 32.0 22.7 32.8 57.4 66.6 17.7 23.9 9,621 Region Northern 37.1 25.6 36.6 53.0 70.9 16.2 22.2 1,552 Central 29.3 21.1 32.3 53.4 65.2 16.9 26.5 4,734 Southern 33.7 25.3 36.1 60.5 64.6 21.1 24.8 5,412 District Blantyre 44.3 37.5 48.3 59.7 69.5 31.6 24.9 914 Kasungu 19.3 12.4 20.1 36.9 69.9 8.0 24.7 497 Machinga 27.8 22.5 35.5 57.5 69.7 19.0 26.0 427 Mangochi 26.7 22.8 31.7 43.6 50.9 17.8 39.4 599 Mzimba 41.5 23.6 35.7 57.9 77.7 15.0 15.4 778 Salima 27.8 19.2 31.6 53.4 63.1 15.3 29.8 303 Thyolo 30.3 22.5 33.2 78.8 74.2 19.0 14.1 618 Zomba 26.7 20.6 30.6 57.0 61.7 17.6 27.2 637 Lilongwe 30.7 23.4 36.5 52.8 61.3 19.6 29.4 1,705 Mulanje 29.9 24.5 33.8 61.2 61.4 21.6 29.2 512 Other districts 33.3 23.2 34.0 57.7 65.6 17.9 23.9 4,708 Education No education 36.3 27.9 38.3 63.2 71.8 22.5 18.7 2,734 Primary 1-4 30.3 21.3 32.0 57.8 68.1 17.7 22.8 2,998 Primary 5-8 31.3 21.7 34.3 54.8 64.4 16.6 26.5 4,154 Secondary+ 32.3 25.5 34.2 49.2 55.1 19.8 35.8 1,811 Employment Not employed 25.0 17.2 27.7 46.2 56.3 13.4 35.2 5,235 Employed for cash 44.6 39.6 53.1 68.4 77.7 31.8 15.6 2,033 Employed not for cash 35.5 23.8 34.2 63.6 71.2 19.0 17.7 4,417 Wealth quintile Lowest 42.0 33.5 42.7 63.4 71.4 28.6 19.8 2,037 Second 30.4 20.9 30.4 58.5 67.2 17.0 23.0 2,277 Middle 28.8 19.8 30.4 54.7 65.4 15.0 24.9 2,383 Fourth 28.5 19.5 31.3 56.4 65.4 13.9 25.0 2,361 Highest 33.4 25.6 38.9 51.9 60.5 20.5 31.6 2,639 Total 32.4 23.6 34.6 56.7 65.7 18.8 25.2 11,698 Note: Total includes 13 women with missing information on employment status Characteristics of Respondents and Women’s Status | 47 Table 3.11.2 Men’s attitudes towards women’s control of decisionmaking by background characteristics Percentage of men who say that in a couple the wife should have an equal or greater say than the husband in specific decisions, by background characteristics, Malawi 2004 Wife should have an equal or greater say in: Background characteristic Making large purchases Making daily purchases Visits to family or relatives Control over money she earns How many children to have and when All of the specified decisions Number of men Age 15-19 35.7 46.9 71.7 66.6 58.4 19.5 650 20-24 41.0 51.6 70.9 66.5 63.6 25.1 587 25-29 49.2 55.2 76.1 71.0 69.4 32.6 634 30-34 47.8 57.1 75.4 71.9 68.2 29.3 485 35-39 49.7 56.5 72.6 66.1 61.2 27.8 294 40-44 45.6 53.3 74.3 68.4 61.9 27.6 282 45-49 43.3 51.9 70.1 73.6 64.9 27.7 182 50-54 45.6 52.9 65.2 60.6 54.0 27.7 148 Marital status Never married 41.2 52.6 74.9 69.5 63.4 25.3 1,084 Married or living together 45.7 52.9 71.8 67.7 64.2 27.6 2,079 Divorced/separated/widowed 40.0 55.0 74.4 72.0 54.9 26.5 98 Number of living children 0 40.7 51.7 73.3 69.0 63.4 24.5 1,253 1-2 46.1 53.0 72.6 68.6 65.6 28.7 794 3-4 48.8 53.9 75.1 70.3 64.4 30.1 588 5+ 43.9 54.1 70.3 65.3 60.7 25.8 625 Residence Urban 55.0 68.5 83.8 79.8 79.1 43.6 669 Rural 41.3 48.8 70.1 65.5 59.6 22.5 2,593 Region Northern 35.2 74.8 58.3 70.9 52.0 21.2 423 Central 45.0 45.4 71.2 64.3 62.0 26.8 1,370 Southern 45.8 53.5 78.6 71.6 68.6 28.4 1,468 Education No education 36.4 40.3 66.8 58.5 55.3 20.0 383 Primary 1-4 26.8 40.1 62.0 56.3 50.0 13.6 798 Primary 5-8 41.7 53.5 71.4 67.2 60.7 23.6 1,220 Secondary+ 66.9 69.3 87.8 86.0 84.3 46.6 859 Wealth quintile Lowest 30.3 41.4 61.3 60.3 51.8 15.4 412 Second 35.5 39.9 68.7 59.0 57.3 15.6 640 Middle 41.4 48.9 66.6 65.4 58.2 21.0 699 Fourth 46.3 56.7 75.4 71.3 65.6 29.5 709 Highest 58.3 69.0 85.4 80.3 77.9 44.2 802 District Blantyre 64.9 68.0 89.3 85.3 82.3 47.0 316 Kasungu 29.5 40.7 48.0 51.0 43.1 12.6 156 Machinga 56.4 70.7 74.2 70.6 73.7 48.2 114 Mangochi 30.3 43.4 68.1 59.1 51.6 18.9 150 Mzimba 30.2 71.0 55.8 69.8 51.2 17.1 212 Salima 28.4 28.0 64.7 52.9 47.4 7.7 78 Thyolo 43.3 46.0 70.9 59.1 58.5 21.2 169 Zomba 32.1 46.6 67.2 53.4 50.3 21.4 159 Lilongwe 50.5 53.5 71.0 66.3 66.5 37.3 542 Mulanje 51.2 40.2 79.4 68.3 67.4 28.1 114 Other districts 42.7 51.1 76.9 72.2 65.9 22.0 1,250 Total 44.1 52.8 72.9 68.5 63.6 26.8 3,261 48 | Characteristics of Respondents and Women’s Status To assess women’s degree of acceptance of wife beating, the 2004 MDHS survey asked 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 are: 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 3.12.1 show how acceptance of wife beating varies for each reason. The last column gives the percentages of women who feel that wife beating is justified for at least one of the given reasons. A woman who believes that a husband is justified in hitting or beating his wife for any reason at all may believe herself to be of low status, both absolutely and relative to men. Such a perception could act as a barrier to accessing health care for her and her children, could affect her attitude toward contraceptive use, and could impact her general well being. Twenty-eight percent of women agree with at least one of the selected reasons for wife beating. Neglecting the children was the reason for which women were most likely to find wife beating justified (17 percent). Differentials across respondents’ background characteristics are small, although younger women, married women, rural women, and women with less than secondary education are more likely to accept justifications for wife beating. Women in the Northern Region are much more likely than women in other regions to agree with at least one reason for wife beating (45 percent compared to 32 percent or less). Table 3.12.2 shows men’s perception on justifications for wife beating. Interestingly, men are less likely than women to justify wife beating for any reason (16 percent compared to 28 percent). In general, younger men, never-married men, men with no living children, men in the Northern or Central Regions, and men in the lower wealth quintiles are more likely than other men to agree to wife beating for any reason. 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 2004 MDHS 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. These four circumstances for which women’s opinions are sought have been chosen because they are effective in combining issues of women’s rights and consequences for women’s health. Table 3.13.1 shows the percentage of 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 a belief in women’s sexual rights. Characteristics of Respondents and Women’s Status | 49 Table 3.12.1 Women's attitude towards wife beating Percentage of women who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Malawi 2004 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sex with him Agrees with at least one specified reason Number of women Age 15-19 14.2 14.8 15.9 20.9 13.5 31.8 2,392 20-24 12.0 12.8 13.9 18.4 14.4 29.8 2,870 25-29 10.8 10.9 14.9 16.7 14.2 27.6 2,157 30-34 9.1 10.5 11.6 14.7 12.4 24.4 1,478 35-39 10.6 9.7 12.1 14.1 13.1 25.8 1,117 40-44 9.5 10.5 13.5 15.5 14.2 27.4 935 45-49 9.7 8.1 12.4 13.7 12.5 24.7 749 Marital status Never married 11.1 11.5 13.0 17.5 10.8 26.9 1,970 Married or living together 11.7 12.3 14.6 17.6 14.8 29.2 8,312 Divorced/separated/widowed 10.1 9.1 11.0 14.1 11.1 24.5 1,416 Number of living children 0 12.5 13.0 14.4 18.5 12.9 29.7 2,655 1-2 11.7 12.3 13.9 17.5 14.2 28.8 4,092 3-4 10.8 11.0 13.4 16.5 13.7 27.6 2,726 5+ 10.1 10.5 13.9 15.7 13.5 26.3 2,225 Residence Urban 6.3 7.1 10.1 10.5 8.6 18.1 2,076 Rural 12.5 12.8 14.7 18.6 14.7 30.4 9,621 Region Northern 17.7 17.6 24.5 28.2 22.6 45.1 1,552 Central 13.7 14.6 15.3 20.2 17.5 31.8 4,734 Southern 7.5 7.6 9.6 11.4 7.7 20.2 5,412 District Blantyre 4.0 3.9 4.8 6.2 4.0 10.1 914 Kasungu 24.9 25.8 32.6 38.2 27.5 50.4 497 Machinga 5.6 3.1 3.1 4.9 4.6 12.5 427 Mangochi 9.1 12.1 12.4 15.9 11.7 28.0 599 Mzimba 20.2 21.0 28.4 29.5 23.2 47.4 778 Salima 10.0 8.9 8.8 12.3 26.7 35.8 303 Thyolo 11.4 9.5 11.9 14.8 8.7 24.2 618 Zomba 6.7 8.4 8.7 9.6 7.0 18.5 637 Lilongwe 10.8 11.6 11.3 13.9 13.6 20.5 1,705 Mulanje 7.4 7.5 9.3 10.1 9.6 19.9 512 Other districts 12.1 12.6 15.2 19.9 14.7 32.8 4,708 Education No education 11.8 11.4 13.4 16.3 15.1 28.3 2,734 Primary 1-4 13.7 12.8 13.9 17.2 15.0 30.2 2,998 Primary 5-8 11.6 12.5 15.8 19.0 14.3 30.2 4,154 Secondary+ 6.5 9.2 10.2 14.1 7.8 20.3 1,811 Employment Not employed 10.6 10.8 12.5 16.3 13.6 26.5 5,235 Employed for cash 10.1 12.1 15.6 17.3 13.8 29.7 2,033 Employed not for cash 12.9 12.9 14.8 18.2 13.7 29.7 4,417 Number of decisions in which woman has final say1 0 12.5 12.7 14.6 17.9 12.9 27.7 2,945 1-2 12.1 13.4 15.7 19.2 15.1 31.1 4,501 3-4 10.9 10.9 13.1 16.9 14.4 29.9 2,057 5 9.0 8.2 9.9 12.2 11.0 21.6 2,195 Wealth quintile Lowest 13.2 12.8 14.4 17.7 14.7 30.0 2,037 Second 12.5 12.8 14.8 18.2 16.6 31.9 2,277 Middle 13.0 14.3 14.6 20.3 15.8 32.0 2,383 Fourth 11.6 12.2 15.5 18.9 14.3 30.0 2,361 Highest 7.3 7.6 10.7 11.6 7.8 18.8 2,639 Total 11.4 11.8 13.9 17.2 13.7 28.2 11,698 Note: Total includes 13 women with missing information on employment. 1 Either by herself or jointly with others 50 | Characteristics of Respondents and Women’s Status Table 3.12.2 Men's attitude towards wife beating Percentage of men who agree that a husband is justified in hitting or beating his wife for specific reasons, by background character- istics, Malawi 2004 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sex with him Agrees with at least one specified reason Number of men Age 15-19 7.8 14.2 10.6 14.2 11.0 27.9 650 20-24 5.4 11.5 11.6 12.5 9.1 21.9 587 25-29 3.9 5.2 5.3 7.1 4.0 12.0 634 30-34 3.0 4.9 4.5 6.0 6.6 13.1 485 35-39 1.8 3.7 4.8 5.0 4.7 9.5 294 40-44 1.4 2.0 2.5 2.9 2.0 6.5 282 45-49 1.5 4.9 2.5 2.3 2.2 5.4 182 50-54 2.4 4.5 4.4 5.9 6.4 12.9 148 Marital status Never married 7.1 11.9 9.8 12.9 10.2 23.8 1,084 Married or living together 2.7 5.3 5.4 6.2 4.5 12.1 2,079 Divorced/separated/widowed 5.3 8.3 6.4 6.1 10.6 15.1 98 Number of living children 0 6.6 11.8 9.7 12.7 9.9 22.9 1,253 1-2 3.2 5.3 6.6 5.8 4.5 13.3 794 3-4 2.5 5.1 4.9 6.2 4.8 11.7 588 5+ 2.2 4.4 3.6 5.3 4.3 10.0 625 Residence Urban 4.6 5.5 5.7 5.8 6.5 14.1 669 Rural 4.1 8.1 7.2 9.1 6.6 16.6 2,593 Region Northern 6.5 10.9 10.4 14.2 11.7 22.7 423 Central 6.0 10.3 8.7 10.8 8.8 21.1 1,370 Southern 1.9 4.1 4.2 4.5 3.1 9.5 1,468 District Blantyre 2.1 3.1 2.8 3.0 3.9 6.8 316 Kasungu 6.2 12.5 8.1 12.5 8.3 22.5 156 Machinga 1.5 4.6 3.5 1.4 0.7 6.5 114 Mangochi 2.8 5.0 4.0 5.6 3.6 10.0 150 Mzimba 6.7 12.0 7.8 12.9 10.2 21.2 212 Salima 5.8 9.2 8.6 7.5 12.0 17.5 78 Thyolo 3.5 4.7 2.4 6.3 2.0 11.5 169 Zomba 1.6 6.6 5.1 6.3 5.6 13.7 159 Lilongwe 6.0 7.2 8.2 8.5 9.3 19.0 542 Mulanje 2.4 8.6 9.5 10.4 5.3 16.6 114 Other districts 4.2 8.5 8.3 9.9 6.7 17.9 1,250 Education No education 3.1 5.7 3.8 4.8 5.6 12.2 383 Primary 1-4 5.3 9.6 7.4 10.6 9.7 20.3 798 Primary 5-8 5.0 9.6 8.5 9.9 7.0 18.0 1,220 Secondary+ 2.5 3.8 5.5 6.0 3.6 11.3 859 Number of decisions in which a woman should have final say1 0 (0.0) (3.0) (5.1) (5.9) (7.8) (12.9) 35 1-2 5.4 9.1 9.1 9.4 7.8 19.2 911 3-4 3.8 7.1 6.1 8.1 6.1 14.9 2,316 Wealth quintile Lowest 7.0 11.5 7.7 11.0 9.8 19.0 412 Second 4.9 9.1 7.5 11.0 6.8 17.7 640 Middle 3.9 8.0 7.7 8.9 7.2 16.4 699 Fourth 3.4 6.5 5.2 7.1 4.8 15.0 709 Highest 3.2 5.0 6.9 5.9 5.8 14.0 802 Total 4.2 7.6 6.9 8.4 6.6 16.1 3,261 Note: Figures in parentheses are based on 25-49 cases. 1 Either by herself or jointly with others Characteristics of Respondents and Women’s Status | 51 Fifty-two percent of women agree that a woman is justified in refusing sex for all selected reasons and only 13 percent say that a woman is not justified in refusing sex for any of the selected reasons. In general, women are most likely to justify refusing sex if a woman recently gave birth (80 percent), perhaps because it is a cultural taboo in Malawi to have sex right after birth. Hence this finding may not be a sign of empowerment as much as adherence to an important traditional belief. The next most accepted reasons for refusing sex are the knowledge that the husband has a sexually transmitted disease (74 percent), and if the husband has sex with other women (71 percent). Women are the least likely to agree with refusing sex because the woman is tired or not in the mood (64 percent). There is little variation in this index by background characteristics. The percentage of women who say that a woman is justified in refusing sex for all the specified reasons increases with the woman’s education and independence in decisionmaking. Women in the Southern Region are more likely than women in other regions to agree with all of the reasons for refusing sex (59 percent compared with 51 percent in the Northern Region and 45 percent in the Central Region). Table 3.13.2 looks at the same issue from the men’s perspective. Men are more likely than women to think that wives are justified in refusing sex with their husbands for each of the specified reasons. While 74 percent of women say that a wife is justified to refuse sex with her husband if the husband has a sexually transmitted disease, the corresponding proportion for men is 81 percent. Men are least likely to justify a wife refusing sex because she is tired or not in the mood (67 percent), but they are still slightly more likely to find this reason justifiable than women (64 percent). As in the case of women, there are small variations in this index by background characteristics. The differentials among men are similar to those of women. For example, men in the Southern Region are also more likely than men in other regions to agree with all of the reasons for refusing sex (60 percent compared with 51 percent in the Central Region and 42 percent in the Northern Region). 52 | Characteristics of Respondents and Women’s Status Table 3.13.1 Women's attitude towards refusing sex with husband Percentage of women who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background characteristics, Malawi 2004 Wife is justified in refusing sex with husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has had sex with other women Has recently given birth Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of women Age 15-19 66.0 65.6 69.1 57.7 47.1 22.1 2,392 20-24 74.2 72.8 81.8 67.2 53.4 10.7 2,870 25-29 76.6 72.7 83.4 65.6 53.5 9.5 2,157 30-34 77.3 73.2 83.6 65.7 53.0 9.5 1,478 35-39 76.7 71.2 83.6 68.6 55.4 10.5 1,117 40-44 75.8 72.0 83.7 65.6 54.0 10.0 935 45-49 76.3 72.8 80.5 61.2 51.9 12.1 749 Marital status Never married 65.9 65.2 65.8 56.7 47.9 24.5 1,970 Married or living together 75.3 72.2 83.0 65.9 53.0 10.3 8,312 Divorced/separated/widowed 76.5 72.9 82.1 66.0 53.8 10.2 1,416 Number of living children 0 67.9 67.0 70.0 58.3 48.2 20.9 2,655 1-2 75.6 72.7 82.9 66.6 53.4 10.0 4,092 3-4 75.7 71.7 82.1 65.8 53.4 10.9 2,726 5+ 75.3 72.4 84.0 65.9 53.5 10.0 2,225 Residence Urban 79.8 76.5 83.8 69.7 61.2 11.1 2,076 Rural 72.6 70.0 79.1 63.3 50.3 13.0 9,621 Region Northern 80.1 71.0 85.3 65.3 51.1 6.7 1,552 Central 68.1 67.0 75.0 55.8 44.6 17.4 4,734 Southern 77.1 74.8 82.8 71.7 59.3 10.3 5,412 Education No education 69.5 65.9 78.1 61.5 46.7 13.6 2,734 Primary 1-4 71.0 69.5 78.5 62.5 49.6 14.8 2,998 Primary 5-8 75.5 72.7 80.8 65.2 53.7 11.8 4,154 Secondary or higher 81.4 78.3 83.3 70.0 61.5 9.8 1,811 Employment Not employed 70.7 69.1 76.7 61.6 50.2 16.1 5,235 Employed for cash 78.4 74.8 84.9 67.4 55.6 9.0 2,033 Employed not for cash 75.5 71.8 81.6 66.2 53.0 10.3 4,417 Number of decisions in which woman has final say1 0 67.8 65.4 71.4 60.3 48.4 19.7 2,945 1-2 74.1 73.0 81.4 66.0 52.8 11.2 4,501 3-4 77.8 73.3 85.0 64.5 51.8 8.2 2,057 5 77.6 73.0 83.7 66.5 56.5 10.5 2,195 Number of reasons wife beating is justified 0 73.5 71.3 78.8 65.4 55.3 14.9 8,395 1-2 76.0 68.7 81.6 59.3 42.2 7.3 1,975 3-4 71.6 73.2 83.6 65.5 45.1 6.5 898 5 75.8 74.7 86.6 66.6 53.6 7.2 430 Wealth quintile Lowest 70.0 67.4 77.5 61.8 48.7 14.6 2,037 Second 71.3 69.5 79.2 63.6 50.0 13.5 2,277 Middle 71.9 68.4 78.4 62.4 48.9 13.1 2,383 Fourth 74.9 71.9 81.1 63.5 51.0 11.7 2,361 Highest 79.9 77.2 82.9 69.6 61.1 11.0 2,639 Total 73.9 71.1 80.0 64.4 52.2 12.7 11,698 Note: Total includes 13 women with missing information on employment. 1 Either by herself or jointly with others Characteristics of Respondents and Women’s Status | 53 Table 3.13.2 Men's attitude towards a woman refusing sex with husband Percentage of men who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background char- acteristics, Malawi 2004 Wife is justified in refusing sex with husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has had sex with other women Has recently given birth Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of men Age 15-19 75.1 66.3 80.8 58.7 46.8 11.3 650 20-24 80.6 74.1 87.3 65.4 52.8 5.1 587 25-29 82.8 75.0 91.3 71.1 58.1 4.9 634 30-34 81.5 73.2 89.9 70.1 55.5 6.9 485 35-39 87.0 79.3 98.3 70.8 59.2 1.3 294 40-44 84.0 76.6 95.2 69.1 55.8 2.1 282 45-49 87.3 77.8 94.1 64.5 54.3 2.2 182 50-54 80.2 72.4 89.1 62.0 49.3 6.9 148 Marital status Never married 76.7 69.3 82.7 61.7 50.9 9.8 1,084 Married or living together 83.6 75.8 92.6 69.4 55.9 3.9 2,079 Divorced/separated/widowed 83.8 68.3 92.2 56.0 42.2 3.8 98 Residence Urban 84.5 78.5 87.5 69.5 62.7 7.9 669 Rural 80.5 72.1 89.8 65.7 51.5 5.4 2,593 Region Northern 77.0 71.0 87.9 52.2 42.3 7.3 423 Central 80.1 72.1 87.9 62.3 50.9 6.5 1,370 Southern 83.7 75.3 91.0 74.5 59.8 4.9 1,468 Education No education 79.7 70.1 91.3 63.0 47.9 5.2 383 Primary 1-4 76.9 67.8 85.0 61.6 46.8 8.6 798 Primary 5-8 81.2 73.3 90.1 63.9 52.1 4.9 1,220 Secondary or higher 86.2 80.3 91.3 76.2 65.4 5.1 859 Wealth quintile Lowest 80.4 69.7 88.6 57.7 45.4 6.7 412 Second 80.8 74.6 91.5 68.0 52.4 4.2 640 Middle 80.5 71.0 89.8 64.1 49.9 4.4 699 Fourth 81.0 72.0 88.0 66.7 54.2 7.2 709 Highest 83.1 77.7 88.7 71.6 62.3 7.0 802 Total 81.3 73.4 89.3 66.5 53.8 5.9 3,261 Fertility | 55 FERTILITY 4 James Kaphuka The 2004 Malawi Demographic and Health Survey (MDHS) collected information on current and past fertility. A set of carefully worded questions to obtain accurate and reliable data on fertility was administered to measure fertility levels, trends, and differentials. The fertility measures presented here are calculated directly from the birth history. All women age 15-49 were asked to report on all live births. Questions were asked about children still living at home, those living elsewhere, and those who had died. The women were then asked the name, month, and year of birth, sex, survival status, current age (if alive), and age at death (if dead). The accuracy of fertility data is affected primarily by underreporting of births (especially children who died in early infancy) and misreporting of the date of birth. Errors in underreporting of births affect the estimates of fertility levels, while misreporting of dates of births can distort estimates of fertility trends. If these errors vary by socioeconomic characteristics of the women, the differentials in fertility will also be affected. 4.1 CURRENT FERTILITY LEVELS AND TRENDS 4.1.1 Fertility Levels The most commonly used measures of current fertility are the total fertility rate (TFR) and its components, age-specific fertility rates. The TFR is a summary measure of fertility and can be interpreted as the average number of births a hypothetical woman would have at the end of her reproductive life if she were subject to the currently prevailing age-specific fertility rates (ASFRs) throughout her reproductive years (15-49). The ASFRs are a valuable measure of the age pattern of childbearing. They are defined as the number of live births to women in a particular age group divided by the number of woman-years in that age group during the specified period. The TFR is the most significant demographic indicator in the analysis of the impact of national population programmes—in particular, family planning programmes—on individual or group reproductive behaviour. To reduce sampling errors and avoid possible problems of displacement of births, a three-year TFR was computed to provide the most recent estimates of current levels of fertility1. Table 4.1 presents the current TFRs and ASFRs for Malawi by urban-rural residence. The results indicate that a woman in Malawi would, on average, bear 6.0 children in her lifetime if fertility were to remain constant at the current age-specific rates measured in the survey (for the 36 months preceding the survey). The table also shows that urban women have lower fertility than their rural counterparts (4.2 children per woman compared with 6.4 children per woman), and lower 1 Numerators of the ASFRs are calculated by summing the number of live births that occurred in the period 1 to 36 months preceding the survey (determined by the date of interview and the date of birth of the child) and classifying them by the age (in five-year groups) of the mother at the time of birth (determined by the mother’s date of birth). The denominators of the rates are the number of woman-years lived in each of the specified five-year groups during the period 1 to 36 months preceding the survey. 56 | Fertility urban fertility is observed across all age groups. The TFR measured from the 2004 MDHS (6.0) is slightly lower than the TFR measured in the 2000 MDHS (6.3). Examination of the age pattern of fertility rates show that the peak of childbearing in Malawi is at ages 20-24. The same age pattern was observed in the 2000 Malawi DHS. Table 4.1 further shows a general fertility rate of 215 live births per 1,000 women age 15-44 years and a crude birth rate of 42 births per 1,000 population. Compared with other eastern and southern African countries that have participated in the DHS programme, Malawi still has one of the highest fertility rates (see Figure 4.1). Table 4.1 Current fertility Age-specific and cumulative fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by urban-rural residence, Malawi 2004 Residence Age group Urban Rural Total 15-19 109 175 162 20-24 237 308 293 25-29 195 266 254 30-34 159 233 222 35-39 97 174 163 40-44 29 87 80 45-49 22 37 35 TFR 4.2 6.4 6.0 GFR 162 227 215 CBR 37.0 43.4 42.4 Note: 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 divided by the number of women age 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Fertility | 57 4.1.2 Fertility Differentials This section examines associations between a woman’s background characteristics and her fertility. Fertility varies by residence, educational background, and other background characteristics of a woman. Table 4.2 and Figure 4.2 show fertility differentials by urban-rural residence, region, education, wealth index quintile and by the ten oversampled districts. The analysis of the fertility differentials in this report is done using the TFR, percentage of currently pregnant women, and completed fertility in terms of the mean number of births to women age 40-49 by these characteristics. As noted earlier, urban women have fewer children (average of 4.2 children per woman) than their rural counterparts (6.4 children per woman). This rural-urban difference in the TFR is the same as observed in the 2000 MDHS. There is substantial regional variation in the TFR between the Central and the other two regions. The TFR in the Central Region is 6.4 births per woman, while in the Southern and Northern regions it is 5.8 and 5.6 births per woman, respectively. Among the ten oversampled districts, The TFR varies from 4.8 births per woman in Blantyre to 7.2 per woman in Mangochi. In addition to urban-rural, region, and district differentials, there are variations in TFR when measuring a woman’s education and economic status (measured by the wealth index). Education consistently appears as an important variable in the analysis of fertility-related behaviour. Generally, the TFR declines as educational level increases. Women with no education or with primary education 1-4 have a TFR that is higher than that of women with primary education 5-8 and secondary or higher education levels (Table 4.2). A similar relationship is reflected in the association between fertility rates and the wealth index, which shows that women have fewer children as wealth Figure 4.1 Total Fertility Rates for Selected Sub-Saharan Countries 6.9 6.0 5.9 5.7 5.5 5.0 4.0 2.9 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 Ug an da 20 00 -01 Ma law i 2 00 4 Za mb ia 20 01 -02 Ta nz an ia 20 04 -0 5 Mo za mb iqu e 2 00 3 Ke ny a 2 00 3 Zim ba bw e 1 99 9 So uth Af ric a 1 99 8 B irt hs p er w om an 58 | Fertility increases. The TFR for women in the lowest (poorest) quintile is 7.1 births per woman, compared with 4.1 births for women in the highest (richest) quintile. Table 4.2 also shows that at the time of the survey 12 percent of women were pregnant. The proportion of pregnant women in urban areas, those with secondary and higher education, and women in the highest wealth quintile is lower than those for the other population subgroups. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Malawi 2004 Background characteristic Total fertility rate1 Percentage currently pregnant1 Mean number of children ever born to women age 40-49 Residence Urban 4.2 8.9 5.7 Rural 6.4 12.8 6.7 Region Northern 5.6 11.2 6.6 Central 6.4 12.3 6.9 Southern 5.8 12.1 6.3 District Blantyre 4.8 11.9 5.4 Kasungu 7.0 12.5 7.4 Machinga 7.0 10.6 6.2 Mangochi 7.2 10.0 6.5 Mzimba 5.5 11.7 6.7 Salima 6.8 15.0 6.5 Thyolo 5.7 14.4 6.1 Zomba 5.3 12.1 6.1 Lilongwe 5.7 10.4 6.5 Mulanje 5.6 13.6 6.0 Other districts 6.3 12.5 6.8 Education No education 6.9 11.8 6.7 Primary 1-4 6.6 14.5 6.8 Primary 5-8 5.8 11.8 6.4 Secondary+ 3.8 9.1 4.7 Wealth quintile Lowest 7.1 12.2 6.9 Second 7.0 14.1 6.5 Middle 6.5 14.4 6.8 Fourth 5.8 12.1 6.8 Highest 4.1 8.1 5.7 Total 6.0 12.1 6.5 1 Women age 15-49 years The last column in Table 4.2 shows the mean number of children ever born (CEB) to women age 40-49. This is an indicator of cumulative fertility; it reflects the fertility performance of older women who are nearing the end of their reproductive period and thus represents completed fertility. If fertility had remained stable over time, the two fertility measures, TFR and CEB, would be equal or similar. The findings show that the mean number of children ever born to women age 40-49 (6.5 children per woman) is slightly higher than the TFR for the 3 years preceding the survey (6.0 children per woman), suggesting a slight recent reduction in fertility. Fertility | 59 4.1.3 Trends in Fertility The trend in fertility can be assessed by comparing the current TFR with estimates from previous DHS surveys. Tables 4.3 and 4.4 and Figures 4.3 and 4.4 show changes in fertility rates across four surveys that were conducted in Malawi since the early 1980s: the 1984 Family Formation Survey (FFS), the 1992 MDHS, the 2000 MDHS, and the 2004 MDHS. Direct estimates of fertility for the three years preceding the survey have been used in this comparison, because a three-year rate is more robust than rates based on a shorter period of time. The TFR substantially declined from 7.6 children per woman in the 1984 FFS to 6.7 children per woman in 1992 MDHS, to 6.0 children per woman in 2004. This is a 1.5 child drop in fertility over two decades. Table 4.3 shows that since 1984 fertility has fallen primarily in older age groups (30 and above). The pace of fertility decline varied, but was fastest between 1984 and 1992 and between 2000 and 2004. Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates (per 1,000 women) and total fertility rate for the three years preceding the survey, Malawi 1984-2004 Age group 1984 FFS1 1992 MDHS 2000 MDHS 2004 MDHS 15-19 202 161 172 162 20-24 319 287 305 293 25-29 309 269 272 254 30-34 273 254 219 222 35-39 201 197 167 163 40-44 129 120 94 80 45-49 83 58 41 35 TFR 7.6 6.7 6.3 6.0 1 Data from the Family Formation Survey (FFS) are based on the four years preced- ing the survey. Figure 4.2 Total Fertility Rate by Background Characteristics 4.1 5.8 6.5 7.0 7.1 3.8 5.8 6.6 6.9 5.8 6.4 5.6 6.4 4.2 0 1 2 3 4 5 6 7 8 Highest Fourth Middle Second Lowest WEALTH QUINTILE Secondary + Primary 5 - 8 Primary 1 - 4 No education EDUCATION Southern Central Northern REGION Rural Urban RESIDENCE Births per woman MDHS 2004 60 | Fertility Figure 4.3 Trends in the Total Fertility Rate 1984 FFS, 1992 MDHS, 2000 MDHS, and 2004 MDHS7.6 6.7 6.3 6.0 0 1 2 3 4 5 6 7 8 1984 FFS 1992 MDHS 2000 MDHS 2004 MDHS Note: Rates refer to the 3-year period preceding the survey, except for the FFS rate, which is for the 4-year period before the survey. Figure 4.4 Trends in Age-Specific Fertility Rates 1984 FFS, 1992 MDHS, 2000 MDHS, and 2004 MDHS 0 50 100 150 200 250 300 350 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Bi rth s pe r 1 ,0 00 w om en 1984 FFS 1992 MDHS 2000 MDHS 2004 MDHS Fertility | 61 Table 4.4 Trends in fertility by background characteristics Total fertility rate for the three years preceding the survey, by back- ground characteristics, Malawi 1992, 2000, and 2004 Background characteristic 1992 MDHS 2000 MDHS 2004 MDHS Residence Urban 5.5 4.5 4.2 Rural 6.9 6.7 6.4 Region Northern 6.7 6.2 5.6 Central 7.4 6.8 6.4 Southern 6.2 6.0 5.8 District Blantyre na 4.3 4.8 Kasungu na 7.0 7.0 Machinga na 7.0 7.0 Mangochi na 7.4 7.2 Mzimba na 6.7 5.5 Salima na 6.7 6.8 Thyolo na 5.3 5.7 Zomba na 6.2 5.3 Lilongwe na 6.5 5.7 Mulanje na 5.5 5.6 Other districts na 6.8 6.3 Education No education 7.2 7.3 6.9 Primary 1-4 6.7 6.7 6.6 Primary 5-8 6.2 6.0 5.8 Secondary+ 4.4 3.0 3.8 Total 6.7 6.3 6.0 na = Not applicable Further information on fertility trends comes from the analysis of the fertility of age cohorts of women (i.e., by examining trends within age groups). Table 4.5 shows age-specific fertility rates (ASFRs) for successive five-year periods preceding the survey. Examining the 10-14 year, 5-9 year and 0-4 year periods preceding the survey, a decline is seen in the ASFRs for each period. Since women age 50 and above were not interviewed in the survey, the rates are truncated as the number of years before the survey increases. Table 4.5 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Ma- lawi 2004 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 160 164 181 176 20-24 291 296 320 292 25-29 252 274 302 296 30-34 222 226 275 [261] 35-39 162 169 [239] - 40-44 88 [129] - - 45-49 [38] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 62 | Fertility 4.2 CHILDREN EVER BORN AND CHILDREN SURVIVING Table 4.6 presents the distribution of all women and currently married women by the number of children ever born (CEB). The table also shows the mean number of children ever born and the mean number of living children for each five-year age group. The distribution of children ever born is the outcome of lifetime fertility. Information on lifetime fertility is useful for examining the momentum of childbearing and for estimating levels of primary infertility. The number of children ever born (CEB) or current parity is based on a cross-sectional view at the time of survey. It does not refer directly to the timing of fertility of the individual respondent but is a measure of her completed fertility. Table 4.6 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 2004 Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number of women Mean num- ber of CEB Mean num- ber of living chil- dren ALL WOMEN 15-19 74.7 21.3 3.7 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,392 0.30 0.26 20-24 15.8 32.1 33.0 15.4 2.9 0.8 0.0 0.0 0.0 0.0 0.0 100.0 2,870 1.60 1.40 25-29 4.9 9.4 21.1 29.3 22.6 9.0 2.9 0.6 0.2 0.0 0.0 100.0 2,157 2.99 2.54 30-34 2.6 5.0 7.1 13.3 23.9 22.9 15.6 6.3 2.0 1.1 0.1 100.0 1,478 4.35 3.60 35-39 2.2 2.9 5.0 7.2 12.3 15.9 18.6 14.9 11.2 6.5 3.1 100.0 1,117 5.60 4.55 40-44 1.3 2.9 4.3 6.3 8.4 12.6 14.1 14.2 15.6 10.1 10.2 100.0 935 6.33 5.01 45-49 2.1 2.7 5.4 5.3 6.6 8.0 13.9 11.3 12.4 12.1 20.1 100.0 749 6.83 5.19 Total 20.8 15.3 14.8 12.4 10.2 7.8 6.3 4.2 3.4 2.3 2.4 100.0 11,698 3.03 2.49 CURRENTLY MARRIED WOMEN 15-19 39.7 49.7 9.9 0.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 788 0.72 0.63 20-24 8.0 33.6 36.6 17.7 3.2 1.0 0.0 0.0 0.0 0.0 0.0 100.0 2,283 1.78 1.55 25-29 2.7 8.3 20.9 30.4 23.9 9.7 3.1 0.7 0.3 0.0 0.0 100.0 1,814 3.11 2.67 30-34 1.9 4.0 6.6 12.5 24.2 22.9 16.9 7.1 2.4 1.3 0.1 100.0 1,225 4.50 3.76 35-39 1.9 2.6 4.5 5.8 11.9 16.5 19.3 16.5 11.0 7.0 3.1 100.0 903 5.73 4.66 40-44 1.1 3.0 3.6 4.9 7.6 12.6 13.3 14.6 17.1 11.0 11.3 100.0 754 6.54 5.18 45-49 1.6 1.1 4.2 4.9 6.2 8.5 14.1 10.3 11.5 12.5 25.1 100.0 545 7.23 5.49 Total 7.2 17.0 17.6 14.8 12.1 9.3 7.4 5.0 3.9 2.8 3.0 100.0 8,312 3.59 2.96 Table 4.6 shows that one out of every five women does not have any children, while among married women the proportion is only 7 percent. While three in four women age 15-19 have no children, six in ten married women age 15-19 have started childbearing. Since voluntary childlessness is rare in Malawi, it is assumed that married women with no births by the time they reach the end of their reproductive years are infertile, or their husbands are. The percentage of women who are childless at the end of the reproductive period is an indirect measure of primary infertility (the proportion of women who are unable to bear children at all). The data show that less than two percent of married women remain childless by their 40s. Table 4.6 also shows that on average, women have given birth to more than one child by their early 20s, about 3 children by their late 20s, and about 7 children by the end of their reproductive period. Overall, the mean number of children ever born is 3.0 children for all women Fertility | 63 and 3.6 children for currently married women. There is a slight difference in the mean number of children ever born between all women and currently married women at all ages. In addition to giving a description of average family size, information on CEB and number of children surviving also gives some indication on the extent of childhood mortality. The 2004 MDHS results indicate that on average, all women have over two surviving children, and currently married women have three children. The difference between the mean number of CEB and mean number of children still living for the two groups of women increases with a woman’s age. By the end of the reproductive period, women have lost, on average, almost two of the children they had given birth to. 4.3 BIRTH INTERVALS The study of birth intervals is important in understanding the health status of young children. That women with closely spaced births have higher fertility than women with longer birth intervals has been observed in many countries. It has also been shown that short birth intervals, particularly those less than 24 months, elevate risks of death for both children on either side of the interval; maternal health is also jeopardised when births are closely spaced. The study of birth intervals is done using two measures, namely median birth interval and proportion of non–first births that are born with an interval of 24 months or more after the previous birth. Table 4.7 shows the percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, according to selected demographic and socioeconomic variables. In general, the median length of birth interval in Malawi is 36 months. While 25 percent of births were born four or more years after a previous birth, 15 percent of births occur within two years of a previous birth, and five percent of births occur less than 18 months since the previous birth. 64 | Fertility Table 4.7 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, according to background characteristics, Malawi 2004 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48+ Total Number of non-first births Median number of months since preceding birth Age 15-19 11.4 21.8 41.3 24.9 0.6 100.0 103 27.2 20-29 5.6 11.4 40.5 25.9 16.6 100.0 4,543 33.9 30-39 4.1 8.0 30.4 24.9 32.6 100.0 2,789 38.6 40-49 3.8 7.5 20.5 22.8 45.4 100.0 785 44.9 Birth order 2-3 5.0 10.9 39.4 25.6 19.2 100.0 3,922 34.4 4-6 4.1 8.6 33.2 25.5 28.5 100.0 3,014 37.1 7+ 7.2 10.6 26.7 23.7 31.7 100.0 1,283 37.8 Sex of preceding birth Male 5.7 9.4 34.9 25.2 24.9 100.0 4,074 36.0 Female 4.4 10.6 35.4 25.4 24.3 100.0 4,145 35.9 Survival of preceding birth Living 2.9 9.0 36.1 26.4 25.6 100.0 6,972 36.5 Dead 17.0 15.4 29.7 19.2 18.6 100.0 1,247 30.5 Residence Urban 4.4 9.5 33.4 23.6 29.0 100.0 946 36.9 Rural 5.1 10.1 35.4 25.5 24.0 100.0 7,273 35.8 Region Northern 3.1 7.0 37.3 28.7 23.9 100.0 1,015 36.5 Central 5.7 11.5 35.8 23.9 23.1 100.0 3,460 34.9 Southern 5.0 9.4 34.0 25.6 26.1 100.0 3,744 36.4 District Blantyre 5.6 8.5 28.2 25.9 31.8 100.0 537 38.8 Kasungu 4.8 11.5 36.6 27.7 19.3 100.0 428 35.3 Machinga 5.1 12.0 36.1 23.4 23.4 100.0 358 34.6 Mangochi 5.0 10.1 36.9 23.3 24.6 100.0 499 35.4 Mzimba 3.5 5.5 37.5 28.5 25.0 100.0 519 36.7 Salima 6.4 10.3 34.9 24.2 24.2 100.0 247 35.2 Thyolo 3.3 11.6 34.7 25.7 24.7 100.0 452 36.1 Zomba 5.7 7.9 32.6 27.7 26.0 100.0 397 37.0 Lilongwe 5.6 12.8 35.3 21.8 24.4 100.0 1,083 34.7 Mulanje 4.7 10.8 31.2 26.5 26.8 100.0 340 37.2 Other districts 5.0 9.5 36.1 25.6 23.7 100.0 3,359 35.8 Education No education 4.9 9.7 33.9 23.8 27.6 100.0 2,617 36.5 Primary 1-4 5.3 11.2 35.5 26.4 21.6 100.0 2,428 35.3 Primary 5-8 4.6 9.6 36.7 25.8 23.2 100.0 2,602 35.7 Secondary or higher 5.9 8.2 31.8 25.0 29.1 100.0 571 37.1 Wealth quintile Lowest 5.4 10.4 33.6 24.5 26.1 100.0 1,659 36.2 Second 6.3 10.2 35.5 24.7 23.2 100.0 1,852 35.2 Middle 4.5 9.5 39.2 25.1 21.8 100.0 1,891 35.1 Fourth 4.6 10.6 35.7 27.8 21.3 100.0 1,632 35.7 Highest 3.9 9.3 29.5 24.1 33.3 100.0 1,186 38.6 Total 5.0 10.0 35.1 25.3 24.6 100.0 8,219 35.9 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. In general, the results indicate that younger women (mostly adolescents) have shorter birth intervals than older women in Malawi. As age increases, the median length of birth interval also Fertility | 65 increases. There are no strong differentials in median birth interval by region. District variation ranges from 34.6 months in Machinga to 38.8 months in Blantyre. 4.4 AGE OF MOTHERS AT FIRST BIRTH The onset of childbearing is an important fertility indicator. Women who marry early are typically exposed to pregnancy for a longer period, and early childbearing often takes place, the combination of which generally leads to a large family size. The age at which childbearing commences is an important determinant of the overall level of fertility as well as the health and welfare of the mother and the child. In some societies, postponement of first births due to an increase in age at marriage has contributed to overall fertility decline. However, in Malawi, it is not uncommon for women to have children before getting married. Table 4.8 shows 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 initiation of childbearing has not changed much over time. Data from the 2000 MDHS show almost the same pattern, suggesting that there has been no significant change in age at first birth in Malawi in the recent past years. Table 4.8 shows that the median age at first birth has not changed in the past decades. The higher median age at first birth for the oldest cohort (19.4 years) may be affected by recall lapse. The results indicate that women are delaying having their first child. While 8 percent of women age 45-49 had their first child by age 15, less than 2 percent of women age 15-19 did so. The percentage of women who had their first child by age 18 years is highest among women age 35- 39 (42 percent) and lowest among women age 45-49 (33 percent). Table 4.8 Age at first birth Among all women, percentage who gave birth by exact age, and median age at first birth, by current age, Malawi 2004 Percentage who gave birth by exact age Current age 15 18 20 22 25 Percentage who have never given birth Number of women Median age at first birth 15-19 1.5 na na na na 74.7 2,392 a 20-24 4.6 34.1 63.2 na na 15.8 2,870 19.0 25-29 5.6 33.8 64.2 82.8 92.7 4.9 2,157 19.0 30-34 7.9 37.8 64.8 81.9 92.7 2.6 1,478 18.9 35-39 11.4 41.6 63.6 80.0 91.1 2.2 1,117 18.8 40-44 8.4 38.2 64.2 80.9 92.4 1.3 935 18.9 45-49 8.0 33.1 55.2 73.2 84.9 2.1 749 19.4 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group 4.5 MEDIAN AGE AT FIRST BIRTH BY BACKGROUND CHARACTERISTICS Age at first birth varies by demographic and socioeconomic characteristics of the woman. Table 4.9 shows the median age at first birth among women age 20-49 years and 25-49 years, by current age and background characteristics. The median age at first birth for women age 20-49 for Malawi is 19.0 years. Urban women have their first birth half a year later than their rural counterparts. Across regions, first births in the Central Region occur later than in the Southern and 66 | Fertility Northern Regions (19.4 years compared to 19.0 years or younger). For the oversampled districts, the median age at first birth ranges from 18.4 years in Mulanje and Thyolo to 19.6 years in Lilongwe. Age at first birth increases with education. The data also show that women who belong to the wealthiest quintile have their first child about a year later than women in most other wealth quintiles. Table 4.9 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 2004 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Residence Urban 20.0 19.6 18.8 19.1 18.7 19.3 19.5 19.2 Rural 18.9 18.9 18.9 18.7 18.9 19.5 18.9 18.9 Region Northern 18.7 19.0 19.0 19.4 19.4 19.0 19.0 19.2 Central 19.6 19.3 19.0 19.2 19.1 19.9 19.4 19.3 Southern 18.7 18.7 18.8 18.0 18.5 19.1 18.7 18.7 District Blantyre 18.8 18.8 18.9 18.3 17.8 18.9 18.7 18.6 Kasungu 19.1 18.8 18.6 19.2 19.0 19.1 18.9 18.9 Machinga 18.3 18.3 19.0 18.8 18.5 20.2 18.6 18.7 Mangochi 18.2 18.3 18.4 18.6 18.6 20.5 18.5 18.6 Mzimba 18.9 19.3 19.2 19.6 19.4 20.0 19.2 19.4 Salima 19.3 19.0 18.6 20.0 19.8 19.5 19.2 19.1 Thyolo 18.0 18.5 19.2 18.6 19.0 17.9 18.4 18.7 Zomba 19.0 19.1 18.6 17.9 18.2 18.8 18.8 18.6 Lilongwe a 19.5 18.9 19.4 18.8 20.5 19.6 19.4 Mulanje 18.4 18.4 18.7 17.9 18.0 19.1 18.4 18.4 Other districts 19.2 19.1 19.1 18.5 19.1 19.4 19.1 19.0 Education No education 17.8 18.2 18.5 18.0 18.8 19.7 18.4 18.5 Primary 1-4 18.5 18.9 19.1 18.2 18.3 19.4 18.7 18.8 Primary 5-8 18.8 18.9 18.9 19.0 19.0 19.0 18.9 18.9 Secondary+ a 21.6 22.2 21.4 21.7 19.6 a 21.6 Wealth quintile Lowest 18.8 19.0 18.8 17.9 18.7 20.1 18.8 18.8 Second 18.8 19.0 18.3 18.7 19.0 19.7 18.9 18.9 Middle 18.7 18.5 18.8 18.6 18.6 19.1 18.7 18.7 Fourth 19.1 19.0 19.3 18.4 19.1 19.2 19.0 19.0 Highest a 19.8 19.3 19.6 18.9 19.3 19.7 19.5 Total 19.0 19.0 18.9 18.8 18.9 19.4 19.0 19.0 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 4.6 ADOLESCENT FERTILITY Adolescent childbearing has potentially negative demographic and social consequences. Children born to very young mothers face an increased risk of illness and death. This may be due to the fact that teenage mothers are more likely to suffer from pregnancy and delivery complications than older mothers, resulting in higher morbidity and mortality for both themselves and their Fertility | 67 children. In addition, early childbearing may foreclose a teenager’s ability to pursue educational or job opportunities. Table 4.10 shows the percentage of women age 15-19 who are mothers or pregnant with their first child, by background characteristics. One in three adolescents has begun childbearing; one in four has already had a child and a further 9 percent are currently pregnant. There is a substantial difference in childbearing among teenagers who live in urban and rural areas (25 percent compared with 36 percent, respectively). At the regional level, the proportion of teenagers who have started childbearing is highest in the Southern Region (40 percent) compared with the Northern Region (33 percent) and the Central Region (28 percent). Among the oversampled districts, Mangochi has the highest proportion of teenagers who have started childbearing (48 percent), while Lilongwe District has the lowest (25 percent). Table 4.10 Adolescent pregnancy and motherhood Percentage of women age 15-19 who are mothers or pregnant with their first child, by back- ground characteristics, Malawi 2004 Percentage who are: Background characteristic Mothers Pregnant with first child Percentage who have begun childbearing Number of women Age 15 1.4 1.8 3.2 445 16 6.0 5.5 11.5 467 17 21.9 8.8 30.7 427 18 37.8 12.1 49.9 554 19 53.9 14.0 67.9 499 Residence Urban 18.2 6.6 24.8 455 Rural 27.0 9.2 36.2 1,937 Region Northern 24.9 7.7 32.7 371 Central 20.1 7.9 28.1 972 Southern 30.3 9.8 40.1 1,049 District Blantyre 27.1 9.9 37.0 187 Kasungu 19.3 8.7 28.0 100 Machinga 29.1 11.0 40.1 83 Mangochi 43.3 4.7 48.0 114 Mzimba 24.1 9.4 33.5 182 Salima 20.4 11.6 32.0 51 Thyolo 29.8 14.7 44.4 120 Zomba 29.2 9.2 38.4 133 Lilongwe 18.3 6.3 24.6 334 Mulanje 28.6 14.7 43.3 96 Other districts 24.7 8.0 32.7 993 Education No education 48.8 14.3 63.1 132 Primary 1-4 32.2 9.6 41.8 580 Primary 5-8 24.4 8.9 33.2 1,196 Secondary+ 13.2 5.7 18.9 484 Wealth quintile Lowest 32.6 10.7 43.2 395 Second 36.1 10.7 46.9 412 Middle 25.4 10.4 35.8 444 Fourth 23.6 8.4 32.0 511 Highest 15.1 5.3 20.4 629 Total 25.3 8.7 34.1 2,392 68 | Fertility The results further show that there is a negative relationship between adolescent childbearing and both educational level and wealth status. For example, while 63 percent of adolescents with no education have begun childbearing, the proportion for those with at least secondary education is just 19 percent. Adolescents in the lowest wealth quintile are also more than twice as likely to have begun childbearing compared with those in the wealthiest quintile. Fertility Regulation | 69 FERTILITY REGULATION 5 Jane Namasasu Each year, over 210 million women worldwide become pregnant, and 30 million (15 percent) develop complications, which lead to death in over half a million women. It is estimated that between 10 percent and 20 percent of these pregnancies were unwanted at the time of conception. Thus, up to 100,000 maternal deaths could be avoided if women who did not want children practiced effective fertility regulation. When we take into consideration that for every woman who dies a maternal death, about 30 more suffer from serious conditions that can affect them for the rest of their lives, it is estimated that preventing unwanted pregnancies would avert a total of 4.6 million disability-adjusted life years (DALYs) worldwide (UNFPA, 2001). Thus, effective fertility regulation actually has the potential to contribute to better maternal health beyond simply reducing the proportion of births that are unwanted. In fact, increased use of contraception does have an obvious and direct effect on the number of maternal deaths, simply by reducing the number of pregnancies. A recent study conducted in Malawi indicated that the most frequent direct obstetric complications treated in 48 hospitals were obstructed and prolonged labour (40 percent), followed by complications of abortion (30 percent). The high proportion of abortion complications did not differentiate between complicated and uncomplicated cases of abortion. Nor did it do so with respect to spontaneous or induced abortion (Ministry of Health, 2005a). Increased use of fertility regulation to avoid unwanted pregnancies will lead to a decrease in the number of induced abortions in the country. This chapter presents the findings of the 2004 MDHS on contraceptive knowledge, contraceptive use, attitudes, and reproductive behaviour and intentions. The main focus is on women. However, some results are included for men. In order to evaluate trends in Malawi over the years, comparisons are made where feasible. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Knowledge about fertility control is an important step toward getting access to and using a suitable contraceptive method in a timely and effective manner. Information on knowledge of contraception was collected in two ways. First, respondents were asked to name ways or methods couples can use to prevent or delay pregnancy. When a respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent knew it. Using this approach, information was collected for nine modern family planning methods: female and male sterilisation, the pill, the IUD, injectables, implants, male and female condoms, and emergency contraception. Information was also collected on three traditional methods: the lactational amenorrhoea method (LAM), rhythm or natural family planning, and withdrawal. Provision was also made in the questionnaire to record any other methods named spontaneously by respondents. Both prompted and unprompted knowledge were combined in this survey. In Table 5.1.1, knowledge of contraceptive methods is presented for all women, for currently married women, for sexually active unmarried women, for sexually inactive unmarried women, and for women with no sexual experience, by specific method. The 2004 MDHS finds that 97 percent of 70 | Fertility Regulation all women know at least one contraceptive method. Knowledge of a modern method of family planning is highest for currently married women at 99 percent. There is no difference in level of knowledge of a modern contraceptive method among unmarried women with sexual experience, whether they are sexually active or not. Unmarried women with no sexual experience have much lower levels of knowledge of any contraceptive method than currently married women and unmarried women with sexual experience. Table 5.1.1 Knowledge of contraceptive method: women Percentage of all women, of currently married women, of sexually active unmarried women, of sexually inactive unmarried women, and of women with no sexual experience who know any contraceptive method, by specific method, Malawi 2004 Unmarried women who ever had sex Method All women Currently married women Sexually active1 Not sexually active2 Unmarried women who never had sex Any method 96.7 98.6 97.9 97.9 82.7 Any modern method 96.6 98.5 97.9 97.7 82.7 Female sterilisation 82.7 87.1 79.9 84.1 53.3 Male sterilisation 64.0 68.7 65.3 63.4 35.1 Pill 90.1 93.9 91.7 91.8 63.0 IUD 67.7 72.6 71.1 67.9 35.2 Injectables 93.2 96.9 94.2 93.9 68.6 Implants 62.4 67.7 64.3 62.7 27.7 Male condom 89.9 92.3 90.7 91.1 72.3 Female condom 53.6 55.7 59.7 56.6 34.5 Emergency contraception 26.3 28.3 29.2 26.5 12.6 Any traditional method 64.2 70.5 64.4 63.4 24.4 Rhythm/periodic abstinence 37.3 40.1 44.1 37.6 17.1 Withdrawal 46.9 52.4 48.8 45.0 14.2 Other traditional methods 29.4 33.1 29.0 28.8 6.0 Mean number of methods known 7.8 8.3 8.1 7.9 4.6 Number of women 11,698 8,312 260 1,827 1,301 1 Had sexual intercourse in the month preceding the survey 2 Did not have sexual intercourse in the month preceding the survey The most widely known modern methods of contraception among all women are: injectables (93 percent), pill (90 percent), male condom (90 percent), and female sterilisation (83 percent). Among women with no sexual experience, the male condom is the most widely known contraceptive method (72 percent). These findings are similar to those of the 2000 MDHS. Table 5.1.2 shows that almost all currently married men know about fertility regulation. Even among men with no sexual experience, knowledge of any method of contraception is high (89 percent). The most widely known modern methods of contraception among men are: the male condom (96 percent of all men), injectables (85 percent), the pill (82 percent), female sterilisation (79 percent), and male sterilisation (72 percent). It is interesting to note that knowledge of female sterilisation is higher among men than knowledge of male sterilisation. This finding is similar to that of the 2000 MDHS. Fertility Regulation | 71 Table 5.1.2 Knowledge of contraceptive method: men Percentage of all men, of currently married men, of sexually active unmarried men, of sexually inactive unmarried men, and of men with no sexual experience who know any contraceptive method, by specific method, Malawi 2004 Unmarried men who ever had sex Method All men Currently married men Sexually active1 Not sexually active2 Unmarried men who never had sex Any method 97.4 98.8 97.6 98.3 89.1 Any modern method 97.4 98.8 97.6 98.3 89.1 Female sterilisation 79.3 85.9 70.9 77.0 53.9 Male sterilisation 71.5 77.4 60.6 71.8 48.1 Pill 82.1 89.5 76.1 79.0 51.5 IUD 55.9 63.5 44.7 51.9 29.4 Injectables 85.4 92.5 79.4 81.1 58.0 Implants 42.2 48.3 35.9 35.6 23.0 Male condom 95.8 97.4 95.0 97.3 85.8 Female condom 56.4 59.6 56.1 58.7 37.0 Emergency contraception 21.6 23.6 19.4 23.2 10.8 Any traditional method 55.8 64.9 48.6 47.7 23.7 Rhythm/periodic abstinence 39.8 46.3 32.5 32.9 19.7 Withdrawal 45.6 53.9 42.0 37.7 15.5 Mean number of methods known 6.8 7.4 6.1 6.5 4.3 Number of men 3,261 2,079 278 506 399 1 Had sexual intercourse in the month preceding the survey 2 Did not have sexual intercourse in the month preceding the survey Table 5.2 shows that knowledge of at least one modern method of family planning is universally high (95 percent or more) among all subgroups of currently married women in Malawi. Young women age 15-19 have the lowest awareness of methods (95 percent). Married men with no education have marginally lower levels of knowledge of family planning methods than men with education (97 and 99-100 percent, respectively). Married men from Mangochi District are the least likely to know a modern method of fertility regulation (90 percent), while all men from Mzimba, Thyolo, and Zomba know of at least one modern method. 72 | Fertility Regulation Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and men who know at least one contra- ceptive method and who know at least one modern method by background char- acteristics, Malawi 2004 Women Men Background characteristic Knows any method Knows any modern method1 Number of women Knows any method Knows any modern method1 Number of men Age 15-19 95.3 95.3 788 * * 15 20-24 98.5 98.5 2,283 98.6 98.6 260 25-29 99.2 99.2 1,814 98.6 98.6 493 30-34 99.2 99.2 1,225 98.8 98.7 445 35-39 99.6 99.4 903 98.3 98.3 280 40-44 98.8 98.8 754 99.8 99.8 271 45-49 98.5 98.3 545 98.8 98.8 173 50-54 na na 0 99.5 99.5 143 Residence Urban 99.3 99.3 1,337 97.7 97.7 355 Rural 98.5 98.4 6,975 99.0 99.0 1,724 Region Northern 99.6 99.6 1,087 100.0 100.0 243 Central 97.9 97.9 3,346 99.4 99.4 885 Southern 98.9 98.8 3,880 98.0 98.0 951 District Blantyre 98.0 98.0 643 99.3 99.3 199 Kasungu 98.0 97.8 385 99.7 99.7 103 Machinga 99.6 99.6 317 98.7 98.7 70 Mangochi 97.1 97.0 437 91.0 90.4 106 Mzimba 99.4 99.4 570 100.0 100.0 129 Salima 98.4 98.1 230 99.3 99.3 58 Thyolo 99.9 99.7 433 100.0 100.0 116 Zomba 99.7 99.7 436 100.0 100.0 100 Lilongwe 97.1 97.1 1,175 99.4 99.4 322 Mulanje 99.3 99.0 359 98.7 98.7 74 Other districts 98.9 98.9 3,326 98.9 98.9 802 Education No education 97.8 97.7 2,229 96.5 96.5 329 Primary 1-4 98.3 98.2 2,291 98.8 98.7 536 Primary 5-8 99.3 99.3 2,850 99.3 99.3 773 Secondary+ 99.3 99.3 940 99.8 99.8 440 Wealth quintile Lowest 97.8 97.8 1,256 97.7 97.7 271 Second 98.5 98.3 1,787 98.5 98.4 434 Middle 98.2 98.1 1,851 99.2 99.2 509 Fourth 98.7 98.7 1,779 99.1 99.1 465 Highest 99.8 99.8 1,640 99.2 99.2 400 Total 98.6 98.6 8,312 98.8 98.8 2,079 Note: An asterisk indicates that an estimate is based on fewer than 25 un- weighted cases and has been suppressed. 1 Female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, and emergency contraception. na = Not applicable Fertility Regulation | 73 5.2 EVER USE OF CONTRACEPTION All women interviewed who said they had heard of a method of family planning were asked whether they had ever used that method. Table 5.3.1 shows the percentage of all women, currently married women, and sexually active women who have ever used a method of contraception. Overall, 51 percent of women report having used a method at some time and 46 percent report having ever used a modern method. Among currently married women, 60 percent have used a method in the past and 55 percent have ever used a modern method. The most widely ever used modern methods among currently married women are: injectables (41 percent), the pill (12 percent), male condom (9 percent), and female sterilisation (6 percent). Half of women who are sexually active but unmarried have used a family planning method at some time. Most of these women used a modern method (47 percent). The most frequently used modern methods among sexually active unmarried women are injectables (27 percent), the male condom (22 percent) and the pill (7 percent). Table 5.3.1 Ever use of contraception: women Percentage of all women, of currently married women, and of sexually active unmarried women who have ever used any contraceptive method, by specific method and age, Malawi 2004 Modern method Traditional method Age Any method Any modern method Female sterili- sation Male sterili- sation Pill IUD Inject- ables Implants Male con- dom Female con- dom Dia- phragm Emer- gency contra- ception Any tradi- tional method Rhythm/ periodic absti- nence With- drawal Other traditional methods Number of women ALL WOMEN 15-19 15.9 14.6 0.0 0.0 1.4 0.0 6.6 0.1 7.7 0.0 0.7 0.0 3.3 0.7 2.2 0.7 2,392 20-24 50.7 46.8 0.1 0.0 6.1 0.1 35.1 0.8 12.5 0.2 2.1 0.3 10.4 2.1 6.8 2.8 2,870 25-29 64.8 60.0 1.3 0.2 13.3 0.7 49.4 1.0 10.7 0.0 3.1 0.4 14.7 3.1 8.4 5.0 2,157 30-34 65.9 62.0 6.3 0.3 14.8 0.8 50.5 1.1 6.6 0.1 3.5 0.3 15.1 3.5 7.7 6.3 1,478 35-39 65.7 59.8 12.9 0.1 16.2 1.0 44.7 0.3 6.4 0.2 3.2 0.5 17.1 3.2 7.8 8.2 1,117 40-44 64.0 55.5 17.7 0.5 16.1 1.9 33.8 1.2 4.4 0.2 3.6 0.3 21.1 3.6 10.4 10.5 935 45-49 49.1 43.1 17.0 0.5 11.6 1.9 23.6 0.1 2.5 0.0 2.8 0.0 16.0 2.8 6.3 9.2 749 Total 50.5 46.3 4.8 0.2 9.7 0.6 33.9 0.7 8.6 0.1 2.4 0.3 12.2 2.4 6.6 4.7 11,698 CURRENTLY MARRIED WOMEN 15-19 32.9 29.3 0.0 0.1 3.7 0.1 16.7 0.2 11.2 0.0 0.6 0.1 8.2 0.6 5.9 2.1 788 20-24 55.9 51.4 0.1 0.0 7.0 0.2 39.7 0.8 12.9 0.3 2.3 0.3 12.0 2.3 8.1 3.2 2,283 25-29 68.2 63.0 1.3 0.1 14.3 0.7 51.6 1.2 11.0 0.0 3.5 0.5 16.2 3.5 9.4 5.4 1,814 30-34 68.0 63.6 7.0 0.3 15.3 0.6 52.0 1.1 6.8 0.2 3.6 0.2 16.1 3.6 8.6 6.7 1,225 35-39 68.2 62.0 14.0 0.1 17.4 1.1 46.3 0.4 7.1 0.1 3.1 0.6 18.5 3.1 8.6 8.9 903 40-44 67.5 58.3 19.1 0.5 17.2 1.8 35.0 1.3 4.5 0.1 3.7 0.3 23.5 3.7 12.1 11.7 754 45-49 51.4 45.6 19.1 0.7 11.7 2.4 26.2 0.1 2.9 0.0 2.5 0.0 16.1 2.5 6.4 9.8 545 Total 60.3 55.0 5.8 0.2 11.9 0.7 41.3 0.8 9.4 0.1 2.8 0.3 15.2 2.8 8.5 5.9 8,312 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-19 39.9 39.2 0.0 0.0 0.0 0.0 9.2 0.0 30.9 0.0 2.8 0.0 4.2 2.8 1.4 0.0 87 20-24 48.5 47.0 0.0 0.0 7.0 0.0 26.9 0.0 22.6 0.0 0.8 0.8 3.7 0.8 0.8 2.1 76 25+ 59.8 54.6 3.1 0.0 14.1 1.4 43.0 0.0 14.0 0.0 2.3 1.2 11.0 2.3 2.8 7.1 97 Total 49.8 47.2 1.2 0.0 7.3 0.5 27.0 0.0 22.2 0.0 2.0 0.7 6.6 2.0 1.7 3.3 260 1 Women who had sexual intercourse in the month preceding the survey In the 2004 MDHS, male respondents were asked about ever use of male-oriented methods. Table 5.3.2 shows that 50 percent of men report having used a method at some time and 40 percent report having ever used a modern method. Currently married men are more likely than other men to have ever used a method; 57 percent of currently married men have used a method in the past; and 42 percent have ever used a modern method. Among all men and currently married men, the male condom is the main contraceptive method ever used (40 and 41 percent, respectively). Use of male 74 | Fertility Regulation sterilisation is extremely low (1 percent). Among sexually active unmarried men, the male condom is virtually the only modern method of family planning ever used (65 percent). Table 5.3.2 Ever use of contraception: men Percentage of all men, of currently married men, and of sexually active unmarried men who have ever used any contraceptive method, by specific method and age, Malawi 2004 Modern method Traditional method Age Any method Any modern method Male sterilisation Male condom Any traditional method Rhythm/ periodic abstinence Withdrawal Number of men ALL MEN 15-19 24.3 23.1 0.8 22.5 6.2 2.8 4.4 650 20-24 57.4 53.2 0.4 53.2 17.1 10.3 10.5 587 25-29 60.0 48.9 0.5 48.8 27.5 14.7 18.0 634 30-34 67.2 52.5 0.7 52.0 34.8 20.8 23.6 485 35-39 52.1 35.6 1.5 35.3 34.6 22.2 22.2 294 40-44 48.9 31.6 0.5 31.6 30.6 15.1 26.3 282 45-49 49.6 29.9 3.0 27.7 31.3 16.6 20.5 182 50-54 38.4 17.4 0.5 16.9 30.1 19.7 17.5 148 Total 50.3 39.9 0.8 39.5 23.7 13.5 16.0 3,261 CURRENTLY MARRIED MEN 15-19 40.6 29.7 0.0 29.7 10.9 10.9 10.9 15 20-24 57.4 49.8 0.0 49.8 25.0 15.7 16.3 260 25-29 61.1 47.8 0.4 47.7 32.1 17.1 21.2 493 30-34 67.6 51.9 0.8 51.4 36.2 21.5 24.8 445 35-39 52.7 35.4 1.6 35.2 34.8 22.3 22.2 280 40-44 49.3 31.7 0.6 31.7 31.2 15.7 26.6 271 45-49 49.7 31.1 3.1 28.8 30.7 15.9 20.4 173 50-54 39.1 18.0 0.5 17.5 30.5 19.9 17.9 143 Total 56.8 41.6 0.8 41.2 32.0 18.4 21.8 2,079 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 54.3 51.6 1.0 51.1 18.7 6.4 16.6 119 20-24 84.4 83.1 0.0 83.1 17.4 11.3 8.6 102 25+ 70.0 63.0 0.0 63.0 25.7 14.3 15.5 57 Total 68.6 65.5 0.4 65.3 19.6 9.8 13.4 278 1 Men who had sexual intercourse in the month preceding the survey 5.3 CURRENT USE OF CONTRACEPTIVE METHODS In the 2004 MDHS, women were asked about the contraceptive method they were currently using. Table 5.4 shows the percent distribution of women who are currently using specific family planning methods by age. The survey shows that 26 percent of all women and 33 percent of currently married women are using a method of family planning. Twenty-eight percent of all currently married women are using a modern method of contraception. This is a marginal increase over the 26 percent reported in the 2000 MDHS. Current use of modern contraceptive methods among currently married women increases with age, from 17 percent for women age 15-19 to 33 percent for married women age 40-44 years, and then drops to 27 percent for those age 45-49. Injectables, female sterilisation, and the pill are the most commonly used contraceptive methods, used by 18, 6, and 2 percent of married women, Fertility Regulation | 75 respectively. The choice of methods among sexually active unmarried women is different; these women prefer to use injectables (11 percent) and male condoms (10 percent). Table 5.4 Current use of contraception Percent distribution of all women, of currently married women, and of sexually active unmarried women by contraceptive method currently used, according to age, Malawi 2004 Modern method Traditional method Age Any method Any modern method Female sterili- sation Pill IUD Inject- ables Im- plants Male con- dom Any tradi- tional method Rhythm/ periodic absti- nence With- drawal Other tradi- tional meth- ods Not cur- rently using Total Number of women ALL WOMEN 15-19 8.5 7.6 0.0 0.5 0.0 4.6 0.0 2.6 0.8 0.1 0.4 0.3 91.5 100.0 2,392 20-24 25.6 22.5 0.1 1.4 0.1 17.5 0.5 3.0 3.1 0.4 1.8 0.9 74.4 100.0 2,870 25-29 32.0 27.8 1.3 2.3 0.1 21.9 0.6 1.6 4.1 0.7 2.2 1.2 68.0 100.0 2,157 30-34 32.1 28.6 6.3 2.3 0.1 18.4 0.8 0.7 3.5 0.5 1.7 1.3 67.9 100.0 1,478 35-39 32.8 28.6 12.9 2.0 0.1 12.9 0.1 0.5 4.1 0.3 1.7 2.1 67.2 100.0 1,117 40-44 35.0 29.7 17.7 0.9 0.1 10.2 0.3 0.5 5.2 0.3 1.9 3.1 65.0 100.0 935 45-49 28.2 22.9 17.0 1.1 0.1 4.2 0.0 0.2 5.3 0.7 1.0 3.6 71.8 100.0 749 Total 25.7 22.4 4.8 1.5 0.1 13.9 0.4 1.7 3.3 0.4 1.5 1.3 74.3 100.0 11,698 CURRENTLY MARRIED WOMEN 15-19 18.9 16.6 0.0 1.3 0.0 11.8 0.1 3.4 2.3 0.0 1.4 1.0 81.1 100.0 788 20-24 29.2 25.4 0.1 1.5 0.1 20.2 0.4 3.0 3.7 0.5 2.2 1.1 70.8 100.0 2,283 25-29 35.3 30.8 1.3 2.7 0.1 24.3 0.7 1.6 4.6 0.7 2.6 1.2 64.7 100.0 1,814 30-34 35.5 31.6 7.0 2.7 0.1 20.1 0.9 0.7 3.9 0.5 2.0 1.4 64.5 100.0 1,225 35-39 36.7 31.8 14.0 2.3 0.2 14.5 0.2 0.6 4.8 0.4 2.2 2.3 63.3 100.0 903 40-44 39.5 33.3 19.1 1.1 0.1 12.1 0.4 0.6 6.2 0.2 2.3 3.6 60.5 100.0 754 45-49 33.0 26.7 19.1 1.1 0.2 5.7 0.0 0.2 6.3 0.6 1.4 4.3 67.0 100.0 545 Total 32.5 28.1 5.8 2.0 0.1 18.0 0.5 1.8 4.3 0.5 2.1 1.7 67.5 100.0 8,312 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-19 25.0 23.5 0.0 0.0 0.0 9.2 0.0 14.3 1.5 1.5 0.0 0.0 75.0 100.0 87 20-24 28.2 27.0 0.0 4.8 0.0 10.4 0.0 11.9 1.2 0.0 0.0 1.2 71.8 100.0 76 25+ 25.9 22.9 3.1 1.8 0.0 14.1 0.0 3.9 3.0 0.0 0.0 3.0 74.1 100.0 97 Total 26.3 24.3 1.2 2.0 0.0 11.4 0.0 9.7 2.0 0.5 0.0 1.5 73.7 100.0 260 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1Women who have had sexual intercourse in the month preceding the survey As expected, female sterilisation is used more commonly by women age 35 and older, while injectables are mostly used by women at the peak of childbearing years (age 20-39) and male condoms are used by women age 15-24. 5.4 CURRENT USE OF CONTRACEPTION BY BACKGROUND CHARACTERISTICS Table 5.5 presents the percent distribution of currently married women by their current use of contraceptive methods according to background characteristics. Married women in urban areas are more likely to use modern contraceptives (35 percent) than rural women (27 percent), while rural women are more likely than urban women to use traditional methods (5 percent compared with 3 percent). While women in the Northern Region show the highest overall use of family planning methods (41 percent), a large proportion of these women use traditional methods (13 percent). In the Northern Region, married women are much more likely to use male condoms than women in other regions (7 percent compared with 1 percent or less). 76 | Fertility Regulation Table 5.5 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Malawi 2004 Modern method Traditional method Background characteristic Any method Any modern method Fe- male sterili- sation Male sterili- sation Pill IUD Inject- ables Im- plants Male con- dom Any tradi- tional method Rhythm/ periodic absti- nence With- drawal Other tradi- tional meth- ods Not cur- rently using Total Number of women Number of living children 0 1.9 1.8 0.1 0.0 0.1 0.1 0.4 0.0 1.1 0.1 0.1 0.0 0.0 98.1 100.0 773 1-2 29.5 26.2 1.0 0.0 2.2 0.1 19.8 0.4 2.8 3.3 0.4 2.0 0.9 70.5 100.0 3,327 3-4 37.8 33.0 5.7 0.0 2.5 0.1 22.2 0.9 1.6 4.9 0.5 2.8 1.6 62.2 100.0 2,319 5+ 43.7 36.5 17.0 0.1 1.8 0.1 16.8 0.2 0.4 7.1 0.6 2.6 4.0 56.3 100.0 1,893 Residence Urban 37.2 34.7 6.4 0.0 3.2 0.2 22.5 1.4 1.1 2.5 0.6 0.9 1.0 62.8 100.0 1,337 Rural 31.6 26.9 5.7 0.0 1.7 0.1 17.1 0.3 1.9 4.7 0.4 2.4 1.9 68.4 100.0 6,975 Region Northern 41.2 28.7 6.6 0.0 3.7 0.1 11.0 0.6 6.7 12.5 0.5 10.3 1.7 58.8 100.0 1,087 Central 33.2 29.8 6.8 0.0 1.9 0.1 19.0 0.6 1.4 3.3 0.4 1.6 1.3 66.8 100.0 3,346 Southern 29.4 26.5 4.8 0.0 1.6 0.1 19.0 0.3 0.7 2.9 0.5 0.4 2.0 70.6 100.0 3,880 District Blantyre 36.5 33.7 6.2 0.0 2.1 0.2 23.6 0.4 1.2 2.8 0.9 0.2 1.7 63.5 100.0 643 Kasungu 38.4 27.3 5.9 0.0 3.0 0.0 16.0 0.8 1.6 11.0 0.7 8.2 2.1 61.6 100.0 385 Machinga 28.0 23.8 3.7 0.0 0.3 0.4 17.8 0.0 1.5 4.2 0.1 0.2 3.9 72.0 100.0 317 Mangochi 20.5 17.1 2.0 0.2 2.3 0.2 11.1 0.8 0.6 3.4 0.7 0.9 1.7 79.5 100.0 437 Mzimba 39.3 27.8 6.5 0.0 2.9 0.3 10.7 0.7 6.7 11.4 0.6 10.4 0.4 60.7 100.0 570 Salima 20.7 19.6 4.2 0.0 0.9 0.4 12.4 0.6 1.1 1.2 0.3 0.4 0.5 79.3 100.0 230 Thyolo 30.5 28.2 6.1 0.0 1.3 0.0 19.7 0.0 1.1 2.3 0.6 0.0 1.7 69.5 100.0 433 Zomba 32.0 28.2 3.6 0.0 1.4 0.0 22.2 0.3 0.8 3.7 0.3 1.2 2.2 68.0 100.0 436 Lilongwe 36.3 34.3 7.3 0.0 2.4 0.0 22.1 1.1 1.4 2.0 0.3 0.6 1.1 63.7 100.0 1,175 Mulanje 28.5 24.6 7.2 0.0 0.9 0.0 15.4 0.6 0.5 3.9 0.4 0.6 2.9 71.5 100.0 359 Other districts 32.1 27.9 6.1 0.0 2.0 0.1 17.7 0.3 1.7 4.2 0.4 2.0 1.8 67.9 100.0 3,326 Education No education 27.0 23.1 6.9 0.0 0.9 0.0 14.6 0.1 0.5 3.9 0.6 1.1 2.2 73.0 100.0 2,229 Primary 1-4 29.4 25.5 5.2 0.0 2.0 0.0 17.3 0.1 0.8 3.9 0.4 2.0 1.4 70.6 100.0 2,291 Primary 5-8 35.4 30.0 5.8 0.0 2.0 0.1 19.0 0.5 2.6 5.4 0.3 3.2 1.9 64.6 100.0 2,850 Secondary+ 44.2 41.0 5.1 0.0 4.4 0.4 24.5 2.0 4.6 3.2 0.8 1.6 0.7 55.8 100.0 940 Wealth quintile Lowest 25.3 21.8 3.7 0.0 0.9 0.2 15.9 0.1 1.0 3.5 0.5 1.7 1.3 74.7 100.0 1,256 Second 27.9 24.2 4.6 0.0 0.9 0.1 16.8 0.1 1.7 3.8 0.4 1.4 1.9 72.1 100.0 1,787 Middle 30.4 25.2 4.6 0.1 1.8 0.1 16.4 0.4 1.9 5.3 0.3 2.9 2.0 69.6 100.0 1,851 Fourth 36.7 31.1 7.3 0.0 2.9 0.0 18.6 0.4 1.8 5.7 0.5 3.2 2.0 63.3 100.0 1,779 Highest 40.6 37.6 8.6 0.0 3.1 0.3 21.9 1.4 2.2 3.0 0.6 1.3 1.1 59.4 100.0 1,640 Total 32.5 28.1 5.8 0.0 2.0 0.1 18.0 0.5 1.8 4.3 0.5 2.1 1.7 67.5 100.0 8,312 Note: If more than one method is used, only the most effective method is considered in this tabulation. As expected, contraceptive use increases with level of education. Use of modern methods increases from 23 percent among married women with no education to 41 percent among women with at least some secondary education. Few women start using contraceptives before having any children. The proportion of married women using modern methods increases with the number of children they have, ranging from 26 percent for women with 1-2 children to 37 percent for women with five or more children. Use of modern methods rises from 22 percent among married women in the lowest wealth quintile to 38 percent among those in the highest wealth quintile. Table 5.5 also shows that levels of use of modern family planning methods vary by district. Married women in Lilongwe and Blantyre are the most likely to use modern methods of contraception (34 percent each), followed by Mzimba, Thyolo, and Zomba (28 percent). The lowest levels of modern contraceptive use are found in Mangochi (17 percent) and Salima (20 percent). Injectables are particularly popular in the urban areas such as Blantyre, Lilongwe and Zomba Fertility Regulation | 77 (22 percent or higher), while female sterilisation is popular in Lilongwe and Mulanje (7 percent or higher). 5.5 TRENDS IN CONTRACEPTIVE USE Table 5.6 shows that while the proportion of currently married women using any method of family planning increased greatly from 13 percent in 1992 to 31 percent in 2000, there is a slight increase from 31 percent in 2000 to 33 percent in 2004. Use of modern contraceptive methods increased fourfold from 7 percent in 1992 to 28 percent in 2004. This dramatic rise in use of modern methods can be attributed to a sharp increase in the use of injectables and female sterilisation. Use of male condoms remains unchanged at 2 percent. Table 5.6 Trends in contraceptive use Percentage of currently married women who are currently using contraception, by specific method, Malawi 1992, 2000, and 2004 Method 1992 MDHS 2000 MDHS 2004 MDHS Any method 13.0 30.6 32.5 Any modern method 7.4 26.1 28.1 Female sterilisation 1.7 4.7 5.8 Male sterilisation 0.0 0.1 0.0 Pill 2.2 2.7 2.0 IUD 0.3 0.1 0.1 Injectables 1.5 16.4 18.0 Implants na 0.1 0.5 Male condom 1.6 1.6 1.8 Any traditional method 5.6 4.5 4.3 Rhythm/periodic abstinence 2.2 0.9 0.5 Withdrawal 1.5 1.5 2.1 Other traditional methods 2.0 2.1 1.7 Number of women 3,492 9,452 8,312 78 | Fertility Regulation 5.6 CURRENT USE OF CONTRACEPTION BY WOMAN'S STATUS A woman’s status and her self-image affect, to some extent, her desire and ability to control her fertility and her choice of contraceptive method. A woman who is not empowered to make decisions generally affecting her life is less likely to make decisions relating to her reproductive rights and responsibilities. Table 5.7 shows the distribution of currently married women by contraceptive use, according to selected indicators of women’s status. Use of a modern method of contraception is reported by 24 percent of women who have a final say in no decisions, 28 percent of women with a final say in 1-2 decisions, and at least 30 percent of women with a final say in three or more decisions. There is a small positive trend in the proportion of women using modern methods of contraception relative to the number of reported reasons to refuse sexual relations with the husband, and a small negative relationship with agreement with reported reasons to justify wife beating. This table shows that these indicators of women’s status have a weak but consistent relationship with the use of contraceptive methods in Malawi: women with more decisionmaking power and women who believe that a wife has the right to refuse sex to her husband and that wife beating is not justified are slightly more likely to use a modern method of contraception. Table 5.7 Current use of contraception by women's status Percent distribution of currently married women by contraceptive method currently used, according to indicators of women's status, Malawi 2004 Modern method Traditional method Women's status indicators Any method Any modern method Female sterili- sation Pill IUD Inject- ables Im- plants Male condom Any tradi- tional method Rhythm/ periodic absti- nence With- drawal Other tradi- tional methods Not currently using Total Number of women Number of decisions in which woman has final say1 0 26.3 23.6 3.7 1.6 0.2 16.1 0.2 1.9 2.8 0.3 0.9 1.7 73.7 100.0 1,390 1-2 32.3 27.6 6.0 1.9 0.1 17.1 0.4 2.1 4.7 0.6 2.5 1.6 67.7 100.0 4,040 3-4 36.5 31.9 6.6 2.1 0.2 20.7 0.9 1.2 4.7 0.4 2.7 1.6 63.5 100.0 1,879 5 34.1 30.0 7.1 2.4 0.1 19.0 0.3 1.1 4.2 0.2 1.4 2.5 65.9 100.0 1,004 Number of reasons to refuse sex with husband 0 27.9 24.7 5.3 1.9 0.1 16.0 0.0 1.4 3.2 0.5 1.2 1.5 72.1 100.0 857 1-2 29.9 26.2 4.5 1.8 0.0 18.4 0.2 1.4 3.6 0.3 1.6 1.7 70.1 100.0 1,556 3-4 33.8 29.2 6.3 2.0 0.2 18.1 0.6 1.9 4.7 0.5 2.4 1.8 66.2 100.0 5,900 Number of reasons wife beating is justified 0 32.6 28.7 6.5 2.0 0.2 18.1 0.5 1.5 3.9 0.4 1.8 1.7 67.4 100.0 5,886 1-2 32.4 27.1 4.8 1.7 0.1 17.7 0.7 2.2 5.3 0.7 2.3 2.3 67.6 100.0 1,446 3-4 33.0 26.9 3.7 2.6 0.0 17.0 0.1 3.5 6.1 0.3 4.3 1.5 67.0 100.0 648 5 29.7 25.8 4.0 1.1 0.0 19.0 0.2 1.4 3.9 0.2 3.2 0.5 70.3 100.0 333 Total 32.5 28.1 5.8 2.0 0.1 18.0 0.5 1.8 4.3 0.5 2.1 1.7 67.5 100.0 8,312 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Either by herself or jointly with others. Fertility Regulation | 79 5.7 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION The reason to practice family planning may be either to limit family size or to postpone the next birth. Couples using family planning to stop having any more children start using this when they have already had the number of children they desire. When family planning is used to delay the timing of pregnancy, couples may use contraception earlier in their reproductive lives. This may be done before a couple has had the number of children they desire, indeed even before the first pregnancy. Table 5.8 shows that 37 percent of young women age 15-19 who have ever used contraception started using contraceptives before they have had their first child. This compares with less than 1 percent of women age 35 years and over. While the vast majority of women age 20-29 start using a family planning method after the birth of their first child, 53-70 percent of women age 35 years and older start using contraceptive methods after they have had four or more children. Table 5.8 Number of children at first use of contraception Percent distribution of women who have ever used contraception by number of living children at the time of first use of contraception, according to current age, Malawi 2004 Number of living children at time of first use of contraception Current age 0 1 2 3 4+ Missing Total Number of women 15-19 36.8 55.2 6.5 0.0 0.8 0.6 100.0 380 20-24 8.8 61.5 24.3 4.7 0.6 0.1 100.0 1,454 25-29 2.6 41.5 33.5 15.0 7.4 0.2 100.0 1,398 30-34 1.6 22.8 27.7 22.2 25.6 0.1 100.0 975 35-39 0.7 15.0 15.6 16.0 52.6 0.1 100.0 733 40-44 0.1 15.3 10.4 10.8 62.9 0.5 100.0 598 45-49 0.9 12.0 8.0 9.0 70.0 0.0 100.0 368 Total 5.6 36.4 22.4 12.0 23.4 0.2 100.0 5,907 5.8 KNOWLEDGE OF FERTILE PERIOD Knowledge of the fertile period is important to assess the likelihood of conception in the absence of any use of contraception. This is especially important for couples that use periodic abstinence to prevent pregnancy. Table 5.9 shows the percent distributions of women and men by knowledge of the fertile period during the ovulatory cycle. Table 5.9 shows that knowledge of the fertile period is generally low among women. Only 16 percent of women think that their fertile period falls halfway between two periods. This proportion is even lower (6 percent) for women who report that they use periodic abstinence as a contraceptive method. The majority of all women (35 percent) think that their fertile period is right after their period has ended. Seventeen percent of all women report that they do not know their fertile period. Table 5.9 also shows that one in four men (26 percent) report that they do not know when a woman’s fertile period is, and another quarter (26 percent) believe that the fertile period is the time right after the monthly period has ended. Yet another 25 percent think the fertile period is just before the period begins. Only 10 percent of men know that a woman’s fertile period is about halfway between two periods. 80 | Fertility Regulation Table 5.9 Knowledge of fertile period Percent distribution of women and men by knowledge of the fertile period during the ovula- tory cycle, according to current use/nonuse of periodic abstinence, Malawi 2004 Women Perceived fertile period Users of periodic abstinence Nonusers of periodic abstinence All women All men Just before her period begins (6.7) 15.4 15.3 24.6 During her period (1.3) 3.8 3.8 2.2 Right after her period has ended (67.6) 34.9 35.0 25.7 Halfway between two periods (5.5) 15.9 15.8 9.9 Other (0.0) 0.1 0.1 0.1 No specific time (10.7) 13.0 13.0 11.1 Don't know (8.2) 16.9 16.8 26.4 Missing (0.0) 0.1 0.1 0.0 Total 100.0 100.0 100.0 100.0 Number of respondents 47 11,651 11,698 3,261 Note: Figures in parentheses are based on 25-49 unweighted cases. These findings indicate that use of periodic abstinence is not a reliable method of contraception among the couples using this method, because knowledge of the fertile period is very limited among both men and women in Malawi. 5.9 TIMING OF STERILISATION Table 5.10 shows that most women who are sterilised have the operation between the ages of 30 and 39 (58 percent). This proportion is about the same as that for women in the 2000 MDHS. There is a decrease in the proportion of women reporting to have been sterilised before age 25, from 7 percent in 2000 to 4 percent in 2004; there is also a decrease from 7 percent to 3 percent for women age 45-49 in the same period. Table 5.10 Timing of sterilisation Percent distribution of sterilised women by age at the time of sterilisation, and median age at sterilisation, according to the number of years since the operation, Malawi 2004 Age at time of sterilisation Years since operation <25 25-29 30-34 35-39 40-44 45-49 Total Number of women Median age1 <2 3.1 17.4 24.4 26.2 22.6 6.4 100.0 179 33.5 2-3 1.6 14.2 28.7 31.4 20.7 3.3 100.0 101 33.9 4-5 3.0 19.6 22.6 31.5 23.3 0.0 100.0 91 33.6 6-7 6.1 12.9 33.6 38.5 8.8 0.0 100.0 78 34.0 8-9 2.0 11.5 42.8 42.6 1.1 0.0 100.0 33 34.5 10+ 8.1 42.7 27.3 21.8 0.0 0.0 100.0 79 a Total 3.9 19.8 27.7 30.1 16.0 2.6 100.0 561 33.4 a = Not calculated due to censoring 1 Median age is calculated only for women sterilised at less than 40 years of age to avoid problems of censoring. Fertility Regulation | 81 5.10 SOURCE OF CONTRACEPTION All current users of modern contraceptives were asked about the most recent source of their methods. Table 5.11 shows that the public sector is the main source of contraceptive methods in Malawi, providing methods to 67 percent of current users. This is about the same proportion captured in the 2000 MDHS (68 percent). Thirteen percent of all current users get their methods from Mission (religious) facilities, 4 percent from the private medical sector, and 17 percent from other sources including NGOs, where Banja La Mtsogola (BLM) is the most commonly used source (13 percent). In the public sector, 40 percent of current users obtain their contraceptive methods from government health centres and 20 percent from government hospitals. Four percent and 2 percent of users obtain their methods from mobile clinics and fieldworkers, respectively. Table 5.11 Source of contraception Percent distribution of women who are currently using modern contraceptive methods by most recent source of method, according to specific method, Malawi 2004 Source of supply Female sterilisation Pill Injectables Implants Male condom Total Public 39.4 72.9 77.9 (66.6) 45.4 66.5 Government hospital 34.6 14.6 15.9 (58.7) 8.8 20.0 Government health centre 4.6 44.8 55.1 (7.9) 21.1 40.0 Family planning clinic 0.1 0.0 0.9 (0.0) 0.0 0.6 Mobile clinic 0.0 2.7 4.8 (0.0) 6.8 3.7 Field worker 0.0 10.4 0.9 (0.0) 7.9 2.0 Other public 0.0 0.3 0.4 (0.0) 0.8 0.3 Mission 17.4 11.5 11.1 (33.4) 8.6 12.6 Mission hospital, clinic 16.0 6.1 5.1 (26.0) 2.3 7.6 Mission health centre 1.4 4.6 5.3 (7.4) 5.0 4.4 Mobile clinic 0.0 0.8 0.7 (0.0) 1.3 0.6 Private 0.9 5.4 5.4 (0.0) 3.2 4.2 Private hospital/clinic 0.9 1.1 4.6 (0.0) 0.5 3.2 Pharmacy 0.0 0.0 0.0 (0.0) 0.3 0.0 Private doctor 0.0 0.4 0.2 (0.0) 0.0 0.1 Mobile clinic 0.0 1.5 0.1 (0.0) 0.0 0.2 CBDA/fieldworker 0.0 2.3 0.5 (0.0) 2.4 0.7 other private medical 0.0 0.0 0.0 (0.0) 0.0 0.0 Other 42.3 9.6 5.5 (0.0) 41.8 16.5 BLM 42.3 8.6 5.3 (0.0) 1.4 13.2 Shop 0.0 1.0 0.0 (0.0) 38.9 3.1 Friend/relative 0.0 0.0 0.1 (0.0) 1.5 0.2 Other 0.0 0.0 0.0 (0.0) 1.0 0.1 Missing 0.0 0.6 0.0 (0.0) 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 561 176 1,625 43 203 2,620 Note: Total includes some women whose husband/partner has been sterilised and some women who use the IUD. Figures in parentheses are based on 25-49 unweighted cases. Among mission health facilities, mission hospitals are the most commonly used source, providing contraceptives to 8 percent of all users of modern methods. Mission health centres provide contraceptives to 4 percent of all current users. The private medical sector is the source of contraceptive methods to only 4 percent of all users of modern methods of contraception. 82 | Fertility Regulation Female sterilisations are conducted mainly in BLM (42 percent) and government hospitals (35 percent). The pill is obtained mainly from government health centres (45 percent) and government hospitals (15 percent). Injectables are also supplied primarily in government health centres (55 percent) and government hospitals (16 percent). Male condoms are obtained mainly from shops (39 percent), government health centres (21 percent), and government hospitals (9 percent). Overall, these results reaffirm the reliance on government health facilities for the provision of contraceptive services in Malawi. These are complemented by services provided by BLM and mission health institutions. 5.11 INFORMED CHOICE Current users of modern methods who are well informed about the side effects and problems associated with methods and know of a range of method options are in a better position to make an informed choice about the method they would like to use. Providers of family planning services must inform potential clients about the various methods available, their effectiveness in preventing pregnancy, and their potential side effects. Prior to administering a sterilisation operation, providers must inform potential users that the operation is a permanent and irreversible method. Knowledge of various methods also helps minimise discontinuation rates. In the 2004 MDHS, current users of various modern contraceptive methods were asked whether at the time they were adopting the particular method, they were informed about side effects or problems that they might have with the method. Table 5.12 shows the percentage of current users of modern methods who were informed about side effects or problems of the method used, informed of other methods they could use, and informed that sterilisation is a permanent method; these are presented by method type, initial source, and various background characteristics. Table 5.12 shows that 77 percent of users of modern contraceptive methods were informed about side effects of the method they use, 74 percent were told what to do in case of side effects, and 76 percent say that they were told about other contraceptive options. Table 5.12 also shows that virtually all (97 percent) of sterilized women were informed that the operation is permanent and that they would not be able to have any more children after the operation. Fertility Regulation | 83 Table 5.12 Informed choice Among current users of modern contraceptive methods who adopted the current method in the five years preceding the survey, percentage who were informed about the side effects of the method used, percentage who were informed what to do if side effects were experienced, percentage who were informed of other methods that could be used for contraception, and percentage of women who were sterilised in the five years preceding the survey who were informed that they would not be able to have any more children, by specific method, initial source of method, and background characteristics, Malawi 2004 Method/source/ background characteristic Informed about side effects or problems of method used1 Informed what to do if experienced side effects1 Informed of other methods that could be used2 Informed that sterilisation is permanent3 Method Female sterilisation 73.0 72.8 58.8 96.7 Pill 74.8 74.4 77.3 na Injectables 100.0 100.0 100.0 na Implants 77.6 74.2 79.4 na Initial source of method4 83.6 88.1 94.4 na Public sector 76.5 72.6 76.8 98.0 Government hospital 76.6 75.0 73.5 97.6 Government health center 76.6 72.5 78.4 100.0 Family planning clinic 84.9 43.8 72.7 100.0 Mobile clinic 76.6 71.8 78.1 na CBD/fieldworker 70.9 62.4 69.1 na Private medical sector 79.7 80.2 78.6 89.9 Private doctor 80.9 80.1 84.1 88.4 Private hospital or clinic 77.9 79.2 70.4 100.0 Pharmacy 80.4 90.2 82.9 na Other private sector 78.3 92.3 89.5 na Residence Urban 80.8 77.5 79.3 96.5 Rural 75.9 73.6 75.5 96.7 Region Northern 84.5 80.7 81.3 95.5 Central 75.6 73.2 74.4 98.2 Southern 76.3 74.0 76.8 95.0 Education No education 75.0 72.7 69.7 96.8 Primary 1-4 74.0 71.3 73.2 97.7 Primary 5-8 80.5 78.2 81.7 96.0 Secondary+ 75.9 72.9 77.9 96.1 Wealth quintile Lowest 77.0 71.4 72.5 98.8 Second 76.2 75.8 80.7 96.5 Middle 77.5 73.6 75.8 94.0 Fourth 74.1 72.3 71.1 99.1 Highest 79.2 77.3 80.0 95.5 Total 76.9 74.4 76.3 96.7 na = Not applicable 1 Among users of female sterilisation, pill, IUD, injectables and implants 2 Among users of female sterilisation, pill, IUD, injectables, implants, and female condom 3 Sterilised women who were told that they would not be able to have any more children 4 Source at start of current episode of use 5.12 CONTRACEPTIVE DISCONTINUATION Correct and continuous use of contraceptive methods helps couples to realise their reproductive goals. A major concern for managers of family planning programmes is the discontinuation of methods. The “calendar” section in the 2004 MDHS Women’s Questionnaire is used to record all births, pregnancies and pregnancy terminations, as well as all segments of contraceptive use between January 2000 and the date of interview, along with reasons for any 84 | Fertility Regulation discontinuation. One-year contraceptive discontinuation rates based on these data are presented in Table 5.13.1 Table 5.13 shows that 36 percent of contraceptive users in Malawi discontinue use of the method within 12 months after of starting its use. Eight percent of users report that they stopped because they wanted to become pregnant, 4 percent switched to another method, and 3 percent stopped using because of unintended pregnancy (method failure). Twenty percent of users gave various other reasons for discontinuing. Discontinuation rates are highest for condom users (62 percent) and pill users (52 percent). Users of injectables are least likely to discontinue use within 12 months of use (33 percent). Condom users are the most likely to switch to another method, while method failure is highest for other methods and users of withdrawal. Table 5.13 First-year contraceptive discontinuation rates Percentage of contraceptive users who discontinued use of a method within 12 months after beginning its use, by reason for discontinuation and specific method, Malawi 2004 Reason for discontinuation Method Method failure Desire to become pregnant Switched to another method1 Other reason Total Pill 6.8 9.5 8.0 28.1 52.3 Injectables 1.4 7.6 1.8 21.8 32.5 Male condom 2.3 14.8 11.6 33.2 61.9 Withdrawal 10.1 10.9 8.1 11.0 40.1 Other 13.4 8.4 2.0 12.8 36.6 All methods 3.3 8.4 3.7 20.3 35.8 Note: Table is based on episodes of contraceptive use that began 3-59 months prior to the survey. 1Used a different method in the month following discontinuation or said they wanted a more effective method and started another method within two months of discontinuation Table 5.14 presents reasons for discontinuation of the 3,808 contraceptive discontinuations occurring in the five years preceding the survey, distributed by the main reason for discontinuation, according to method. The most prominent reason for discontinuation is the desire to become pregnant (35 percent), followed by side effects of the method (18 percent). Injectables and pills are the methods that contribute most to discontinuation because of side effects. Users of the pill and injectables are by far the most likely to cite and health concerns (8-9 percent). It is interesting to note that 11 percent of pill users stopped using the pill because they became pregnant. Overall, method failure is reported in 10 percent of the discontinuations. This reason is cited more frequently for discontinuations of traditional methods such as periodic abstinence or withdrawal (19 and 27 percent, respectively). Lack of access or lack of availability of the methods is not seen as a major problem for discontinuing use, cited in only 3 percent of discontinuations. 1 The discontinuation rates presented here include only those segments of contraceptive use that began since January 1999. The rates apply to the 3-63 month period prior to the survey; exposure during the month of interview and the two months prior are excluded to avoid the biases that may be introduced by unrecognised pregnancies. These cumulative discontinuation rates represent the proportion of users discontinuing a method within 12 months after the start of use. The rates are calculated by dividing the number of women discontinuing a method by the number exposed at that duration. The single-month rates are then cumulated to produce a one-year rate. In calculating the rate, the various reasons for discontinuation are treated as competing risks. Fertility Regulation | 85 Table 5.14 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason for discontinuation, according to specific method, Malawi 2004 Reason Pill Injectables Condom Periodic absti- nence With- drawal Other All methods Became pregnant while using 10.8 4.6 5.6 19.3 26.8 35.6 9.9 Wanted to become pregnant 29.1 36.0 29.9 49.7 40.4 33.8 35.2 Husband disapproved 2.4 2.5 11.2 2.2 5.6 2.7 3.7 Side effects 25.4 25.4 1.6 2.7 0.4 1.4 18.3 Health concerns 8.4 9.3 0.0 0.0 0.0 1.5 6.6 Access/availability 3.5 3.8 3.8 0.0 0.0 1.5 3.2 Wanted a more effective method 3.3 1.5 7.7 5.9 9.7 5.3 3.6 Inconvenient to use 3.0 0.9 9.1 0.0 5.2 3.4 2.6 Infrequent sex/husband away 3.7 3.0 11.0 2.5 3.4 1.0 3.8 Cost too much 0.1 0.1 1.8 0.0 0.0 0.0 0.2 Fatalistic 0.5 0.0 0.3 0.0 0.0 0.5 0.1 Difficult to get pregnant/menopausal 0.5 0.5 0.0 1.5 0.7 0.6 0.5 Marital dissolution/separation 1.2 2.8 5.1 2.2 1.8 1.2 2.6 Other 4.4 4.2 5.3 11.8 1.3 4.3 4.2 Don't know 0.5 0.3 0.6 0.0 0.1 0.2 0.3 Missing 3.1 5.2 6.9 2.3 4.6 7.1 5.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 426 2,247 395 73 419 221 3,808 Note: Total includes 2 discontinuations reported by women whose husband/partners were sterilised, 8 by women who used the IUD, 13 by women who used implants, and one by a woman who used the female condom. 5.13 FUTURE USE OF CONTRACEPTION Demand for specific methods is assessed in the 2004 MDHS by asking nonusers which method they intend to use in the future. Table 5.15 presents the findings. Among married women who are not using contraception at the time of the survey, 74 percent report that they intend to adopt a family planning method in the future, 23 percent say they do not intend to use any method, and 4 percent are not sure of their intention. There are no major differences in the percentage of women who intend to use family planning according to their number of living children. Table 5.15 Future use of contraception Percent distribution of currently married women who are not using a contraceptive method by intention to use in the future, according to number of living children, Malawi 2004 Number of living children1 Intention 0 1 2 3 4+ Total Intends to use 67.1 77.6 76.8 77.2 68.5 73.6 Unsure 7.5 4.0 3.6 2.3 3.0 3.6 Does not intend to use 24.7 18.3 19.3 20.1 28.0 22.5 Missing 0.7 0.1 0.3 0.4 0.4 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 423 1,239 1,164 935 1,852 5,613 1 Includes current pregnancy 86 | Fertility Regulation 5.14 REASONS FOR NOT INTENDING TO USE CONTRACEPTION Table 5.16 presents the main reasons why currently married women who are not using any contraceptive method do not intend to use one in the future. Among women under 30 years of age, the main reasons reported for not intending to use a contraceptive method are method-related (49 percent). Fear of side effects (29 percent), health concerns (12 percent), the woman’s own opposition to the use of any contraceptive (11 percent), and the desire to have as many children as possible (11 percent) are reported as the specific reasons for not intending to use any family planning method. Table 5.16 Reason for not intending to use contraception Percent distribution of currently married women who are not us- ing a contraceptive method and who do not intend to use in the future by main reason for not intending to use, according to age, Malawi 2004 Age Reason 15-29 30-49 Total Fertility-related reasons 19.2 51.3 39.1 Infrequent sex/no sex 2.1 6.9 5.1 Menopausal/had hysterectomy 0.2 17.0 10.6 Subfecund/infecund 6.1 19.0 14.1 Wants as many children as possible 10.8 8.4 9.3 Opposition to use 20.7 13.4 16.2 Respondent opposed 10.5 5.8 7.6 Husband/partner opposed 7.0 4.0 5.1 Others opposed 0.1 0.4 0.2 Religious prohibition 3.1 3.3 3.2 Lack of knowledge 2.1 0.9 1.4 Knows no method 1.8 0.7 1.2 Knows no source 0.2 0.2 0.2 Method-related reasons 49.2 30.6 37.7 Health concerns 11.9 9.3 10.3 Fear of side effects 28.8 15.6 20.6 Lack of access/too far 1.9 0.4 1.0 Costs too much 0.3 0.1 0.2 Inconvenient to use 1.9 0.9 1.3 Interfere with body's normal processes 4.4 4.2 4.3 Other 2.9 2.8 2.8 Don’t know 5.2 1.0 2.6 Missing 0.7 0.0 0.3 Total 100.0 100.0 100.0 Number of women 480 783 1,264 For women 30 years of age and older, the reasons for not intending to adopt family planning are largely fertility-related. Infertility (19 percent), menopause/hysterectomy (17 percent), fear of side effects (16 percent), and health concerns (9 percent) are the most frequently specified reasons for not adopting a contraceptive method. Fertility Regulation | 87 5.15 PREFERRED METHOD OF CONTRACEPTION FOR FUTURE USE Currently married women who are not using a contraceptive method but intend to adopt family planning were asked about contraceptive methods they prefer to use in the future. Table 5.17 shows that the majority of currently married women who are not currently using a contraceptive method intend in the future to use injectables (59 percent) as a family planning method. This preference is the same as that expressed in the 2000 MDHS survey (59 percent). Fourteen percent of women intend to use female sterilisation as a method in the future, while only 11 percent of the women intend to use the pill as a family planning method. Injectables are more popular among younger women, while women age 30-49 are more likely than younger women to say that they intend to use sterilisation. Table 5.17 Preferred method of contraception for future use Percent distribution of currently married women who are not using a contraceptive method but who intend to use in the future by preferred method, according to age, Malawi 2004 Age Method 15-29 30-49 Total Female sterilisation 5.4 31.8 13.8 Male sterilisation 0.1 0.4 0.2 Pill 11.8 9.0 10.9 IUD 1.2 0.8 1.1 Injectables 65.7 45.0 59.1 Implants 2.9 2.5 2.8 Condom 4.5 2.8 4.0 Female condom 0.1 0.0 0.1 Rhythm/periodic abstinence 0.7 1.4 0.9 Withdrawal 1.1 0.7 0.9 Other 3.0 3.7 3.2 Unsure 3.4 2.0 2.9 Total 100.0 100.0 100.0 Number of women 2,814 1,317 4,131 5.16 EXPOSURE TO FAMILY PLANNING MESSAGES THROUGH THE MEDIA Radio, television and print media, namely newspapers and magazines, are potential media for disseminating family planning information. Television is still not widespread in Malawi. In the 2004 MDHS, women and men were asked whether they heard or saw a family planning message on the radio, television, or in a newspaper or magazine. The results are shown in Tables 5.18.1 and 5.18.2. Table 5.18.1 shows that the majority of women (67 percent) have heard a family planning message recently on the radio. Fourteen percent are reached by newspaper/magazine and only 8 percent by television. Thirty-two percent of the women are not reached by any of the three media sources. Rural women are much less exposed to television than their urban counterparts (4 percent compared with 26 percent). Women in the Northern Region are more likely to have been exposed to each of the three types of media than those in the other regions. A woman’s education is positively related to her exposure to family planning messages through the media. For example, 44 percent of 88 | Fertility Regulation women with no education have not been exposed to family planning information through the media, compared with only 16 percent of women with secondary or higher education. While overall, 32 percent of all women have had no exposure to family planning messages through the media, only 22 percent of women in Blantyre District have had no such exposure. Table 5.18.2 shows that exposure to family planning messages through the media is greater among men than it is among women. Eighteen percent of men have no exposure to those messages through the media, compared with 32 percent of women. The same pattern of differentials in exposure to family planning messages exists among men with respect to place of residence, education, and wealth status, but differences are less pronounced than for women. Table 5.18.1 Exposure to family planning messages: women Percentage of women who heard or saw a family planning message the radio or television, or in a newspaper/magazine in the past few months, according to background characteristics, Malawi 2004 Background characteristic Radio Television Newspaper/ magazine None of these three media sources Number of women Age 15-19 58.5 8.0 15.5 39.5 2,392 20-24 69.9 8.5 16.3 29.3 2,870 25-29 71.9 9.8 14.0 27.1 2,157 30-34 68.1 6.1 11.0 31.3 1,478 35-39 71.3 8.8 12.8 28.2 1,117 40-44 68.2 6.8 11.2 31.2 935 45-49 63.3 6.5 8.2 36.6 749 Residence Urban 77.6 25.7 30.8 20.4 2,076 Rural 65.0 4.3 10.1 34.2 9,621 Region Northern 72.4 10.8 19.9 25.9 1,552 Central 63.6 7.4 12.5 35.8 4,734 Southern 69.0 7.9 13.2 29.9 5,412 District Blantyre 76.1 19.0 27.3 21.8 914 Kasungu 66.4 4.9 11.4 33.2 497 Machinga 66.1 5.7 11.1 33.2 427 Mangochi 65.2 7.5 10.8 33.7 599 Mzimba 70.9 9.1 15.9 27.8 778 Salima 69.7 4.9 9.2 30.2 303 Thyolo 70.1 3.7 11.2 29.0 618 Zomba 67.4 9.9 13.8 31.6 637 Lilongwe 63.0 13.6 17.3 36.4 1,705 Mulanje 67.7 5.7 13.1 31.1 512 Other districts 66.4 5.2 11.1 32.7 4,708 Education No education 56.0 2.4 3.2 43.8 2,734 Primary 1-4 63.3 2.5 5.3 36.4 2,998 Primary 5-8 71.5 6.8 14.2 27.2 4,154 Secondary+ 81.1 28.8 42.9 16.4 1,811 Wealth quintile Lowest 42.1 1.4 4.4 57.3 2,037 Second 62.7 2.2 7.0 36.9 2,277 Middle 69.7 2.4 7.4 29.5 2,383 Fourth 74.9 3.6 11.6 24.4 2,361 Highest 81.7 27.5 34.5 16.2 2,639 Total 67.3 8.1 13.8 31.8 11,698 Fertility Regulation | 89 Table 5.18.2 Exposure to family planning messages: men Percentage of men who heard or saw a family planning message on the radio or television, or in a newspaper/magazine in the past few months, according to background characteristics, Malawi 2004 Background characteristic Radio Television Newspaper/ magazine None of these three media sources Number of men Age 15-19 68.6 15.5 26.6 28.6 650 20-24 79.0 19.3 36.0 18.4 587 25-29 82.8 14.3 35.0 15.3 634 30-34 85.9 19.2 34.6 13.2 485 35-39 84.7 13.1 33.1 13.3 294 40-44 89.0 12.0 33.7 11.0 282 45-49 85.5 8.8 22.6 14.2 182 50-54 79.8 6.8 21.8 19.8 148 Residence Urban 84.2 35.9 50.0 12.3 669 Rural 79.5 9.8 27.2 19.2 2,593 Region Northern 84.1 19.5 29.9 15.0 423 Central 79.4 17.6 32.9 18.5 1,370 Southern 80.5 11.7 31.5 18.0 1,468 District Blantyre 84.2 13.4 25.3 13.8 316 Kasungu 82.5 15.5 33.0 17.2 156 Machinga 86.4 20.3 49.6 11.9 114 Mangochi 69.9 9.6 19.1 28.7 150 Mzimba 86.5 19.3 27.0 12.9 212 Salima 78.5 6.7 27.0 17.3 78 Thyolo 80.2 6.8 26.1 17.5 169 Zomba 86.6 19.4 27.8 13.0 159 Lilongwe 78.4 30.4 41.2 18.5 542 Mulanje 80.7 11.5 34.0 18.4 114 Other districts 79.3 10.0 31.5 19.2 1,250 Education No education 73.9 3.6 8.9 25.6 383 Primary 1-4 71.3 6.5 14.2 27.0 798 Primary 5-8 82.9 11.9 30.6 15.7 1,220 Secondary+ 88.7 33.2 60.4 8.6 859 Wealth quintile Lowest 63.8 4.9 16.1 34.9 412 Second 77.4 4.2 18.5 21.9 640 Middle 83.0 7.3 26.6 15.5 699 Fourth 85.1 11.0 32.7 14.0 709 Highest 85.3 39.9 54.5 11.0 802 Total 80.5 15.2 31.9 17.8 3,261 5.17 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS As in the 2000 MDHS survey, respondents in the 2004 MDHS who were not using contraception were asked whether they had any contact with a family planning provider in the last 12 months. They were also asked whether they had attended a health facility in the last year and, if so, whether a member of the staff at that facility spoke to them about family planning methods. This information is important for determining whether family planning initiatives in Malawi are reaching nonusers of family planning. This information is also used to evaluate whether there are missed opportunities in introducing family planning to nonusers. 90 | Fertility Regulation Table 5.19 shows that 68 percent of women neither received a visit from a family planning worker nor visited a health facility where family planning information or services could potentially have been provided. One in ten women reported that they were visited by a health fieldworker who discussed family planning. One in four women (24 percent) visited a health facility but the health worker they saw did not discuss family planning. This is a missed opportunity and may indicate that family planning has not been fully integrated into the health services delivery system for women. Overall, only 26 percent of women who visited a health facility in the past year discussed family planning at the facility with health personnel. Table 5.19 Contact of nonusers with family planning providers Percentage of women who are not using contraception who were visited by a fieldworker who discussed family planning (FP), who visited a health facility and discussed family planning, and who visited a health facility but did not discuss family planning, in the 12 months preceding the survey, by background characteristics, Malawi 2004 Background characteristic Women visited by fieldworker who discussed family planning Women visited health facility and discussed family planning Women visited health facility didn't discuss family planning Did not discuss FP with field worker or at a health facility Number of women Age 15-19 5.1 10.4 21.6 86.1 2,190 20-24 9.8 32.5 26.3 62.4 2,136 25-29 14.2 36.3 27.4 57.0 1,468 30-34 13.1 35.6 22.5 58.1 1,004 35-39 15.3 30.6 25.6 60.8 751 40-44 11.6 21.4 21.9 71.2 608 45-49 10.6 14.5 19.6 77.5 538 Residence Urban 9.9 20.4 26.0 73.1 1,489 Rural 10.5 27.0 23.7 67.4 7,205 Region Northern 10.5 24.7 28.3 69.6 1,054 Central 9.3 22.4 25.3 72.5 3,526 Southern 11.3 29.1 22.0 64.5 4,114 District Blantyre 7.9 23.0 23.3 72.7 646 Kasungu 7.1 22.2 21.6 73.2 343 Machinga 8.5 28.3 18.2 68.1 328 Mangochi 16.5 21.2 20.6 67.6 493 Mzimba 10.9 24.9 28.2 69.6 537 Salima 14.7 30.6 25.6 62.5 249 Thyolo 13.6 41.5 22.3 53.5 458 Zomba 8.3 34.0 27.6 62.8 478 Lilongwe 8.1 15.8 26.9 79.1 1,233 Mulanje 10.6 36.2 17.9 58.3 396 Other districts 10.8 26.2 24.2 67.5 3,533 Education No education 11.7 25.2 21.1 68.1 2,064 Primary 1-4 10.6 28.2 23.5 66.2 2,272 Primary 5-8 10.3 25.7 25.2 68.7 3,041 Secondary+ 8.3 23.2 27.2 71.6 1,315 Wealth quintile Lowest 10.1 25.8 22.8 69.0 1,636 Second 11.1 26.9 22.3 67.2 1,743 Middle 11.1 28.5 24.1 65.5 1,776 Fourth 10.1 27.2 24.9 67.5 1,665 Highest 9.7 21.2 26.1 72.4 1,873 Total 10.4 25.9 24.1 68.4 8,694 It should be noted that there are small variations across subgroups of women. However, access to family planning information and services are most limited to teenagers at both the community- and the facility-levels. Not only are these young women less likely to visit a health facility but when they do, they are less likely to discuss family planning with the health personnel. Fertility Regulation | 91 Among the oversampled districts, lack of access to family planning information either from health personnel at a health facility or from a fieldworker at home ranges from 54 percent of women in Thyolo to 79 percent in Lilongwe. However, women in Thyolo are more likely than women in other districts to have a discussion about family planning at a health facility when they visit the facility. 5.18 DISCUSSION OF FAMILY PLANNING WITH HUSBAND Although discussion between husband and wife about contraceptive use is not a precondition for adoption of family planning, the lack of such discussions may prevent its adoption. Communication between spouses is therefore important for the adoption and eventual continuation of family planning. Lack of discussion may indicate a lack of personal interest, opposition to contraception, or an expression of traditional taboo associated with talking about sex-related matters even in the family. It may also indicate that the couple has settled into a long-term pattern of use of a contraceptive method, rendering continued discussion of the matter moot. The 2004 MDHS asked currently married women who know a contraceptive method about the number of times they discussed family planning with their husbands in the past 12 months. Table 5.20 shows that the majority of currently married women with knowledge of a contraceptive method discussed family planning with their husbands at least once during the past year (72 percent). Thirty eight percent of them did so at least three times during that year. However, 28 percent of married women report that they never discussed family planning with their husbands in the past year. Currently married teenagers and women above 40 years of age are less likely than other women to discuss family planning with their husbands; 37 percent of women age 15-19 and 35 percent or higher of women age 40 and older did not discuss family planning with their husbands. Table 5.20 Discussion of family planning with husband Percent distribution of currently married women who know a contraceptive method by the number of times they discussed family planning with their husband in the past year, according to current age, Malawi 2004 Number of times family planning discussed with husband Age Never One or two Three or more Missing Total Number of women 15-19 36.5 35.5 27.6 0.5 100.0 751 20-24 25.1 36.2 38.4 0.3 100.0 2,249 25-29 19.5 37.7 42.4 0.3 100.0 1,800 30-34 24.4 31.7 43.6 0.3 100.0 1,216 35-39 29.1 31.6 39.3 0.0 100.0 899 40-44 34.6 30.1 35.1 0.2 100.0 745 45-49 45.9 26.9 26.8 0.3 100.0 537 Total 27.5 34.1 38.1 0.3 100.0 8,197 92 | Fertility Regulation 5.19 MEN'S ATTITUDES TOWARDS CONTRACEPTION When couples have a positive attitude toward family planning, they are more likely to adopt a family planning method. This is especially important when the man’s attitude is positive, as the man is usually the main decisionmaker in the home. Table 5.21 shows that 34 percent of men who know a method of family planning report that a woman should use a contraceptive because she is the one who becomes pregnant and 27 percent say that contraception is women’s business. While only 17 percent say that women who use contraceptives may become promiscuous, this view is expressed strongly by men who are not living together with their partners (30 percent). In general, rural men, men in the Central Region, less educated men, and men in the lower wealth quintiles are more likely to agree with the three statements. For instance, while 35 percent of men with no education say that using contraception is women’s business, the corresponding proportion for men with secondary or higher education is 12 percent. Similarly, while 40 percent of men in the lowest wealth quintile say that women should use contraception because they are the ones who become pregnant, this view is shared by only 23 percent of men in the highest wealth quintile. Table 5.21 Men's attitudes towards contraception Among men age 15-54 who know of a method of family plan- ning, percentage who agree with specific statements about con- traceptive use, by background characteristics, Malawi 2004 Background characteristic Contra- ception is women's business Women who use contracep- tion may become promiscu- ous Woman should use contracep- tion, she becomes pregnant Number of men Age 15-19 25.2 16.1 30.7 605 20-24 27.6 19.3 34.8 572 25-29 24.2 18.1 33.7 624 30-34 23.1 16.8 33.4 480 35-39 33.5 22.8 40.3 289 40-44 28.3 16.8 36.7 282 45-49 26.4 10.4 36.6 179 50-54 32.4 13.9 35.2 147 Marital status Never married 21.1 16.8 28.5 1,027 Married 29.3 17.2 37.5 2,026 Living together (24.5) (17.9) (33.7) 28 Widowed * * * 17 Divorced (26.5) (29.9) (29.5) 38 Not living together (34.7) (29.8) (37.3) 42 Residence Urban 22.5 18.1 28.5 645 Rural 27.6 17.3 35.9 2,533 Region Northern 13.0 18.1 16.3 416 Central 35.8 21.1 46.9 1,331 Southern 21.8 13.9 28.0 1,431 District Blantyre 15.4 15.3 30.2 311 Kasungu 44.1 20.5 44.8 153 Machinga 4.3 3.3 6.7 109 Mangochi 11.8 10.8 12.6 137 Mzimba 13.5 15.0 15.9 208 Salima 19.8 18.1 32.1 76 Thyolo 43.1 16.1 50.7 169 Zomba 19.1 27.6 28.6 159 Lilongwe 38.7 24.2 46.2 517 Mulanje 41.9 22.4 54.0 112 Other Districts 25.6 15.5 34.1 1,227 Education No education 34.6 22.8 48.8 369 Primary 1-4 41.0 18.0 45.1 772 Primary 5-8 25.4 18.2 36.1 1,185 Secondary+ 11.7 13.4 15.9 850 Wealth quintile Lowest 34.6 20.1 40.3 396 Second 32.7 17.6 40.1 621 Middle 29.5 18.0 38.3 684 Fourth 23.4 16.0 34.8 695 Highest 17.8 16.7 23.1 782 Total 26.6 17.4 34.4 3,178 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Other Proximate Determinants of Fertility | 93 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 George Mandere This chapter focuses on the principal factors, other than contraception, which affect a woman’s risk of becoming pregnant. These factors include marriage, sexual activity, postpartum amenorrhoea and abstinence from sexual activity, and onset of menopause. While it is by no means exact, marriage is an indicator of exposure of a woman to the risk of becoming pregnant. An inverse relationship exists between age at marriage and level of fertility; the level of fertility tends to be high in populations in which age at marriage is low. Postpartum amenorrhoea and abstinence affect the length of the interval between births. The onset of menopause signals the end of a woman’s childbearing life. These factors determine the pace and length of reproductive activity and are therefore important for understanding levels and trends of fertility in a population. 6.1 MARITAL STATUS The 2004 DHS collected information on the marital status of both male and female respondents. In this context, the term “married” refers to legal or formal marriage, while “living together” designates an informal union. Marriage is a primary indicator of the exposure of a woman to the risk of becoming pregnant. Table 6.1 shows the percent distribution of respondents by their current marital status according to age. The data in the first panel indicate that 17 percent of women of reproductive age have never been married, 67 percent are married, 4 percent are in informal unions, and 12 percent are divorced, separated, or widowed. Men are much less likely to be married than women; 33 percent have never been married, and 63 percent are married. Few men are divorced, separated, or widowed. Table 6.1 Current marital status Percent distribution of women and men by current marital status, according to age, Malawi 2004 Marital status Age Never married Married Living together Divorced Separated Widowed Total Number of respondents WOMEN 15-19 63.7 29.8 3.1 1.5 1.6 0.2 100.0 2,392 20-24 12.0 75.1 4.4 4.5 3.0 1.0 100.0 2,870 25-29 3.4 78.8 5.3 6.1 3.8 2.6 100.0 2,157 30-34 0.9 78.5 4.3 6.2 4.8 5.1 100.0 1,478 35-39 0.7 75.9 4.9 6.9 3.6 8.0 100.0 1,117 40-44 0.4 76.2 4.4 5.9 5.0 8.1 100.0 935 45-49 0.4 69.4 3.3 9.3 3.4 14.0 100.0 749 Total 16.8 66.8 4.3 5.0 3.3 3.7 100.0 11,698 MEN 15-19 96.8 1.9 0.4 0.1 0.8 0.0 100.0 650 20-24 52.4 42.7 1.5 1.2 2.2 0.0 100.0 587 25-29 18.4 76.7 1.0 1.8 1.2 0.8 100.0 634 30-34 3.4 90.7 1.1 1.9 2.6 0.3 100.0 485 35-39 2.7 94.8 0.3 0.8 0.8 0.6 100.0 294 40-44 1.1 95.8 0.3 1.4 0.3 1.2 100.0 282 45-49 1.8 94.2 1.2 1.5 0.0 1.4 100.0 182 50-54 0.2 95.0 1.7 1.2 0.4 1.5 100.0 148 Total 33.2 62.9 0.9 1.2 1.3 0.5 100.0 3,261 94 | Other Proximate Determinants of Fertility A similar pattern is observed in the 2000 DHS, except that the proportion of women who are living with a man has increased from 1 percent to 4 percent. The percentage of women who have never married decreases sharply from 64 percent at age 15-19 to 3 percent or less at age 25-29 and older. Less than 1 percent of women age 30 and older remain unmarried. There is a rise in the percentage of women widowed with increasing age. For example, the percentage of widowed women increases from less than 3 percent in age 25-29 to 14 percent in age 45-49. 6.2 POLYGYNY In Malawi, marriages can be classified as polygynous or monogamous unions. The extent of polygyny in Malawi was measured in the 2004 MDHS by asking married women whether their husbands had other wives, and if so, how many. Table 6.2 presents the percent distribution of currently married women by number of cowives according to background characteristics. Overall, 84 percent of all currently married women are in monogamous unions, 12 percent are in polygynous unions with one cowife, and 3 percent are in polygynous unions with two or more cowives. In general, women in older age groups, living in rural areas or the Northern Region, less educated, and in the lowest wealth quintile are also more likely to be in a polygynous union. Among the oversampled districts, polygyny is most common in Mangochi and Mzimba (24 percent each). While polygyny in Malawi declined substantially from 21 percent in the 1992 MDHS to 17 percent in the 2000 MDHS, it has since remained at a similar level (16 percent in 2004). Data on polygynous unions among currently married men are also given in Table 6.2 and Figure 6.1. One in ten married men report being in a polygynous union. However, this proportion varies by age, place of residence, region, and level of education. Polygyny increases with age; whereas only 11 percent of married men age 30-34 are in a polygynous union, the corresponding proportion for men age 50-54 is 16 percent. Other Proximate Determinants of Fertility | 95 Table 6.2 Number of cowives and wives Percent distribution of currently married women by number of cowives, and percent distribution of currently married men by number of wives, according to background characteristics, Malawi 2004 Women Men Number of cowives Number of wives Background characteristic 0 1 2+ Missing Total Number of women 1 2+ Total Number of men Age 15-19 94.6 4.6 0.4 0.4 100.0 788 * * 100.0 15 20-24 90.5 8.2 1.1 0.2 100.0 2,283 97.9 2.1 100.0 260 25-29 84.4 12.6 2.7 0.3 100.0 1,814 95.5 4.5 100.0 493 30-34 79.0 15.8 4.9 0.2 100.0 1,225 89.3 10.7 100.0 445 35-39 76.5 18.4 5.1 0.0 100.0 903 86.5 13.5 100.0 280 40-44 73.9 17.9 7.5 0.7 100.0 754 84.1 15.9 100.0 271 45-49 80.1 15.5 4.2 0.1 100.0 545 83.8 16.2 100.0 173 50-54 na na na na na na 84.2 15.8 100.0 143 Residence Urban 94.3 4.3 1.3 0.0 100.0 1,337 94.5 5.5 100.0 355 Rural 82.2 14.0 3.5 0.3 100.0 6,975 89.1 10.9 100.0 1,724 Region Northern 73.7 19.3 6.6 0.5 100.0 1,087 79.3 20.7 100.0 243 Central 84.3 12.6 2.9 0.2 100.0 3,346 88.7 11.3 100.0 885 Southern 86.9 10.4 2.4 0.3 100.0 3,880 93.9 6.1 100.0 951 District Blantyre 95.0 3.8 1.1 0.1 100.0 643 97.3 2.7 100.0 199 Kasungu 82.7 14.4 2.9 0.0 100.0 385 90.7 9.3 100.0 103 Machinga 79.2 16.7 3.8 0.3 100.0 317 94.6 5.4 100.0 70 Mangochi 75.5 19.2 5.1 0.2 100.0 437 86.6 13.4 100.0 106 Mzimba 76.2 18.7 4.9 0.1 100.0 570 84.0 16.0 100.0 129 Salima 80.8 16.8 2.3 0.0 100.0 230 89.4 10.6 100.0 58 Thyolo 87.8 10.5 1.6 0.2 100.0 433 93.7 6.3 100.0 116 Zomba 91.5 6.0 2.4 0.2 100.0 436 98.7 1.3 100.0 100 Lilongwe 87.2 10.2 2.4 0.2 100.0 1,175 87.4 12.6 100.0 322 Mulanje 88.1 10.3 1.2 0.5 100.0 359 93.6 6.4 100.0 74 Other districts 82.5 13.3 3.8 0.4 100.0 3,326 88.2 11.8 100.0 802 Education No education 77.7 17.6 4.4 0.4 100.0 2,229 92.1 7.9 100.0 329 Primary 1-4 85.2 11.2 3.4 0.2 100.0 2,291 88.7 11.3 100.0 536 Primary 5-8 85.5 11.7 2.7 0.1 100.0 2,850 87.5 12.5 100.0 773 Secondary+ 92.9 5.5 1.1 0.5 100.0 940 94.3 5.7 100.0 440 Wealth quintile Lowest 77.9 17.5 4.2 0.4 100.0 1,256 90.8 9.2 100.0 271 Second 82.7 13.4 3.8 0.1 100.0 1,787 89.1 10.9 100.0 434 Middle 85.0 12.2 2.6 0.2 100.0 1,851 90.5 9.5 100.0 509 Fourth 83.3 13.0 3.2 0.5 100.0 1,779 88.9 11.1 100.0 465 Highest 90.5 7.0 2.4 0.1 100.0 1,640 91.0 9.0 100.0 400 Total 84.2 12.4 3.2 0.2 100.0 8,312 90.0 10.0 100.0 2,079 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 96 | Other Proximate Determinants of Fertility 6.3 AGE AT FIRST MARRIAGE For most societies, marriage marks the point of a woman’s life when childbearing first becomes socially acceptable. Women who marry early will, on average, have longer exposure to reproductive risk; therefore, early age at marriage often implies early age at childbearing and higher fertility for a society. Information on age at first marriage was obtained by asking all ever-married respondents the month and year they started living together with their first spouse. Table 6.3 shows the percentage of women and men who were first married by exact ages and median age at first marriage, according to current age. The median age at first marriage for women age 20-49 in Malawi has remained constant since 2000 at 18.0 years. Overall, 51 percent of women age 20-49 are married by age 18, and 73 percent are married by age 20. The percentage of women who are married by age 15 declined from 15 percent among women age 45-49 to 6 percent among women age 15-19. Men enter into first marriage about five years later than women; the median age at first marriage for men is 22.9 years compared with 18.0 years for women. While only 22 percent of men are married by age 20, the corresponding proportion for women is 73 percent. Figure 6.1 Percentage of Currently Married Men in a Polygynous Marriage, by Background Characteristics 10 6 11 21 11 6 8 11 13 6 0 5 10 15 20 25 Malawi RESIDENCE Urban Rural REGION Northern Central Southern EDUCATION No education Primary 1-4 Primary 5-8 Secondary + Percent MDHS 2004 Other Proximate Determinants of Fertility | 97 Table 6.3 Age at first marriage Percentage of women and men who were first married by specific exact ages and median age at first marriage, according to current age, Malawi 2004 Percentage first married by exact age: Current age 15 18 20 22 25 Percentage never married Number Median age at first marriage WOMEN 15-19 6.2 na na na na 63.7 2,392 a 20-24 10.7 48.9 73.1 na na 12.0 2,870 18.1 25-29 12.7 47.5 72.4 85.7 94.9 3.4 2,157 18.2 30-34 14.1 52.7 74.1 85.3 93.8 0.9 1,478 17.8 35-39 19.0 54.5 74.9 84.1 92.9 0.7 1,117 17.7 40-44 16.1 54.7 76.2 86.6 93.7 0.4 935 17.7 45-49 15.3 49.2 69.6 81.7 90.8 0.4 749 18.1 20-49 13.6 50.5 73.3 na na 4.8 9,306 18.0 MEN 15-19 0.0 na na na na 96.8 650 a 20-24 0.1 7.8 21.5 na na 52.4 587 a 25-29 0.2 7.4 19.9 44.0 69.2 18.4 634 23.1 30-34 0.0 8.5 21.0 39.7 67.6 3.4 485 23.0 35-39 0.0 11.4 25.2 41.4 68.8 2.7 294 23.0 40-44 0.4 10.3 26.7 47.3 72.4 1.1 282 22.2 45-49 0.0 7.8 15.2 38.2 64.7 1.8 182 23.2 50-54 1.3 5.2 23.4 42.0 71.2 0.2 148 23.0 25-54 0.2 8.5 21.7 42.4 68.9 7.3 2,025 22.9 na = Not applicable a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Table 6.4 examines the median age at first marriage among women age 20-49 and men age 25-54, by age and background characteristics. Overall, Table 6.4 shows small variations in the median age at first marriage across subgroups of women. Urban women tend to marry one year later than their rural counterparts (18.9 years compared with 17.8 years). Education is strongly related to later marriage among women; for example, the median age at first marriage among women age 25 to 29 with no education is 17.2 years compared to 21.6 years for those with secondary education or higher. Wealth status is not closely associated with age at first marriage; women in the highest wealth quintile marry about one year older than women in the lower quintiles. The median age at first marriage among men age 25-54 is also presented in Table 6.4. The data show that rural men marry one year earlier than urban men. Age at first marriage among men does not vary much by other background characteristics. 98 | Other Proximate Determinants of Fertility Table 6.4 Median age at first marriage Median age at first marriage among women age 20-49 and men age 25-54, by current age and back- ground characteristics, Malawi 2004 WOMEN Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Residence Urban 19.6 19.3 18.1 17.7 18.0 18.3 18.9 Rural 17.8 18.0 17.8 17.7 17.6 18.0 17.8 Region Northern 17.8 17.9 17.9 17.8 17.7 17.8 17.8 Central 18.7 18.6 17.9 18.1 18.1 18.4 18.4 Southern 17.6 17.9 17.7 16.9 17.3 17.8 17.6 Education No education 16.6 17.2 17.3 16.9 17.3 18.0 17.2 Primary 1-4 17.2 17.8 17.9 17.5 17.4 18.1 17.5 Primary 5-8 17.7 18.1 17.8 17.9 18.1 17.8 17.9 Secondary+ a 21.6 22.2 20.8 20.5 20.0 a Wealth quintile Lowest 17.4 17.9 17.7 17.1 17.6 18.3 17.6 Second 17.7 17.8 17.3 18.0 17.9 18.4 17.7 Middle 17.6 17.8 17.7 17.6 17.3 17.6 17.6 Fourth 18.2 18.0 18.0 17.3 17.5 17.8 17.9 Highest a 19.5 18.7 18.3 18.0 18.4 19.2 Total 18.1 18.2 17.8 17.7 17.7 18.1 18.0 MEN Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 50-54 Men age 25-54 Residence Urban 24.2 23.8 23.8 22.7 24.2 19.3 23.8 Rural 22.5 22.7 22.8 22.1 23.2 23.1 22.6 Region Northern 23.8 22.9 24.8 22.5 22.7 22.8 23.1 Central 23.2 23.2 23.1 22.8 24.0 21.6 23.1 Southern 22.3 22.8 22.7 21.5 23.0 24.2 22.6 Education No education 21.1 22.2 23.8 22.0 21.9 22.5 22.1 Primary 1-4 21.4 22.0 20.6 22.1 24.5 23.0 21.8 Primary 5-8 21.7 22.1 22.8 22.0 22.3 22.0 22.1 Secondary+ a 26.5 25.6 22.7 27.4 24.3 a Wealth quintile Lowest 23.3 22.5 22.5 22.4 20.8 22.2 22.5 Second 21.4 22.7 22.6 22.1 22.8 24.4 22.2 Middle 22.4 23.1 22.5 21.6 24.0 23.4 22.6 Fourth 22.5 21.9 22.2 21.9 22.8 22.8 22.2 Highest 24.9 26.4 25.0 23.1 24.7 22.6 a Total 23.1 23.0 23.0 22.2 23.2 23.0 22.9 Note: Age at first marriage is the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50 percent of respondents married for the first time before reaching the beginning of the age group Other Proximate Determinants of Fertility | 99 6.4 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is often used as a proxy for the onset of women’s exposure to the risk of pregnancy. However, since some women are sexually active before marriage, the age at which women initiate sexual intercourse more precisely marks the beginning of their exposure to reproductive risk. Table 6.5 shows the percentage of women and men who had first sexual intercourse by exact ages. Overall, 17 percent of women age 20-49 have had sexual intercourse by age 15. By age 20, this proportion is 78 percent. The median age at first sexual intercourse for women has increased slightly since 2000 from 16.9 years to 17.3 years in 2004. While nearly half (48 percent) of women age 15-19 have never had sexual intercourse, this percentage drops to 5 percent among women age 20 and older. By age 25, virtually all women have had sex. Data for men show that 9 percent of men aged 25-54 have had sexual intercourse by age 15, 64 percent have had sex by age 20, and 90 percent have had sex by age 25. As in the case for women, nearly half (48 percent) of men age 15-19 have never had sexual intercourse, compared with 11 percent of men age 20-24. Virtually all men age 30 and older have had sex. The median age at first sexual intercourse decreases from 19.0 years for men aged 45-49 to 18.1 years for men 20-24 years. Table 6.5 Age at first sexual intercourse Percentage of women and men who had first sexual intercourse by exact ages and median age at first intercourse, according to current age, Malawi 2004 Percentage who had first sexual intercourse by exact age: Current age 15 18 20 22 25 Percentage who never had intercourse Number of respondents Median age at first intercourse WOMEN 15-19 14.1 na na na na 47.8 2,392 a 20-24 15.5 57.1 79.0 na na 4.5 2,870 17.4 25-29 16.4 55.5 78.6 86.0 88.8 1.3 2,157 17.5 30-34 17.2 60.0 78.6 84.6 88.2 0.0 1,478 17.1 35-39 20.7 59.5 76.1 81.5 85.3 0.1 1,117 17.2 40-44 18.5 60.3 77.6 83.6 87.5 0.0 935 17.1 45-49 17.4 55.2 71.8 80.9 85.4 0.0 749 17.6 20-49 17.0 57.6 77.8 a a 1.7 9,306 17.3 25-49 17.8 57.9 77.2 84.0 87.5 0.5 6,436 17.3 MEN 15-19 18.0 na na na na 47.7 650 a 20-24 9.1 47.7 74.1 na na 11.2 587 18.1 25-29 10.0 39.9 65.0 80.0 91.9 3.0 634 18.6 30-34 9.7 43.5 67.5 80.4 93.5 0.4 485 18.4 35-39 9.7 42.7 64.5 77.1 87.2 0.0 294 18.4 40-44 6.7 37.0 62.0 77.5 88.5 0.0 282 18.8 45-49 5.2 32.7 55.3 69.6 81.9 1.0 182 19.0 50-54 4.8 29.5 59.2 74.0 89.2 0.2 148 19.0 20-54 8.7 41.2 66.1 79.8 89.4 3.4 2,612 18.5 25-54 8.6 39.4 63.8 77.9 90.0 1.1 2,025 18.6 na = Not applicable a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group 100 | Other Proximate Determinants of Fertility Table 6.6.1 shows the differentials in the median age at first sexual intercourse for women age 20-49 by background characteristics. While there are small urban-rural differences, women in the Southern Region started having sex at an earlier age than women in Northern and Central Regions (16.7 years compared to 17.7 years or older). The data show that there is a strong inverse relationship between a woman’s education and her initiation to sexual activity. Women with secondary or higher education have their first sexual intercourse more than two years later than women with less education (19.2 years compared with 16.5 years). Wealth quintile is also associated with the median age at first sexual intercourse; median age at first intercourse for women in the highest wealth quintile (18.2 years) is more than one year higher than for women in the lowest quintile (16.9 years). The median age at first sexual intercourse varies by district, ranging between 15.6 years in Thyolo and 18.2 years in Lilongwe. Table 6.6.1 Median age at first intercourse: women Median age at first sexual intercourse among women age 20-49, by current age and background characteristics, Malawi 2004 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women 20-49 Residence Urban 18.1 18.2 17.7 17.6 17.2 17.8 17.9 Rural 17.2 17.4 17.0 17.2 17.1 17.5 17.2 Region Northern 17.6 17.6 18.1 17.6 17.5 18.1 17.7 Central 18.2 18.2 17.5 17.8 17.5 18.1 18.0 Southern 16.7 16.8 16.6 16.4 16.6 16.9 16.7 District Blantyre 17.4 18.2 17.3 18.1 17.7 19.2 17.7 Kasungu 17.7 17.7 17.8 17.8 17.5 17.0 17.6 Machinga 16.7 16.0 16.5 16.1 16.1 16.1 16.3 Mangochi 16.8 16.1 16.5 16.5 17.7 17.9 16.8 Mzimba 17.5 17.9 17.8 17.6 17.7 17.8 17.7 Salima 17.8 17.8 16.9 17.1 17.9 20.0 17.6 Thyolo 15.8 15.6 15.7 15.3 15.7 15.2 15.6 Zomba 16.4 16.5 16.3 15.9 16.4 16.5 16.4 Lilongwe 18.6 18.5 17.2 17.8 17.6 18.3 18.2 Mulanje 16.2 16.1 16.0 16.5 16.0 16.8 16.2 Other districts 17.6 17.6 17.5 17.5 17.0 17.8 17.5 Education No education 16.1 16.2 16.4 16.7 16.6 17.5 16.5 Primary 1-4 16.6 17.0 17.4 17.1 16.6 17.5 16.9 Primary 5-8 17.3 17.5 17.3 17.5 17.8 17.4 17.4 Secondary+ 19.1 19.2 19.7 18.8 19.7 18.8 19.2 Wealth quintile Lowest 16.7 16.9 16.8 16.9 16.6 17.7 16.9 Second 16.9 17.3 16.5 16.9 17.3 17.1 16.9 Middle 17.1 17.1 16.9 17.5 16.8 17.0 17.1 Fourth 17.7 17.7 17.5 17.0 17.0 17.9 17.5 Highest 18.5 18.3 18.0 17.8 17.6 17.9 18.2 Total 17.4 17.5 17.1 17.2 17.1 17.6 17.3 Unlike women, men do not show much variation with regard to their age at first sex by their background characteristics (Table 6.6.2). Among the oversampled districts, the median ranges from 17.2 years in Salima to 19.2 years in Mzimba. Other Proximate Determinants of Fertility | 101 Table 6.6.2 Median age at first intercourse: men Median age at first sexual intercourse among men age 20-54, by current age and background characteristics, Malawi 2004 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 50-54 Men 20-54 Residence Urban 18.3 18.5 18.4 18.4 18.0 17.5 18.2 18.3 Rural 18.1 18.6 18.4 18.4 18.8 19.9 19.2 18.6 Region Northern 18.3 18.9 18.4 19.6 18.7 19.8 a 18.8 Central 18.5 18.8 18.4 18.4 19.0 20.1 18.8 18.7 Southern 17.4 18.3 18.5 18.3 18.7 18.5 19.3 18.3 District Blantyre 18.1 17.3 17.1 18.2 18.4 17.1 a 17.7 Kasungu 18.1 17.3 18.2 20.2 18.0 18.8 19.4 18.3 Machinga 17.0 18.2 18.9 16.6 18.8 17.5 a 18.3 Mangochi 17.1 17.8 18.1 20.1 18.2 19.7 19.3 18.2 Mzimba 18.4 18.7 19.2 19.7 18.8 22.1 a 19.2 Salima 17.5 16.4 16.2 19.2 18.0 18.9 17.4 17.2 Thyolo 17.3 18.4 17.5 17.3 19.2 20.0 18.3 18.1 Zomba 17.0 18.8 18.1 16.7 17.7 18.0 17.5 18.0 Lilongwe 18.4 20.0 18.7 18.1 18.6 19.7 16.9 18.6 Mulanje 16.5 19.2 19.3 18.2 17.4 18.5 18.2 18.2 Other districts 18.3 18.7 19.0 18.7 20.0 20.3 19.8 18.8 Education No education 16.9 18.1 18.3 18.5 18.2 21.0 a 18.5 Primary 1-4 18.0 18.5 18.3 18.6 18.5 18.0 18.8 18.4 Primary 5-8 18.3 18.4 18.3 18.0 19.1 18.8 18.9 18.4 Secondary+ 18.3 19.0 19.0 18.7 19.7 20.0 19.9 18.8 Wealth quintile Lowest 18.4 18.8 17.7 19.5 20.8 16.9 18.9 18.7 Second 17.9 18.4 18.8 18.2 18.4 20.0 19.1 18.4 Middle 17.2 19.2 18.5 17.7 18.8 21.2 18.7 18.6 Fourth 18.0 18.2 18.3 18.0 18.5 18.7 19.4 18.3 Highest 18.5 18.5 18.6 19.4 18.8 18.6 19.0 18.6 Total 18.1 18.6 18.4 18.4 18.8 19.0 19.0 18.5 a = Omitted because less than 50 percent of the men had intercourse for the first time before reaching the beginning of the age group 6.5 RECENT SEXUAL ACTIVITY Although few women age 20-49 have never had sexual intercourse, not all those who have ever had sex are currently sexually active. In the absence of effective contraception, the probability of becoming pregnant is related to the frequency of intercourse. Information on recent sexual activity, therefore, can be used to refine measures of exposure to pregnancy. Women who have ever had sex were asked how long ago their last sexual activity occurred; this allows an assessment of whether they had a recent sexual encounter. Table 6.7.1 shows the distribution of women by their most recent sexual activity. Women are considered to be sexually active if they had sexual intercourse at least 102 | Other Proximate Determinants of Fertility once in the four weeks preceding the survey. Women who are not sexually active may be abstaining for various reasons, such as having recently given birth (i.e., postpartum abstinence). The data indicate that 55 percent of women had sexual intercourse in the four weeks preceding the survey, another 22 percent had sexual intercourse in the past year, and 9 percent had intercourse one or more years before the survey. Eleven percent of women age 15-49 have never had sex. Recent sexual activity varies by age, ranging from 28 percent of women age 15-19 having sex within the 4 weeks prior to the survey to 66 percent of women age 25-29. As expected, women who are married or living together are much more likely to be sexually active than women who are not in union (divorced, separated, widowed, and never-married women). While 75 percent of married women were sexually active in the four weeks preceding the survey, the proportion for nonmarried women is 16 percent. While there is no urban-rural difference in sexual activity in the last four weeks, women in the Central Region are more likely to have had sex in the last four weeks than women in the Southern and Northern Regions (58 percent compared with 55 percent and 49 percent, respectively). There is a negative association between recent sexual activity and the respondent’s education. The percentage of women with no education who had sex in the last four weeks is 61 percent compared with 44 percent of women with at least a secondary education. Women who are using family planning methods are more likely than women who are not to have had sexual intercourse within the past four weeks. Among users of family planning methods, sexual activity is highest among pill users. There are marked variations in recent sexual activity according to wealth index, with women in the middle wealth quintile being more likely to have had sex in the four weeks before the survey than those in the higher and lower wealth quintiles. The percentage of women who were sexually active in the past four weeks increases from 46 percent among women in the lowest wealth quintile to 60 percent for women with the middle wealth quintile, and declines to 53 percent for women in the highest quintile. Among the oversampled districts, the proportion of women who had sex in the four weeks before the survey ranges from 47 percent in Mangochi to 64 percent in Kasungu. Table 6.7.2 shows that 64 percent of men had sexual intercourse in the four weeks preceding the survey, another 15 percent had sex within the past year, and 10 percent had sexual intercourse one or more years before the survey. Twelve percent of men have never had sex. Men’s recent sexual activity increases with age; while 21 percent of men age 15-19 were sexually active in the past four weeks, the corresponding proportion for men age 25 and older is 73 percent or higher. As with women, men who are married or living together are the most active sexually in recent weeks (86 percent), compared with divorced, separated or widowed men (34 percent), and never-married men (23 percent). The percentage of men who were sexually active in the four weeks preceding the survey increases from 82 percent for men who have been married 0-4 years to 92 percent among those married for 10-14 years. Urban men are less likely than rural men to have had sexual intercourse in the past four weeks (57 and 65 percent, respectively). There are small differentials across regions in men’s recent sexual activity. Other Proximate Determinants of Fertility | 103 Table 6.7.1 Recent sexual activity: women Percent distribution of women by timing of last sexual intercourse, according to background characteristics, Malawi 2004 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within one year1 One or more years Missing Never had sexual intercourse Total Number of women Age 15-19 28.4 17.2 4.9 1.8 47.8 100.0 2,392 20-24 60.1 25.1 6.0 4.3 4.5 100.0 2,870 25-29 66.0 23.2 6.1 3.4 1.3 100.0 2,157 30-34 65.1 22.9 9.3 2.8 0.0 100.0 1,478 35-39 60.3 22.8 11.5 5.3 0.1 100.0 1,117 40-44 63.5 17.8 15.1 3.6 0.0 100.0 935 45-49 55.8 17.1 25.5 1.5 0.0 100.0 749 Marital status Never married 6.6 16.0 10.1 1.3 65.9 100.0 1,970 Married or living together 74.8 20.5 2.3 2.4 0.0 100.0 8,312 Divorced/separated/widowed 9.0 35.1 44.4 11.4 0.0 100.0 1,416 Marital duration2 Married only once 0-4 years 73.0 22.2 1.5 3.2 0.1 100.0 2,088 5-9 years 75.1 20.0 1.8 3.1 0.0 100.0 1,710 10-14 years 79.2 16.5 2.1 2.3 0.0 100.0 985 15-19 years 72.5 24.3 2.0 1.3 0.0 100.0 687 20-24 years 75.9 19.7 2.8 1.5 0.0 100.0 540 25+ years 77.8 14.3 6.8 1.2 0.0 100.0 532 Married more than once 73.8 22.0 2.4 1.8 0.0 100.0 1,770 Residence Urban 55.8 17.2 9.9 2.1 14.9 100.0 2,076 Rural 55.2 22.5 8.4 3.6 10.3 100.0 9,621 Region Northern 48.6 20.4 12.2 3.5 15.2 100.0 1,552 Central 57.7 17.8 7.5 3.4 13.6 100.0 4,734 Southern 55.2 25.1 8.8 3.1 7.8 100.0 5,412 District Blantyre 59.3 20.9 7.5 3.1 9.2 100.0 914 Kasungu 63.9 15.6 5.9 2.7 11.9 100.0 497 Machinga 53.8 28.9 7.5 2.3 7.5 100.0 427 Mangochi 47.2 30.1 11.4 5.3 6.0 100.0 599 Mzimba 47.9 21.5 12.7 2.8 15.1 100.0 778 Salima 60.3 19.7 7.0 3.0 10.2 100.0 303 Thyolo 58.9 25.3 5.9 3.5 6.3 100.0 618 Zomba 56.1 24.1 9.0 2.4 8.4 100.0 637 Lilongwe 58.5 15.7 7.7 3.5 14.7 100.0 1,705 Mulanje 56.3 25.7 9.2 2.4 6.4 100.0 512 Other districts 54.0 21.5 9.1 3.5 12.0 100.0 4,708 Education No education 61.2 22.9 10.3 4.2 1.5 100.0 2,734 Primary 1-4 59.5 22.1 6.8 3.1 8.5 100.0 2,998 Primary 5-8 53.5 20.3 8.2 3.2 14.8 100.0 4,154 Secondary+ 43.9 21.4 10.6 2.4 21.7 100.0 1,811 Current contraceptive method Female sterilisation 76.2 11.6 9.6 2.6 0.0 100.0 561 Pill 83.2 14.3 1.2 1.3 0.0 100.0 176 Condom 76.6 21.1 0.3 1.4 0.5 100.0 203 Periodic abstinence (65.0) (19.5) (15.5) (0.0) (0.0) 100.0 47 Other method 79.9 15.5 2.5 2.0 0.0 100.0 2,006 No method 47.2 23.7 10.4 3.7 14.9 100.0 8,694 Wealth quintile Lowest 46.1 27.9 12.0 5.5 8.5 100.0 2,037 Second 58.6 22.5 7.8 3.3 7.7 100.0 2,277 Middle 60.1 21.1 6.3 3.0 9.5 100.0 2,383 Fourth 58.6 19.3 6.8 3.0 12.3 100.0 2,361 Highest 52.5 18.2 10.7 2.1 16.5 100.0 2,639 Total 55.3 21.5 8.7 3.3 11.1 100.0 11,698 Note: Total includes 11 women who are using an IUD. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes women who had sexual intercourse in the past 4 weeks 2 Excludes women who are not currently married 104 | Other Proximate Determinants of Fertility Table 6.7.2 Recent sexual activity: men Percent distribution of men by timing of last sexual intercourse, according to background characteristics, Malawi 2004 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within one year1 One or more years Missing Never had sexual intercourse Total Number of men Current age 15-19 20.5 13.8 18.1 0.0 47.7 100.0 650 20-24 52.2 21.8 14.6 0.1 11.2 100.0 587 25-29 72.8 16.1 8.1 0.0 3.0 100.0 634 30-34 84.1 11.2 4.3 0.0 0.4 100.0 485 35-39 81.5 12.8 5.7 0.0 0.0 100.0 294 40-44 85.4 11.6 3.1 0.0 0.0 100.0 282 45-49 84.3 8.5 5.2 1.1 1.0 100.0 182 50-54 87.5 8.8 3.4 0.0 0.2 100.0 148 Marital status Never married 22.6 19.0 21.7 0.0 36.8 100.0 1,084 Married or living together 86.3 11.6 2.0 0.1 0.0 100.0 2,079 Divorced/separated/widowed 33.7 26.5 39.8 0.0 0.0 100.0 98 Marital duration2 Married only once 0-4 years 82.2 16.1 1.6 0.1 0.0 100.0 487 5-9 years 85.5 11.4 3.1 0.0 0.0 100.0 381 10-14 years 91.5 6.9 1.6 0.0 0.0 100.0 248 15-19 years 83.9 13.2 2.8 0.0 0.0 100.0 185 20-24 years 87.0 9.6 2.7 0.7 0.0 100.0 140 25+ years 87.7 10.0 1.4 0.9 0.0 100.0 111 Married more than once 88.5 10.1 1.5 0.0 0.0 100.0 528 Residence Urban 57.1 16.8 9.9 0.0 16.3 100.0 669 Rural 65.2 13.9 9.6 0.1 11.2 100.0 2,593 Region Northern 51.8 17.1 13.5 0.0 17.6 100.0 423 Central 65.0 12.0 9.2 0.2 13.7 100.0 1,370 Southern 65.5 16.1 9.1 0.0 9.3 100.0 1,486 District Blantyre 62.1 18.7 9.5 0.0 9.7 100.0 316 Kasungu 65.6 13.5 9.3 0.0 11.5 100.0 156 Machinga 60.8 23.6 4.6 0.4 10.6 100.0 114 Mangochi 71.7 15.2 8.5 0.0 4.5 100.0 150 Mzimba 48.8 18.9 15.5 0.0 16.8 100.0 212 Salima 69.6 18.3 4.5 0.0 7.5 100.0 78 Thyolo 67.6 15.4 8.2 0.0 8.7 100.0 169 Zomba 71.6 12.9 8.7 0.0 6.8 100.0 159 Lilongwe 61.4 13.0 10.0 0.0 15.6 100.0 542 Mulanje 69.8 12.6 10.5 0.0 7.1 100.0 114 Other Districts 63.8 12.5 9.8 0.2 13.7 100.0 1,250 Education No education 79.7 11.8 6.0 0.5 2.0 100.0 383 Primary 1-4 66.4 14.6 7.3 0.0 11.8 100.0 798 Primary 5-8 63.8 12.3 8.9 0.0 15.0 100.0 1,220 Secondary+ 53.3 18.8 14.6 0.0 13.2 100.0 859 Wealth quintile Lowest 63.4 16.5 10.2 0.0 9.9 100.0 412 Second 66.4 13.4 8.2 0.2 11.8 100.0 640 Middle 69.4 13.0 8.6 0.1 8.9 100.0 699 Fourth 64.1 14.2 10.4 0.1 11.3 100.0 709 Highest 55.6 16.0 10.9 0.0 17.5 100.0 802 Total 63.5 14.5 9.7 0.1 12.2 100.0 3,261 1 Excludes men who had sexual intercourse in the past 4 weeks 2 Excludes men who are not currently married Other Proximate Determinants of Fertility | 105 The level of recent sexual activity decreases with increasing education; 80 percent of men with no education had sexual intercourse in the four weeks prior to the survey, compared with 53 percent of men with secondary or higher education. Variations in recent sexual activity among men by wealth index are similar to those for women, with men in the middle quintile being the most active sexually. With respect to district, the proportion ranges from 49 percent in Mzimba to 72 percent in Mangochi and Zomba. 6.6 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea refers to the interval between childbirth and the return of menstruation. During this period, the risk of a woman becoming pregnant is much reduced. How long this protection from conception following childbirth lasts depends on the length and intensity of breastfeeding and the length of time before the resumption of sexual intercourse. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. Women are considered to be insusceptible to pregnancy if they are not exposed to the risk of pregnancy either because they are amenorrhoeic or because they are abstaining from sexual intercourse after a birth. In the MDHS 2004, women who gave birth during the three years prior to the survey were asked about their breastfeeding practices, the duration of amenorrhoea, and sexual abstinence. The results are presented in Table 6.8. The period of postpartum amenorrhoea is considerably longer than the period of postpartum abstinence and is, therefore, a principal determinant of the length of postpartum insusceptibility. The median duration of postpartum amenorrhoea is 11.5 months, median duration of postpartum abstinence is 5.5 months, and the median duration of Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Malawi 2004 Percentage of births for which the mother is: Months since birth Amenorrhoeic Abstaining Insusceptible Number of births < 2 93.5 95.3 98.5 327 2-3 91.4 77.7 96.1 430 4-5 76.6 60.9 85.6 382 6-7 76.5 38.9 83.0 439 8-9 63.8 26.1 70.7 417 10-11 53.6 21.3 61.5 393 12-13 45.6 14.0 50.1 408 14-15 38.6 12.8 44.0 419 16-17 27.4 12.2 35.2 388 18-19 22.8 8.2 28.7 399 20-21 14.9 7.7 20.4 390 22-23 12.2 7.2 18.2 305 24-25 9.2 5.5 13.7 333 26-27 4.1 4.2 7.9 298 28-29 3.5 1.8 5.2 328 30-31 2.4 4.0 5.7 334 32-33 4.0 5.5 8.9 310 34-35 2.1 2.9 5.0 305 Total 38.2 23.6 43.7 6,607 Median 11.5 5.5 12.9 - Mean 13.1 8.4 15.0 - Note: Estimates are based on status at the time of the survey. 106 | Other Proximate Determinants of Fertility insusceptibility is 12.9 months. Nearly all women are insusceptible to pregnancy in the first two months after a birth, and both postpartum amenorrhoea and postpartum abstinence are equally important for insusceptibility. Beginning with two months after childbirth, the contribution of abstinence to insusceptibility decreases faster than that of amenorrhoea as a result of the resumption of sexual relations. In the 12-13 month period after the birth of a child, 46 percent of the women are amenorrhoeic, 14 percent are practicing abstinence, and 50 percent are still insusceptible to the risk of pregnancy. Table 6.9 shows the median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility for births in the three years preceding the survey, by background characteristics. Women age 30-49 years have more than two months longer postpartum insusceptibility than women age 15-29 years (14.7 months compared with 12.2 months). Table 6.9 Median duration of postpartum insusceptibility by background characteristics Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Malawi 2004 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility Number of births Age 15-29 10.8 5.4 12.2 4,663 30-49 13.5 5.9 14.7 1,944 Residence Urban 9.9 5.3 12.9 895 Rural 11.6 5.6 12.9 5,712 Region Northern 9.1 6.2 13.0 810 Central 11.5 4.0 12.2 2,770 Southern 12.1 6.7 13.3 3,027 District Blantyre 11.1 6.3 12.4 424 Kasungu 12.5 2.7 12.9 311 Machinga 12.5 6.9 13.5 267 Mangochi 12.4 9.2 13.6 398 Mzimba 10.1 7.8 15.0 407 Salima 9.8 5.1 10.3 198 Thyolo 13.3 7.2 13.4 349 Zomba 10.1 5.8 11.4 333 Lilongwe 9.9 4.5 9.9 930 Mulanje 11.7 7.8 12.2 269 Other districts 11.8 4.7 13.2 2,722 Education No education 14.0 6.0 15.2 1,656 Primary 1-4 12.2 5.4 12.8 1,925 Primary 5-8 11.3 5.5 12.4 2,263 Secondary+ 8.3 4.8 9.7 761 Wealth quintile Lowest 14.2 6.6 16.0 1,304 Second 12.2 5.4 13.0 1,522 Middle 10.4 5.6 11.9 1,474 Fourth 11.2 5.2 12.5 1,261 Highest 9.0 4.8 10.4 1,046 Total 11.5 5.5 12.9 6,607 Note: Medians are based on current status. Other Proximate Determinants of Fertility | 107 While urban women have the same median duration of postpartum insusceptibility as women in the rural areas (12.9 months), women in the urban areas have a shorter median duration of postpartum amenorrhoea than women in the rural areas. At the regional level, insusceptibility lasts for 12.2 months for women in the Central Region, almost one month shorter than women in the other regions (13.0 months or longer). Women in the Northern Region have the shortest duration of amenorrhoea compared to women in the Southern and Northern Regions (9.1 months and 11.5 months or longer, respectively). The 2004 MDHS results show that the mean durations of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility are inversely related to a woman’s educational attainment and wealth quintile. Women with secondary or higher education have the shortest median duration of postpartum amenorrhoea (8.3 months), postpartum abstinence (4.8 months), and postpartum insusceptibility (9.7 months), while women with no education have the longest median duration of postpartum amenorrhoea (14.0 months), postpartum abstinence (6.0 months), and postpartum insusceptibility (15.2 months). Similarly, women in the lowest wealth quintile have the longest duration of postpartum amenorrhoea (14.2 months), abstinence (6.6 months), and insusceptibility (16.0 months), while women in the highest wealth quintile have the shortest durations of amenorrhoea (9.0 months), abstinence (4.8 months), and insusceptibility (10.4 months). There are some variations in the duration of postpartum amenorrhoea, abstinence and insusceptibility among districts in Malawi. The duration of amenorrhoea ranges from 9.8 months in Salima to 13.3 months in Thyolo. Women in Kasungu have the shortest duration of postpartum abstinence (2.7 months), while women in Mangochi have the longest duration of abstinence (9.2 months). The period of insusceptibility is longest in Mzimba (15.0 months) and shortest in Lilongwe (9.9 months). 6.7 TERMINATION OF EXPOSURE TO PREGNANCY The onset of infecundability in a woman is difficult to determine. However, there are ways of estimating the start of the termination of the exposure to the risk of pregnancy. Table 6.10 shows the percentage of women aged 30 years and over who are not pregnant and not postpartum amenorrhoeic, and whose last menstrual period occurred six or more months preceding the survey. After age 30, exposure to the risk of pregnancy declines with age as an increasing proportion of women become infecund. The percentage of women who are menopausal increases slowly from 3 percent for women age 30-34 to 11 percent of women age 40-41 and to 17 percent for women 44-45. After age 45, the percentage of women who are menopausal increases sharply from 28 percent among women age 46-47 to 42 percent among women 48-49. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Malawi 2004 Age Percentage menopausal1 Number of women 30-34 2.9 1,478 35-39 4.4 1,117 40-41 11.1 443 42-43 15.9 322 44-45 17.4 338 46-47 28.3 292 48-49 41.9 289 Total 10.6 4,279 1 Percentage of all women who are not preg- nant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences and Unmet Need for Family Planning | 109 FERTILITY PREFERENCES AND UNMET NEED FOR FAMILY PLANNING 7 Sophie Kang’oma Information on the fertility preferences of men and women provides family planning programmes with an assessment of trends in ideal family size, the prevailing need for contraception, and the extent of unwanted and mistimed pregnancies. Data on fertility preferences can also be useful as an indicator of future fertility trends. In the 2004 MDHS, women and men were asked a series of questions to ascertain their fertility preferences, including their desire to have another child, the length of time they would like to wait before having another child, and what they consider to be the ideal number of children. These data make it possible to quantify fertility preferences and, in combination with data on contraceptive use, allow estimation of the unmet need for family planning, for both spacing and limiting births. Interpretation of results on fertility preferences is a matter of controversy because respondents’ reported preferences are, in most cases, hypothetical and thus subject to change and rationalisation. 7.1 DESIRE FOR MORE CHILDREN Men and women in the 2004 MDHS were asked, “Would you like to have (a/another) child or would you prefer not to have any (more) children?” For pregnant women the question started with, “After the child you are expecting now …” Respondents who said they wanted to have (a/another) child were then asked how long they would like to wait before the birth of the next child. Tables 7.1.1 and 7.1.2 show fertility desires among married women and men by the number of living children they currently have. Although slightly more than half of women and men (54 percent each) wanted another child, only 14 percent of women and 12 percent of men wanted a child soon. Thirty-eight percent of women and 40 percent of men wanted to have another child after two or more years. Thirty-five percent of women indicated that they wanted no more children and therefore wanted to limit the family size at its current level, and 6 percent had already been sterilised. Thirty-eight percent of men also report wanting no more children. The data indicate that a majority of women (79 percent) want to space their next birth or end childbearing altogether. These women are potentially in need of either a reversible or permanent method of family planning. The desire to end childbearing increases with the number of living children, from 5 percent among married women with no children to 67 percent among women with six or more children. This pattern is similar to that for men. There has been no change in fertility preferences among currently married women since 2000, despite the fact that the proportion of married women who wanted to end childbearing rose from 25 percent in 1992 to 42 percent in 2000. 110 | Fertility Preferences and Unmet Need for Family Planning Table 7.1.1 Fertility preferences by number of living children: women Percent distribution of currently married women by desire for children, according to number of living children, Malawi 2004 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total Have another soon 2 76.3 21.1 12.8 10.3 6.6 3.3 1.4 14.0 Have another later 3 7.9 62.4 55.2 44.0 27.8 16.1 8.2 38.2 Have another, undecided when 3.9 2.9 1.5 1.2 1.7 0.7 0.2 1.6 Undecided 2.1 4.0 4.3 5.0 4.4 3.3 1.8 3.8 Want no more 5.0 8.5 23.0 34.7 50.3 63.6 67.3 35.0 Sterilised4 0.1 0.2 1.6 3.8 7.4 11.3 19.2 5.9 Declared infecund 4.5 0.6 1.3 0.9 1.8 1.5 1.6 1.4 Missing 0.2 0.2 0.1 0.1 0.0 0.1 0.3 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 438 1,657 1,726 1,440 1,033 810 1,209 8,312 1 Includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilisation Table 7.1.2 Fertility preferences by number of living children: men Percent distribution of currently married men by desire for children, according to number of living children, Malawi 2004 Number of living children Desire for children 0 1 2 3 4 5 6+ Total Have another soon 1 35.1 12.4 15.5 12.9 7.0 6.6 3.7 11.8 Have another later 2 52.1 66.4 54.5 38.9 29.6 21.5 14.4 39.6 Have another, undecided when 4.5 3.6 3.3 0.8 2.7 2.2 0.9 2.4 Undecided 1.9 4.7 4.3 8.9 5.6 7.5 5.3 5.5 Want no more 5.8 12.3 22.4 36.5 52.5 57.7 70.8 38.4 Declared infecund 0.6 0.8 0.1 2.0 2.5 4.5 5.0 2.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 160 346 383 310 266 213 402 2,079 1 Wants next birth within 2 years 2 Wants to delay next birth for 2 or more years 7.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS Table 7.2 shows the percentage of currently married women who want no more children by number of living children and background characteristics. Women living in urban areas are slightly more likely than women living in rural areas to want to stop childbearing (43 percent to 40 percent). This difference is more pronounced among those with 2-5 living children. Regional and district-level differentials are also notable. Currently married women in the Central Region are more likely to want to stop childbearing (45 percent) than those in the Northern or Southern Regions (38 percent each). Among districts, the proportion of women who want to stop childbearing ranges from 46 percent in Lilongwe to 29 percent in Mangochi. Blantyre, Kasungu, Salima, Thyolo, Mzimba, and Mulanje fall between 40-44 percent of women desiring no more children. Fertility Preferences and Unmet Need for Family Planning | 111 Table 7.2 Desire to limit childbearing Percentage of currently married women who want no more children, by number of living children and background characteristics, Malawi 2004 Number of living children 1Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 5.4 9.6 38.0 51.8 70.2 83.8 89.6 43.2 Rural 5.0 8.5 21.8 35.9 55.6 73.7 86.1 40.4 Region Northern 9.2 7.6 14.7 27.9 47.8 73.7 86.3 38.1 Central 4.5 9.0 28.0 40.8 67.1 78.7 89.7 45.0 Southern 4.7 8.8 24.7 39.2 52.7 71.6 83.2 38.0 District Blantyre 13.4 9.6 30.6 44.8 66.6 86.2 89.4 41.3 Kasungu 2.4 3.7 21.2 29.5 62.6 71.9 85.4 41.9 Machinga 0.0 8.5 20.2 17.4 40.2 61.2 78.0 32.1 Mangochi 4.4 7.0 14.2 30.2 27.1 47.5 72.3 28.7 Mzimba 14.1 6.2 15.1 32.4 46.2 77.3 88.0 39.5 Salima 0.0 8.6 16.8 34.8 57.5 74.9 95.4 40.2 Thyolo 6.8 10.8 26.6 39.8 59.0 70.8 85.6 40.3 Zomba 4.8 8.1 23.6 38.8 68.3 73.3 78.6 38.2 Lilongwe 4.0 8.3 32.5 46.4 73.4 86.5 94.1 45.9 Mulanje 2.2 6.0 29.0 47.1 69.2 83.8 93.0 44.3 Other districts 4.1 10.0 24.3 38.9 55.8 72.9 86.4 41.7 Education No education 9.9 14.7 26.2 35.7 50.7 69.2 84.4 49.8 Primary 1-4 5.1 6.7 21.5 32.9 59.1 73.3 84.6 38.7 Primary 5-8 4.3 6.4 22.8 40.5 62.0 82.5 91.9 38.4 Secondary+ 0.0 11.9 32.8 57.5 72.5 85.1 83.1 32.3 Wealth quintile Lowest 4.7 8.8 27.7 32.8 52.5 70.4 85.3 40.1 Second 8.3 7.6 22.3 37.0 55.7 75.4 86.7 39.5 Middle 1.6 5.7 19.9 32.4 57.8 70.3 84.2 38.1 Fourth 5.7 10.4 18.5 37.5 54.9 71.2 85.7 40.4 Highest 5.0 11.4 36.0 52.7 66.8 90.0 91.8 46.5 Total 5.1 8.8 24.7 38.5 57.7 74.9 86.5 40.9 Note: Women who have been sterili sed are considered to want no more children. 1 Includes current pregnancy The desire to limit childbearing appears to decline as the respondent’s education increases; this is because more educated women have, on average, much lower fertility (i.e., lower average parity). As such, interpretation of the relationship between education level and fertility preferences needs to be based on comparisons within parity categories. For example, for women with 6 or more children, there are minimal educational differentials, but at parities 3-5, the desire to limit childbearing increases with women’s education. There is no clear pattern with regard to the desire to limit childbearing by household wealth status, although women in the wealthiest quintile tend to be the most likely to report that they want to limit childbearing. Figure 7.1 shows the percentage of women with two living children who want no additional children, according to urban-rural residence, region, district, and education level. Urban women, women in the Central and Southern Regions, and women with secondary or higher education are more likely than other women to want to stop childbearing. Women in Lilongwe, Blantyre, 112 | Fertility Preferences and Unmet Need for Family Planning Mulanje, and Thyolo are more likely than women in other districts to want to stop childbearing at parity two. 7.3 UNMET NEED FOR FAMILY PLANNING Women who say either that they do not want any more children or that they want to wait two or more years before having another child, but in both cases are not using contraception, are considered to have an unmet need for family planning. Women who are using family planning methods are said to have a met need for family planning. Women with unmet need and those with met need together constitute the total demand for family planning, which can be categorised according to whether the need is for spacing or limiting births. Table 7.3 presents estimates of currently married women with unmet need, met need, and total demand for family planning services according to intention to space or limit births and by background characteristics. Twenty-eight percent of women have an unmet need for family planning services: 17 percent of women have an unmet need for spacing and 10 percent of women have an unmet need for limiting births. In Malawi the total demand1 for family planning among married women is 62 percent. This is about the same level of demand observed in the 2000 MDHS data (60 percent). At present, 55 percent of the demand for family planning is satisfied. 1 The total demand is comprised of unmet need and met need. The combination of unmet and met need is not always equal to the total demand (see footnote 3, Table 7.3). Figure 7.1 Percentage of Currently Married Women Who Have Two Children Who Want to End Childbearing 38 22 15 28 25 31 21 20 14 15 17 27 24 33 29 24 0 5 10 15 20 25 30 35 40 RESIDENCE Urban Rural REGION Northern Central Southern DISTRICT Blantyre Kasungu Machinga Mangochi Mzimba Salima Thyolo Zomba Lilongwe Mulanje Other districts Percent MDHS 2004 Fertility Preferences and Unmet Need for Family Planning | 113 Table 7.3 Need for family planning Percentage of currently married women with unmet need for family planning, and with met need for family planning, and the total de- mand for family planning, by background characteristics, Malawi 2004 Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning3 Background characteristic For spacing For limit ing Total For spacing For limit ing Total For spacing For limiting Total Percentage of demand satisfied Number of women Age 15-19 23.0 3.1 26.1 16.9 2.0 18.9 41.0 5.2 46.2 43.6 788 20-24 25.1 4.8 29.9 23.3 5.9 29.2 49.5 10.9 60.4 50.6 2,283 25-29 19.8 8.9 28.7 22.5 12.8 35.3 43.7 22.2 65.9 56.5 1,814 30-34 14.4 14.3 28.7 11.4 24.1 35.5 27.2 39.2 66.4 56.7 1,225 35-39 10.9 20.8 31.7 4.6 32.0 36.7 16.4 54.2 70.6 55.0 903 40-44 4.6 19.4 24.1 3.1 36.4 39.5 8.4 56.5 64.9 62.9 754 45-49 1.7 11.1 12.8 1.4 31.6 33.0 3.5 43.0 46.4 72.4 545 Residence Urban 13.3 9.7 23.0 15.8 21.4 37.2 29.7 32.2 61.9 62.8 1,337 Rural 18.0 10.5 28.5 15.4 16.2 31.6 34.6 27.1 61.7 53.8 6,975 Region Northern 15.9 7.2 23.1 22.2 19.0 41.2 41.0 26.9 68.0 66.0 1,087 Central 17.1 13.2 30.3 15.1 18.1 33.2 33.1 32.2 65.3 53.5 3,346 Southern 17.7 8.9 26.6 14.0 15.5 29.4 32.4 24.6 57.0 53.3 3,880 District Blantyre 13.7 7.5 21.2 15.9 20.6 36.5 30.0 28.2 58.2 63.6 643 Kasungu 13.9 12.5 26.4 19.8 18.6 38.4 35.8 31.4 67.1 60.7 385 Machinga 19.1 6.3 25.5 14.2 13.8 28.0 33.9 20.4 54.3 53.1 317 Mangochi 24.1 8.6 32.8 10.9 9.5 20.5 35.6 18.6 54.3 39.6 437 Mzimba 15.0 6.9 21.8 19.9 19.4 39.3 38.9 27.1 66.1 66.9 570 Salima 20.1 13.2 33.3 9.5 11.2 20.7 30.5 24.4 54.8 39.3 230 Thyolo 17.4 10.6 28.0 15.7 14.8 30.5 33.1 25.7 58.8 52.4 433 Zomba 17.5 8.4 25.9 16.0 15.9 32.0 34.7 24.7 59.4 56.4 436 Lilongwe 15.5 12.5 28.0 16.8 19.5 36.3 33.5 33.9 67.4 58.4 1,175 Mulanje 16.2 12.7 28.9 11.4 17.1 28.5 29.0 30.3 59.3 51.2 359 Other districts 18.1 11.0 29.1 15.1 16.9 32.1 34.0 28.2 62.2 53.2 3,326 Education No education 14.9 14.8 29.7 9.3 17.8 27.0 25.2 32.9 58.1 48.9 2,229 Primary 1-4 18.8 10.4 29.2 14.1 15.3 29.4 34.1 26.4 60.5 51.7 2,291 Primary 5-8 17.3 8.7 26.0 18.0 17.4 35.4 36.5 26.7 63.2 58.8 2,850 Secondary+ 18.6 5.2 23.8 25.9 18.3 44.2 45.4 23.7 69.1 65.6 940 Wealth quintile Lowest 19.6 12.4 31.9 12.4 12.9 25.3 32.6 25.7 58.3 45.2 1,256 Second 18.8 11.0 29.7 13.5 14.4 27.9 33.5 25.5 59.0 49.7 1,787 Middle 18.4 9.9 28.3 16.1 14.3 30.4 35.9 24.7 60.7 53.4 1,851 Fourth 17.3 10.0 27.3 18.3 18.4 36.7 37.1 28.7 65.8 58.5 1,779 Highest 12.5 9.3 21.8 16.1 24.5 40.6 29.0 35.2 64.2 66.1 1,640 Total 17.2 10.4 27.6 15.5 17.0 32.5 33.8 27.9 61.7 55.2 8,312 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrhoeic women who are not using family planning and whose last birth was mistimed, and fecund women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth unless they say it would not be a problem if they discovered they were pregnant in the next few weeks. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhoeic women whose last child was unwanted, and fecund women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are pregnant and amenorrhoeic women who be- came pregnant while using a method (these women are in need of a better method of contraception). 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 3 Nonusers who are pregnant or amenorrhoeic and whose pregnancy was the result of a contraceptive failure are not included in the category of unmet need, but are included in total demand for contraception (since they would have been using had their method not failed). Figure 7.2 illustrates the trend of unmet need, total demand, and demand satisfied for currently married women since the 1992 MDHS. The percentage of married women with unmet need for family planning has declined from 36 percent in 1992 to 28 percent in 2004, while the 114 | Fertility Preferences and Unmet Need for Family Planning total demand and percentage of demand satisfied has increased (26 percent in 1992 to 55 percent in 2004). Although there has been considerable progress, much more needs to be done to satisfy women’s demand for family planning. Table 7.3 shows that younger women have a higher unmet need for spacing births, while older women have a higher unmet need for limiting childbearing. While the overall demand for contraception is lowest among adolescents and women age 45-49 years, the percentage of demand satisfied is lowest among the adolescents (44 percent) and highest among women age 45-49 (72 percent). This indicates that young women are relatively underserved in Malawi. Total unmet need for family planning services is greater among rural women (29 percent) than among urban women (23 percent). Unmet need is higher in the Central Region (30 percent) than in the Southern or Northern Regions (27 and 23 percent, respectively). There is no difference in the total demand for family planning services for rural and urban women (62 percent each), but urban women are more likely to have their demand satisfied than their rural counterparts (63 and 54 percent, respectively). The demand for family planning is higher among women in the Northern Region (68 percent) than among women in the Central and Southern Regions (65 and 57 percent, respectively). Sixty-six percent of women in the Northern Region have their demand satisfied compared with 54 percent of women in the Central Region and 53 percent in the Southern Region. Unmet need is lower and met need is higher among women with some secondary or higher education when compared to women with less education. The overall demand for family planning services increases with the increasing level of education. Women with no education have a higher demand for family planning for limiting, while those with secondary or higher education have higher demand for family planning for spacing. The percentage of demand satisfied increases with the increasing level of education. Figure 7.2 Trend in Unmet Need for Family Planning, Total Demand, and Percentage of Demand Satisfied, Malawi 1992, 2000, and 2004 36 49 26 30 60 51 28 62 55 0 10 20 30 40 50 60 70 Unmet need Total demand Demand satisfied Percent 1992 MDHS 2000 MDHS 2004 MDHS Fertility Preferences and Unmet Need for Family Planning | 115 Among the districts, Salima and Mangochi have the highest levels of unmet need (33 percent) followed by Mulanje and other districts (29 percent). Total demand is highest among women in Kasungu and Lilongwe (67 percent each). Blantyre has the lowest unmet need (21 percent), while Machinga and Mangochi have the lowest levels of demand for family planning at 54 percent. The percentage of demand satisfied ranges from 39 percent in Salima to 67 percent in Mzimba. 7.4 IDEAL FAMILY SIZE Information on what men and women believe to be their ideal family size was elicited through two questions. Respondents who had no children were asked, “If you could choose exactly the number of children to have in your whole life, how many would that be?” For respondents who had children, the question was rephrased as follows: “If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?” Some respondents, especially those for whom fertility control is an unfamiliar concept, may have some difficulty in answering this hypothetical question. The results presented in Table 7.4 indicate that nearly all respondents were able to give a numeric response to this question: only 3-4 percent of men and women gave non-numeric responses like, “up to God” or “any number.” Slightly more than one-third of women and men (35 percent and 37 percent, respectively) said they would choose to have four children. The proportion of women and men who indicated that they would choose to have four or fewer children in Malawi has increased over time. This proportion was 38 percent for women and 45 percent for men in 1992, 64 percent for women and 69 percent for men in 2000, and 67 percent for women and 71 percent for men in 2004. 116 | Fertility Preferences and Unmet Need for Family Planning Table 7.4 Ideal number of children Percent distribution of all women and men by ideal number of children, and mean ideal number of children for all women and for currently married women, according to number of living children, Malawi 2004 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total WOMEN 0 2.8 0.5 0.8 0.4 1.8 1.1 2.7 1.4 1 2.7 3.3 0.6 0.9 0.3 0.3 0.1 1.4 2 30.3 21.9 13.3 7.0 4.5 3.6 2.8 14.3 3 20.4 23.2 18.4 14.5 5.3 6.0 4.2 15.0 4 29.5 34.8 45.7 44.3 40.4 23.2 22.1 35.1 5 7.2 9.1 11.4 18.8 21.0 24.7 13.2 13.5 6+ 3.3 5.4 7.8 12.1 23.5 36.9 46.4 15.8 Non-numeric responses 3.7 1.7 2.0 2.1 3.2 4.1 8.4 3.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,277 2,116 2,060 1,678 1,206 950 1,411 11,698 Mean ideal number children for 2: All women 3.1 3.4 3.8 4.2 4.6 5.2 5.6 4.1 Number 2,193 2,080 2,019 1,642 1,168 911 1,292 11,304 Currently married women 3.4 3.5 3.8 4.2 4.6 5.2 5.6 4.3 Number 417 1,629 1,691 1,405 1,001 783 1,104 8,030 MEN 0 1.0 0.0 0.0 0.0 1.1 0.0 0.2 0.5 1 0.8 0.2 0.1 0.0 0.0 0.0 0.5 0.4 2 21.0 18.6 11.2 5.9 4.8 3.0 4.3 13.4 3 28.9 29.6 19.7 16.0 3.5 6.2 6.3 20.1 4 32.4 37.2 46.9 45.8 43.0 34.5 27.4 36.5 5 9.3 10.0 15.2 17.5 17.5 26.5 14.5 13.4 6+ 4.0 2.4 5.5 8.7 20.0 25.8 36.6 11.3 Non-numeric responses 2.6 2.1 1.4 6.1 10.1 4.0 10.2 4.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,253 391 403 319 270 218 407 3,261 Mean ideal number children for2 : All men 3.4 3.5 4.1 4.1 4.6 4.8 5.5 4.0 Number 1,221 383 398 300 242 210 366 3,119 Currently married men 3.3 3.5 4.1 4.1 4.6 4.8 5.5 4.3 Number 158 338 377 291 238 204 362 1,969 1 Includes current pregnancy 2 Means are calculated excluding women/men giving non-numeric responses. Fertility Preferences and Unmet Need for Family Planning | 117 Survey findings show that women’s actual and ideal number of children are correlated. The average ideal family size among women with one child is 3.4 children, compared with 5.6 children among women with six or more children. There are two principal reasons for this pattern. First, to the extent that women are able to implement their fertility desires, women who want smaller families will tend to achieve smaller families. Second, some women may have difficulty admitting that they would have had fewer children if they could begin childbearing again. Such women are likely to report their actual number of children as their preferred number. Despite this tendency to rationalise, the 2004 MDHS data provide evidence of unwanted fertility; close to half (45 percent) of the women with six or more children said that ideally they would have liked fewer than six children. In general, men and women want families of a similar size. Currently married women and men want on average 4.3 children. For both men and women, there has been a decline of one child in the ideal family size since 1992. The average ideal family size for all women in 1992 was 5.1 children, in 2000 it was 5.0 children, and in 2004 it was 4.1 children. For all men, changes over time in ideal family size is sharper: it is 5.2 children in 1992, 4.8 children in 2000, and 4.0 children in 2004. Table 7.5.1 shows the mean ideal number of children for all women by age, according to background characteristics. The mean ideal family size increases with age, from 3.2 children for women age 15-19 to 5.3 children for women age 40-49. At every age, rural women have larger family size desires than urban women: the average ideal number of children in the rural areas is 4.2 children, compared to 3.4 children in urban areas. Small regional variations are observed in ideal family size. However, a woman’s education is strongly related to her ideal family size: as the woman’s level of education increases, her desired family size decreases. There is also a decline in ideal family size as wealth increases. All patterns observed for women hold true for men as well (Table 7.5.2). At the district level, the average ideal number of children for women ranges from 3.5 children for women in Blantyre to 4.5 children for women in Mangochi. For men, the corresponding figures are 3.5 children in Lilongwe to 4.5 children in Salima. 118 | Fertility Preferences and Unmet Need for Family Planning Table 7.5.1 Mean ideal number of children by background characteristics: women Mean ideal number of children for all women, by age and background characteristics, Malawi 2004 AgeBackground characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 All women Residence Urban 2.8 3.2 3.4 3.7 4.1 4.3 4.9 3.4 Rural 3.3 3.7 4.1 4.6 5.0 5.5 5.3 4.2 Region Northern 3.2 3.7 4.1 4.8 5.0 6.0 5.7 4.2 Central 3.3 3.5 3.9 4.4 4.7 5.2 4.9 4.0 Southern 3.2 3.6 4.0 4.4 5.1 5.1 5.4 4.1 District Blantyre 2.8 3.3 3.4 3.8 4.1 4.4 4.2 3.5 Kasungu 3.3 3.8 4.3 4.6 4.8 5.0 5.2 4.2 Machinga 3.4 3.9 4.5 4.7 5.4 4.7 5.4 4.4 Mangochi 3.4 3.9 4.7 4.7 5.7 5.7 5.9 4.5 Mzimba 3.0 3.6 4.0 4.6 4.8 5.6 5.9 4.1 Salima 3.6 3.9 4.3 4.6 4.8 5.6 5.6 4.3 Thyolo 3.1 3.7 4.1 4.8 4.9 5.1 5.6 4.1 Zomba 2.9 3.5 3.9 4.4 5.5 5.0 5.2 3.9 Lilongwe 3.1 3.2 3.6 4.1 4.3 4.6 4.0 3.6 Mulanje 3.2 3.6 3.9 4.3 4.7 5.0 5.2 4.0 Other districts 3.4 3.7 4.1 4.7 5.0 5.7 5.5 4.2 Education No education 3.5 4.0 4.4 4.8 5.3 5.6 5.3 4.8 Primary 1-4 3.3 3.9 4.2 4.5 5.0 5.3 5.3 4.2 Primary 5-8 3.3 3.6 4.0 4.4 4.6 5.2 5.4 3.9 Secondary+ 2.9 3.1 3.1 3.5 3.7 4.2 3.9 3.1 Wealth quintile Lowest 3.3 3.9 4.1 4.6 5.0 6.1 5.3 4.3 Second 3.5 3.9 4.3 4.7 5.4 5.3 5.3 4.3 Middle 3.4 3.7 4.3 4.6 5.0 5.5 5.3 4.2 Fourth 3.2 3.5 4.0 4.6 5.0 5.3 5.3 4.1 Highest 2.8 3.1 3.4 3.8 4.1 4.5 4.9 3.5 Total 3.2 3.6 4.0 4.5 4.9 5.3 5.3 4.1 Fertility Preferences and Unmet Need for Family Planning | 119 Table 7.5.2 Mean ideal number of children by background characteristics: men Mean ideal number of children for all men, by age and background characteristics, Malawi 2004 AgeBackground characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 All men Residence Urban 3.3 3.2 3.3 3.7 3.8 4.0 4.8 3.5 Rural 3.5 3.5 4.0 4.3 4.6 4.9 5.2 4.1 Region Northern 3.5 3.6 4.2 4.8 4.2 4.6 5.6 4.2 Central 3.6 3.3 3.8 3.9 4.5 4.6 4.6 3.9 Southern 3.4 3.5 3.8 4.1 4.5 5.0 5.4 4.0 District Blantyre 3.1 3.0 3.3 3.8 3.9 4.5 5.2 3.6 Kasungu 4.1 3.3 3.7 4.5 4.4 5.7 5.0 4.2 Machinga 3.5 3.6 3.6 4.2 4.6 5.0 4.9 4.0 Mangochi 4.3 3.7 4.1 4.3 4.0 5.0 4.2 4.2 Mzimba 3.3 3.5 3.8 4.3 4.6 4.9 5.3 4.0 Salima 4.2 3.2 4.4 4.3 5.1 5.1 5.6 4.5 Thyolo 2.9 3.5 3.7 4.2 4.3 4.7 6.8 4.0 Zomba 3.1 3.8 3.6 3.8 3.8 5.1 4.6 3.9 Lilongwe 3.3 3.3 3.1 3.5 4.5 4.1 3.9 3.5 Mulanje 3.3 3.5 3.9 4.1 5.2 5.2 3.7 4.1 Other districts 3.6 3.6 4.4 4.5 4.6 4.8 5.5 4.3 Education No education 4.0 3.6 4.1 4.3 4.5 4.7 4.8 4.4 Primary 1-4 3.9 3.8 4.6 4.4 5.1 5.2 5.6 4.5 Primary 5-8 3.4 3.4 3.9 4.4 4.5 4.9 5.1 4.0 Secondary+ 3.0 3.3 3.3 3.5 3.4 3.9 4.6 3.4 Wealth quintile Lowest 4.1 3.8 4.2 4.6 4.7 4.8 4.7 4.3 Second 3.5 3.6 4.7 4.5 4.6 5.2 6.0 4.3 Middle 3.6 3.6 3.9 4.3 4.8 5.1 5.2 4.2 Fourth 3.4 3.4 3.6 4.3 4.6 4.7 4.7 4.0 Highest 3.2 3.2 3.1 3.5 3.7 3.9 5.0 3.4 Total 3.5 3.5 3.9 4.1 4.5 4.8 5.1 4.0 7.5 WANTED AND UNWANTED FERTILITY There are two main ways of looking at the issue of unwanted fertility. In the first approach, responses to a question about children born in the five years preceding the survey (and any current pregnancy) are used to determine whether the pregnancy was planned (wanted then), wanted but at a later time (mistimed), or unwanted (not wanted at all). The answers to these questions provide some insight into the degree to which couples are able to control fertility. The second approach is asking the respondents their ideal family size. The difference between the actual fertility and the ideal family size is a measure of unwanted fertility. Table 7.6 shows the percent distribution of births (including current pregnancy) in the five years preceding the survey by fertility planning status, according to birth order and mother’s age at 120 | Fertility Preferences and Unmet Need for Family Planning birth. Sixty percent of the births in the five years preceding the survey were wanted at the time of conception, 21 percent were wanted later, and 20 percent were not wanted at all. The percentage of unwanted or mistimed births increases from 27 percent for first order births to 51 percent of fourth or higher order births. The proportion of births that were not wanted at all tends to increase with the woman’s age. The percentage of recent births that were not wanted increased from 14 percent in 1992 to 22 percent in 2000, then declined to 20 percent in 2004. Paradoxically, there was a substantial increase in the use of contraception between 1992 and 2000, compared with between 2000 and 2004. Table 7.6 Fertility planning status Percent distribution of births in the five years preceding the survey (including current pregnancies), by fertility planning status, according to birth order and mother's age at birth, Malawi 2004 Planning status of birthBirth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 72.5 13.4 13.9 0.2 100.0 2,862 2 63.8 22.8 13.3 0.1 100.0 2,506 3 60.2 24.5 15.0 0.3 100.0 1,949 4+ 49.3 22.0 28.7 0.1 100.0 4,867 Age at birth <20 67.1 17.6 15.1 0.2 100.0 2,433 20-24 63.9 21.3 14.6 0.2 100.0 4,177 25-29 58.5 23.8 17.5 0.2 100.0 2,536 30-34 52.8 20.5 26.7 0.0 100.0 1,648 35-39 42.5 20.8 36.7 0.0 100.0 911 40-44 41.5 11.4 46.9 0.3 100.0 401 45-49 44.7 8.2 47.0 0.0 100.0 78 Total 59.5 20.5 19.9 0.1 100.0 12,183 Table 7.7 shows the total wanted fertility rates and total actual fertility rates for the three years preceding the survey, by selected background characteristics. The wanted fertility rate is calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. (Women who did not report a numeric ideal family size were assumed to want all their births). The rate represents the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births were prevented. A comparison of the total wanted fertility rate and the actual total fertility rate suggests the potential demographic impact of the elimination of unwanted births. The total wanted fertility rate is 4.9 births per woman for Malawi as a whole, more than one child lower than the actual total fertility rate (6.0 births). The difference between wanted and actual total fertility is greatest among those subgroups of women who have the greatest unmet need for fertility control: rural women, less educated women, and women in the Central Region. In Mangochi, Machinga, and Kasungu Districts, the gap between wanted and actual total fertility is 1.2 children, 1.2 children, and 1.5 children, respectively. These districts have the highest total wanted fertility rate and total fertility rate. Fertility Preferences and Unmet Need for Family Planning | 121 An examination of women’s mean ideal number of children according to women’s status shows that the ability of a woman to participate in household decisionmaking, her opinion on justifications for refusing sex with her husband, and her opinion on justifications for wife beating are not associated with her ideal family size (data not shown). Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Malawi 2004 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 3.3 4.2 Rural 5.2 6.4 Region Northern 5.0 5.6 Central 5.0 6.4 Southern 4.8 5.8 District Blantyre 3.4 4.8 Kasungu 5.5 7.0 Machinga 5.8 7.0 Mangochi 6.0 7.2 Mzimba 4.9 5.5 Salima 5.5 6.8 Thyolo 4.9 5.7 Zomba 4.5 5.3 Lilongwe 4.3 5.7 Mulanje 4.7 5.6 Other districts 5.1 6.3 Education No education 5.6 6.9 Primary 1-4 5.3 6.6 Primary 5-8 4.8 5.8 Secondary+ 3.2 3.8 Wealth quintile Lowest 5.7 7.1 Second 5.6 7.0 Middle 5.2 6.5 Fourth 4.6 5.8 Highest 3.3 4.1 Total 4.9 6.0 Note: Rates are calculated based on births to women age 15- 49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Infant and Child Mortality | 123 INFANT AND CHILD MORTALITY 8 Macleod W. Mwale This chapter reports on levels, trends, and differentials in infant and child mortality based on the 2004 MDHS. The information on infant and child mortality is relevant to evaluating the pro- gress of health programmes and in monitoring the current demographic situation. In addition, the data can be used to identify subgroups of the population that have high mortality risks. The data for the calculation of mortality rates are collected in the reproduction section of the Women’s Questionnaire. The section begins with aggregate questions about the total number of sons and daughters who live with the mother, the number who live elsewhere, and the number who have died. Then a detailed birth history is administered. For each live birth, information is obtained on the child’s name, date of birth, sex, whether the birth was single or multiple, and survivorship status. For living children, information about his or her age at last birthday and whether the child resides with his or her mother is obtained. For children who had died, the respondent is asked to provide the age at death. 8.1 DEFINITIONS The mortality rates presented in this report are defined as follows: Neonatal mortality (NN): the probability of dying within the first month of life Postneonatal mortality PNN): the difference between infant and neonatal mortality Infant mortality (1q0): the probability of dying before the first birthday Child mortality (4q1): the probability of dying between the first and the fifth birthday Under-five mortality (5q0): the probability of dying between birth and the fifth birthday All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. Population censuses and demographic surveys are the major sources of mortality data in Ma- lawi, as in most developing countries. Vital registration is another potential source of mortality data. In Malawi, however, the vital registration data are incomplete in coverage and unrepresentative of the population. Mortality data from the Health Management Information System (HMIS) is not a suitable basis for the calculation of mortality rates from a population perspective because the system is facility-based and does not include data on deaths that occur outside the facilities. Given these cir- cumstances, birth history data from surveys provide the most reliable estimates of infant and child mortality for Malawi. 124 | Infant and Child Mortality 8.2 METHODOLOGICAL CONSIDERATIONS The DHS surveys estimate mortality rates for specific time periods preceding the survey, typically five-year periods, i.e., 0-4 years, 5-9 years, and so on. The estimates are based on births and infant and child deaths reported by women age 15-49 as of the interview date. Inherent in this methodology are possible biases arising from incomplete and possibly unrepresentative data. Since only surviving women age 15-49 are interviewed, no data are available for the children of women who have died. In this case, mortality estimates will be biased if the mortality experience of children born to surviving and nonsurviving women differs. Of course, any method of estimating childhood mortality rates that relies on retrospective reporting of events by mothers is susceptible to bias from this source. The higher the level of adult female mortality and the longer ago the time pe- riods for which mortality is estimated, the greater is the potential for bias. Another methodological constraint arises from the fact that women older than age 49 at the time of the survey are not interviewed and thus cannot contribute information on the exposure and deaths of their children for periods preceding the survey. This censoring of information and the re- sulting potential for bias becomes more severe as mortality estimates are made for time periods more distant prior to the survey. To reduce the effect of these methodological limitations, estimation of infant and child mortality in this report is restricted to the period 15 years prior to the survey. 8.3 ASSESSMENT OF DATA QUALITY Potential data collection problems include misreporting dates of birth, misreporting age at death, and underreporting of events. It is possible to test the birth history data collected in the 2004 MDHS for these kinds of errors. The testing involves checking the internal consistency of the col- lected data, essentially determining if the data conform to expected patterns. 8.3.1 Misreporting Dates of Birth The 2004 MDHS Women’s Questionnaire includes two sections on maternal and child health, in which data are collected on antenatal, delivery, and postnatal care of the mother for recent births and on many health and nutrition issues for these children (see Chapters 9 and 10). These sec- tions of the questionnaire must be administered for each birth which occurs after some cut-off date, typically set to January of the fifth calendar year prior to a survey. In the case of the 2004 MDHS, the cut-off date was January 1999. Interviewers in DHS surveys can lessen their workload by recording births that actually occur after the cut-off date as occurring before that date. This type of birth transference occurs in many DHS surveys. In the case of the 2004 MDHS, the occurrence of birth transference can be detected by inspecting the reported number of births in each calendar year before and after the cut-off date for the health sections. Appendix Table C.4 shows the relevant data. Substantial misreporting of dates of birth is evident in terms of the calendar year pattern of reported events: 1,575 total births for 1999 and 2,143 births for 1998 (an increase of 36 percent). Misreporting of dates of birth for nonsurviving children is even more severe: 233 for 1999 and 424 for 1998 (an increase of 82 per- cent). In terms of mortality analysis, what is important is the extent to which this birth transference distorts the time period in which child deaths occur. To the extent that birth transference results in a Infant and Child Mortality | 125 shortfall of deaths in the five-year period prior to the survey, the time trend of mortality estimates will be distorted; mortality rates for the most recent five years before the survey will tend to be un- derestimated, while the estimates for the earlier five-year period will tend be overestimated. This is the case with the MDHS 2004.1 8.3.2 Misreporting Age at Death Misreporting age at death can distort the age pattern of mortality. Of particular concern is the rounding of reported ages at death so that some deaths which actually occur in late infancy are reported as deaths at one year of age. This type of misreporting would tend to underestimate infant mortality rates and overestimate child mortality rates. To avoid this problem, interviewers in DHS surveys are instructed to collect age-at-death data in terms of months of age for children that die af- ter the first month of life but before two years of age. If a respondent reports the age at death as age one, the interviewer must probe to determine the number of months that the child lived, being par- ticularly careful to determine if the child died before or after the first birthday. This procedure of data collection is designed to minimise the misreporting of age at death and, if digit preference oc- curs in reported ages at death, it will be obvious from a frequency distribution of deaths by age in months. Appendix Table C.6 shows reported deaths by age at death in months (0 through 23 months of age) and the number of deaths reported as occurring at age one year.2 For the 15-year period im- mediately preceding the 2004 MDHS, the number of deaths reported at one year of age (422) ex- ceeds the total number reported at 12 through 23 months of age (403), indicating that interviewers did not follow standard DHS procedures and making it impossible to assess age at death misreport- ing by inspection of the distribution of deaths by months of age. However, the possibility of misreporting late infant deaths as deaths at one year of age can be indirectly assessed by comparison of the pattern of mortality between the first and the fifth birthday from the three DHS surveys conducted in Malawi (1992, 2000, and 2004). In each of the three sur- veys, the age pattern of mortality is similar, with infant mortality rates exceeding child mortality rates by between 10 and 24 percent. The absence of a significant change in the age pattern of mortality over the three surveys suggests that, relative to the earlier surveys, substantial age at death misreport- ing did not occur in the 2004 MDHS. 8.3.3 Underreporting of Deceased Children Underreporting of the births of deceased children (and their subsequent deaths) is always a concern when collecting birth histories of women. The women may not wish to report such sad events, and interviewers may fail to record some of these events for the five-year period preceding the survey in order to avoid asking questions contained in the maternal and child health sections of the questionnaire. When there is underreporting of births of deceased children, it is usually most pronounced in early infancy. If there is severe underreporting of neonatal deaths, the result would be an unusu- 1The extent to which the time trend of mortality is distorted by birth transference could be investigated by more detailed analysis. 2The number of deaths at one year of age should be minimal in DHS surveys because of the DHS procedure of probing to determine age at deaths in months when a respondent initially reports one year as the age at death. 126 | Infant and Child Mortality ally low ratio of neonatal deaths to all infant deaths. Appendix Table C.6 indicates that the percent- age of neonatal deaths relative to all infant deaths was lower in the five-year period immediately pre- ceding the survey (39 percent) than in the periods 5-9 years (43 percent) and 10-14 years preceding the survey (42 percent). These differences are not great, but the pattern is consistent with the under- reporting of deceased children in the five-year period immediately preceding the survey. This is espe- cially curious since the low ratio occurs in a time period of falling infant mortality, when neonatal mortality is expected to be a greater component of infant mortality. The assessment of data quality has found that standard DHS procedures were not followed in the collection of age-at-death data; that birth dates were misreported (especially in the case of non-surviving children), resulting in the transference of births out of the five-year period immedi- ately preceding the survey; and that the ratio of neonatal to infant mortality is unexpectedly lower for the five-years preceding the survey than for earlier time periods. For these reasons the mortality estimates from the 2004 MDHS must be interpreted with caution. 8.4 LEVELS AND TRENDS OF EARLY CHILDHOOD MORTALITY Table 8.1 presents estimates of childhood mortality for three five-year periods preceding the survey. For the most recent five-year period, corresponding approximately to 2000-2004, the infant mortality rate was 76 per 1,000 live births, and child mortality was 62 per 1,000, resulting in an overall under-five mortality rate of 133 per 1,000 live births. During the 15-year period preceding the survey, the estimates indicate that under-five mor- tality has declined by 30 percent (from 190 deaths per 1,000 to 133 per 1,000). Infant mortality de- clined by 27 percent (from 104 per 1,000 to 76 per 1,000). Neonatal mortality, however, declined by 36 percent (from 42 per 1,000 to 27 per 1,000). Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Malawi 2004 Years preceding the survey Approximate calendar period Neonatal mortality (NN)1 Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 2000-2004 27 49 76 62 133 5-9 1995-1999 49 64 112 84 187 10-14 1990-1994 42 62 104 96 190 1Computed as the difference between the infant and neonatal mortality rates The fact that the largest age-specific decline in mortality occurs in the neonatal period is in- consistent with the pattern of decline usually observed in developing countries. The usual pattern is greater decline in postneonatal mortality and child mortality than in neonatal mortality, because some of the causes of neonatal mortality (preterm delivery, injury at delivery, and congenital mal- formations) are the last to be alleviated in a developing country. Thus it is possible that births ending in neonatal deaths were underreported for the period immediately preceding the survey, as is sug- gested in the data quality assessment in Section 8.3.3. Infant and Child Mortality | 127 There are many causes of childhood mortality in the developing world, and their impact var- ies from one country to another. Similarly, increases and decreases in mortality for different age groups from infancy through early childhood can be a result of many factors. A detailed analysis of these factors is beyond the scope of this report, however, looking at the three MDHS surveys (1992, 2000, and 2004), it is apparent there has been little change in the factors typically associated with deceases in neonatal mortality. Among women giving birth in the five years preceding each survey, the percentage receiving antenatal care from a doctor or nurse/midwife was about the same (90, 91 and 93 percent, respectively), the percentage receiving tetanus toxoid during pregnancy was un- changed (85 percent in all three surveys), and the proportion of deliveries assisted by a doctor or nurse/midwife changed little (55, 56, and 57 percent) (see Chapter 9). 8.5 SOCIOECONOMIC DIFFERENTIALS IN CHILDHOOD MORTALITY The 2004 MDHS data allows the estimation of mortality levels by socioeconomic indicators (Table 8.2). A ten-year period (approximately 1995-2004) is used to calculate the mortality esti- mates in order to reduce the sampling variability for the subclasses of the indicators. Urban mortality rates are generally lower than rural rates; the under-five mortality rate is 116 per 1,000 in urban areas compared to 164 per 1,000 in rural areas. Comparing the three regions, the Northern Region has lower under-five mortality (120 per 1,000 live births), than either the Central (162 per 1,000) or the Southern Regions (164 per 1,000). Similarly, the infant mortality rate is low- est in the Northern Region (82 per 1,000), compared with either the Central Region (90 per 1,000) or the Southern Regions (98 per 1,000). These regional differences in mortality were also observed in the 1992 MDHS and the 2000 MDHS. Table 8.2 also presents childhood mortality rates for 10 oversampled districts. Under-five mortality is lowest in Mzimba (112 per 1,000) and Machinga (130 per 1,000) and is highest in Mu- lanje (221 per 1,000), Kasungu (192 per 1,000), and Thyolo (187 per 1,000). For infant mortality, the lowest rates are found in Lilongwe (73 per 1,000) and Machinga (78 per 1,000), while the high- est rates are also observed in Mulanje (145 per 1,000), Thyolo (119 per 1,000), and Kasungu (117 per 1,000). The 2004 MDHS shows the same relationship between mother’s education and child sur- vival as the 2000 MDHS. For every age interval, higher levels of education are generally strongly as- sociated with lower mortality risks. The same is true for the wealth index. 128 | Infant and Child Mortality Table 8.2 Early childhood mortality rates by background characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, Malawi 2004 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 22 38 60 60 116 Rural 39 59 98 74 164 Region Northern 39 44 82 41 120 Central 34 56 90 80 162 Southern 39 59 98 73 164 District Blantyre 46 43 90 69 153 Kasungu 56 61 117 85 192 Machinga 33 45 78 57 130 Mangochi 45 59 104 70 167 Mzimba 38 41 80 36 112 Salima 25 59 84 76 154 Thyolo 43 76 119 77 187 Zomba 31 53 84 66 144 Lilongwe 21 52 73 78 145 Mulanje 55 89 145 89 221 Other districts 36 55 91 74 158 Education No education 36 65 101 89 181 Primary 1-4 39 61 101 77 170 Primary 5-8 38 46 85 59 139 Secondary+ 25 38 63 25 86 Wealth quintile Lowest 36 73 109 83 183 Second 41 58 100 79 171 Middle 40 55 95 82 168 Fourth 36 54 89 62 146 Highest 29 37 66 49 111 1Computed as the difference between the infant and neonatal mortality rates 8.6 BIODEMOGRAPHIC DIFFERENTIALS IN CHILDHOOD MORTALITY This section looks at the association between biodemographic factors and childhood mortal- ity levels (Table 8.3). With the exception of the mother’s perception of birth size, mortality rates are presented for the ten-year period preceding the survey. As is the case in most populations, male children are more likely to die before reaching the age of five (166 per 1,000 live births) than female children (149 per 1,000). The mother’s age at birth is also associated with a child’s chances of survival. Children born to younger mothers (under 20 years of age) and older mothers (40 years and older) have higher mor- Infant and Child Mortality | 129 tality than children born to mothers in the middle reproductive years (ages 20-39). Children of mothers under age of 20 are especially vulnerable, particularly in the first month of life. Neonatal mortality is 56 deaths per 1,000 among children of teenage mothers, compared with 29 per 1,000 among children of women age 20-29. There is a strong association between the length of the preceding birth interval and mortal- ity. Under-five mortality of children born following a short birth interval (less than two years) is 67 percent greater than for children born after an interval of 2 years and 162 percent greater than for children born after an interval of 4 years. This relative mortality disadvantage of children born after a short birth interval is even more pronounced during the neonatal period. In the 2004 MDHS, mothers were also asked their perception of the size of their child at birth for births occurring in the five years preceding the survey. The findings indicate children per- ceived by their mothers to be small or very small were much more likely to die in the first year of life (121 per 1,000 live births) than those perceived as average or large in size (65 per 1,000 live births). Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Malawi 2004 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 42 55 97 76 166 Female 32 56 88 67 149 Mother's age at birth <20 56 66 121 78 190 20-29 29 53 82 72 148 30-39 34 54 88 63 145 40-49 48 44 92 76 161 Birth order 1 47 61 108 72 172 2-3 33 53 87 71 151 4-6 26 52 78 69 141 7+ 51 63 114 80 185 Previous birth interval2 <2 years 62 92 154 112 249 2 years 31 54 85 70 149 3 years 22 34 56 57 110 4+ years 20 35 55 43 95 Birth size3 Small/very small 52 69 121 na na Average or larger 21 44 65 na na na = Not applicable 1Computed as the difference between the infant and neonatal mortality rates 2Excludes first-order births 3Rates for the five-year period before the survey 130 | Infant and Child Mortality 8.7 CHILDHOOD MORTALITY BY WOMEN’S STATUS The ability to access information, make decisions, and act effectively in their own interest, or the interest of those who depend on them, are essential aspects of women’s empowerment. If women, the primary caretakers of children, are empowered, the health and survival of their infants is likely to be enhanced. Table 8.4 shows infant and child mortality rates in relation to women’s status as measured by three empowerment indicators: participation in household decisionmaking, attitude towards a woman being able to refuse to have sex with her husband, and attitude towards wife beat- ing. There is no consistent relationship between levels of mortality and the first two empower- ment indicators: participation in household decisionmaking and number of reasons justifying a woman’s refusal to have sex with her husband. However, there does appear to be a relationship in the case of attitude towards wife beating. For example, among women reporting fewer reasons justi- fying wife beating (i.e., more empowered women) under-five mortality is lower (approximately 150 per 1,000) than among women reporting more reasons justifying wife beating (approximately 180 per 1,000). Table 8.4 Early childhood mortality rates by women's status Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preced- ing the survey, by women's status indicators, Malawi 2004 Women's status indicators Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which woman has final say2 0 38 51 89 75 158 1-2 36 59 95 79 166 3-4 37 48 85 58 138 5 38 61 99 68 160 Number of reasons to refuse sex with husband 0 28 57 85 79 157 1-2 33 61 94 75 162 3-4 39 54 93 70 157 Number of reasons wife beat- ing is justified 0 36 56 92 71 156 1-2 39 49 89 66 149 3-4 37 69 106 78 176 5 37 61 98 95 184 1Computed as the difference between the infant and neonatal mortality rates 2Either by herself or jointly with others Infant and Child Mortality | 131 8.8 PERINATAL MORTALITY The 2004 MDHS survey also asked women to report on their pregnancy losses in the five-year period preceding the survey and the gestational age of each lost pregnancy. In this report, perinatal deaths include pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths to live births less than seven days old (early neonatal deaths). The perinatal mortality rate is the sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies reaching seven months’ gestation. The causes of stillbirths and early neonatal deaths overlap, and examining just one or the other can un- derstate the true level of mortality around de- livery. For this reason, stillbirths and early neonatal mortality are combined and examined together. Table 8.5 shows the number of still- births, the number of early neonatal deaths, and the perinatal mortality rates for the five- year period preceding the survey by back- ground characteristics. The perinatal mortality rate is 34 per 1,000. This is lower than the rate measured in the 2000 MDHS (46 per 1,000). By demographic characteristics, there is a clear pattern of elevated perinatal mortality among women younger than 20 and 40 and older. First pregnancies and pregnancies with a short preceding interpregnancy interval are also at an elevated risk of perinatal mortality. First pregnancies and pregnancies with an in- terpregnancy interval of less than 27 months have a perinatal risk of approximate 46 per 1,000, as opposed to a risk of approximately 25 per 1,000 when the interpregnancy interval is 27 months or longer. Differences in perinatal mortality by urban-rural residence are substantial. The urban perinatal mortality rate (15 per 1,000) is less than half that of the rural rate (37 per 1,000). Differences by district range from 15 per 1,000 (Lilongwe) to 40 per 1,000 (Mulange). Differences by region and mother’s characteristics are much less pro- nounced. Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortal- ity rate (per 1,000 pregnancies) for the five-year period preceding the survey, by background characteristics, Malawi 2004 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 45 63 48 2,249 20-29 73 91 28 5,963 30-39 39 42 35 2,293 40-49 11 8 (43) 434 Previous pregnancy interval in months First pregnancy 51 62 46 2,465 <15 7 12 (47) 390 15-26 38 53 45 2,028 27-38 33 36 24 2,902 39+ 38 42 25 3,155 Residence Urban 9 13 15 1,434 Rural 159 191 37 9,505 Region Northern 24 31 40 1,369 Central 72 75 32 4,566 Southern 72 99 34 5,005 District Blantyre 7 12 26 731 Kasungu 10 15 48 536 Machinga 7 11 39 447 Mangochi 12 15 42 648 Mzimba 10 16 39 686 Salima 4 4 25 316 Thyolo 7 12 33 582 Zomba 7 14 39 552 Lilongwe 12 11 15 1,501 Mulanje 7 16 50 444 Other districts 84 78 36 4,498 Education No education 48 46 32 2,951 Primary 1-4 63 59 39 3,165 Secondary 5-8 47 79 34 3,685 Secondary + 9 20 26 1,136 Wealth quintile Lowest 28 23 24 2,127 Second 59 52 45 2,485 Middle 31 56 35 2,477 Fourth 25 47 34 2,116 Highest 26 26 30 1,735 Total 168 204 34 10,939 Note: Rates in parentheses are based on 250-499 pregnancies 1Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2Early neonatal deaths are deaths at age 0-6 days among live-born chil- dren. 3The sum of the number of stillbirths and early neonatal deaths dvided by the number of pregnancies of seven or more months’ duration. 132 | Infant and Child Mortality 8.9 HIGH-RISK FERTILITY BEHAVIOUR Numerous studies have demonstrated a strong relationship between a woman’s pattern of fertility and her children’s survival. Table 8.6 shows the distribution of children born in the five years preceding the survey (approximately calendar years 2000-2004) by category of increased risk of dying due to the woman’s fertility behaviour, i.e., in terms of being relatively young or relatively old at the time of birth (less than age 18 or age 35 or older), having a high birth order (birth order 4 or higher), or having a short preceding birth interval (less than 24 months). Column one of Table 8.6 shows the percentage of births during the five years before the survey that fall into various risk categories. More than half of all births (53 percent) fall into a single or multiple high-risk category, with 16 percent falling into a multiple high-risk category. The risk ratios for categories of births in the last five years are pre- sented in column two: the risk ratio is the ratio of the proportion dead among live births in a specific high-risk cate- gory to the proportion dead among births not in any high-risk category. Two points merit comment. First, in Malawi, high birth order as a single- risk factor is not associated with higher mortality risk. The only single high- risk factors leading to heightened mor- tality risk are young age at birth and short birth interval. Second, short birth interval coupled with another high-risk factor always results in a risk ratio in excess of 2.0. This latter finding under- scores the need to reduce, through greater use of contraception, the num- ber of closely spaced births in Malawi. Column three of Table 8.6 in- dicates the potential for high-risk births among currently married, non- sterilised women at the time of the sur- vey. The table shows the distribution of risk categories into which a birth would fall if all of these women con- ceived at the time of the survey. Thirty-five percent of married women have the potential to give birth to a child that falls into a multiple high-risk category. Table 8.6 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Malawi 2004 Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women1 Not in any high-risk category 30.0 1.00 25.1a Unavoidable risk category First order births between ages 18 and 34 years 16.8 1.21 6.0 Single high-risk category Mother's age <18 7.2 1.76 0.9 Mother's age >34 0.3 (0.94) 2.1 Birth interval <24 months 5.3 1.49 12.9 Birth order >3 24.1 0.97 17.9 Subtotal 36.9 1.20 33.9 Multiple high-risk category Age <18 & birth interval <24 months2 0.4 3.45 0.4 Age >34 & birth interval <24 months 0.0 na 0.0 Age >34 & birth order >3 10.1 0.90 16.9 Age >34 & birth interval <24 months & birth order >3 1.2 2.95 4.8 Birth interval <24 months and birth order >3 4.5 2.12 13.0 Subtotal 16.2 1.46 35.0 In any avoidable high-risk category 53.2 1.28 68.9 Total 100.0 na 100.0 Number of births 10,773 na 8,312 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 1Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2Includes the category age <18 and birth order >3 aIncludes sterilised women Maternal and Child Health | 133 MATERNAL AND CHILD HEALTH 9 Ann Phoya and Sophie Kang’oma This chapter presents the 2004 MDHS findings on maternal and child health in Malawi. Topics discussed include the utilisation of maternal and child health services; maternal and childhood immunisations; common childhood illnesses and their treatment; barriers to obtaining health care; ability to negotiate sex; and attitudes towards family violence. Combined with information on childhood mortality, this information can be used to identify women and children who are at risk because of nonuse of health services and to provide information that would assist in planning interventions to improve maternal and child health. The results presented in the following sections are based on data collected from mothers on all live births that occurred in the five years preceding the survey. 9.1 ANTENATAL CARE Table 9.1 shows the percent distribution of women who had a live birth in the five years preceding the survey and used antenatal care (ANC) services. Overall, there has been no change in the coverage of ANC from a medical professional since 2000 (93 percent). Most women receive ANC from a nurse or a midwife (82 percent); 10 percent of pregnant women went to see a doctor for ANC. Maternal age at birth and the birth order of the child are not strongly related to the practice of ANC. Urban women are more likely to have seen a health professional for antenatal services than women living in rural areas, though rural women are slightly more likely to have seen a doctor. The use of antenatal services is strongly associated with level of education and wealth. While 8 percent of women with no education had no antenatal care, the proportion among women with some secondary or higher education is only 2 percent. However, women with no education are slightly more likely than women with secondary education to receive antenatal care from a doctor/clinical officer (10 percent compared with 8 percent). This is the reverse of the situation observed in the 2000 DHS, where women with secondary or higher education are slightly more likely than women with less education to receive care from a doctor/clinical officer (10 percent compared with 9 percent). Use of antenatal services varies among districts. Women receive ANC from health care providers most commonly in Mzimba, Blantyre, Salima, and Zomba (96 to 98 percent). However, lack of any antenatal care is as high as 6 to 7 percent in Lilongwe and Mangochi. The high level of nonuse of antenatal services in Lilongwe is also recorded in the 2000 MDHS (7 percent). Variations in the utilisation of doctors for antenatal care continue to persist among districts. As reported in the 2000 MDHS, women in Salima are more likely to go to a doctor for antenatal care than women in other districts (28 percent). However, this observation should be viewed with caution because the definition among respondents of what constitutes a “doctor” is loose and may vary by locality. Benefits of antenatal care in influencing outcomes of pregnancy depend to a large extent on the timing of the antenatal care as well as the content and quality of the services provided. In 134 | Maternal and Child Health Malawi, women are advised to have a minimum of four ANC visits spread throughout the pregnancy, with the first visit in the first trimester. Table 9.1 Antenatal care Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during preg- nancy for the most recent birth, according to background characteristics, Malawi 2004 Background characteristic Doctor/ clinical officer Nurse/ midwife Patient attendant Traditional birth attendant/ other No one Missing Total Number of women Age at birth <20 10.0 82.5 0.9 2.3 4.3 0.1 100.0 1,293 20-34 10.0 82.4 1.0 1.8 4.6 0.2 100.0 4,979 35-49 8.8 81.9 1.2 2.4 5.5 0.2 100.0 1,000 Birth order 1 10.1 83.7 0.5 1.8 3.9 0.0 100.0 1,518 2-3 9.8 83.1 1.1 1.8 4.0 0.3 100.0 2,659 4-5 10.0 81.7 1.1 1.9 5.0 0.2 100.0 1,622 6+ 9.5 80.3 1.1 2.8 6.1 0.2 100.0 1,473 Residence Urban 6.8 90.8 0.3 0.1 1.9 0.1 100.0 1,041 Rural 10.3 80.9 1.1 2.3 5.1 0.2 100.0 6,231 Region Northern 8.3 87.1 0.4 0.6 3.5 0.1 100.0 924 Central 11.4 79.5 0.5 1.7 6.6 0.3 100.0 2,959 Southern 8.9 83.5 1.6 2.6 3.2 0.1 100.0 3,389 District Blantyre 5.1 92.2 0.2 1.4 1.1 0.0 100.0 520 Kasungu 18.2 72.4 0.7 3.8 4.8 0.1 100.0 330 Machinga 4.7 81.1 7.6 4.0 2.3 0.3 100.0 284 Mangochi 17.9 73.3 1.1 1.8 6.0 0.0 100.0 411 Mzimba 5.8 91.0 0.4 0.2 2.5 0.1 100.0 464 Salima 28.1 68.4 0.0 0.8 2.5 0.2 100.0 199 Thyolo 10.0 80.9 0.2 5.2 3.4 0.3 100.0 386 Zomba 6.0 89.7 1.4 2.2 0.6 0.2 100.0 389 Lilongwe 3.4 88.3 0.0 1.4 6.5 0.5 100.0 1,013 Mulanje 10.4 79.0 1.1 7.0 1.9 0.8 100.0 296 Other districts 11.1 80.2 1.0 1.4 6.1 0.1 100.0 2,981 Education No education 10.3 76.2 1.6 3.2 8.4 0.2 100.0 1,885 Primary 1-4 11.0 80.2 0.9 2.8 4.8 0.3 100.0 2,021 Primary 5-8 9.1 86.3 0.7 1.0 2.7 0.2 100.0 2,485 Secondary+ 8.1 89.3 0.5 0.3 1.7 0.2 100.0 880 Wealth quintile Lowest 10.6 78.1 1.0 2.5 7.4 0.4 100.0 1,380 Second 11.0 78.8 1.6 2.7 5.5 0.3 100.0 1,579 Middle 10.4 80.7 1.0 2.6 5.0 0.2 100.0 1,610 Fourth 9.0 85.9 0.7 1.2 3.1 0.0 100.0 1,432 Highest 7.7 89.5 0.3 0.7 1.8 0.1 100.0 1,271 Total 9.8 82.3 1.0 2.0 4.6 0.2 100.0 7,271 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. Maternal and Child Health | 135 Table 9.2 presents information about the number and timing of ANC visits. For 57 percent of births, mothers meet the recommended number of four or more antenatal care visits. This is the same level reported in the 2000 MDHS. Women in urban areas are more likely than rural women to go for antenatal care visits. Messages regarding the importance of initiating antenatal care in the first trimester have not made a significant impact on the timing of antenatal care. Table 9.2 shows that only 8 percent of women initiated antenatal care before the fourth month of pregnancy, about the same as found in the 2000 MDHS (7 percent). While urban women make more frequent visits for antenatal care than rural women, they initiate the ANC visit at about the same time as their rural counterparts (5.8-5.9 months). The persistent delay in initiating antenatal care indicates that a large proportion of pregnant women in Malawi miss out on intended benefits of early antenatal care services. Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent birth, and by the timing of the first visit according to residence, Malawi 2004 Residence Number and timing of ANC visits Urban Rural Total Number of ANC visits None 1.9 5.1 4.6 1 3.4 2.3 2.5 2-3 28.7 36.2 35.2 4+ 65.2 55.7 57.1 Don't know/missing 0.9 0.6 0.7 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.9 5.1 4.6 <4 9.4 7.4 7.7 4-5 46.3 43.0 43.5 6-7 39.3 41.5 41.2 8+ 3.1 2.7 2.8 Don't know/missing 0.0 0.3 0.3 Total 100.0 100.0 100.0 Median months pregnant at first visit (for those with ANC) 5.8 5.9 5.9 Number of women 1,041 6,231 7,271 In addition to the number and timing of ANC visits, another important aspect of antenatal care is the content and quality of services. Women who received antenatal care in the five years preceding the survey were asked what services they received. The limited content of antenatal care services in Malawi indicates that women are not getting the care that would assist in the identification and management of complications that can have a negative impact on the mother and her baby. Table 9.3 shows that seven in ten women report that they were told about pregnancy complications and where to go in case of problems during pregnancy. The most frequent checks for 136 | Maternal and Child Health Table 9.3 Components of antenatal care Percentage of women with a live birth in the five years preceding the survey who received antenatal care for the most recent birth, by content of antenatal care, and percentage of women with a live birth in the five years preceding the survey who received iron tablets or syrup or antimalarial drugs for the most recent birth, according to background characteristics, Malawi 2004 Among women who received antenatal care Background characteristic Informed of signs of pregnancy complica- tions Informed where to go with complica- tions Weight measured Height measured Blood pressure measured Urine sample taken Blood sample taken Heart beat Eye exam Number of women Received iron tablets or syrup Received anti- malarial drugs Number of women Age at birth <20 64.1 61.1 94.7 40.9 70.6 17.4 33.9 90.2 60.1 1,237 80.5 75.2 1,293 20-34 71.5 68.4 94.8 40.4 78.9 21.4 36.1 90.8 66.2 4,750 79.5 82.8 4,979 35-49 72.5 69.6 95.0 44.6 82.4 21.1 37.2 89.8 69.6 943 77.3 77.1 1,000 Birth order 1 67.5 64.4 95.1 41.9 73.7 22.3 37.9 92.1 60.7 1,458 82.4 77.5 1,518 2-3 70.4 67.5 94.8 41.8 78.3 20.9 35.2 90.0 65.6 2,552 80.7 82.4 2,659 4-5 70.0 67.0 94.8 39.9 79.5 20.8 35.0 89.6 65.7 1,537 77.0 81.8 1,622 6+ 73.4 70.1 94.5 40.0 80.0 18.5 35.8 91.0 70.4 1,383 76.4 79.4 1,473 Residence Urban 71.1 68.8 96.5 57.6 89.3 39.7 57.4 94.1 73.9 1,021 83.4 86.7 1,041 Rural 70.2 67.0 94.5 38.2 75.9 17.4 32.1 89.9 64.1 5,909 78.7 79.6 6,231 Region Northern 76.1 74.2 93.4 37.5 85.7 23.1 47.2 86.1 58.6 891 91.2 86.6 924 Central 66.6 63.5 94.5 32.6 78.8 22.4 32.0 88.9 65.4 2,763 75.9 77.9 2,959 Southern 71.8 68.5 95.5 49.1 75.0 18.6 36.0 93.1 67.5 3,276 79.2 81.4 3,389 District Blantyre 73.4 66.7 96.8 58.0 78.3 16.7 33.3 94.2 73.8 514 78.1 87.0 520 Kasungu 67.6 65.7 94.9 23.4 76.2 7.2 14.1 85.6 71.6 314 84.1 78.2 330 Machinga 67.7 65.2 96.0 50.5 62.6 15.3 20.3 88.6 70.1 277 72.7 79.6 284 Mangochi 66.6 63.3 94.5 46.6 75.1 22.0 29.0 85.0 65.5 386 70.6 67.2 411 Mzimba 79.7 77.5 93.0 40.9 90.5 23.1 44.1 79.4 58.4 452 91.5 88.9 464 Salima 77.4 73.6 97.4 44.6 87.1 18.0 28.8 88.7 62.9 193 74.0 87.1 199 Thyolo 84.4 82.4 93.1 47.2 74.6 24.1 38.0 94.7 73.5 372 84.9 81.2 386 Zomba 77.7 74.3 97.1 62.0 84.6 34.2 58.4 97.1 62.2 386 84.4 88.5 389 Lilongwe 61.9 60.1 96.1 38.5 86.1 37.1 44.9 91.2 65.9 947 72.2 76.8 1,013 Mulanje 68.8 66.6 91.4 45.0 68.1 7.6 15.9 94.9 58.1 290 82.3 82.1 296 Other districts 68.9 65.7 94.3 34.7 75.0 16.6 36.0 91.2 64.3 2,799 80.2 80.1 2,981 Education No education 64.9 60.8 93.4 39.9 75.4 18.1 32.2 88.0 62.8 1,725 72.2 70.8 1,885 Primary 1-4 66.4 63.4 94.4 39.4 74.6 18.1 31.3 91.4 66.4 1,923 78.3 78.0 2,021 Primary 5-8 73.5 71.1 95.2 40.7 79.8 19.9 36.9 90.6 65.9 2,416 83.5 86.7 2,485 Secondary+ 80.5 78.3 97.4 47.8 84.9 33.9 50.1 93.6 68.1 864 85.6 90.8 880 Wealth quintile Lowest 64.8 61.3 92.9 35.9 73.5 15.7 30.2 89.2 67.2 1,278 77.2 77.0 1,380 Second 67.0 64.0 92.8 37.6 73.8 17.5 31.3 89.2 62.6 1,491 75.7 75.4 1,579 Middle 72.1 68.9 94.8 39.8 76.1 16.1 31.1 90.8 61.6 1,526 79.2 78.0 1,610 Fourth 72.4 69.7 96.5 39.6 79.4 20.1 37.5 91.0 63.9 1,386 81.5 84.6 1,432 Highest 75.2 72.7 97.2 53.6 87.8 35.9 51.1 92.8 73.9 1,248 84.2 90.0 1,271 Total 70.3 67.3 94.8 41.1 77.9 20.7 35.9 90.6 65.5 6,930 79.4 80.7 7,271 pregnant women during an antenatal visit are measuring weight (95 percent) and blood pressure (78 percent). Blood samples were taken from 36 percent of women, and a urine sample was collected from 21 percent of pregnant women. For nine in ten women, the baby’s heartbeat was checked; for two in three women, their eyes were examined during an antenatal visit for their most recent birth. These figures, as well as the coverage of iron supplementation and antimalarial treatments, are similar to those found in the 2000 MDHS, suggesting that there is no improvement in the utilisation of health services for expectant mothers. Maternal and Child Health | 137 There are variations in the provision of services during antenatal visits across subgroups of women. In general, women in urban areas, in the Northern Region, more educated women and women in the highest wealth quintile are more likely than other women to receive quality care during pregnancy. At the district level, the content of antenatal care varies widely. Blood pressure measurements were taken for only 63 percent of women in Machinga. The collection of blood and urine samples is even less common. The collection of blood samples ranges from 14 percent of women in Kasungu to 58 percent in Zomba. Women in Zomba seem to get the best antenatal care services based on the types of checks during pregnancy. Table 9.4 shows that 85 percent of women who had a birth in the five years preceding the survey report that they received at least one tetanus toxoid injection during the pregnancy. The coverage of tetanus toxoid injection has not changed since 1992 (85-86 percent). Table 9.4 also shows that only 66 percent of women had two or more tetanus toxoid injections. This figure is lower than that reported in the 1992 MDHS (73 percent). Younger women, women pregnant with their first child, and women who live in urban areas are more likely to have received two or more doses of tetanus toxoid injections. Women with secondary or higher education and women in the highest wealth quintile are also more likely than other women to have two or more tetanus toxoid injections. Across districts, coverage of two or more doses of tetanus toxoid is 59 to 60 percent in Mulanje, Kasungu, and Thyolo and 74 to 75 percent in Mangochi and Salima. Table 9.4 Tetanus toxoid injections Percent distribution of women who had a live birth in the five years preceding the sur- vey by number of tetanus toxoid injections received during pregnancy for the most recent birth, according to background characteristics, Malawi 2004 Background characteristic None One injection Two or more injections Don't know/ missing Total Number of women Age at birth <20 12.2 16.5 70.7 0.6 100.0 1,293 20-34 14.8 19.3 65.4 0.6 100.0 4,979 35-49 18.3 16.4 64.7 0.7 100.0 1,000 Birth order 1 11.1 15.6 72.8 0.5 100.0 1,518 2-3 12.7 19.6 66.8 0.8 100.0 2,659 4-5 17.5 20.2 62.1 0.1 100.0 1,622 6+ 19.4 17.0 62.8 0.8 100.0 1,473 Residence Urban 9.6 18.5 71.5 0.4 100.0 1,041 Rural 15.7 18.4 65.3 0.6 100.0 6,231 Region Northern 14.2 18.3 67.2 0.3 100.0 924 Central 15.2 16.5 67.6 0.6 100.0 2,959 Southern 14.6 20.0 64.7 0.6 100.0 3,389 District Blantyre 15.0 16.4 67.7 0.8 100.0 520 Kasungu 20.9 17.5 60.4 1.2 100.0 330 Machinga 17.4 20.2 62.2 0.2 100.0 284 Mangochi 9.0 16.1 74.2 0.7 100.0 411 Mzimba 14.8 16.6 68.4 0.2 100.0 464 Salima 7.7 16.8 75.2 0.4 100.0 199 Thyolo 19.0 20.7 60.1 0.2 100.0 386 Zomba 11.2 21.7 66.5 0.6 100.0 389 Lilongwe 14.5 16.4 68.9 0.2 100.0 1,013 Mulanje 16.2 24.2 59.2 0.4 100.0 296 Other districts 15.0 18.7 65.5 0.8 100.0 2,981 Education No education 18.6 16.0 64.7 0.6 100.0 1,885 Primary 1-4 14.9 19.2 65.3 0.6 100.0 2,021 Primary 5-8 13.8 20.0 65.8 0.4 100.0 2,485 Secondary+ 9.3 17.0 72.7 1.1 100.0 880 Wealth quintile Lowest 15.7 19.8 64.2 0.3 100.0 1,380 Second 16.6 16.8 65.7 0.8 100.0 1,579 Middle 14.8 18.6 66.1 0.4 100.0 1,610 Fourth 14.8 17.5 67.2 0.5 100.0 1,432 Highest 11.5 19.6 68.0 0.9 100.0 1,271 Total 14.8 18.4 66.2 0.6 100.0 7,271 138 | Maternal and Child Health The aim of antenatal care is to minimise adverse maternal and fetal outcomes of pregnancy. Data in Table 9.5 and Figure 9.1 show that common complications among women are high blood pressure (14 percent) and swollen feet (13 percent), both indications of pre-eclampsia. Anaemia is reported by 12 percent of women, and 6 percent of women report experiencing bleeding during pregnancy. It is important to note that the data show self-reported complications as opposed to medically documented problems. Table 9.5 Complications during pregnancy Among women who had a birth in the five years preceding the survey, percentage who had specific com- plications associated with the pregnancy leading to the most recent birth, by background characteristics, Malawi 2004 Background characteristic High blood pressure Swollen feet Anaemia Bleeding Number of women Number of ANC visits None na na na na 337 1-3 13.9 12.7 12.1 5.7 3,703 4+ 15.5 15.2 13.2 6.1 3,184 Age at birth <20 13.9 10.7 12.9 5.4 1,293 20-34 13.8 12.8 12.0 5.2 4,979 35-49 15.3 18.2 11.1 7.8 1,000 Birth order 1 14.1 12.9 13.6 5.5 1,518 2-3 13.5 10.9 11.1 4.6 2,659 4-5 13.5 13.4 12.6 6.0 1,622 6+ 15.5 17.3 11.5 7.0 1,473 Residence Urban 11.9 12.4 7.7 4.2 1,041 Rural 14.4 13.3 12.8 5.8 6,231 Region Northern 11.9 11.9 11.2 4.4 924 Central 16.6 15.6 14.8 6.2 2,959 Southern 12.3 11.4 9.9 5.4 3,389 District Blantyre 15.8 13.1 10.6 10.9 520 Kasungu 18.9 18.1 20.7 7.1 330 Machinga 8.4 8.4 7.4 2.8 284 Mangochi 16.4 15.7 12.7 5.2 411 Mzimba 12.1 12.6 13.6 5.1 464 Salima 17.7 15.5 15.4 5.7 199 Thyolo 14.0 8.9 10.9 5.7 386 Zomba 13.6 13.7 8.3 4.9 389 Lilongwe 12.3 13.1 10.5 3.3 1,013 Mulanje 9.2 9.0 7.7 3.8 296 Other districts 14.6 13.6 12.8 5.9 2,981 Education No education 13.3 13.5 12.4 6.6 1,885 Primary 1-4 15.6 12.1 13.3 6.3 2,021 Primary 5-8 13.5 12.7 11.3 5.0 2,485 Secondary+ 13.5 16.3 10.8 3.2 880 Wealth quintile Lowest 13.4 11.0 13.0 6.0 1,380 Second 14.8 13.1 13.5 6.2 1,579 Middle 15.2 14.1 13.1 6.3 1,610 Fourth 12.9 12.2 11.4 4.5 1,432 Highest 13.5 15.6 8.8 4.8 1,271 Total 14.0 13.2 12.1 5.6 7,271 Note: Total includes 53 cases with number of ANC visits missing. na = Not applicable Maternal and Child Health | 139 These problems are slightly more prevalent in older women and women with higher order births. Women in rural areas and those living in the Central Region are also more likely to report having problems during pregnancy. In general, a woman’s education and wealth status have no association with the likelihood of having pregnancy complications. Across districts, however, there are wide variations. Women in Kasungu are most likely to report problems during pregnancy, while women in Machinga are the least likely to do so. Table 9.6 shows places where women sought advice and care for complications experienced in pregnancy. The 2004 MDHS did not explore the quality or effect of care received from these facilities. For any complication, the most common source of treatment is a public health facility (44 to 57 percent). About one in five women went to a private health facility for assistance with pregnancy complications. While 85 percent of pregnant women sought treatment for anaemia, one in three women with high blood pressure, swollen feet, and bleeding left the problem untreated. Figure 9.1 Complications During Pregnancy 14 13 12 6 0 2 4 6 8 10 12 14 16 High blood pressure Swollen feet Anaemia Bleeding Type of complication Pe rc en t MDHS 2004 140 | Maternal and Child Health Table 9.6 Treatment for complications during pregnancy Among women with a birth in the five years preceding the survey who had complications associated with the most recent pregnancy, percentage who sought advice or treatment, by type of complication, Malawi 2004 Health facility Type of complication Public sector Private sector Home Traditional birth attendant Other Not treated Number of women with complications High blood pressure 47.0 17.5 0.9 3.1 2.2 30.7 1,019 Swollen feet 44.5 17.4 1.1 2.6 2.0 33.5 958 Anaemia 56.9 20.1 1.1 3.7 5.4 15.5 877 Bleeding 43.7 18.1 0.5 5.3 4.3 31.9 406 9.2 ASSISTANCE AND MEDICAL CARE AT DELIVERY An important component in the effort to reduce the health risks of mothers and children is to increase the proportion of babies that are delivered in facilities where skilled attendance is available. Services in a health facility include trained health workers, appropriate supplies, equipment to identify and manage complications in a timely manner, and maintenance of hygienic conditions to prevent infections. The 2004 MDHS respondents were asked to report the place of birth of all children born in the five years before the survey. Table 9.7 shows that 57 percent of births took place in a health facility. This figure shows that there has been no notable improvement from the 1992 and 2000 MDHS surveys (both 55 percent). Government-run health facilities were used for 42 percent of the births, while private facilities managed 15 percent of births. A considerable proportion of births took place at home, either in the respondent’s home (29 percent) or the traditional birth attendant (TBA)’s home (12 percent). Children born to women less than 34 years of age and first-order births are more likely to be delivered in a heath facility than other children. Similarly, the majority of births in urban areas, births to women with secondary or higher education, and to women in the highest wealth quintile occurred in a health facility. The proportion of births delivered in a health facility varies from less than 50 percent in Kasungu and Salima (43 percent and 46 percent, respectively) to 79 percent in Blantyre. The assistance of a TBA during delivery is most common in Salima (23 percent) and least common in Mangochi (4 percent). Maternal and Child Health | 141 Table 9.7 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics, Malawi 2004 Health facility Background characteristic Public sector Private sector Home Traditional birth attendant Other Missing Total Number of births Mother's age at birth <20 43.3 13.6 29.7 12.3 1.0 0.1 100.0 2,205 20-34 42.3 16.0 28.3 12.2 1.2 0.1 100.0 7,321 35-49 37.2 14.7 35.1 11.7 1.1 0.2 100.0 1,246 Birth order 1 47.6 15.8 24.2 11.4 0.8 0.2 100.0 2,530 2-3 42.3 15.6 28.7 11.9 1.3 0.2 100.0 3,945 4-5 39.8 15.1 32.2 11.7 1.1 0.0 100.0 2,308 6+ 36.4 14.4 33.9 13.9 1.3 0.1 100.0 1,989 Residence Urban 66.4 17.9 12.3 2.7 0.6 0.1 100.0 1,425 Rural 38.2 14.9 32.0 13.6 1.2 0.1 100.0 9,347 Region Northern 46.9 20.0 23.2 8.7 1.1 0.1 100.0 1,345 Central 37.2 15.3 31.9 14.3 1.2 0.2 100.0 4,494 Southern 44.8 14.1 28.7 11.1 1.1 0.1 100.0 4,933 District Blantyre 70.0 8.6 14.1 5.7 1.7 0.0 100.0 724 Kasungu 36.0 7.4 36.9 18.9 0.9 0.0 100.0 525 Machinga 42.0 13.4 33.7 10.0 0.7 0.1 100.0 441 Mangochi 38.4 12.5 44.9 3.6 0.6 0.0 100.0 636 Mzimba 40.6 25.4 25.2 7.5 1.2 0.1 100.0 676 Salima 38.7 7.7 29.5 23.3 0.7 0.1 100.0 312 Thyolo 37.9 13.5 27.1 19.3 2.2 0.0 100.0 575 Zomba 47.7 18.0 22.9 11.0 0.5 0.0 100.0 544 Lilongwe 37.9 17.0 32.4 12.4 0.1 0.1 100.0 1,489 Mulanje 38.7 20.8 22.7 16.6 1.0 0.1 100.0 437 Other districts 40.4 15.8 29.7 12.4 1.5 0.2 100.0 4,414 Education No education 32.2 10.7 41.9 13.9 1.2 0.1 100.0 2,903 Primary 1-4 39.3 12.7 32.3 14.3 1.0 0.3 100.0 3,102 Primary 5-8 47.1 17.9 22.6 10.9 1.4 0.1 100.0 3,637 Secondary+ 57.2 26.1 10.6 5.8 0.3 0.0 100.0 1,127 Antenatal care visits1 None 19.2 6.3 58.2 14.9 1.3 0.0 100.0 337 1-3 38.0 13.8 34.1 12.6 1.4 0.0 100.0 2,738 4+ 47.4 17.5 23.2 10.9 1.0 0.1 100.0 4,149 Wealth quintile Lowest 36.2 10.6 40.4 11.9 0.8 0.0 100.0 2,099 Second 34.6 12.0 36.1 15.6 1.4 0.4 100.0 2,426 Middle 38.9 13.3 31.9 14.1 1.7 0.1 100.0 2,446 Fourth 45.3 18.2 23.3 12.4 0.6 0.2 100.0 2,091 Highest 59.6 25.1 10.1 4.4 0.8 0.0 100.0 1,709 Total 41.9 15.3 29.4 12.1 1.1 0.1 100.0 10,771 Note: Private health facility includes Mission health facility. Total includes 53 cases with the number of antenatal care visits missing. 1 Includes only the most recent birth in the five years preceding the survey. 142 | Maternal and Child Health The 2004 MDHS asked questions about the person who assisted with the delivery. The majority of births were attended by medical professionals, 50 percent by a nurse or midwife, 6 percent by a doctor, and 1 percent by a patient attendant. In the four years since the 2000 MDHS there has been a slight increase in the proportion of births that are attended by a doctor—from 5 to 6 percent. The role of traditional birth attendants (TBAs) in delivery assistance has also increased— from 23 to 26 percent (Table 9.8). Table 9.8 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, according to background characteristics, Malawi 2004 Background characteristic Doctor/ clinical officer Nurse or midwife Patient attendant Traditional birth attendant Relative/ friend/ other No one Don't know/ missing Total Number of births Mother's age at birth <20 5.3 50.9 0.5 28.4 13.6 0.8 0.5 100.0 2,205 20-34 6.3 50.6 1.1 25.2 14.4 1.9 0.4 100.0 7,321 35-49 5.8 45.4 0.6 27.7 14.1 5.2 1.1 100.0 1,246 Birth order 1 6.7 56.1 0.5 24.5 11.3 0.6 0.3 100.0 2,530 2-3 6.1 50.5 1.1 25.9 14.6 1.4 0.5 100.0 3,945 4-5 5.8 47.9 1.0 25.6 16.8 2.4 0.4 100.0 2,308 6+ 5.3 44.1 1.3 29.5 14.1 4.9 0.9 100.0 1,989 Residence Urban 8.3 74.8 0.7 8.4 6.7 0.9 0.2 100.0 1,425 Rural 5.7 46.3 1.0 28.9 15.4 2.2 0.6 100.0 9,347 Region Northern 6.1 60.2 0.3 18.8 11.4 3.0 0.1 100.0 1,345 Central 5.8 45.5 0.8 31.5 14.1 1.7 0.8 100.0 4,494 Southern 6.2 51.5 1.3 23.4 15.1 2.2 0.4 100.0 4,933 District Blantyre 8.5 69.2 0.3 14.3 5.4 1.9 0.3 100.0 724 Kasungu 8.8 33.1 1.1 38.9 13.8 3.6 0.7 100.0 525 Machinga 2.3 46.5 6.2 16.2 25.2 2.2 1.4 100.0 441 Mangochi 11.9 38.3 2.0 24.8 21.0 1.9 0.1 100.0 636 Mzimba 7.0 58.6 0.3 15.8 14.5 3.6 0.1 100.0 676 Salima 8.8 37.1 0.1 41.6 10.7 0.4 1.4 100.0 312 Thyolo 6.0 44.9 0.3 35.8 10.5 2.3 0.3 100.0 575 Zomba 7.2 57.2 1.1 19.7 11.8 2.5 0.4 100.0 544 Lilongwe 3.7 50.2 0.8 30.0 14.5 0.7 0.1 100.0 1,489 Mulanje 5.2 53.7 1.0 24.9 14.1 0.8 0.4 100.0 437 Other districts 5.2 50.1 0.6 26.7 14.5 2.3 0.7 100.0 4,414 Education No education 3.9 37.9 1.0 31.8 21.2 3.5 0.7 100.0 2,903 Primary 1-4 6.2 44.2 1.3 29.5 16.0 2.1 0.7 100.0 3,102 Primary 5-8 6.2 57.8 0.8 23.4 10.1 1.3 0.3 100.0 3,637 Secondary+ 10.1 72.8 0.5 11.7 4.5 0.4 0.1 100.0 1,127 Wealth quintile Lowest 5.5 40.4 0.7 30.5 19.9 2.3 0.7 100.0 2,099 Second 4.1 41.2 1.3 32.9 17.7 2.1 0.7 100.0 2,426 Middle 5.5 45.2 1.2 29.2 15.6 2.9 0.5 100.0 2,446 Fourth 6.4 56.2 0.6 24.0 10.8 1.7 0.4 100.0 2,091 Highest 9.5 74.2 0.9 9.8 4.5 1.0 0.1 100.0 1,709 Total 6.0 50.1 1.0 26.2 14.2 2.1 0.5 100.0 10,771 Note: If the respondent mentioned more than one attendant, only the most qualified attendant is considered in this tabulation. Maternal and Child Health | 143 While 78 percent of births in Blantyre were assisted by a health professional, the corresponding proportions in Kasungu and Salima are 43 and 46 percent, respectively (Figure 9.2). Delivery by a TBA is most common in Salima (42 percent) and Kasungu (39 percent), while Blantyre has the lowest level of TBA deliveries (14 percent). In rural areas 15 percent of births are attended by relatives or other persons who may not be trained in assisting deliveries, and 29 percent of the births are assisted by TBAs. With poor quality and inadequate antenatal care, as well as limited access to skilled attendance at delivery, the concept of safe pregnancy and child birth may not be realised by some Malawian women, especially those residing in rural areas. One outcome of pregnancy assessed during the survey was assisted operative delivery such as caesarean section (C-section). This operation is one of the emergency obstetric care functions recommended for addressing some complications that contribute to high maternal mortality. According to the survey data, 3 percent of births in the five years preceding the survey were delivered by C-section. This rate is similar to that recorded in the 2000 MDHS. The stagnation in the C- section rate since 1992 in Malawi suggests that emergency obstetric care is limited to a small proportion of women. Table 9.9 shows that C-section deliveries are more common among births to younger women, for the first child, births to women with higher education, and women residing in urban areas. In four districts, Blantyre, Mzimba, Thyolo, and Zomba, the proportion of births delivered by C-section is slightly higher (4 to 5 percent) than the national average of 3 percent. The higher proportion of C-section operations in Blantyre and Zomba was also reported in the 2000 MDHS. Figure 9.2 Assistance at Delivery from a Health Professional, by Residence and District 84 53 78 43 55 52 66 46 51 66 55 60 56 0 10 20 30 40 50 60 70 80 90 RESIDENCE Urban Rural DISTRICT Blantyre Kasungu Machinga Mangochi Mzimba Salima Thyolo Zomba Lilongwe Mulanje Other districts Percent MDHS 2004 144 | Maternal and Child Health Table 9.9 Delivery characteristics Percentage of live births in the five years preceding the survey delivered by caesarean section, and percent distribution by birth weight and by mother's estimate of baby's size at birth, according to background characteristics, Malawi 2004 Birth weight Size of child at birth Background characteristic Delivery by C- section Less than 2.5 kg 2.5 kg or more Don't know/ missing Total Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 3.9 6.5 40.0 53.5 100.0 4.3 15.4 77.4 3.0 100.0 2,205 20-34 3.0 5.2 45.1 49.7 100.0 3.6 10.9 83.2 2.3 100.0 7,321 35-49 2.0 4.2 39.1 56.7 100.0 4.2 10.4 83.0 2.4 100.0 1,246 Birth order 1 4.7 6.7 45.2 48.1 100.0 4.2 14.0 78.9 2.9 100.0 2,530 2-3 3.1 5.0 45.2 49.8 100.0 3.3 10.9 83.4 2.4 100.0 3,945 4-5 2.5 5.0 43.3 51.7 100.0 3.5 11.0 82.9 2.6 100.0 2,308 6+ 1.8 4.7 37.4 57.9 100.0 4.9 11.4 82.0 1.8 100.0 1,989 Residence Urban 4.4 6.1 67.5 26.3 100.0 2.4 7.7 88.8 1.0 100.0 1,425 Rural 2.9 5.2 39.7 55.1 100.0 4.0 12.3 80.9 2.7 100.0 9,347 Region Northern 4.6 7.5 63.0 29.5 100.0 2.9 7.3 88.4 1.4 100.0 1,345 Central 2.8 4.8 36.7 58.5 100.0 4.8 13.7 79.5 2.0 100.0 4,494 Southern 2.9 5.2 44.1 50.7 100.0 3.2 11.1 82.5 3.2 100.0 4,933 District Blantyre 3.5 7.5 62.3 30.1 100.0 3.2 9.6 85.2 2.0 100.0 724 Kasungu 1.9 7.3 44.0 48.7 100.0 6.7 14.8 77.5 1.0 100.0 525 Machinga 1.3 7.1 29.4 63.4 100.0 4.9 11.9 82.0 1.2 100.0 441 Mangochi 2.5 4.3 37.7 58.0 100.0 1.8 15.1 81.4 1.7 100.0 636 Mzimba 5.2 7.9 61.7 30.4 100.0 3.1 11.4 84.4 1.1 100.0 676 Salima 2.5 3.5 26.3 70.2 100.0 5.6 13.1 73.0 8.3 100.0 312 Thyolo 4.2 4.9 41.6 53.5 100.0 3.6 9.8 78.4 8.3 100.0 575 Zomba 3.5 6.3 56.1 37.6 100.0 5.0 12.0 79.6 3.4 100.0 544 Lilongwe 2.6 5.1 41.2 53.6 100.0 6.4 12.4 80.2 1.0 100.0 1,489 Mulanje 2.6 5.8 45.8 48.3 100.0 2.5 8.2 85.6 3.7 100.0 437 Other districts 3.2 4.4 39.9 55.7 100.0 3.0 11.5 83.3 2.2 100.0 4,414 Education No education 1.9 4.7 27.4 67.9 100.0 4.5 14.1 78.3 3.0 100.0 2,903 Primary 1-4 2.9 3.9 36.4 59.7 100.0 4.1 12.9 79.9 3.2 100.0 3,102 Primary 5-8 3.2 6.4 52.1 41.5 100.0 3.1 10.4 84.6 1.9 100.0 3,637 Secondary+ 6.3 7.5 75.3 17.2 100.0 3.8 6.6 88.9 0.7 100.0 1,127 Wealth quintile Lowest 3.4 4.5 31.6 64.0 100.0 4.3 14.1 78.4 3.2 100.0 2,099 Second 2.5 5.1 33.4 61.5 100.0 4.7 13.4 78.5 3.3 100.0 2,426 Middle 2.2 5.0 39.4 55.6 100.0 3.7 12.0 81.7 2.6 100.0 2,446 Fourth 3.3 5.8 48.6 45.6 100.0 3.4 10.1 84.8 1.7 100.0 2,091 Highest 4.5 6.8 71.2 22.0 100.0 2.6 8.0 88.3 1.1 100.0 1,709 Total 3.1 5.3 43.4 51.3 100.0 3.8 11.7 82.0 2.5 100.0 10,771 Women who gave birth in the five years before the survey were asked whether their baby was weighed at birth and, if so, what the baby’s weight was. Interviewers were instructed to use any written record of birth weight available. In addition, because many women do not deliver at a health facility, and hence the baby was not weighed, all respondents were asked for their own subjective assessment of their child’s size. Table 9.9 also provides information on the birth weights according to the background characteristics of the mother. Birth weight was reported for slightly less than one- Maternal and Child Health | 145 half of the births. Forty-three percent of all births (or 89 percent of those with a birth weight reported) were reported to be of 2.5 kilograms or more. Five percent of births (11 percent of those with a birth weight) were less than 2.5 kilograms, the cutoff point below which a baby is considered to have low birth weight. The proportion of low birth weight babies is 7 percent or higher in Blantyre, Kasungu, Machinga, and Mzimba. Regarding the size of the child at birth, 82 percent of births were reported by the mother as being average or larger than average in size. For 16 percent of births, mothers said that their child was smaller than average (12 percent) or very small (4 percent); in the 2000 MDHS, 17 percent of births were reported as smaller than average or very small. District estimates of low birth weight, using subjective assessment, vary from a low of 11 percent in Mulanje to 22 percent in Kasungu. 9.3 POSTNATAL CARE Postnatal care is an important component of obstetric and neonatal care aimed at preventing and managing any complications that may endanger the survival of the mother and the baby. Postnatal care is therefore recommended immediately after the birth of the baby and placenta to 42 days after delivery. Respondents who gave birth in a health facility are assumed to have received a postnatal check during their stay in the health facility. Those who gave birth outside a health facility were asked whether someone checked on their health following the delivery. Table 9.10 shows that 31 percent of women received postnatal care, and 21 percent of these women reported receiving care within two days of delivery. Few women had a checkup 3 to 6 days after delivery, and 8 percent received care between the first and sixth week after delivery. Table 9.10 further shows that postnatal care is more common for older women, women residing in urban areas, more educated women, and women in the highest wealth quintile. Women who live in Blantyre and Thyolo are the most likely to have had a postnatal checkup, whereas three in four women in Salima and Lilongwe did not receive postnatal care. The low utilisation of health facilities for delivery as well as nonutilisation of postnatal care services shows that most women do not get skilled care during delivery and the postpartum period. Strategies for improving maternal health should therefore focus on pull factors for health facility care or bringing the skilled care to the home. 146 | Maternal and Child Health Table 9.10 Postnatal care Among women who gave birth in the five years preceding the survey, the percent distribution by timing of postnatal checkup, according to background characteristics, Malawi 2004 Timing of first postnatal checkup Background characteristic Within 2 days of delivery 3-6 days after delivery 7-41 days after delivery Don't know/ missing Did not receive postnatal checkup1 Total Number of women Age at birth <20 19.9 2.0 6.5 0.2 71.3 100.0 1,293 20-34 19.9 3.1 8.3 0.1 68.5 100.0 4,979 35-49 24.4 2.6 6.6 0.3 66.0 100.0 1,000 Birth order 1 21.8 2.8 8.7 0.2 66.5 100.0 1,518 2-3 19.8 3.1 8.3 0.2 68.6 100.0 2,659 4-5 18.1 2.9 8.4 0.2 70.4 100.0 1,622 6+ 23.3 2.3 5.3 0.2 68.9 100.0 1,473 Residence Urban 27.2 2.6 12.1 0.1 57.9 100.0 1,041 Rural 19.4 2.9 7.0 0.2 70.4 100.0 6,231 Region Northern 25.0 3.6 5.8 0.3 65.3 100.0 924 Central 17.6 2.3 6.7 0.0 73.4 100.0 2,959 Southern 21.9 3.1 9.3 0.3 65.4 100.0 3,389 District Blantyre 22.8 3.8 18.4 0.2 54.7 100.0 520 Kasungu 25.9 1.1 5.0 0.0 68.0 100.0 330 Machinga 22.2 2.5 3.2 0.5 71.6 100.0 284 Mangochi 28.0 4.3 7.4 0.5 59.8 100.0 411 Mzimba 22.9 3.3 7.0 0.3 66.5 100.0 464 Salima 11.6 3.8 9.8 0.2 74.5 100.0 199 Thyolo 29.8 2.6 11.6 0.2 55.8 100.0 386 Zomba 20.6 2.9 7.3 0.0 69.2 100.0 389 Lilongwe 17.3 2.3 5.7 0.0 74.7 100.0 1,013 Mulanje 16.9 4.8 13.3 0.7 64.2 100.0 296 Other districts 18.9 2.5 6.4 0.1 72.0 100.0 2,981 Education No education 16.8 2.4 4.6 0.1 76.1 100.0 1,885 Primary 1-4 19.2 3.0 6.7 0.2 70.9 100.0 2,021 Primary 5-8 22.6 2.7 8.2 0.3 66.2 100.0 2,485 Secondary+ 25.7 3.8 15.9 0.2 54.4 100.0 880 Wealth quintile Lowest 16.9 1.9 5.3 0.2 75.7 100.0 1,380 Second 18.8 2.4 6.2 0.3 72.3 100.0 1,579 Middle 18.4 3.5 6.7 0.1 71.3 100.0 1,610 Fourth 23.0 2.5 7.9 0.3 66.3 100.0 1,432 Highest 26.8 3.9 13.6 0.0 55.7 100.0 1,271 Total 20.6 2.8 7.8 0.2 68.6 100.0 7,271 Note: If a woman had more than one live birth outside a health facility, only the most recent birth is considered. 1Includes women who received the first postnatal checkup after 41 days Maternal and Child Health | 147 Women who gave birth in the five years preceding the survey were asked to report any problems, such as heavy bleeding, high blood pressure, stroke or convulsions, infection or fever, postpartum depression, and leakage of urine or stools from the vagina (probable fistula) post partum for their most recent birth. Table 9.11 shows that heavy bleeding is the most often reported problem (7 percent), followed by infection and high blood pressure (3 percent each). Probable fistula, postpartum depression, and stroke/convulsions were each reported by two percent of women. Table 9.11 Complications after delivery Percentage of last births in the five years preceding the survey for which the mother had complications associated with the pregnancy, by type of complications, according to background characteristics, Malawi 2004 Background characteristic Heavy bleeding High blood pressure Stroke/ convulsions Infection/ fever Leakage of urine or stool from vagina Postpartum depression/ blues Number of women Number of ANC visits None 3.0 2.2 1.6 3.0 3.0 2.1 337 1-3 6.7 2.7 1.5 2.7 1.6 1.7 3,703 4+ 7.2 3.3 1.4 4.1 1.5 1.6 3,184 Age at birth <20 6.8 2.8 1.5 2.3 2.7 1.7 1,293 20-34 6.5 2.6 1.3 3.2 1.3 1.8 4,979 35-49 7.6 4.7 1.9 4.9 1.5 1.0 1,000 Birth order 1 6.6 1.8 1.5 2.8 2.3 1.6 1,518 2-3 6.5 3.1 1.3 2.8 1.5 1.4 2,659 4-5 6.5 2.4 1.1 3.8 1.6 2.4 1,622 6+ 7.4 4.4 2.0 4.1 1.0 1.5 1,473 Residence Urban 6.1 2.2 0.7 2.3 1.6 1.5 1,041 Rural 6.8 3.0 1.6 3.5 1.6 1.7 6,231 Region Northern 6.8 2.4 1.8 2.9 1.3 1.4 924 Central 6.4 2.6 1.8 3.6 1.4 1.3 2,959 Southern 6.9 3.4 1.1 3.1 1.9 2.1 3,389 District Blantyre 8.7 4.5 0.9 4.1 4.0 3.3 520 Kasungu 8.4 4.0 3.8 3.8 2.1 1.3 330 Machinga 5.9 3.7 0.9 2.0 1.4 0.8 284 Mangochi 8.7 6.2 3.0 6.3 2.7 3.5 411 Mzimba 7.0 3.4 2.9 3.0 1.3 2.3 464 Salima 4.9 1.4 2.3 2.4 1.1 1.6 199 Thyolo 7.6 4.4 1.6 3.9 2.3 1.3 386 Zomba 6.5 2.9 1.5 3.3 1.8 1.2 389 Lilongwe 5.3 1.3 0.9 3.2 1.7 1.7 1,013 Mulanje 5.9 3.3 0.5 1.5 1.1 1.5 296 Other districts 6.5 2.4 1.1 3.1 1.0 1.3 2,981 Education No education 5.5 2.5 1.5 3.0 1.4 1.4 1,885 Primary 1-4 6.9 4.0 1.5 2.9 1.6 2.0 2,021 Primary 5-8 8.1 2.9 1.5 3.9 1.9 1.8 2,485 Secondary+ 5.1 1.5 0.9 3.3 1.0 1.4 880 Wealth quintile Lowest 5.4 3.1 1.7 2.4 1.4 1.4 1,380 Second 6.4 3.1 1.7 3.4 1.8 1.4 1,579 Middle 6.4 2.8 1.3 3.3 2.0 1.4 1,610 Fourth 8.6 3.4 1.3 3.0 1.3 2.1 1,432 Highest 6.8 2.1 1.2 4.4 1.3 2.2 1,271 Total 6.7 2.9 1.5 3.3 1.6 1.7 7,271 Note: Total includes 53 cases with the number of antenatal care visits missing. 148 | Maternal and Child Health 9.4 WOMEN’S PARTICIPATION IN DECISIONMAKING Health-seeking behaviour is influenced by a number of factors, including the ability to make decisions regarding one’s health or to have control over family income. Lack of these abilities has been cited as a barrier for proper utilisation of maternal and child health services. Women who had a live birth in the five years preceding the survey were asked whether they participated in making decisions about their own health care, making large household purchases, purchasing daily household needs, visiting family members or relatives, and determining what food to cook each day. Women were also asked about their attitude towards a wife’s ability to negotiate sex with her husband, as well as their perceptions about wife beating (see Chapter 3). Data in Table 9.12 indicate that women who were more empowered were generally somewhat more likely to receive health care during pregnancy, delivery, and the postpartum period. For example, the proportion of women who received antenatal care increases from 91 percent among women who have no final say in decisionmaking to 93 percent or higher for women who participated in one or more decisions. Similarly, the percentage of women who received delivery care from a health professional declines from 60 percent among women who do not think there was any reason for a husband to beat his wife to 52 percent or lower for women who think that a husband is justified in beating his wife. Table 9.12 Reproductive health care by women's status Percentage of women with a live birth in the five years preceding the survey who received antenatal and postnatal care from a health professional for the most recent birth, and percentage of births in the five years preceding the survey for which mothers received professional delivery care, by women's status indicators, Malawi 2004 Percentage of women who: Women’s status indicator Received antenatal care from a doctor, clinical officer, nurse, midwife, or patient attendant Received postnatal care within the first two days of delivery1 Number of women Percentage of births assisted by a doctor, clinical officer, nurse/ midwife/ patient attendant Number of births Number of decisions in which woman has final say2 0 91.4 59.6 1,264 55.2 1,911 1-2 93.1 58.8 3,227 54.9 4,880 3-4 94.8 63.8 1,476 61.7 2,184 5 93.0 64.0 1,305 59.2 1,797 Number of reasons to refuse sex with husband 0 91.1 59.9 753 54.1 1,130 1-2 92.1 58.2 1,362 55.2 2,028 3-4 93.8 61.7 5,157 58.0 7,614 Number of reasons wife beating is justified 0 93.4 63.1 5,159 59.9 7,628 1-2 92.5 56.1 1,245 52.2 1,840 3-4 93.7 52.6 582 45.9 866 5 89.9 57.6 286 50.5 437 Total 93.2 60.9 7,271 57.0 10,771 1Includes mothers who delivered in a health facility 2Either by herself or jointly with others Maternal and Child Health | 149 9.5 CHILDHOOD VACCINATIONS Malawi’s Expanded Programme on Immunisation (EPI) follows guidelines for vaccinating children set by the World Health Organisation (WHO). A child is considered fully vaccinated if she or he has received one dose of BCG vaccine, three doses each of DPT and polio vaccine, and one dose of measles vaccine. BCG protects against tuberculosis and should be given at birth or first clinic contact. DPT protects against diphtheria, pertussis (whooping cough), and tetanus. DPT and polio vaccines are given at approximately 6, 10, and 14 weeks of age. The measles vaccine should be given at or soon after the child reaches nine months of age. The Malawi EPI recommends that children receive the complete schedule of vaccinations before 12 months of age. A dose of polio vaccine at or around birth is being promoted, although it is not yet widely practised in Malawi. To assist in the evaluation of the EPI, the 2004 MDHS survey collected information on vaccination coverage for all living children born in the five years preceding the survey. Information on vaccination coverage was collected in two ways: from child health cards seen by the interviewer and from mothers’ verbal reports. Health cards on which vaccinations are recorded are typically provided by health centres and clinics. If a mother was able to present such a card to the interviewer, this was used as the source of information, with the interviewer recording vaccination dates directly from the card. In addition to collecting vaccination information from cards, there were two ways of collecting the information from the mother herself. If a vaccination card was presented but a vaccine was not recorded on the card as being given, the mother was asked to recall whether or not that particular vaccine had been given. If the mother was not able to provide a card for the child at all, she was asked through a series of probing questions whether or not the child had received BCG, polio, DPT (including the number of doses for each), and measles vaccinations. Table 9.13 presents information on vaccination coverage for children age 12-23 months1 according to the source of information used to determine coverage, i.e., the child health card or mother's report. Based on information from the health card and mother’s report, 91 percent of children age 12-23 months had been vaccinated against tuberculosis, 82 percent received DPT3, 78 percent received polio3, and 79 percent received measles vaccine. Overall, 64 percent of children age 12-23 months have received all the recommended vaccines, and 4 percent of children have received none. Vaccinations are most effective when given at the proper age. While 79 percent of children age 12-23 months have been vaccinated against measles, only 63 percent were vaccinated before their first birthday, indicating that some children were late in receiving their measles vaccination. This is important because measles at a young age is potentially life threatening, especially in malnourished children. Figure 9.3 shows the percentage of children age 12-23 months who received the recommended six vaccines by 12 months of age. Coverage of DPT1 and polio1 is 94 percent, 90 percent for BCG, and 63 percent for measles. Another way to evaluate the success of an immunisation programme is to calculate the dropout rate for DPT and polio. The dropout rate is defined as the percentage of children who receive the first dose but do not receive the third dose of a 1 These children are supposed to have received a complete schedule of vaccinations. 150 | Maternal and Child Health specific vaccine. Using data in Table 9.13, the dropout rate for DPT is 14 percent, and that for polio is 18 percent. Table 9.13 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Malawi 2004 DPT Polio Source of information BCG 1 2 3 01 1 2 3 Measles All2 No vacci- nations Number of children Vaccinated at any time before survey Vaccination card 70.3 73.3 71.8 67.2 29.1 73.7 71.8 67.4 61.8 57.4 0.2 1,631 Mother's report 21.1 21.6 18.8 14.3 8.0 21.3 18.0 10.2 16.9 7.0 3.3 563 Either source 91.4 95.0 90.6 81.5 37.1 94.9 89.7 77.7 78.7 64.4 3.5 2,194 Vaccinated by 12 months of age3 89.7 94.0 88.4 76.1 36.8 93.9 87.7 73.2 62.7 51.1 4.3 2,194 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. Figure 9.3 Percentage of Children Age 12-23 Months Who Were Vaccinated by 12 Months of Age 72 64 63 58 71 64 73 57 69 55 61 69 84 0 10 20 30 40 50 60 70 80 90 BIRTH ORDER 1 2-3 4-5 6+ RESIDENCE Urban Rural REGION Northern Central Southern MOTHER'S EDUCATION No education Primary 1-4 Primary 5.8 Secondary+ MDHS 2004 Maternal and Child Health | 151 Table 9.14 shows the trends in childhood vaccination coverage reported in MDHS surveys from 1992 to 2004. Data in the table indicate that vaccination coverage in Malawi has declined. The first indication comes from a small drop in the percentage of children with a vaccination card from 86 percent in 1992 to 81 in 2000 and to 74 percent in 2004. The decline may indicate decreased access to services. The failure of some children to complete the polio and the DPT series has resulted in a decline in polio3 coverage from 88 percent in 1992 to 80 percent in 2000 and to 78 percent in 2004. Similarly, DPT3 coverage dropped from 89 percent in 1992 to 84 percent in 2000 and to 82 percent in 2004. The percentage of children considered fully immunized declined from 82 percent in 1992 to 64 percent in 2004. Table 9.14 Trends in vaccination coverage Percentage of children age 12-23 months who received specific vaccines at any time before the survey, Malawi 1992- 2004 DPT Polio Source BCG 1 2 3 0 1 2 3 Measles All No vacci- nations Percen- tage with card Number of children 1992 MDHS 97.0 96.9 94.3 88.6 na 96.9 94.2 88.1 85.8 81.8 2.5 86.3 772 2000 MDHS 92.4 95.9 92.6 84.2 46.9 95.7 91.3 79.8 83.2 70.1 2.8 81.1 2,238 2004 MDHS 91.4 95.0 90.6 81.5 37.1 94.9 89.7 77.7 78.7 64.4 3.5 74.3 2,194 na = Not applicable Table 9.15 presents the vaccination coverage in 2004 among children age 12-23 months by selected background characteristics. First-born children, children in urban areas, children in the Northern Region, children born to women with secondary and higher education, and those born to women in the higher wealth quintiles are more likely than other children to be fully vaccinated. Among the oversampled districts, vaccination coverage ranges from 53 percent or lower in Kasungu, Salima, and Lilongwe to 84 percent in Blantyre. While nationally 4 percent of children age 12-23 months have never received any vaccination, the percentage varies substantially across districts. Lilongwe shows the highest percentage of children who have had no vaccinations (10 percent). 152 | Maternal and Child Health Table 9.15 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Malawi 2004 DPT Polio1 Background characteristic BCG 1 2 3 0 1 2 3 Measles All2 No vacci- nations Percentage with a vaccination card Number of children Sex Male 90.7 94.5 90.9 81.5 36.2 94.2 89.1 77.7 78.8 65.7 4.3 75.4 1,100 Female 92.1 95.5 90.4 81.6 38.0 95.6 90.4 77.7 78.6 63.1 2.7 73.2 1,094 Birth order 1 94.8 97.6 94.8 86.7 41.4 96.7 92.1 84.1 84.0 72.2 1.8 75.3 473 2-3 91.7 94.7 91.8 83.1 37.4 95.2 90.4 77.3 78.1 64.1 3.7 75.4 811 4-5 92.0 96.4 89.1 79.0 35.6 95.7 89.7 76.0 78.7 62.8 2.3 76.0 489 6+ 86.5 91.0 85.2 75.7 33.5 91.5 85.8 73.1 73.8 58.3 6.6 69.2 421 Residence Urban 97.2 98.5 95.1 89.8 56.5 99.3 94.0 81.7 86.8 70.7 0.7 73.7 274 Rural 90.6 94.5 90.0 80.3 34.4 94.3 89.1 77.1 77.6 63.5 3.9 74.4 1,920 Region Northern 93.9 97.2 95.0 89.7 59.6 97.3 95.0 82.4 84.9 72.5 1.5 78.8 250 Central 88.2 91.4 86.0 75.4 35.5 91.5 85.5 70.7 72.5 56.8 6.1 68.6 921 Southern 93.7 97.6 93.7 85.1 33.1 97.5 92.3 82.7 82.8 69.3 1.7 78.4 1,023 District Blantyre 95.9 100.0 99.1 95.7 55.8 100.0 97.6 92.9 93.0 83.7 0.0 78.6 147 Kasungu 84.6 89.4 81.8 75.4 36.3 89.6 81.2 72.7 64.6 53.4 9.0 74.6 116 Machinga 87.3 94.7 91.1 81.4 25.3 95.2 89.5 80.0 72.7 61.1 3.9 83.3 97 Mangochi 92.5 93.3 87.6 82.5 33.8 92.8 88.1 73.8 76.9 59.5 4.3 68.6 138 Mzimba 94.3 98.3 96.1 92.1 63.8 98.3 96.1 84.3 82.8 72.3 1.7 81.1 129 Salima 94.1 95.6 86.0 71.3 37.9 94.6 84.6 67.4 77.2 51.1 1.5 60.3 69 Thyolo 97.9 99.0 96.8 88.4 22.2 98.9 96.8 87.2 87.0 74.8 0.0 74.7 116 Zomba 93.4 98.3 97.7 91.3 30.9 98.3 93.6 88.1 84.7 72.9 1.7 81.0 108 Lilongwe 85.8 87.2 80.4 69.0 32.5 88.6 82.5 65.3 70.7 52.5 10.0 59.0 292 Mulanje 94.4 98.5 95.0 83.9 24.7 97.8 90.4 83.2 81.2 68.5 1.5 85.9 81 Other districts 91.7 95.9 91.6 80.9 37.4 95.5 90.2 77.0 79.2 64.9 2.4 76.7 901 Mother’s education No education 89.3 93.7 86.3 74.9 29.4 92.9 85.7 68.7 72.1 54.8 4.6 70.5 586 Primary 1-4 88.0 92.3 87.5 76.4 29.9 93.0 87.9 76.1 75.7 61.2 5.1 72.2 643 Primary 5-8 93.9 97.2 94.4 87.3 44.3 97.1 92.4 82.7 81.7 68.5 2.0 77.0 729 Secondary+ 98.4 98.5 98.3 94.1 53.9 98.6 96.7 88.6 93.9 84.3 1.4 81.2 236 Wealth quintile Lowest 86.2 92.4 85.2 73.8 30.3 91.8 84.3 68.7 67.4 51.9 5.5 67.6 449 Second 90.4 93.3 87.3 77.4 30.5 94.0 87.9 73.4 76.5 58.0 4.5 69.8 519 Middle 91.9 96.3 93.3 82.6 34.7 95.7 91.1 79.4 78.9 65.5 2.2 80.6 473 Fourth 94.5 95.9 94.3 87.1 40.6 96.3 93.2 83.9 85.6 73.8 2.9 74.5 413 Highest 95.5 97.8 94.6 89.9 55.4 97.5 93.8 85.9 88.3 77.7 2.2 81.1 340 Total 91.4 95.0 90.6 81.5 37.1 94.9 89.7 77.7 78.7 64.4 3.5 74.3 2,194 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doeses of DPT and polio vaccine (excluding polio vaccine given at birth). Maternal and Child Health | 153 9.6 ACUTE RESPIRATORY INFECTION Pneumonia is a leading cause of death of young children in Malawi. The programme to control acute respiratory infection (ARI) aims at treating cases of ARI early, before complications develop. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths due to pneumonia. Emphasis is therefore placed on recognition of signs of impending severity, both by mothers and primary health care workers, so help can be sought. The prevalence of ARI was estimated by asking mothers whether their children under age five had been ill with cough accompanied by short, rapid breathing in the two weeks preceding the survey. These symptoms are compatible with pneumonia. It should be borne in mind that morbidity data collected in surveys are subjective (i.e., mother's perception of illness) and not validated by medical examination. Table 9.16 shows that 19 percent of children under five years of age were ill with a cough and short, rapid breathing at some time in the two weeks preceding the survey. Using the same definition, the 2000 MDHS and 1992 MDHS survey reported that 27 percent and 15 percent of children had ARI in the previous two weeks, respectively. Prevalence of respiratory illness varies by age of the child, with the highest prevalence occurring at 6-11 months. Since 1992, symptoms of respiratory illnesses have increased among children age 6-11 months. Children in rural areas are more likely to have symptoms of ARI than their urban counterparts, and children born to women with less education are more likely to have ARI symptoms than those born to women with no education or secondary and higher education. ARI is higher among children born to women in the middle wealth quintile. ARI is slightly higher in the Central and Southern regions (20 and 19 percent, respectively) than in the Northern Region (15 percent). District prevalence is as low as 14 percent in Blantyre and as high as 25 percent in Kasungu and Zomba. It cannot be ascertained from these data whether this wide range in ARI prevalence reflects genuine differences in morbidity or rather socio-cultural differences in the perception of disease or disease severity. Just over one-third of children were reported to have had a fever in the two weeks preceding the survey. The percentage of children with fever is highest among children age 6-11 months (53 percent) and lowest among children age 48-49 months (21 percent). Children born to rural women, women in the Central Region, women with less education, and women living in households in the lowest wealth quintiles are more likely to have had fever than other children. Among children with symptoms of ARI and/or fever, just 20 percent were taken to a health facility. Younger children age less than 6 months are more likely to be taken to a health facility, as are urban children, children born to women in the Southern Region, children of women with upper primary or higher education, and children of women in the highest wealth quintiles. By district, children are most likely to be taken to a health facility in Salima and Zomba districts (28 percent each) and least likely to be taken in Machinga District (13 percent). These findings, although underscoring serious problems of access to health services, may also suggest that mothers and other household members do not always understand the importance of quick response to ARI symptoms and fever. 154 | Maternal and Child Health Table 9.16 Prevalence and treatment of symptoms of ARI and fever Percentage of children under five years of age who had a cough accompanied by short, rapid breathing (symptoms of ARI) and percentage of children who had fever in the two weeks preceding the survey, and percentage of chil- dren with symptoms of ARI and/or fever for whom treatment was sought from a health facility or provider, by background characteristics, Malawi 2004 Background characteristic Percentage of children with symptoms of ARI Percentage of children with fever Number of children Among children with symptoms of ARI and/or fever, percentage for whom treatment was sought from a health facility/provider1 Number of children Age in months <6 20.8 30.7 1,109 22.6 431 6-11 26.6 53.2 1,188 21.0 732 12-23 22.2 49.5 2,194 20.7 1,227 24-35 17.6 39.5 1,743 15.6 817 36-47 15.7 28.8 1,741 20.5 630 48-59 12.5 21.1 1,802 17.9 522 Sex Male 20.2 37.1 4,839 20.4 2,197 Female 17.5 37.2 4,938 18.8 2,163 Residence Urban 11.3 29.9 1,341 22.6 466 Rural 20.0 38.3 8,436 19.3 3,894 Region Northern 15.2 28.4 1,239 17.9 459 Central 19.6 39.9 4,071 18.2 1,925 Southern 19.1 37.1 4,468 21.4 1,976 District Blantyre 14.4 29.4 670 20.8 237 Kasungu 24.5 40.0 471 13.9 241 Machinga 16.0 35.6 405 13.0 162 Mangochi 21.5 36.8 566 20.8 259 Mzimba 17.4 28.9 630 14.7 237 Salima 18.1 42.1 281 28.2 139 Thyolo 21.9 47.3 514 23.6 281 Zomba 24.5 40.1 498 27.8 249 Lilongwe 16.0 38.3 1,376 15.5 601 Mulanje 22.2 44.3 375 21.9 184 Other districts 18.6 36.5 3,992 20.0 1,770 Mother’s education No education 17.6 37.3 2,594 17.0 1,136 Primary 1-4 20.6 40.4 2,805 16.9 1,358 Primary 5-8 19.7 35.9 3,314 22.4 1,457 Secondary+ 14.5 32.1 1,062 26.0 407 Wealth quintile Lowest 19.7 40.0 1,889 15.6 903 Second 19.9 41.2 2,170 18.3 1,042 Middle 23.4 37.6 2,206 20.2 1,044 Fourth 17.6 35.3 1,916 22.5 818 Highest 11.5 29.7 1,597 23.2 553 Total 18.8 37.1 9,777 19.6 4,360 ARI = Acute respiratory infection 1 Excludes pharmacy, shop, and traditional practitioner. Maternal and Child Health | 155 9.7 DIARRHOEAL DISEASE Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children in Malawi. Exposure to agents that cause diarrhoea is frequently related to use of contaminated water and unhygienic practices in food preparation and excreta disposal. Table 9.17 shows the prevalence of diarrhoea in children under five years of age according to background characteristics. The results indicate that 22 percent of children had diarrhoea at some time in the two weeks preceding the survey, an increase from 18 percent reported in the 2000 MDHS survey. As reported in previous MDHS surveys, diarrhoea prevalence peaks at age 6-11 months (41 percent). The prevalence of diarrhoea varies little by the child’s sex. Children in urban areas experience a lower rate of diarrhoea than rural children. Children in the Central Region are more likely to have diarrhoea (27 percent) than children in the Southern Region (21 percent) and Northern Region (12 percent). Diarrhoea is less prevalent among children who live in houses with piped water and children in the highest wealth quintile. Among the oversampled districts, diarrhoea is most prevalent in Salima, Kasungu, and Thyolo (27 percent or higher), and least prevalent in Blantyre and Mzimba (17 percent or lower). Table 9.17 Prevalence of diarrhoea Percentage of children under five years with diarrhoea in the two weeks preceding the survey, by background characteristics, Malawi 2004 Background characteristic Diarrhoea in the two weeks preceding the survey Number of children Age in months <6 9.2 1,109 6-11 41.2 1,188 12-23 38.9 2,194 24-35 21.5 1,743 36-47 11.8 1,741 48-59 8.3 1,802 Sex Male 23.4 4,839 Female 21.1 4,938 Residence Urban 17.5 1,341 Rural 23.0 8,436 Region Northern 12.3 1,239 Central 26.6 4,071 Southern 21.1 4,468 District Blantyre 17.0 670 Kasungu 27.8 471 Machinga 19.3 405 Mangochi 25.0 566 Mzimba 15.7 630 Salima 28.8 281 Thyolo 27.4 514 Zomba 24.0 498 Lilongwe 24.4 1,376 Mulanje 22.1 375 Other districts 21.4 3,992 Mother’s education No education 21.4 2,594 Primary 1-4 25.8 2,805 Primary 5-8 20.6 3,314 Secondary+ 20.3 1,062 Source of drinking water Piped 18.3 1,699 Protected well 22.6 4,248 Open well 24.9 2,648 Surface 21.2 1,169 Wealth quintile Lowest 26.4 1,889 Second 23.9 2,170 Middle 22.4 2,206 Fourth 19.6 1,916 Highest 18.1 1,597 Total 22.3 9,777 156 | Maternal and Child Health A simple and effective response to a child's dehydration is a prompt increase in the intake of appropriate fluids, i.e., oral rehydration therapy (ORT), which has been promoted in Malawi since the early 1980s. ORT is promoted in three types of interventions. The first is the mixture of commercially prepared packets of oral rehydration salts (ORS) commonly known as Thanzi, and water. The other two types are facility-based provision of premixed ORS, and various home-made grain-based rehydration fluids such as rice water and maize water. In the 2004 MDHS survey, women who had a birth in the last five years were asked questions about their knowledge of ORS packets. Table 9.18 shows that almost all women (94 percent) know of these packets. Knowledge of ORS has increased from 90 percent in 1992 and 86 percent in 2000. Knowledge of this life- saving technology is slightly higher among women in urban areas, more educated women, women in the Southern Region, and women in the highest wealth quintile. Age differences in the knowledge of ORS packets are minimal. Mothers of children who were reported to have had diarrhoea in the two weeks prior to the survey were asked about their response to the illness. Treatment of children with diarrhoea has improved since 2000. While 28 percent of mothers reported that they took their child to a health facility in 2000, the proportion had increased to 36 percent in 2004. In 2000, 24 percent of children with diarrhoea received no treatment (Table 9.19). This number dropped to 18 percent in 2004. ORS was given to 61 percent of children with diarrhoea, an increase from 43 percent in the 1992 MDHS and 48 percent in the 2000 MDHS. Overall, 70 percent of children were given either ORS or increased fluids, an increase from 63 percent in the 1992 MDHS and 62 percent in 2000 MDHS. Table 9.18 Knowledge of ORS packets Percentage of mothers with births in the five years preceding the survey who know about ORS packets for treatment of diarrhoea, by back- ground characteristics, Malawi 2004 Background characteristic Percentage of mothers who know about ORS packets Number of mothers Age 15-19 92.2 605 20-24 94.6 2,345 25-29 95.0 1,835 30-34 92.1 1,132 35-49 93.0 1,354 Residence Urban 96.5 1,041 Rural 93.4 6,231 Region Northern 92.8 924 Central 92.9 2,959 Southern 94.9 3,389 District Blantyre 96.4 520 Kasungu 93.4 330 Machinga 91.8 284 Mangochi 87.8 411 Mzimba 94.1 464 Salima 93.4 199 Thyolo 97.9 386 Zomba 98.4 389 Lilongwe 92.0 1,013 Mulanje 96.7 296 Other districts 93.7 2,981 Education No education 88.6 1,885 Primary 1-4 93.7 2,021 Primary 5-8 96.1 2,485 Secondary+ 98.7 880 Wealth quintile Lowest 92.8 1,380 Second 93.0 1,579 Middle 92.2 1,610 Fourth 94.7 1,432 Highest 97.0 1,271 Total 93.8 7,271 Maternal and Child Health | 157 Table 9.19 Diarrhoea treatment Among children under five years who had diarrhoea in the two weeks preceding the survey, percentage taken for treatment to a health provider, percentage who received oral rehydration therapy (ORT), and percentage given other treatments, according to background char- acteristics, Malawi 2004 Oral rehydration therapy (ORT) Other treatments Background characteristic Percentage taken to a health facility1 ORS packets Increased fluids ORS or increased fluids Pill/ syrup Injection Intra- venous solution Home remedy/ other Missing No treatment Number of children Age in months <6 22.5 35.8 30.6 51.8 9.8 0.0 0.0 13.9 0.3 38.0 102 6-11 41.3 62.1 34.0 70.6 26.3 0.3 0.1 12.5 0.0 18.5 490 12-23 39.5 67.3 38.4 74.7 27.6 0.4 0.0 12.8 0.1 14.0 853 24-35 29.2 58.2 34.4 69.6 29.8 0.3 0.2 10.9 0.1 19.0 375 36-47 35.3 55.1 30.2 62.1 28.4 0.8 0.0 12.4 0.2 18.1 206 48-59 32.0 55.3 42.1 66.9 23.0 0.9 2.1 15.7 0.0 19.2 150 Sex Male 37.9 63.2 37.1 72.7 27.5 0.1 0.4 14.1 0.1 15.3 1,134 Female 34.9 58.9 34.5 67.2 25.7 0.7 0.0 11.1 0.1 20.3 1,043 Residence Urban 38.7 67.0 52.8 79.2 27.9 0.6 0.0 5.2 0.0 17.1 234 Rural 36.2 60.4 33.8 69.0 26.5 0.4 0.2 13.5 0.1 17.8 1,943 Region Northern 24.3 48.5 24.5 59.9 19.6 1.2 0.7 21.0 0.0 19.2 153 Central 32.4 57.8 30.8 67.0 25.2 0.2 0.2 13.8 0.1 19.4 1,083 Southern 43.0 67.0 43.5 75.3 29.3 0.5 0.1 9.9 0.1 15.6 942 District Blantyre 47.7 68.7 61.6 82.9 31.4 0.0 0.0 6.8 0.0 12.4 114 Kasungu 23.8 48.3 16.5 55.0 31.2 0.0 0.2 18.4 0.0 23.4 131 Machinga 32.7 57.0 20.8 62.4 33.2 0.0 0.0 7.8 0.6 19.5 78 Mangochi 33.3 59.5 33.3 66.7 31.9 0.8 0.5 9.8 0.0 20.9 142 Mzimba 15.6 41.5 32.9 55.8 20.5 0.7 0.0 28.4 0.0 20.2 99 Salima 43.0 65.9 40.4 77.7 38.7 0.4 0.0 11.5 1.2 13.1 81 Thyolo 53.2 80.2 45.9 85.0 24.0 0.9 0.0 7.6 0.0 9.3 141 Zomba 47.3 68.9 45.7 77.6 33.3 2.0 0.0 3.5 0.6 15.3 120 Lilongwe 29.0 59.5 35.7 69.1 20.0 0.0 0.6 9.6 0.0 21.5 336 Mulanje 34.2 57.5 44.4 68.3 29.4 0.0 0.7 13.3 0.0 24.2 83 Other districts 38.4 61.3 33.4 69.9 25.2 0.4 0.1 14.9 0.0 16.7 854 Education No education 29.1 59.1 29.5 68.4 22.4 0.0 0.5 15.0 0.1 19.3 554 Primary 1-4 36.6 58.9 31.4 65.6 25.9 0.8 0.2 14.1 0.0 19.8 724 Primary 5-8 36.7 63.0 41.8 73.2 28.4 0.4 0.0 10.5 0.1 15.4 683 Secondary+ 53.9 68.2 48.5 79.5 34.1 0.0 0.3 8.7 0.2 14.2 216 Wealth quintile Lowest 34.6 56.0 29.2 64.9 23.6 0.1 0.4 17.3 0.1 18.2 498 Second 40.6 63.4 36.6 72.3 27.2 0.5 0.0 11.8 0.0 17.2 519 Middle 31.7 59.0 31.5 66.5 25.5 0.0 0.1 13.7 0.1 22.0 495 Fourth 35.9 63.6 38.8 74.2 28.0 1.5 0.5 9.7 0.1 15.1 375 Highest 40.9 66.4 49.7 75.9 30.6 0.1 0.0 8.2 0.2 14.1 289 Total 36.4 61.1 35.9 70.1 26.6 0.4 0.2 12.6 0.1 17.7 2,177 1 Excludes pharmacy, shop, and traditional practitioners. Treatment-seeking behaviour, particularly the use of ORT, is found most commonly among more educated mothers, mothers in urban areas, and those in the Southern Region. Children age 6- 23 months are more likely to get ORS than other children. Other differentials are small. 158 | Maternal and Child Health There are other common responses to diarrhoea; 27 percent of children were given a pill or syrup, and 13 percent were given some type of home remedy. Home remedies, including herbal medicines, are more common in rural areas and in the Northern Region, among children with less educated mothers, and children in households in the lowest wealth quintile. All mothers of children with diarrhoea in the past two weeks were asked whether they modified the child’s feeding practices because of the illness. Table 9.20 indicates that only 36 percent of children with diarrhoea were given more to drink, the recommended action in response to diarrhoea. One in four children were given the same amount as usual, 32 percent were given less than usual, and 8 percent were given no fluids at all, which greatly increases the risks of serious complications and death. Data in Table 9.20 show that only 25 percent of children with diarrhoea received more food, 30 percent were receiving the same amount of food as usual, 35 percent received less food, and 6 percent were given no food at all. Four percent of children were never given food, presumably because they were being exclusively breastfed. These figures reflect a gap in practical knowledge among mothers about the nutritional requirements of children during episodes of diarrhoeal illness. 9.8 WOMEN’S PERCEPTIONS OF PROBLEMS IN ACCESSING HEALTH CARE In the 2004 MDHS, all women were asked whether they thought certain issues or circumstances were “a big problem or not” when they are sick and want to get medical advice or treatment. Table 9.21 shows the percentage of women who reported that they have big problems in accessing health care for themselves when they are sick. The most often cited problems have to do with distance and cost. Overall, 63 percent of women mention the cost of transport, 62 percent mention the cost for treatment, 60 percent say that distance to a health facility is a big problem, and 55 percent say that having to take transport is a problem. Additionally, 16 percent of women say that knowledge of a source was a big problem for them in gaining access to health services. Concern that there may not be a female health provider is mentioned by only 13 percent of women (Figure 9.4). More than one-fourth of women (27 percent) say that not wanting to go alone is a big problem in accessing health care for themselves, while only 9 percent say getting permission to go for treatment is a big problem. Table 9.20 Feeding practices during diarrhoea Percent distribution of children under five years who had diarrhoea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, Malawi 2004 Percent Amount of liquids offered Same as usual 24.8 More 35.9 Somewhat less 16.6 Much less 15.1 None 7.5 Don't know/missing 0.2 Total 100.0 Amount of food offered Same as usual 30.0 More 25.1 Somewhat less 20.0 Much less 15.1 None 5.7 Never gave food 4.0 Don't know/missing 0.2 Total 100.0 Number of children 2,177 Maternal and Child Health | 159 Table 9.21 Problems in accessing health care Percentage of women who reported they have big problems in accessing health care for themselves when they are sick, by type of problem and background char- acteristics, Malawi 2004 Problems in accessing health care Background characteristic Knowing where to go for treatment Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Cost of transport Not wanting to go alone Concern there may not be a female provider Any of the specified problems Number of women Age 15-19 15.5 11.2 57.5 57.7 52.5 58.8 30.4 16.2 78.8 2,392 20-29 15.0 8.4 59.4 57.5 51.6 60.1 24.5 12.1 78.1 5,027 30-39 16.5 8.4 64.9 63.4 59.3 67.9 27.2 13.3 81.7 2,595 40-49 16.2 7.9 68.0 64.8 60.6 69.6 27.4 13.5 83.2 1,684 Number of living children 0 17.0 11.1 55.5 54.8 48.9 56.1 29.7 16.5 75.7 2,655 1-2 14.0 8.3 59.3 59.0 53.2 61.1 26.0 12.1 78.7 4,092 3-4 15.9 8.4 64.3 61.7 56.9 65.4 24.0 12.1 81.3 2,726 5+ 16.5 8.1 69.1 65.5 62.2 71.4 27.6 13.6 84.6 2,225 Marital status Never married 15.3 10.7 54.2 52.6 47.1 53.0 29.3 15.6 73.5 1,970 Married or living together 15.1 8.3 61.4 61.0 55.5 63.7 25.6 13.1 80.5 8,312 Divorced/separated/widowed 19.2 10.0 71.8 63.4 61.2 72.0 29.6 12.4 83.9 1,416 Residence Urban 9.5 6.3 37.4 30.6 23.0 31.2 12.6 7.6 51.0 2,076 Rural 16.9 9.5 66.7 66.2 61.7 69.8 29.7 14.7 86.0 9,621 Region Northern 20.8 10.5 44.0 57.0 46.7 52.6 24.9 13.7 74.9 1,552 Central 16.7 9.8 64.5 61.1 57.7 66.2 29.9 15.7 81.9 4,734 Southern 13.2 7.8 63.8 59.7 54.5 63.0 24.5 11.3 79.3 5,412 District Blantyre 11.8 6.8 50.4 48.7 39.3 48.1 18.5 9.1 67.5 914 Kasungu 22.1 10.7 69.9 74.9 67.2 76.2 30.5 27.0 90.5 497 Machinga 13.4 8.9 62.8 64.0 61.6 63.6 25.8 12.3 77.0 427 Mangochi 14.0 9.2 58.3 53.2 43.7 59.7 25.5 13.1 77.3 599 Mzimba 21.9 10.0 52.5 56.9 49.1 57.1 27.6 16.9 75.1 778 Salima 27.9 22.1 69.0 68.3 62.2 68.6 43.8 31.3 89.5 303 Thyolo 19.9 5.2 70.2 65.3 62.5 68.8 34.2 13.0 81.9 618 Zomba 13.1 10.5 59.1 56.7 56.9 59.7 24.5 13.6 76.0 637 Lilongwe 12.6 9.8 52.2 50.7 50.9 56.3 26.0 11.2 70.4 1,705 Mulanje 11.0 5.4 65.6 59.2 58.4 69.8 33.1 16.2 79.9 512 Other Districts 15.6 8.5 66.1 64.1 57.5 66.6 25.8 11.7 85.3 4,708 Education No education 18.0 10.2 74.3 69.8 66.4 75.5 28.7 15.8 88.9 2,734 Primary 1-4 18.2 9.7 67.1 65.0 63.0 69.1 30.3 15.2 85.9 2,998 Primary 5-8 14.9 8.8 58.6 57.9 51.3 60.7 26.7 12.5 78.9 4,154 Secondary+ 9.4 6.1 39.2 41.0 31.7 38.7 17.8 9.0 57.6 1,811 Employment Not employed 15.6 9.5 59.6 56.6 52.2 60.1 25.6 13.3 77.2 4,874 Working for cash 14.9 7.7 54.3 53.7 46.4 54.8 24.4 11.8 73.3 2,125 Not working for cash 16.0 8.9 66.7 66.1 61.3 69.6 28.9 14.3 85.4 4,693 Wealth quintile Lowest 17.0 9.9 75.8 71.5 68.8 77.1 32.0 15.2 90.3 2,037 Second 20.1 11.0 73.1 68.3 65.6 74.6 32.8 16.9 89.8 2,277 Middle 18.5 10.9 68.8 68.3 63.8 71.4 29.3 14.9 87.7 2,383 Fourth 14.5 7.8 60.3 60.2 54.5 62.7 26.1 12.9 81.3 2,361 Highest 9.0 5.5 34.8 35.9 26.8 34.4 15.6 8.1 54.4 2,639 Total 15.6 8.9 61.5 59.9 54.8 62.9 26.7 13.4 79.8 11,698 Note: Total includes 7 women with missing information on employment. 160 | Maternal and Child Health In general, older women, rural women, women in the Central Region, less-educated women, women who are not working for cash, and women in the lowest wealth quintiles are more likely than other women to mention specified problems in accessing health care. Needing permission to obtain treatment is cited as a problem more often by younger women and women with no children. Getting money for treatment, on the other hand, is more often mentioned by older women, women with a large number of children, divorced, separated, or widowed women, rural women, and women living in households in the lowest wealth quintiles. Not surprisingly, money and distance are the major constraints to women’s access to health services. These problems are felt most acutely by women living in remote parts of the country and women living in poorer households. Still, these findings underscore the inequities in real access to health care in the country. As an example, 76 percent of women without formal education mentioned cost of transport as a big problem in getting health services, compared with 39 percent of women with some secondary education (Figure 9.5). Figure 9.4 Percentage of Women Who Reported They Have Big Problems in Accessing Health Care, by Type of Problem 80 13 27 63 55 60 62 9 16 0 10 20 30 40 50 60 70 80 90 Any of the specified problems Absence of a female provider Not wanting to go alone Cost of transport Availability of transport Distance Money for treatment Getting permission to go Knowing where to go Percent MDHS 2004 Maternal and Child Health | 161 Figure 9.5 Percentage of Women Who Reported the Cost of Transport as a Big Problem in Accessing Health Care 31 70 76 69 61 39 77 75 71 63 34 0 10 20 30 40 50 60 70 80 90 RESIDENCE Urban Rural EDUCATION No education Primary 1-4 Primary 5-8 Secondary+ WEALTH QUINTILE Lowest Second Middle Fourth Highest Percent MDHS 2004 Infant Feeding and Children’s and Women’s Nutritional Status | 163 INFANT FEEDING AND CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS 10 Theresa Banda Malnutrition remains one of the major public health and developmental problems that Malawians are challenged with. The extent of chronic malnutrition in Malawi has not changed for decades and specific micronutrient deficiencies of vitamin A, iron/folate, and iodine are high as confirmed by the National Micronutrient Survey 2001 (MOHP, 2003b), exerting an additional threat to child and maternal health, and development. There is also an increase in the non- communicable diseases related to nutrition, such as overweight and obesity. Women of reproductive age, infants, and young children are the most vulnerable groups to these diseases. Immediate causes of malnutrition are inadequate dietary intake of various nutrients and frequent infections due to household food insecurity, as well as poor access to high quality health care and environment. In Malawi, the government and its collaborating partners recognise the consequences of malnutrition and are committed to improve the situation through development and implementation of policies, programmes, and interventions. Some of the interventions include improvement in maternal, infant, and young child feeding practices, increasing micronutrient intake through supplementation, fortification, dietary diversification, and public health measures. This chapter covers infant and young child feeding practices including breastfeeding and complementary foods; micronutrient intake, anaemia and anthropometric assessment of the nutritional status of children under five years and of women age 15-49. 10.1 BREASTFEEDING Appropriate feeding practices are important for survival, growth and development of infants and young children and for the wellbeing of mothers. They are one of the major determinants of child nutritional status. Malnutrition in young children exposes them to greater risk of illness and death. The Malawi Ministry of Health promotes exclusive breastfeeding for the first six months of life and continued breastfeeding with appropriate complementary feeding up to two years or beyond. This policy applies to all children unless there are medical indications. This is in line with the UNICEF and WHO Global Strategy on Infant and Young Child Feeding (WHO, 2003). Breastfeeding is convenient and has nutritive and protective properties important for the child’s nutritional status. Mothers benefit from breastfeeding through biological suppression of the return to fertile status which contributes to the duration of birth intervals and pregnancy outcomes. These effects are influenced by initiation, duration and intensity of breastfeeding, and by the age when the child receives supplementary foods and liquids. 10.1.1 Initiation of Breastfeeding Early initiation of breastfeeding (within one hour of birth) facilitates breast milk production and consumption of colostrum which appears right after delivery. Colostrum has a 164 | Infant Feeding and Children’s and Women’s Nutritional Status high concentration of nutrients and antibodies which protect the baby from infection before the baby’s immune system has matured. Early initiation also encourages bonding between the mother and the infant and helps to maintain body temperature. Prelacteal feeds delay initiation and establishment of effective lactation. It is recommended that children be fed colostrum (the first breast milk) immediately after birth and continue to be exclusively fed at the breast even if regular breast milk has not started to flow. Table 10.1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and among children ever breastfed, per- centage who started breastfeeding within one hour and within one day of birth, and percentage who received a prelacteal feed, by background characteristics, Malawi 2004 Percentage who started breastfeeding Background characteristic Percentage ever breastfed Number of children Within 1 hour of birth Within 1 day of birth1 Percentage who received a prelacteal feed2 Number of children ever breastfed Sex Male 98.0 5,381 69.3 96.7 5.9 5,275 Female 98.7 5,390 70.4 96.4 5.0 5,318 Residence Urban 98.6 1,425 78.1 97.5 1.5 1,405 Rural 98.3 9,347 68.6 96.4 6.0 9,187 Region Northern 98.2 1,345 69.5 97.4 8.1 1,320 Central 98.5 4,494 68.4 95.0 8.6 4,426 Southern 98.3 4,933 71.2 97.8 1.8 4,847 District Blantyre 98.9 724 77.5 96.9 1.9 715 Kasungu 98.0 525 56.4 97.6 20.1 515 Machinga 98.5 441 79.4 98.8 0.9 434 Mangochi 97.9 636 78.4 96.9 3.4 622 Mzimba 98.4 676 70.6 98.0 14.7 665 Salima 98.9 312 79.9 97.6 9.5 308 Thyolo 98.4 575 62.0 98.4 1.9 565 Zomba 97.8 544 78.9 96.9 2.0 532 Lilongwe 98.7 1,489 76.6 94.6 4.0 1,470 Mulanje 97.6 437 68.4 98.9 2.3 427 Other districts 98.3 4,414 64.9 96.0 5.0 4,339 Mother's education No education 98.7 2,903 68.0 95.8 6.8 2,865 Primary 1-4 98.0 3,102 69.2 95.9 6.1 3,040 Primary 5-8 98.4 3,637 70.8 97.7 4.2 3,578 Secondary+ 98.2 1,127 72.8 96.7 3.9 1,107 Assistance at delivery Health professional3 98.4 6,145 72.9 97.3 3.4 6,047 Traditional birth attendant 98.5 2,819 66.4 95.8 7.7 2,778 Other 97.8 1,531 65.8 96.0 7.9 1,496 No one 97.6 221 61.3 96.1 16.1 216 Place of delivery Health facility 98.4 5,990 72.6 97.2 3.5 5,891 At home 98.1 3,164 66.8 95.2 8.0 3,105 Other 98.7 1,603 65.9 97.4 7.8 1,582 Wealth quintile Lowest 98.9 2,099 66.0 96.6 6.5 2,076 Second 98.4 2,426 67.7 95.6 6.0 2,388 Middle 97.9 2,446 70.4 96.3 6.3 2,394 Fourth 98.1 2,091 70.9 97.3 4.8 2,052 Highest 98.4 1,709 75.3 97.5 3.0 1,682 Total 98.3 10,771 69.8 96.6 5.4 10,593 Note: Table is based on all births whether the children are living or dead at the time of interview. Total includes some children with no information on assistance at delivery and place of delivery. 1 Includes children who started breastfeeding within one hour of birth. 2 Children given something other than breast milk during the first three days of life before the mother started breastfeeding regularly. 3 Doctor, clinical officer, nurse, midwife, or patient attendant Infant Feeding and Children’s and Women’s Nutritional Status | 165 Table 10.1 shows that almost all (98 percent) children born in the five years preceding the survey were breastfed for some period of time. Almost all of these children were breastfed within 24 hours (97 percent), while 70 percent were breastfed within one hour of birth. There are minor differences according to background characteristics. However, urban children, children who were assisted at delivery by medically-trained health professionals, and those delivered in a health facility are more likely to be breastfed within the recommended one hour of birth. The likelihood of a child being breastfed within one hour after birth is positively related with the mother’s education and wealth status. Only 5 percent of children were given prelacteal feeds (Table 10.1). However, this is more than double the percentage reported in the 2000 MDHS (2 percent). There are variations within subgroups of children. Rural children, children in the Northern and Central Regions, children of less educated mothers, those who were born outside a health facility and in the lower wealth quintiles are more likely than other children to be given prelacteal feeds. Children whose mothers did not receive assistance from anyone during delivery are much more likely to receive prelacteal feeds (16 percent). It is interesting to note that children in Kasungu and Mzimba, both of which are in the Northern Region, are much more likely than children in other districts to be given prelacteal feeds (20 and 15 percent, respectively). 10.1.2 Age Pattern of Breastfeeding Breast milk contains all the nutrients and fluids needed by the baby in the first six months of life. Supplementing breast milk before six months is not necessary and is strongly discouraged because of the likelihood of contamination and resulting risk of diarrhoeal diseases. Early introduction of liquids and solids reduces breast milk output because the production and release of milk is influenced by the frequency and intensity of suckling. In line with UNICEF and WHO’s recommendation, the Ministry of Health recommends that all children should be given breast milk with no supplementary liquid or solid food during the first six months of life. Children should be given solid or semisolid complementary food beginning in the seventh month of life unless medically indicated. Table 10.2 and Figure 10.1 show data on the breastfeeding status of young children from birth up to three years of age. Table 10.2 shows that virtually all (99 percent) children are breastfed for at least a year. By 16-19 months, 92 percent of children are still breastfeeding and 80 percent are still breastfeeding toward their second birthday. While far fewer children are still being breastfed in the third year, 13 percent of children are still breastfeeding at age 32-35 months. More than half (53 percent) of children under six months are exclusively breastfed, compared with 45 percent in the 2000 MDHS. This shows great improvement since the early 1990s when exclusive breastfeeding even for the first four months was almost non existent (3 percent in the 1992 MDHS). The improvement in exclusive breastfeeding could be attributed to the continued support of the Ministry of Health and its key collaborators through programmes such as Baby Friendly Hospital Initiative (BFHI). It should also be noted that the questions about complementary feeding changed somewhat between the surveys. 166 | Infant Feeding and Children’s and Women’s Nutritional Status A large increase is observed in the percentage of children under 4 months of age that are given plain water in addition to breast milk. Twenty-six percent of children 4-5 months are given plain water in 2004 compared with 3 percent in the 2000 MDHS. On the other hand, introduction of complementary foods to children 4-5 months has declined from 80 percent in the 2000 MDHS to 37 percent in the 2004 MDHS survey. These figures suggest that in 2004 children were much more likely to be given plain water than complementary foods as is the case in 2000. Table 10.2 Breastfeeding status by age Percent distribution of youngest children under three years living with the mother by breastfeeding status and percentage of children under three years using a bottle with a nipple, according to age in months, Malawi 2004 Breastfeeding and consuming: Age in months Not breast- feeding Exclusively breastfed Plain water only Water- based liquids/ juice Other milk Complementary foods Total Number of children Percentage using a bottle with a nipple1 Number of children <2 1.6 75.2 11.2 3.9 1.7 6.5 100.0 316 1.6 326 2-3 0.0 59.2 17.2 6.7 3.9 13.1 100.0 415 2.9 419 4-5 0.5 27.5 26.1 6.6 2.0 37.1 100.0 361 3.4 363 6-7 1.2 3.8 20.0 4.3 0.9 69.9 100.0 416 6.3 420 8-9 1.5 0.9 10.3 1.0 0.0 86.3 100.0 400 4.9 402 10-11 1.2 1.0 4.4 1.9 0.6 91.0 100.0 364 8.2 366 12-15 2.3 0.3 1.1 0.7 0.0 95.5 100.0 783 4.6 795 16-19 7.9 0.3 2.0 0.2 0.2 89.4 100.0 709 5.3 740 20-23 19.7 0.0 1.5 0.0 0.2 78.6 100.0 615 5.0 660 24-27 66.6 0.0 0.3 0.0 0.0 33.1 100.0 465 2.5 584 28-31 82.4 0.1 0.0 0.0 0.0 17.5 100.0 437 3.4 597 32-35 87.4 0.1 0.6 0.0 0.0 11.9 100.0 358 2.2 562 <6 0.6 53.3 18.4 5.9 2.6 19.1 100.0 1,092 2.7 1,109 6-9 1.4 2.4 15.2 2.7 0.5 77.9 100.0 815 5.6 822 Note: Breastfeeding status refers to a ‘24-hour’ period (yesterday and last night). Children classified as breastfeeding and consuming plain water only consume no supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, water-based liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and water-based liquids and who do not receive complementary foods are classified in the water-based liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1Based on all children under three years Infant Feeding and Children’s and Women’s Nutritional Status | 167 Another indicator of infant feeding in Table 10.2 is the percentage of children who are fed using a bottle with a nipple. Bottle-feeding is not recommended in Malawi even when breastfeeding is contraindicated, as when a mother who is HIV positive has chosen replacement feeding. Replacement feeds are supposed to be given using a cup and not a bottle with a nipple. The use of a bottle with a nipple, regardless of the contents requires hygienic handling and causes nipple confusion in breastfeeding children. The 2004 MDHS findings indicate that use of feeding bottles in children under age 6 months has remained at the same level as in the 2000 MDHS (about 3 percent). Table 10.3 shows that the median duration of breastfeeding in Malawi is 23.2 months, one month shorter than in the 2000 MDHS. The median duration of exclusive breastfeeding is 2.5 months, whereas the median for predominant breastfeeding is 4.8 months, twice as long as that reported in 2000 (2-4 months). Overall, 98 percent of breastfed children are breastfeeding on demand (six or more times in the last 24 hours) with a median of 8.9 times during the day and 6.6 times at night. There are small differences in the frequency of breastfeeding across background characteristics. However, children in the Northern Region are fed less frequently than children in the Central and Southern regions. For example, children in the Northern Region are fed on average 7.3 times during the day, compared with 9 or more times in the other two regions. Children in Blantyre, Mangochi, Salima, and Lilongwe are in general breastfed more frequently than children in other districts. Figure 10.1 Distribution of Children by Breastfeeding (BF) Status, According to Age 0% 20% 40% 60% 80% 100% <2 2-3 4-5 6-7 8-9 10-11 12-15 16-19 20-23 24-27 28-31 32-35 Age in months Pe rc en t Exclusively breastfed BF + Water only BF + Complementary foods Not breastfeeding MDHS 2004 168 | Infant Feeding and Children’s and Women’s Nutritional Status Table 10.3 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preced- ing the survey, percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Malawi 2004 Median duration (months) of breastfeeding1 Breastfeeding children under six months2 Background characteristic Any breastfeeding Exclusive breastfeeding Predominant breastfeeding3 Number of children Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 23.4 2.1 4.6 3,340 96.8 9.0 6.7 552 Female 23.0 3.0 5.0 3,375 98.4 8.9 6.5 546 Residence Urban 22.8 3.2 4.3 910 98.4 9.6 7.1 121 Rural 23.2 2.4 4.9 5,805 97.5 8.9 6.5 977 Region Northern 23.1 2.6 5.3 824 97.6 7.3 5.2 127 Central 23.0 2.2 4.6 2,816 97.6 9.3 6.7 482 Southern 23.4 2.8 4.8 3,075 97.6 9.0 6.9 488 District Blantyre 23.8 1.3 4.5 440 97.5 11.8 8.5 76 Kasungu 23.3 0.8 5.8 314 95.3 8.0 5.3 52 Machinga 24.6 3.2 4.3 272 96.6 8.0 5.9 50 Mangochi 23.4 3.0 5.5 407 97.2 10.5 8.7 71 Mzimba 23.7 2.1 4.6 413 95.1 7.3 4.8 62 Salima 22.8 1.8 2.9 201 100.0 11.0 7.1 31 Thyolo 23.3 3.4 4.7 351 96.2 6.8 4.5 53 Zomba 23.0 4.0 5.3 337 94.2 6.9 5.6 51 Lilongwe 22.9 3.4 5.0 944 96.3 10.3 7.0 166 Mulanje 22.8 4.0 5.1 273 97.4 8.4 7.8 43 Other districts 22.9 2.1 4.6 2,763 99.3 8.5 6.5 444 Mother's education No education 24.1 1.9 4.8 1,697 99.1 8.9 6.7 262 Primary 1-4 23.1 2.6 4.5 1,951 95.0 8.9 6.6 326 Primary 5-8 22.9 2.6 5.1 2,295 98.1 8.9 6.6 387 Secondary+ 22.6 3.2 4.7 771 99.4 9.1 6.2 122 Wealth quintile Lowest 24.8 2.6 4.6 1,328 95.2 9.1 6.3 227 Second 22.9 2.0 4.4 1,550 98.4 8.5 6.5 267 Middle 23.2 2.2 5.0 1,492 98.2 8.9 6.5 236 Fourth 22.9 3.0 5.2 1,278 98.0 9.0 6.8 202 Highest 22.8 3.2 4.7 1,066 98.3 9.5 6.9 166 Total 23.2 2.5 4.8 6,715 97.6 8.9 6.6 1,098 Mean for all children 23.1 3.6 5.9 na na na na na Note: Median and mean durations are based on current status. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Excludes children who do not have a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, water-based liquids, and/or juice only (excludes other milk) Infant Feeding and Children’s and Women’s Nutritional Status | 169 10.2 COMPLEMENTARY FEEDING Breastfeeding alone is not adequate to meet child’s nutritional needs after the age of six months. Mothers are encouraged to introduce adequate, safe and high quality complementary foods to the child after six months. Any food or drink given to a child before six months of age is considered to be a supplement. Complementary foods are only those that are given to the child from six months of age. This is a critical stage as the child is put at increased risk of malnutrition and illness if foods are introduced before six months of age or if foods are exposed to unhygienic conditions. On the other hand, delays in introduction of complementary foods can cause the child’s growth to falter. It is recommended that by nine months all children are given complementary foods and from 6-18 months children should be fed meals that are both energy and nutrient dense and easy to digest at least four times daily. 10.2.1 Type of Complementary Foods In Malawi, most of the complementary foods are made from grains or cereal and prepared in the form of porridge where a legume, milk or milk products, meat, and oil may be added to enrich it. Table 10.4 shows that 91 percent of breastfeeding children 6-9 months are fed some semi-solid or solid foods. Most children age 6-9 months receive foods made from grains (73 percent), while 50 percent are fed fruits and vegetables, 16 percent are fed foods made from legumes, and 11 percent receive foods made from roots and tubers. Almost half (48 percent) of children 6-9 months are given fruits and vegetables rich in vitamin A, while over one-fifth are given meat, fish, poultry, or eggs. The pattern of food consumption among children 6-9 months is similar to that reported in the 2000 MDHS, with a slight decrease in the consumption of foods rich in vitamin A from 54 percent in the 2000 MDHS to 48 percent in the 2004 MDHS and a slight increase in consumption of other fruits and vegetables. The decline in the consumption of food groups like grains, may be partly due to a less detailed questionnaire used in the 2004 MDHS. In the 2000 MDHS, two specific types of foods are listed in the questionnaire, porridge and thobwa. These items are not listed separately in 2004. The sharpest percentage change is in the consumption of liquids other than milk. Only 4 percent of breastfeeding children age 6-9 months were fed infant formula. Effective utilisation of vitamin A in the body requires oil-rich foods. Figures in Table 10.4 show that complementary feeding is still a problem in Malawi, in that consumption of high energy and nutrient dense foods such as legumes, meats, fish eggs, milk and milk products, and oil is very low. This means that children are unable to get the required nutrients from the foods they consume, which may result in long-term nutrition problems. 170 | Infant Feeding and Children’s and Women’s Nutritional Status Table 10.4 Foods consumed by children in the day or night preceding the interview Percentage of youngest children under three years of age living with the mother who consumed specific foods in the day or night preceding the inter- view, by breastfeeding status and age, Malawi 2004 Age in months Infant formula Other milk/ cheese/ yoghurt Other liquids1 Food made from grains Fruits/ vegetables2 Food made from roots/ tubers Food made from legumes Meat/ fish/ shellfish/ poultry/ eggs Food made with oil/ fat/ butter Fruits and vegetables rich in vitamin A3 Any solid or semisolid food Number of children BREASTFEEDING CHILDREN <2 1.2 4.4 6.2 4.6 1.5 0.4 0.1 1.3 1.4 1.5 8.1 311 2-3 4.2 2.8 10.0 10.6 3.6 1.2 2.7 1.7 1.7 3.6 24.3 415 4-5 3.0 4.7 17.5 30.8 13.1 2.6 7.2 5.6 1.4 12.3 62.1 359 6-7 3.9 7.6 23.0 64.7 38.0 7.0 11.7 16.8 2.1 35.6 87.6 411 8-9 4.4 9.0 25.2 81.6 63.1 15.4 21.1 28.5 4.5 60.2 95.2 394 10-11 5.0 10.5 30.6 86.8 72.6 24.4 26.2 32.9 5.1 69.9 96.8 360 12-15 3.8 11.1 33.2 92.8 85.2 31.0 35.1 39.1 7.7 81.2 99.3 765 16-19 5.4 9.0 30.9 91.8 88.9 35.9 34.7 43.6 6.5 87.5 98.8 653 20-23 3.3 11.2 33.9 93.8 89.2 29.7 36.0 44.7 7.9 87.5 99.0 493 24-35 2.2 9.1 29.6 94.7 91.6 37.3 33.7 39.3 6.0 90.2 98.8 277 <6 2.9 3.9 11.4 15.6 6.1 1.4 3.5 2.9 1.5 5.9 32.1 1,086 6-9 4.2 8.3 24.1 73.0 50.3 11.1 16.3 22.5 3.3 47.6 91.3 804 NONBREASTFEEDING CHILDREN <15 (27.2) (17.4) (51.0) (62.3) (60.2) (27.3) (26.9) (23.4) (3.0) (60.2) (88.6) 40 16-19 13.8 23.8 43.9 97.0 93.7 35.0 35.9 54.4 17.9 92.6 98.1 56 20-23 5.1 13.1 41.9 96.4 91.4 39.9 26.8 57.6 6.5 89.6 100.0 121 24-35 6.1 18.4 39.1 97.2 92.6 42.0 41.3 51.8 7.7 91.1 99.8 982 Note: Breastfeeding status and food consumed refer to a ‘24-hour’ period (yesterday and last night). Figures in parentheses are based on 25-49 un- weighted cases. 1Does not include plain water 2Includes fruits and vegetables rich in vitamin A 3Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A 10.2.2 Frequency of Foods Consumed by Children Table 10.5 shows the frequency of foods consumed by children in the day and night preceding the survey. The table shows that children 6-9 months consumed foods made from grain and fruits and vegetables rich in vitamin A at least once in the past 24 hours. Consumption of other types of foods is very infrequent. Nonbreastfeeding children are more likely to eat solid food than breastfeeding children. These children on average ate foods made from grains two times a day, fruits and vegetables four times, and fruits and vegetables rich in vitamin A three times a day. Foods which are sources of protein are consumed less than once a day. Infant Feeding and Children’s and Women’s Nutritional Status | 171 Table 10.5 Frequency of foods consumed by children in the day or night preceding the interview Mean number of times specific foods were consumed in the day or night preceding the interview by youngest children under three years of age living with the mother, according to breastfeeding status and age, Malawi 2004 Age in months Infant formula Other milk/ cheese/ yoghurt Other liquids1 Food made from grains Fruits/ vegetables2 Food made from roots/ tubers Food made from legumes Meat/ fish/ shellfish/ poultry/ eggs Food made with oil/ fat/ butter Fruits and vegetables rich in vita- min A3 Number of children BREASTFEEDING CHILDREN <2 0.0 0.1 0.2 0.1 0.1 0.0 0.0 0.0 0.0 0.1 311 2-3 0.1 0.1 0.2 0.2 0.1 0.0 0.1 0.0 0.0 0.1 415 4-5 0.0 0.2 0.3 0.6 0.4 0.0 0.1 0.1 0.0 0.3 359 6-7 0.0 0.1 0.4 1.2 1.0 0.1 0.2 0.2 0.0 0.7 411 8-9 0.1 0.2 0.5 1.6 1.6 0.2 0.3 0.4 0.1 1.3 394 10-11 0.1 0.2 0.6 1.8 2.2 0.3 0.4 0.5 0.1 1.8 360 12-15 0.1 0.2 0.7 2.1 2.8 0.5 0.5 0.6 0.1 2.2 765 16-19 0.1 0.2 0.6 2.1 3.0 0.5 0.5 0.7 0.1 2.5 653 20-23 0.0 0.2 0.8 2.2 3.2 0.4 0.5 0.7 0.1 2.7 493 24-35 0.0 0.1 0.6 2.2 3.3 0.6 0.6 0.6 0.1 2.7 277 <6 0.1 0.1 0.3 0.3 0.2 0.0 0.1 0.0 0.0 0.1 1,086 6-9 0.1 0.2 0.4 1.4 1.3 0.1 0.2 0.3 0.0 1.0 804 NONBREASTFEEDING CHILDREN <15 (0.1) (0.0) (0.1) (0.0) (0.1) (0.0) (0.0) (0.0) (0.0) (0.0) 40 16-19 0.2 0.5 1.0 2.5 4.0 0.7 0.5 0.8 0.3 3.2 56 20-23 0.1 0.3 0.8 2.5 3.5 0.5 0.4 0.9 0.1 2.8 121 24-35 0.1 0.3 0.8 2.4 3.8 0.6 0.6 0.8 0.1 3.1 982 Note: Breastfeeding status and food consumed refer to a ‘24-hour period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases. 1Does not include plain water 2Includes fruits and vegetables rich in vitamin A 3Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables rich in vitamin A 10.3 MICRONUTRIENTS In Malawi micronutrient deficiencies of vitamin A, iodine, and iron/folate are public health concerns. According to the 2001 National Micronutrient Survey (MOHP, 2003b), about 60 percent of children under five, 57 percent of nonpregnant women, and 38 percent of men and school-age children have sub-clinical vitamin A deficiency. The survey also reported that 80 percent of children under five, 27 percent of nonpregnant women, and 17 percent of men have anaemia. Sixty percent of anaemia among children under three years of age was due to iron deficiency. The government and its collaborating partners have developed an action plan which promotes supplementation, fortification, and dietary diversification as strategies to deal with micronutrient deficiencies. The 2004 MDHS collected data that will be used to assess the coverage of vitamin A and iron/folate supplementation, consumption of foods rich in vitamin A, and of vitamin A status of mothers through the assessment of night blindness. 172 | Infant Feeding and Children’s and Women’s Nutritional Status 10.3.1 Micronutrient Intake among Children Vitamin A is essential for good vision, resistance to infections, growth, and development. Vitamin A is believed to improve immunity and has been shown to contribute to the reduction of morbidity and mortality. The Ministry of Health’s policy is to supplement children age 6-59 months with a vitamin A capsule once every six months. Table 10.6 shows that 65 percent of children under age three had consumed fruits and vegetables rich in vitamin A in the 24 hours preceding the survey and 65 percent of children had received a vitamin A capsule in the last six months preceding the survey. There are small differences in vitamin A supplementation across children’s background characteristics. Consumption of foods rich in vitamin A increases with age. Whereas less than half of the children 6-9 months (47 percent) consumed foods rich in vitamin A, nine in ten children 24-35 months did. Non-breastfeeding children, children in urban areas, and children in the highest wealth quintile are more likely to consume foods rich in vitamin A than other children. Vitamin A supplementation is higher than the national average in most of the oversampled districts. However, the coverage is only 53 percent in Machinga and Mzimba. The coverage of vitamin A supplementation declines after the child’s second year of life. This is a reflection of reduced attendance at Growth Monitoring and Promotion Centres where supplementation is done routinely as part of the Expanded Programme on Immuni- Table 10.6 Micronutrient intake among children Percentage of youngest children under age three living with the mother who con- sumed fruits and vegetables rich in vitamin A in the 24 hours preceding the survey, and percentage of children age 6-59 months who received vitamin A supplements in the six months preceding the survey, by background characteristics, Malawi 2004 Background characteristic Foods rich in vitamin A1 Number of children Vitamin A supplements in the past 6 months Number of children Age in months <6 5.9 1,092 na 0 6-9 47.2 815 65.8 822 10-11 70.2 364 73.3 366 12-23 85.5 2,107 75.6 2,194 24-35 90.9 1,259 67.5 1,743 36-47 na 0 58.8 1,741 48-59 na 0 55.6 1,802 Sex Male 64.3 2,809 65.2 4,281 Female 65.2 2,829 65.6 4,388 Birth order 1 64.8 1,232 64.6 2,019 2-3 64.4 2,130 66.9 3,197 4-5 65.7 1,242 66.1 1,893 6+ 64.6 1,035 62.5 1,560 Breastfeeding status Breastfeeding 58.0 4,438 73.0 3,432 Not breastfeeding 89.8 1,186 60.5 5,194 Residence Urban 73.5 799 68.3 1,217 Rural 63.3 4,839 64.9 7,451 Region Northern 68.2 703 63.9 1,108 Central 63.7 2,323 66.8 3,586 Southern 64.8 2,612 64.6 3,973 District Blantyre 62.8 385 68.9 594 Kasungu 64.8 266 60.5 419 Machinga 62.8 229 53.4 355 Mangochi 63.4 331 66.7 495 Mzimba 67.9 360 52.8 567 Salima 60.6 165 79.7 250 Thyolo 70.5 292 65.1 458 Zomba 67.5 290 70.6 448 Lilongwe 66.4 783 67.9 1,210 Mulanje 70.0 223 69.9 332 Other districts 63.2 2,315 65.5 3,541 Mother's education No education 63.8 1,405 60.9 2,331 Primary 1-4 62.1 1,610 65.9 2,477 Primary 5-8 66.2 1,937 66.1 2,923 Secondary+ 69.0 685 73.1 936 Mother's age at birth <20 65.8 1,035 63.5 1,779 20-24 64.7 1,971 68.1 2,967 25-29 62.7 1,187 66.4 1,774 30-34 66.8 777 63.7 1,152 35-49 64.9 668 61.2 997 Wealth quintile Lowest 58.6 1,100 60.8 1,660 Second 64.3 1,271 64.5 1,901 Middle 65.5 1,242 66.1 1,970 Fourth 65.4 1,092 67.7 1,710 Highest 71.0 933 68.3 1,427 Total 64.8 5,638 65.4 8,668 Note: Information on vitamin A supplements is based on mother’s recall. Total includes some children with missing information on breastfeeding status. na = Not applicable 1Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mango, papaya, and other locally grown fruits and vegeta- bles that are rich in vitamin A Infant Feeding and Children’s and Women’s Nutritional Status | 173 zation (EPI). It has been established that most children above two years of age do not attend under-five clinics regularly. The Ministry of Health and its partners complement routine services with campaigns or child health days to achieve the target that 80 percent of children under five receive vitamin A supplementation every six months by 2009. 10.3.2 Micronutrient Intake among Women Provision of vitamin A supplements to women after delivery of a child is intended to boost stores and ensure adequate delivery of this essential micronutrient to the child in breast milk. In the 2004 MDHS, women who had a live birth in the five years before the survey were asked whether they had received a vitamin A supplement in the two-month period after delivery of their last child.1 The women were also asked whether they had experienced any vision problems during the night time and (in a separate question) during the day.2 Night blindness in pregnancy is a common manifestation of vitamin A deficiency (VAD). Table 10.7 shows that 41 percent of women received a vitamin A supplement during the postnatal period. This is the same level as that reported in the 2000 MDHS. Variations in postpartum vitamin A supplementation by age of the mother and child’s birth order are minimal. Supplementation is higher in urban areas, in the Northern Region, among women with more education, and among women in the higher wealth quintiles. Larger variations are found among the districts, ranging from 32 percent in Lilongwe to 53 percent in Mzimba. Table 10.7 also shows that about 6 percent of women with a recent birth experienced night blindness, an indicator of VAD. The small percentages make it difficult to examine variations among subgroups of women. Iron-deficiency anaemia is a major threat to maternal health; it contributes to low birth weight, lowered resistance to infection, poor cognitive development, and decreased work capacity. Further, anaemia increases morbidity from infections because it adversely affects the body’s immune response. The 2004 MDHS collected data from women who had a recent birth about whether they had received or purchased any iron tablets during their last pregnancy. If so, the woman was asked to report the number of days that the tablets were actually taken during that pregnancy. Interviewers assisted the respondent in converting responses provided on a daily or weekly basis to total number of days over the course of the pregnancy. Table 10.7 shows that 18 percent of women reported taking iron supplements on at least 90 days during the pregnancy, as recommended. This is an increase from 12 percent reported in the 2000 MDHS. Iron supplementation coverage is highest in Thyolo (24 percent) and lowest in Salima and Mangochi (7 and 10 percent, respectively). 1When the question was asked, the interviewer showed a vitamin A capsule to the respondent. 2Women are considered to experience night blindness if they report vision problems during the night, but not during the day. 174 | Infant Feeding and Children’s and Women’s Nutritional Status Table 10.7 Micronutrient intake among mothers Percentage of women with a birth in the five years preceding the survey who received a vitamin A dose in the first two months after delivery, percentage who reported night blindness during pregnancy, and percentage who took iron tablets for specific number of days, by background characteristics, Malawi 2004 Night blindness during pregnancy Number of days iron tablets taken during pregnancy Background characteristic Received vitamin A dose postpartum1 Reported Adjusted2 None <60 60-89 90+ Number of women Age at birth <20 40.1 4.9 1.6 19.4 48.8 10.7 18.3 1,293 20-24 41.2 5.1 1.2 16.9 49.3 11.3 19.0 2,429 25-29 41.4 6.1 1.0 23.5 47.3 11.1 15.6 1,545 30-34 40.7 5.7 1.1 23.9 44.5 12.6 16.0 1,005 35-49 41.1 8.6 1.3 22.7 45.3 9.9 18.3 1,000 Number of children ever born 1 39.5 4.6 1.3 17.5 47.5 11.7 20.8 1,518 2-3 41.7 5.1 1.2 19.1 49.1 11.2 17.0 2,659 4-5 40.8 5.7 1.2 22.8 47.3 10.7 15.7 1,622 6+ 41.4 8.4 1.3 23.6 45.1 10.9 17.6 1,473 Residence Urban 45.1 2.2 0.4 16.3 41.6 15.1 20.8 1,041 Rural 40.3 6.4 1.4 21.2 48.6 10.5 17.1 6,231 Region Northern 53.0 4.6 0.9 8.7 55.8 10.0 19.9 924 Central 35.9 7.0 1.4 24.0 46.9 10.4 16.1 2,959 Southern 42.1 5.1 1.2 20.7 46.0 12.1 18.4 3,389 District Blantyre 50.3 3.1 0.9 21.4 47.2 12.1 16.5 520 Kasungu 42.5 5.6 0.9 15.9 59.9 10.2 10.2 330 Machinga 39.9 3.7 1.0 27.2 39.1 12.4 19.7 284 Mangochi 42.3 6.8 1.9 29.4 49.4 6.8 9.8 411 Mzimba 53.2 3.8 0.8 8.5 60.9 12.9 12.6 464 Salima 43.9 5.8 1.5 25.8 59.4 6.6 7.1 199 Thyolo 41.9 6.0 1.8 15.0 42.0 17.0 23.9 386 Zomba 45.5 5.1 0.3 15.5 48.2 14.1 16.6 389 Lilongwe 32.3 6.9 0.9 27.8 40.4 11.4 17.2 1,013 Mulanje 36.6 4.3 1.3 17.6 54.2 10.0 16.1 296 Other districts 39.7 6.6 1.5 19.7 46.4 10.4 20.7 2,981 Education No education 36.4 6.9 1.1 27.8 43.1 9.7 16.7 1,885 Primary 1-4 38.1 7.4 1.6 21.6 48.8 10.9 16.2 2,021 Primary 5-8 44.3 4.7 1.2 16.4 50.7 11.5 18.0 2,485 Secondary+ 48.3 2.9 0.8 14.2 45.4 13.8 22.0 880 Wealth quintile Lowest 34.5 7.3 1.7 22.8 47.4 9.2 18.0 1,380 Second 39.5 6.3 1.3 24.1 48.8 10.4 14.8 1,579 Middle 41.5 7.4 1.6 20.7 50.0 10.3 16.1 1,610 Fourth 43.2 4.3 0.8 18.4 48.2 11.7 18.5 1,432 Highest 46.8 3.2 0.7 15.7 42.5 14.6 21.8 1,271 Total 41.0 5.8 1.2 20.5 47.6 11.1 17.6 7,271 Note: For women with two or more live births in the five-year period, data refer to the most recent birth. 1 In the first two months after delivery 2 Women who reported night blindness but did not report difficulty with vision during the day Infant Feeding and Children’s and Women’s Nutritional Status | 175 10.4 PREVALENCE OF ANAEMIA IN CHILDREN Anaemia is a serious concern for young children because it can result in impaired cognitive performance, behavioural and motor development, coordination, language development, and scholastic achievement, as well as increased morbidity from infectious diseases. Information on the prevalence of anaemia can be useful for the development of health intervention programmes designed to prevent anaemia, such as iron fortification programmes. Table 10.8 shows that 73 percent of children age 6-59 months are anaemic, 26 percent have mild anaemia, 42 percent with moderate anaemia, while 5 percent showed severe anaemia. No substantial differences were reported among girls and boys. However, the level of severe anaemia decreases with the age of the child. For example, 19 percent of children age 10-11 months were found to be severely anaemic compared to 2 percent among children age 48-59 months. Anaemia is related to the child’s birth order and the interval with their older siblings. First births tend to have severe anaemia compared with their siblings. Similarly, children of sixth or higher birth order and children born 48 months or more after a previous sibling are more likely to have severe anaemia. Children from rural areas, children in the Central Region, children whose mother have no education, and children of young mothers are more susceptible to severe anaemia compared with other children. Severe anaemia is most prevalent in Thyolo, Lilongwe, and Salima Districts (7 percent or higher). Table 10.8 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteristics, Malawi 2004 Anaemia status Background characteristic Any anaemia Mild (10.0-10.9 g/dl) Moderate (7.0-9.9 g/dl) Severe (below 7.0 g/dl) Number of children Age in months 6-9 91.3 15.9 62.4 13.0 160 10-11 88.0 21.2 47.5 19.4 82 12-23 83.8 20.8 55.7 7.3 552 24-35 73.6 27.6 43.0 3.0 446 36-47 62.5 28.1 33.0 1.3 471 48-59 62.2 34.7 25.7 1.8 463 Sex Male 73.9 25.4 43.4 5.0 1,060 Female 72.5 27.3 40.6 4.6 1,113 Birth order1 1 74.2 29.8 37.6 6.7 393 2-3 73.9 22.9 47.1 3.9 720 4-5 73.4 27.8 41.1 4.5 471 6+ 75.0 24.5 43.3 7.2 372 Birth interval in months First birth2 74.1 29.6 37.8 6.7 396 <24 72.0 26.9 41.6 3.5 226 24-47 73.5 24.5 44.4 4.6 980 48+ 76.6 24.3 46.0 6.3 354 Residence Urban 65.4 22.8 40.8 1.8 231 Rural 74.1 26.8 42.1 5.2 1,942 Region Northern 71.7 29.5 38.9 3.2 309 Central 74.0 26.6 42.1 5.3 824 Southern 73.0 25.3 42.8 4.9 1,040 Continued … 176 | Infant Feeding and Children’s and Women’s Nutritional Status Table 10.8 Prevalence of anaemia in children (continued) Percentage of children age 6-59 months classified as having anaemia, by background characteristics, Malawi 2004 Anaemia status Background characteristic Any anaemia Mild (10.0-10.9 g/dl) Moderate (7.0-9.9 g/dl) Severe (below 7.0 g/dl) Number of children District Blantyre 69.0 26.8 36.7 5.6 128 Kasungu 74.9 26.3 46.0 2.7 116 Machinga 71.1 20.8 44.2 6.1 93 Mangochi 73.0 25.8 44.3 2.9 131 Mzimba 73.6 29.3 41.4 2.9 159 Salima 81.9 27.9 47.1 6.9 68 Thyolo 70.0 22.2 40.0 7.9 109 Zomba 76.4 22.9 47.6 5.9 119 Lilongwe 72.8 21.4 44.7 6.7 180 Mulanje 80.3 26.7 51.0 2.7 86 Other districts 72.5 28.2 39.7 4.6 985 Mother's education No education 75.4 24.3 44.9 6.2 560 Primary 1-4 77.6 29.2 44.6 3.8 573 Primary 5-8 72.2 24.4 42.3 5.5 681 Secondary+ 64.5 26.0 33.8 4.7 200 Mother's age3 15-19 80.2 22.2 46.3 11.7 115 20-24 75.6 24.8 46.1 4.7 625 25-29 70.5 24.6 42.3 3.7 532 30-34 72.4 31.3 34.5 6.6 373 35-49 75.4 25.8 45.2 4.4 371 Mother’s status Mother interviewed 74.0 25.8 43.0 5.2 1,956 Mother not interviewed, but in household 68.9 31.1 35.8 1.9 60 Mother not interviewed, and not in household4 64.2 31.9 31.5 0.8 158 Wealth quintile Lowest 78.2 27.3 45.8 5.1 414 Second 77.2 25.0 45.5 6.7 490 Middle 72.6 24.9 42.5 5.3 537 Fourth 72.4 28.1 39.8 4.6 454 Highest 60.9 27.6 32.7 0.6 280 Total 73.2 26.4 42.0 4.8 2,173 Note: Table is based on children who stayed in the household the night before the interview in a subsample of households. Prevalence is adjusted for altitude using formulas recommended by CDC (CDC, 1989). g/dl = grams per deciliter 1Excludes children whose mothers were not interviewed 2First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 3For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the household schedule 4Includes children whose mothers are deceased Infant Feeding and Children’s and Women’s Nutritional Status | 177 10.4.1 Prevalence of Anaemia in Women A woman’s nutritional status has important implications for the health status of the woman herself as well as that of her children. A woman who has poor nutritional status has a greater risk of adverse pregnancy outcomes as well as underweight babies. Table 10.9 shows that 44 percent of women are anaemic; 32 percent have mild anaemia, 11 percent have moderate anaemia, and 2 percent have severe anaemia. There are small differ- ences in severe the levels of anaemia by the woman’s back- ground characteristics. 10.4.2 Prevalence of Anaemia in Children by Anaemia Status of Mother Mother’s nutritional status is strongly associated with their children’s. Table 10.10 shows that among the children who are anaemic, 82 percent have mothers who are anaemic. Mother’s severity of anaemia is consistent with their children’s. For instance, children with mild anaemia tend to have mothers with mild anaemia, and children with moderate anaemia tend to have mothers with moderate anaemia. Table 10.9 Prevalence of anaemia in women Percentage of women age 15-49 with anaemia, by background characteristics, Malawi 2004 Anaemia status Background characteristic Any anaemia Mild Moderate Severe Number of women Age1 15-19 42.2 28.9 10.5 2.7 506 20-24 42.0 30.2 10.4 1.5 649 25-29 41.1 30.0 10.3 0.9 478 30-34 47.7 36.2 9.6 1.9 341 35-39 49.9 34.5 12.2 3.2 265 40-44 47.4 36.4 10.4 0.5 218 45-49 49.5 35.7 12.8 1.1 162 Children ever born2 None 45.6 29.6 12.7 3.2 488 1 38.9 25.5 12.6 0.8 399 2-3 44.2 33.6 9.1 1.5 690 4-5 42.8 32.4 8.7 1.7 522 6+ 49.0 36.5 11.0 1.4 521 Preganacy/ breastfeeding status2 Pregnant 47.3 22.5 22.9 1.9 352 Breastfeeding 41.5 33.3 6.5 1.6 1,022 Neither 45.8 33.5 10.5 1.8 1,246 Residence Urban 38.8 24.8 12.4 1.6 375 Rural 45.2 33.2 10.3 1.8 2,246 Region Northern 47.4 36.0 10.2 1.2 431 Central 41.7 30.2 9.7 1.8 946 Southern 45.3 31.9 11.5 1.9 1,243 District Blantyre 31.5 22.8 7.4 1.3 198 Kasungu 39.2 24.9 11.4 2.9 128 Machinga 44.8 29.6 11.4 3.8 110 Mangochi 52.5 35.8 14.3 2.5 135 Mzimba 47.2 36.7 9.8 0.7 203 Salima 47.6 32.9 12.3 2.4 83 Thyolo 43.2 31.1 10.4 1.8 144 Zomba 44.0 35.3 8.3 0.5 132 Lilongwe 42.1 28.2 11.3 2.6 215 Mulanje 47.0 33.0 13.6 0.5 110 Other Districts 45.6 33.6 10.5 1.6 1,162 Education1 No education 46.8 33.8 10.1 2.9 637 Primary 1-4 47.2 34.2 11.4 1.5 662 Primary 5-8 41.4 30.1 10.1 1.3 948 Secondary+ 42.3 29.6 11.5 1.3 372 Wealth quintile Lowest 43.9 33.4 8.1 2.4 443 Second 45.6 33.7 10.6 1.3 530 Middle 45.4 33.1 10.2 2.1 571 Fourth 44.5 30.9 12.2 1.4 570 Highest 41.8 28.9 11.4 1.5 506 Total 44.3 32.0 10.6 1.7 2,620 Note: Table is based on women who stayed in the household the night before the interview. Prevalence is adjusted for altitude and for smoking status if known, using CDC formulas (CDC, 1989). Women with <7.0 g/dl of haemoglobin have severe anaemia, women with 7.0-9.9 g/dl have moderate anaemia, and pregnant women with 10.0-10.9 g/dl and nonpregnant women with 10.0-11.9 g/dl have mild anaemia. Total includes five cases with missing information on mother’s smoking status. 1 For women who are not interviewed, information is taken from the Household Questionnaire. 2 Excludes women who were not interviewed. 178 | Infant Feeding and Children’s and Women’s Nutritional Status Table 10.10 Prevalence of anaemia in children by anaemia status of mother Percentage of children age 6-59 months classified as having anaemia, by anaemia status of mother, Malawi 2004 Anaemia status of child Anaemia status of mother Any anaemia Mild (10.0-10.9 g/dl) Moderate (7.0-9.9 g/dl) Severe (below 7.0 g/dl) Number of children Any anaemia 81.4 26.1 49.0 6.3 737 Anaemia status Mild anaemia 81.3 28.2 47.1 6.0 571 Moderate anaemia 83.3 20.3 56.2 6.7 145 Severe anaemia (72.3) (10.1) (51.5) (10.7) 21 Total 73.8 25.7 43.3 4.7 1,756 Note: Table is based on children who stayed in the household the night before the interview. Prevalence is adjusted for altitude (and for smoking in the case of mothers with information on smoking status) using formulas in CDC, 1989. Table includes only cases with anaemia measurements for both mothers and children. Figures in parentheses are based on 25-49 unweighted cases. 10.5 NUTRITIONAL STATUS 10.5.1 Nutritional Status of Children Nutritional status is an important health indicator as it allows evaluation of the susceptibility of the population to disease, impaired mental development, and early death. Three standard indicators of growth for children are used in this report, based on the relationship between height, weight, and age. The indicators are height-for-age, weight-for-height, and weight-for-age. A child is considered stunted if he is too short for his age, which indicates chronic undernutrition, typically due to poor nutrition over an extended period. A child is considered wasted if he is too thin, i.e., weighs too little for his height. Wasting is an indicator of acute or recent nutritional deficits and is closely tied to mortality risk. Finally, a child is considered underweight if he weighs too little for his age. A child can be underweight for his age because he is stunted, wasted, or both. To allow standardised measurement over time and between settings, height and weight data are routinely compared to a reference population. The World Health Organisation (WHO) recommends using the child population data maintained by the NCHS (U.S. National Center for Health Statistics) as reference. The reference population serves as a point of comparison, facilitating the examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. The data from the reference population have been normalised to produce a distribution in which the mean coincides with the median. The use of the international reference population is based on the finding that well-nourished children of all population groups for which data exist follow very similar growth patterns before puberty. A presentation of anthropometric status of young children complements the information on feeding practices. Nutritional status, along with mortality rates, represents an outcome measure. The status of a child with regard to stunting, wasting, and underweight is determined by how many statistical units, called standard deviations, the child is measured below the mean of the NCHS reference population. If a child is between two and three standard deviations below the mean, the child is considered moderately malnourished (stunted, wasted, or underweight); if Infant Feeding and Children’s and Women’s Nutritional Status | 179 the child is three or more standard deviations below the mean, the child is considered severely malnourished. In the 2004 MDHS, the height and weight of children under age five were measured in order to estimate their nutritional status. Table 10.11 shows that 48 percent of children under five in Malawi are stunted, or too short for their age, 5 percent of children are wasted or too thin, and 22 percent are underweight. Data in Table 10.11 indicate further that 22 percent of children are severely stunted. Children’s nutritional status in 2004 is similar to the status in 1992 and 2000, indicating that there has been no improvement in the nutritional status of children under five since 1992. In general, there are only small differences in nutritional status between boys and girls. However, stunting varies substantially across subgroups of children. Older children, children born less than 24 months after their older sibling, children whose birth size is small, children who live in rural areas or in the Central Region, children whose mothers have less education, children not living with their mothers, and children in the lower wealth quintiles are more likely than other children to be stunted. Stunting ranges from 42 percent in Zomba to 56 percent in Kasungu. Variations in wasting across subgroups of children are less notable than those for stunting. Variations in underweight, however, are more apparent. For example, children whose mothers are uneducated are twice as likely to be underweight as children whose mothers have secondary or higher education (26 and 13 percent, respectively). Similarly, children in the lowest wealth quintile are twice as likely to be underweight as children in the highest quintile (28 and 13 percent, respectively). 180 | Infant Feeding and Children’s and Women’s Nutritional Status Table 10.11 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Malawi 2004 Height-for-age Weight-for-height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Number of children Age in months <6 1.9 11.6 (0.3) 0.9 4.0 0.7 0.5 2.1 0.4 758 6-9 7.2 28.6 (1.1) 3.2 6.9 0.2 3.1 18.2 (0.7) 657 10-11 15.4 40.3 (1.6) 2.0 10.7 (0.1) 7.1 32.4 (1.3) 299 12-23 30.3 60.7 (2.2) 1.8 6.8 (0.1) 7.4 28.8 (1.4) 1,886 24-35 24.2 47.7 (1.9) 1.9 5.3 (0.1) 5.4 25.1 (1.2) 1,588 36-47 24.8 52.9 (2.0) 1.1 3.1 0.1 3.9 20.3 (1.2) 1,645 48-59 25.0 53.5 (2.1) 1.3 4.1 0.0 3.1 21.8 (1.3) 1,689 Sex Male 23.8 50.0 (1.9) 1.9 5.5 0.0 4.5 22.4 (1.1) 4,221 Female 20.7 45.6 (1.8) 1.4 4.8 0.1 4.5 21.6 (1.0) 4,299 Birth order2 1 19.4 47.1 (1.8) 1.8 5.5 0.1 4.6 21.5 (1.1) 1,666 2-3 20.8 45.4 (1.8) 1.9 5.7 0.1 4.3 20.7 (1.0) 2,916 4-5 23.3 50.1 (1.9) 1.6 5.1 0.0 4.4 24.0 (1.1) 1,758 6+ 24.4 48.7 (1.9) 0.9 4.0 0.0 5.5 23.1 (1.1) 1,433 Birth interval in months2 First birth3 19.7 47.4 (1.8) 1.8 5.5 0.1 4.6 21.6 (1.1) 1,681 <24 28.2 51.6 (2.0) 0.9 5.3 0.1 4.8 24.4 (1.1) 823 24-47 21.6 47.7 (1.8) 1.8 5.3 0.0 4.7 22.4 (1.1) 3,797 48+ 20.7 44.6 (1.7) 1.5 4.5 0.1 4.0 20.4 (1.0) 1,471 Size at birth2 Very small 26.7 53.2 (2.0) 1.7 9.0 (0.3) 10.5 35.7 (1.4) 240 Small 27.2 54.6 (2.1) 2.8 6.3 (0.1) 7.6 31.7 (1.4) 853 Average or larger 20.6 46.1 (1.8) 1.5 5.0 0.1 3.9 20.2 (1.0) 6,502 Residence Urban 15.8 37.8 (1.5) 1.6 5.9 0.0 3.2 16.8 (0.9) 1,071 Rural 23.1 49.2 (1.9) 1.6 5.1 0.1 4.7 22.8 (1.1) 7,449 Region Northern 19.0 42.4 (1.6) 1.2 5.9 0.1 4.3 17.7 (1.0) 1,210 Central 24.8 52.7 (2.0) 0.9 3.6 0.2 4.2 22.5 (1.1) 3,330 Southern 21.1 45.3 (1.8) 2.4 6.3 (0.0) 4.9 23.0 (1.1) 3,980 District Blantyre 18.1 40.2 (1.6) 2.8 4.8 0.1 3.6 17.0 (0.9) 579 Kasungu 27.0 56.1 (2.1) 0.8 4.0 0.2 5.1 21.3 (1.1) 447 Machinga 19.6 44.8 (1.7) 1.4 6.0 (0.1) 3.8 21.4 (1.1) 376 Mangochi 24.2 48.3 (2.0) 0.1 2.5 0.1 5.7 23.6 (1.2) 512 Mzimba 23.0 46.8 (1.8) 1.1 4.1 0.3 4.2 17.9 (0.9) 614 Salima 23.8 49.3 (2.0) 1.0 5.2 0.3 4.9 20.6 (1.0) 264 Thyolo 24.3 48.1 (1.8) 3.1 8.7 (0.1) 5.0 22.2 (1.1) 414 Zomba 19.8 42.3 (1.6) 2.6 7.6 0.1 3.6 22.0 (1.0) 476 Lilongwe 24.3 52.3 (1.9) 1.1 4.7 0.1 3.0 24.5 (1.1) 952 Mulanje 23.3 50.5 (1.9) 1.9 6.0 (0.1) 6.4 26.5 (1.2) 329 Other districts 21.5 47.5 (1.8) 1.7 5.1 0.0 4.9 22.5 (1.1) 3,557 Continued… Infant Feeding and Children’s and Women’s Nutritional Status | 181 Table 10.11 Nutritional status of children (continued) Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Malawi 2004 Height-for-age Weight-for-height Weight-for-age Background characteristic Percent- age below -3 SD Percent- age below -2 SD1 Mean Z-score (SD) Percent- age below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percent- age below -2 SD1 Mean Z-score (SD) Number of children Mother's educa- tion4 No education 25.6 52.4 (2.0) 2.1 5.8 (0.0) 6.6 26.2 (1.2) 2,130 Primary 1-4 25.2 52.2 (1.9) 1.8 5.3 0.1 4.2 24.4 (1.1) 2,276 Primary 5-8 18.6 43.8 (1.7) 1.4 4.8 0.1 4.1 19.2 (1.0) 2,718 Secondary+ 13.0 33.1 (1.4) 1.2 4.8 0.1 2.1 12.9 (0.8) 841 Mother's age4 15-19 15.6 41.6 (1.5) 2.8 7.3 0.1 4.1 21.9 (0.9) 493 20-24 21.4 46.9 (1.8) 1.7 5.1 0.1 4.9 21.0 (1.0) 2,510 25-29 20.0 46.5 (1.8) 1.7 5.4 0.0 3.4 20.6 (1.1) 2,171 30-34 24.6 51.0 (1.9) 1.6 5.5 0.0 5.9 25.0 (1.2) 1,321 35-49 24.5 48.1 (1.9) 1.2 4.1 0.0 4.9 22.6 (1.2) 1,475 Mother’s status Mother inter- viewed 21.7 47.4 (1.8) 1.6 5.2 0.1 4.6 22.1 (1.1) 7,773 Mother not interviewed, but in household 22.5 44.4 (1.8) 2.1 5.4 0.2 5.2 14.4 (0.9) 196 Mother not interviewed, and not in household5 29.1 53.9 (2.0) 0.9 4.2 0.1 3.8 24.2 (1.1) 551 Wealth quintile Lowest 29.2 53.9 (2.1) 2.2 6.1 (0.0) 7.1 28.4 (1.3) 1,680 Second 24.7 53.1 (2.0) 1.7 5.1 0.1 4.7 24.4 (1.1) 1,813 Middle 24.3 51.8 (1.9) 1.5 4.6 0.1 4.2 22.8 (1.1) 1,916 Fourth 18.5 44.4 (1.7) 1.3 5.0 0.0 4.0 20.1 (1.0) 1,732 Highest 12.2 32.0 (1.4) 1.5 4.9 0.1 2.4 12.6 (0.8) 1,380 Total 22.2 47.8 (1.8) 1.6 5.2 0.1 4.5 22.0 (1.1) 8,520 Note: Table is based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the NCHS/CDC/WHO International Reference Population. The percentage of chil- dren who are more than three or more than two standard deviations below the median of the International Reference Population (-3 SD and -2 SD) are shown according to background characteristics. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Figures in parentheses are based on 25-49 unweighted cases. 1Includes children who are below -3 standard deviations (SD) from the International Reference Population median. 2Excludes children whose mothers were not interviewed 3First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 4For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the household schedule. 5Includes children whose mothers are deceased Figure 10.2 shows the percentage of children under age five who are stunted, wasted, and underweight by age in months. Stunting is lowest among children under six months and peaks at age 18-19 months (63 percent). Wasting is highest at age 10-15 months (8 percent), after which it fluctuates between 3-6 percent. The extent of underweight is less than 10 percent among children under 6 months and is highest among children 12-10 months (30 percent). 182 | Infant Feeding and Children’s and Women’s Nutritional Status 10.6 NUTRITIONAL STATUS OF WOMEN Data on height and weight of all women aged 15-49 were collected in the 2004 MDHS to assess the nutritional status of women. Two indices are used, namely height and body mass index (BMI) which combines the height and weight measures. A woman’s height is related to socio- economic status and nutrition during childhood and adolescence. Maternal height is also used to predict the risk of difficult delivery; small stature is always associated with small pelvis size and the potential for obstructed labour (NSO and ORC Macro, 2001). The risk of low birth weight is also increased in short women. The optimal cutoff point, below which a woman is identified as at risk, is in the range of 140 to 150 centimetres. The nutritional status of women in Malawi has remained constant since 2000; the mean height of mothers is 156 centimetres and 3 percent of women are less than 145 centimetres in height (Table 10.12). The table also shows that women’s height varies little according to their background characteristics. To assess thinness and obesity the report uses the body mass index, defined as the weight in kilograms divided by the squared height in metres. A lower cut off point of 18.5 is used to define chronic energy deficiency. The table shows that the mean BMI among the weighed and measured women is 22, with 77 percent of women classified as normal. Nine percent of women have a BMI below 18.5, signifying a nutritional deficit. Table 10.12 shows that rural women are almost twice as likely to be thin as urban women. Women in the Southern Region and women in Mangochi and Mulanje are more likely to be thin compared with women in other districts (see Figure 10.3). Women in the highest wealth quintile, on the other hand, are the least likely to be thin compared with other women. Figure 10.2 Percentage of Children with Low Height-for-Age, Weight-for-Height, and Weight-for-Age, by Age of Child 0 10 20 30 40 50 60 70 0 5 9 13 17 21 25 29 33 37 41 45 49 53 57 Age in Months Pe rc en t Height-for-age Weight-for-height Weight-for-age MDHS 2004 Infant Feeding and Children’s and Women’s Nutritional Status | 183 Table 10.12 Nutritional status of women Among women age 15-49, mean height, percentage under 145 cm, mean body mass index (BMI), and percentage with specific BMI levels, by background characteristics, Malawi 2004 Height BMI (kg/m2) Background characteristic Mean Percentage <145 cm Number of women Mean BMI 18.5- 24.9 (normal) <18.5 (thin) 17.0- 18.4 (mildly thin) 16.0- 16.9 (mod- erately thin) <16.0 (severely thin) ≥25.0 (over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of women Age 15-19 154.4 4.7 2,212 21.0 79.7 13.8 9.1 2.8 1.9 6.5 5.6 0.8 1,911 20-24 155.8 2.3 2,658 21.8 81.4 8.1 6.2 1.3 0.7 10.4 9.2 1.3 2,097 25-29 156.1 3.2 2,018 22.0 79.5 7.3 5.8 1.1 0.4 13.1 11.4 1.7 1,667 30-34 156.5 2.8 1,386 22.3 76.0 8.0 5.9 1.4 0.7 16.1 13.4 2.7 1,139 35-39 156.3 2.7 1,063 22.8 69.5 8.4 6.9 0.8 0.7 22.2 17.5 4.6 956 40-44 156.9 2.0 868 22.8 69.5 8.8 6.6 1.6 0.6 21.7 15.9 5.8 821 45-49 156.2 3.5 706 22.5 72.2 8.5 6.1 1.4 1.0 19.3 14.4 4.8 689 Residence Urban 156.7 2.4 1,810 23.2 71.7 5.5 4.3 0.7 0.5 22.8 17.2 5.7 1,600 Rural 155.6 3.3 9,101 21.7 78.2 10.0 7.3 1.7 1.0 11.7 10.0 1.8 7,680 Region Northern 155.9 3.6 1,516 22.2 76.7 8.8 6.2 1.4 1.2 14.6 11.1 3.4 1,309 Central 156.1 3.1 4,203 22.1 77.9 7.2 5.6 0.8 0.9 14.9 12.5 2.3 3,532 Southern 155.6 3.0 5,192 21.8 76.6 11.0 7.9 2.2 0.9 12.4 10.2 2.2 4,439 District Blantyre 156.9 1.7 881 22.6 72.3 8.6 6.2 1.7 0.7 19.1 15.4 3.7 761 Kasungu 156.1 3.9 487 22.1 78.6 8.6 6.9 0.8 0.9 12.8 9.7 3.2 410 Machinga 155.0 3.3 413 21.3 81.3 11.4 8.4 2.7 0.3 7.3 6.5 0.8 356 Mangochi 155.3 3.1 580 21.4 79.3 12.5 8.2 2.6 1.7 8.2 6.8 1.4 500 Mzimba 156.3 2.3 763 22.2 77.5 8.4 6.2 1.0 1.2 14.1 10.5 3.6 653 Salima 156.5 2.1 294 22.0 78.7 8.1 6.5 1.1 0.5 13.2 11.0 2.2 241 Thyolo 154.6 4.6 576 21.8 81.4 8.9 7.1 1.2 0.6 9.8 7.0 2.7 486 Zomba 155.5 3.4 625 22.3 70.7 11.4 7.5 3.0 0.9 17.9 13.8 4.1 535 Lilongwe 156.1 3.8 1,300 22.2 77.9 6.0 4.7 0.7 0.6 16.1 13.9 2.2 1,119 Mulanje 155.3 2.4 478 21.5 75.6 13.4 9.3 2.9 1.2 11.0 7.9 3.1 403 Other districts 155.7 3.2 4,513 21.9 77.3 9.3 6.9 1.4 1.0 13.4 11.4 2.0 3,817 Education No education 155.4 4.2 2,551 21.8 78.8 8.9 7.0 1.2 0.7 12.3 10.8 1.5 2,181 Primary 1-4 155.4 3.5 2,804 21.7 77.3 10.5 7.6 1.7 1.2 12.2 10.1 2.1 2,301 Primary 5-8 155.8 2.8 3,896 21.9 77.5 9.7 6.8 1.7 1.1 12.8 10.3 2.5 3,330 Secondary+ 157.2 1.8 1,658 22.8 73.3 6.9 5.2 1.3 0.4 19.8 15.6 4.2 1,467 Wealth quintile Lowest 155.5 3.9 1,897 21.4 81.3 10.3 7.3 2.1 1.0 8.4 7.7 0.7 1,610 Second 155.4 3.4 2,100 21.5 82.4 9.6 7.4 1.7 0.5 8.0 7.4 0.6 1,736 Middle 155.5 3.6 2,261 21.6 78.8 11.1 7.8 1.8 1.4 10.2 8.4 1.8 1,866 Fourth 155.7 2.5 2,246 22.0 75.8 9.7 6.9 1.6 1.2 14.4 12.4 2.1 1,918 Highest 156.8 2.3 2,407 23.2 69.4 6.1 5.0 0.7 0.5 24.5 18.4 6.1 2,150 Total 155.8 3.1 10,911 22.0 77.1 9.2 6.8 1.5 0.9 13.7 11.2 2.4 9,280 1Excludes pregnant women and women with a birth in the preceding 2 months 184 | Infant Feeding and Children’s and Women’s Nutritional Status The body mass index is also used to measure the percentage of women who are overweight or obese. Women are said to be overweight or obese if their BMI is 25 or higher. The 2004 MDHS indicates that 14 percent of women are overweight and 2 percent have a BMI of 30 or higher (severely overweight or obese). Women living in wealthier households are more likely to be overweight or obese. For example, 25 percent of women in the highest wealth quintile are overweight or obese compared with 8 percent of women in the lowest quintile. Urban women are also more likely to be overweight or obese than women in the rural areas (23 and 12 percent, respectively). There are large variations in BMI across districts. For overweight or obese women, the proportions range from 18 to 19 percent in Zomba and Blantyre to 7 percent in Machinga. Figure 10.3 Prevalence of Chronic Energy Deficiency (Percentage with BMI <18.5) Among Women Age 15-49, for Selected Districts 9.2 6.0 8.1 8.4 8.6 8.6 8.9 11.4 11.4 12.5 13.4 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 Malawi DISTRICTS Lilongwe Salima Mzimba Blantyre Kasungu Thyolo Machinga Zomba Mangochi Mulanje Percentage MDHS 2004 HIV/AIDS and Other Sexually Transmitted Infections | 185 HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS 11 D. Zanera and I. Miteka 11.1 INTRODUCTION The 2004 Malawi Demographic and Health Survey (MDHS) collected information on HIV/AIDS as well as other sexually transmitted infections (STIs). AIDS, or acquired immune deficiency syndrome, is one of the most serious public health and development challenges to face sub-Saharan Africa. The total number of people infected with HIV is estimated to be between 700,000 and one million people in 2003. This figure includes 60,000–80,000 HIV-positive children under age 15. One-third of those infected live in urban areas and two-thirds in rural areas. AIDS- related deaths constitute personal, economic, and social tragedies in the lives of surviving family, friends, and employers. The principal mode of HIV transmission in Malawi is heterosexual contact. This accounts for 90 percent of HIV infections in the country (UNAIDS/WHO, 2000). The duration between HIV infection and the onset of AIDS varies but averages 9-10 years, and death typically ensues within 1-2 years of symptom onset. This is followed in importance by perinatal transmission (9 percent of all HIV infections), when the mother passes HIV to the child during pregnancy, delivery or breastfeeding. It is estimated that approximately 20 percent of babies born to HIV- positive mothers will be infected around the time of birth. About one-half of children infected during the perinatal period will die before their fifth birthday. The children of HIV-infected parents who are not themselves infected are still at a great disadvantage, due to the health and social consequences of possibly losing one or both parents to AIDS. It is estimated that between 1990 and 2003, the number of children under 18 who were living without one or both parents in Malawi grew from about 800,000 to 1.2 million (NAC, 2004b), with most of the increase being the result of sharp rises in the rates of adult mortality. The future course of Malawi’s AIDS epidemic depends on a number of important variables, including the level of public awareness about HIV/AIDS, the level and pattern of risk-related behaviours, access to high quality services for sexually transmitted infections (STIs), and provision of HIV testing and counselling. The impact of AIDS is now affecting all sectors of Malawian society, and the nation’s response needs to be matched with multisectoral strategies and interventions. The National AIDS Commission (NAC) is on the leading edge of efforts to bring down barriers to effective HIV/AIDS programmes and has identified the key challenges and opportunities to galvanise an effective national effort (NAC, 2000). This chapter presents data about the extent of relevant knowledge, perceptions, and behaviours at the national and sub-national levels, and for various socioeconomic subgroups of the population. This information is relevant for AIDS control programmes to be able to target groups of individuals most in need of information and service and most vulnerable to the risk of HIV infection. 186 | HIV/AIDS and Other Sexually Transmitted Infections The data obtained from the 2004 MDHS provide an excellent opportunity to assess the levels and trends of factors related to the HIV infection. These factors include current levels of knowledge on AIDS-related issues, experience with HIV testing, and knowledge of and experience with other sexually transmitted infections, which may be important cofactors in HIV transmission. Information on patterns of sexual activity and condom use, especially among young women and men are also discussed in this section. Finally, schooling status and living arrangements of orphaned children are also presented in this chapter. 11.2 KNOWLEDGE OF AIDS AND HIV TRANSMISSION 11.2.1 Awareness of AIDS Table 11.1 shows the percentage of women and men who have heard of AIDS by their background characteristics. Know- ledge of AIDS among women and men in Malawi is almost universal. This is true across age group, urban-rural residence, marital status, wealth index, and education. 11.2.2 Knowledge of Ways to Reduce AIDS Transmission Table 11.2 presents the percentage of women and men who reported selected ways that people can do to reduce the risk of getting the AIDS virus. The specific ways are abstaining from sex, being faithful to one uninfected sexual partner, and using condoms. Overall, for women and men, abstaining from sex was mentioned most frequently (71 percent for women and 90 percent for men). The second most cited reason for avoiding AIDS infection is by limiting sex to one uninfected person (68 percent and 80 percent, respectively). Condom use is cited by 57 percent of women and 76 percent of men. The combination of using condoms and limiting sex to one uninfected partner is mentioned by 47 percent of women and 63 percent of men. Small variations are shown in the proportion by age, marital status, and residence. Table 11.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Malawi 2004 Women Men Background characteristic Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-19 98.5 2,392 98.4 650 20-24 98.3 2,870 100.0 587 25-29 98.6 2,157 99.6 634 30-39 98.8 2,595 99.8 779 40-49 98.9 1,684 100.0 464 15-24 98.4 5,262 99.2 1,237 Marital status Never married 98.8 1,970 99.0 1,084 Ever had sex 99.6 671 99.9 686 Never had sex 98.4 1,299 97.5 398 Married/living together 98.5 8,312 99.8 1,936 Divorced/separated/ widowed 99.0 1,416 100.0 93 Residence Urban 99.2 2,076 99.7 661 Rural 98.4 9,621 99.5 2,453 Region Northern 99.9 1,552 99.4 404 Central 97.3 4,734 99.2 1,302 Southern 99.3 5,412 99.8 1,408 District Blantyre 99.7 914 100.0 315 Kasungu 99.0 497 99.3 148 Machinga 99.5 427 100.0 106 Mangochi 97.1 599 99.6 141 Mzimba 99.8 778 99.3 203 Salima 97.7 303 100.0 72 Thyolo 99.6 618 100.0 156 Zomba 99.5 637 100.0 155 Lilongwe 96.2 1,705 99.3 523 Mulanje 99.4 512 100.0 105 Other districts 98.8 4,708 99.3 1,189 Education No education 97.3 2,734 99.2 350 Primary 1-4 97.7 2,998 98.3 746 Primary 5-8 99.6 4,154 100.0 1,171 Secondary+ 99.8 1,811 100.0 845 Wealth quintile Lowest 97.4 2,037 98.6 383 Second 98.0 2,277 99.5 614 Middle 98.7 2,383 99.4 666 Fourth 99.4 2,361 99.8 666 Highest 99.3 2,639 99.8 785 Total 15-49 98.6 11,698 99.5 3,114 Total men 15-54 na na 99.5 3,261 na = Not applicable HIV/AIDS and Other Sexually Transmitted Infections | 187 Table 11.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sex, and by having sex with just one partner who is not infected and who has no other partners, and by abstain- ing from sex, by background characteristics, Malawi 2004 Women Men Background characteristics Using condoms Limiting sex to one uninfected partner Using condoms and limiting sex to one uninfected partner Abstaining from sex Number of women Using condoms Limiting sex to one uninfected partner Using condoms and limiting sex to one uninfected partner Abstaining from sex Number of men Age 15-19 55.3 62.1 42.3 69.2 2,392 72.4 74.7 59.4 83.1 650 20-24 61.0 67.9 49.9 70.9 2,870 79.7 79.7 64.7 92.2 587 25-29 59.4 68.4 48.4 71.6 2,157 76.1 79.6 63.5 90.9 634 30-39 55.6 70.8 46.8 71.4 2,595 77.0 82.2 66.1 90.9 779 40-49 53.6 69.3 44.2 70.2 1,684 71.5 83.9 62.5 92.8 464 15-24 58.4 65.2 46.5 70.2 5,262 75.8 77.1 61.9 87.4 1,237 Marital status Never married 55.1 63.1 42.5 70.6 1,970 74.1 76.2 60.9 87.2 1,084 Ever had sex 59.7 65.3 46.0 73.1 671 76.1 78.7 62.4 88.3 686 Never had sex 52.7 61.9 40.6 69.4 1,299 70.5 71.8 58.3 85.4 398 Married/living together 57.7 68.8 47.4 70.9 8,312 76.4 81.8 64.6 91.4 1,936 Divorced/separated/ widowed 57.9 67.1 47.2 69.2 1,416 74.4 82.5 65.8 87.9 93 Residence Urban 54.8 66.7 45.0 70.9 2,076 73.5 80.2 60.6 90.7 661 Rural 57.8 67.8 46.9 70.6 9,621 76.1 79.8 64.1 89.6 2,453 Region Northern 63.7 77.9 56.1 78.6 1,552 64.9 88.2 61.9 83.3 404 Central 52.2 61.6 41.0 68.2 4,734 78.0 73.6 59.5 90.7 1,302 Southern 60.0 69.9 48.7 70.6 5,412 76.3 83.4 67.3 90.9 1,408 District Blantyre 60.9 72.8 50.2 73.8 914 75.7 87.3 68.5 89.1 315 Kasungu 49.6 70.7 40.3 71.9 497 82.3 87.4 73.4 94.3 148 Machinga 54.9 56.3 40.4 57.5 427 79.0 84.7 74.0 87.5 106 Mangochi 53.4 55.7 37.9 55.3 599 80.4 84.6 72.5 84.5 141 Mzimba 70.3 86.9 67.1 85.9 778 61.7 87.2 58.0 74.9 203 Salima 62.8 65.3 48.3 65.9 303 84.0 89.4 76.1 96.5 72 Thyolo 67.2 76.8 55.9 82.0 618 76.3 84.6 68.2 97.5 156 Zomba 56.5 69.9 46.6 71.6 637 81.0 80.6 67.8 92.8 155 Lilongwe 43.9 56.3 35.9 66.2 1,705 72.1 64.3 48.4 88.0 523 Mulanje 75.2 78.8 61.4 91.7 512 54.8 75.2 45.1 85.8 105 Other districts 57.3 67.2 45.6 68.6 4,708 78.1 80.7 65.8 92.2 1,189 Education No education 48.9 62.0 39.4 62.9 2,734 73.6 71.2 55.5 90.4 350 Primary 1-4 57.3 65.4 46.0 69.2 2,998 73.0 73.7 59.4 86.1 746 Primary 5-8 61.6 70.9 50.4 73.3 4,154 77.5 82.4 66.3 89.0 1,171 Secondary+ 60.1 72.2 49.4 79.0 1,811 75.8 85.5 66.1 94.0 845 Wealth quintile Lowest 53.6 63.2 42.4 67.1 2,037 73.5 76.0 60.8 86.9 383 Second 56.4 64.7 45.3 67.7 2,277 75.9 80.5 65.2 88.7 614 Middle 58.6 68.5 47.7 70.4 2,383 74.8 80.6 62.9 89.5 666 Fourth 59.7 70.5 49.4 72.4 2,361 76.6 79.1 63.1 91.1 666 Highest 57.6 70.2 47.3 74.7 2,639 75.9 81.3 63.7 91.3 785 Total 15-49 57.3 67.6 46.6 70.7 11,698 75.5 79.9 63.4 89.8 3,114 Total men 15-54 na na na na na 75.1 80.2 63.2 89.9 3,261 na = Not applicable 188 | HIV/AIDS and Other Sexually Transmitted Infections There is a strong association between the respondent’s educational level and knowledge of AIDS prevention. For example, the percentage of women who mention abstaining from sex increases from 63 percent for women with no education to 79 percent for women with secondary or higher education. In all subgroups of men, the percentage who mention abstaining from sex is high (83 percent or higher). Knowledge of all three means of HIV transmission tends to increase with wealth. 11.2.3 Beliefs about AIDS More than two decades since the first cases of AIDS were reported in Malawi, many people still do not know how the disease is transmitted. The 2004 MDHS asked questions to find out whether people have misconceptions about HIV/AIDS. The questions included in the survey are: whether a healthy-looking person can have AIDS virus, whether a mosquito can transmit AIDS, whether AIDS can be transmitted by supernatural powers, and whether a person can be infected by AIDS by sharing food with a person who has the AIDS virus. Table 11.3.1 shows that four in five women correctly say that a healthy-looking person can have the AIDS virus and that a person cannot become infected by sharing a meal with a person who has the AIDS virus. Three in four women report that AIDS cannot be transmitted by supernatural powers, while two in three women say that AIDS cannot be transmitted by mosquitoes. Overall, less than half of women can identify the two most common misconceptions and know that a healthy- looking person can have the AIDS virus. Table 11.3.1 also shows that the pattern among women 15-24 is similar to that for all women. Beliefs about AIDS do not vary much by marital status. The percentage of women who correctly identify two misconceptions and say that a healthy-looking person can have the AIDS virus ranges from 47 percent among women who are currently married to 63 percent among women who have never married but have had sex. Beliefs about AIDS vary by residence; urban women are more knowledgeable about AIDS than rural women. While 88 percent of urban women say that a healthy-looking person can have the AIDS virus, the proportion for rural women is 81 percent. Further, whereas 64 percent of women in urban areas can identify two misconceptions and confirm that a healthy-looking person can have AIDS virus, the corresponding proportion for rural women is 45 percent. There is a strong association between a respondent’s education and wealth status and her beliefs about AIDS. For example, 93 percent of women with secondary or higher education say that a healthy-looking person can have AIDS virus, compared with 73 percent of women with no education. While two in three women in the highest wealth quintile identify the two most common misconceptions and say that a healthy-looking person can have the AIDS virus, only 38 percent of women in the lowest quintile share this belief. There are no significant regional differences in the level of comprehensive correct knowledge of HIV/AIDS prevention and transmission. However, there are differentials in misconceptions levels by districts, comprehensive knowledge about HIV/AIDS among women ranges from 13 percent in Kasungu and 15 percent in Mangochi to 33 percent in Mulanje. Table 11.3.2 shows information on beliefs about AIDS among men. In general, the proportions for men are higher than those for women, which suggests that men are more knowledgeable than women in matters related to AIDS. Whereas slightly less than half of women can identify two of the most common misconceptions and say that a healthy-looking person can have the AIDS virus, the corresponding proportion for men is 60 percent. HIV/AIDS and Other Sexually Transmitted Infections | 189 Table 11.3.1 Beliefs about AIDS: women Percentage of women who, in response to prompted questions, correctly rejected local misconceptions about AIDS transmission andprevention, and who know that a healthy-looking person can have the AIDS virus, by background characteristics, Malawi 2004 Percentage of women who know that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by super- natural means A person cannot get infected by sharing food with a person who has AIDS Percentage who reject the two most common local misconceptions and say that a healthy-looking person can have the AIDS virus1 Percentage with comprehensive knowledge about AIDS2 Number of women Age 15-19 76.8 70.0 77.6 81.2 49.9 21.1 2,392 20-24 83.4 69.0 79.4 84.2 52.5 25.6 2,870 25-29 83.5 65.7 75.6 81.0 49.8 25.2 2,157 30-39 83.7 63.0 74.6 82.0 46.6 21.0 2,595 40-49 81.2 60.5 68.7 78.4 41.1 17.4 1,684 15-24 80.4 69.4 78.6 82.8 51.3 23.6 5,262 Marital status Never married 79.1 74.9 81.1 83.5 56.5 24.2 1,970 Ever had sex 83.5 80.4 84.1 88.3 63.0 28.1 671 Never had sex 76.9 72.0 79.6 81.0 53.1 22.1 1,299 Married/living together 82.1 64.1 74.9 81.1 46.8 22.1 8,312 Divorced/separated/ widowed 83.7 65.3 73.1 82.8 47.6 22.0 1,416 Residence Urban 88.0 78.1 82.2 85.2 63.7 29.4 2,076 Rural 80.5 63.4 74.3 80.9 45.3 20.9 9,621 Region Northern 76.1 61.4 76.0 76.5 42.6 26.2 1,552 Central 79.1 63.4 73.7 81.0 46.1 19.5 4,734 Southern 85.9 69.6 77.4 83.7 52.4 23.9 5,412 District Blantyre 88.6 73.2 79.4 86.8 56.7 29.2 914 Kasungu 78.8 52.2 74.9 78.0 37.3 12.9 497 Machinga 78.0 77.5 78.4 82.2 51.6 19.4 427 Mangochi 74.9 59.9 60.7 71.1 38.4 14.9 599 Mzimba 80.6 60.2 72.2 74.8 44.6 32.4 778 Salima 80.0 63.3 66.5 81.8 41.6 20.9 303 Thyolo 91.6 60.8 76.9 87.5 47.7 25.9 618 Zomba 85.3 76.4 78.0 82.1 56.9 22.5 637 Lilongwe 78.9 69.9 75.8 80.8 53.9 20.9 1,705 Mulanje 91.1 68.7 83.7 88.6 56.3 33.9 512 Other districts 80.6 64.6 76.6 82.2 46.4 20.6 4,708 Education No education 73.0 56.6 64.3 72.5 34.7 14.2 2,734 Primary 1-4 80.0 57.9 70.0 77.1 39.9 17.6 2,998 Primary 5-8 84.2 69.8 81.4 86.0 53.3 25.5 4,154 Secondary+ 92.5 85.1 89.2 93.1 72.9 35.8 1,811 Wealth quintile Lowest 75.2 57.8 68.6 75.6 38.1 16.0 2,037 Second 78.3 60.0 71.5 79.0 40.9 18.4 2,277 Middle 80.0 63.2 74.6 81.2 44.5 20.9 2,383 Fourth 83.3 66.4 77.7 82.1 49.1 24.1 2,361 Highest 90.3 79.9 84.0 88.8 66.3 30.7 2,639 Total 81.8 66.0 75.7 81.7 48.5 22.4 11,698 1 Two most common local misconceptions: mosquito bites and supernatural means. 2 Respondents with comprehensive knowledge say that use of condom for every sexual intercourse and having just one uninfected and faithful partner can reduce the chance of getting the AIDS virus, say that a healthy-looking person can have the AIDS virus, and reject the two most common local misconceptions. 190 | HIV/AIDS and Other Sexually Transmitted Infections Table 11.3.2 Beliefs about AIDS: men Percentage of men age 15-49 who, in response to prompted questions, correctly rejected local misconceptions about AIDS transmis- sion and prevention, and who know that a healthy-looking person can have the AIDS virus, by background characteristics, Malawi 2004 Percentage of men who know that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by super- natural means A person cannot get infected by sharing food with a person who has AIDS Percentage who reject the two most common local misconceptions and say that a healthy-looking person can have the AIDS virus1 Percentage with comprehensive knowledge about AIDS2 Number of men Age 15-19 85.7 66.9 84.4 88.1 55.6 34.5 650 20-24 93.3 68.9 87.6 91.0 61.7 38.3 587 25-29 92.4 68.5 85.9 92.9 59.7 40.3 634 30-39 95.5 72.2 83.2 92.3 63.0 42.9 779 40-49 92.9 68.2 84.3 87.2 59.0 37.0 464 15-24 89.3 67.9 85.9 89.5 58.5 36.3 1,237 Marital status Never married 88.3 71.9 85.9 89.4 61.9 38.8 1,084 Ever had sex 92.1 74.0 86.5 91.5 63.6 40.0 686 Never had sex 81.7 68.2 84.7 85.9 59.0 36.6 398 Married/living together 94.0 67.6 84.6 91.2 58.7 38.9 1,936 Divorced/separated/ widowed 94.3 69.6 83.8 91.0 63.1 38.1 93 Residence Urban 93.6 81.0 89.3 91.2 74.7 46.4 661 Rural 91.6 66.0 83.8 90.4 56.0 36.8 2,453 Region Northern 88.1 64.0 85.0 89.6 54.6 36.7 404 Central 91.3 63.9 83.1 90.3 55.0 34.4 1,302 Southern 93.8 75.5 86.7 91.1 66.1 43.6 1,408 District Blantyre 97.1 85.2 89.1 93.9 77.3 48.0 315 Kasungu 87.1 57.8 80.6 91.8 46.2 36.7 148 Machinga 90.8 71.6 85.8 83.4 64.0 51.8 106 Mangochi 88.0 72.0 74.5 80.9 55.0 37.7 141 Mzimba 90.3 57.3 82.2 87.8 46.8 29.9 203 Salima 93.2 69.1 84.1 92.2 55.4 41.5 72 Thyolo 96.2 64.7 86.4 92.4 55.2 37.4 156 Zomba 96.3 68.8 85.0 93.8 61.6 40.7 155 Lilongwe 90.1 67.1 84.4 89.5 59.1 33.6 523 Mulanje 93.9 79.8 90.7 93.3 73.2 34.4 105 Other districts 91.7 68.4 85.7 91.2 59.4 39.7 1,189 Education No education 92.8 50.9 74.4 83.9 43.1 25.2 350 Primary 1-4 86.4 54.5 76.7 82.7 41.5 24.8 746 Primary 5-8 92.3 71.9 87.7 93.9 62.1 41.8 1,171 Secondary+ 96.2 85.8 92.9 95.6 80.3 52.8 845 Wealth quintile Lowest 90.0 57.2 77.0 84.5 48.0 32.4 383 Second 90.3 62.1 83.4 89.4 52.2 33.8 614 Middle 92.0 65.2 85.6 90.5 55.4 37.2 666 Fourth 92.7 73.0 86.8 91.8 63.4 40.0 666 Highest 93.8 80.6 88.1 93.3 72.7 46.4 785 Total 15-49 92.0 69.1 85.0 90.6 60.0 38.9 3,114 Total 15-54 91.8 68.9 84.8 90.1 59.5 38.6 3,261 1 Two most common local misconceptions: mosquito bites and supernatural means. 2 Respondents with comprehensive knowledge say that use of condom for every sexual intercourse and having just one uninfected and faithful partner can reduce the chance of getting the AIDS virus, say that a healthy-looking person can have the AIDS virus, and reject the two most common local misconceptions. HIV/AIDS and Other Sexually Transmitted Infections | 191 Overall, 92 percent of men are aware that a healthy-looking person can have the AIDS virus and 91 percent say that a person can not become infected by sharing a meal with a person who has AIDS. Individual beliefs about AIDS vary little across subgroups of men. However, the likelihood that a man identifies two misconceptions and agrees that a healthy-looking person can have the AIDS virus varies by residence and increases with education and wealth status. While 43 percent of men with no education agree with these statements, the corresponding proportion for men with secondary or higher education is 80 percent. The majority of respondents do not have comprehensive knowledge of HIV/AIDS transmission and prevention methods: 22 percent of women and 39 percent of men know about condom use and limiting sex to one uninfected partner as HIV prevention methods, are aware that a healthy-looking person can have the AIDS virus, and reject the two most common local misconceptions, i.e., HIV can be transmitted through mosquito bites and through supernatural means. Education is positively correlated with the likelihood of having comprehensive knowledge about HIV/AIDS. The youngest and oldest respondents have the lowest levels of comprehensive knowledge. There is room for growth in educating the population about the modes of transmission of the AIDS virus, especially in the rural areas, where levels of knowledge are lower. There are no significant variations in the level of correct knowledge of HIV/AIDS prevention and transmission among men. The proportion of men with comprehensive knowledge ranges from 30 percent in Mzimba to 50 percent in Machinga. 11.2.4 Knowledge of Mother-to-Child Transmission The 2004 MDHS collected information as to whether women and men who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of maternal to child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy. Table 11.4 shows the results. Overall, three in four women agree that HIV can be transmitted by breastfeeding, while 39 percent said the risk of MTCT can be reduced by the mother taking drugs during pregnancy and 37 percent reported both, that HIV can be transmitted by breastfeeding and the risk of MTCT can be reduced by the mother taking special drugs during pregnancy. Knowledge of MTCT through breastfeeding varies by the women’s marital status, ranging from 77 percent for ever-married women to 58 percent for women who have never had sex. Urban women, more educated women, and women in higher wealth quintiles are more knowledgeable about MTCT than other women. Overall, almost seven in ten men say that HIV can be transmitted by breastfeeding, 35 percent say that the risk of MTCT can be reduced by the mother taking drugs during pregnancy, and 29 percent report that HIV can be transmitted by breastfeeding and that the risk of MTCT can be reduced by taking special drugs during pregnancy. Knowledge of HIV transmission from mother to child among men varies. In general, better educated men and men in the higher wealth quintiles are more likely to know ways to prevent the risk of babies contracting HIV from their mothers. Regional differentials show that men in the Northern Region are more likely than men in other regions to know that HIV can be transmitted by breastfeeding, but less likely to say that drugs can be taken during pregnancy to reduce the risk of transmission. Predictably, knowledge of MTCT transmission is lower among men than among women (29 percent compared with 37 percent). 192 | HIV/AIDS and Other Sexually Transmitted Infections Table 11.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Malawi 2004 Women Men Background characteristic HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking drugs during pregnancy HIV can be transmitted by breastfeeding and risk can be reduced by mother taking drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking drugs during pregnancy HIV can be transmitted by breastfeeding and risk can be reduced by mother taking drugs during pregnancy Number of men Age 15-19 64.3 32.5 29.7 2,392 55.5 25.2 21.6 650 20-24 76.2 43.7 41.7 2,870 68.0 40.0 32.9 587 25-29 78.5 43.6 41.8 2,157 68.2 36.9 30.2 634 30-39 79.1 40.4 38.0 2,595 70.1 35.2 30.8 779 40-49 75.0 33.7 32.5 1,684 75.7 36.2 31.6 464 15-24 70.8 38.6 36.2 5,262 61.5 32.2 27.0 1,237 Marital status Never married 63.4 35.9 32.4 1,970 58.8 32.6 26.6 1,084 Ever had sex 73.2 47.0 44.3 671 62.2 37.6 30.2 686 Never had sex 58.3 30.2 26.3 1,299 53.0 24.1 20.4 398 Married/living together 76.9 40.1 38.3 8,312 71.4 35.8 30.9 1,936 Divorced/separated/widowed 77.2 38.7 36.7 1,416 74.9 30.1 27.7 93 Residence Urban 79.1 57.2 53.7 2,076 60.9 35.4 29.5 661 Rural 73.7 35.3 33.5 9,621 68.8 34.3 29.3 2,453 Region Northern 68.2 33.1 30.5 1,552 72.3 26.3 24.1 404 Central 72.3 32.9 30.9 4,734 66.5 33.9 27.2 1,302 Southern 78.5 46.5 44.4 5,412 66.2 37.4 32.8 1,408 District Blantyre 83.6 60.2 58.0 914 74.7 40.9 37.6 315 Kasungu 75.5 36.4 35.1 497 66.0 42.8 35.7 148 Machinga 83.3 37.2 35.8 427 48.9 24.6 23.0 106 Mangochi 73.8 31.9 31.0 599 67.4 32.0 24.1 141 Mzimba 71.0 39.2 36.5 778 70.7 26.5 22.8 203 Salima 65.7 21.1 19.9 303 67.9 25.3 20.7 72 Thyolo 84.7 64.9 61.4 618 77.9 53.4 49.9 156 Zomba 79.2 52.0 49.1 637 62.3 32.2 22.3 155 Lilongwe 69.8 40.6 37.6 1,705 60.8 33.7 24.4 523 Mulanje 77.0 32.8 31.2 512 71.1 41.6 35.8 105 Other districts 72.9 32.8 31.0 4,708 67.8 32.4 28.9 1,189 Education No education 69.8 26.6 25.8 2,734 62.3 24.0 21.3 350 Primary 1-4 71.6 34.3 32.9 2,998 63.7 26.0 23.4 746 Primary 5-8 77.1 42.4 39.9 4,154 68.7 33.4 28.2 1,171 Secondary+ 81.5 58.9 54.6 1,811 70.1 48.0 39.3 845 Wealth quintile Lowest 70.1 28.0 27.1 2,037 61.9 24.3 20.4 383 Second 72.8 34.5 33.1 2,277 68.8 32.2 28.2 614 Middle 72.8 33.7 32.2 2,383 66.7 33.9 28.0 666 Fourth 76.6 41.2 38.7 2,361 70.9 31.8 27.9 666 Highest 79.7 55.1 51.3 2,639 65.5 44.1 36.7 785 Total 15-49 74.7 39.2 37.1 11,698 67.1 34.5 29.3 3,114 Total men 15-54 na na na na 67.0 34.3 29.2 3,261 Na = Not applicable HIV/AIDS and Other Sexually Transmitted Infections | 193 11.3 ACCEPTING ATTITUDES TOWARDS THOSE WITH HIV/AIDS In the 2004 MDHS, to gauge stigma associated with AIDS, respondents who had heard of HIV/AIDS were asked questions about their attitudes towards people with HIV. These questions include whether respondents would be willing to take care of orphaned children of family member who died of HIV, whether they would buy fresh vegetables from shopkeepers who have HIV, and whether they believe an HIV-positive female teacher should be allowed to keep on teaching. Almost all women (94 percent) say that they are willing to take care of orphaned children of a family member who died of HIV. About two in three women said they would buy fresh vegetables from a shopkeeper who has HIV, that an HIV-positive teacher should be allowed to keep teaching and that they would not necessarily fear disclosure of a family member’s HIV-positive status. When taking into account all of the stigmas toward persons with AIDS, about one in three women express their acceptance of all four measures. The attitudes of women toward persons infected with HIV do not vary much across subgroups, except that urban women appear to be more accepting of an HIV infected female teacher continuing to work than rural women (80 percent compared with 64 percent). There is a strong positive correlation between the level of accepting attitudes and the woman’s education with one exception; women with more education are less likely than others to not care that the HIV status of a family member remains a secret. Table 11.5.1 also shows that urban women are as willing as rural women to take care of orphaned children of a family member who died of AIDS (94 percent). In general, women in the Southern Region, better educated women, and women in higher wealth quintiles are less likely than other women to have a stigma towards persons with AIDS. For instance, while 26 percent of women in the lowest wealth quintile have accepting attitudes on all four measures of stigma, the corresponding proportion for women in the highest wealth quintile is 36 percent. There are variations in attitudes towards persons living with AIDS across districts, women in Machinga have the least accepting attitudes (20 percent) and women in Thyolo have the most accepting attitudes (41 percent). In the 2004 MDHS, the same questions were asked to men who heard of HIV/AIDS. The findings are presented in Table 11.5.2. The table shows that 97 percent of men age 15-49 are willing to take care of orphaned children of a relative who died of HIV, 84 percent would buy fresh vegetables from a shopkeeper who has HIV, 80 percent believed that an HIV-positive female teacher should be allowed to keep on teaching, and 48 percent say that they would not want the HIV status of family to remain secret. Differentials in stigma towards persons with AIDS among men are less pronounced and than among women, and do not show a particular pattern. 194 | HIV/AIDS and Other Sexually Transmitted Infections Table 11.5.1 Accepting attitudes towards people living with HIV: women Among women age 15-49 who have heard of AIDS, percentage expressing specific positive attitudes towards people with HIV, by background characteristics, Malawi 2004 Percentage of women who: Background characteristic Would be willing to take orphaned children of relative who died of AIDS Would buy fresh vegetables from vendor who has the AIDS virus Believe a female teacher who has the AIDS virus should be allowed to continue teaching Would not fear disclosing status of family member who became infected with AIDS virus Percentage expressing acceptance on all four measures Number of women who have heard of HIV/AIDS Age 15-19 91.6 63.0 62.0 67.9 28.6 2,356 20-24 94.3 69.6 70.9 63.6 33.2 2,821 25-29 94.6 66.9 68.5 63.2 30.8 2,127 30-39 95.0 67.6 66.7 63.8 30.7 2,563 40-49 94.3 65.0 63.3 65.8 30.2 1,665 Marital status Never married 91.2 66.7 66.5 63.5 28.8 1,946 Ever had sex 91.4 74.4 74.3 66.2 35.3 668 Never had sex 91.0 62.7 62.4 62.1 25.4 1,278 Married/living together 94.4 66.8 66.6 64.7 31.1 8,185 Divorced/separated/widowed 95.1 65.3 67.0 67.0 32.1 1,402 Residence Urban 93.8 76.5 80.0 57.6 34.3 2,060 Rural 94.0 64.5 63.7 66.3 30.1 9,471 Region Northern 92.2 66.0 67.3 62.5 29.6 1,551 Central 91.9 65.9 58.4 61.4 24.9 4,605 Southern 96.3 67.5 73.5 68.3 36.2 5,375 District Blantyre 97.4 78.7 82.6 59.5 37.8 912 Kasungu 92.7 63.6 54.3 59.1 22.5 492 Machinga 95.5 50.0 58.9 54.0 20.1 425 Mangochi 91.7 55.3 65.2 65.0 25.2 582 Mzimba 94.4 70.4 68.8 62.2 31.8 777 Salima 92.7 61.0 65.6 61.3 23.5 296 Thyolo 98.3 73.1 71.5 74.7 41.2 615 Zomba 95.6 71.8 78.3 59.9 34.7 634 Lilongwe 89.9 70.1 60.4 52.3 21.5 1,640 Mulanje 97.4 66.1 72.4 76.4 40.3 509 Other districts 93.9 64.6 64.7 70.5 32.7 4,650 Education No education 91.7 54.4 55.4 70.7 25.5 2,659 Primary 1-4 93.3 57.8 58.5 68.6 26.3 2,928 Primary 5-8 94.5 71.9 70.5 63.9 34.3 4,137 Secondary+ 97.1 87.0 87.4 51.7 38.2 1,807 Wealth quintile Lowest 93.6 56.7 55.0 69.7 25.7 1,983 Second 93.0 58.3 60.2 69.4 27.5 2,231 Middle 93.5 63.4 63.0 65.7 28.9 2,352 Fourth 94.2 69.6 69.4 64.3 34.0 2,345 Highest 95.2 81.5 81.6 56.7 36.4 2,620 Total 94.0 66.6 66.6 64.8 30.8 11,532 Note: Some of these questions differ from the standard questions on stigma related to HIV/AIDS HIV/AIDS and Other Sexually Transmitted Infections | 195 Table 11.5.2 Accepting attitudes towards people living with HIV: men Among men age 15-49 who have heard of AIDS, percentage expressing specific positive attitudes towards people with HIV, by background characteristics, Malawi 2004 Percentage of men who: Background characteristic Would be willing to take orphaned children of relative who died of AIDS Would buy fresh vegetables from vendor who has the AIDS virus Believe a female teacher who has the AIDS virus should be allowed to continue teaching Would not fear disclosing status of family member who became infected with AIDS virus Percentage expressing acceptance on all four measures Number of men who have heard of HIV/AIDS Age 15-19 95.3 77.7 70.9 54.0 29.2 639 20-24 96.7 87.2 77.1 47.5 28.2 587 25-29 96.7 86.2 83.8 45.1 29.5 631 30-39 97.5 83.6 83.7 44.5 30.4 777 40-49 97.4 85.4 81.1 48.0 32.5 464 Marital status Never married 95.2 82.0 76.2 49.5 28.3 1,073 Ever had sex 95.9 83.3 77.1 51.1 29.7 685 Never had sex 94.1 79.7 74.5 46.6 25.9 388 Married/living together 97.5 85.0 81.5 47.0 31.1 1,932 Divorced/separated/widowed 97.2 82.3 75.3 41.5 22.0 93 Residence Urban 95.2 89.9 89.4 39.5 27.6 659 Rural 97.1 82.2 76.8 49.9 30.5 2,439 Region Northern 96.0 82.3 71.7 44.1 27.2 401 Central 97.2 83.3 74.3 44.4 24.9 1,292 Southern 96.4 84.8 86.4 51.7 35.2 1,405 District Blantyre 94.0 94.1 90.3 50.5 37.7 315 Kasungu 97.4 78.9 67.9 34.6 19.6 147 Machinga 97.7 83.9 91.1 49.8 38.1 106 Mangochi 95.9 71.2 74.2 37.3 18.0 141 Mzimba 97.0 83.2 72.5 40.0 26.3 202 Salima 93.9 83.1 69.4 38.3 18.2 72 Thyolo 99.2 83.3 86.8 57.2 41.5 156 Zomba 95.5 86.7 83.1 42.0 25.5 155 Lilongwe 97.0 86.1 81.8 43.0 26.8 519 Mulanje 94.8 83.2 86.0 57.5 35.6 105 Other districts 97.4 82.2 76.4 52.1 31.0 1,181 Education No education 96.4 70.2 69.5 60.5 32.4 347 Primary 1-4 96.1 72.6 68.6 56.3 26.7 734 Primary 5-8 96.9 87.0 79.7 46.3 31.6 1,171 Secondary+ 97.1 94.9 92.8 36.7 29.1 845 Wealth quintile Lowest 96.8 78.7 70.4 53.5 28.4 377 Second 97.0 77.6 74.1 50.2 26.0 611 Middle 97.4 81.7 77.2 48.8 31.2 662 Fourth 97.8 87.8 81.3 45.9 30.8 665 Highest 95.0 89.8 88.3 43.4 31.7 783 Total 15-49 96.7 83.9 79.5 47.7 29.9 3,098 Total 15-54 96.7 83.3 79.4 47.5 29.7 3,246 Note: Some of these questions differ from the standard questions on stigma related to HIV/AIDS 196 | HIV/AIDS and Other Sexually Transmitted Infections 11.4 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH AIDS transmission can be reduced by using condoms. Table 11.6 shows the level of adult support for educating children age 12-14 in condom use to prevent AIDS. In the 2004 MDHS, women and men were asked whether they agree that children age 12-14 years should be taught about using condoms to avoid getting the AIDS virus. Half of the women and 56 percent of men age 18-49 agree that children in that age group should be taught about condom use in order to prevent contracting HIV/AIDS. Table 11.6 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 years should be taught about using a condom to avoid AIDS, by background characteristics, Malawi 2004 Women Men Background characteristic Percent Number Percent Number Age 18-19 52.3 1,054 62.5 283 20-24 54.1 2,870 57.3 587 25-29 50.8 2,157 56.6 634 30-39 47.8 2,595 55.4 779 40-49 42.5 1,684 50.7 464 Marital status Never married 50.4 863 57.8 720 Ever had sex 54.0 459 61.1 542 Never had sex 46.3 404 47.6 179 Married/living together 50.3 8,104 55.1 1,935 Divorced/separated/widowed 46.5 1,393 61.7 91 Residence Urban 53.3 1,830 56.1 585 Rural 49.0 8,530 56.0 2,162 Region Northern 45.6 1,341 49.7 352 Central 47.4 4,174 58.9 1,161 Southern 53.0 4,845 55.0 1,235 District Blantyre 59.7 829 57.1 293 Kasungu 45.5 435 50.4 129 Machinga 50.6 378 41.6 89 Mangochi 49.2 548 51.0 129 Mzimba 49.0 684 46.3 179 Salima 44.9 276 52.4 66 Thyolo 57.2 545 67.9 139 Zomba 46.7 566 58.6 133 Lilongwe 44.8 1,507 63.8 467 Mulanje 60.4 454 67.0 90 Other districts 48.8 4,139 53.7 1,033 Education No education 42.3 2,679 52.1 337 Primary 1-4 48.7 2,673 52.5 631 Primary 5-8 53.5 3,428 57.0 979 Secondary+ 56.3 1,579 59.2 799 Wealth quintile Lowest 45.0 1,830 56.8 329 Second 47.4 2,069 53.6 541 Middle 49.8 2,132 56.8 604 Fourth 51.4 2,062 55.5 590 Highest 54.4 2,266 57.2 683 Total 18-49 49.8 10,360 56.0 2,747 Total men 18-54 na na 55.5 2,895 na = Not applicable HIV/AIDS and Other Sexually Transmitted Infections | 197 The proportion of women and men who agree to the idea varies across subgroups of respondents. For both women and men, those who are younger and better educated are more likely than other respondents to say that children age 12-14 should be taught about using condoms. Interestingly, women and men who have never had sex are the least likely to agree to this idea (46 percent for women and 48 percent for men). While urban women are more likely to support condom use education than rural women (53 percent compared with 49 percent), there is no difference among men by residence. 11.5 ATTITUDES TOWARD NEGOTIATING SAFER SEX Table 11.7 shows the percentage of women who believe that, if a husband has an STI, the wife is justified refusing to have sex, or asking the husband to use a condom. For men, the table shows the percentage of men who believe that a wife can refuse to have sex with her husband if the Table 11.7 Attitudes toward negotiating safer sex with husband Percentage of women and men age 15-49 who believe that if a husband has a sexually transmitted infection his wife is justified in either refusing to have sex with him or proposing condom use, by background characteristics, Malawi 2004 Women Men Background characteristic Refuse sex Propose condom use Refuse sex or propose condom use Number of women Refuse sex Propose condom use Refuse sex or propose condom use Number of men Age 15-19 66.0 75.3 84.6 2,392 75.1 75.2 89.5 650 20-24 74.2 84.8 93.0 2,870 80.6 80.4 93.4 587 25-29 76.6 84.8 93.9 2,157 82.8 82.2 93.3 634 30-39 77.0 82.3 93.6 2,595 83.6 82.8 95.8 779 40-49 76.0 78.6 91.0 1,684 85.3 76.8 93.6 464 15-24 70.5 80.5 89.2 5,262 77.7 77.7 91.4 1,237 Marital status Never married 65.9 73.1 82.5 1,970 76.7 77.0 90.0 1,084 Ever had sex 73.5 79.7 89.3 671 78.5 80.4 91.4 686 Never had sex 61.9 69.7 79.0 1,299 73.5 71.3 87.6 398 Married/living together 75.3 82.6 92.9 8,312 83.9 81.3 94.8 1,936 Divorced/separated/widowed 76.5 85.9 94.4 1,416 83.3 79.1 97.8 93 Residence Urban 79.8 87.7 94.8 2,076 84.3 82.5 95.1 661 Rural 72.6 80.1 90.5 9,621 80.5 79.0 92.7 2,453 Region Northern 80.1 75.8 91.2 1,552 76.6 79.4 90.4 404 Central 68.1 80.3 88.8 4,734 80.3 78.9 91.8 1,302 Southern 77.1 84.0 93.5 5,412 83.7 80.7 95.2 1,408 District Blantyre 80.8 89.2 95.3 914 84.9 83.8 97.1 315 Kasungu 57.8 70.0 81.8 497 76.4 73.3 87.8 148 Machinga 77.3 81.2 91.3 427 76.3 83.6 94.0 106 Mangochi 69.1 69.6 84.9 599 76.0 83.7 94.0 141 Mzimba 79.3 77.8 91.9 778 77.3 77.7 88.4 203 Salima 70.3 75.5 87.9 303 83.6 77.8 94.2 72 Thyolo 82.4 84.8 96.2 618 81.2 79.2 93.6 156 Zomba 79.3 85.9 95.4 637 85.3 76.6 95.5 155 Lilongwe 65.2 83.0 90.0 1,705 79.5 81.1 92.1 523 Mulanje 80.5 80.5 94.1 512 78.3 79.7 92.6 105 Other districts 74.4 82.1 91.4 4,708 83.3 79.1 93.6 1,189 Education No education 69.5 76.0 88.8 2,734 78.8 67.2 90.4 350 Primary 1-4 71.0 79.4 89.5 2,998 77.2 71.0 89.5 746 Primary 5-8 75.5 83.9 92.7 4,154 81.2 82.7 93.9 1,171 Secondary+ 81.4 87.1 94.8 1,811 86.3 88.7 96.8 845 Wealth quintile Lowest 70.0 79.7 90.1 2,037 79.7 74.4 90.3 383 Second 71.3 78.6 89.6 2,277 80.8 76.3 92.4 614 Middle 71.9 79.2 90.0 2,383 80.3 80.9 93.0 666 Fourth 74.9 83.2 92.7 2,361 81.5 78.9 92.6 666 Highest 79.9 85.5 93.6 2,639 83.4 84.9 96.0 785 Total 15-49 73.9 81.4 91.3 11,698 81.4 79.8 93.2 3,114 Total men 15-54 na na na na 81.3 79.4 93.3 3,261 na = Not applicable 198 | HIV/AIDS and Other Sexually Transmitted Infections husband has an STI. Women are less likely than men to say that a wife can refuse having sex with her husband if the husband has an STI (74 percent compared with 81 percent). However, women are as likely as men to say that a wife can propose to her husband to use a condom (81 percent and 80 percent, respectively). Overall, 81 percent of women say that a wife is justified to propose condom use if her husband has an STI and nine in ten women agree with both, refusing to have sex and proposing condom use. The corresponding proportion for men is 93 percent. Wide variations exist across population groups, with older respondents, those living in urban areas, those with more education, and those in higher wealth quintiles are more likely to agree with women’s ability to negotiate safer sex. 11.6 MULTIPLE SEXUAL PARTNERSHIPS In the context of HIV/AIDS/STI prevention, limiting the number of sexual partners and having protected sex are crucial to the fight against the epidemic. Table 11.8 shows the percentage of women and men who had sexual intercourse with more than one partner in the last 12 months. Men in general are more likely to have more sexual partners than women. While only one percent of women had two or more sexual partners in the past year, the corresponding proportion for men is 11 percent. Teenagers are more likely than older women to have two or more partners (2 percent compared with 1 percent or less for older women). Married women are the least likely to have multiple partners (less than 1 percent) compared with never married women (5 percent) or formerly married women (2 percent). Differentials across subgroups of women are not substantial. Data for men show that men’s behaviour with respect to having sex with multiple partners does not vary much across background characteristics. The only exception is that men in the Northern Region are twice as likely as men in the Southern Region (19 percent and 10 percent, respectively) to have multiple sex partners. HIV/AIDS and Other Sexually Transmitted Infections | 199 Table 11.8 Multiple sex partners among women and men Among women and men age 15-49 who had sexual intercourse in the past 12 months, the percentage who had intercourse with more than one partner and among women and men who have ever had sex, the mean number of sexual partners in the past 12 months, by background characteristics, Malawi 2004 Women Men Background characteristic Percentage who had 2+ partners in the past 12 months Number of women who had sex in the past 12 months Mean number of sexual partners in the past 12 months Number of women who ever had sex Percentage who had 2+ partners in the past 12 months Number of men who had sex in the past 12 months Mean number of sexual partners in the past 12 months Number of men who ever had sex Age 15-19 2.2 1,095 0.9 1,249 14.4 223 0.8 340 20-24 1.4 2,499 0.9 2,741 12.6 435 1.1 521 25-29 0.9 1,940 0.9 2,126 11.5 564 1.0 615 30-39 0.7 2,241 0.9 2,594 10.9 738 1.1 776 40-49 0.4 1,312 0.8 1,684 11.7 442 1.1 460 15-24 1.7 3,594 0.9 3,991 13.2 658 1.0 861 Marital status Never married 6.3 434 0.7 670 15.5 451 0.9 686 Married/living together 0.6 8,004 1.0 8,309 10.8 1,893 1.1 1,933 Divorced/separated/widowed 3.2 649 0.5 1,416 16.9 57 0.8 93 Residence Urban 1.6 1,534 0.9 1,766 9.7 486 1.0 552 Rural 1.0 7,553 0.9 8,628 12.4 1,915 1.0 2,159 Region Northern 1.1 1,068 0.8 1,316 19.4 273 1.0 329 Central 0.9 3,635 0.9 4,090 12.4 990 1.0 1,113 Southern 1.2 4,383 0.9 4,989 9.5 1,138 1.0 1,269 District Blantyre 1.5 741 0.9 830 4.7 254 0.9 284 Kasungu 0.3 403 0.9 438 13.5 116 1.0 130 Machinga 0.6 355 0.9 396 9.8 89 1.1 93 Mangochi 1.1 468 0.8 563 16.1 122 1.1 135 Mzimba 0.9 532 0.8 661 15.4 135 0.9 168 Salima 1.2 242 0.9 272 18.4 63 1.2 66 Thyolo 0.4 533 0.9 578 11.1 126 1.0 140 Zomba 1.2 518 0.9 584 13.1 130 1.0 144 Lilongwe 1.3 1,304 0.9 1,454 12.2 386 1.0 438 Mulanje 3.2 416 0.9 479 14.3 85 1.0 97 Other districts 0.9 3,574 0.9 4,141 11.7 895 1.1 1,016 Education No education 0.8 2,338 0.9 2,694 7.5 318 1.0 340 Primary 1-4 1.1 2,467 0.9 2,744 12.0 594 1.0 651 Primary 5-8 1.2 3,092 0.9 3,539 13.5 881 1.1 988 Secondary+ 1.1 1,189 0.8 1,417 11.4 606 1.0 732 Wealth quintile Lowest 1.6 1,525 0.8 1,864 10.4 301 1.0 342 Second 0.8 1,880 0.9 2,102 11.2 485 1.0 538 Middle 0.7 1,949 0.9 2,157 13.0 544 1.0 603 Fourth 1.1 1,852 0.9 2,068 13.2 513 1.1 584 Highest 1.3 1,880 0.9 2,204 10.7 558 1.0 645 Total 15-49 1.1 9,087 0.9 10,395 11.8 2,401 1.0 2,712 200 | HIV/AIDS and Other Sexually Transmitted Infections 11.7 HIGHER-RISK SEX Table 11.9 shows the percentage of sexually active women and men who had higher-risk sex (i.e., sex with a partner other than their husband or cohabiting partner) and the extent of condom Table 11.9 Higher-risk sex and condom use at last higher-risk sex in the past year Among women and men reporting sexual activity in the 12 months preceding the survey, percentage who had sex with a nonmarital, noncohabiting partner in the past 12 months and among women and men who had higher-risk sex1 in the past 12 months, percentage who say they used a condom the last time they had sex with a nonmarital, noncohabiting partner, by background characteristics, Malawi 2004 Women Men Background characteristic Percentage who had higher- risk sex1 in the past 12 months Number of women sexually active in the past 12 months Percentage who used condom at last higher- risk sex Number of women who had higher-risk sex in past 12 months Percentage who had higher- risk sex1 in the past 12 months Number of men sexually active in the past 12 months Percentage who used condom at last higher- risk sex Number of men who had higher- risk sex in past 12 months Age 15-19 27.5 1,095 34.9 302 94.8 223 35.8 211 20-24 7.9 2,499 35.6 197 45.4 435 58.5 198 25-29 5.4 1,940 26.9 105 20.7 564 55.9 117 30-39 4.8 2,241 17.9 107 13.1 739 41.7 97 40-49 3.3 1,312 9.7 44 5.4 442 (31.0) 24 Marital status Never married 99.0 434 37.5 430 98.6 451 47.9 444 Married/living together 0.8 8,004 24.7 67 8.3 1,894 46.9 156 Divorced/separated/widowed 39.8 649 19.2 258 77.9 57 39.5 45 Residence Urban 13.8 1,534 43.7 211 35.0 486 57.2 170 Rural 7.2 7,553 24.8 544 24.8 1,916 43.5 475 Region Northern 7.0 1,068 43.1 75 27.2 273 55.3 74 Central 6.2 3,635 39.0 224 24.6 990 50.7 244 Southern 10.4 4,383 23.6 456 28.7 1,139 42.5 328 District Blantyre 13.6 741 31.6 101 25.6 254 (58.1) 65 Kasungu 2.8 403 * 11 23.9 116 47.9 28 Machinga 7.4 355 (19.0) 26 37.4 89 25.5 33 Mangochi 8.5 468 21.5 40 33.8 122 31.0 41 Mzimba 5.1 532 (45.7) 27 21.0 135 (62.1) 28 Salima 4.8 242 (46.6) 12 22.7 63 (47.6) 14 Thyolo 13.1 533 16.2 70 22.5 128 (53.5) 29 Zomba 12.5 518 21.2 65 32.3 130 30.7 42 Lilongwe 7.2 1,304 (43.5) 94 28.7 386 51.8 111 Mulanje 12.9 416 15.6 54 28.1 85 (25.2) 24 Other districts 7.2 3,574 32.4 256 25.8 895 50.2 230 Education No education 4.1 2,338 9.9 97 14.5 318 (22.1) 46 Primary 1-4 6.1 2,467 18.7 151 24.9 596 39.4 148 Primary 5-8 8.8 3,092 30.1 273 25.9 881 40.5 228 Secondary+ 19.7 1,189 45.8 234 36.7 606 64.2 223 Wealth quintile Lowest 10.7 1,525 17.2 163 24.8 301 41.6 75 Second 5.1 1,880 16.6 96 24.1 485 43.3 117 Middle 6.1 1,949 27.1 119 21.1 544 37.8 115 Fourth 5.9 1,852 29.5 110 26.3 515 46.5 135 Highest 14.2 1,880 44.4 267 36.6 558 56.9 204 Total 15-49 8.3 9,087 30.1 755 26.9 2,402 47.1 646 Total men 15-54 na na na na 25.7 2,545 47.1 653 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1Sexual intercourse with a partner who is neither a spouse nor a person who lives with the respondent na = Not applicable HIV/AIDS and Other Sexually Transmitted Infections | 201 use the last time they had sex with such a partner. Women are much less likely to engage in higher risk sex than men (8 percent compared with 27 percent of those who had sex in the 12 months before the survey). Both younger women and men age 15-19 are substantially more likely to have higher-risk sex than older respondents, mainly because they are less likely to be married. While almost all sexually active men age 15-19 had sex with a noncohabiting partner (95 percent), only 5 percent of men age 40-49 engaged in higher-risk sex. Condom use for higher-risk sex is reported by 30 percent of women and 47 percent of men. Women and men in urban areas are more likely to use condoms than their rural counterparts. For women, the percentage who used condoms at the last higher-risk sex in urban areas is 44 percent compared with 25 percent in rural areas. Predictably, the respondent’s education and wealth status are positively correlated with condom use. 11.8 PAID SEX AND CONDOM USE Male respondents in the 2004 MDHS were asked whether they had paid money in exchange for sex in the 12 months preceding the survey. Among men age 15-49, 5 percent reported paying for sex in the last 12 months, 43 percent of whom reported that they used condoms at the most recent paid sex (Table 11.10). Younger men are slightly more likely than older men to have sex with prostitutes (8 percent among men 15-19 compared with 6 percent or less for older men). Married men are less likely than never-married men and divorced, separated or widowed men to have sex with Table 11.10 Paid sex in past year and condom use at last paid sex Percentage of men reporting sex with a prostitute in the past 12 months, and among these men percentage reporting condom use the last time they had sex with a prostitute, by background characteristics, Malawi 2004 Background characteristic Percentage reporting sex with prostitute in past 12 months Number of men Percentage reporting condom use at last sex with prostitute Number of men reporting sex with prostitute in past 12 months Age 15-19 8.2 650 30.3 53 20-24 5.8 587 (40.6) 34 25-29 3.8 634 (56.7) 24 30-39 4.5 779 53.8 35 40-49 1.7 464 * 8 15-24 7.1 1,237 34.3 87 Marital status Never married 7.4 1,084 33.6 80 Ever had sex 11.6 686 33.6 80 Never had sex 0.0 398 * 0 Married/ living together 3.4 1,936 52.3 66 Divorced/ separated/widowed 9.4 93 * 9 Residence Urban 3.1 661 * 20 Rural 5.5 2,453 41.4 134 Region Northern 2.3 404 * 9 Central 4.2 1,302 50.2 54 Southern 6.5 1,408 34.9 91 Education No education 5.9 350 * 21 Primary 1-4 6.2 746 (28.4) 47 Primary 5-8 5.3 1,171 41.9 62 Secondary+ 3.0 845 (83.2) 25 Wealth quintile Lowest 4.0 383 * 15 Second 7.0 614 (26.7) 43 Middle 4.9 666 (41.5) 33 Fourth 5.8 666 (52.8) 39 Highest 3.1 785 (59.1) 25 Total 15-49 5.0 3,114 42.4 155 Total 15-54 4.8 3,261 42.5 156 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 202 | HIV/AIDS and Other Sexually Transmitted Infections a prostitute (3 percent compared with 12 and 9 percent, respectively). Paid sex is more common among men in the rural areas, in the Southern Region, and those with less education. The relationship between payment for sex and wealth quintile is less clear. Due to the small number of men who report using condoms at last sex with a prostitute, the results have to be used with caution. While young men are more likely than older men to report having sex with a prostitute, they are less likely to use condoms. Also, while married men are less likely than men who are not in a union to have sex with a prostitute, they are more likely than other men to use condoms. 11.9 COUNSELLING AND TESTING FOR HIV Knowledge of HIV status helps HIV-negative individuals make specific decisions to reduce the risk of contracting the disease and to increase safer sex practices so they can remain disease free. For those who are HIV infected, knowledge of their status allows them to better protect their sexual partners, to access treatment, and to plan for their future. In order to gauge the coverage of HIV testing as well as the unmet need for testing, respondents in the 2004 MDHS were asked if they had ever been tested to see if they have the AIDS virus. Those who had been tested were asked when they were last tested, whether they had asked for the test or were required to take it, and whether they received their results. Those who had not been tested were asked if they would like to be tested and whether they know of a place to go for an AIDS test. Table 11.11 shows the percentage of women and men who have ever been tested and those who were tested and received the test results in the 12 months preceding the survey, by background characteristics. Overall, 83 percent of women and 83 percent of men have never been tested. Table 11.11 further shows that 13 percent of women and 15 percent of men were tested and received the results, while 2 percent report that they did not receive the test results. The table also shows that 4 percent of women and 8 percent of men were tested and received the test results in the 12 months preceding the survey. HIV/AIDS and Other Sexually Transmitted Infections | 203 Table 11.11 HIV testing status and receipt of test results Percent distribution of women and men by HIV testing status, and percentage who were tested for HIV and received test results in the past 12 months, by back-ground characteristics, Malawi 2004 Women Men Tested Tested Background characteristic Received results Results not received Not tested Don’t know/ missing Total Percentage tested and received results in past 12 months Number of women Received results Results not received Not tested Don’t know/ missing Total Percentage tested and received results in past 12 months Number of men Age 15-19 6.8 1.5 89.9 1.7 100.0 3.7 2,392 6.1 0.8 91.5 1.6 100.0 4.1 650 20-24 17.2 3.0 77.9 1.9 100.0 4.6 2,870 18.0 1.1 80.9 0.0 100.0 10.1 587 25-29 15.9 2.8 79.9 1.4 100.0 3.3 2,157 21.6 1.5 76.5 0.4 100.0 10.3 634 30-39 14.0 2.6 82.0 1.4 100.0 3.5 2,595 15.5 1.5 82.8 0.2 100.0 7.6 779 40-49 8.5 2.0 88.2 1.4 100.0 2.3 1,684 14.5 2.9 82.5 0.0 100.0 6.2 464 15-24 12.5 2.3 83.4 1.8 100.0 4.2 5,262 11.7 0.9 86.5 0.8 100.0 7.0 1,237 Marital status Never married 8.3 0.6 89.8 1.3 100.0 5.0 1,970 12.9 0.7 85.4 1.0 100.0 7.9 1,084 Ever had sex 17.2 1.2 81.1 0.6 100.0 9.1 671 17.8 0.8 81.3 0.1 100.0 11.6 686 Never had sex 3.7 0.3 94.4 1.6 100.0 2.8 1,299 4.4 0.5 92.5 2.5 100.0 1.6 398 Married/living together 13.8 2.7 81.8 1.7 100.0 3.1 8,312 16.1 2.0 81.7 0.2 100.0 7.6 1,936 Divorced/separated/ widowed 13.9 3.1 81.8 1.2 100.0 4.4 1,416 20.9 0.5 78.6 0.0 100.0 7.7 93 Residence Urban 22.9 2.1 74.2 0.9 100.0 5.8 2,076 25.1 1.5 73.1 0.3 100.0 13.6 661 Rural 10.7 2.5 85.1 1.7 100.0 3.1 9,621 12.4 1.5 85.6 0.5 100.0 6.1 2,453 Region Northern 13.2 2.9 83.5 0.5 100.0 3.8 1,552 18.1 1.2 80.1 0.6 100.0 9.5 404 Central 10.9 2.0 84.3 2.8 100.0 2.5 4,734 14.2 1.9 83.2 0.8 100.0 6.5 1,302 Southern 14.5 2.7 82.0 0.8 100.0 4.5 5,412 15.1 1.2 83.5 0.2 100.0 8.2 1,408 District Blantyre 20.7 2.2 76.5 0.6 100.0 7.7 914 20.5 2.6 76.9 0.0 100.0 9.4 315 Kasungu 6.3 1.5 90.9 1.3 100.0 2.2 497 12.1 2.1 85.1 0.7 100.0 3.6 148 Machinga 8.1 2.9 88.2 0.9 100.0 2.2 427 6.8 1.3 92.0 0.0 100.0 2.2 106 Mangochi 7.5 4.5 85.2 2.9 100.0 2.7 599 9.7 0.0 89.9 0.4 100.0 5.9 141 Mzimba 15.9 1.6 82.3 0.3 100.0 4.4 778 21.1 0.3 77.8 0.7 100.0 11.2 203 Salima 5.1 2.3 90.3 2.3 100.0 1.2 303 11.8 1.2 87.0 0.0 100.0 4.1 72 Thyolo 29.1 3.3 67.2 0.5 100.0 7.0 618 24.2 0.9 74.9 0.0 100.0 17.0 156 Zomba 12.1 1.9 85.4 0.5 100.0 3.8 637 10.4 0.4 89.2 0.0 100.0 4.9 155 Lilongwe 16.9 1.4 78.0 3.7 100.0 2.8 1,705 16.5 1.3 81.5 0.7 100.0 8.5 523 Mulanje 7.1 2.9 89.4 0.7 100.0 2.0 512 10.6 1.7 87.7 0.0 100.0 5.8 105 Other districts 10.3 2.7 85.5 1.5 100.0 3.2 4,708 13.8 1.8 83.7 0.7 100.0 7.0 1,189 Education No education 8.4 2.9 85.8 2.9 100.0 2.0 2,734 10.1 0.4 88.7 0.8 100.0 5.6 350 Primary 1-4 9.8 2.6 85.2 2.4 100.0 2.6 2,998 10.1 1.8 86.5 1.7 100.0 4.1 746 Primary 5-8 12.6 2.3 84.4 0.7 100.0 3.3 4,154 12.0 1.4 86.6 0.0 100.0 6.2 1,171 Secondary+ 25.3 1.6 72.9 0.2 100.0 8.4 1,811 25.9 1.7 72.3 0.0 100.0 13.7 845 Wealth quintile Lowest 8.6 2.4 86.2 2.9 100.0 2.5 2,037 10.1 2.3 86.2 1.4 100.0 5.0 383 Second 9.4 2.6 85.8 2.2 100.0 2.6 2,277 7.8 1.6 90.0 0.5 100.0 4.2 614 Middle 10.1 2.6 85.9 1.4 100.0 2.3 2,383 14.1 1.1 84.1 0.6 100.0 7.1 666 Fourth 12.3 2.7 84.2 0.8 100.0 3.2 2,361 13.8 0.9 85.1 0.2 100.0 5.4 666 Highest 22.3 1.9 74.9 0.8 100.0 6.8 2,639 25.2 1.7 72.9 0.2 100.0 14.2 785 Total 15-49 12.9 2.4 83.1 1.6 100.0 3.6 11,698 15.1 1.5 82.9 0.5 100.0 7.7 3,114 Total men 15-54 na na na na na na na 14.9 1.5 83.2 0.5 100.0 7.5 3,261 na = Not applicable Women and men age 20-29 are the most likely to have taken the test. Testing is more common among urban residents, never-married women and men who have ever had sex, and women and men who are no longer married. Similar to many other indicators, in Malawi HIV testing appears to an urban phenomenon and is more often practised by better educated and wealthier individuals. Women and men with at least some secondary education and those in the highest wealth quintile are more likely to have been tested for HIV than other respondents. For 204 | HIV/AIDS and Other Sexually Transmitted Infections example, 25 percent of women with secondary or higher education were ever tested and received the test result, compared with 8 percent of women with no education. Among the oversampled districts, while 29 percent of women in Thyolo were tested and received the results, in Kasungu, Machinga, Mangochi, Salima, and Mulanje this proportion is less than 10 percent. For men, coverage of testing and receiving results ranges from and 6 percent in Machinga to 23 percent imn Thyolo. In the 2004 MDHS, women who had a live birth in the five years preceding the survey were asked whether they received information about HIV/AIDS and whether they were asked to give blood for HIV testing during an antenatal visit for the most recent birth. They were also asked whether they received the test result. Table 11.12 shows the findings for women who gave birth in the two years preceding the survey. Overall, 53 percent of women were counselled about HIV during an antenatal care visit, 4 percent were tested for HIV, and most of them received the result. Counselling and testing are more often reported by urban women. In general, coverage of counselling and testing increases with the woman’s education level and wealth status. Women in the Central Region are less likely than women in other regions to report counselling. However, they are as likely to be tested for HIV. Table 11.12 also shows that 3 percent of women who gave birth in the two years preceding the survey were counselled about HIV, tested for HIV, and received the HIV test result. While there are small age differentials, women in the urban areas are four times more likely than rural women to receive the full service on HIV during antenatal care (8 percent compared with 2 percent). Wide variations are found across districts, with women in Blantyre and Thyolo being the most likely to receive counselling about HIV and being tested for HIV (6 and 8 percent, respectively). As mentioned above, 83 percent of women and men have never been tested for HIV. Table 11.13 shows that most of the respondents who have never been tested say that they know where to go for a test for the AIDS virus (79 percent of women age 15-49 and 85 percent of men age 15-49). Of those who know a place to have a test for HIV, about half mention a government-run hospital or clinic (47 percent of women and 40 percent of men). The next most often cited place for HIV testing is Malawi AIDS Counselling and Resource Organisation (MACRO), mentioned by 12 percent of women and 23 percent of men. Mission health facilities are mentioned by 12 percent of women and 8 percent of men. Another testing place frequently cited is Banja La Mtsogolo (BLM) clinics (6 percent of women and 9 percent of men). HIV/AIDS and Other Sexually Transmitted Infections | 205 Table 11.12 Pregnant women counselled and tested for HIV Among women who gave birth in the two years preceding the survey, percentage who were counselled and offered HIV testing during antenatal care for their most recent birth, accepted an offer of testing and received test results, by background characteristics, Malawi 2004 Voluntarily tested for HIV during antenatal care visit Background characteristic Counselled during antenatal visit Received results Results not received Counselled, tested for HIV, and received results Number of women who gave birth in the past 2 years Age 15-19 45.1 2.8 0.9 2.3 534 20-24 50.5 3.8 0.5 3.3 1,641 25-29 53.3 3.6 0.9 2.9 1,109 30-39 56.2 4.2 0.2 3.4 1,079 40-49 62.1 3.7 0.2 3.4 241 15-24 49.2 3.6 0.6 3.1 2,175 Residence Urban 67.7 8.7 0.9 8.0 583 Rural 50.3 3.0 0.5 2.4 4,021 Region Northern 56.3 4.3 0.5 3.5 559 Central 43.6 3.6 0.4 3.0 1,931 Southern 59.6 3.7 0.7 3.2 2,115 District Blantyre 64.7 6.2 0.8 6.2 303 Kasungu 39.5 1.2 0.7 0.7 226 Machinga 52.3 1.0 0.8 1.0 191 Mangochi 52.5 2.0 1.2 1.4 274 Mzimba 56.7 3.4 0.2 2.7 289 Salima 44.8 0.0 0.5 0.0 138 Thyolo 74.4 8.9 0.8 8.4 240 Zomba 63.1 2.1 0.5 1.4 239 Lilongwe 51.3 6.8 0.0 5.5 627 Mulanje 66.5 0.9 0.6 0.6 178 Other districts 47.0 3.3 0.6 2.7 1,900 Education No education 42.2 2.7 1.1 2.4 1,153 Primary 1-4 48.7 2.8 0.4 1.9 1,354 Primary 5-8 59.1 3.8 0.5 3.2 1,561 Secondary+ 64.9 8.1 0.1 7.7 534 Wealth quintile Lowest 47.6 2.6 0.6 2.1 919 Second 47.0 2.3 0.7 1.6 1,111 Middle 53.1 3.8 0.4 3.2 1,001 Fourth 52.0 2.7 0.5 2.5 871 Highest 67.5 8.5 0.6 7.7 701 Total 52.5 3.7 0.6 3.1 4,604 Table 11.13 Knowledge of source for test Among women and men age 15-49 who have not been tested for AIDS, percent distribution by reported place to get an AIDS test, according to background characteristics, Malawi 2004 Women Men Background characteristic Public Mission Private BLM MACRO Other Missing Don't know place Total Number never tested Public Mission Private BLM MACRO Other Missing Don't know place Total Number never tested Age 15-19 43.0 9.4 0.8 5.7 14.8 1.2 0.0 25.1 100.0 2,150 42.1 8.0 0.7 8.9 18.7 2.2 1.4 18.0 100.0 595 20-24 48.1 11.6 0.9 7.8 12.4 0.9 0.1 18.2 100.0 2,236 39.6 7.1 0.8 8.8 28.3 0.6 2.4 12.4 100.0 475 25-29 50.0 13.2 1.3 6.1 12.1 0.6 0.2 16.5 100.0 1,724 38.5 7.7 0.4 10.9 22.2 3.0 4.4 13.0 100.0 485 30-39 46.8 13.4 0.9 5.3 11.7 0.8 0.2 21.0 100.0 2,129 39.0 8.6 0.2 8.6 25.7 0.4 2.3 15.1 100.0 645 40-49 47.4 11.4 0.6 4.8 10.4 0.2 0.3 24.9 100.0 1,485 39.2 10.3 1.0 8.3 20.8 2.3 2.5 15.6 100.0 383 15-24 45.6 10.5 0.9 6.8 13.6 1.0 0.0 21.6 100.0 4,386 41.0 7.6 0.7 8.8 23.0 1.5 1.8 15.5 100.0 1,070 Marital status Never married 40.4 8.0 0.9 5.7 20.2 1.0 0.0 23.8 100.0 1,770 40.5 6.1 0.6 9.7 24.4 2.0 1.7 15.0 100.0 926 Ever had sex 42.8 6.9 0.5 6.2 25.0 0.8 0.0 17.8 100.0 544 42.2 6.8 0.6 10.6 23.7 1.6 1.6 12.9 100.0 557 Never had sex 39.3 8.4 1.0 5.5 18.1 1.1 0.0 26.5 100.0 1,226 38.1 5.0 0.7 8.3 25.5 2.7 1.7 18.1 100.0 368 Married/living together 48.6 12.4 1.0 6.5 10.7 0.7 0.1 20.1 100.0 6,796 39.2 9.7 0.5 8.9 22.9 1.3 2.9 14.7 100.0 1,583 Divorced/separated/widowed 47.2 13.8 0.5 3.8 10.8 1.0 0.5 22.5 100.0 1,158 43.4 6.3 0.4 5.6 14.7 3.5 6.4 19.7 100.0 73 Residence Urban 36.7 1.9 0.7 9.9 37.0 1.2 0.1 12.6 100.0 1,540 33.0 1.0 0.0 9.7 43.2 2.9 0.9 9.4 100.0 484 Rural 48.8 13.6 0.9 5.3 7.8 0.7 0.1 22.7 100.0 8,183 41.3 10.0 0.7 9.0 18.6 1.3 2.9 16.2 100.0 2,099 Region Northern 47.2 12.6 0.4 2.3 19.8 0.3 0.1 17.3 100.0 1,296 49.7 3.4 0.0 2.4 24.2 0.5 7.2 12.5 100.0 323 Central 42.7 11.6 1.2 6.7 11.7 0.5 0.1 25.6 100.0 3,992 28.4 8.1 0.8 9.6 29.4 2.1 3.0 18.5 100.0 1,083 Southern 50.6 11.6 0.8 6.5 11.0 1.2 0.2 18.1 100.0 4,435 47.5 9.7 0.5 10.4 17.2 1.5 0.8 12.4 100.0 1,176 District Blantyre 22.5 4.8 0.7 12.4 43.2 2.6 0.0 13.8 100.0 699 24.4 0.0 0.0 7.8 50.7 2.9 3.7 10.5 100.0 242 Kasungu 56.9 8.6 0.3 5.8 6.0 0.6 0.0 21.7 100.0 452 41.8 15.4 1.7 11.6 17.8 0.4 0.0 11.4 100.0 126 Machinga 65.2 7.9 0.0 4.5 2.0 0.0 0.0 20.4 100.0 377 55.0 6.2 0.0 5.8 9.6 0.5 0.0 23.0 100.0 97 Mangochi 52.1 3.7 0.4 6.3 3.1 0.3 0.1 34.0 100.0 510 53.5 7.9 0.6 12.3 9.2 1.1 0.6 14.9 100.0 127 Mzimba 33.1 18.3 0.6 1.8 28.4 0.3 0.0 17.4 100.0 640 33.4 0.0 0.0 2.9 39.0 0.5 14.7 9.6 100.0 158 Salima 61.7 2.3 0.5 5.2 5.0 0.8 0.0 24.5 100.0 273 44.7 2.9 0.0 13.6 17.4 0.0 0.0 21.4 100.0 63 Thyolo 71.9 15.0 0.6 2.4 3.2 0.0 0.3 6.5 100.0 415 58.9 11.5 0.6 6.5 12.8 0.6 0.0 9.1 100.0 117 Zomba 56.5 8.6 0.3 5.9 8.2 3.6 0.0 16.8 100.0 545 45.2 10.3 0.0 16.3 13.6 5.8 0.0 8.8 100.0 138 Lilongwe 24.2 9.5 0.9 6.8 25.4 0.9 0.1 32.1 100.0 1,331 13.4 0.0 0.0 8.0 48.7 3.5 7.6 18.8 100.0 426 Mulanje 53.4 17.3 2.2 4.4 3.3 0.3 0.2 18.8 100.0 457 49.9 20.1 0.0 12.1 7.8 0.0 0.0 10.1 100.0 92 Other districts 51.8 14.5 1.2 6.1 6.2 0.4 0.2 19.7 100.0 4,025 48.1 13.1 1.1 9.2 11.3 0.8 0.0 16.5 100.0 996 Education No education 45.8 12.3 0.4 3.7 4.2 0.7 0.2 32.6 100.0 2,344 34.9 7.8 0.5 12.2 14.4 0.9 2.0 27.4 100.0 310 Primary 1-4 48.8 13.1 1.0 5.6 6.9 0.5 0.0 24.1 100.0 2,554 37.9 10.8 0.7 8.2 13.6 1.4 3.0 24.3 100.0 645 Primary 5-8 48.7 11.8 0.9 6.9 14.0 0.9 0.2 16.5 100.0 3,504 44.2 8.5 0.6 8.5 20.9 2.0 2.6 12.8 100.0 1,014 Secondary+ 40.5 8.0 1.5 8.5 33.6 1.3 0.0 6.7 100.0 1,320 36.9 5.6 0.3 9.5 41.6 1.5 2.2 2.4 100.0 612 Wealth quintile Lowest 48.3 12.3 0.4 3.3 4.9 0.8 0.2 29.9 100.0 1,756 37.4 7.2 0.1 8.1 17.7 0.9 4.7 23.9 100.0 330 Second 48.1 14.0 1.1 3.8 5.4 0.7 0.0 27.0 100.0 1,954 39.9 11.2 0.8 9.2 16.7 1.7 2.3 18.2 100.0 553 Middle 50.0 13.1 0.9 6.6 7.4 0.6 0.2 21.2 100.0 2,048 42.3 11.3 0.2 8.9 17.1 1.0 2.2 17.0 100.0 560 Fourth 50.5 12.1 0.6 6.2 11.9 0.7 0.1 17.9 100.0 1,988 44.7 8.3 0.6 8.2 22.1 1.3 2.4 12.3 100.0 567 Highest 37.8 7.3 1.5 10.0 31.9 1.2 0.1 10.4 100.0 1,978 33.6 3.0 0.9 10.6 39.7 2.9 1.9 7.3 100.0 572 Total 15-49 46.9 11.7 0.9 6.0 12.4 0.8 0.1 21.1 100.0 9,724 39.8 8.3 0.6 9.1 23.2 1.6 2.5 15.0 100.0 2,582 Total men 15-54 na na na na na na na na na na 39.7 8.2 0.6 9.2 22.6 1.6 2.6 15.6 100.0 2,713 Note: Interviewers were instructed to record only the first place mentioned if the respondent knew two or more places. MACRO = Malawi AIDS Counseling and Resource Organization BLM = Banja La Mtsogola na = Not applicable HIV/AIDS and Other Sexually Transmitted Infections | 207 The proportion of women and men who cited a public hospital as a source of test is lower among those who live in the urban areas than in rural areas. However, reporting of other sites such as MACRO is much higher among urban respondents and those with higher education. It is interesting that for women, knowledge of BLM as a test site increases with education, while men show the reverse pattern. Men with no education are more likely to mention BLM than educated men. 11.10 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS AND SYMPTOMS The 2004 MDHS collected information from female and male respondents about their knowledge of sexually transmitted infections other than HIV. Respondents who had ever had sex were further asked whether they have had a sexually transmitted infection (STI) in the 12 months preceding the survey or if they had either one of the symptoms of STI; abnormal genital discharge or a genital sore or ulcer. Table 11.14 shows that only 1 percent of women and 1 percent of men report having an STI. Abnormal genital discharge is reported by 3 percent of women and 3 percent of men, while 6 percent of women and 3 percent of men say that they had a genital sore or ulcer. Women are more likely than men to report having an STI or symptoms associated with STI (8 percent compared with 6 percent). Small differences are observed across subgroups of population. However, women and men in the Central Region are much more likely than respondents in other regions to report having an STI or symptoms of an STI. The percentage of women who have ever had sex reporting an STI or symptoms of an STI is 10 percent or higher in Zomba, Lilongwe, and Mulanje, and in Lilongwe and Mulanje for men. Figure 11.1 shows the percentage of women and men who reported having an STI or symptoms of an STI in the past 12 months who sought treatment from specific sources for their problems. Women are more likely than men to seek treatment for their infection (60 percent compared with 40 percent). Women also rely more on the advice of a traditional healer than men (31 percent compared with 11 percent), while men rely more on modern personnel or facilities such as health professionals, or pharmacy. 208 | HIV/AIDS and Other Sexually Transmitted Infections Table 11.14 Self-reporting of sexually transmitted infection (STI) and STI symptoms Among women and men who ever had sex, percentage self-reporting an STI and/or symptoms of an STI in the 12 months preceding the survey, by back- ground characteristics, Malawi 2004 Women Men Background characteristic Percentage with STI Percentage with abnormal genital discharge Percentage with genital sore/ulcer Percentage with STI/ discharge/ genital sore/ulcer Number of women who ever had sex Percentage with STI Percentage with abnormal genital discharge Percentage with genital sore/ulcer Percentage with STI/ discharge/ genital sore/ulcer Number of men who ever had sex Age 15-19 0.4 3.9 4.9 7.7 1,249 0.6 4.6 4.2 8.6 340 20-24 1.1 4.2 6.2 9.5 2,742 0.3 3.1 2.6 5.6 521 25-29 1.4 2.8 6.4 8.4 2,128 1.0 2.1 3.5 5.4 615 30-39 1.3 3.2 6.6 8.4 2,594 0.8 2.5 3.5 5.7 777 40-49 0.9 2.8 5.1 6.9 1,684 0.6 0.8 3.5 3.7 462 Marital status Never married 1.0 3.5 4.7 7.8 671 0.6 4.4 2.6 6.9 686 Married/living together 1.1 3.2 6.0 8.3 8,311 0.8 2.0 3.7 5.3 1,936 Divorced/separated/widowed 1.2 4.4 6.8 9.3 1,416 0.0 0.0 3.8 3.8 93 Residence Urban 1.1 2.9 5.3 7.1 1,766 0.9 1.9 2.6 4.5 552 Rural 1.1 3.5 6.1 8.6 8,631 0.7 2.7 3.6 5.9 2,163 Region Northern 0.8 1.7 1.5 2.9 1,316 1.6 1.0 2.0 2.5 329 Central 1.2 4.0 8.1 11.0 4,092 0.3 4.1 4.0 7.3 1,115 Southern 1.1 3.4 5.4 7.7 4,989 0.9 1.5 3.2 5.0 1,271 District Blantyre 0.5 3.7 5.1 7.1 830 1.7 1.0 1.4 3.7 284 Kasungu 0.6 1.7 5.6 6.7 438 0.9 1.6 2.6 3.3 130 Machinga 1.1 2.6 4.1 5.7 396 0.0 0.0 4.0 4.0 94 Mangochi 0.5 2.3 4.7 6.8 563 0.4 1.0 1.1 2.5 135 Mzimba 0.4 1.7 0.4 2.0 661 1.6 0.4 2.4 2.7 168 Salima 0.5 4.2 6.0 8.8 272 0.0 0.0 1.5 1.5 66 Thyolo 1.7 4.2 6.2 9.1 578 1.9 4.2 2.4 7.5 142 Zomba 0.8 3.3 9.9 11.3 584 0.8 1.2 6.1 6.5 144 Lilongwe 1.7 3.5 7.5 9.9 1,454 0.5 7.3 5.7 11.4 438 Mulanje 1.6 6.7 7.5 11.7 479 1.7 3.3 6.7 10.8 97 Other districts 1.2 3.4 6.2 8.8 4,144 0.3 1.8 3.1 4.4 1,018 Education No education 1.6 3.7 5.9 8.7 2,694 0.8 1.4 3.1 4.2 342 Primary 1-4 0.8 3.9 7.1 9.9 2,744 0.7 3.8 4.4 7.6 652 Primary 5-8 1.1 3.1 5.9 7.9 3,541 0.6 2.2 3.2 5.3 989 Secondary+ 0.8 2.7 4.2 5.9 1,417 0.9 2.3 2.9 5.1 732 Wealth quintile Lowest 0.8 4.7 6.4 9.5 1,864 0.5 1.5 2.0 2.7 342 Second 1.5 3.3 6.4 8.8 2,102 0.3 3.8 2.6 6.6 539 Middle 1.0 3.2 5.6 8.0 2,157 1.0 1.3 5.5 6.7 604 Fourth 1.1 2.7 5.9 7.7 2,071 0.6 2.7 3.8 5.9 586 Highest 1.1 3.2 5.7 8.0 2,204 1.0 2.8 2.5 5.2 645 Total 15-49 1.1 3.4 6.0 8.4 10,397 0.7 2.5 3.4 5.6 2,715 Total men 15-54 na na na na na 0.7 2.5 3.4 5.5 2,863 na = Not applicable HIV/AIDS and Other Sexually Transmitted Infections | 209 11.11 PREVALENCE OF INJECTIONS Respondents in the 2004 MDHS were asked if they had any injections in the 12 months preceding the survey, how many injections they received in those 12 months, and who gave the last injection. It should be noted that medical injections can be self-administered (e.g., insulin for diabetes) and these injections are not included in the tabulation. Table 11.15 shows the percentage of women and men age 15-49 who received an injection from a health care provider and whether the syringe and needle used were pulled from unopened package or not. Table 11.15 shows that 30 percent of women and 12 percent of men report having received an injection in the 12 months preceding the survey, with an average of 0.8 injections per year for women and 0.3 injections per year for men. Women age 20-29 are the most likely to report getting an injection (37-39 percent), probably because of injections given at ANC settings or for family planning purposes. When asked whether the syringe used in the last injection came from a new unopened package, 94 percent of women and 90 percent of men gave a positive response. There are small variations in this proportion across subgroups of population. Figure 11.1 Percentage of Women and Men Reporting an STI or Symptoms of an STI in the Past 12 Months Who Sought Care, by Source of Advice or Treatment 27 31 6 21 60 41 29 11 8 11 40 60 0 10 20 30 40 50 60 70 Clinic/hospital/health professional Traditional healer Advice or medicine from shop/pharmacy Advice from friends/relatives Advice or treatment from any source No advice or treatment Women Men MDHS 2004 210 | HIV/AIDS and Other Sexually Transmitted Infections Table 11.15 Injections by background characteristics Percentage of women and men age 15-49 who received an injection from a health care provider in the past 12 months, average number of injec- tions per person per year, and of those who received an injection, the percentage whose provider pulled the syringe and needle from a new, unopened package the last time they received an injection, Malawi 2004 Women Men Background characteristic Percent received an injection in past 12 months Average number injections per person per year Number of women Last injection from a new, unopened package Number who received injection Percent received an injection in past 12 months Average number injections per person per year Number of men Last injection from a new, unopened package Number who received injection Age 15-19 21.1 0.5 2,392 91.1 505 15.7 0.7 648 86.4 102 20-24 38.6 1.0 2,870 94.6 1,109 9.2 0.3 587 90.7 54 25-29 36.9 0.9 2,157 95.1 796 10.9 0.2 633 96.8 69 30-39 29.8 0.8 2,595 95.2 774 12.9 0.2 779 85.5 101 40-49 17.3 0.4 1,684 94.4 291 10.8 0.3 464 95.2 50 Residence Urban 26.8 0.8 2,076 97.0 557 12.2 0.6 661 93.9 81 Rural 30.3 0.8 9,621 93.8 2,917 12.1 0.3 2,449 88.8 296 Region Northern 24.8 0.6 1,552 94.1 385 9.7 0.2 404 88.8 39 Central 28.4 0.7 4,734 91.4 1,344 13.1 0.5 1,302 89.1 171 Southern 32.3 0.8 5,412 96.6 1,745 11.8 0.3 1,405 90.9 166 District Blantyre 33.0 0.9 914 97.6 301 11.0 0.3 316 (100.0) 35 Kasungu 28.2 0.6 497 85.8 140 16.8 0.4 156 92.5 26 Machinga 24.7 0.6 427 95.4 106 9.2 0.2 114 * 11 Mangochi 27.8 0.7 599 98.0 167 11.9 0.2 150 * 18 Mzimba 25.2 0.7 778 95.4 196 13.6 0.3 212 (95.7) 29 Salima 36.5 0.9 303 91.8 110 12.8 0.3 78 (100.0) 10 Thyolo 41.5 1.2 618 98.1 256 16.0 0.4 166 (85.0) 27 Zomba 37.0 1.0 637 96.7 236 10.7 0.2 159 * 17 Lilongwe 25.1 0.7 1,705 93.5 429 12.0 0.7 542 (86.1) 65 Mulanje 35.9 0.8 512 94.9 184 18.6 0.4 114 (79.9) 21 Other districts 28.7 0.7 4,708 93.0 1,350 10.9 0.3 1,250 87.5 136 Education No education 25.7 0.6 2,734 92.8 704 7.7 0.2 350 (79.8) 27 Primary 1-4 30.4 0.8 2,998 93.7 910 14.5 0.7 745 86.1 108 Primary 5-8 30.9 0.8 4,154 94.6 1,285 11.9 0.2 1,168 89.3 139 Secondary+ 31.8 0.9 1,811 96.6 575 12.2 0.2 845 97.1 103 Wealth quintile Lowest 29.4 0.7 2,037 95.2 600 10.6 0.2 383 92.7 41 Second 30.4 0.8 2,277 91.8 692 10.8 0.2 613 90.7 66 Middle 29.6 0.7 2,383 92.3 707 13.0 0.2 666 89.4 86 Fourth 29.8 0.8 2,361 95.6 704 12.4 0.3 664 85.6 83 Highest 29.3 0.8 2,639 96.6 773 12.8 0.6 784 92.1 100 Total 15-49 29.7 0.8 11,698 94.3 3,474 12.1 0.3 3,110 89.9 376 Total men 15-54 na na na na na 12.1 0.3 3,258 89.5 394 Note: Figures in parentheses are based on unweighted 25-49 cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 11.12 HIV/AIDS-RELATED KNOWLEDGE AND BEHAVIOUR AMONG YOUTH This section addresses knowledge of HIV/AIDS issues and related sexual behaviour among youths age 15-24 who are of particular interest for HIV/AIDS programmes. The period between initiation of sexual activity and marriage is often a time of sexual experimentation, but it may also involve risky behaviours. Comprehensive knowledge of HIV/AIDS transmission and prevention and knowledge of sources of condoms among youth is analysed in this section. Issues such as abstinence, age at sexual debut, age differences between partners, and condom use are also covered. Young HIV/AIDS and Other Sexually Transmitted Infections | 211 respondents in the 2004 MDHS were asked the same set of questions as older respondents about whether condom use and limiting number of partners to one uninfected partner can help protect against getting the AIDS virus, and whether a healthy-looking person can have the AIDS virus (see Tables 11.3.1 and 11.3.2). The data in Table 11.16 show the level of comprehensive knowledge among young people, namely, the proportion who, in response to prompted questions, agree that people can reduce their Table 11.16 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percent with knowledge of a source of condoms, by background characteristics, Malawi 2004 Women Men Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of women 15-24 Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of men 15-24 Age 15-17 21.5 64.0 1,338 35.7 81.0 367 18-19 20.7 75.6 1,054 33.0 87.2 283 15-19 21.1 69.1 2,392 34.5 83.7 650 20-22 25.1 83.2 1,888 36.1 91.0 369 23-24 26.6 83.9 981 42.0 96.2 218 20-24 25.6 83.5 2,870 38.3 92.9 587 Marital status Never married 24.1 69.0 1,869 37.1 86.7 937 Ever had sex 28.0 82.9 600 37.9 91.6 561 Never had sex 22.2 62.4 1,269 35.9 79.2 375 Ever married 23.3 81.3 3,393 33.7 92.6 300 Residence Urban 30.3 82.4 1,063 48.0 94.5 269 Rural 21.9 75.5 4,199 33.1 86.3 968 Region Northern 26.1 86.1 739 32.1 87.9 168 Central 20.5 64.6 2,140 30.3 84.9 525 Southern 25.6 85.2 2,383 43.4 91.3 543 District Blantyre 31.5 83.2 424 48.9 94.7 105 Kasungu 14.6 68.3 224 34.6 85.8 61 Machinga 19.9 85.3 177 46.3 80.7 51 Mangochi 16.8 67.5 247 41.6 90.7 51 Mzimba 35.4 83.8 366 24.0 89.2 86 Salima 20.8 65.5 127 48.9 90.5 25 Thyolo 25.5 92.1 267 29.5 97.7 61 Zomba 24.1 90.2 294 39.8 97.2 62 Lilongwe 21.5 58.4 770 31.4 84.9 209 Mulanje 39.7 77.2 212 37.0 94.5 47 Other districts 21.0 79.4 2,154 36.1 85.5 478 Education No education 11.8 62.9 497 19.9 91.8 64 Primary 1-4 16.5 67.4 1,351 22.4 75.8 319 Primary 5-8 24.7 79.2 2,243 37.5 89.7 493 Secondary+ 34.7 89.4 1,170 49.9 96.1 360 Wealth quintile Lowest 17.0 70.5 868 33.6 82.8 165 Second 19.1 72.4 1,013 29.6 82.5 248 Middle 22.1 75.8 1,061 34.5 86.7 225 Fourth 24.8 77.5 1,060 35.4 91.4 255 Highest 32.0 85.5 1,260 44.2 93.1 344 Total 23.6 76.9 5,262 36.3 88.1 1,237 1 Respondents with a comprehensive knowledge say that use of condom for every sexual intercourse and having just one uninfected and faithful partner can reduce the chance of getting the AIDS virus, say that a healthy-looking person can have the AIDS virus, and reject the two most common local misconceptions. 2 Friends, family members, and home are not considered sources for condoms. 212 | HIV/AIDS and Other Sexually Transmitted Infections chances of getting the AIDS virus by having sex with only one uninfected, faithful partner and by using condoms consistently; who know that a healthy-looking person can have the AIDS virus; and who know that HIV cannot be transmitted by mosquito bites or by supernatural means. Only two in ten young women and four in ten men meet the criteria of having comprehensive knowledge about HIV/AIDS. The level of comprehensive knowledge increases with age, education, and wealth status. It is much higher among urban youths than rural youths. Interestingly, compared to other youths, never married young women and men who have ever had sex are most likely to have comprehensive knowledge about HIV/AIDS. While regional differences among young women are not substantial, young men in the Southern Region are much more knowledgeable about HIV than their counterparts in other regions. Because of the important role that condoms play in preventing the transmission of HIV, respondents were asked if they know where condoms could obtained. Note that only responses about ‘formal’ sources were counted, that is friends and family, and other similar sources were not included. Table 11.16 shows that 77 percent of women 15-24 and 88 percent of men 15-24 can name a place where they can obtain male condoms. Knowledge of a source for condoms varies widely across background characteristics, with the lowest levels among women with no education and in the lowest socioeconomic status. Knowledge of a condom source among men generally follows the same pattern as that for women, with less variation. 11.13 AGE AT FIRST SEX AMONG YOUTH This section discusses the initiation of sex, premarital and other higher-risk sex, and condom use among young women and men. Overall, 15 percent of women age 15-24 and 14 percent of men age 15-24 had sex by age 15. However, men’s sexual debut occurs at a slightly earlier age than women; 18 percent of men 15-19 had sex by the time they are 15 compared with 14 percent of women of the same age. Marital status makes a difference in the likelihood of women having sex. While 19 percent of women 15-24 who have been married had sex by age 15, the corresponding proportion for never-married women is 8 percent. Women in the Southern Region start having sex at an earlier age than women in other regions, 21 percent of women in the Southern Region had sex by age 15, compared with 10 percent in the Northern and Central Regions. For women, education is related to the start of sexual act; 29 percent of women with no education had sex by age 15, compared with 5 percent for women with at least some secondary education. Men show the same differentials, albeit less pronounced, as women in age at sexual debut by urban-rural residence, region, education, and wealth status. Women and men who know a source for condoms are slightly more likely to have had sex by age 15 than those who do not. HIV/AIDS and Other Sexually Transmitted Infections | 213 Table 11.17 Age at first sex among young women and men Percentage of young women and men age 15-24 who had sex by exact age 15 and 18, by background characteristics, Malawi 2004 Women Men Background characteristic 15 18 Number of women 15-24 15 18 Number of men 15-24 Age 15-17 12.8 a 1,338 18.1 a 367 18-19 15.7 62.4 1,054 17.7 59.4 283 15-19 14.1 a 2,392 18.0 a 650 20-22 16.2 57.5 1,888 8.9 44.8 369 23-24 14.1 56.5 981 9.4 52.6 218 20-24 15.5 57.1 2,870 9.1 47.7 587 Marital status Never married 7.5 23.4 1,869 14.3 46.8 937 Ever married 18.9 67.5 3,393 12.0 52.3 300 Residence Urban 11.0 45.0 1,063 3.7 40.0 269 Rural 15.8 53.5 4,199 16.5 50.4 968 Region Northern 9.6 47.8 739 14.5 42.1 168 Central 10.2 41.2 2,140 12.3 41.6 525 Southern 20.6 62.6 2,383 14.9 56.3 543 Education No education 28.6 71.9 497 13.7 70.2 64 Primary 1-4 20.3 60.8 1,351 14.3 50.0 319 Primary 5-8 13.5 52.3 2,243 17.2 47.7 493 Secondary+ 5.2 31.9 1,170 8.5 43.1 360 Wealth quintile Lowest 20.3 60.5 868 16.7 48.3 165 Second 19.5 59.1 1,013 12.5 49.2 248 Middle 14.4 55.1 1,061 18.3 55.2 225 Fourth 12.1 48.9 1,060 18.0 52.6 255 Highest 9.9 39.7 1,260 7.1 39.4 344 Knows condom source1 Yes 15.2 54.1 4,048 14.1 50.3 1,090 No 13.7 44.3 1,214 11.5 31.9 147 Total 15-24 14.8 na 5,262 13.7 na 1,237 1 Friends, family members, and home are not considered sources for condoms. a Omitted because less than 50 percent of the women/men had inter- course for the first time before reaching the beginning of the age group. na = Not applicable Figure 11.2 shows the trend in age at first sex among women and men age 15-19 from the 2000 MDHS and the 2004 MDHS. For both women and men, the proportion who have had sex by each specific age has declined. For example, while 17 percent of women age 15-19 in 2000 had sex by age 15, this proportion declined to 14 percent in 2004. The corresponding proportions for men are 29 and 18 percent, respectively. 214 | HIV/AIDS and Other Sexually Transmitted Infections 11.14 CONDOM USE AT FIRST SEX AMONG YOUTH Table 11.18 shows, among women and men age 15-24 who have ever had sex, the percentage who used a condom at their first sexual encounter. Young men are more likely than young women to report using a condom at first sex (26 percent compared with 16 percent). Reported condom use at first sex varies widely across background characteristics. Never-married women and men are much more likely than ever-married individuals to have used condoms. For women, the proportion is 40 percent for never-married women compared with 12 percent for ever- married women. Low levels of education and wealth status are associated with low levels of condom use at first sex. Interestingly, current knowledge of a source for condoms is not strongly related to the use of condoms at first sex. Young women in Blantyre and young men in Lilongwe are much more likely than those in other districts to use a condom at first sex (26 and 39 percent, respectively). Figure 11.2 Percentage of Respondents Age 15-19 Who Had Sex Before Age 15 and Percentage of Respondents Age 18-19 Who Had Sex Before Age 18, MDHS 2000 and MDHS 2004 17 29 67 68 14 18 62 60 0 10 20 30 40 50 60 70 80 Women Men Women Men Pe rc en t Malawi DHS 2000 Malawi DHS 2004 Had sex before age 15 Had sex before age 18 HIV/AIDS and Other Sexually Transmitted Infections | 215 Table 11.18 Condom use at first sex among young women and men Among women and men age 15-24 who have ever had sex, percentage who used a con- dom the first time they ever had sex, by background characteristics Malawi 2004 Women Men Background characteristic Used a condom at first sex Number of women 15-24 who have ever had sex Used a condom at first sex Number of men 15-24 who have ever had sex Age 15-17 25.8 442 28.3 147 18-19 21.9 807 30.3 193 15-19 23.3 1,249 29.4 340 20-22 14.2 1,780 25.8 312 23-24 8.8 962 21.5 210 20-24 12.3 2,742 24.0 521 Marital status Never married 39.9 600 32.1 561 Ever married 11.5 3,391 15.1 300 Residence Urban 26.2 765 36.7 173 Rural 13.3 3,227 23.5 689 Region Northern 16.8 506 22.3 98 Central 14.5 1,512 32.0 349 Southern 16.5 1,974 22.2 414 District Blantyre 26.2 342 (33.2) 77 Kasungu 13.1 165 27.0 45 Machinga 14.1 145 12.4 38 Mangochi 12.8 211 21.5 45 Mzimba 17.9 249 23.4 51 Salima 12.2 96 (16.5) 19 Thyolo 12.7 228 26.7 47 Zomba 16.0 242 10.8 52 Lilongwe 16.5 527 39.0 132 Mulanje 15.5 181 15.3 39 Other districts 14.4 1,605 26.2 315 Education No education 5.8 464 18.4 59 Primary 1-4 7.9 1,102 20.8 228 Primary 5-8 15.6 1,632 23.1 315 Secondary+ 32.9 793 36.4 259 Wealth quintile Lowest 10.5 699 14.3 125 Second 12.9 844 26.9 172 Middle 10.5 835 17.1 171 Fourth 15.4 777 30.2 178 Highest 28.6 836 36.3 215 Knows condom source1 Yes 17.8 3,255 27.2 792 No 6.7 736 14.6 69 Total 15-24 15.8 3,991 26.2 861 Note: Figures in parentheses are based on 25-49 cases. 1 Friends, family members, and home are not considered sources for condoms. 216 | HIV/AIDS and Other Sexually Transmitted Infections 11.15 PREMARITAL SEX The most common means of HIV transmission in many countries is unprotected sex with an infected person. To prevent HIV transmission, it is important that young people practice safe sex through the advocated “ABC” methods (abstinence, being faithful to one uninfected partner, and condom use). Table 11.19 shows the percentage of never-married young women and men who had never had sex, the percentage who had sex in the 12 months preceding the survey, as well as the percentage Table 11.19 Premarital sex and condom use during premarital sex Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who have had sexual inter- course in the past 12 months, and, among those who have had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Malawi 2004 Women Men Background characteristic Never had sex Had sex in past 12 months Number of never- married women 15-24 Used condom at last sex Number of women 15-24 sexually active in past 12 months Never had sex Had sex in past 12 months Number of never- married men 15-24 Used condom at last sex Number of men 15-24 sexually active in past 12 months Age 15-17 80.9 14.0 1,107 38.7 155 60.4 25.5 364 26.6 93 18-19 58.8 25.8 418 32.9 108 34.0 41.3 265 41.1 110 15-19 74.8 17.2 1,525 36.3 263 49.2 32.2 629 34.4 202 20-22 37.3 37.1 291 41.2 108 24.8 50.5 231 55.7 117 23-24 (36.3) (46.3) 54 * 25 10.9 61.2 76 (74.2) 47 20-24 37.1 38.5 344 43.3 133 21.4 53.1 307 61.0 163 Residence Urban 60.3 27.8 494 49.2 137 40.6 40.8 236 57.1 96 Rural 70.6 18.8 1,375 33.1 258 39.9 38.5 700 42.4 269 Region Northern 77.1 14.3 302 (58.9) 43 50.7 31.5 138 (46.9) 43 Central 75.1 15.7 835 48.2 131 45.0 33.7 391 51.0 132 Southern 55.9 30.2 732 29.1 221 31.7 46.8 407 42.9 190 District Blantyre 52.0 38.6 159 35.1 61 33.6 40.3 83 * 34 Kasungu 74.4 10.7 80 * 9 37.3 41.8 43 (51.2) 18 Machinga 61.2 19.9 51 * 10 30.9 59.5 39 (23.7) 23 Mangochi 52.5 24.8 67 * 17 19.7 (56.1) 31 (26.4) 17 Mzimba 80.5 10.6 145 * 15 48.7 24.6 71 (58.8) 17 Salima 73.7 15.7 41 * 6 37.3 (45.6) 16 * 7 Thyolo 48.2 43.3 81 (21.4) 35 32.0 47.0 44 (48.2) 21 Zomba 51.3 35.4 102 (23.2) 36 22.8 57.3 43 (23.2) 24 Lilongwe 74.5 18.6 326 * 61 44.2 35.2 175 (55.6) 61 Mulanje 48.4 34.6 64 (14.7) 22 23.0 49.4 35 (27.7) 17 Other districts 72.8 16.3 752 43.3 123 45.8 35.0 357 47.8 125 Education No education (75.2) (21.0) 44 * 9 (17.5) (65.2) 32 * 21 Primary 1-4 75.0 17.1 331 25.0 57 40.6 41.7 225 38.5 94 Primary 5-8 72.6 19.2 841 33.0 162 46.4 35.2 383 40.5 135 Secondary+ 57.8 25.7 653 49.7 168 33.9 39.4 297 63.1 117 Wealth quintile Lowest 66.5 23.2 253 23.8 59 37.9 42.0 104 (37.9) 44 Second 77.0 16.8 220 (20.3) 37 42.3 40.8 179 47.7 73 Middle 75.3 16.9 300 39.0 51 39.1 38.7 140 34.8 54 Fourth 70.3 17.5 400 35.7 70 38.0 35.6 201 43.6 72 Highest 60.9 25.8 695 48.4 179 41.3 39.5 312 55.1 123 Knows condom source1 Yes 61.4 25.8 1,290 40.5 333 36.6 41.3 812 48.3 335 No 82.3 10.7 579 28.7 62 62.4 24.3 125 24.1 30 Total 15-24 67.9 21.1 1,869 38.7 395 40.1 39.1 937 46.3 366 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Friends, family members, and home are not considered sources for condoms. HIV/AIDS and Other Sexually Transmitted Infections | 217 who used a condom the last time they had sex. Seven in ten never-married women 15-24 and four in ten never-married men age 15-24 report that they have never had sex. The proportion of unmarried youths who have never had sex drops rapidly as age increases. For instance, 81 percent of women age 15-17 have never had sex compared with 37 percent of women age 20-22. A significant proportion of never-married respondents age 15-24 had sex in the past 12 months (21 percent of women and 39 percent of men). Less than half of never-married respondents reported using a condom during last sexual intercourse (39 percent of women and 46 percent of men). While never-married urban women are more likely to have had sex in the preceding 12 months than rural women (28 and 19 percent, respectively), the difference is not as pronounced among men (41 and 39 percent, respectively). A significantly larger proportion of single young women and men with the highest education and in the highest wealth quintile reported condom use at last sex. 11.16 HIGHER-RISK SEX AND CONDOM USE AMONG YOUTH As mentioned above, condom use is an important tool in the fight to stop the spread of HIV/AIDS. While effective protection would require condom use at every sexual encounter, the most important sexual encounters to cover are those considered to be “higher risk.” In the context of this survey, higher-risk sex is defined as sex with a nonmarital, noncohabitating partner in the 12 months preceding the survey. Table 11.20 and Figure 11.3 show the proportion of young women and men who have been sexually active in the 12 months before the survey who have engaged in higher-risk sex and the extent to which they use condoms in higher-risk sexual encounters. Among sexually active youths age 15 to 24 years, the percentage of women and men who have engaged in higher-risk sex activity in the 12 months preceding the survey is 14 and 62 percent, respectively. Condom use at higher-risk sex in the last year among youth shows a mixed pattern. Never- married female youths are less likely to report using a condom at last higher-risk sex than male youths (39 percent compared with 46 percent). For both women and men, condom use increases with education. As shown in the previous table, knowledge of a source for condoms does not make a difference in its use. Differences in the extent of higher risk sex among youth by regions are not significant. However, young women and men in the Southern Region are more likely to have had higher-risk sex in the 12 months preceding the survey, they are also the least likely to report using condoms. Figure 11.3 and Figure 11.4 show trends in “ABC” prevalence among women and men age 15-24 between the 2000 MDHS and the 2004 MDHS. These women and men are classified into five groups of increasing risk, namely those who have never had sex; those who have had sex but not in the last 12 months; those who had sex with only one partner in the last 12 months and who used a condom the last time; those who had sex with more than one partner in the past 12 months and who used a condom the last time; and those who had sex with more than one partner in the past 12 months and who did not use a condom the last time. As seen from the figure, abstinence rates among women 15-24 remained at a similar level (23 to 24 percent) between 2000 and 2004, while for young men it increased from 24 percent to 30 percent. Reported condom use has increased, especially for men who had sex with one partner (2 percent in 2000 and 14 percent in 2004). 218 | HIV/AIDS and Other Sexually Transmitted Infections Table 11.20 Higher-risk sex and condom use at last higher risk sex in the past year among young women and men Among young women age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual inter- course in the 12 months preceding the survey, and among those having higher-risk intercourse in the past 12 months, the percentage reporting that a condom was used at last higher-risk sex, by background characteristics, Malawi 2004 Women Men Background characteristic Percentage engaging in higher-risk sex in past 12 months1 Number of women sexually active in past 12 months Percentage used condom at last higher- risk sex1 Number of women 15-24 who had higher- risk sex in past 12 months Percentage engaging in higher-risk sex in past 12 months1 Number of men sexually active in past 12 months Percentage used condom at last higher- risk sex1 Number of men 15-24 who had higher- risk sex in past 12 months Age 15-17 44.9 380 37.9 171 98.6 96 28.1 95 18-19 18.3 715 30.9 131 91.9 127 42.0 116 15-19 27.5 1,095 34.9 302 94.8 223 35.8 211 20-22 8.9 1,614 34.3 144 53.2 249 54.7 133 23-24 6.0 885 39.0 53 35.0 186 66.3 65 20-24 7.9 2,499 35.6 197 45.4 435 58.5 198 Marital status Never married 99.0 395 38.5 391 98.5 366 45.9 360 Ever married 3.4 3,199 23.0 108 16.6 292 53.5 49 Residence Urban 22.4 685 48.6 153 74.2 129 58.2 95 Rural 11.9 2,910 29.2 346 59.2 529 43.3 313 Region Northern 11.5 426 52.9 49 62.4 73 49.2 45 Central 11.5 1,374 46.4 158 58.4 262 51.1 153 Southern 16.3 1,794 26.1 292 65.1 323 43.1 210 District Blantyre 21.9 315 32.3 69 (58.0) 55 * 32 Kasungu 6.0 151 * 9 50.2 35 (44.2) 18 Machinga 11.4 131 (17.5) 15 79.6 34 (20.6) 27 Mangochi 13.6 184 (26.4) 25 65.4 38 (29.2) 25 Mzimba 9.4 205 (53.5) 19 (58.0) 32 (61.0) 18 Salima 9.7 87 * 8 (45.4) 17 * 8 Thyolo 19.2 216 19.7 41 (54.6) 38 (48.2) 21 Zomba 20.5 223 22.0 46 67.5 43 (25.5) 29 Lilongwe 13.8 492 (52.6) 68 (68.2) 96 (55.2) 65 Mulanje 19.9 161 16.9 32 (65.0) 29 (28.2) 19 Other districts 11.6 1,429 38.9 166 61.1 241 51.1 147 Education No education 5.3 434 (10.4) 23 (46.0) 53 (14.5) 24 Primary 1-4 7.9 1,018 21.8 80 58.5 187 41.6 110 Primary 5-8 14.2 1,481 30.7 210 63.6 238 42.8 151 Secondary+ 28.1 662 48.9 186 68.7 180 62.5 124 Wealth quintile Lowest 13.2 620 21.6 82 48.2 103 39.7 50 Second 7.6 792 15.1 60 59.4 139 46.4 82 Middle 8.5 776 35.6 66 52.4 138 39.2 72 Fourth 13.1 691 33.0 91 64.7 123 44.9 79 Highest 28.0 715 47.5 201 80.5 155 55.4 125 Knows condom source2 Yes 13.9 2,827 34.8 394 61.5 591 48.3 364 No 13.8 767 36.5 106 67.8 66 (34.4) 45 Total 15-24 13.9 3,594 35.2 499 62.1 658 46.8 409 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a partner who neither was a spouse nor who lived with the respondent 2 Friends, family members and home are not considered sources for condoms. HIV/AIDS and Other Sexually Transmitted Infections | 219 Figure 11.3 Scale of Risk for Young Women: Abstinence, Being Faithful, and Condom Use 0% 20% 40% 60% 80% 100% 2000 2004 2000 2004 2000 2004 15-19 20-24 15-24 >1 partner, no condom >1 partner, used condom Only 1 partner, no condom Only 1 partner and used condom Had sex, not last year Never had sex Figure 11.4 Scale of Risk for Young Men: Abstinence, Being Faithful, and Condom Use 0% 20% 40% 60% 80% 100% 2000 2004 2000 2004 2000 2004 15-19 20-24 15-24 >1 partner, no condom >1 partner, used condom Only 1 partner, no condom Only 1 partner and used condom Had sex, not last year Never had sex In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the wider spread of HIV and other STIs, because if a younger, uninfected partner has sex with an older, infected partner, this can introduce the virus into a younger, uninfected cohort. To investigate this practice, in the 2004 MDHS, women age 15- 220 | HIV/AIDS and Other Sexually Transmitted Infections 19 who had sex in the 12 months preceding the survey with a nonmarital, noncohabiting partner were asked whether the partner was younger, about the same age, or older than they. Table 11.21 shows the percentage of young women who had sex with nonmarital non- cohabiting men who are 10 years or older than they are. Overall, 2 percent of teenagers who had nonmarital sex report having sex with an older man. Examination of differentials by background characteristics is hampered by small sample sizes. Table 11.21 Age-mixing in sexual relationships Among women age 15-19 who had higher-risk sexual intercourse1 in the 12 months preceding the survey, percentage who had sex with a man who was 10 years or more older than themselves, by background characteristics, Malawi 2004 Background characteristic Percentage who had non- marital sex with a man 10+ years older Number of women 15-19 having non- marital sex in past 12 months Age 15-17 0.9 171 18-19 2.4 131 Marital status Never married 1.4 261 Ever married (2.7) 40 Residence Urban 0.6 78 Rural 1.9 224 Region Northern (4.5) 26 Central 1.2 94 Southern 1.3 182 Education No education * 10 Primary 1-4 1.9 57 Primary 5-8 1.5 154 Secondary+ 1.5 81 Wealth quintile Lowest 0.0 49 Second (3.0) 39 Middle 0.0 47 Fourth 1.1 61 Highest 2.7 106 Knows condom source1 Yes 1.5 235 No 1.6 67 Total 15-19 1.6 302 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 un- weighted cases and has been suppressed. 1 Friends, family members, and home are not considered sources of condoms. HIV/AIDS and Other Sexually Transmitted Infections | 221 11.17 HIV TESTING AMONG YOUTH Young people may feel that there are barriers to accessing and using many services and facilities, particu- larly for sensitive concerns relating to sexual health, including sexually transmitted infections, such as HIV/AIDS. Data in Table 11.22 present the degree of reach of HIV testing services among sexually active young people and their awareness of their HIV status. Overall, 5 percent of sexually active women 9 percent of sexually active men were tested for HIV and received the test results in the 12 months preceding the survey. While the proportion of young women who have been tested for HIV testing decreases with age, young men show the reverse relationship. Men age 20-24 are almost twice as likely to be tested as men 15-19 (11 and 6 percent, respectively). For both women and men, those who have never married are more likely to have taken the test than those who are married or are no longer married. Young women and men in urban areas are much more likely than those in rural areas to have been tested for HIV. For men, the proportion is 19 and 7 percent, respect- tively. As in the case with the general population, young women and men in the highest wealth quintile are more likely than those in lower quintiles to have taken the HIV test. Table 11.22 Recent HIV tests among youth Among young women and young men age 15-24 who had sexual intercourse in the 12 months preceding the survey, the percentage who had an HIV test in the past 12 months and received the results of the test, by background characteristics, Malawi 2004. Women Men Background characteristic Percentage tested in past 12 months and received results Number of women Percentage tested in past 12 months and received results Number of men Age 15-17 6.8 380 0.7 96 18-19 5.0 715 9.1 127 15-19 5.6 1,095 5.5 223 20-22 4.1 1,614 10.5 249 23-24 4.2 885 11.0 186 20-24 4.1 2,499 10.7 435 15-24 4.6 3,594 8.9 658 Marital status Never married 10.0 395 10.0 366 Married/Living together 3.7 2,975 8.0 269 Divorced/Separated/Widowed 6.0 224 3.0 23 Residence Urban 7.9 685 18.6 129 Rural 3.8 2,910 6.6 529 Region Northern 3.8 426 10.8 73 Central 3.9 1,374 7.8 262 Southern 5.3 1,794 9.4 323 District Blantyre 8.5 315 15.1 55 Kasungu 3.5 151 5.7 35 Machinga 1.2 131 2.7 34 Mangochi 2.8 184 6.2 38 Mzimba 3.8 205 15.4 32 Salima 1.2 87 0.0 17 Thyolo 8.5 216 29.4 38 Zomba 3.4 223 0.0 43 Lilongwe 6.0 492 10.8 96 Mulanje 2.6 161 5.6 29 Other districts 4.0 1,429 7.1 241 Education No education 2.3 434 6.0 53 Primary 1-4 2.1 1,018 5.2 187 Primary 5-8 4.0 1,481 7.3 238 Secondary+ 11.1 662 15.9 180 Wealth quintile Lowest 2.8 620 5.9 103 Second 3.2 792 6.6 139 Middle 2.3 776 6.1 138 Fourth 4.5 691 5.7 123 Highest 10.2 715 18.2 155 Knows condom source1 Yes 5.0 2,934 9.7 605 No 2.7 660 0.0 53 Total 4.6 3,594 8.9 658 1 Friends, family members, and home are not considered sources of condoms. 222 | HIV/AIDS and Other Sexually Transmitted Infections 11.18 ORPHANHOOD AND SCHOOL ATTENDANCE As a consequence of high adult mortality rates partly due to HIV/AIDS-related infections in Malawi, the number of orphans has increased in recent years. The 2004 MDHS collected information on orphanhood and fostering. Table 11.23 shows the percentage of children 10-14 who are attending achool by survival status of parents and the ratio of de jure children age 10-14 who have lost both parents and who are attending school to children who are not orphaned and are living with at least one parent and who are attending school. Table 11.23 shows that children whose parents are both alive and who are living with at least one parent have the best chances of attending school than other children (90 percent compared with 89 percent or less). However, the survivorship of the parents and the living arrangements of the children do not make much difference in the child’s chances of attending school. In fact, for all groups of children, orphaned children have about the same chance of attending school as non- orphaned children. Table 11.23 Schooling of children age 10-14 by orphanhood and living arrangements Ratio of the percentage of de jure children age 10-14 attending school among those whose parents have both died to the per- centage of children age 10-14 attending school and whose parents are both alive and at least one of whom lives with the child, by background characteristics, Malawi 2004 Both alive, living with at least one parent Both alive, not living with either parent Only mother dead Only father dead Both parents dead Mother, father or both dead Background characteristic Percent in school Number Percent in school Number Percent in school Number Percent in school Number Percent in school Number Percent in school Number Ratio of orphaned to non- orphaned children in school Sex Male 89.7 2,675 84.1 556 88.4 167 87.7 555 85.5 269 86.6 991 1.0 Female 90.8 2,738 84.6 744 90.0 216 86.3 561 89.4 259 84.9 1,036 1.0 Residence Urban 95.3 744 86.6 199 89.2 73 93.2 211 91.3 98 90.2 382 1.0 Rural 89.4 4,669 84.0 1,101 89.4 310 85.5 905 86.6 430 84.7 1,645 1.0 Region Northern 97.7 725 94.7 147 93.1 51 96.3 151 91.3 66 94.1 268 0.9 Central 89.7 2,361 82.1 666 87.8 164 86.7 462 86.4 205 86.2 832 1.0 Southern 88.4 2,327 84.4 487 89.6 168 84.4 502 87.2 257 82.9 927 1.0 Wealth quintile Lowest 82.6 942 85.9 365 86.6 79 78.3 300 81.6 116 79.3 496 1.0 Second 85.4 1,137 83.9 216 82.4 63 88.6 195 88.9 87 86.0 345 1.0 Middle 89.6 1,125 83.2 214 93.9 69 85.7 205 89.0 84 85.0 358 1.0 Fourth 94.1 1,122 83.7 250 88.0 71 90.6 193 81.6 110 86.1 375 0.9 Highest 98.5 1,087 84.5 255 93.6 100 95.3 222 95.6 131 92.8 453 1.0 Total 90.2 5,413 84.4 1,300 89.3 383 87.0 1,116 87.4 528 85.7 2,027 1.0 HIV/AIDS and Other Sexually Transmitted Infections | 223 11.19 MALE CIRCUMCISION In Malawi, circumcision is practiced in many communities and often serves as a rite of passage to adulthood. Recently, male circumcision has been associated with lower transmission of STIs, including HIV. In order to investigate this relationship, men interviewed in the 2004 MDHS were asked if they were circumcised. Table 11.24 shows that 21 percent of Malawian men are circumcised. Younger men in age groups 15-19 and 20-24 are less likely to have been circumcised (17 to 18 percent) than those at older ages (21 percent or higher). This could indicate a decline in the practice, although it is also possible that some young men may not have yet gone through the circumcision process. There are no differentials by urban-rural residence, however, men living in the Southern Region are much more likely to be circumcised than men in other regions (33 percent, compared with 5 percent in the Northern Region and 12 percent in the Central Region). The practice of male circumcision varies widely across ethnic groups and religion. While 82 percent of Yao men and 30 percent of Lomwe men are circumcised, the rate for other specific ethnic groups is only 7 percent or lower. Muslims (93 percent) are much more likely to be circumcised than those who belong to other religious groups. Circumcision is also practiced among Christians; 20 percent of Anglican men, 21 percent of men who belong to Seventh Day Adventist or Baptist, and 14 percent of men whose religion is other Christianity are circumcised. Table 11. 24 Male circumcision Percentage of men age 15-49 who have been circumcised, by background characteristics, Malawi 2004 Background characteristic Percent circumcised Number of men Age 15-19 18.4 650 20-24 17.1 587 25-29 20.8 634 30-34 21.4 485 35-39 25.0 294 40-44 26.7 282 45-49 22.3 182 Residence Urban 21.3 661 Rural 20.5 2,453 Region Northern 5.0 404 Central 12.2 1,302 Southern 33.1 1,408 Education No education 26.3 350 Primary 1-4 24.9 746 Primary 5-8 19.9 1,171 Secondary+ 15.8 845 Wealth quintile Lowest 17.5 383 Second 22.5 614 Middle 20.1 666 Fourth 22.6 666 Highest 19.8 785 Ethnicity Chewa 6.7 1,019 Tumbuka 2.0 303 Lomwe 29.8 527 Tonga 4.0 65 Yao 82.3 412 Sena 7.4 149 Nkonde (8.6) 48 Ngoni 4.2 366 Other 18.4 225 Religion Catholic 8.6 660 CCAP 6.1 588 Anglican 19.4 73 Seventh Day Advenist/ Baptist 21.2 208 Other Christian 13.9 1,123 Muslim 93.3 359 No religion * 91 Total 20.7 3,114 Note: Total includes some men with other religion. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indi- cates that an estimate is based on fewer than 25 unweighted cases and has been supporessed. HIV Prevalence and Associated Risk Factors | 225 HIV PREVALENCE AND ASSOCIATED FACTORS 12 John Chipeta, Erik Schouten, John Aberle-Grasse AIDS is one of the greatest public health and social problems threatening the human race. The greatest burden of the HIV/AIDS pandemic is in sub-Saharan Africa. According to the Joint UN Committee on HIV/AIDS (UNAIDS, 2004), an estimated 38 million people worldwide were living with HIV in 2003, of which 5 million were newly infected. In 2003, two-thirds of all people living with HIV/AIDS (25 million) were in sub-Saharan Africa, which has about 10 percent of the world’s population. Malawi has one of the highest national prevalence rates in the world. Heterosexual contact is the principal mode of HIV transmission, while mother-to-child transmission (MTCT) accounts for about 25 percent of all new HIV infections (NAC, 2004a). Monitoring and evaluation data for 2004 show a momentous increase in programme intervention coverage. Subsequently, some positive changes in behaviour, especially among men, have been observed and documented (NAC, 2004a). The National AIDS Commission (NAC) has coordinated the development of a National AIDS Framework for 2005 to 2009, which is expected to galvanise a decentralised comprehensive multi-sectoral national response. With the strengthening of the multi-sectoral national response to HIV and AIDS, HIV transmission is expected to decline. However, HIV prevalence will likely remain high or even increase for some time, as antiretroviral therapy is scaled up. Consequently, deaths due to AIDS are reduced. As in most sub-Saharan countries, Malawi monitors HIV prevalence primarily through antenatal clinic (ANC) sentinel surveillance. The surveillance is conducted every one to two years using consistent methodology in the same population group. The system has collected data from 19 sentinel sites dating back to 1994. Some sentinel sites started data collection in 1990. Data from the Malawi HIV sentinel surveillance indicate that HIV prevalence among antenatal attendees increased rapidly from the late 1980s to the early 1990s. By the middle of the 1990s, prevalence stabilised and has since remained fairly constant. ANC sentinel surveillance systems use unlinked anonymous methods for specimen collection and testing to avoid participation bias which can significantly affect the HIV prevalence rates. However, other biases are inherent in sentinel surveillance systems: health facilities are not randomly selected and tend to be urban; pregnant women may be having unprotected sex at a greater rate than the general population, which could overestimate the prevalence; the prevalence in ANC attendees may underestimate what is happening in the general population because women with HIV associated infertility are not captured; and men and non-pregnant women are not included in the sentinel surveillance sample. To obtain a nationally-representative HIV prevalence estimate for all adults, sentinel surveillance data should be adjusted based on assumptions about the biases in the clientele who use the selected facilities and part of the population that does not use antenatal clinic services. The 2004 MDHS is the third survey in Malawi conducted as part of the international DHS program, and the first to anonymously link the HIV results with key behavioural, social and 226 | HIV Prevalence and Associated Risk Factors demographic factors. With the inclusion of HIV testing in the MDHS, for the first time Malawi has a national population-based HIV prevalence estimates for women and men. Population-based surveys are expected to give more accurate national estimates compared with that based on ANC sentinel surveillance results. However, population-based surveys are expensive and logistically difficult to carry out and are therefore not conducted every year. Results from population-based surveys can be used to calibrate the existing ANC sentinel surveillance data and to point out improvements in the sentinel surveillance system. This chapter presents characteristics of respondents who accepted and refused to take an HIV test. Findings are presented on HIV prevalence by various demographic and socioeconomic characteristics. Being the first survey to present estimates of HIV prevalence at the national, urban- rural, regional, and district levels, data from the 2004 MDHS serve as baseline findings. Trend analysis can only be done after another national sero-survey is conducted. 12.1 COVERAGE OF HIV TESTING As described in Chapter 1, every third households in the 2004 MDHS sample was selected for individual interviews with male respondents. All men age 15-54 were eligible for individual interview. In the same households, all women age 15-49 and all men age 15-54 were eligible for HIV testing. Overall, 4,071 women age 15-49 and 3,797 men age 15-54 were identified as eligible for testing. Of these, testing was successfully conducted on 2,686 women and 2,581 men, resulting in a response rate of 70 percent for women and 63 percent for men. Table 12.1 presents the coverage rates for HIV testing by sex, urban-rural residence, and region. Based on the reason for nonresponse, respondents who were not tested are divided into four categories: • those who refused testing when asked for informed consent by the health worker (22 percent overall) • those who were interviewed in the survey, but who were not at home when the health worker arrived for testing and were not found on callbacks (less than one percent) • those who were not at home for the testing and were never interviewed (9 percent), and • those who were missing test results for some other reason, such as they were incapable of giving consent for testing, there was a mismatch between the questionnaire and the blood sample, or there was a technical problem in taking blood (1 percent). While refusal rates for women and men are similar (23 percent and 22 percent, respectively), women are more likely to be found at home than men; 5 percent of women were absent compared with 14 percent of men. The difference in nonresponse rates between women and men are more significant in urban areas and in the Southern Region. Table 12.1 shows that response rates are consistently higher in rural areas. For both women and men, urban respondents are more likely to refuse taking the test or to be absent during the survey. For example, nonresponse resulting from absence for urban men is 20 percent compared with 13 percent for rural men. Across regions, respondents in the Northern Region are much less likely than those in the other regions to refuse testing. Overall, the refusal rate in the Northern HIV Prevalence and Associated Risk Factors | 227 Region is 14 percent, compared with 26 percent in the Central Region and 22 percent in the Southern Region. Interestingly, as discussed in the next section, the prevalence rate among men in the Southern Region is also higher compared with rates in the other two regions. Table 12.1 Coverage of HIV testing by residence and region Percent distribution of women age 15-49 and men age 15-54 eligible for HIV testing by testing status, according to resi- dence and region (unweighted), Malawi 2004 Residence Region Testing status Urban Rural Northern Central Southern Total WOMEN Tested 65.3 71.2 78.3 66.0 71.3 70.4 Refused 26.4 21.9 16.1 26.3 21.5 22.5 Absent for testing 7.0 5.1 5.1 5.5 5.3 5.3 Interviewed in survey 0.0 0.3 0.3 0.2 0.3 0.3 Not interviewed 7.0 4.7 4.7 5.3 5.0 5.1 Other/missing 1.2 1.9 0.5 2.2 1.9 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 571 3,500 572 1,478 2,021 4,071 MEN Tested 55.7 64.8 76.5 61.7 60.9 63.3 Refused 23.9 21.5 10.9 26.1 21.7 21.9 Absent for testing 19.8 13.1 11.5 11.7 16.9 14.2 Interviewed in survey 0.0 0.1 0.0 0.2 0.0 0.1 Not interviewed 19.8 13.0 11.5 11.4 16.9 14.1 Other/missing 0.6 0.6 1.2 0.5 0.5 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 632 3,165 515 1,424 1,858 3,797 TOTAL Tested 60.3 68.2 77.5 63.9 66.3 67.0 Refused 25.1 21.7 13.6 26.2 21.6 22.2 Absent for testing 13.7 8.9 8.1 8.5 10.9 9.6 Interviewed in survey 0.0 0.2 0.2 0.2 0.2 0.2 Not interviewed 13.7 8.7 7.9 8.3 10.7 9.4 Other/missing 0.9 1.3 0.8 1.3 1.2 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,203 6,665 1,087 2,902 3,879 7,868 Table 12.2.1 shows that response rates also vary across the respondent’s background characteristics. HIV testing coverage among women varies from 65 percent among those age 15-19 to 76 percent among women age 40-44. Women with no education and in the highest wealth quintile are the least likely to have been tested. The response rate for women in the richest group is 67 percent, with 26 percent of non response due to refusal and 7 percent due to absence. The response rate for testing in Lilongwe is surprisingly low (39 percent). Field implementation of blood sample collection was not adequate to provide district-specific estimates (see Section 12.2.2 below for a modeling approach that provides a prevalence estimate). In other oversampled districts, the rate ranges from 65 percent in Blantyre to 77 percent in Salima. Testing coverage among men also varies by age (Table 12.2.2). Men 15-19 are the least likely to be tested (60 percent) while men age 35-44 years have the highest coverage (67 to 68 percent). It is interesting to note that response rates among men increases with education ranging from 57 percent for men with no education to 65 percent or men with secondary or higher education. As 228 | HIV Prevalence and Associated Risk Factors in the case with women, coverage is low among men in the lowest and highest wealth quintile, 59 and 57 percent, respectively. Table 12.2.1 Coverage of HIV testing by background characteristics: women Percent distribution of women age 15-49 eligible for HIV testing by testing status, according to background characteristics (unweighted), Malawi 2004 Testing status Background characteristic Tested Refused Absent for testing Other/ missing Total Number Age 15-19 65.3 24.4 8.5 1.8 100.0 835 20-24 70.6 23.9 4.2 1.3 100.0 979 25-29 70.8 21.8 5.2 2.2 100.0 744 30-34 72.9 20.9 3.9 2.3 100.0 532 35-39 68.7 24.6 5.0 1.7 100.0 403 40-44 75.9 18.0 4.6 1.5 100.0 323 45-49 74.9 18.8 3.9 2.4 100.0 255 District Blantyre 64.7 23.0 10.6 1.7 100.0 235 Kasungu 75.6 18.2 5.2 1.0 100.0 308 Machinga 73.5 21.6 3.8 1.1 100.0 264 Mangochi 67.8 22.7 2.9 6.6 100.0 273 Mzimba 73.8 21.4 4.5 0.3 100.0 332 Salima 77.0 17.1 3.6 2.4 100.0 252 Thyolo 69.0 21.4 7.9 1.7 100.0 290 Zomba 73.2 23.3 3.5 0.0 100.0 257 Lilongwe 39.0 51.5 7.5 2.1 100.0 241 Mulanje 70.5 23.4 5.4 0.8 100.0 261 Other districts 73.3 19.6 5.2 2.0 100.0 1,358 Education No education 66.9 23.2 7.3 2.7 100.0 1,048 Primary 1-4 70.9 23.4 4.3 1.4 100.0 1,064 Primary 5-8 72.7 21.0 4.5 1.9 100.0 1,389 Secondary+ 70.0 23.3 5.8 0.9 100.0 570 Wealth quintile Lowest 69.5 23.5 5.4 1.5 100.0 718 Second 70.7 22.2 4.8 2.3 100.0 817 Middle 72.1 20.5 4.8 2.6 100.0 894 Fourth 72.1 21.3 5.3 1.4 100.0 875 Highest 66.6 25.7 6.5 1.2 100.0 767 Total 70.4 22.5 5.3 1.8 100.0 4,071 As in the case of women, men in Lilongwe are the least likely to be tested for HIV (38 percent). Response rates are also low in Mangochi (50 percent) and Blantyre (54 percent). On the other hand, men in Kasungu have the highest response rates (76 percent). In all districts, absence is an important reason for nonresponse among men. The highest absence rate was observed in Blantyre (26 percent) and Thyolo (22 percent). The highest refusal rate is recorded in Lilongwe (49 percent), while the lowest refusal rate is in Salima (17 percent). HIV Prevalence and Associated Risk Factors | 229 Table 12.2.2 Coverage of HIV testing by background characteristics: men Percent distribution of men age 15-54 eligible for HIV testing by testing status, according to background characteristics (unweighted), Malawi 2004 Testing status Background characteristic Tested Refused Absent for testing Other/ missing Total Number Age 15-19 59.8 25.0 14.7 0.5 100.0 761 20-24 61.6 22.5 15.7 0.3 100.0 690 25-29 64.5 21.5 13.2 0.7 100.0 710 30-34 63.7 21.0 14.9 0.4 100.0 557 35-39 67.0 18.0 13.8 1.2 100.0 333 40-44 68.1 18.5 12.5 0.9 100.0 335 45-49 61.8 24.6 12.6 1.0 100.0 207 50-54 64.7 21.1 13.7 0.5 100.0 204 District Blantyre 53.9 19.6 25.7 0.7 100.0 280 Kasungu 76.2 16.9 6.3 0.6 100.0 332 Machinga 66.5 19.1 13.9 0.4 100.0 230 Mangochi 50.4 29.1 18.8 1.7 100.0 234 Mzimba 73.2 12.8 12.5 1.6 100.0 313 Salima 68.8 14.9 15.3 0.9 100.0 215 Thyolo 56.5 21.9 21.6 0.0 100.0 269 Zomba 67.1 21.1 11.8 0.0 100.0 237 Lilongwe 38.2 49.0 12.0 0.8 100.0 259 Mulanje 62.6 20.9 15.6 0.9 100.0 211 Other districts 66.6 21.0 12.2 0.2 100.0 1,217 Education No education 56.7 25.1 18.0 0.2 100.0 467 Primary 1-4 60.4 24.9 13.9 0.8 100.0 961 Primary 5-8 66.8 19.7 12.9 0.6 100.0 1,413 Secondary+ 64.5 20.6 14.3 0.5 100.0 950 Wealth quintile Lowest 58.9 24.4 16.5 0.2 100.0 509 Second 64.6 22.2 12.4 0.8 100.0 765 Middle 67.2 19.3 13.3 0.2 100.0 865 Fourth 67.3 18.6 12.9 1.2 100.0 851 Highest 56.5 26.3 16.7 0.5 100.0 807 Total 63.3 21.9 14.2 0.6 100.0 3,797 Note: Total includes some men with missing information on education 230 | HIV Prevalence and Associated Risk Factors 12.2 HIV PREVALENCE 12.2.1 HIV Prevalence by Socioeconomic Characteristics The 2004 MDHS indicates that 12 percent of the population age 15-49 in Malawi is living with HIV/AIDS (Table 12.3). HIV prevalence among women is higher for women than for men (13 percent compared with 10 percent). Prevalence peaks at 19 percent for women and men age 30- 34, 18 percent for women and 20 percent for men. Women start getting the infection at a younger age than men; the prevalence among women age 15-19 is 4 percent compared with less than 1 percent for men of the same age. HIV prevalence among women is higher than that for men until age group 30-34 and 35-39. At ages 40-49, the prevalence among men is again lower than the prevalence among women (Figure 12.1). Surveillance of AIDS cases indicate that very few children who were infected through mother-to-child transmission survive up to 15 years of age. Therefore, prevalence among the youth represents more recent HIV infections and is recognised and used as a proxy indicator for tracking incidence. Overall, HIV prevalence among women and men age 15-24 is 6 percent. Prevalence among women in this age group is more than four times higher than that for men 15-24 (9 and 2 percent, respectively). These figures are useful in measuring progress towards the National HIV and AIDS Action Framework 2005 to 2009. Table 12.3 HIV prevalence by age Percentage HIV positive among women age 15-49 and men age 15-49 (54) by age, Malawi 2004 Women Men Total Age Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 3.7 500 0.4 467 2.1 967 20-24 13.2 661 3.9 442 9.5 1,103 25-29 15.5 477 9.8 509 12.6 986 30-34 18.1 382 20.4 397 19.2 779 35-39 17.0 257 18.4 262 17.7 520 40-44 17.9 235 16.5 242 17.2 477 45-49 13.3 173 9.5 146 11.6 319 Total age 15-24 9.1 1,161 2.1 910 6.0 2,071 Total age 15-49 13.3 2,686 10.2 2,465 11.8 5,150 Total age 15-54 na na 10.2 2,580 na na na = Not applicable HIV Prevalence and Associated Risk Factors | 231 Figure 12.1 Percentage HIV Positive Among Women and Men Age 15-49 0 5 10 15 20 25 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Pe rc en t Women Men MDHS 2004 Table 12.4 shows that urban residents have a significantly higher risk of HIV infection than rural residents. While 18 percent of urban women are HIV positive, the corresponding proportion for rural women is 13 percent. For men, the urban-rural difference in HIV prevalence is even greater; urban men are nearly twice as likely to be infected as rural men (16 and 9 percent, respectively). Since 85 percent of Malawi’s population live in rural areas, the greatest burden of HIV infection is in the rural population. The HIV epidemic shows regional heterogeneity. The prevalence among women in the three regions is similar to what has been seen in ANC sentinel surveillance estimates, high in the Southern Region (20 percent), and low in the Northern (10 percent) and Central (7 percent) Regions. The regional differential in HIV prevalence for men is somewhat different than that for women, high in the Southern Region (15 percent) and lower in the Northern (5 percent) and Central (6 percent) Regions. ANC surveillance system data and VCT data for Malawi show that women with secondary or higher education have higher infection levels than women with less education (NAC, 2004a). Data in Table 12.4 show that HIV prevalence is somewhat constant across education levels, but higher among women with secondary or higher education. For men, however, education has a positive relationship with the risk of infection; the rate of infection increases with education. Work status is related to the HIV rate for both women and men. Fifteen percent of working women are HIV positive compared with 12 percent of women who are not working. For men, the difference is more dramatic, 13 percent for working men, compared with 6 percent for men who are not working. Rates of HIV infection also increase with the wealth quintile; overall, the infection rate in the highest quintile is two times that in the lowest quintile (16 and 8 percent, respectively). This 232 | HIV Prevalence and Associated Risk Factors relationship is true for both women and men. However, it is much more pronounced for men (15 percent compared with 4 percent). Table 12.4 HIV prevalence by socioeconomic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by background characteristics, Malawi 2004 Women Men Total Background characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Residence Urban 18.0 410 16.3 462 17.1 872 Rural 12.5 2,276 8.8 2,003 10.8 4,279 Region Northern 10.4 403 5.4 348 8.1 751 Central 6.6 1,032 6.4 994 6.5 2,026 Southern 19.8 1,251 15.1 1,122 17.6 2,373 District Blantyre 22.5 211 22.1 247 22.3 457 Kasungu 5.5 116 2.8 116 4.1 232 Machinga 14.9 99 8.2 86 11.8 185 Mangochi 21.4 136 19.9 108 20.8 244 Mzimba 6.4 178 3.9 157 5.2 336 Salima 9.5 74 8.2 59 8.9 133 Thyolo 23.1 145 18.6 126 21.0 271 Zomba 24.6 134 10.5 124 17.8 258 Lilongwe a 352 a 398 a 750 Mulanje 23.3 117 15.1 86 19.8 202 Other districts 12.6 1,124 8.7 958 10.8 2,082 Education No education 13.6 667 9.2 295 12.3 962 Primary 1-4 12.3 690 6.5 550 9.7 1,240 Primary 5-8 13.2 958 10.8 957 12.0 1,916 Secondary+ 15.1 370 12.9 662 13.7 1,032 Employment Currently working 14.6 1,545 13.4 1,360 14.0 2,904 Not currently working 11.6 1,141 6.3 1,105 9.0 2,246 Wealth quintile Lowest 10.9 455 4.4 300 8.3 755 Second 10.3 546 4.6 487 7.6 1,033 Middle 12.7 581 12.1 568 12.4 1,149 Fourth 14.6 595 11.7 564 13.2 1,159 Highest 18.0 508 14.9 546 16.4 1,054 Ethnicity Chewa 8.3 915 5.7 796 7.1 1,711 Tumbuka 8.8 280 5.1 231 7.1 511 Lomwe 20.0 450 17.9 433 19.0 884 Tonga 15.9 53 (9.2) 49 12.6 102 Yao 17.5 337 12.4 300 15.1 637 Sena 12.4 126 10.3 115 11.4 241 Nkonde (19.1) 30 4.9 51 10.2 82 Ngoni 14.5 288 14.5 299 14.5 587 Other 17.3 204 9.2 190 13.4 394 Religion Catholic 13.8 634 10.5 552 12.3 1,185 CCAP 9.7 481 8.7 464 9.2 945 Anglican 17.7 56 (5.6) 47 12.1 103 Seventh Day Adventist/Baptist 12.1 158 16.5 175 14.4 334 Other Christian 13.8 1,025 10.0 890 12.0 1,915 Muslim 17.0 309 11.3 251 14.4 560 No religion * 20 0.0 75 0.7 95 Total 13.3 2,686 10.2 2,465 11.8 5,150 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Total includes persons with missing information on education, ethnicity, and religion. a = Observed estimates for Lilongwe are not shown; see Section 12.2.2 and Appendix G. HIV Prevalence and Associated Risk Factors | 233 Respondents who identify themselves as Chewa and Tumbuka have the lowest prevalence compared with other ethnic groups (7 percent each). On the other hand, HIV prevalence is highest among the Lomwe ethnic group (19 percent). Yaos and Ngonis also show high prevalence compared with other groups, both 15 percent. Across religions, HIV prevalence varies by gender. Anglican and Muslim women have the highest infection rate (18 and 17 percent, respectively). For men, those who are Seventh Day Adventists have the highest rate (17 percent). 12.2.2 Adjusted HIV Prevalence Because of the low response rate for HIV testing in Lilongwe (see Tables 12.2.1 and 12.2.2), and the implausible pattern of infection where male prevalence is higher than female prevalence, additional analysis of the Lilongwe results was undertaken. A statistical model was developed using the questionnaire information from individuals who were tested for HIV in Malawi outside of Lilongwe. A nationally common set of predictor variables, including background and behavioural characteristics, were used to predict HIV status for women and men separately. Where individual interviews were not carried out, information from the household questionnaire was used to predict HIV status. The model parameters were then applied to the Lilongwe sample to predict HIV status. The resulting predictions, or adjusted HIV rates, for Lilongwe are substantially higher than the observed prevalence. For women, the observed HIV prevalence of 1.6 percent is raised to 11.5 percent by the adjustment (Table 12.5). For men, the observed rate of 5.5 percent is increased to 9.2 percent. The resulting adjusted figures for Lilongwe are much closer to the expected HIV levels based on the ANC sentinel surveillance results. In addition, the adjusted prevalence for women and men in Lilongwe are consistent with the patterns by sex observed in other districts and regions in Malawi. Table 12.5 Observed and adjusted HIV prevalence Observed and adjusted HIV prevalence among women and men age 15-49, Malawi 2004 Geographic area Observed prevalence Adjusted prevalence WOMEN Malawi, excluding Lilongwe 15.1 14.8 Lilongwe 1.6 11.5 Malawi total 13.3 14.4 MEN Malawi, excluding Lilongwe 11.1 11.2 Lilongwe 5.5 9.2 Malawi total 10.2 10.8 TOTAL Malawi, excluding Lilongwe 13.2 13.1 Lilongwe 3.7 10.3 Malawi total 11.8 12.7 Because nonresponse for HIV testing may bias the results, HIV prevalence rates among non- tested women and men in the rest of Malawi were predicted using the same multivariate statistical models. The results of this analysis, including the above adjustment for Lilongwe, show that the 234 | HIV Prevalence and Associated Risk Factors adjusted HIV prevalence rates among non-tested women (12 percent) and men (10 percent) are similar to the observed national prevalence rates among tested women and men (13 percent and 10 percent, respectively). Adjusting the observed prevalence rates to account for those non-tested women and men makes little difference to the observed national rates. The adjusted HIV prevalence rates for all eligible women and men are 14 percent and 11 percent, respectively, which are well within the error margins of the observed prevalence rates based on tested respondents. A detailed description of the methodology and adjusted estimates by background characteristics is presented in Appendix G. 12.2.3 HIV Prevalence by Other Sociodemographic Characteristics Table 12.6 shows the HIV prevalence by other sociodemographic characteristics. As expected, marital status is related to HIV infection. Women who are no longer in union (widowed and divorced or separated) have significantly higher rates (37 and 26 percent, respectively), while women who have never been in a marital union have the lowest prevalence (5 percent). The type of Table 12.6 HIV prevalence by sociodemographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by sociodemographic characteristics, Malawi 2004 Women Men Total Sociodemographic characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Currently in union 12.5 1,990 14.1 1,588 13.2 3,578 Widowed 37.4 91 * 12 35.6 103 Divorced/separated 25.5 209 16.0 64 23.3 272 Never in union 5.3 396 1.8 802 3.0 1,198 Ever had sex 10.0 149 1.8 536 3.6 684 Never had sex 2.5 247 1.8 266 2.2 513 Type of union In polygynous union 16.4 373 10.4 157 14.6 529 Not in polygynous union 11.6 1,615 14.5 1,431 13.0 3,046 Not currently in union 15.5 695 3.1 877 8.6 1,573 Currently pregnant Pregnant 9.8 362 na na na na Not pregnant/not sure 13.9 2,323 na na na na Births in the past 3 years1 None 16.5 1,282 na na na na Birth and ANC 10.5 1,321 na na na na Birth and no ANC 7.6 83 na na na na Circumcision status Circumcised na na 13.2 502 na na Not circumcised na na 9.5 1,963 na na Number of times slept away None na na 9.2 1,567 na na 1-2 na na 10.2 431 na na 3-4 na na 9.2 216 na na 5+ na na 17.9 245 na na Away for more than one month Away for more than 1 month na na 13.2 307 na na Away always for < 1 month na na 11.4 583 na na Never away na na 9.2 1,567 na na Total 13.3 2,686 10.2 2,465 11.8 5,150 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Total includes some men with missing information on away for one month. na = Not applicable 1 None = no births, Birth and ANC = ANC for any birth, Births no ANC = No ANC for any of the births. HIV Prevalence and Associated Risk Factors | 235 union women are in is associated with their risk of infection. Women who are in a polygynous union have higher HIV prevalence (16 percent) than those who are in a monogamous union (12 percent). It should be noted that that the practice of polygyny is associated with specific ethnic groups and cultures. HIV prevalence among men also varies by marital status. Men who are divorced or separated have higher infection rates than married men. Men who have never been in a union have a much lower prevalence rate of 2 percent. HIV prevalence among pregnant women is lower than that for non-pregnant women (10 percent compared with 14 percent).Two percent of respondents (3 percent of women and 2 percent of men) who have never had sex were found to be HIV positive. This suggests either misreporting of sexual behaviour or non-sexual transmission of HIV. The relationship between HIV prevalence and circumcision status is not in the expected direction. In Malawi, circumcised men have a slightly higher HIV infection rate than men who were not circumcised (13 percent compared with 10 percent). In Malawi, the majority of men are not circumcised (80 percent). The practice of circumcision varies greatly across ethnicity, ranging from 82 percent among the Yao and 30 percent among the Lomwe to 2 percent among the Tumbuka (see Chapter 11). As in Table 12.4, ethnicity is also significantly associated with HIV infection. It is interesting to note that women and men in ethnic groups with high proportion of circumcision such as Yao and Lomwe, the prevalence of HIV infection is also high. For example, 20 percent of Lomwe women and 18 percent of Lomwe men as well as 18 percent of Yao women and 12 percent of Yao men are HIV positive. While Ngoni men are not customarily circumcised, they also have a higher prevalence compared with other ethnic groups (15 percent). These observations suggest that the relationship between circumcision and HIV sero status is not straightforward. Further analysis is needed to determine the relationship between male circumcision and the risk of HIV infection. In the 2004 MDHS, male respondents were asked whether they spent any time in past 12 months away from home, and in the same time period, whether they were away from home for more than one month. The survey results show that in general, men who stayed home have the lowest HIV prevalence. Men who were away from home for more than one month have a higher risk (13 percent) of HIV infection than those who were away for less than one month at a time (11 percent). 12.2.4 HIV Prevalence by Other Sociodemographic Characteristics Table 12.7 examines the prevalence of HIV infection by sexual behaviour indicators among respondents who have ever had sexual intercourse. In reviewing these results, it is important to remember that responses about sexual risk behaviours may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk. For women, there is a clear pattern of higher HIV prevalence with earlier sexual debut. Women who started having sex at an early age (before age 15) have higher HIV prevalence than those with a later sexual debut (18 percent compared with 15 percent or lower). This pattern is not evident among men. Having a higher-risk sexual partner (non-marital, non-cohabiting partner) in the 12 months preceding the survey increases the risk of infection. Twenty-two percent of women who had higher risk sex are HIV infected compared with 12 percent of women who are sexually active but did not have a higher risk partner. In contrast, men reporting a higher-risk partner in the past year have a similar HIV prevalence to sexually active men who did not have a higher-risk partner (9 and 236 | HIV Prevalence and Associated Risk Factors 11 percent, respectively). Women who did not have sex in the past year have a much higher prevalence than men in the same situation (21 percent compared with 8 percent). Table 12.7 HIV prevalence by sexual behaviour characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by sexual behaviour characteristics, Malawi 2004 Women Men Total Sexual behaviour characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sex < 15 18.0 462 11.7 270 15.6 732 15-17 14.2 1,063 10.3 841 12.5 1,904 18-19 12.6 472 14.1 508 13.4 981 20+ 14.6 199 9.2 539 10.7 739 Higher-risk sex in past 12 months1 Had higher-risk sex 21.9 171 9.1 488 12.4 659 Had sex, not higher-risk sex 12.8 1,982 12.5 1,470 12.7 3,452 No sex in past 12 months 21.0 284 7.9 241 15.0 525 Number of partners in past 12 months 0 21.0 284 7.9 241 15.0 525 1 13.3 2,135 11.0 1,713 12.3 3,849 2 * 18 17.3 210 19.4 227 3+ * 0 (4.4) 31 (4.3) 31 Number of higher-risk partners in past 12 months 0 13.9 2,266 11.9 1,708 13.0 3,974 1 19.6 162 10.1 408 12.8 570 2 * 10 3.0 60 10.7 69 3+ * 0 * 20 * 20 Paid for sex In past 12 months na na 11.3 123 na na Prior to past 12 months na na 17.7 343 na na Never na na 9.9 1,733 na na Any condom use Ever used condom 15.4 263 13.8 1,033 14.2 1,296 Never used condom 14.6 1,999 8.9 1,113 12.6 3,112 Never heard of condom 10.3 171 9.7 52 10.2 223 Total 14.4 2,438 11.2 2,199 12.9 4,636 Note: Figures in parentheses are based on 25-49 cases. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Total includes respondents with missing information on sexual behaviour. na = Not applicable 1 Sex with a person who is neither married to nor lives with the respondent. Men who paid for sex in the period prior to the 12 months preceding the survey have a higher HIV prevalence (18 percent) than either those who have never paid for sex (10 percent) or those who paid for sex in the past 12 months (11 percent). Condom use does not make much difference in the likelihood of a woman being infected with HIV. HIV prevalence among women who said that they never used a condom and those who used a condom at some time is 15 percent each. In contrast, men who never used a condom have a lower prevalence of HIV than those who did use a condom at some time (9 and 14 percent, respectively). HIV Prevalence and Associated Risk Factors | 237 Some of the results discussed above demonstrate an inconsistent relationship between sexual behaviour and HIV prevalence. Detailed analysis is required to thoroughly examine this relationship, since it may be complicated by confounding factors such as age, residence, socioeconomic status, and cultural background that are associated with both the behavioural measures and HIV prevalence. 12.2.5 HIV Prevalence by Other Characteristics Related to HIV Risk Table 12.8 presents HIV prevalence by other characteristics related to HIV risk among men and women who have ever had sex. As expected, women and men with a history of a sexually transmitted infections (STIs) or STI symptoms have much higher rates of HIV infection than those with none. Women and men with STIs are twice as likely to be HIV positive as those who have no STI. For example, 26 percent of women who report having an STI or symptoms of an STI are HIV positive, compared with 13 percent of women who did not have an STI or STI symptoms. Table 12.8 HIV prevalence by other characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and who were tested, by other characteristics, Malawi 2004 Women Men Total Other characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Sexually transmitted infection Had STI or STI symptom 25.6 224 20.0 129 23.6 353 No STI, no symptoms 13.3 2,214 10.7 2,070 12.0 4,283 HIV testing status Ever tested 16.5 374 12.6 424 14.4 798 Never tested 14.1 2,064 10.9 1,774 12.6 3,838 Total 14.4 2,438 11.2 2,199 12.9 4,636 The uptake of HIV testing in Malawi remains below 25 percent in the adult population and data on HIV testing indicate that the most common reasons for seeking testing is concern regarding infection risk and illness (MACRO, 2004). As might be expected from this finding, women and men who have been tested for HIV have higher rates of HIV infection than those who have never been tested. For example, 13 percent of men who have been tested for HIV are HIV positive, compared with 11 percent of men who have never been tested. Although the individual’s HIV status is associated with prior HIV testing, the results in Figure 12.2 show that four of five of those infected with HIV (85 percent of infected women and 80 percent of infected men) do not know their HIV status, either because they were never tested or, to a small extent, because they were tested and did not receive their results. Men are more likely than women to know their sero status. This is particularly true for HIV-positive individuals. 238 | HIV Prevalence and Associated Risk Factors 12.2.6 HIV Prevalence among Youth Table 12.9 presents HIV prevalence among youth by background characteristics. Young people living with HIV are more likely to have been more recently infected compared with adults. Consequently, statistics on variation of HIV prevalence among youth is critical in understanding the patterns of recent HIV infections. HIV prevalence among younger people does not reflect the cumulative burden of AIDS because it does not take into account AIDS-related mortality in the general population. Overall, 6 percent of youth are infected with HIV. Prevalence of HIV is more than four times higher among young women than among young men (9 percent compared with 2 percent). Youths in the Southern Region have the highest HIV prevalence compared with those in the Northern and Central Regions (9 percent compared with 6 and 3 percent, respectively). HIV prevalence in youth in the urban areas is similar to that in rural areas (7 and 6 percent, respectively). In the past seven years, HIV prevalence in urban areas was estimated to be substantially higher than in rural areas (NAC, 2004b). The 2004 MDHS result suggests that incidence of HIV in rural areas has reached that in urban areas. The highest HIV prevalence among young women is found among women in the urban areas, in the Southern Region, and women who are divorced or separated. Prevalence is consistently higher among female youth compared with that among male youth. Figure 12.2 HIV Prevalence by Prior Testing Status 15 2 2 2 2 2 2 13 20 16 17 14 0% 10% 20% 30% 40% 50% 60% HIV Positive HIV Negative HIV Positive HIV Negative HIV Positive HIV Negative Pe rc en ta ge o f w om en a nd m en Ever tested, knows result Ever tested, does not know result Never tested 83 86 78 82 81 84 Women Men Total 100 80 60 40 20 0 HIV Prevalence and Associated Risk Factors | 239 Table 12.9 HIV prevalence among young people Percentage HIV positive among women and men age 15-24 who were tested for HIV, by background characteristics, Malawi 2004 Women Men Total Background characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 3.7 500 0.4 467 2.1 967 15-17 1.3 263 0.7 267 1.0 530 18-19 6.3 237 0.0 200 3.4 438 20-24 13.2 661 3.9 442 9.5 1,103 20-22 11.2 427 4.2 258 8.5 684 23-24 16.8 235 3.4 185 10.9 419 Marital status Currently in union 10.4 714 5.5 202 9.4 916 Widowed * 5 * 0 * 5 Divorced/separated 18.8 68 * 25 13.7 93 Never in union 4.8 375 1.2 682 2.4 1,057 Ever had sex 8.9 131 0.7 432 2.6 563 Never had sex 2.5 243 2.0 250 2.2 494 Residence Urban 13.3 205 0.3 183 7.2 388 Rural 8.2 957 2.5 726 5.8 1,683 Region Northern 9.0 205 0.7 150 5.5 355 Central 3.9 431 1.2 325 2.7 756 Southern 13.4 525 3.2 435 8.8 960 Number of partners in past 12 months 0 4.3 338 1.5 408 2.7 746 1 10.6 812 2.3 425 7.7 1,237 2+ * 12 4.3 77 10.1 88 Number of higher-risk partners in past 12 months 0 8.5 1,050 2.3 595 6.3 1,644 1 11.4 105 2.0 258 4.8 363 2+ * 7 0.0 56 7.2 63 Total 9.1 1,161 2.1 910 6.0 2,071 Note: An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. The high prevalence among youth who are in a union (9 percent) compared with those who have never been in a union (2 percent) indicates that early marriages may be linked to early sexual debut and other risks. HIV prevalence increases with increasing number of sexual partners in the past 12 months. Women and men who report having two or more partners are more likely to be HIV positive than those who had only one partner in the past 12 months (10 and 7 percent, respectively). For women and men who have higher-risk sex, the corresponding proportions are 7 and 5 percent, respectively. 240 | HIV Prevalence and Associated Risk Factors 12.2.7 HIV Prevalence among Couples Among the 1,324 cohabiting couples who were tested for HIV in the 2004 MDHS, for 83 percent both partners are HIV negative and for 7 percent both partners are HIV positive. Ten percent of the couples are discordant, that is, one partner is infected and the other not (Table 12.10). The variations in the level of HIV infection of both partners by background characteristics generally conform to the patterns observed in the variations in women’s seroprevalence rates. Infection rates are highest among couples in urban areas and in the Southern Region, and among those with higher education and in the higher wealth quintiles. Table 12.10 HIV prevalence among couples Among cohabiting couples who were tested, percent distribution by results of HIV testing, according to background characteris- tics, Malawi 2004 Background characteristic Both partners positive Man positive, woman negative Woman positive, man negative Both partners HIV negative Total Number Woman's age 15-19 3.1 2.4 2.7 91.8 100.0 126 20-29 7.1 5.5 4.1 83.3 100.0 658 30-39 9.4 8.2 4.7 77.7 100.0 380 40-49 4.1 3.5 2.9 89.5 100.0 159 Man's age 15-19 * * * * 100.0 9 20-29 4.4 4.0 2.5 89.2 100.0 460 30-39 9.7 6.4 5.5 78.4 100.0 460 40-54 7.1 7.0 3.8 82.1 100.0 395 Marital status Married 6.9 5.8 3.9 83.4 100.0 1,243 Living together 9.4 4.9 5.2 80.5 100.0 80 Type of union Monogamous 7.1 5.7 4.0 83.2 100.0 1,157 Polygynous 6.4 5.8 4.2 83.6 100.0 167 Residence Urban 14.6 13.8 4.5 67.0 100.0 151 Rural 6.0 4.7 3.9 85.3 100.0 1,173 Region Northern 2.1 4.8 1.7 91.4 100.0 170 Central 3.6 2.8 1.7 91.9 100.0 565 Southern 11.7 8.8 6.9 72.6 100.0 589 Woman's education No education 5.0 6.2 3.0 85.7 100.0 377 Primary 1-4 6.0 4.9 4.5 84.6 100.0 394 Primary 5-8 9.3 4.7 5.2 80.8 100.0 440 Secondary+ 8.5 10.8 0.9 79.9 100.0 113 Man's education No education 4.5 6.9 4.3 84.3 100.0 199 Primary 1-4 6.2 2.1 4.6 87.2 100.0 354 Primary 5-8 7.3 5.8 4.8 82.0 100.0 505 Secondary+ 9.5 9.5 1.6 79.4 100.0 264 Wealth quintile Lowest 3.6 1.5 2.1 92.8 100.0 164 Second 3.2 3.1 3.9 89.8 100.0 315 Middle 7.4 6.8 5.5 80.3 100.0 340 Fourth 9.8 5.7 4.0 80.5 100.0 331 Highest 11.2 12.5 3.0 73.3 100.0 173 Total 7.0 5.7 4.0 83.3 100.0 1,324 Note: An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. HIV Prevalence and Associated Risk Factors | 241 Looking more specifically at discordant couples, in 6 percent of couples, the man is infected and the woman uninfected, while in 4 percent of couples, the woman is infected and the man is not. The fact that there are more couples with discordant HIV status than couples where both partners are infected represents an unmet need for HIV prevention, because the vast majority of these couples may not know each other’s HIV status. Couple-oriented voluntary counselling and testing (VCT) services, where partners (including those in polygynous marriages) go together and receive results together, are available in some locations in the country, but couples attend as clients in only a few VCT centres. 12.3 Measuring the HIV Burden in Malawi The inclusion of HIV testing in the 2004 MDHS provides the basis for a more precise estimate of the burden of HIV in Malawi and permits the calibration of estimates of HIV prevalence based on sentinel surveillance in pregnant women. Malawi has a heterogeneous HIV epidemic, with significant differences in the disease burden by region and ethnicity. The linkage of biological and behavioural data in this survey has strengthened the validity of this survey for allowing multivariate analyses. The measurement of HIV prevalence in the 2004 MDHS should prove useful in calibrating HIV prevalence estimates of the general population from sentinel surveillance in pregnant women. This link between HIV test results and demographic and behavioural data also enhances the understanding of the distribution, patterns, and risk factors for HIV in Malawi, with the potential for improved planning and implementation of programs as a result of this information. Finally, the prevalence of couples that are discordant for HIV underscores the need for knowledge of both one’s own HIV status and that of one’s partner to prevent the continued spread of HIV. Subsequently, some positive changes in behaviour, especially among men, have been observed and documented (NAC, 2004b). Adult and Maternal Mortality | 243 ADULT AND MATERNAL MORTALITY 13 Sri Poedjastoeti and Ann Phoya In an earlier chapter of this report, estimates of mortality during the first years of life were presented and discussed. Early childhood mortality varies substantially as an index of social and economic development and thus tends to be predictably high in disadvantaged settings. Mortality during later childhood and adolescence is, on the other hand, relatively low in all societies but begins to rise with age starting in the late teenage years. The pattern and pace of the rise in adult mortality with increasing age is tied closely to the occupational profile, fertility pattern, and epidemiological characteristics of a population. Two aspects of adult mortality dynamics deserve close attention. First, given sharp rises in the prevalence of HIV infection and AIDS (discussed in the previous chapter) over the last 20 years, Malawi is expected to suffer increases in both female and male adult mortality in the near term. Second, mortality related to pregnancy and childbearing (maternal mortality) serves as an important indicator to monitor women=s and reproductive health programmes in the country. In the 2000 Malawi Demographic and Health Survey (MDHS), data were collected on adult and maternal mortality. Similar data were collected in the 2004 MDHS, allowing estimation of adult and maternal mortality using a direct estimation procedure. The basis for the calculation of the mortality rates is the survivorship of all live births to the respondent’s natural mother (i.e., the respondent’s brothers and sisters). The direct approach to estimating adult and maternal mortality maximise use of the available data, including information on the age of surviving siblings, the age at death of siblings who died, and the number of years ago the sibling died. The data are aggregated for determining the number of person-years of exposure to mortality risk and the number of sibling deaths occurring in defined calendar periods. Rates of maternal and adult mortality are obtained by dividing maternal (or all female or male adult) deaths by person-years of exposure (Rutenberg and Sullivan, 1991). The procedure calculates rates in each of the five- year age groups, then aggregates the estimates for the whole age 15-49 range, weighting the age- specific estimates using the observed age structure of the female population. 13.1 DATA Each female respondent in the 2004 MDHS was first asked to give the total number of her mother’s live births. Then she was asked to report how many siblings were born ahead of her. Then, she was asked to provide a list of the children born to her mother, starting with the first born and including whether or not each sibling was still alive at the survey date. For living siblings, current age was collected; for deceased siblings, age at death and years since death were collected. Interviewers were instructed to accept approximate answers when a respondent could not provide precise information on ages or years ago. For sisters who died at age 10 years or older, three questions were used to determine if the death was maternity related: “Was [NAME OF SISTER] pregnant when she died?” and if negative, “Did she die during childbirth?” and if negative, “Did she die within six weeks of the birth of a child or pregnancy termination?” 244 | Adult and Maternal Mortality The estimation of adult and maternal mortality requires reasonably accurate reporting of the number of sisters and brothers the respondent ever had, the number who died, and (for maternal mortality) the number of sisters who died of maternity-related causes. Table 13.1 shows the number of siblings reported by the respondents and the completeness of the reported data on current age, age at death, and years since death. The sex ratio of respondents’ siblings (the ratio of brothers to sisters) is 1.01, which is slightly lower than the expected value of 1.02 or 1.03. MDHS respondents are highly knowledgeable about the survival status of their brothers and sisters, with only 16 out of 62,733 siblings missing this information. They also tend to know the ages of their surviving siblings, with only 0.2 percent of siblings missing this information. Respondents are also able to report the age at death or years since death for their deceased siblings: 98 percent of deceased siblings have both age at death and years since death reported and less than 2 percent are missing years since death or age at death or both. Rather than exclude the siblings with missing data from further analysis, information on the birth order of siblings, in conjunction with other information, was used to impute the missing data.1 The sibling survivorship data, including cases with imputed values, were used in the direct estimation of adult and maternal mortality. Table 13.1 Data on siblings: completeness of reported data Number of siblings reported by female survey respondents and completeness of the reported data on age, age at death, and years since death, Malawi 2004 Sisters Brothers Total Sibling status and completeness of reporting Number Percent Number Percent Number Percent All siblings 31,195 100.0 31,538 100.0 62,733 100.0 Surviving 24,256 77.8 24,429 77.5 48,686 77.6 Deceased 6,932 22.2 7,099 22.5 14,031 22.4 Missing information 6 0.0 10 0.0 16 0.0 Living siblings 24,256 100.0 24,429 100.0 48,686 100.0 Age reported 24,217 99.8 24,366 99.7 48,583 99.8 Age missing 39 0.2 64 0.3 103 0.2 Dead siblings 6,932 100.0 7,099 100.0 14,031 100.0 AD and YSD reported 6,817 98.3 6,959 98.0 13,777 98.2 Missing only AD 57 0.8 44 0.6 101 0.7 Missing only YSD 23 0.3 28 0.4 50 0.4 Missing both 36 0.5 67 0.9 103 0.7 AD = Age at death YSD = Years since death 1 The imputation procedure is based on the assumption that the reported birth order of siblings in the history is correct. The first step is to calculate birth dates. For each living sibling with a reported age and for each dead sibling with complete information on both age at death and years since death, the birth date was calculated. For a sibling missing these data, a birth date was imputed within the range defined by the birth dates of the bracketing siblings. In the case of living siblings, an age was then calculated from the imputed birth date. In the case of dead siblings, if either the age at death or years since death was reported, that information was combined with the birth date to produce the missing information. If both pieces of information were missing, the distribution of the age at death for siblings for whom years since death was unreported, but age at death was reported, was used as a basis for imputing the age at death. Adult and Maternal Mortality | 245 13.2 DIRECT ESTIMATES OF ADULT MORTALITY Another way to assess the quality of data used to estimate maternal mortality is to evaluate the plausibility of the adult mortality rates obtained. If the overall adult mortality rates display a generally stable, plausible pattern, it lends credence to the maternal mortality estimates. This is because maternal mortality is a subset of adult mortality. Table 13.2 shows age-specific mortality rates for men and women age 15-49, for the calendar period 0-6 years before the survey, such as the 7-year period before the interview, which roughly corresponds to 1998-2004. Age-specific death rates are computed by dividing the number of deaths in each age group by the total person-months of exposure in that age group during a specified reference period. Since the number of deaths on which the rates are based is not large (in the 2004 MDHS they are 1,376 female and 1,193 male deaths), the age-specific rates are subject to large sampling variation. Also shown are identically calculated estimates drawn from the 1992 MDHS and the 2000 MDHS, for the same period before those surveys. The reference periods for the earlier surveys is 1986-1992 and 1994-2000, respectively. The centre of the reference period of the estimates from the three surveys are early 1989, early 1997, and mid- 2001, respectively. Table 13.2 Adult mortality rates Direct estimates of age-specific mortality rates for women and men age 15-49, for the periods 0-6 years prior to the 2004 MDHS and 2000 MDHS 2004 MDHS 2000 MDHS 1992 MDHS Age Deaths Exposure (person years) Mortality rate/1000 Mortality rate/1000 Mortality rate/1000 WOMEN 15-19 117 27,622 4.2 4.1 5.3 20-24 227 29,331 7.7 8.6 3.6 25-29 299 23,763 12.6 11.4 6.8 30-34 245 17,228 14.2 15.5 7.2 35-39 230 12,206 18.9 17.1 9.0 40-44 177 7,892 22.5 17.9 8.9 45-49 82 4,574 17.9 18.7 9.6 15-49 1,376 122,616 11.6 11.3 6.5 MEN 15-19 118 27,675 4.2 3.4 3.8 20-24 143 28,966 4.9 5.9 4.1 25-29 178 24,514 7.3 9.1 6.8 30-34 258 17,404 14.8 14.4 8.4 35-39 204 11,992 17.0 20.3 7.6 40-44 178 7,579 23.5 22.5 10.1 45-49 115 4,560 25.2 23.2 9.7 15-49 1,193 122,690 10.5 11.1 6.3 Data in Table 13.2 show that there was an increase in adult mortality from early 1989 to early 1997. However, mortality for both women and men has remained at the same levels since 1997 (Figure 13.1 and Figure 13.2). 246 | Adult and Maternal Mortality Figure 13.2 Trends in Age-specific Mortality among Men Age 15-49 0.0 5.0 10.0 15.0 20.0 25.0 30.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age M or ta lit y ra te 1992 MDHS 2000 MDHS 2004 MDHS Figure 13.1 Trends in Age-specific Mortality among Women Age 15-49 0.0 5.0 10.0 15.0 20.0 25.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age M or ta lit y ra te 1992 MDHS 2000 MDHS 2004 MDHS Adult and Maternal Mortality | 247 13.3 MATERNAL MORTALITY Maternal deaths are defined as any death that occurred during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy.2 Estimates of maternal mortality are therefore based solely on the timing of the death in relationship with pregnancy and childbearing. Two survey methods are generally used to estimate maternal mortality in developing countries: the sisterhood method (Graham et al., 1989) and a direct variant of the sisterhood method (Rutenberg and Sullivan, 1991). The approach used to obtain the maternal mortaility results in this report is the same as that used to obtain overall adult mortality. Age-specific mortality rates are calculated by dividing the number of maternal deaths by woman-years of exposure. The number of maternal deaths (240) is small, so age-specific rates are subject to very large sampling errors and should be interpreted with caution. The preferred approach is to calculate one estimate for all childbearing ages (15-49 years). To remove the effect of truncation bias in the upper age limit (the upper boundary for eligibility for individual interview for women in the MDHS is 49 years), the overall rate for women age 15- 49 is standardized by the age distribution of the survey respondents. Direct age-specific estimates of maternal mortality from the reported sibling survivorship histories are shown in Table 13.3 for the period 0-6 years before the survey, alongside estimates based on the 1992 MDHS and the 2000 MDHS data for the period 0-6 years before that survey. The proportion of all female deaths that are maternity-related in the 7-year period prior to 2004 (approximately 1998-2004) is 17 percent. This proportion is lower than that recorded in the 1992 MDHS (21 percent) and the Table 13.3 Direct estimates of maternal mortality Direct estimates of maternal mortality rates and the maternal mortality ratio, for the periods 0-6 years prior to the 2004 MDHS 2004 MDHS 2000 MDHS 1992 MDHS Age group Deaths Exposure (person years) Mortality rate/1000 Mortality rate/1000 Mortality rate/1000 15-19 8 27,622 0.3 0.4 1.3 20-24 52 29,331 1.8 2.4 0.5 25-29 64 23,763 2.7 2.7 1.5 30-34 50 17,228 2.9 3.7 1.8 35-39 33 12,206 2.7 2.9 1.9 40-44 22 7,892 2.8 4.5 0.8 45-49 12 4,574 2.7 1.9 3.4 15-49 240 122,616 2.0 2.4 1.4 General fertility rate (GFR) 0.204 0.210 0.220 Maternal mortality ratio (MMR)1 984 1,120 620 1 Per 100,000 live births, calculated as the maternal mortality rate divided by the general fertility rate. 2 This time-dependent definition includes all deaths that occurred during pregnancy and two months after pregnancy, even if the death was due to nonmaternal causes. However, this definition is unlikely to result in overreporting of maternal deaths because most deaths to women during the two-month period are due to maternal causes. And mater- nal deaths are more likely to be underreported than overreported. 248 | Adult and Maternal Mortality 2000 MDHS (22 percent).3 At face value, this means that maternal mortality changes at a slightly faster pace than nonmaternal mortality. The maternal mortality rate is converted to a maternal mortality ratio (MMR) and expressed per 100,000 live births by dividing the rate by the general fertility rate (0.204) associated with the same period. In this way, the obstetrical risk of pregnancy and childbearing is underlined. Using direct estimation procedures based on the 2004 MDHS survey, the maternal mortality ratio is estimated to be 984 maternal deaths per 100,000 live births applicable to the seven-year period before the survey (centred in mid-2001). As in the case of adult mortality, the MMR based on the 2000 MDHS is significantly higher that that calculated from the 1992 MDHS. However, the estimated MMR based on the 2004 MDHS data is lower than the rate from the 2000 MDHS survey of 1,120 maternal deaths per 100,000 live births. It is unlikely that maternal mortality has gone up and then down again so dramatically, especially since the reference periods for the estimates overlap each other. Maternal mortality ratios measured in this way are subject to very high sampling errors and cannot adequately indicate trends over the short term. 3 These proportionate maternal mortality estimates are in the range of those presented by Stanton et al. (1997) in their exhaustive review of similar data collected around the world. Malaria | 249 MALARIA 14 Storn Kabuluzi Malaria is a major public health problem in Malawi. It is the leading cause of morbidity and mortality, especially among children under the age of five years and pregnant women. The Ministry of Health (MOH) estimates that over the past five years there have been more than 8 million episodes of malaria per year throughout the country (MOHP, 2003a). Malaria accounts for 40 percent of all outpatient visits to health facilities in the country. Anaemia, most of which is considered to be attributable to malaria, is estimated to be responsible for about 40 percent of all hospitalisations and 40 percent of all hospital deaths in children under age five. Over 85 percent of malaria infections in Malawi are due to Plasmodium falciparum. This type of malaria can lead to death; however, the most severe cases are typically limited to those who are not immune or have low immunity. Those most at risk are children age three months to five years, when they no longer have the immunity transferred from their mother, to the age when they have developed their own immunity. Also at risk are pregnant women because their natural immunity is reduced. Pregnant women are four times more likely to suffer from complications of malaria than non-pregnant women. Malaria is a cause of pregnancy loss, low birth weight, and neonatal mortality (Jamison et al., 1993). In economic terms, malaria has both direct and indirect costs. Direct costs borne by individuals, households and government include the cost of treatment. The indirect costs of malaria include not only the negative economic impact of morbidity and mortality in work days lost in agriculture and industry, but also absenteeism in the education system, which further contributed to loss in productivity (MOHP, 2002b). Malaria therefore aggravates poverty. The call for the Roll Back Malaria (RBM) initiative was made in 1998 by WHO as an international effort to control malaria. Malawi endorsed this initiative by committing herself to the Abuja Declaration. The RBM initiative is the framework within which the country implements malaria control activities. The initiative’s goal is to halve the 2000 levels of malaria morbidity and mortality by 2010, and to reduce this malaria burden by a further 50 percent by 2015. The objectives of the initiative are to ensure that by the year 2005 at least 60 percent of those at risk of malaria, particularly pregnant women and children under five years of age, have access to the most suitable and affordable combination of personal and community protective measures such as insecticide-treated mosquito nets (ITNs) and prompt, effective treatment for malaria within 24 hours of onset of illness. Another objective is to ensure that at least 60 percent of all pregnant women who are at risk of malaria, especially those in their first pregnancies, have access to intermittent preventive treatment (IPT). To control malaria, the Government of Malawi has put in place several strategies through the National Malaria Control Programme. The main strategic areas that have been identified for scaling-up of malaria control activities, include malaria case management, intermittent preventive treatment (IPT) of pregnant women with sulfadoxine-pyrimethamine (SP), and 250 | Malaria malaria prevention with special emphasis on the use of insecticide-treated mosquito nets (ITNs) (MOHP, 2002a; MOH, 2005b). Malaria | 251 14.1 MOSQUITO NETS The use of ITNs is a primary health intervention to reduce malaria transmission. In an effort to make mosquito nets affordable, the Government of Malawi has since November 2002 introduced a subsidy on mosquito nets and developed ITN guidelines to standardise and facilitate the distribution of mosquito nets in the country. The Government and development partners supply mosquito nets and insecticide treatment kits for distribution at subsidised costs to communities. Mosquito nets in Malawi are distributed through three main distribution channels: health facilities, community organisations, and the private sector. Less than 10 percent of the nets are distributed through the commercial distribution channel. The nets distributed through health facilities and communities are green and rectangular. The nets for commercial distribution are blue and conical. This section presents the 2004 MDHS findings collected at the household level on mosquito net possession and use of mosquito nets by household members, in particular children under five years of age and pregnant women. 14.1.1 Ownership of Mosquito Nets All households in the 2004 MDHS survey were asked whether they own mosquito nets and, if so, how many they own. The respondents were asked to show the mosquito nets to the interviewer. Table 14.1 shows the percentage of households with at least one mosquito net, with at least one ever-treated mosquito net, and the average number of nets per household, by background characteristics. The data show that 42 percent of households in Malawi have at least one net. Less than one-fifth of households (18 percent) have more than one net. Data in Table 14.1 also show that 34 percent of the households own at least one ever-treated mosquito net, and 15 percent of these households have more than one ever-treated net. Just over one-fourth (27 percent) of households own an ITN, that is, a net that has been soaked in insecticide within the past 12 months or a factory-treated net that does not require further treatment. Almost one in eight households have more than one ITN. The average number of mosquito nets per household is 0.7, while the average number of ever-treated mosquito nets per household is 0.6, The average number of ITNs per household is 0.4. Urban households are more likely than rural households to own ITNs (41 percent compared with 25 percent). The Northern Region has the highest coverage of ITNs while the Central Region has the lowest coverage (31 percent compared with 24 percent). Among the oversampled districts, it is interesting to note that Salima and Machinga have the highest coverage of ITNs. The data also show that ownership of mosquito nets is directly related to the wealth status of the household; better off households are more likely than poorer households to own a mosquito net. 252 | Malaria Table 14.1 Ownership of mosquito nets Percentage of households with at least one and with more than one mosquito net (treated or untreated) and average number of mosquito nets per household, by background characteristics, Malawi 2004 Background characteristic Percentage of households that have at least one net Percentage of households that have more than one net Average number of nets per household Percentage of households with at least one ever- treated net Percentage of house- holds with more than one ever- treated net Average number of ever- treated nets per household Percentage of households that have at least one ITN Percentage of households that have more than one ITN Average number of ITNs per household Number of households Residence Urban 55.8 30.7 1.1 47.5 25.8 0.9 40.5 21.0 0.8 2,262 Rural 39.1 15.8 0.6 31.6 12.4 0.5 24.8 9.7 0.4 11,402 Region Northern 46.8 27.3 0.9 37.0 20.5 0.7 31.3 16.9 0.6 1,584 Central 38.5 16.1 0.6 30.8 12.8 0.5 24.0 9.8 0.4 5,589 Southern 43.6 17.9 0.7 36.5 14.9 0.6 29.4 11.8 0.5 6,491 District Blantyre 41.4 16.5 0.7 34.6 14.4 0.6 30.0 12.1 0.5 1,111 Kasungu 32.8 13.1 0.5 26.8 10.6 0.4 19.7 7.9 0.3 544 Machinga 63.8 27.9 1.0 53.0 22.7 0.8 43.4 19.7 0.7 539 Mangochi 56.6 28.1 1.0 44.0 22.3 0.8 34.8 16.4 0.6 727 Mzimba 37.7 19.8 0.7 31.4 16.1 0.6 25.4 12.9 0.5 795 Salima 62.2 26.1 1.0 55.4 22.9 0.9 42.7 17.4 0.7 392 Thyolo 31.8 10.7 0.5 25.5 8.2 0.4 20.9 6.7 0.3 734 Zomba 50.3 22.6 0.9 44.2 19.2 0.7 37.3 17.0 0.6 760 Lilongwe 42.9 18.2 0.7 33.0 14.6 0.5 26.4 11.4 0.4 2,127 Mulanje 29.7 10.6 0.5 25.4 8.8 0.4 21.7 7.6 0.3 611 Other districts 39.0 17.3 0.7 31.8 13.3 0.5 24.7 10.1 0.4 5,325 Wealth quintile Lowest 20.3 3.9 0.2 14.9 2.6 0.2 10.7 1.7 0.1 3,168 Second 31.6 9.3 0.4 24.4 7.2 0.3 18.5 5.3 0.2 2,748 Middle 39.1 14.2 0.6 31.4 10.9 0.5 24.8 8.9 0.4 2,622 Fourth 52.5 23.0 0.8 43.6 18.2 0.7 35.6 14.5 0.5 2,569 Highest 71.9 44.9 1.5 62.1 37.9 1.3 52.2 30.4 1.0 2,557 Total 41.9 18.2 0.7 34.2 14.7 0.6 27.4 11.6 0.4 13,664 1An ever-treated net is (1) a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at any time. 2An Insecticide Treated Net (ITN) is (1) a factory treated net that does not require any further treatment or (2) a pretreated net obtained within the last six months or (3) a net that has been soaked with insecticide within the past six months. 14.1.2 Colour and Shape of Mosquito Nets In the 2004 Malawi DHS, the respondents to the Household Questionnaire were asked to show their mosquito nets to the interviewers. To allow monitoring of the distribution of mosquito nets made available under social marketing initiatives, the interviewer also noted the colour, shape and condition of the net. Interviewers were instructed to record whether the net has holes that are the size of the tip of a thumb or larger. Table 14.2 shows that one in four of the nets observed have holes. Green nets are the most popular; 74 percent of the nets observed are green. One in five observed nets is blue, and 5 percent are white. Rectangular nets are more common than conical nets (71 and 29 percent, respectively). The major net distribution effort in Malawi distributes green, rectangular nets Malaria | 253 through health facilities and blue, conical nets through private sector channels. As anticipated by the net distribution strategy, these results show that rural residents are more likely to have green and rectangular nets while urban residents are more likely to have blue and conical nets. Table 14.2 Colour and shape of mosquito nets Percentage of households with an observed mosquito net, percentage of observed nets with holes, and percent distribution of observed nets by colour and shape, according to background characteristics, Malawi 2004 Percentage of observed nets that are: Percentage of observed nets that are: Background characteristic Percentage of housholds with observed net Number of house- holds Percentage of observed nets with at least one hole Blue Green White Other Conical Rectangle Number of observed nets Residence Urban 18.9 2,262 20.6 42.5 51.2 6.2 0.1 51.7 48.0 722 Rural 20.4 11,402 27.2 16.7 78.6 4.6 0.1 23.7 75.9 3,439 Region Northern 19.7 1,584 26.0 24.4 66.2 9.3 0.1 41.0 58.4 533 Central 17.2 5,589 27.6 20.8 74.6 4.5 0.2 26.8 73.0 1,416 Southern 22.8 6,491 25.0 20.6 75.3 4.0 0.0 26.8 72.9 2,212 District Blantyre 18.5 1,111 18.5 40.6 53.9 5.6 0.0 46.9 53.1 300 Kasungu 21.5 544 38.0 14.3 83.6 2.1 0.0 18.7 81.3 178 Machinga 36.7 539 26.6 9.4 84.8 5.7 0.0 15.9 83.6 299 Mangochi 24.2 727 41.5 22.3 72.8 4.9 0.0 29.6 70.4 308 Mzimba 19.6 795 26.8 26.3 65.9 7.5 0.2 46.6 52.6 280 Salima 32.4 392 44.2 34.9 57.0 7.6 0.6 47.3 52.7 186 Thyolo 18.4 734 29.5 14.0 84.1 2.0 0.0 15.9 83.4 185 Zomba 26.1 760 16.8 19.6 75.7 4.6 0.0 30.2 69.2 314 Lilongwe 13.0 2,127 15.0 30.2 66.7 3.1 0.0 28.3 71.1 389 Mulanje 17.9 611 21.7 15.6 79.3 5.0 0.0 26.0 73.6 165 Other districts 19.8 5,325 25.3 17.2 77.8 4.8 0.2 24.4 75.2 1,558 Wealth quintile Lowest 10.9 3,168 36.3 12.3 84.0 3.6 0.1 18.5 81.3 393 Second 16.6 2,748 31.2 12.6 83.9 3.2 0.2 17.6 82.1 600 Middle 21.7 2,622 28.1 12.9 83.6 3.4 0.0 17.8 81.5 813 Fourth 26.4 2,569 24.2 18.1 77.5 4.2 0.2 25.3 74.6 1,012 Highest 27.6 2,557 20.9 34.8 57.8 7.3 0.0 45.4 54.2 1,342 Total 20.2 13,664 26.0 21.2 73.9 4.8 0.1 28.6 71.1 4,161 Respondents in households which have no mosquito nets were asked their preference for colour and shape of net. Figure 14.1 shows that there is about equal preference for blue (38 percent) and green (41 percent) nets. However, analysis of colour preference by residence reveals that urban residents tend to prefer blue nets while rural residents tend to prefer green nets. Figure 14.2 shows a similar parity in preference of net shape at the national level: 45 percent of household respondents prefer conical nets while 43 percent prefer rectangular nets. By residence, urban respondents are more likely to prefer conical nets while rural respondents prefer rectangular nets. 254 | Malaria Figure 14.1 Preferred Colour of Mosquito Net among Households Without Mosquito Nets, by Residence 58 25 5 36 43 8 38 41 8 0 10 20 30 40 50 60 70 Blue Green White Pe rc en t Urban Rural Total MDHS 2004 Figure 14.2 Preferred Shape of Mosquito Net among Households Without Mosquito Nets, by Residence 63 25 12 42 46 12 45 43 12 0 10 20 30 40 50 60 70 Conical Rectangular Don't know/No preference Pe rc en t Urban Rural Total MDHS 2004 Malaria | 255 14.1.3 Use of Mosquito Nets by Children In the 2004 Malawi DHS, respondents were asked if anyone slept under the mosquito nets they showed to the interviewers. This section analyses mosquito net usage among children. Because malaria is especially dangerous to children under five years of age, the malaria prevention strategies in Malawi have targeted children under age five. Table 14.3 shows the percentage of children under age five years who slept under a mosquito net the night before the survey, by background characteristics. The data show that 20 percent of children under age five slept under a mosquito net, 18 percent slept under an ever-treated net, and 15 percent slept under an ITN. Older children are less likely than younger children to sleep under a bed net. There are no marked differences in mosquito net usage by sex of child. Urban children are much more likely to use a mosquito net than children in the rural areas. ITN usage by children under five in the Northern Region and Southern Region is higher than in the Central Region (17 percent compared with 12 percent). The proportion of children who slept under an ITN among the oversampled districts ranges from 29 percent in Salima to 6 percent in Kasungu. ITNs are more available in wealthier households (34 percent for the highest wealth quintile and 6 percent for the lowest wealth quintile). While still below the Roll Back Malaria target of 60 percent of children under age five sleeping under an ITN, use of any mosquito net has more than doubled for children under five since the 2000 MDHS (8 percent) (Figure 14.3). Table 14.3 Use of mosquito nets by children Percentage of de facto children (in households) under age five years who slept under a mosquito net the night before the survey and percentage who slept under an ever-treated net the night before the survey, by background characteristics, Malawi 2004 Background Characteristic Percentage who slept under a net the preceding night Percentage who slept under an ever-treated net the preceding night1 Percentage who slept under an ITN the preceding night2 Number of children Age in months < 12 22.0 18.6 15.3 2,378 12-23 21.2 18.6 15.7 2,293 24-35 21.7 18.9 15.8 1,881 36-47 19.2 17.1 14.3 1,941 48-59 16.7 15.4 12.7 2,047 Sex Male 19.4 17.1 14.3 5,195 Female 21.0 18.4 15.2 5,344 Residence Urban 39.3 35.2 30.2 1,420 Rural 17.3 15.0 12.4 9,119 Region Northern 22.7 19.6 17.4 1,350 Central 16.7 14.9 11.9 4,397 Southern 22.8 19.9 16.7 4,791 District Blantyre 23.9 20.6 18.8 708 Kasungu 7.9 7.2 5.9 510 Machinga 31.5 26.4 22.4 435 Mangochi 32.9 27.1 21.5 639 Mzimba 20.9 19.1 16.7 694 Salima 37.5 35.0 29.3 301 Thyolo 10.9 9.3 8.0 548 Zomba 32.0 29.6 27.2 550 Lilongwe 21.7 19.8 15.5 1,473 Mulanje 15.9 14.8 12.9 405 Other districts 16.3 13.9 11.3 4,276 Wealth quintile Lowest 10.1 8.0 6.4 2,090 Second 13.3 11.5 9.2 2,294 Middle 18.0 15.4 12.1 2,358 Fourth 21.7 19.4 16.7 2,071 Highest 43.1 39.1 33.8 1,726 Total 20.2 17.8 14.8 10,539 1An ever-treated net is (1) a pretreated net or (2) a non-pretreated net that has subsequently been soaked with insecticide at any time. 2An insecticide treated net (ITN) is (1) a factory-treated net that does not require any further treatment or (2) a pretreated net obtained within the past six months or (3) a net that has been soaked with insecticide within the past six months. 256 | Malaria 14.1.4 Use of Mosquito Nets by Pregnant Women The danger of malaria for pregnant women has prompted many advocacy campaigns to educate not only pregnant women but also the general public on the importance of preventing malaria during pregnancy. Table 14.4 shows that 21 percent of women slept under a mosquito net, 18 percent slept under an ever-treated mosquito net and 15 percent slept under an ITN. There are virtually no differences in the use of mosquito nets between pregnant women and non- pregnant women. Women in urban areas are more than twice as likely to sleep under an ITN as women in rural areas. As with the data for children, use of ITNs by women is higher in the Northern and Southern regions (16 and 17 percent, respectively) than in the Central Region (11 percent). Women in Salima and Mangochi are also the most likely to sleep under an ITN. Those in Thyolo are the least likely to use a net. The use of mosquito nets by women increases as wealth quintile and level of education increases. This is particularly true with ITNs. Figure 14.4 shows that use of mosquito nets among women age 15-49 has increased substantially since the 2000 MDHS, from 8 to 21 percent. Figure 14.3 Percentage of Children Under Age Five Who Slept Under a Mosquito Net the Night Before the Survey, Malawi 2000-2004 8 21 6 17 6 7 20 39 17 23 17 23 0 5 10 15 20 25 30 35 40 45 Malawi RESIDENCE Urban Rural REGION Northern Central Southern Percent 2000 MDHS 2004 MDHS Malaria | 257 Table 14.4 Use of mosquito nets by pregnant women Percentage of all de facto women and pregnant de facto women age 15-49 (in household) who slept under a mosquito net (treated or untreated) and who slept under an Insecticide Treated Net (ITN) the night before the survey, by background characteristics, Malawi 2004 All women Pregnant women Background characteristic Percentage who slept under a net the preceding night Percentage who slept under an ever-treated net the preceding night1 Percentage who slept under an ITN the preceding night2 Number of women Percentage who slept under a net the preceding night Percentage who slept under an ever-treated net the preceding night1 Percentage who slept under an ITN the preceding night2 Number of pregnant women Residence Urban 37.0 33.1 27.2 2,184 38.3 35.7 29.8 183 Rural 16.9 14.8 12.2 10,018 16.4 14.9 12.4 1,222 Region Northern 22.9 19.6 16.4 1,622 22.2 19.1 15.7 173 Central 17.1 15.2 12.1 4,946 15.3 14.3 11.1 578 Southern 22.9 20.2 16.9 5,634 22.0 20.2 17.6 655 Education No education 19.3 16.6 13.5 2,873 18.3 17.4 15.7 382 Primary 1-4 17.0 15.0 12.6 3,200 16.4 14.6 12.3 377 Primary 5-8 21.0 18.4 14.9 4,358 19.7 17.4 14.1 478 Secondary+ 27.7 25.3 21.1 1,770 26.7 25.2 19.4 168 District Blantyre 22.5 19.6 17.4 954 25.8 24.7 20.9 106 Kasungu 9.1 8.6 7.2 517 7.4 7.4 7.4 62 Machinga 32.5 28.0 24.5 446 31.0 23.8 21.7 46 Mangochi 35.9 30.3 23.9 626 38.5 34.1 29.3 61 Mzimba 22.2 19.9 16.6 811 20.0 17.6 14.6 91 Salima 35.1 32.2 27.3 314 36.5 33.0 27.3 45 Thyolo 11.7 10.8 9.2 645 7.0 6.3 5.5 87 Zomba 30.1 28.0 26.2 666 36.0 36.0 36.0 79 Lilongwe 23.2 20.9 16.0 1,782 18.1 17.1 12.9 175 Mulanje 14.0 12.8 11.7 536 18.2 15.0 15.0 70 Other districts 16.7 14.3 11.2 4,904 15.0 13.7 10.3 583 Wealth quintile Lowest 9.0 6.9 5.2 2,147 10.2 7.8 6.0 247 Second 13.1 11.5 9.2 2,368 12.6 11.4 9.6 319 Middle 15.7 13.6 11.0 2,474 14.8 14.2 12.6 342 Fourth 21.6 19.1 16.2 2,438 20.9 19.6 17.0 284 Highest 39.2 35.5 29.5 2,776 44.9 41.1 32.6 213 Total 20.5 18.1 14.9 12,202 19.3 17.6 14.7 1,405 1An ever-treated net is (1) a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at any time. 2An insecticide treated net (ITN) is (1) a factory-treated net that does not require any further treatment or (2) a pretreated net obtained within the past six months or (3) a net that has been soaked with insecticide within the past six months. 258 | Malaria 14.2 INTERMITTENT PREVENTIVE TREATMENT DURING PREGNANCY Pregnant women are at particular risk of malaria infection. Its consequences in the mother are anaemia and fever, while newborns suffer low birth weight. Placental parasitaemia may be high with undetectable peripheral parasitaemia. Intermittent Preventive Treatment (IPT) in pregnancy prevents development of malaria and eliminates malaria parasites from the placenta. IPT with SP has been shown to reduce low birth weight, anaemia and severe disease. As a protective measure, the Malawi National Malaria Policy recommends that pregnant women receive Intermittent Preventive Treatment with SP at least twice during the pregnancy (at least one month apart) to clear malaria parasites from the body. The treatment should be administered once in the second trimester and once in the third trimester. In the 2004 MDHS, women who gave birth in the past five years were asked whether they took any antimalarial tablets during pregnancy, which drug was taken, and how many times it was taken. The data do not allow assessment of the timing of the doses relative to stage of pregnancy. Table 14.5 shows that 79 percent of pregnant women SP/Fansidar during pregnancy to prevent malaria. However, less than half (47 percent) took were covered by the recommended two doses. Most women who took SP/Fansidar during pregnancy received the drug during their antenatal care visits. Forty-three percent of pregnant women received a complete course of IPT, that is, two doses of SP/Fansidar as part of their routine ANC. According to the data in Table 14.5 and Figure 14.5, urban women are more likely to take two doses of SP/Fansidar during pregnancy than rural women (54 percent and 45 percent, respectively). Better educated women and those living in households in the highest wealth Figure 14.4 Percentage of Women Age 15-49 Who Slept Under a Mosquito Net on the Night Before the Survey, Malawi 2000-2004 8 19 5 14 6 7 3 4 6 23 21 37 17 23 17 23 19 17 21 28 0 5 10 15 20 25 30 35 40 Malawi RESIDENCE Urban Rural REGION Northern Central Southern EDUCATION No education Primary 1-4 Primary 5-8 Secondary + Percent 2000 MDHS 2004 MDHS Malaria | 259 quintile are also more likely than other women to receive two doses of SP/Fansidar during pregnancy. The percentage of women who took at least two doses of SP/Fansidar during pregnancy is slightly higher in the Northern Region (49 percent) than in the Central and Southern regions (46 percent). Among the oversampled districts, the proportion of women who took at least two doses of SP/Fansidar ranges from 36 percent in Thyolo to 60 percent in Blantyre. Table 14.5 Prophylactic use of antimalarial drugs and of Intermittent Preventive Treatment (IPT) by women during pregnancy Percentage of women who took any antimalarial drugs for prevention of malaria, who took SP/Fansidar, and who received Intermittent Preventive Treatment (IPT), during pregnancy for their last live birth in the five years preceding the survey, by background characteristics, Malawi 2004 SP/Fansidar Background characteristic Percentage who took any antimalarial drug Percentage who took any SP/Fansidar Percentage who took 2+ doses Percentage who received any SP/Fansidar during an ANC visit Percentage who received 2+ doses, at least one during an ANC visit Number of women Birth order 1 78.1 75.7 47.8 71.4 45.0 1,026 2-3 81.8 80.2 47.0 74.1 43.3 1,705 4-6 82.7 80.8 46.0 74.8 42.7 1,330 7+ 76.0 74.6 43.4 66.6 38.4 542 Timing of birth < 1 year ago 80.4 78.5 46.1 72.5 42.6 2,388 1 year ago 80.7 79.0 46.8 73.2 43.3 2,216 Residence Urban 86.2 84.6 53.8 80.3 51.1 583 Rural 79.7 77.9 45.4 71.8 41.7 4,021 Region Northern 85.8 84.8 49.4 82.9 48.1 559 Central 77.8 75.0 45.7 68.1 41.6 1,931 Southern 81.6 80.5 46.4 74.5 42.8 2,115 District Blantyre 87.9 86.8 60.1 79.4 53.8 303 Kasungu 78.3 73.6 41.2 69.4 39.3 226 Machinga 82.1 78.4 46.5 61.8 37.3 191 Mangochi 66.3 64.6 43.9 58.3 38.7 274 Mzimba 89.1 87.9 50.6 86.9 50.4 289 Salima 87.7 86.5 56.6 84.2 55.0 138 Thyolo 81.8 81.2 35.6 76.3 34.8 240 Zomba 90.8 90.3 58.3 88.6 56.8 239 Lilongwe 76.5 74.9 44.9 69.2 41.7 627 Mulanje 80.3 80.3 44.9 75.0 42.4 178 Other districts 79.6 77.5 44.5 71.1 40.5 1,900 Education No education 70.8 68.4 39.6 60.8 35.3 1,153 Primary 1-4 77.8 75.6 43.8 68.5 39.2 1,354 Primary 5-8 86.4 85.1 50.3 80.8 47.5 1,561 Secondary+ 91.3 90.0 57.0 86.8 55.6 534 Missing 100.0 100.0 0.0 100.0 0.0 1 Wealth quintile Lowest 78.5 76.1 42.1 70.3 39.0 919 Second 75.4 73.2 42.6 65.8 37.6 1,111 Middle 79.4 77.6 46.2 73.1 43.7 1,001 Fourth 82.2 80.6 47.8 74.5 44.4 871 Highest 91.1 90.2 57.0 84.9 53.5 701 Total 80.5 78.7 46.5 72.9 42.9 4,604 1 IPT: Intermittent Preventive Treatment is preventive intermittend treatment with SP/Fansidar during an antenatal care (ANC) visit. 260 | Malaria It should be noted that data from the 2004 MDHS do not include IPT for women whose pregnancy in the five years preceding the survey did not end in a live birth. 14.3 PREVALENCE AND MANAGEMENT OF MALARIA IN CHILDREN Fever is the major manifestation of malaria. In the 2004 Malawi DHS, mothers were asked whether their children under age five had fever in the two weeks preceding the survey. Although fever occurs all year round, malaria is more prevalent during the rainy season, and such temporal factors must be taken into account when interpreting the occurrence of fever as an indicator of malaria prevalence. If fever was reported, the mother was asked whether treatment was sought at a health facility and whether the child was given any medication and, if so, how soon the medication was taken after the episode of illness started. 14.3.1 Initial Response to Child’s Fever Table 14.6 shows the percent distribution of children with fever in the past two weeks by specific actions taken as the first response to the fever. The data show that 21 percent of children were given medication that was already present in the home and 39 percent were given medication without prescription. Almost one in three children was taken to a health facility; 24 percent were taken to a government-run facility. Six percent of children with fever were not treated. Response to fever in a child varies by the child’s age, residence, and socioeconomic status. Younger children, children who live in urban areas, in the Northern Region, children of better-educated mothers, and who are in households in the highest wealth quintile are more likely Figure 14.5 Percentage of Pregnant Women Who Took at Least 2 Doses of SP for IPT of Malaria During Pregnancy in the Five Years Preceeding the Survey 47 54 45 49 46 46 40 44 50 57 0 10 20 30 40 50 60 Malawi RESIDENCE Urban Rural REGION Northern Central Southern EDUCATION No education Primary 1-4 Primary 5-8 Secondary + Percent MDHS 2004 Malaria | 261 than other children to be treated by going to a health facility or giving the child medicine that was already available in the home, whereas women with less education are more likely to give the child medicine obtained in a shop or pharmacy or to not treat the child’s fever at all. Table 14.6 Initial response to fever Percent distribution of children with fever in the past two weeks by specific actions taken as the first response to the fever, according to back- ground characteristics, Malawi 2004 Gave child medicine Took child to a health centre: Background characteristic From home Without prescrip- tion Govern- ment Mission Private Con- sulted tradi- tional healer Con- sulted com- munity health worker Gave tepid spong- ing Gave herbs at home Other Did nothing Don't know Total Number of children with fever Age in months < 6 14.3 32.4 24.3 4.5 4.5 0.4 0.2 1.5 1.1 0.0 16.8 0.0 100.0 341 6-11 19.4 35.6 28.7 5.1 2.9 0.7 0.4 2.5 1.5 0.6 2.2 0.3 100.0 632 12-23 22.1 36.6 27.3 3.7 2.1 0.4 0.4 3.1 0.4 0.3 3.7 0.0 100.0 1,087 24-35 19.9 40.6 21.5 4.5 3.4 0.9 0.8 2.4 0.2 0.2 5.6 0.0 100.0 689 36-47 21.3 46.1 17.6 1.5 1.2 0.8 0.0 3.6 1.4 0.0 6.3 0.2 100.0 501 48-59 26.4 41.1 19.4 3.7 2.4 0.4 0.5 0.8 0.3 0.0 4.9 0.0 100.0 381 Sex Male 20.7 39.2 24.1 3.9 2.7 0.4 0.4 2.4 0.4 0.3 5.4 0.1 100.0 1,793 Female 20.9 38.0 23.9 3.9 2.5 0.8 0.4 2.7 1.0 0.1 5.6 0.1 100.0 1,837 Residence Urban 23.6 29.2 31.9 3.3 7.4 0.5 0.0 1.5 0.0 0.8 1.8 0.0 100.0 401 Rural 20.5 39.8 23.0 3.9 2.0 0.6 0.5 2.7 0.8 0.1 6.0 0.1 100.0 3,230 Region Northern 35.5 24.9 22.1 3.0 1.7 1.7 0.6 2.3 0.9 0.0 7.0 0.3 100.0 351 Central 17.9 40.2 22.8 4.3 3.7 0.4 0.1 2.5 0.9 0.3 6.8 0.1 100.0 1,624 Southern 20.6 39.9 25.5 3.6 1.7 0.6 0.7 2.7 0.6 0.2 3.9 0.0 100.0 1,655 Education No education 19.0 43.0 20.3 3.6 1.4 0.5 0.7 3.4 0.9 0.2 6.6 0.3 100.0 967 Primary 1-4 19.8 40.5 24.9 3.2 1.7 0.8 0.1 1.9 0.9 0.3 6.0 0.0 100.0 1,132 Primary 5-8 22.4 35.5 25.8 4.5 3.0 0.6 0.5 2.4 0.6 0.1 4.6 0.0 100.0 1,189 Secondary+ 24.2 30.6 25.5 4.9 7.6 0.1 0.2 2.9 0.0 0.0 4.1 0.0 100.0 340 Wealth quintile Lowest 19.0 42.3 22.0 2.8 0.9 0.8 0.5 2.3 1.5 0.3 7.4 0.3 100.0 757 Second 19.8 40.6 24.5 4.3 2.2 0.4 0.5 2.7 0.9 0.2 4.0 0.0 100.0 894 Middle 20.5 39.8 23.3 3.0 2.2 1.1 0.7 2.9 0.8 0.1 5.6 0.0 100.0 830 Fourth 21.8 34.4 28.0 3.6 2.8 0.4 0.1 2.0 0.2 0.5 6.0 0.2 100.0 676 Highest 24.9 32.8 21.7 6.5 6.7 0.2 0.0 2.8 0.0 0.0 4.4 0.0 100.0 474 Total 20.8 38.6 24.0 3.9 2.6 0.6 0.4 2.6 0.7 0.2 5.5 0.1 100.0 3,630 14.3.2 Timing of Antimalarial Response to Child’s Fever Prompt and effective treatment of malaria within 24 hours of onset of symptoms has been highlighted as one of the key objectives in the Malawi Malaria Policy (MOHP, 2002b). Most deaths due to malaria in children could be avoided by prompt recognition and treatment with antimalarial drugs. For each medicine reported by the mother, the 2004 MDHS interviewers asked: “How long after the fever began was [NAME OF MEDICINE] first given to [NAME OF CHILD]?” 262 | Malaria Table 14.7 shows the prevalence and treatment of fever by background characteristics. The data show that four in ten children had fever in the two weeks preceding the survey. Children 6-23 months are the most likely to suffer from fever or convulsions. Children in rural areas are more likely (38 percent) to have fever than urban children (30 percent). The incidence of fever is also related the socioeconomic status of the household; children in the lowest wealth quintile are the more likely to have fever or convulsions than children in the higher quintiles. Table 14.7 Prevalence and prompt treatment of fever by background characteristics Percentage of children under five years of age with fever in the two weeks preceding the survey, and among children with fever, percentage who received antimalarial drugs and who received the drugs the same/next day after developing the fever, by background characteristics, Malawi 2004 Among children with fever: Background characteristics Percentage of children with fever Number of children Percentage who received antimalarial drugs Percentage who received antimalarial drugs same/ next day Number of children Age in months < 6 30.7 1,109 14.3 12.6 341 6-11 53.2 1,188 29.7 22.0 632 12-23 49.5 2,194 31.4 25.2 1,087 24-35 39.5 1,743 31.1 26.4 689 36-47 28.8 1,741 26.2 20.1 501 48-59 21.1 1,802 28.6 22.9 381 Sex Male 37.1 4,839 28.7 23.0 1,793 Female 37.2 4,938 28.2 22.5 1,837 Residence Urban 29.9 1,341 42.0 36.5 401 Rural 38.3 8,436 26.7 21.0 3,230 Region Northern 28.4 1,239 38.2 30.0 351 Central 39.9 4,071 24.5 20.3 1,624 Southern 37.1 4,468 30.2 23.6 1,655 District Blantyre 29.4 670 31.7 27.8 197 Kasungu 40.0 471 21.8 15.0 188 Machinga 35.6 405 30.1 21.3 144 Mangochi 36.8 566 24.7 17.7 208 Mzimba 28.9 630 31.0 22.5 182 Salima 42.1 281 32.0 22.7 118 Thyolo 47.3 514 40.0 27.0 243 Zomba 40.1 498 38.5 26.3 200 Lilongwe 38.3 1,376 27.2 25.0 528 Mulanje 44.3 375 29.0 25.4 166 Other districts 36.5 3,992 25.7 21.6 1,455 Education No education 37.3 2,594 21.2 16.3 967 Primary 1-4 40.4 2,805 24.6 18.8 1,132 Primary 5-8 35.9 3,314 34.1 27.8 1,189 Secondary+ 32.1 1,062 41.4 36.3 340 Wealth quintile Lowest 40.0 1,889 23.2 15.6 757 Second 41.2 2,170 26.3 22.2 894 Middle 37.6 2,206 25.5 19.4 830 Fourth 35.3 1,916 33.0 27.6 676 Highest 29.7 1,597 39.5 34.0 474 Total 37.1 9,777 28.4 22.7 3,630 Malaria | 263 Among children with fever, 28 percent were given antimalarial drugs and 23 percent were given the drug on the same day or the day following the onset of the fever. Children in urban areas are more likely to be given antimalarial drugs the same day or the following day than children in the rural areas (37 and 21 percent, respectively). Children in households in the highest wealth quintile and children of educated mothers are more likely to be given antimalarial drugs on the same day or the following day compared to children from poorer households or whose mothers have less education. Table 14.8 provides a breakdown of use and timing of antimalarial drugs by type of drug. Quinine is the most commonly used antimalarial drug, received by 45 percent of children under five with fever during the two weeks preceding the survey. Amodiaquine is the second most common antimalarial drug (39 percent), followed by SP/Fansidar (23 percent). Less than 1 percent of children under five with fever took Chloroquine or Artesunate. SP/Fansidar was the drug most likely to be taken soon after the onset of illness. Nineteen percent of children with fever took SP/Fansidar the same day or the day following the start of the fever. This finding reflects Malawi’s policy to use SP/Fansidar as the first-line treatment for malaria. Analysis of the use of antimalarial drugs by background characteristics shows some interesting trends. Use of SP/Fansidar and quinine increases with educational level and wealth quintile of the mother. On the other hand, Amodiaquine is more common among children whose mothers have less education and are in the wealth quintiles. Children with fever in the Central Region are less likely to receive SP/Fansidar and Amodiaquine than children in the Northern and Southern regions, but they are more likely to receive quinine. In the oversampled districts, use of SP/Fansidar by children under five with fever ranges from 37 percent in Thyolo to 16 percent in Kasungu. Use of SP/Fansidar on the day the fever started or the day after is highest in Blantyre (24 percent) and lowest in Kasungu (11 percent). 264 | Malaria Table 14.8 Type and timing of antimalarial drugs received by children with fever Among children under age five with fever in the two weeks preceding the survey, the percentage who received specific antimalarial drugs and the percentage who received each type of drug the same or next day after developing fever, by background characteristics, Malawi 2004 Percentage of children who received drug Percentage of children who received drug the same or next day Background characteristic SP/ Fansi- dar Chloro- quine Amodia- quine Quinine Artesu- nate SP/ Fansi- dar Chloro- quine Amodia- quine Quinine Artesu- nate Number of children Age in months < 6 12.8 0.3 28.1 39.1 0.3 11.3 0.3 3.2 4.0 0.1 341 6-11 24.0 0.4 40.8 50.8 0.0 18.6 0.0 7.1 8.8 0.0 632 12-23 26.0 1.1 40.7 47.2 0.1 20.4 1.0 9.0 7.5 0.0 1,087 24-35 25.2 0.8 36.4 45.4 0.0 21.0 0.8 7.5 10.9 0.0 689 36-47 20.2 0.9 39.6 37.8 0.2 16.1 0.4 6.1 4.7 0.0 501 48-59 24.8 0.6 40.9 40.5 0.0 19.7 0.6 6.3 7.6 0.0 381 Sex Male 24.0 0.9 39.7 45.4 0.1 19.6 0.6 7.7 8.2 0.0 1,793 Female 22.7 0.6 37.5 44.0 0.1 17.8 0.6 6.6 7.1 0.0 1,837 Residence Urban 34.3 1.5 21.2 60.4 0.2 30.7 0.9 4.5 18.7 0.0 401 Rural 22.0 0.7 40.7 42.8 0.1 17.2 0.6 7.5 6.3 0.0 3,230 Region Northern 28.3 0.5 40.3 41.8 0.3 22.4 0.5 6.1 10.4 0.0 351 Central 19.9 1.0 34.7 46.5 0.1 16.4 0.8 6.9 6.7 0.0 1,624 Southern 25.7 0.6 42.1 43.6 0.1 20.1 0.4 7.6 8.0 0.0 1,655 District Blantyre 27.4 2.1 19.2 61.0 0.0 24.8 0.8 1.2 12.4 0.0 197 Kasungu 16.4 1.2 39.3 48.4 0.0 11.2 0.9 6.6 4.4 0.0 188 Machinga 24.9 0.6 50.6 34.8 0.3 17.8 0.6 10.7 3.4 0.3 144 Mangochi 21.5 0.6 40.1 49.1 0.0 15.5 0.6 6.8 5.8 0.0 208 Mzimba 23.9 0.4 51.4 37.9 0.0 17.9 0.4 6.3 5.1 0.0 182 Salima 27.4 1.1 29.0 47.1 1.1 19.9 0.9 5.2 6.1 0.0 118 Thyolo 36.6 0.0 43.1 42.7 0.3 23.9 0.0 11.9 6.2 0.0 243 Zomba 32.5 0.3 48.4 41.4 0.0 22.1 0.3 6.0 12.4 0.0 200 Lilongwe 22.5 0.4 28.8 44.2 0.0 20.7 0.4 6.9 9.7 0.0 528 Mulanje 23.4 0.6 41.2 35.1 0.0 21.2 0.6 7.7 5.3 0.0 166 Other districts 20.3 1.0 40.1 45.1 0.1 17.0 0.8 7.4 7.7 0.0 1,455 Education No education 17.7 0.9 44.8 38.5 0.2 13.5 0.9 6.7 4.6 0.0 967 Primary 1-4 21.2 0.6 42.6 42.2 0.0 16.2 0.5 7.1 4.6 0.0 1,132 Primary 5-8 27.6 0.8 33.7 49.3 0.0 22.5 0.6 7.2 10.9 0.0 1,189 Secondary+ 31.7 1.1 25.1 54.5 0.2 28.1 0.3 8.7 14.7 0.0 340 Wealth quintile Lowest 19.4 1.1 42.0 38.3 0.1 12.6 1.1 4.8 4.2 0.0 757 Second 22.3 0.4 44.6 43.1 0.0 18.9 0.4 9.1 5.9 0.0 894 Middle 20.3 0.5 41.1 43.6 0.0 15.8 0.4 7.6 5.7 0.0 830 Fourth 27.6 1.2 35.8 47.1 0.2 23.0 0.8 8.8 9.5 0.0 676 Highest 30.9 1.0 21.3 56.6 0.3 26.8 0.5 4.0 17.2 0.1 474 Total 23.4 0.8 38.6 44.7 0.1 18.7 0.6 7.1 7.6 0.0 3,630 Domestic Violence | 265 DOMESTIC VIOLENCE 15 Christobel Deliwe Chakwana 15.1 INTRODUCTION The 2004 survey represents the first time the Malawi Demographic and Health Survey (MDHS) collected information on domestic violence. The inclusion of the domestic violence module in the 2004 MDHS is in recognition of the presence of gender-based violence as an economic, human right, and health issue in Malawi. Gender-based violence is defined as any act of violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, where occurring in public or private life (United Nations, 1993 and 1995). Domestic violence includes physical, sexual, emotional, psychological or economic abuse committed by a person against a spouse, child, and any other person who is a member of the household, dependent or parent of a child of that household. Domestic violence has negative health consequences on the victims and more especially on the reproductive health of women. It contributes to the maternal mortality rates as it results in health-related problems like gynaecological problems. In traditional Malawian culture, wife battering is regarded as normal. In Malawi, domestic violence occurs across all socio-economic and cultural backgrounds. This type of violence has been treated as a private issue until recently when the government and its stakeholders, in response to the international and regional instruments on women’s rights, started to implement various initiatives aimed at creating awareness of the dangers of gender-based violence and changing the social order in which a woman is assumed to be of lesser status and her husband leads in all family aspects. Having ratified a number of international and regional documents on women’s rights and gender equality, Malawi has developed a National Strategy to Combat Gender-Based Violence (2000-2006). Furthermore, a draft Prevention of Domestic Violence Bill is in place awaiting Cabinet approval. This bill emphasises Section 24 in the 1994 Constitution of Malawi which guarantees equality between women and men as well as women’s right to property, and invalidates any law that discriminates against women, in particular, practices such as sexual abuse, harassment and violence. The collection of data on domestic violence is challenging because women may not disclose issues of domestic violence as it is regarded as bringing shame to their family. The society discourages women from talking about their experiences of domestic violence to maintain respect from the community. In a household survey such as the 2004 MDHS, the collection of sensitive information such as violence in the house, requires the establishment of rapport between the interviewer and the respondent. This is the main reason this module is placed toward the end of the woman’s questionnaire. If there is more than one eligible for individual interview woman in a household, the interviewer selected one woman randomly to be interviewed with the domestic violence module using the Kish-grid technique. Informed consent of the respondents was obtained for the survey at the onset of individual interview. A statement was read to the 2004 MDHS respondents informing them of the survey 266 | Domestic Violence objectives and that they were going to be asked questions that may be personal in nature. The statement highlights the importance of the information to be obtained in understanding the situation of women in Malawi. To prepare the 2004 MDHS field staff in collecting data on domestic violence, they received a special presentation on gender-based violence, focusing on domestic violence. Interviewers were instructed that interviews can only proceed when maximum privacy had been ensured. If privacy was not assured, the domestic violence module was not to be asked. 15.2 PHYSICAL VIOLENCE SINCE AGE 15 Table 15.1 shows the percent distribution of all women who report experiencing physical violence since age 15 and in the 12 months prior to the survey. In the survey, respondents to the domestic violence module have multiple opportunities to disclose their experiences. Women are considered as having experienced violence if they report ever experiencing one or more types of violence. All women who experienced any form of violence were also asked how often this happened in the 12-month period before the survey. Women who reported violence during pregnancy only were not asked the frequency of violence over the past 12 months. The data show that one in three women (28 percent) experienced physical violence since age 15 and 15 percent experienced it in the 12 months preceding the survey. Women age 20-39 are more likely to have experienced violence since they were 15 than younger and older women (28-30 percent compared with 26 percent or less). The 2004 MDHS data show that a woman’s marital status is associated with her experience of domestic violence; while 42 of women who are divorced or separated from their spouse report having experienced physical violence since the age of 15, the proportions for currently married and widowed women are 28 percent and 15 percent, respectively. Physical violence is also experienced by a high proportion of women who have never been married (23 percent). There are no significant differentials in the experience of physical violence since age 15 by residence. However, rural women are more likely than urban women to have experienced physical violence in the 12 months prior to the survey (15 percent compared with 11 percent). The social and economic background of a woman has a bearing on her chances of experiencing physical violence. This experience does not vary consistently with their education; women with no education are less likely than women with some primary education to experience violence. Among educated women, education is negatively associated with the likelihood of experiencing violence. Women who have at least some secondary education are slightly less likely to have experienced domestic physical violence than less educated women. Small variations are found in the experience of physical violence by women’s employment. Women’s experience with physical violence since age 15 does not vary much by wealth index. However, women’s recent experience in violence is negatively associated with their wealth status; women in the lowest wealth quintile are slightly more likely to experience physical violence than the women in higher wealth categories. Domestic Violence | 267 Table 15.1 Experience of physical violence since age 15 Percentage of women who have ever experienced violence since age 15 and percentage who experienced violence during the 12 months preced- ing the survey, by background characteristics, Malawi 2004 Percent who have experienced physical violence since the age of 15 Background characteristic Ever In past 12 months1 Number of women Age 15-19 25.7 15.1 1,970 20-29 30.3 16.0 4,192 30-39 28.3 14.5 2,130 40-49 24.4 9.5 1,409 Marital status Currently married 28.3 15.9 6,856 Divorced/separated 42.2 16.5 832 Widowed 14.5 2.1 365 Never married 23.1 10.8 1,647 Residence Urban 28.0 10.6 1,740 Rural 28.1 15.4 7,961 Region Northern 28.1 14.5 9,701 Central 29.6 15.2 3,919 Southern 27.6 14.0 4,500 Education No education 24.6 12.0 2,266 Primary 1-4 31.5 17.9 2,513 Primary 5-8 28.4 15.2 3,386 Secondary+ 26.9 11.4 1,534 Employment status Employed for cash 30.1 16.4 1,723 Employed, but not for cash 29.6 15.0 3,635 Not employed 26.0 13.4 4,341 Wealth quintile Lowest 29.4 15.7 1,705 Second 29.3 17.0 1,880 Middle 27.4 14.6 1,966 Fourth 27.7 14.3 1,943 Highest 26.9 11.7 2,206 Total 28.1 14.5 9,701 1Excludes women who have been beaten only during pregnancy 15.3 PERPETRATORS OF PHYSICAL VIOLENCE Table 15.2 shows the percent distribution of women reporting any physical violence by the person or persons who subject them to physical violence according to their marital status. Overall, the data show that husbands are the main perpetrators of violence. Among currently married women who have experienced physical violence, 77 percent reported either a current or previous husband as 268 | Domestic Violence being the perpetrator. The 2004 MDHS also indicates that 85 percent of divorced and separated women who ever reported experiencing physical violence say a husband was involved. Table 15.2 Perpetrators of physical violence Percent distribution of women reporting any physical violence by perpetrator of the violence, according to current marital status, Malawi 2004 Perpetrator Current marital status Current husband1 Last/ previous husband only Any husband and other persons Persons other than husband Total Number Currently married 60.7 2.5 14.2 22.5 100.0 1,940 Divorced/separated na 71.3 13.3 15.3 100.0 351 Widowed na 18.7 7.0 74.3 100.0 53 Never married na na na 100.0 100.0 380 Total 43.2 11.4 12.0 33.4 100.0 2,724 1 Includes women who were also beaten by a previous husband na = Not applicable 15.4 VIOLENCE DURING PREGNANCY Women experience violence in all stages of their life cycle. In the 2004 MDHS, women who had a pregnancy (whether it resulted in a live birth or not) and those who are currently pregnant at the time of the survey were asked whether they experienced any type of physical violence during any of their pregnancies and who administered that violence. Table 15.3 shows the findings. The data show that 5 percent of women experienced violence when they were pregnant. Violence during pregnancy takes place at all ages of the woman. There are small variations in the prevalence by age. The prevalence of physical violence during pregnancy varies by the woman’s marital status. Divorced or separated women are the most likely to report they experienced physical violence during pregnancy, suggesting that the violence may have contributed to the marriage breakdown (11 percent compared with 5 percent or less for currently married women, widowed women, and never married women. Pregnant women in the rural areas are at a slightly higher risk of facing physical violence than their counterparts in the urban areas (6 percent compared with 4 percent). There is little regional variation in the experience of violence during pregnancy. Women’s experience with domestic violence also does not vary much according to their employment status. Most women who experience physical violence during pregnancy do so at the hands of a husband (70 percent). Almost one in three women who experienced violence during pregnancy did so at the hand of someone other than a husband (data not shown). Domestic Violence | 269 Table 15.3 Violence during pregnancy Percentage of ever-pregnant women who were physically violated during pregnancy, according to background characteristics, Malawi 2004 Background characteristic Percent experiencing violence during pregnancy Number of women ever pregnant Age 15-19 3.6 689 20-29 5.7 3,839 30-39 5.4 2,091 40-49 4.6 1,389 Marital status Currently married 4.7 6,642 Divorced/separated 10.7 798 Widowed 3.5 363 Never married 4.0 205 Residence Urban 3.8 1,286 Rural 5.5 6,722 Region Northern 5.5 1,039 Central 5.7 3,110 Southern 4.9 3,859 Employment status Employed for cash 6.0 1,522 Employed not for cash 5.8 3,249 Not employed 4.4 3,235 Total 5.3 8,008 15.5 MARITAL CONTROL BY HUSBAND Marital violence refers to violence perpetuated by partners in a marital union. A series of questions were included in the 2004 MDHS to elicit the degree of marital control exercised by the spouse or partner over the respondent. Attempts by male spouses/partners to closely control and monitor their female counterparts have been found to be among the most important early warning signs, as well as correlates of violence in a relationship. Controlling behaviours most often manifest themselves in terms of extreme possessiveness, jealousy, and attempts to isolate the woman from her family and friends. Since the accumulation of such behaviours is more significant than the display of any single behaviour, the proportion of women whose husbands display at least three of the specified behaviours is highlighted. In order to determine the degree of marital control by husbands on their wives, women were asked whether they experienced any of a list of specific acts of controlling behaviours by their husbands, such as the husband is jealous or gets angry if she talks to other men, accuses her of being unfaithful, does not permit meetings with girl friends, tries to limit contact with family, insists on knowing where she is at all times, and does not trust her with any money. Table 15.4 shows the 270 | Domestic Violence percentage of ever-married women whose husbands or partners display each of the listed behaviours by the background characteristics of the respondent. Table 15.4 Degree of marital control by husband Percentage of ever-married women by whether the current/last husband demonstrates(d) different types of controlling behaviour, according to background characteristics, Malawi 2004 Percentage of women whose husband: Background characteristic Is jealous/ angry if she talks to other men Frequently accuses her of being unfaithful Does not permit meetings with girl friends Tries to limit contact with family Insists on knowing where she is at all times Doesn't trust her with any money Does at least 3 of these acts Does none of these acts Number of women Age 15-19 46.1 16.5 19.4 19.3 60.2 19.3 29.9 20.0 708 20-29 50.5 17.1 19.6 21.2 59.3 19.0 30.5 20.7 3,833 30-39 53.0 17.9 19.5 19.6 55.9 18.6 31.3 18.0 2,110 40-49 45.8 16.9 16.6 16.8 52.1 14.5 26.7 21.8 1,402 Marital status Married 50.8 16.6 19.1 19.8 59.4 18.5 29.7 21.7 6,856 Married once 49.6 16.1 18.7 19.6 58.4 17.8 28.7 22.4 5,403 Married more than once 55.1 18.4 20.6 20.7 63.0 21.2 33.2 19.2 1,453 Previously married 45.2 20.9 18.5 20.1 44.8 15.9 32.0 10.8 1,197 Number of living children 0 49.2 17.9 21.9 23.2 61.2 19.3 32.9 18.6 723 1-2 49.1 16.3 18.8 20.2 57.9 18.1 29.6 20.3 3,228 3-4 52.1 19.0 19.5 19.7 57.5 18.9 30.6 19.0 2,262 5 or more 49.1 16.5 17.7 18.0 54.2 16.8 28.9 21.7 1,840 Education No education 49.5 19.3 20.3 21.0 57.3 18.9 32.4 20.0 2,217 Primary 1-4 49.6 19.2 19.6 19.8 58.9 18.8 30.6 18.5 2,216 Primary 5-8 50.9 16.0 18.7 19.1 56.0 18.3 29.5 20.7 2,695 Secondary+ 48.8 11.1 15.6 19.3 56.7 13.9 24.6 22.6 925 Employment status Employed For cash 47.7 18.0 18.8 18.4 54.2 17.2 28.9 20.4 1,520 Not for cash 50.7 17.2 19.4 20.4 61.6 16.8 30.0 17.2 3,300 Not employed 50.2 16.9 18.7 20.0 54.2 19.9 30.5 23.0 3,232 Husband’s education No education 52.6 23.2 22.2 23.8 60.3 21.6 35.8 18.1 1,199 Primary 1-4 50.3 19.3 18.4 19.0 60.0 18.8 31.4 20.4 1,493 Primary 5-8 49.8 16.4 19.2 19.3 56.7 18.2 29.2 19.6 3,294 Secondary+ 48.0 13.3 17.0 18.9 54.5 14.9 26.3 22.3 1,951 Continued… Domestic Violence | 271 Table 15.4 Degree of marital control by husband (continued) Percentage of ever-married women by whether the current/last husband demonstrates(d) different types of controlling behav- iour, according to background characteristics, Malawi 2004 Percentage of women whose husband: Background characteristic Is jealous/ angry if she talks to other men Frequently accuses her of being unfaithful Does not permit meetings with girl friends Tries to limit contact with family Insists on knowing where she is at all times Doesn't trust her with money Does at least 3 of these acts Does none of these acts Number of women Difference in age between husband and wife Wife 3+ years older than husband 54.7 14.6 13.9 14.6 56.0 11.3 23.9 21.6 104 Same age or 1-2 years dif- ferent 47.5 15.7 20.9 20.2 58.3 19.1 29.7 22.6 1,299 Wife 3-4 years younger 51.3 14.6 18.8 19.9 59.1 17.0 28.2 21.2 1,700 Wife 5-9 years younger 51.0 17.5 18.3 18.8 59.4 18.3 29.1 22.0 2,489 Wife 10+ years younger 52.8 18.4 19.7 21.3 61.1 20.7 32.7 20.6 1,214 Formerly married 45.2 20.9 18.5 20.1 44.8 15.9 32.0 10.8 1,197 Wealth quintile Lowest 52.1 21.9 20.6 20.6 61.2 21.3 34.7 15.0 1,473 Second 51.5 19.8 21.1 22.8 59.1 19.7 32.8 18.5 1,698 Middle 47.4 18.0 19.8 20.3 54.8 19.4 30.1 22.1 1,706 Fourth 49.0 15.1 17.2 17.1 57.8 16.6 28.2 21.2 1,605 Highest 49.9 11.5 16.3 18.3 53.6 13.6 24.4 23.4 1,572 Total 49.9 17.2 19.0 19.9 57.2 18.1 30.0 20.1 8,054 Note: Total includes some women for whom husband’s education and age difference is missing. The 2004 MDHS results show that insistence on knowing where they are at all times and being jealous or angry if they talk to other men are the main controlling behaviours that women experience from their husbands (57 percent and 50 percent, respectively). Just under 20 percent of ever-married women say that their husbands try to limit their contact with their families (20 percent), do not permit them to meet with their female friends (19 percent), do not trust them with any money (18 percent), or frequently accuse them of being unfaithful (17 percent). Overall, there are few significant differences in the experience of marital control by the woman’s other background characteristics; domestic violence cuts across socioeconomic status of women. Women experience domestic violence irrespective of their education levels, employment status, economic status, number of children and their husbands’ educational levels. Women age 20- 39 are more likely than women in other age groups to face their husband’s jealousy or anger if they talk to other men (51-53 percent compared with 46 percent). Women in younger age groups are more likely than older women to report that their husbands insist on knowing where they are at all times. Considering the summary measures, 30 percent of women indicate that they experience their husbands’ controlling behaviours through three of the listed behaviours and 20 percent of women indicate that their husbands do not exercise marital control of any kind. The controlling behaviours lessen somewhat as the woman’s education and the wealth status increases. Husbands with secondary 272 | Domestic Violence or higher education and those in the highest wealth quintile are the least likely to show control over their wives. 15.6 FORMS OF MARITAL VIOLENCE Table 15.5 shows the percentage of ever-married women by their experience of emotional, physical or sexual spousal violence by selected background characteristics. It should be noted that different types of violence are not mutually exclusive and women may report multiple forms of violence. Research suggests that physical violence in intimate relationships is often accompanied by psychological abuse and in one-third to over one half of cases, by sexual abuse (Krug et al., 2002). Table 15.5 Marital violence Percentage of ever-married women who have ever suffered emotional, physical or sexual violence at the hands of their current/last husbands, according to background characteristics, Malawi 2004 Type of violence Physical violence Background characteristic Emotional violence Less severe1 Severe1 Total2 Sexual violence Physical or sexual violence1 Emotional, physical, or sexual violence1 Emotional, physical, and sexual violence1 Number of women Age 15-19 10.3 14.6 2.3 16.9 14.0 25.0 27.2 3.1 708 20-29 12.3 18.6 2.8 21.4 13.6 28.2 31.5 3.4 3,833 30-39 14.6 16.5 3.5 20.0 14.6 26.4 30.5 4.9 2,110 40-49 12.1 15.8 2.0 17.8 10.7 23.2 27.2 2.6 1,402 Marital status Married 12.0 17.1 2.4 19.5 13.2 26.3 29.7 3.4 6,856 Married once 11.6 17.5 2.2 19.7 13.1 26.7 29.9 3.2 5,403 Married more than once 13.3 15.6 3.1 18.7 13.8 25.0 29.1 4.0 1,453 Formerly married 16.7 18.0 5.2 23.2 14.1 27.9 32.1 5.1 1,197 Residence Urban 10.8 17.9 2.3 20.2 10.3 25.7 29.1 2.3 1,278 Rural 13.0 17.1 2.9 20.0 13.9 26.7 30.3 3.9 6,776 Region Northern 12.7 17.2 2.8 20.0 13.4 26.6 30.1 3.6 8,054 Central 16.1 18.2 3.5 21.7 17.6 31.1 36.0 4.7 3,136 Southern 10.3 16.8 2.4 19.1 9.0 22.6 25.5 2.8 3,895 Number of living children 0 11.7 13.4 2.7 16.1 15.5 24.7 28.7 3.4 723 1-2 11.8 17.1 2.3 19.4 12.1 25.7 29.0 3.1 3,228 3-4 14.0 18.3 3.5 21.8 14.8 28.9 32.7 3.9 2,262 5 + 13.0 17.5 2.9 20.4 12.9 26.1 29.4 4.3 1,840 Education No education 11.3 16.0 2.5 18.5 10.5 23.8 27.2 2.5 2,217 Primary 1-4 14.6 19.1 4.1 23.2 14.8 29.1 32.9 5.0 2,216 Primary 5-8 12.6 17.8 2.3 20.1 15.2 28.3 31.6 3.6 2,695 Secondary+ 11.7 14.0 2.1 16.1 11.1 22.1 25.9 3.2 925 Employment status Employed for cash 14.8 18.6 3.1 21.7 16.2 29.6 33.6 5.4 1,520 Employed, but not for cash 12.8 17.9 3.4 21.4 13.0 27.3 30.4 3.5 3,300 Not employed 11.6 15.8 2.0 17.9 12.4 24.5 28.2 3.0 3,232 Total 12.7 17.2 2.8 20.0 13.4 26.6 30.1 3.6 8,054 Note: Total includes two women with missing information on employment 1 Less severe violence includes pushing, shaking, slapping, punching and kicking, while severe violence includes trying to strangle or burn, threats with a weapon, and attacks with a weapon. 2 Excludes women who experienced physical violence only during pregnancy due to lack of information on degree of severity. The data show that 13 percent of ever-married women reported to having ever experienced emotional violence, 20 percent experienced physical violence, and 13 percent experienced sexual Domestic Violence | 273 violence. About one-third of ever-married women (30 percent) experience at least one of the three forms of violence, while 4 percent experience all three forms of violence. Among women who have experienced physical violence, most report forms of violence considered “less severe.” Women age 20-39, women who are previously married, women with 3-4 living children, women who have incomplete primary education, and women who are employed for cash are more likely than other women to report emotional, physical, or sexual violence by their husbands. Nonetheless, the survey results show that all women irrespective of age, marital status, number of children, educational levels and employment status are at risk of all forms of violence by their husbands. Figure 15.1 shows the proportion of ever-married women (those currently married, divorced or separated) who have ever experienced different forms of violence by their current or last husbands and experienced violence during the 12 months preceding the survey. The most common forms of spousal violence are slapping and arm twisting (16 percent) and forced intercourse or marital rape (13 percent). Other forms of violence frequently reported include punching (8 percent), pushing, shaking or having something thrown (7 percent), being kicked or dragged (5 percent), and being forced into sexual acts (4 percent). Marital rape appears to be common, with 10 percent of women reporting forced sexual intercourse in the 12 months preceding the survey. It should be noted that due to cultural norms in Malawi, which discourage the discussion of sexual or conjugal issues, marital violence in the survey may have been underreported. Figure 15.1 Percentage of Ever-married Women Who have Experienced Violence by Their Current or Last Husband (ever, and in past 12 months) 4 13 1 1 2 5 8 16 7 3 10 1 1 1 4 5 9 5 0 2 4 6 8 10 12 14 16 18 Forced sexual acts Forced intercourse Attacked with weapon Threatened with weapon Strangled or burned Kicked or dragged Punched Slapped, twist arm Pushed, shaken, or thrown Percent Ever Past 12 months MDHS 2004 274 | Domestic Violence Figure 15.2 summarises the information on various types of marital violence. Sixty-eight percent of women have never experienced marital violence. Of those who did, one in five women experienced physical abuse and 4 percent are abused sexually, emotionally, and physically. 15.7 FREQUENCY OF SPOUSAL VIOLENCE The frequency of spousal violence is an indicator of the prevalence of domestic violence. Table 15.6 shows the percent distribution of ever-married women reporting any kind of physical or sexual spousal violence by how often it occurred in the 12 months prior to the survey according to their background characteristics. The 2004 MDHS results show that only 30 percent of women who have ever experienced physical or sexual violence by their husband did not experience such violence in the past 12 months, 39 percent of women experienced physical or sexual violence once or twice, 21 percent experienced the same forms of violence three to five times, and 10 percent experienced the violence more than five times in the last 12 months. The data also show that marital violence varies by the woman’s background characteristics. Frequency of violence decreases with age; while 10 percent of ever-abused women age 15-19 did not experience violence from their spouse in the last 12 months, almost half (45 percent) of women 40- 49 did not experience spousal violence during this time. Formerly married women are the least likely while currently married women are the most likely to report physical or sexual violence in the last 12 months. The frequency of physical or sexual violence decreases with increasing number of children. Ever-abused women who are not employed are the most likely to have experienced physical or sexual violence in the last 12 months. Figure 15.2 Percentage of Women Who Ever Experienced Sexual, Physical, and/or Emotional Violence Sexually abused Emotionally abused Physically abused 68% Never abused 5% 3% 4% 2% 11%3% 4% Note: Includes non-marital violence MDHS 2004 Domestic Violence | 275 One would expect that women with no education would be more likely to experience physical or sexual violence in the past 12 months than educated women. The survey results, however, show that among women who experienced violence by their current or last husband, the frequency of violence does not vary much by the woman’s education. Table 15.6 Frequency of spousal violence Percent distribution of ever-married women reporting physical or sexual violence by current or last husband by frequency of any form of such violence in the 12 months preceding the survey, according to selected background characteristics, Malawi 2004 Frequency of any type of physical or sexual violence in the past 12 months1 Background characteristic 0 1-2 3-5 5 + Don’t know Total Number of women Woman's age 15-19 10.1 56.2 20.1 13.3 0.3 100.0 177 20-29 25.7 41.1 22.4 10.9 0.0 100.0 1,082 30-39 35.5 30.6 23.2 10.3 0.5 100.0 556 40-49 44.9 36.2 11.7 6.7 0.5 100.0 325 Marital status Married once 26.9 42.2 21.1 9.8 0.1 100.0 1,442 Married more than once 20.1 42.4 23.0 13.5 1.0 100.0 364 Formerly married 53.4 20.6 16.9 9.0 0.0 100.0 334 Number of living children 0 42.0 32.8 16.3 8.9 0.0 100.0 179 1-2 27.7 39.9 21.6 10.5 0.3 100.0 828 3-4 35.0 35.8 19.0 9.8 0.4 100.0 653 5 + 38.6 36.3 17.1 7.6 0.4 100.0 479 Education No education 34.2 39.0 16.8 9.7 0.3 100.0 527 Primary 1-4 24.6 41.4 22.8 11.3 0.0 100.0 646 Primary 5-8 30.8 36.7 22.1 9.9 0.4 100.0 763 Secondary+ 32.0 38.4 19.6 10.0 0.0 100.0 204 Employment status Employed for cash 31.8 33.9 19.9 14.2 0.2 100.0 449 Employed not for cash 33.6 37.5 20.1 8.5 0.2 100.0 900 Not employed 24.5 43.1 22.0 10.0 0.3 100.0 791 Total 29.9 38.8 20.8 10.3 0.2 100.0 2,140 1 Excludes women who experienced physical violence during pregnancy only. 15.8 ONSET OF SPOUSAL VIOLENCE To study the timing of the onset of marital violence, the 2004 MDHS asked ever-married women who experienced physical or sexual spousal violence when the first episode of violence took place after marriage. Table 15.7 shows the interval between marriage and the first episode of spousal physical or sexual violence. 276 | Domestic Violence Table 15.7 Onset of spousal violence Percent distribution of ever-married women who have experienced physical or sexual violence by current or last husband by time between marriage and first experience of violence, according to marital status and duration since first marriage, Malawi 2004 Years between union and first experience of violence1 Marital status/duration since first marriage Before marriage Less than 1 year 1-2 years 3-5 years 6-9 years 10 or more years After divorce Don’t know/ missing Total Number of women Currently married Married once 2.3 19.5 36.3 21.6 10.8 7.6 na 2.0 100.0 1,442 < 6 years 3.5 32.7 49.9 11.2 na na na 2.7 100.0 510 6-9 years 1.7 17.5 35.7 27.4 16.4 na na 1.3 100.0 307 10 or more years 1.5 9.7 25.5 27.1 16.8 17.5 na 1.8 100.0 625 Married more than once 1.2 25.7 30.3 22.5 8.8 7.0 0.5 4.1 100.0 364 Divorced/separated 1.2 27.3 34.7 22.5 4.4 3.5 3.7 2.8 100.0 334 Total 1.9 21.8 35.0 21.9 9.5 6.8 0.8 2.3 100.0 2,140 1 Excludes women who experienced physical violence during pregnancy only. na = Not applicable Table 15.7 shows that spousal violence can be initiated throughout a woman’s married life. It may begin before marriage, although it is more likely to start during the first five years of marriage. One in five women who have experienced physical or sexual spousal violence report that violence began during the first year of marriage. Initiation of violence is most prevalent 1-2 years after marriage (35 percent)and drops below 10 percent after the first five years. A small percentage of women who experienced violence say it began before marriage or after being divorced from their spouse (2 percent and 1 percent, respectively). 15.9 PHYSICAL CONSEQUENCES OF SPOUSAL VIOLENCE The severity of violence can be judged from the severity of the act itself or from its consequences. Table 15.8 provides insight into the physical consequences of violence, including the type and severity of the violence. The consequences of spousal violence range from bruises and aches to injury or broken bones, which may require medical attention. Table 15.8 shows that 7 percent of all ever-married women report ever having been beaten to the point of sustaining bruises and aches, while 2 percent had an injury or broken bone, and 2 percent had to get medical help. Most of these women sustained such injuries in the year before the survey. All three consequences (bruises and aches, injuries and medical treatment) are most often reported by women who ever experienced severe physical violence. Ever-married women who report having experienced emotional violence, less severe physical violence, or sexual violence from a husband are about equally likely to report ever having bruisies and aches (23-29 percent), injuries or broken bones (5-7 percent), or medical treatment (5-8 percent). Domestic Violence | 277 Table 15.8 Physical consequences of spousal violence Percentage of ever-married women reporting different types of physical consequences resulting from something the husband/partner did to them, by type of violence reported, Malawi 2004 Had bruises and aches Had injury or broken bone Went to a doctor or health centre Type of violence Ever Past year1 Ever Past year1 Ever Past year1 Total Emotional violence Ever 29.0 21.6 7.1 4.2 7.6 5.3 1,015 At least once in past year 30.1 26.6 6.5 5.2 7.9 6.6 776 Less severe physical violence1, 2 Ever 23.3 16.8 5.7 3.6 5.2 4.0 1,386 At least once in past year 28.5 27.1 6.7 5.9 7.3 6.6 838 Severe physical violence1, 2 Ever 62.0 47.0 18.5 11.0 21.2 15.0 226 At least once in past year 66.0 62.7 16.2 13.8 21.4 20.0 161 Sexual violence Ever 24.2 18.7 5.0 3.2 6.4 4.6 1,076 At least once in past year 24.7 22.1 4.6 3.7 6.4 5.5 872 Physical or sexual violence1 Ever 22.9 16.9 5.7 3.5 5.7 4.2 2,140 At least once in past year 22.9 16.9 5.7 3.5 5.7 4.2 2,140 No violence reported 0.5 0.4 0.2 0.1 0.1 0.1 5,914 Total 6.5 4.8 1.6 1.0 1.6 1.2 8,054 1 Excludes women who experienced physical violence during pregnancy only, due to lack of information on degree of severity and/or timing of violence. 2 Less severe violence includes pushing, shaking, slapping, punching and kicking, while severe violence includes trying to strangle or burn, threats with a weapon, and attacks with a weapon. 15.10 VIOLENCE BY SPOUSAL CHARACTERISTICS AND WOMEN’S INDICATORS Since the most frequent perpetrator of spousal violence is the woman’s husband, it is important to observe the characteristics of the husbands to help understand their relationship with the violence. Table 15.9 shows that women who are married to men with secondary or higher education are the least likely to experience violence of any kind. Seventy-two percent of women with husbands who have secondary or higher education have never experienced violence compared to only 66 to 68 percent of women whose husbands have a lower level of education. It is interesting to note that women who have more education than their husbands are the most likely to experience all forms of spousal violence. 278 | Domestic Violence Table 15.9 Spousal violence by spousal characteristics Percentage of ever-married women who experienced different types of violence by the current or most recent husband ever and in the past year, and percentage of women who have been violent to their husbands, by spousal characteristics and selected women's status variables, Malawi 2004 Emotional violence Physical violence Sexual violence Physical or sexual violence Violence against husband by respondent Spousal characteristic Ever Past year1 Ever Past year1 Ever Past year1 Ever Past year1 Never experienced violence Ever Past year Number of women Husband’s education No education 14.8 11.2 24.2 13.1 12.4 10.1 28.9 17.8 66.3 2.9 1.2 1,199 Primary 1-4 12.9 10.0 22.7 13.6 13.7 11.2 28.9 19.5 67.9 3.3 2.4 1,493 Primary 5-8 13.2 10.2 22.4 12.7 14.6 12.2 29.8 20.2 67.0 1.9 1.4 3,294 Secondary+ 10.4 7.4 20.2 11.1 11.7 8.8 25.5 15.7 71.6 2.6 1.5 1,951 Husband's age minus wife's age Wife older than husband 3+years 10.3 6.6 11.4 6.3 6.6 6.6 15.4 10.3 81.9 3.2 0.6 104 Same age or 1,2 years different 13.0 11.0 22.1 14.0 14.2 12.3 29.6 21.4 67.3 3.2 2.2 1,299 3-4 years 10.6 8.8 20.9 12.5 13.4 11.7 27.3 19.0 69.8 2.6 1.9 1,700 5-9 years 10.9 8.9 20.9 12.8 13.1 11.2 27.4 19.3 69.2 3.0 1.7 2,489 10+ years 14.6 11.4 22.6 12.1 12.4 10.8 28.8 19.0 67.2 1.6 1.3 1,214 Not currently married 16.7 8.3 26.3 10.5 14.1 7.2 30.9 13.0 65.2 1.5 0.5 1,197 Educational differences Husband has more education 12.2 9.1 22.1 12.2 13.3 10.8 28.6 18.5 68.2 2.4 1.6 4,948 Wife has more education 14.8 11.9 23.8 14.3 14.8 11.7 30.5 20.5 65.8 2.6 2.0 1,514 Both have equal education 12.0 9.4 19.8 12.0 13.1 11.0 25.6 18.0 71.1 1.7 1.2 801 Neither educated 12.6 8.8 21.3 10.8 10.7 9.2 25.8 15.2 69.9 4.0 1.1 665 Husband’s alcohol consumption Does not drink 10.2 8.1 17.6 9.5 11.4 9.3 23.8 15.3 73.0 1.4 0.7 4,843 Drinks/never gets drunk 11.5 7.6 26.9 9.3 14.3 11.4 33.2 17.1 62.1 1.9 1.5 202 Gets drunk sometimes 14.6 10.3 26.5 15.9 16.3 13.2 34.3 23.7 62.6 3.2 2.3 1,764 Gets drunk very often 28.0 20.4 45.2 27.6 23.7 18.8 51.0 34.2 43.2 8.9 5.8 870 Total 12.7 9.6 22.1 12.4 13.4 10.8 28.4 18.5 68.3 2.5 1.6 8,054 Note: Total includes women for whom husband’s education, spousal age difference, spousal education difference and husband’s alcohol consumption are missing. 1 Excludes women who experienced physical violence during pregnancy only The age difference between husband and wife also has some bearing on the likelihood that a woman experiences violence. Women who are three or more years older than their husbands are the least likely to have experienced all types of violence. Women who are about the same age as their husbands are slightly more likely than women who are three to nine years younger than their spouses to experience physical or sexual violence. Women who are ten or more years younger than their husbands are most likely to experience emotional and physical violence. Women’s experience with violence is strongly associated with the extent of their husbands’ or partners’ alcohol consumption. Women whose husbands do not drink are the least likely to report violence, while women whose husbands frequently get drunk are the most likely to report violence. It is useful to examine whether spousal violence varies with indicators of women’s status. Women’s empowerment status is measured by their attitudes towards a wife’s ability to refuse sex with their husband and the number of household decisions in which the women participate. Table 15.10 shows that there is no strong relationship between women’s empowerment status and their Domestic Violence | 279 experience in spousal violence, nor is there any clear pattern in the relationship between marital harmony and spousal violence. While women in the least harmonious relationships are expected to report more violence than women with more harmonious marriages, it is women with a score of one or two on the marital harmony index who are the most likely to report any kind of spousal violence. Table 15.10 Spousal violence by women's status Percentage of ever-married women by the type of spousal violence by the current or most recent husband, by time of violence, by selected indicators of women's status, Malawi 2004 Emotional violence Physical violence Sexual violence Physical or sexual violence Women’s status indicator Ever Past year1 Ever Past year2 Ever Past year2 Ever Past year2 Never experienced violence Number of women Woman can refuse sex to husband Yes to all reasons 11.8 8.6 22.2 11.6 13.0 10.6 28.4 17.9 68.2 4,271 No to one or more reasons 13.7 10.7 22.0 13.3 13.8 11.1 28.2 19.2 68.3 3,783 Number of decisions in which woman has final say 0 11.5 8.8 19.7 11.1 10.6 7.8 25.4 15.3 71.6 1,435 1-2 12.2 9.8 21.7 12.9 15.0 12.9 29.1 20.8 67.5 3,734 3-4 13.9 9.7 23.8 12.4 12.7 9.7 28.8 17.1 67.6 2,885 Index of marital harmony3 Least harmonious 16.2 12.1 25.5 15.4 14.7 12.1 29.6 19.3 67.4 1,169 1-2 positive 21.0 15.6 31.4 19.2 19.8 15.2 38.8 26.3 56.7 1,259 3-4 positive 10.1 7.7 19.3 10.3 11.6 9.6 25.8 16.6 71.0 5,625 Family structure4 Nuclear 12.6 10.0 22.8 13.3 13.1 11.0 28.6 19.2 68.0 5,357 Non-nuclear 12.9 8.7 20.7 10.7 13.9 10.5 27.8 17.0 68.8 2,697 Total 12.7 9.6 22.1 12.4 13.4 10.8 28.4 18.5 68.3 8,054 1Excludes women who have been married more than once and say they have been beaten only by a previous husband only during pregnancy. 2Excludes currently married women who have experienced physical violence only during pregnancy by their current hus- band and formerly married women who have been beaten only during pregnancy by their last husband from experienced physical violence. 3The index of marital harmony is the sum of responses to questions about spending his free time with the respondent, consulting her on various household matters, being affectionate to the respondent, and respecting the respondent’s wishes, for which the respondent says that her husband acted frequently. 4A woman is considered to be in a nuclear family if the woman lives alone, lives with her husband, or lives with her hus- band and children. 15.11 HELP SEEKING FOR WOMEN WHO EXPERIENCE VIOLENCE Data in previous tables show that women experience violence mainly from husbands. Table 15.11 shows that some women who experience violence from their partners seek help from relatives such as their own families, in-laws, and other relatives or friends. Less than half of women who experienced violence sought help (42 percent). Forty-four percent of women sought help from other relatives or friends, one in three went to their own family, and 11 percent went to their in-laws. 280 | Domestic Violence While women who are abused by their husbands tend to go to other relatives or friends for help, women whose perpetrator is not her husband tend to seek help from their own family. The likelihood that a woman seeks help in domestic violence depends on the perpetrator. Women who were abused by their previous husbands are the most likely to have sought help (52 percent). These data suggest that domestic violence may be a contributing cause for divorce or separation. Women whose perpetrators are not their spouse are the least likely to seek help. The probability of seeking help increases with the frequency of violence. While 49 percent of women who experienced physical or sexual violence four or more times in the past year sought help, the corresponding proportion for women with one experience of violence in the last year is 40 percent. Table 15.11 Help seeking for women who experience violence Among women who reported ever experiencing physical or sexual violence, percentage who tried to get any help, and among those who sought help, persons from whom help was sought, by person who perpetrated the violence, Malawi 2004 Persons from whom help was sought Aspects of violence Percentage who sought help Number of women who experi- enced violence Own family In-laws Other relatives/ friends Medical personnel Other officials Other Number of women who sought help Persons perpetrating violence Husband only 41.3 1,545 24.2 14.7 56.7 1.6 3.2 17.2 638 Earlier husband only 52.3 361 21.0 18.3 56.8 3.1 6.4 14.5 189 Husband and others 47.1 348 20.1 9.0 45.4 5.5 9.3 24.6 164 Others only 37.1 908 59.0 1.4 10.9 3.8 5.3 29.3 337 Frequency of beatings in past year 0 times 39.9 1,465 35.3 11.2 36.2 3.1 2.7 23.4 584 1 time 40.1 610 35.3 10.6 44.7 2.3 3.3 19.5 245 2-3 times 44.3 608 28.8 10.4 52.8 1.8 7.1 17.0 270 4+ times 49.0 364 21.0 13.4 57.7 3.2 7.2 19.7 179 DK frequency1 42.9 116 33.8 8.1 27.7 6.7 19.2 20.4 50 Total 41.9 3,164 32.0 11.1 43.7 2.8 4.9 20.8 1,327 1 Includes four women for whom data on frequency of beatings is missing. The remaining cases are women beaten only during pregnancy for which data on frequency of beating in the past year was not collected. Men’s Participation in Health Care | 281 MEN’S PARTICIPATION IN HEALTH CARE 16 Mylen Mahowe and Sophie Kang’oma The 2004 MDHS collected information on men’s participation in their wives and children’s health care. This information enables family planning and health programme managers to gauge men’s role in taking care of the health of their family. In Malawi, where maternal mortality is high, this information will help health programmers to advise men on care necessary for mothers during pregnancy, delivery, and the postpartum period. In the 2004 MDHS, male respondents who had fathered a child born in the five years preceding the survey were asked a series of questions on the care for the child’s mother during pregnancy, delivery, and during the six weeks after delivery. These men were also asked various questions related to their child’s health care and their knowledge of reproductive health. 16.1 ADVICE OR CARE RECEIVED BY MOTHER DURING PREGNANCY, DELIVERY, AND AFTER DELIVERY Table 16.1 presents, based on the father’s report, the percentage of last births in the five years preceding the survey for which mothers received advice or care from a health care provider, by type of advice or care and father’s background characteristics. The data show that 96 percent of fathers report that mothers of their last child received antenatal care, 74 percent report that care was received during delivery, and 80 percent say that the mother received care during the six weeks after delivery. Father’s reporting receipt of antenatal, delivery and postnatal care does not differ consistently by age. Fathers in urban areas and fathers with more education are more likely to report that their child’s mother received care during and after delivery. Wealth index does not have a strong relationship with father’s reporting of receipt of antenatal care for their last birth. However, fathers in the highest wealth quintile are more likely than fathers in the lower wealth quintiles to report that the mother of their last child received delivery care and care after delivery. Fathers in the Central Region are slightly more likely than fathers in other regions to report advice or care during pregnancy and delivery. Among the oversampled districts, reporting of antenatal care varies little. However, the proportion of fathers reporting that a health care provider attended their child’s delivery ranged from 61 percent in Salima to 87 percent in Mulanje and the percentage of fathers reporting postnatal care during the six weeks after delivery ranges from 56 percent in Kasungu to 92 percent in Blantyre. It is interesting to compare the reports of fathers to those of women who gave birth in the five years before the survey. For antenatal care, 96 percent of fathers report that the mother of their last child received care from a health professional, compared to 93 percent of women (see Chapter 9). For delivery assistance by a health care provider, the figures are more discrepant—74 percent for fathers compared to 57 percent from mothers. Differences in question wording could account for some of the difference. It should also be noted that fathers and mothers are not necessarily reporting on the same children. 282 | Men’s Participation in Health Care Table 16.1 Care received by mother during pregnancy, delivery, and after delivery Percentage of men who fathered a child in the five years preceding the survey who report that the mother of the most recent birth received care from a health care pro- vider during pregnancy, delivery and postpartum, by father's background characteristics, Malawi 2004 Background characteristic During pregnancy During delivery During the six weeks after delivery Number of fathers Age 15-19 * * * 10 20-24 97.4 73.6 81.1 212 25-29 97.4 76.1 80.1 435 30-34 95.3 74.7 80.6 369 35-39 95.0 72.9 74.7 213 40-44 97.5 71.1 83.9 183 45-54 93.7 70.2 81.4 148 Residence Urban 96.5 87.0 91.9 253 Rural 96.2 71.4 77.7 1,317 Region Northern 95.7 71.4 69.1 189 Central 96.0 67.6 73.3 675 Southern 96.6 80.6 89.3 706 District Blantyre 95.3 84.0 92.1 127 Kasungu 94.2 65.6 56.2 77 Machinga 97.0 79.1 84.8 57 Mangochi 97.5 68.4 90.1 84 Mzimba 95.2 67.3 58.4 103 Salima 97.6 61.3 79.4 43 Thyolo 97.0 73.7 90.7 87 Zomba 99.1 73.2 84.6 76 Lilongwe 94.5 64.9 73.5 236 Mulanje 94.9 87.0 76.6 54 Other districts 96.8 77.5 83.0 627 Education No education 94.7 64.4 75.0 255 Primary 1-4 96.4 68.9 75.8 412 Primary 5-8 96.0 76.4 80.7 559 Secondary+ 97.5 83.1 87.7 342 Wealth quintile Lowest 95.3 69.2 75.8 208 Second 95.3 67.7 74.0 347 Middle 96.5 71.7 77.1 393 Fourth 96.2 74.7 82.7 347 Highest 97.5 87.4 91.6 276 Total 96.2 73.9 80.0 1,570 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Men’s Participation in Health Care | 283 16.2 MAIN PROVIDER DURING PREGNANCY, DELIVERY, AND AFTER DELIVERY Information on the main provider of payment for services received from a health care provider during pregnancy, delivery, and six weeks after delivery provides insight into the financial arrangements for reproductive health services among Malawian families. This information is also useful in finding out why mothers do not receive advice or care during and after delivery. Table 16.2 shows, based on father’s report, the percentage of last births in the five years preceding the survey for which mothers received care from a health care provider, by the main provider of payment for services during pregnancy, delivery and six weeks after delivery. The majority of fathers report that maternal care services were free: 76 percent receive free antenatal services, 66 percent receive free care during delivery, and 86 percent receive care free of cost during the six weeks after delivery. Fathers reported providing payment for antenatal care for 19 percent of all births receiving antenatal care, 27 percent paid for delivery care themselves, and 12 percent paid out of pocket for services during the six weeks after delivery. Table 16.2 shows that insurance pays for only a small proportion of services received before, during and after delivery: 1 percent for antenatal care, 3 percent for delivery, and 1 percent for care during six weeks after delivery. Table 16.2 Main provider for payment for maternal care Among men who fathered a child in the five years preceding the survey for which they report the mothers received care from a health care provider, percent distribution by the main provider of payment for services during pregnancy, delivery and six weeks after delivery, Malawi 2004 Main provider of payment During pregnancy During delivery During the six weeks after delivery Free 76.4 66.4 85.6 Insurance 1.4 3.0 1.0 Respondent 19.4 27.3 11.8 Child's mother 0.4 0.3 0.4 Respondent and child's mother 0.4 0.5 0.5 Respondent's family 0.2 0.6 0.2 Child's mother's family 0.4 0.4 0.4 Other 0.2 0.4 0.0 Missing 1.2 0.9 0.1 Total 100.0 100.0 100.0 Number 1,510 1,160 1,256 16.3 REASONS FOR NOT GETTING CARE DURING PREGNANCY, DELIVERY, AND AFTER DELIVERY Table 16.3 shows reasons for lack of care for mothers during pregnancy, delivery and after delivery based on father’s report. This information is important for health care providers to know why mothers are not receiving advice or care from a health care provider and may help policy makers to intervene with relevant policies and programs in the area. Data on reasons for lack of care during 284 | Men’s Participation in Health Care the antenatal period is based on a small number of cases, requiring caution in interpreting the figures. It is interesting to note that half of fathers say that distance to a health facility is the major problem for getting care for delivery; 33 percent of fathers cite the same obstacle for obtaining antenatal care. It is worth noting that 44 percent of fathers say that their child’s mother did not get care after delivery because they do not think that the care is necessary. Overall, more than one fifth of fathers say that lack of knowledge of the importance of care during the antenatal, delivery and postpartum periods is the main reason why women are not getting care in this period. Table 16.3 Reason for not getting care during pregnancy, delivery, and after delivery Percentage of last births in the five years preceding the survey for which mothers did not receive advice or care from a health care provider (based on father's report), by reason for not getting care during pregnancy, deliv- ery and six weeks after delivery, Malawi 2004 Reason During pregnancy During delivery During the six weeks after delivery Not necessary (10.1) 10.0 43.7 Not customary (2.2) 1.8 2.0 Respondent did not allow (3.3) 0.6 1.3 Too costly (12.4) 4.3 4.6 Too far, no transport (32.7) 50.1 16.7 Poor service (0.0) 3.1 1.6 Lack of knowledge (27.7) 21.3 24.0 Other (11.7) 8.2 6.2 Missing (0.0) 0.6 0.0 Total 100.0 100.0 100.0 Number 46 393 279 Note: Figures in parentheses are based on 25-49 unweighted cases. 16.4 DECISIONMAKING ON CHILD’S HEALTH CARE The 2004 MDHS also collected information from fathers on who usually decides what to do when a child is ill. This question was asked of men for their youngest child under five who lives with them. The findings are presented in Table 16.4. The data show that fathers and mothers are the main decisionmakers on their child’s health care in case of illness. Fathers make decisions for 87 percent of the children, while mothers make decisions for 64 percent of the children. Female and male relatives decide for the health care of 3-4 percent of children. The age of the child’s father is not strongly related to the decisionmaker of the child’s health. However, female and male relatives are likely to make decisions on a child’s health when the child’s father is young (20-29). Decisionmaking on the health care of the child is more likely to be carried out by the child’s father in rural areas and by the child’s mother in urban areas. In urban areas, female and male relatives and other persons are more likely to have a say in the health care of the child than in rural areas. Men’s Participation in Health Care | 285 Table 16.4 Decisionmaker in child's health care Among men who fathered a child in the five years preceding the survey and living with them, percentage reporting deci- sionmaker on health care for the youngest child in case of illness, by father's background characteristics, Malawi 2004 Decisionmaker Background characteristic Respondent Child's mother Respondent's wife/partner, not child's mother Female relative Male relative Other Child never ill Number of fathers Age 15-19 * * * * * * * 2 20-24 87.6 58.9 0.0 8.8 7.7 0.0 4.9 153 25-29 87.3 68.1 0.3 5.1 6.9 2.0 1.0 368 30-34 85.3 64.3 0.9 1.8 1.4 2.3 1.9 315 35-39 84.3 63.3 1.5 1.2 1.6 0.0 6.8 185 40-44 89.8 65.1 0.5 0.4 0.6 0.6 0.7 161 45-54 90.2 61.2 0.2 3.4 1.8 0.0 0.0 125 Residence Urban 74.3 78.0 0.7 5.4 8.0 4.0 1.6 190 Rural 89.1 62.0 0.6 3.1 3.0 0.7 2.5 1,121 Region Northern 75.6 55.4 1.5 0.9 1.2 0.9 1.8 163 Central 91.7 65.8 0.6 4.5 7.4 1.0 2.8 580 Southern 85.4 65.4 0.3 3.1 0.6 1.5 2.1 567 District Blantyre 77.0 56.8 0.0 0.0 0.0 6.2 4.5 94 Kasungu 88.1 53.5 2.8 0.0 0.7 0.0 4.3 69 Machinga 93.0 68.7 1.0 1.1 0.0 0.0 0.0 47 Mangochi 91.4 33.8 1.1 0.0 0.0 0.0 0.0 65 Mzimba 85.1 62.1 0.0 1.5 2.2 1.5 2.4 91 Salima 86.1 49.7 1.9 4.7 7.7 0.0 3.3 38 Thyolo 84.9 46.0 0.0 1.9 0.0 0.0 3.8 71 Zomba 78.6 71.4 0.0 4.6 2.8 2.7 0.0 64 Lilongwe 88.4 79.6 0.0 9.6 16.5 1.8 4.7 200 Mulanje 94.8 84.6 1.4 7.3 1.5 2.3 0.0 37 Other districts 88.2 66.2 0.6 2.8 1.4 0.4 1.6 533 Education No education 90.3 61.6 0.4 1.1 3.5 0.5 0.9 220 Primary 1-4 89.8 60.7 0.8 4.9 3.1 0.6 2.3 350 Primary 5-8 86.8 64.6 0.2 3.2 3.4 0.9 3.2 471 Secondary+ 80.7 70.7 1.2 3.9 5.3 3.0 2.3 267 Wealth quintile Lowest 87.8 55.8 0.7 5.7 7.0 0.3 2.8 172 Second 91.8 61.3 0.5 2.4 1.9 0.5 1.6 298 Middle 87.8 65.1 0.6 3.6 3.1 0.6 2.0 339 Fourth 88.5 66.4 0.4 2.3 2.5 0.7 2.3 287 Highest 76.3 71.3 0.9 4.3 6.2 4.5 3.9 214 Total 87.0 64.3 0.6 3.4 3.7 1.2 2.4 1,310 An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 286 | Men’s Participation in Health Care The data show that father’s role in their child’s health care decreases with education. For example, 90 percent of fathers with no education make decisions on their child’s health care compared with 81 percent of fathers with at least secondary education. Similarly, the father’s role in making decisions on his child’s health is negatively related to his wealth status; fathers in the highest wealth quintile are less likely to make decisions on their child’s health than fathers in the lower wealth quintiles. The mother’s influence in decisionmaking largely fills the gap. At the district level, more than 90 percent of fathers in Mangochi, Machinga and Mulanje decide on what to do when their children are sick. Fathers in Blantyre and Zomba are less likely to make decisions about health care when their child is sick (less than 80 percent). The role of mothers in making decisions on their children’s treatment ranges from 85 percent in Mulanje to less than 50 percent in Thyolo, Salima, and Mangochi. 16.5 MEN’S KNOWLEDGE OF PREGNANCY COMPLICATIONS In the 2004 MDHS, male respondents were asked about their knowledge about pregnancy complications. Table 16.5 shows the results. The data show that two in three men (65 percent) have no knowledge of any signs or symptoms that indicate that the pregnancy may be in danger. The most often cited sign of pregnancy complication is vaginal bleeding (11 percent). Abdominal pain and swelling of hands and feet are mentioned by 8 percent each of men, while high fever and difficult labour are mentioned by 7 percent and 6 percent of men, respectively. As expected, older men are more likely to know about pregnancy complications. The percentage of men with no knowledge of pregnancy complications declines with increasing age. Never married men, who are presumably young, are the most likely to not know any pregnancy complications (82 percent). However, a man’s knowledge of signs of pregnancy complications increases with his education. Table 16.5 shows that men with secondary or higher education are the most knowledgeable of signs of pregnancy complications, while men with no education are the least knowledgeable. This is true for all signs of complications except prolonged labour. The percentage of men who mention this problem ranges from 8 percent for men with no education to 6 percent for men with secondary and higher education. Men’s Participation in Health Care | 287 Table 16.5 Knowledge of pregnancy complications Percentage of men by knowledge of pregnancy complications, according to background characteristics, Malawi 2004 Pregnancy complications Background characteristic Vaginal bleeding High fever Abdominal pain Swelling of hands and feet Difficult labour for 12 hours or more Convulsions Other Don’t know Number of men Age 15-19 3.3 2.0 2.1 1.5 2.5 0.0 3.7 88.2 650 20-24 6.8 5.4 5.0 6.0 6.4 0.6 12.4 70.7 587 25-29 10.4 6.8 9.5 8.2 4.7 2.0 20.0 60.8 634 30-34 15.7 8.1 11.3 11.6 4.0 1.9 18.0 54.5 485 35-39 14.4 10.1 9.8 8.2 4.9 3.3 19.7 57.9 294 40-44 17.3 11.6 14.2 12.2 9.4 2.5 19.7 51.5 282 45-54 18.9 9.6 8.3 12.5 10.8 2.9 18.3 48.6 329 Marital status Never married 5.0 3.4 3.8 3.1 3.4 0.5 7.4 81.6 1,084 Married/living together 13.9 8.6 9.8 10.3 10.3 2.2 18.8 56.1 2,079 Divorced/separated/ widowed 18.7 6.7 15.3 9.7 9.7 0.0 21.7 45.3 56 Residence Urban 11.1 3.5 6.8 7.8 3.6 0.8 8.8 72.3 669 Rural 10.9 7.6 8.0 7.8 6.0 1.8 16.4 62.8 2,593 Region Northern 16.4 5.1 18.1 3.4 2.9 3.3 15.3 61.1 423 Central 8.6 6.4 5.9 7.5 6.5 0.5 23.1 61.9 1,370 Southern 11.6 7.6 6.6 9.2 5.4 2.1 7.1 68.6 1,468 District Blantyre 12.0 1.1 5.8 7.9 2.5 0.0 4.7 73.2 316 Kasungu 15.0 6.0 16.5 9.3 11.6 1.0 31.7 47.6 156 Machinga 13.7 7.7 13.0 5.2 10.2 7.9 1.7 76.5 114 Mangochi 17.1 10.7 6.7 20.2 2.4 0.0 8.4 63.6 150 Mzimba 9.0 3.7 10.2 4.0 3.0 1.2 21.1 62.6 212 Salima 6.1 6.3 5.1 8.1 4.0 0.0 23.4 63.6 78 Thyolo 22.1 13.7 11.4 20.2 10.2 6.6 5.2 44.4 169 Zomba 6.9 6.0 5.6 1.8 3.7 0.0 5.5 79.4 159 Lilongwe 5.6 2.1 3.7 5.7 2.8 0.0 16.8 73.7 542 Mulanje 13.3 28.7 11.2 9.7 14.5 5.2 24.6 29.4 114 Other districts 10.9 7.5 7.8 6.7 5.9 1.7 16.5 64.6 1,250 Education No education 8.5 5.8 4.9 5.8 7.8 1.0 9.5 71.9 383 Primary 1-4 7.5 5.2 6.7 5.8 6.2 1.5 11.9 70.4 798 Primary 5-8 10.9 6.6 7.9 7.9 4.3 1.5 15.2 66.1 1,220 Secondary+ 15.3 8.9 9.9 10.3 5.6 2.0 19.5 54.7 859 Wealth quintile Lowest 8.2 4.9 6.7 6.0 4.3 1.5 16.0 70.0 412 Second 9.5 6.7 6.5 7.5 5.4 2.0 15.6 63.4 640 Middle 9.1 8.0 9.1 7.4 6.3 1.3 18.4 62.7 699 Fourth 13.3 8.2 9.3 8.4 7.4 1.7 14.0 62.8 709 Highest 12.9 5.4 6.8 8.6 3.8 1.4 11.4 66.8 802 Total 10.9 6.8 7.8 7.8 5.5 1.6 14.9 64.8 3,261 Knowledge of pregnancy complications varies by residence. Ignorance of signs of pregnancy complications is surprisingly high among fathers in urban areas (72 percent), although they tend to 288 | Men’s Participation in Health Care be better educated and have better access to information than their counterparts in the rural areas (63 percent). Men in the Northern Region are more likely to have no knowledge of pregnancy complications (74 percent) than men in Central Region (68 percent) and Southern Region (61 percent). Men’s knowledge of pregnancy complications is inconsistent across wealth status quintiles, except on vaginal bleeding. Men in the highest wealth quintile are more likely to mention this problem than other men. In general, knowledge of pregnancy complications among men in the most urbanised districts in Malawi is limited. Few men in Blantyre and Lilongwe know about high fever (1 percent and 2 percent, respectively), and only 3 percent know about prolonged labour. 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World Health Organisation (WHO). 2003. Global strategy for infant and young child feeding. Geneva, Switzerland: WHO/UNICEF. Appendix A | 293 SAMPLE IMPLEMENTATION Appendix A A.1 SAMPLE DESIGN The primary objective of the 2004 Malawi Demographic and Health Survey (MDHS) is to provide estimates with acceptable precision for important population characteristics such as fertility, contraceptive prevalence, selected health indicators, and infant mortality rates. Administratively, Malawi is divided into twenty-seven districts. In turn, each district is sub- divided into smaller administrative units. In 1998, the National Statistical Office (NSO) carried out a Housing and Population Census. In the census, each administrative unit was sub-divided into enumeration areas (EAs), which is totally classified as urban or rural. For each EA, a sketch map was drawn. The sketch shows the EA boundaries, location of buildings, and other landmarks. The list of EAs serves as the frame for the 2004 MDHS sample. The 2004 MDHS is designed to present important characteristics for Malawi as a whole, urban and rural areas separately, and each of ten large districts. These districts are: Blantyre, Kasungu, Machinga, Mangochi, Mzimba, Salima, Tyolo, Zomba, Lilongwe, and Mulanje. In the interest of presenting estimates for the remaining 17 districts in Malawi in as much breakdown as possible, these districts are grouped as follows: Group 1: The rest of the Northern region (Chitipa, Karonga, Rumphi, Likoma, and Nkhata Bay) Group 2: Dowa, Dedza, and Nkhotakota Group 3: Mchinji and Ntchisi Group 4: Mwanza, Chikwawa, and Nsanje Group 5: Phalombe and Chiradzulu Group 6: Balaka and Ntcheu A.1.1 Sample Alocation The target sample for the 2004 MDHS sample is about 15,140 households. Based on the level of non-response found in the 2000 MDHS, approximately 13,000 women with completed interviews are expected to be obtained. A sample of households will be selected from each EA, and all women age 15 to 49 identified in these households were interviewed. One in every three sampled households was selected for the male survey and HIV testing. All men age 15-54 in these households are eligible for individual interview. The selected households will be distributed in 522 EAs, 64 in the urban and 458 in the rural areas. A.1.2 Sample Selection The 2004 MDHS sample will be selected using a stratified two-stage cluster design. In each domain, the clusters are selected with a probability proportional to household size (based on the 1998 census). An average of 29 households will be selected in each cluster. The selection is done using the following formula: 294 | Appendix A P1i = (b * Mi) / (�i Mi) where b: is the number of clusters selected in DHS sample for a given domain, Mi: is the number of households of the i-th EA reported in the 1998 census information, ∑ Mi: is the number of households in the given domain according to the 1998 census information. If a selected PSU contains two or more standard segments, then segmentation is recommended to choose only one segment with equal probability. Complete household listing is to be implemented in each segment. Households will be selected to achieve a self-weighted sampling fraction in each domain. However, since the 2004 MDHS sample is not proportional among domains, a final adjustment procedure (using weights) is necessary to provide estimates for each domain. In a given domain, if 1. the overall sampling fraction (f) has been calculated, 2. s2i is the number of segments in the selected cluster, and 3. ci is the number of households selected out of the total households (Li) found in the 2004 MDHS listing for the i-th cluster, then the self-weighting condition can be expressed as f = P1i * (1/ s2i )* ( ci / Li ) The final number of households in the i-th cluster can be calculated as ci = ( f * Li ) / (P1i * (1/s2i )) and the household selection interval for the i-th cluster is Ii = Li / ci Ii = (P1i * (1/(s2i )) / f Appendix A | 295 A.1.3 Sample Implementation The results of the sample implementation for the households and the individual interviews are shown in Tables A.1. The results indicate that 15,041 potential households were selected. Of these, the 2004 MDHS fieldwork teams successfully completed interviews in 13,664 households, yielding a household response rate of 98 percent. The main reasons for failure to interview were because the dwelling was vacant or the address was not a dwelling (4 percent). The household response rate varies little across region and urban-rural residence. Table A.1 Sample implementation: women Percent distribution of households and eligible women by results of the household and individual interviews, and house- hold, eligible women and overall response rates, according to urban-rural residence and region, Malawi 2004 Residence Region Result Urban Rural Northern Central Southern Total Selected households Completed (C) 86.9 91.4 91.4 91.0 90.6 90.8 Household present but no competent respondent at home (HP) 2.3 1.1 1.0 1.2 1.3 1.3 Postponed (P) 0.1 0.0 0.0 0.0 0.0 0.0 Refused (R) 1.0 0.4 0.1 0.2 0.8 0.5 Dwelling not found (DNF) 0.5 0.2 0.2 0.4 0.2 0.2 Household absent (HA) 2.2 1.3 1.9 1.0 1.6 1.4 Dwelling vacant/address not a dwelling (DV) 6.0 4.1 3.6 4.4 4.5 4.4 Dwelling destroy (DD) 1.1 1.3 1.7 1.7 1.0 1.3 Other (O) 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 1,984 13,057 1,772 5,443 7,826 15,041 Household response rate (HRR) 1 95.8 98.1 98.5 98.0 97.6 97.8 Eligible women Completed (EWC) 94.6 95.8 95.3 95.2 96.1 95.7 Not at home (EWNH) 2.3 2.1 2.9 2.2 1.8 2.1 Postponed (EWP) 0.1 0.0 0.0 0.0 0.0 0.0 Refused (EWR) 1.7 0.8 0.7 1.0 1.0 1.0 Partly completed (EWPC) 0.4 0.4 0.2 0.5 0.3 0.4 Incapacitated (EWI) 0.8 0.8 0.8 1.0 0.6 0.8 Other (EWO) 0.1 0.1 0.1 0.2 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,733 10,496 1,676 4,411 6,142 12,229 Eligible women response rate (EWRR) 2 94.6 95.8 95.3 95.2 96.1 95.7 Overall response rate (ORR) 3 90.7 94.0 93.9 93.3 93.8 93.6 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C ________________________ C + HP + P + R + DNF 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * EWC ___________________________________________________________________________ EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 296 | Appendix A Table A.2 Sample implementation: men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men and overall response rates, according to urban-rural residence and region Malawi 2004 Residence Region Result Urban Rural Northern Central Southern Total Selected households Completed (C) 87.2 91.7 91.2 92.1 90.3 91.1 Household present but no competent respondent at home (HP) 2.4 1.1 1.0 1.2 1.3 1.2 Postponed (P) 0.2 0.0 0.0 0.1 0.0 0.0 Refused (R) 1.2 0.5 0.0 0.2 1.0 0.6 Dwelling not found (DNF) 0.8 0.3 0.3 0.6 0.2 0.3 Household absent (HA) 2.3 1.4 1.9 1.0 1.9 1.6 Dwelling vacant/address not a dwelling (DV) 5.3 3.7 3.7 3.4 4.3 3.9 Dwelling destroy (DD) 0.8 1.4 1.9 1.5 1.0 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 663 4,366 593 1,816 2,620 5,029 Household response rate (HRR) 1 95.1 98.0 98.5 97.8 97.3 97.7 Eligible men Completed (EMC) 80.2 87.0 88.5 88.6 83.1 85.9 Not at home (EMNH) 14.6 8.2 8.5 7.3 10.9 9.2 Postponed (EMP) 0.2 0.0 0.0 0.0 0.1 0.1 Refused (EMR) 4.3 2.4 2.1 1.6 3.7 2.7 Partly completed (EMPC) 0.0 0.2 0.0 0.2 0.2 0.2 Incapacitated (EMI) 0.2 1.2 0.8 1.3 0.9 1.0 Other (EMO) 0.6 1.0 0.0 1.1 1.1 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 632 3,165 515 1,424 1,858 3,797 Eligible men response rate (EMRR) 2 80.2 87.0 88.5 88.6 83.1 85.9 Overall response rate (ORR) 3 76.3 85.3 87.3 86.6 80.9 83.9 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C _______________________________ C + HP + P + R + DNF 2 Using the number of eligible men falling into specific response categories, the eligible woman response rate (EMRR) is calculated as: 100 * EMC ___________________________________________________________________________ EMC + EMNH + EMP + EMR + EMPC + EMI + EMO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EMRR/100 In the interviewed households, 12,229 eligible women were identified, of whom 96 percent were successfully interviewed. The overall individual women's response rate was 94 percent (Table A.1). This rate varies some across the urban and rural areas (91 percent and 94 percent, respectively), but does not vary across regions. A total of 3,797 men were eligible for individual interview. However, interviews were completed for only 3,261 men. For eligible men, the overall response rate is much lower than that for women (84 percent). The main reasons for failure to interview men were because the men were not at home when the MDHS team visited the EA (9 percent). This is particularly true in urban areas (14 percent). Appendix A | 297 A.2 FIELDWORK AND DATA ANALYSIS A.2.1 Recruitment of Field Staff NSO recruited the field staff through its regional offices in Mzuzu, Lilongwe, and Blantyre. The candidates were interviewed and selection of successful applicants was done at NSO Headquarters in Zomba by the Survey Director assisted by the human resource personnel. A total of 180 people were recruited for the survey; 30 were NSO permanent staff and the remaining 150 were temporary workers. Of the temporary workers, 40 have medical background. A.2.2 Field Staff Training Training for the field staff was conducted at Magomero Training Center which provided class rooms, accommodation and meals. The training lasted for 5 weeks from August 23 to October 1, 2004. The training was done in two stages. In the fist stage, the training was specifically conducted for field staff who were going to be assigned to do the collection of blood samples for anemia and HIV testing. The participants include 34 persons (25 females and 9 males) with medical background, and 16 women and 10 men with no medical background. The training in blood sample collection was conducted by Dr. Ben Chilima of the Community Health Sciences Unit (CHSU), Ministry of Health (MOH). He was assisted by three laboratory technicians: M. Yasin from CHSU, J. Gondwe of Lilongwe Central Hospital, and A. Kashoti of Mzuzu Central Hospital. In the following four weeks, the 60 persons who were trained in taking blood samples were joined by 109 people who are being trained to be interviewers. The training is patterned after standard DHS training procedures, including class lectures, talk by resource persons, demonstration and practice interviews, and written examinations. To enhance the participants’ knowledge on issues covered in the questionnaires, guest lecturers are invited, to either give a presentation on specific subjects or facilitate in the training as resource persons. Training on interviewing procedures was conducted by CSO senior staff (E. Phiri, J. Kaphuka, D. Zanera, S. Kang’oma, M. Mwale) and W. Kazembe of MOH. Sri Poedjastoeti and Adrienne Cox of ORC Macro facilitated the questionnaire training. Apart from class work, field practices in interviews and taking blood samples were also conducted. Since class exercises did not include taking blood from children, field staff assigned to do blood work was taken to health facilities to practice with children. The participants were also be trained in the use of the Global Positioning System (GPS) unit, which identified the location of the sample points in the Geographic Information System (GIS). Fieldwork Prior to the visit of the interviewing teams to the selected EAs, NSO sent listing teams whose main task was to list all households residing in these EAs. The listing teams were also instructed to draw a sketch map which include the EA boundaries and all structures found in the EA. In addition to listing households in the selected EAs, the listing teams were entrusted with two additional tasks; 1) informing local authorities about the implementation of MDHS, including 298 | Appendix A the drawing blood samples for anemia and HIV testing and 2) to obtain information on the estimate the transportation cost from the EA to the nearest VCT facility. Data was collected by 22 mobile teams. Each team comprises one supervisor, one field editor, four female interviewers, one male interviewer, and a driver. Quality control was assured through supervision and monitoring of teams during fieldwork. The supervisor and field editor held work sessions frequently with their team, with the goal of reinforcing the training received and correcting all data collection errors. Five senior NSO staff and one senior MOH staff coordinated and supervised the field activities. The three laboratory technicians supervised the blood sample collection to assure that collection of blood samples was done properly. Specially designed tables were run once a week by NSO during fieldwork to check the data that were entered. Any problems that appear from review of these tables were discussed with the appropriate teams, and attempts will be made to ensure that they do not persist. The field checks tables included data necessary to monitor the response rates for anemia and HIV testing. Social Mobilization In order to ensure a successful survey, the public was informed about the survey, particularly because for the first time the survey includes taking blood samples from the respondents. Social mobilization started with the household listers who were instructed to meet with Districts Commissioners, Traditional Authorities and other local community leaders to inform them about the survey, particularly about the collection of blood samples for HIV testing. Publicity of the survey during data collection included using the mass media: press releases in daily newspapers, radio slots, radio drama (Pamajiga). In addition, meetings were held with district assembly staff, chiefs of the areas, and representatives of the local governments of areas that had been selected in the survey. Data Processing Completed questionnaires were sent to NSO headquarters in Zomba for processing. Data processing commenced on 24th November 2004. The questionnaires are entered, verified, and edited using Census and Survey Processing System (CSPro), a computer package developed by ORC Macro and U.S. Bureau of Census. About 39 people working in two shifts were involved in the data process activities that include registry, editing and data keying, and secondary editing. Data processing was completed on 30th May 2005. A.3 CHARACTERISTICS OF THE SAMPLE This section covers how representative the achieved sample is of the population and the interrelationships among key explanatory variables. The evaluation of how representative the achieved sample is of the population can be made by comparison with other sources of information. The age, residential, and educational characteristics of the sample are probably the most important aspects to discuss with regard to representation. Appendix B | 299 ESTIMATES OF SAMPLING ERRORS Appendix B The estimates from a sample survey are affected by two types of errors: (1) nonsampling errors, and (2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2004 Malawi Demographic and Health Survey (MDHS) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2004 MDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2004 MDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2004 MDHS is the ISSA Sampling Error Module. This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = =− ⎥⎦ ⎤⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ −−== H h h h m i hi h h m zz m m x frvarrSE h 1 2 1 2 1 2 2 1)()( 300 | Appendix B in which hihihi rxyz −= , and hhh rxyz −= where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the h th stratum, yhi is the sum of the weighted values of variable y in the i th cluster in the hth stratum, xhi is the sum of the weighted number of cases in the i th cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2004 MDHS, there were 522 non-empty clusters. Hence, 521 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − −=∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 522 clusters, r(i) is the estimate computed from the reduced sample of 521 clusters (i th cluster excluded), and k is the total number of clusters. In addition to the standard error, ISSA computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. ISSA also computes the relative error and confidence limits for the estimates. Sampling errors for the 2004 MDHS are calculated for selected variables considered to be of primary interest for woman’s survey and for man’s surveys, respectively. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the 11 regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.18 present the value of the statistic (R), its standard error (SE), the number of unweighted (N-UNWE) and weighted (N-WEIG) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R ± 2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of Appendix B | 301 unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to child-bearing. The confidence interval (e.g., as calculated for children ever born to women aged 40-49) can be interpreted as follows: the overall average from the national sample is 6.550 and its standard error is 0.080. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 6.550 ± 2×0.080. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 6.391 and 6.709. Sampling errors are analyzed for the national woman sample and for two separate groups of estimates: (1) means and proportions, and (2) complex demographic rates. The relative standard errors (SE/R) for the means and proportions range between 0.2 percent and 34.2 percent with an average of 3.47 percent; the highest relative standard errors are for estimates of very low values (e.g., currently using IUD). If estimates of very low values (less than 10 percent) were removed, then the average drops to 1.81 percent. So in general, the relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions. The relative standard error for the total fertility rate is small, 1.7 percent. However, for the mortality rates, the average relative standard error is much higher, 5.16 percent. There are differentials in the relative standard error for the estimates of sub-populations. For example, for the variable want no more children, the relative standard errors as a percent of the estimated mean for the whole country and for the urban areas are 1.7 percent and 5.0 percent, respectively. For the total sample, the value of the design effect (DEFT), averaged over all variables, is 1.351 which means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.351 over that in an equivalent simple random sample. 302 | Appendix B Table B.1 List of selected variables for sampling errors, Malawi 2004 Variable Estimate Base Population WOMEN Urban residence Literate No education Secondary education or higher Net attendance ratio for primary school Never married Currently married/in union Married before age 20 Currently pregnant Children ever born Children surviving Children ever born to women age 40-49 TFR (0-3 years) Knows any contraceptive method Ever used any contraceptive method Currently using any contraceptive method Currently using a modern method Currently using pill Currently using IUD Currently using condom Currently using female sterilization Currently using periodic abstinence Obtained method from public sector source Want no more children Want to delay birth at least 2 years Ideal family size Neonatal mortality (0-4 years) Postneonatal mortality (0-4 years) Infant mortality (0-4 years) Infant mortality (5-9 years) Infant mortality (10-14 years) Child mortality (0-4 years) Under five mortality (0-4 years) Mothers received tetanus injection for last birth Mothers received medical assistance at delivery Child has diarrhoea in the 2 weeks prior to survey Treated with oral rehydration salts (ORS) Taken to a health provider Vaccination card seen Received BCG Received DPT (3 doses) Received polio (3 doses) Received measles Fully immunized Height-for-age (below -2SD) Weight-for-height (below -2SD) Weight-for-age (below -2SD) BMI <18.5 Has heard of HIV/AIDS Knows condoms reduce HIV/AIDS Knows limiting partners reduce HIV/AIDS HIV positive Proportion Proportion Proportion Proportion Ratio Proportion Proportion Proportion Proportion Mean Mean Mean Rate Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Mean Rate Rate Rate Rate Rate Rate Rate Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion All women All women All women All women Children 7-12 years All women All women Women age 20-49 All women All women All women Women age 40-49 All women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women Current users of modern methods Currently married women Currently married women All women 15-49 Children exposed to the risk of mortality Children exposed to the risk of mortality Children exposed to the risk of mortality Children exposed to the risk of mortality Children exposed to the risk of mortality Children exposed to the risk of mortality Children exposed to the risk of mortality Births in last five years Births in last five years Children under 5 Children with diarrhoea in two weeks before interview Children with diarrhoea in two weeks before interview Children age 12-23 months Children age 12-23 months Children age 12-23 months Children age 12-23 months Children age 12-23 months Children age 12-23 months Children age 0-59 months Children under 5 who were measured Children under 5 who were measured All women 15-49 who were measured All women 15-49 All women 15-49 All women 15-49 All women 15-49 tested for HIV MEN Urban residence Literate No education Secondary education or higher Never married Currently married/in union Married before age 20 Knows any contraceptive method Want no more children Want to delay birth at least 2 years Ideal family size Has heard of HIV/AIDS Knows condoms reduce HIV/AIDS Knows limiting partners reduce HIV/AIDS HIV postitive Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Mean Proportion Proportion Proportion Proportion All men 15-54 All men15-54 All men15-54 All men 15-54 All men15-54 All men15-54 Men age 20-49 All men15-54 Currently married men15-54 Currently married men15-54 All men 15-54 All men15-54 All men15-54 All men 15-54 All men 15-49 tested for HIV Appendix B | 303 Table B.2 Sampling errors: Total sample, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.178 0.008 11,698 11,698 2.125 0.042 0.162 0.193 Literate 0.624 0.007 11,698 11,698 1.648 0.012 0.609 0.638 No education 0.234 0.006 11,698 11,698 1.499 0.025 0.222 0.245 Secondary education or higher 0.155 0.006 11,698 11,698 1.792 0.039 0.143 0.167 Net attendance ratio for primary school 0.820 0.006 15,035 14,984 1.579 0.007 0.809 0.832 Never married 0.168 0.006 11,698 11,698 1.612 0.033 0.157 0.180 Currently married/in union 0.711 0.007 11,698 11,698 1.658 0.010 0.697 0.724 Married before age 20 0.733 0.006 9,291 9,306 1.219 0.008 0.722 0.745 Currently pregnant 0.121 0.004 11,698 11,698 1.213 0.030 0.113 0.128 Children ever born 3.031 0.032 11,698 11,698 1.279 0.011 2.966 3.095 Children surviving 2.488 0.026 11,698 11,698 1.286 0.011 2.435 2.540 Children ever born to women age 40-49 6.550 0.080 1,710 1,684 1.188 0.012 6.391 6.709 TFR (0-3 years) 6.043 0.101 na 33,006 1.396 0.017 5.841 6.245 Knows any contraceptive method 0.986 0.002 8,385 8,312 1.492 0.002 0.982 0.990 Ever used any contraceptive method 0.603 0.007 8,385 8,312 1.349 0.012 0.588 0.617 Currently using any contraceptive method 0.325 0.007 8,385 8,312 1.359 0.021 0.311 0.339 Currently using a modern method 0.281 0.007 8,385 8,312 1.387 0.024 0.268 0.295 Currently using pill 0.020 0.002 8,385 8,312 1.129 0.087 0.016 0.023 Currently using IUD 0.001 0.000 8,385 8,312 1.083 0.342 0.000 0.002 Currently using condom 0.018 0.002 8,385 8,312 1.297 0.106 0.014 0.021 Currently using female sterilization 0.058 0.003 8,385 8,312 1.311 0.057 0.052 0.065 Currently using periodic abstinence 0.005 0.001 8,385 8,312 1.148 0.183 0.003 0.006 Obtained method from public sector source 0.665 0.014 2,534 2,620 1.540 0.022 0.636 0.694 Want no more children 0.409 0.007 8,385 8,312 1.263 0.017 0.395 0.422 Want to delay birth at least 2 years 0.382 0.006 8,385 8,312 1.122 0.016 0.370 0.394 Ideal family size 4.059 0.025 11,285 11,304 1.504 0.006 4.009 4.108 Neonatal mortality (0-4 years) 27.141 2.024 10,971 10,827 1.182 0.075 23.092 31.190 Postneonatal mortality (0-4 years) 48.997 2.480 11,016 10,872 1.128 0.051 44.037 53.956 Infant mortality (0-4 years) 76.138 3.475 11,018 10,874 1.271 0.046 69.188 83.088 Child mortality (0-4 years) 61.697 3.209 11,192 11,047 1.267 0.052 55.279 68.116 Under 5 mortality (0-4 years) 133.138 4.571 11,241 11,096 1.277 0.034 123.996 142.279 Mothers received tetanus injection for last birth 0.846 0.006 7,309 7,271 1.341 0.007 0.835 0.857 Mothers received medical assistance at delivery 0.570 0.011 10,914 10,771 1.916 0.019 0.549 0.592 Child had diarrhoea in two weeks prior to survey 0.223 0.006 9,858 9,777 1.336 0.025 0.211 0.234 Treated with oral rehydration salts (ORS) 0.611 0.013 2,212 2,177 1.208 0.021 0.585 0.637 Taken to a health provider 0.334 0.013 2,212 2,177 1.227 0.038 0.308 0.359 Vaccination card seen 0.743 0.012 2,233 2,194 1.277 0.016 0.719 0.767 Received BCG 0.914 0.009 2,233 2,194 1.471 0.010 0.896 0.932 Received DPT (3 doses) 0.815 0.013 2,233 2,194 1.502 0.015 0.790 0.841 Received polio (3 doses) 0.777 0.012 2,233 2,194 1.347 0.016 0.752 0.801 Received measles 0.787 0.011 2,233 2,194 1.186 0.013 0.766 0.808 Fully immunized 0.644 0.015 2,233 2,194 1.427 0.023 0.615 0.674 Height-for-age (below -2SD) 0.478 0.008 8,812 8,520 1.356 0.016 0.462 0.493 Weight-for-height (below -2SD) 0.052 0.003 8,812 8,520 1.295 0.062 0.045 0.058 Weight-for-age (below -2SD) 0.220 0.006 8,812 8,520 1.329 0.028 0.208 0.233 BMI <18.5 0.092 0.004 9,432 9,280 1.352 0.044 0.084 0.101 Has heard of HIV/AIDS 0.986 0.002 11,698 11,698 1.478 0.002 0.983 0.989 Knows condoms reduce HIV/AIDS 0.573 0.007 11,698 11,698 1.456 0.012 0.560 0.586 Knows limiting partners reduces HIV/AIDS 0.676 0.007 11,698 11,698 1.508 0.010 0.663 0.689 HIV Positive 0.133 0.007 2,864 2,686 1.099 0.052 0.119 0.147 MEN Urban residence 0.205 0.017 3,261 3,261 2.457 0.085 0.170 0.240 Literate 0.793 0.009 3,261 3,261 1.292 0.012 0.775 0.812 No education 0.117 0.008 3,261 3,261 1.344 0.065 0.102 0.133 Secondary education or higher 0.263 0.012 3,261 3,261 1.497 0.044 0.240 0.286 Never married 0.332 0.012 3,261 3,261 1.431 0.036 0.309 0.356 Currently married/in union 0.638 0.012 3,261 3,261 1.419 0.019 0.614 0.661 Married before age 20 0.217 0.009 2,611 2,612 1.132 0.042 0.198 0.235 Knows any contraceptive method 0.988 0.004 2,114 2,079 1.615 0.004 0.981 0.996 Want no more children 0.384 0.013 2,114 2,079 1.221 0.034 0.358 0.410 Want to delay birth at least 2 years 0.396 0.012 2,114 2,079 1.150 0.031 0.372 0.421 Ideal family size 4.007 0.048 3,112 3,119 1.344 0.012 3.911 4.103 Has heard of HIV/AIDS 0.995 0.001 3,261 3,261 1.215 0.001 0.992 0.998 Knows condoms reduce HIV/AIDS 0.751 0.009 3,261 3,261 1.148 0.012 0.733 0.768 Knows limiting partners reduces HIV/AIDS 0.802 0.011 3,261 3,261 1.604 0.014 0.780 0.824 HIV Positive 0.102 0.009 2,272 2,465 1.338 0.083 0.085 0.119 na = Not applicable 304 | Appendix B Table B.3 Sampling errors: Urban sample, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 1.000 0.000 1,640 2,076 na 0.000 1.000 1.000 Literate 0.840 0.022 1,640 2,076 2.410 0.026 0.797 0.884 No education 0.082 0.012 1,640 2,076 1.821 0.150 0.058 0.107 Secondary education or higher 0.402 0.022 1,640 2,076 1.836 0.055 0.358 0.447 Net attendance ratio for primary school 0.892 0.013 1,671 2,108 1.481 0.014 0.866 0.917 Never married 0.257 0.025 1,640 2,076 2.333 0.098 0.207 0.307 Currently married/in union 0.644 0.030 1,640 2,076 2.504 0.046 0.585 0.703 Married before age 20 0.603 0.018 1,261 1,621 1.295 0.030 0.567 0.638 Currently pregnant 0.089 0.008 1,640 2,076 1.145 0.091 0.073 0.105 Children ever born 2.269 0.087 1,640 2,076 1.497 0.038 2.094 2.444 Children surviving 1.970 0.082 1,640 2,076 1.656 0.042 1.806 2.134 Children ever born to women age 40-49 5.744 0.186 184 230 0.980 0.032 5.372 6.116 TFR (0-3 years) 4.243 0.253 na 5,832 1.546 0.060 3.738 4.748 Knows any contraceptive method 0.993 0.003 1,063 1,337 1.347 0.003 0.986 1.000 Ever used any contraceptive method 0.610 0.015 1,063 1,337 1.018 0.025 0.580 0.640 Currently using any contraceptive method 0.372 0.016 1,063 1,337 1.085 0.043 0.340 0.404 Currently using a modern method 0.347 0.015 1,063 1,337 1.059 0.045 0.316 0.378 Currently using pill 0.032 0.006 1,063 1,337 1.062 0.180 0.020 0.043 Currently using IUD 0.002 0.001 1,063 1,337 0.844 0.574 0.000 0.004 Currently using condom 0.011 0.004 1,063 1,337 1.097 0.314 0.004 0.019 Currently using female sterilization 0.064 0.010 1,063 1,337 1.334 0.157 0.044 0.084 Currently using periodic abstinence 0.006 0.003 1,063 1,337 1.128 0.465 0.000 0.011 Obtained method from public sector source 0.636 0.034 437 552 1.480 0.054 0.568 0.704 Want no more children 0.432 0.021 1,063 1,337 1.412 0.050 0.389 0.475 Want to delay birth at least 2 years 0.354 0.013 1,063 1,337 0.901 0.037 0.327 0.380 Ideal family size 3.410 0.067 1,597 2,015 1.752 0.020 3.276 3.544 Neonatal mortality (0-4 years) 22.387 4.222 2,065 2,575 1.106 0.189 13.943 30.831 Postneonatal mortality (0-4 years) 37.810 5.543 2,067 2,578 1.216 0.147 26.725 48.895 Infant mortality (0-4 years) 60.197 8.006 2,067 2,578 1.333 0.133 44.184 76.210 Child mortality (0-4 years) 59.777 7.794 2,084 2,603 1.190 0.130 44.189 75.364 Under 5 mortality (0-4 years) 116.375 10.632 2,086 2,606 1.209 0.091 95.110 137.640 Mothers received tetanus injection for last birth 0.900 0.010 835 1,041 0.986 0.011 0.879 0.921 Mothers received medical assistance at delivery 0.838 0.022 1,137 1,425 1.701 0.026 0.795 0.881 Child had diarrhoea in two weeks prior to survey 0.175 0.024 1,061 1,341 2.056 0.136 0.127 0.222 Treated with oral rehydration salts (ORS) 0.670 0.036 181 234 1.052 0.054 0.597 0.743 Taken to a health provider 0.378 0.050 181 234 1.397 0.132 0.278 0.479 Vaccination card seen 0.737 0.038 230 274 1.268 0.052 0.661 0.813 Received BCG 0.972 0.013 230 274 1.197 0.014 0.945 0.999 Received DPT (3 doses) 0.898 0.034 230 274 1.677 0.038 0.829 0.967 Received polio (3 doses) 0.817 0.031 230 274 1.192 0.038 0.754 0.880 Received measles 0.868 0.031 230 274 1.331 0.035 0.806 0.929 Fully immunized 0.707 0.040 230 274 1.281 0.056 0.628 0.787 Height-for-age (below -2SD) 0.378 0.023 892 1,071 1.291 0.062 0.332 0.425 Weight-for-height (below -2SD) 0.059 0.008 892 1,071 1.041 0.145 0.042 0.076 Weight-for-age (below -2SD) 0.168 0.019 892 1,071 1.412 0.115 0.130 0.207 BMI <18.5 0.055 0.009 1,321 1,600 1.427 0.166 0.037 0.073 Has heard of HIV/AIDS 0.992 0.003 1,640 2,076 1.544 0.003 0.986 0.999 Knows condoms reduce HIV/AIDS 0.548 0.018 1,640 2,076 1.432 0.032 0.512 0.583 Knows limiting partners reduces HIV/AIDS 0.667 0.016 1,640 2,076 1.374 0.024 0.635 0.699 HIV Positive 0.180 0.017 373 410 0.861 0.095 0.145 0.214 MEN Urban residence 1.000 0.000 507 669 na 0.000 1.000 1.000 Literate 0.921 0.010 507 669 0.838 0.011 0.901 0.941 No education 0.052 0.011 507 669 1.096 0.208 0.030 0.073 Secondary education or higher 0.509 0.029 507 669 1.321 0.058 0.450 0.567 Never married 0.436 0.030 507 669 1.339 0.068 0.377 0.495 Currently married/in union 0.531 0.031 507 669 1.394 0.058 0.469 0.593 Married before age 20 0.179 0.019 410 541 0.985 0.104 0.141 0.216 Knows any contraceptive method 0.977 0.018 269 355 2.016 0.019 0.941 1.014 Want no more children 0.385 0.038 269 355 1.264 0.098 0.310 0.461 Want to delay birth at least 2 years 0.317 0.026 269 355 0.929 0.083 0.264 0.370 Ideal family size 3.538 0.090 486 634 1.350 0.026 3.358 3.719 Has heard of HIV/AIDS 0.997 0.003 507 669 1.215 0.003 0.991 1.003 Knows condoms reduce HIV/AIDS 0.735 0.017 507 669 0.880 0.023 0.700 0.769 Knows limiting partners reduces HIV/AIDS 0.803 0.031 507 669 1.735 0.038 0.742 0.864 HIV Positive 0.163 0.030 346 462 1.516 0.185 0.102 0.224 na = Not applicable Appendix B | 305 Table B.4 Sampling errors: Rural sample, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.000 0.000 10,058 9,621 na na 0.000 0.000 Literate 0.577 0.008 10,058 9,621 1.567 0.013 0.561 0.592 No education 0.266 0.007 10,058 9,621 1.493 0.025 0.253 0.280 Secondary education or higher 0.101 0.006 10,058 9,621 2.033 0.060 0.089 0.114 Net attendance ratio for primary school 0.809 0.006 13,364 12,877 1.573 0.008 0.796 0.821 Never married 0.149 0.004 10,058 9,621 1.254 0.030 0.140 0.158 Currently married/in union 0.725 0.006 10,058 9,621 1.305 0.008 0.713 0.737 Married before age 20 0.761 0.006 8,030 7,685 1.261 0.008 0.749 0.773 Currently pregnant 0.128 0.004 10,058 9,621 1.219 0.032 0.119 0.136 Children ever born 3.195 0.034 10,058 9,621 1.249 0.011 3.126 3.264 Children surviving 2.600 0.027 10,058 9,621 1.211 0.010 2.546 2.654 Children ever born to women age 40-49 6.677 0.084 1,526 1,454 1.181 0.013 6.509 6.845 TFR (0-3 years) 6.403 0.094 na 27,174 1.265 0.015 6.215 6.592 Knows any contraceptive method 0.985 0.002 7,322 6,975 1.519 0.002 0.980 0.989 Ever used any contraceptive method 0.601 0.008 7,322 6,975 1.411 0.013 0.585 0.618 Currently using any contraceptive method 0.316 0.008 7,322 6,975 1.401 0.024 0.300 0.331 Currently using a modern method 0.269 0.007 7,322 6,975 1.427 0.027 0.254 0.284 Currently using pill 0.017 0.002 7,322 6,975 1.145 0.101 0.014 0.021 Currently using IUD 0.001 0.000 7,322 6,975 1.150 0.418 0.000 0.002 Currently using condom 0.019 0.002 7,322 6,975 1.333 0.113 0.015 0.023 Currently using female sterilization 0.057 0.004 7,322 6,975 1.295 0.061 0.050 0.064 Currently using periodic abstinence 0.004 0.001 7,322 6,975 1.141 0.198 0.003 0.006 Obtained method from public sector source 0.673 0.016 2,097 2,068 1.576 0.024 0.641 0.705 Want no more children 0.404 0.007 7,322 6,975 1.219 0.017 0.390 0.418 Want to delay birth at least 2 years 0.387 0.007 7,322 6,975 1.173 0.017 0.374 0.400 Ideal family size 4.199 0.026 9,688 9,289 1.446 0.006 4.148 4.251 Neonatal mortality (0-4 years) 39.020 2.127 17,792 16,908 1.261 0.055 34.765 43.275 Postneonatal mortality (0-4 years) 58.517 2.119 17,834 16,941 1.106 0.036 54.279 62.754 Infant mortality (0-4 years) 97.537 2.993 17,836 16,943 1.184 0.031 91.552 103.522 Child mortality (0-4 years) 73.574 2.784 18,024 17,138 1.177 0.038 68.007 79.142 Under 5 mortality (0-4 years) 163.935 3.815 18,070 17,175 1.171 0.023 156.304 171.566 Mothers received tetanus injection for last birth 0.837 0.006 6,474 6,231 1.376 0.008 0.824 0.850 Mothers received medical assistance at delivery 0.530 0.011 9,777 9,347 1.890 0.021 0.507 0.552 Child had diarrhoea in two weeks prior to survey 0.230 0.005 8,797 8,436 1.170 0.023 0.220 0.241 Treated with oral rehydration salts (ORS) 0.604 0.014 2,031 1,943 1.245 0.023 0.576 0.632 Taken to a health provider 0.328 0.013 2,031 1,943 1.232 0.040 0.302 0.355 Vaccination card seen 0.744 0.013 2,003 1,920 1.283 0.017 0.719 0.770 Received BCG 0.906 0.010 2,003 1,920 1.498 0.011 0.886 0.926 Received DPT (3 doses) 0.803 0.013 2,003 1,920 1.490 0.017 0.777 0.830 Received polio (3 doses) 0.771 0.013 2,003 1,920 1.380 0.017 0.745 0.797 Received measles 0.776 0.011 2,003 1,920 1.209 0.015 0.753 0.798 Fully immunized 0.635 0.016 2,003 1,920 1.465 0.025 0.603 0.667 Height-for-age (below -2SD) 0.492 0.008 7,920 7,449 1.324 0.016 0.476 0.508 Weight-for-height (below -2SD) 0.051 0.003 7,920 7,449 1.340 0.068 0.044 0.057 Weight-for-age (below -2SD) 0.228 0.006 7,920 7,449 1.295 0.028 0.215 0.241 BMI <18.5 0.100 0.004 8,111 7,680 1.322 0.044 0.091 0.109 Has heard of HIV/AIDS 0.984 0.002 10,058 9,621 1.485 0.002 0.981 0.988 Knows condoms reduce HIV/AIDS 0.578 0.007 10,058 9,621 1.447 0.012 0.564 0.593 Knows limiting partners reduces HIV/AIDS 0.678 0.007 10,058 9,621 1.528 0.010 0.664 0.693 HIV Positive 0.125 0.008 2,491 2,276 1.138 0.060 0.110 0.140 MEN Urban residence 0.000 0.000 2,754 2,593 na na 0.000 0.000 Literate 0.760 0.011 2,754 2,593 1.292 0.014 0.739 0.781 No education 0.134 0.009 2,754 2,593 1.335 0.065 0.117 0.152 Secondary education or higher 0.200 0.011 2,754 2,593 1.411 0.054 0.179 0.222 Never married 0.306 0.012 2,754 2,593 1.321 0.038 0.283 0.329 Currently married/in union 0.665 0.012 2,754 2,593 1.304 0.018 0.642 0.689 Married before age 20 0.227 0.011 2,201 2,070 1.185 0.047 0.206 0.248 Knows any contraceptive method 0.990 0.003 1,845 1,724 1.167 0.003 0.985 0.996 Want no more children 0.383 0.014 1,845 1,724 1.194 0.035 0.356 0.410 Want to delay birth at least 2 years 0.413 0.014 1,845 1,724 1.185 0.033 0.385 0.440 Ideal family size 4.127 0.052 2,626 2,485 1.276 0.013 4.023 4.231 Has heard of HIV/AIDS 0.995 0.002 2,754 2,593 1.221 0.002 0.991 0.998 Knows condoms reduce HIV/AIDS 0.755 0.010 2,754 2,593 1.215 0.013 0.735 0.775 Knows limiting partners reduces HIV/AIDS 0.802 0.012 2,754 2,593 1.533 0.015 0.778 0.825 HIV Positive 0.088 0.008 1,926 2,003 1.259 0.092 0.072 0.104 na = Not applicable 306 | Appendix B Table B.5 Sampling errors: Northern Region, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.198 0.010 1,597 1,552 0.985 0.050 0.178 0.218 Literate 0.782 0.017 1,597 1,552 1.628 0.022 0.748 0.816 No education 0.087 0.010 1,597 1,552 1.453 0.118 0.066 0.107 Secondary education or higher 0.221 0.020 1,597 1,552 1.911 0.090 0.181 0.260 Net attendance ratio for primary school 0.922 0.007 1,993 1,922 1.092 0.007 0.908 0.936 Never married 0.202 0.012 1,597 1,552 1.182 0.059 0.179 0.226 Currently married/in union 0.700 0.014 1,597 1,552 1.221 0.020 0.672 0.728 Married before age 20 0.754 0.013 1,214 1,181 1.018 0.017 0.729 0.779 Currently pregnant 0.112 0.008 1,597 1,552 1.058 0.075 0.095 0.129 Children ever born 2.934 0.065 1,597 1,552 0.988 0.022 2.803 3.065 Children surviving 2.535 0.057 1,597 1,552 0.999 0.022 2.422 2.649 Children ever born to women age 40-49 6.571 0.140 246 251 0.942 0.021 6.292 6.851 TFR (0-3 years) 5.580 0.188 na 4,312 1.130 0.034 5.204 5.956 Knows any contraceptive method 0.996 0.002 1,109 1,087 1.021 0.002 0.992 1.000 Ever used any contraceptive method 0.760 0.018 1,109 1,087 1.396 0.024 0.724 0.796 Currently using any contraceptive method 0.412 0.020 1,109 1,087 1.335 0.048 0.372 0.451 Currently using a modern method 0.287 0.021 1,109 1,087 1.568 0.074 0.245 0.330 Currently using pill 0.037 0.006 1,109 1,087 1.109 0.169 0.025 0.050 Currently using IUD 0.001 0.001 1,109 1,087 0.877 0.706 0.000 0.003 Currently using condom 0.067 0.011 1,109 1,087 1.467 0.165 0.045 0.089 Currently using female sterilization 0.066 0.008 1,109 1,087 1.061 0.120 0.050 0.082 Currently using periodic abstinence 0.005 0.002 1,109 1,087 1.005 0.437 0.001 0.009 Obtained method from public sector source 0.575 0.055 364 359 2.136 0.096 0.464 0.686 Want no more children 0.381 0.015 1,109 1,087 0.995 0.038 0.352 0.410 Want to delay birth at least 2 years 0.411 0.013 1,109 1,087 0.902 0.032 0.384 0.437 Ideal family size 4.237 0.070 1,554 1,508 1.557 0.017 4.097 4.377 Neonatal mortality (0-4 years) 38.500 4.486 2,459 2,430 1.059 0.117 29.528 47.472 Postneonatal mortality (0-4 years) 43.656 4.861 2,462 2,433 1.098 0.111 33.933 53.379 Infant mortality (0-4 years) 82.156 5.755 2,462 2,433 0.953 0.070 70.647 93.665 Child mortality (0-4 years) 41.279 5.406 2,477 2,448 1.085 0.131 30.467 52.091 Under 5 mortality (0-4 years) 120.044 7.572 2,480 2,452 0.986 0.063 104.900 135.188 Mothers received tetanus injection for last birth 0.854 0.014 934 924 1.254 0.017 0.825 0.883 Mothers received medical assistance at delivery 0.667 0.026 1,349 1,345 1.733 0.038 0.616 0.718 Child had diarrhoea in two weeks prior to survey 0.123 0.011 1,243 1,239 1.238 0.091 0.101 0.146 Treated with oral rehydration salts (ORS) 0.485 0.051 149 153 1.248 0.105 0.384 0.587 Taken to a health provider 0.228 0.036 149 153 1.056 0.156 0.157 0.299 Vaccination card seen 0.788 0.033 253 250 1.288 0.042 0.722 0.854 Received BCG 0.939 0.013 253 250 0.898 0.014 0.912 0.966 Received DPT (3 doses) 0.897 0.023 253 250 1.201 0.026 0.850 0.943 Received polio (3 doses) 0.824 0.032 253 250 1.324 0.039 0.760 0.888 Received measles 0.849 0.023 253 250 1.005 0.027 0.803 0.894 Fully immunized 0.725 0.039 253 250 1.373 0.053 0.648 0.802 Height-for-age (below -2SD) 0.424 0.016 1,212 1,210 1.082 0.038 0.392 0.456 Weight-for-height (below -2SD) 0.059 0.007 1,212 1,210 1.037 0.123 0.044 0.073 Weight-for-age (below -2SD) 0.177 0.010 1,212 1,210 0.845 0.054 0.158 0.196 BMI <18.5 0.088 0.011 1,340 1,309 1.428 0.125 0.066 0.110 Has heard of HIV/AIDS 0.999 0.001 1,597 1,552 0.877 0.001 0.998 1.000 Knows condoms reduce HIV/AIDS 0.637 0.018 1,597 1,552 1.526 0.029 0.600 0.674 Knows limiting partners reduces HIV/AIDS 0.779 0.013 1,597 1,552 1.286 0.017 0.752 0.805 HIV Positive 0.104 0.015 448 403 1.043 0.145 0.074 0.134 MEN Urban residence 0.177 0.017 456 423 0.944 0.096 0.143 0.211 Literate 0.843 0.017 456 423 1.017 0.021 0.808 0.878 No education 0.031 0.008 456 423 1.024 0.270 0.014 0.047 Secondary education or higher 0.296 0.023 456 423 1.059 0.076 0.251 0.342 Never married 0.386 0.024 456 423 1.043 0.062 0.338 0.433 Currently married/in union 0.574 0.024 456 423 1.050 0.042 0.525 0.623 Married before age 20 0.176 0.023 364 336 1.157 0.131 0.130 0.222 Knows any contraceptive method 1.000 0.000 267 243 na 0.000 1.000 1.000 Want no more children 0.295 0.031 267 243 1.098 0.104 0.233 0.356 Want to delay birth at least 2 years 0.504 0.029 267 243 0.937 0.057 0.447 0.561 Ideal family size 4.175 0.123 438 410 1.611 0.029 3.929 4.421 Has heard of HIV/AIDS 0.994 0.003 456 423 0.941 0.003 0.988 1.001 Knows condoms reduce HIV/AIDS 0.650 0.024 456 423 1.064 0.037 0.602 0.697 Knows limiting partners reduces HIV/AIDS 0.885 0.015 456 423 1.025 0.017 0.854 0.915 HIV Positive 0.054 0.010 370 348 0.819 0.178 0.035 0.073 na = Not applicable Appendix B | 307 Table B.6 Sampling errors: Central Region, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.175 0.014 4,199 4,734 2.348 0.079 0.148 0.203 Literate 0.609 0.011 4,199 4,734 1.459 0.018 0.587 0.631 No education 0.246 0.009 4,199 4,734 1.353 0.037 0.228 0.264 Secondary education or higher 0.158 0.010 4,199 4,734 1.754 0.063 0.138 0.178 Net attendance ratio for primary school 0.806 0.009 5,874 6,470 1.594 0.012 0.787 0.825 Never married 0.185 0.011 4,199 4,734 1.777 0.057 0.164 0.207 Currently married/in union 0.707 0.013 4,199 4,734 1.873 0.019 0.681 0.733 Married before age 20 0.705 0.011 3,339 3,762 1.345 0.015 0.684 0.727 Currently pregnant 0.123 0.006 4,199 4,734 1.141 0.047 0.111 0.134 Children ever born 3.078 0.051 4,199 4,734 1.185 0.017 2.975 3.180 Children surviving 2.509 0.043 4,199 4,734 1.258 0.017 2.422 2.596 Children ever born to women age 40-49 6.892 0.132 599 654 1.179 0.019 6.628 7.156 TFR (0-3 years) 6.429 0.194 na 13,336 1.497 0.030 6.040 6.817 Knows any contraceptive method 0.979 0.004 3,056 3,346 1.606 0.004 0.971 0.988 Ever used any contraceptive method 0.602 0.013 3,056 3,346 1.415 0.021 0.577 0.627 Currently using any contraceptive method 0.332 0.012 3,056 3,346 1.385 0.036 0.308 0.355 Currently using a modern method 0.298 0.011 3,056 3,346 1.382 0.038 0.275 0.321 Currently using pill 0.019 0.003 3,056 3,346 1.161 0.152 0.013 0.025 Currently using IUD 0.001 0.001 3,056 3,346 1.199 0.623 0.000 0.003 Currently using condom 0.014 0.002 3,056 3,346 1.137 0.174 0.009 0.019 Currently using female sterilization 0.068 0.006 3,056 3,346 1.391 0.093 0.056 0.081 Currently using periodic abstinence 0.004 0.001 3,056 3,346 1.114 0.305 0.002 0.007 Obtained method from public sector source 0.692 0.019 914 1,088 1.259 0.028 0.654 0.730 Want no more children 0.450 0.010 3,056 3,346 1.094 0.022 0.431 0.470 Want to delay birth at least 2 years 0.371 0.010 3,056 3,346 1.101 0.026 0.352 0.390 Ideal family size 3.976 0.032 4,017 4,541 1.220 0.008 3.911 4.041 Neonatal mortality (0-4 years) 34.109 3.219 7,496 8,056 1.296 0.094 27.672 40.547 Postneonatal mortality (0-4 years) 55.521 3.392 7,512 8,068 1.146 0.061 48.737 62.306 Infant mortality (0-4 years) 89.631 5.002 7,512 8,068 1.317 0.056 79.626 99.636 Child mortality (0-4 years) 80.007 4.467 7,600 8,172 1.153 0.056 71.072 88.942 Under 5 mortality (0-4 years) 162.467 6.582 7,616 8,184 1.307 0.041 149.304 175.630 Mothers received tetanus injection for last birth 0.842 0.010 2,681 2,959 1.342 0.011 0.823 0.861 Mothers received medical assistance at delivery 0.520 0.019 4,141 4,494 2.012 0.036 0.482 0.558 Child had diarrhoea in two weeks prior to survey 0.266 0.010 3,723 4,071 1.425 0.039 0.245 0.287 Treated with oral rehydration salts (ORS) 0.578 0.020 1,025 1,083 1.196 0.034 0.538 0.618 Taken to a health provider 0.286 0.018 1,025 1,083 1.165 0.062 0.251 0.321 Vaccination card seen 0.686 0.022 859 921 1.346 0.032 0.641 0.730 Received BCG 0.882 0.017 859 921 1.543 0.020 0.847 0.917 Received DPT (3 doses) 0.754 0.024 859 921 1.579 0.032 0.705 0.802 Received polio (3 doses) 0.707 0.020 859 921 1.239 0.028 0.667 0.747 Received measles 0.725 0.019 859 921 1.192 0.026 0.687 0.763 Fully immunized 0.568 0.026 859 921 1.496 0.046 0.516 0.621 Height-for-age (below -2SD) 0.527 0.014 3,237 3,330 1.440 0.027 0.499 0.555 Weight-for-height (below -2SD) 0.036 0.004 3,237 3,330 1.276 0.120 0.027 0.044 Weight-for-age (below -2SD) 0.225 0.011 3,237 3,330 1.346 0.049 0.203 0.247 BMI <18.5 0.072 0.006 3,275 3,532 1.286 0.082 0.061 0.084 Has heard of HIV/AIDS 0.973 0.004 4,199 4,734 1.503 0.004 0.965 0.980 Knows condoms reduce HIV/AIDS 0.522 0.011 4,199 4,734 1.455 0.022 0.499 0.544 Knows limiting partners reduces HIV/AIDS 0.616 0.013 4,199 4,734 1.708 0.021 0.591 0.642 HIV Positive 0.066 0.008 976 1,032 1.064 0.128 0.049 0.083 MEN Urban residence 0.198 0.037 1,261 1,370 3.280 0.186 0.124 0.272 Literate 0.781 0.015 1,261 1,370 1.278 0.019 0.751 0.811 No education 0.138 0.015 1,261 1,370 1.539 0.108 0.108 0.168 Secondary education or higher 0.245 0.019 1,261 1,370 1.573 0.078 0.207 0.283 Never married 0.333 0.021 1,261 1,370 1.592 0.063 0.291 0.376 Currently married/in union 0.646 0.021 1,261 1,370 1.560 0.033 0.604 0.688 Married before age 20 0.198 0.016 1,011 1,092 1.254 0.079 0.167 0.230 Knows any contraceptive method 0.994 0.003 845 885 1.087 0.003 0.988 1.000 Want no more children 0.451 0.021 845 885 1.201 0.046 0.410 0.492 Want to delay birth at least 2 years 0.369 0.019 845 885 1.174 0.053 0.330 0.408 Ideal family size 3.917 0.086 1,187 1,287 1.255 0.022 3.745 4.089 Has heard of HIV/AIDS 0.993 0.003 1,261 1,370 1.211 0.003 0.987 0.998 Knows condoms reduce HIV/AIDS 0.775 0.013 1,261 1,370 1.075 0.016 0.750 0.801 Knows limiting partners reduces HIV/AIDS 0.740 0.021 1,261 1,370 1.662 0.028 0.699 0.782 HIV Positive 0.064 0.013 826 994 1.474 0.197 0.039 0.089 na = Not applicable 308 | Appendix B Table B.7 Sampling errors: Southern Region, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.173 0.012 5,902 5,412 2.502 0.071 0.149 0.198 Literate 0.591 0.012 5,902 5,412 1.858 0.020 0.568 0.615 No education 0.265 0.010 5,902 5,412 1.682 0.036 0.246 0.284 Secondary education or higher 0.133 0.008 5,902 5,412 1.828 0.061 0.117 0.149 Net attendance ratio for primary school 0.805 0.009 7,168 6,592 1.588 0.011 0.787 0.822 Never married 0.144 0.007 5,902 5,412 1.513 0.048 0.130 0.158 Currently married/in union 0.717 0.009 5,902 5,412 1.509 0.012 0.699 0.735 Married before age 20 0.752 0.007 4,738 4,363 1.129 0.009 0.738 0.766 Currently pregnant 0.121 0.006 5,902 5,412 1.299 0.045 0.110 0.132 Children ever born 3.017 0.050 5,902 5,412 1.437 0.017 2.917 3.117 Children surviving 2.456 0.039 5,902 5,412 1.372 0.016 2.379 2.533 Children ever born to women age 40-49 6.256 0.124 865 779 1.263 0.020 6.007 6.504 TFR (0-3 years) 5.844 0.129 na 15,358 1.302 0.022 5.587 6.102 Knows any contraceptive method 0.989 0.002 4,220 3,880 1.221 0.002 0.985 0.993 Ever used any contraceptive method 0.559 0.010 4,220 3,880 1.283 0.018 0.540 0.579 Currently using any contraceptive method 0.294 0.009 4,220 3,880 1.308 0.031 0.276 0.313 Currently using a modern method 0.265 0.009 4,220 3,880 1.278 0.033 0.248 0.283 Currently using pill 0.016 0.002 4,220 3,880 1.063 0.130 0.012 0.020 Currently using IUD 0.001 0.001 4,220 3,880 1.002 0.460 0.000 0.002 Currently using condom 0.007 0.001 4,220 3,880 1.085 0.196 0.004 0.010 Currently using female sterilization 0.048 0.004 4,220 3,880 1.251 0.086 0.039 0.056 Currently using periodic abstinence 0.005 0.001 4,220 3,880 1.212 0.266 0.002 0.008 Obtained method from public sector source 0.668 0.020 1,256 1,173 1.511 0.030 0.628 0.708 Want no more children 0.380 0.011 4,220 3,880 1.421 0.028 0.359 0.402 Want to delay birth at least 2 years 0.383 0.009 4,220 3,880 1.175 0.023 0.365 0.401 Ideal family size 4.079 0.041 5,714 5,254 1.730 0.010 3.997 4.160 Neonatal mortality (0-4 years) 38.783 2.891 9,902 8,997 1.259 0.075 33.002 44.565 Postneonatal mortality (0-4 years) 59.249 2.800 9,927 9,018 1.094 0.047 53.650 64.849 Infant mortality (0-4 years) 98.033 4.118 9,929 9,020 1.194 0.042 89.796 106.269 Child mortality (0-4 years) 72.605 3.626 10,031 9,121 1.162 0.050 65.353 79.858 Under 5 mortality (0-4 years) 163.520 4.967 10,060 9,145 1.137 0.030 153.587 173.454 Mothers received tetanus injection for last birth 0.847 0.008 3,694 3,389 1.346 0.009 0.831 0.863 Mothers received medical assistance at delivery 0.590 0.014 5,424 4,933 1.831 0.024 0.561 0.618 Child had diarrhoea in two weeks prior to survey 0.211 0.007 4,892 4,468 1.209 0.034 0.197 0.225 Treated with oral rehydration salts (ORS) 0.670 0.017 1,038 942 1.137 0.026 0.636 0.704 Taken to a health provider 0.406 0.019 1,038 942 1.190 0.046 0.368 0.443 Vaccination card seen 0.784 0.014 1,121 1,023 1.084 0.017 0.757 0.811 Received BCG 0.937 0.010 1,121 1,023 1.296 0.010 0.918 0.957 Received DPT (3 doses) 0.851 0.014 1,121 1,023 1.283 0.016 0.823 0.879 Received polio (3 doses) 0.827 0.016 1,121 1,023 1.403 0.019 0.795 0.860 Received measles 0.828 0.013 1,121 1,023 1.113 0.016 0.802 0.854 Fully immunized 0.693 0.017 1,121 1,023 1.233 0.025 0.658 0.727 Height-for-age (below -2SD) 0.453 0.010 4,363 3,980 1.292 0.022 0.433 0.473 Weight-for-height (below -2SD) 0.063 0.005 4,363 3,980 1.389 0.085 0.052 0.073 Weight-for-age (below -2SD) 0.230 0.009 4,363 3,980 1.401 0.040 0.211 0.248 BMI <18.5 0.110 0.006 4,817 4,439 1.383 0.057 0.097 0.122 Has heard of HIV/AIDS 0.993 0.001 5,902 5,412 1.104 0.001 0.991 0.996 Knows condoms reduce HIV/AIDS 0.600 0.009 5,902 5,412 1.425 0.015 0.581 0.618 Knows limiting partners reduces HIV/AIDS 0.699 0.007 5,902 5,412 1.216 0.010 0.685 0.714 HIV Positive 0.198 0.011 1,440 1,251 1.079 0.057 0.176 0.220 MEN Urban residence 0.220 0.018 1,544 1,468 1.751 0.084 0.183 0.256 Literate 0.791 0.014 1,544 1,468 1.372 0.018 0.762 0.819 No education 0.124 0.010 1,544 1,468 1.151 0.078 0.104 0.143 Secondary education or higher 0.271 0.018 1,544 1,468 1.557 0.065 0.236 0.306 Never married 0.316 0.016 1,544 1,468 1.333 0.050 0.285 0.348 Currently married/in union 0.648 0.017 1,544 1,468 1.367 0.026 0.615 0.681 Married before age 20 0.245 0.013 1,236 1,183 1.032 0.052 0.220 0.270 Knows any contraceptive method 0.980 0.008 1,002 951 1.783 0.008 0.964 0.996 Want no more children 0.344 0.018 1,002 951 1.216 0.053 0.307 0.380 Want to delay birth at least 2 years 0.394 0.018 1,002 951 1.174 0.046 0.358 0.431 Ideal family size 4.040 0.059 1,487 1,422 1.343 0.015 3.922 4.159 Has heard of HIV/AIDS 0.998 0.002 1,544 1,468 1.293 0.002 0.995 1.000 Knows condoms reduce HIV/AIDS 0.757 0.014 1,544 1,468 1.242 0.018 0.730 0.784 Knows limiting partners reduces HIV/AIDS 0.836 0.014 1,544 1,468 1.458 0.016 0.808 0.863 HIV Positive 0.151 0.014 1,076 1,122 1.255 0.091 0.124 0.178 na = Not applicable Appendix B | 309 Table B.8 Sampling errors: Blantyre District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.577 0.042 703 914 2.238 0.072 0.493 0.660 Literate 0.750 0.018 703 914 1.130 0.025 0.713 0.787 No education 0.129 0.014 703 914 1.099 0.108 0.101 0.157 Secondary education or higher 0.283 0.026 703 914 1.505 0.090 0.232 0.334 Net attendance ratio for primary school 0.865 0.018 785 1,021 1.283 0.021 0.829 0.901 Never married 0.187 0.025 703 914 1.719 0.135 0.136 0.238 Currently married/in union 0.703 0.030 703 914 1.759 0.043 0.642 0.764 Married before age 20 0.670 0.019 550 727 0.967 0.029 0.631 0.709 Currently pregnant 0.119 0.015 703 914 1.224 0.126 0.089 0.148 Children ever born 2.547 0.152 703 914 1.654 0.060 2.243 2.850 Children surviving 2.109 0.109 703 914 1.484 0.052 1.891 2.326 Children ever born to women age 40-49 5.423 0.470 74 94 1.435 0.087 4.483 6.362 TFR (0-3 years) 4.753 0.318 na 2,600 1.378 0.067 4.116 5.389 Knows any contraceptive method 0.980 0.007 487 643 1.172 0.008 0.965 0.995 Ever used any contraceptive method 0.683 0.012 487 643 0.549 0.017 0.660 0.707 Currently using any contraceptive method 0.365 0.021 487 643 0.952 0.057 0.323 0.406 Currently using a modern method 0.337 0.023 487 643 1.084 0.069 0.290 0.383 Currently using pill 0.021 0.005 487 643 0.747 0.230 0.012 0.031 Currently using IUD 0.002 0.002 487 643 0.887 0.975 0.000 0.005 Currently using condom 0.012 0.006 487 643 1.139 0.474 0.001 0.023 Currently using female sterilization 0.062 0.014 487 643 1.245 0.220 0.035 0.089 Currently using periodic abstinence 0.009 0.005 487 643 1.100 0.528 0.000 0.018 Obtained method from public sector source 0.615 0.044 186 249 1.227 0.071 0.528 0.703 Want no more children 0.413 0.021 487 643 0.922 0.050 0.372 0.455 Want to delay birth at least 2 years 0.367 0.014 487 643 0.663 0.040 0.338 0.396 Ideal family size 3.476 0.081 689 900 1.553 0.023 3.313 3.638 Neonatal mortality (0-4 years) 46.322 11.835 1,003 1,331 1.278 0.255 22.652 69.992 Postneonatal mortality (0-4 years) 43.435 6.484 1,005 1,334 0.957 0.149 30.467 56.404 Infant mortality (0-4 years) 89.757 13.679 1,005 1,334 1.170 0.152 62.398 117.116 Child mortality (0-4 years) 69.413 10.468 1,013 1,348 1.106 0.151 48.476 90.349 Under 5 mortality (0-4 years) 152.940 16.214 1,015 1,351 1.152 0.106 120.512 185.367 Mothers received tetanus injection for last birth 0.842 0.028 395 520 1.523 0.033 0.786 0.897 Mothers received medical assistance at delivery 0.780 0.029 547 724 1.411 0.038 0.721 0.839 Child had diarrhoea in two weeks prior to survey 0.170 0.014 504 670 0.842 0.083 0.142 0.198 Treated with oral rehydration salts (ORS) 0.687 0.041 85 114 0.812 0.059 0.606 0.768 Taken to a health provider 0.477 0.051 85 114 0.967 0.108 0.374 0.580 Vaccination card seen 0.786 0.036 109 147 0.901 0.046 0.714 0.857 Received BCG 0.959 0.026 109 147 1.410 0.027 0.907 1.012 Received DPT (3 doses) 0.957 0.022 109 147 1.148 0.023 0.913 1.001 Received polio (3 doses) 0.929 0.026 109 147 1.093 0.028 0.877 0.982 Received measles 0.930 0.022 109 147 0.845 0.024 0.885 0.975 Fully immunized 0.837 0.040 109 147 1.107 0.048 0.756 0.917 Height-for-age (below -2SD) 0.402 0.027 436 579 1.119 0.068 0.348 0.456 Weight-for-height (below -2SD) 0.048 0.009 436 579 0.952 0.198 0.029 0.066 Weight-for-age (below -2SD) 0.170 0.021 436 579 1.103 0.121 0.129 0.211 BMI <18.5 0.086 0.018 575 761 1.535 0.207 0.050 0.122 Has heard of HIV/AIDS 0.997 0.002 703 914 0.958 0.002 0.994 1.001 Knows condoms reduce HIV/AIDS 0.609 0.028 703 914 1.514 0.046 0.553 0.665 Knows limiting partners reduces HIV/AIDS 0.728 0.016 703 914 0.933 0.022 0.696 0.759 HIV Positive 0.225 0.027 152 211 0.804 0.121 0.170 0.281 MEN Urban residence 0.600 0.054 208 316 1.585 0.090 0.493 0.708 Literate 0.908 0.031 208 316 1.537 0.034 0.847 0.970 No education 0.050 0.015 208 316 0.969 0.294 0.020 0.079 Secondary education or higher 0.432 0.055 208 316 1.594 0.127 0.322 0.542 Never married 0.318 0.039 208 316 1.194 0.122 0.240 0.395 Currently married/in union 0.631 0.047 208 316 1.410 0.075 0.536 0.725 Married before age 20 0.168 0.022 178 276 0.766 0.128 0.125 0.211 Knows any contraceptive method 0.993 0.007 128 199 0.935 0.007 0.980 1.000 Want no more children 0.309 0.047 128 199 1.152 0.153 0.215 0.404 Want to delay birth at least 2 years 0.280 0.032 128 199 0.805 0.115 0.215 0.344 Ideal family size 3.605 0.156 202 305 1.479 0.043 3.294 3.917 Has heard of HIV/AIDS 1.000 0.000 208 316 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.758 0.034 208 316 1.159 0.045 0.689 0.827 Knows limiting partners reduces HIV/AIDS 0.874 0.043 208 316 1.861 0.049 0.788 0.960 HIV Positive 0.221 0.038 151 247 1.119 0.172 0.143 0.298 na = Not applicable 310 | Appendix B Table B.9 Sampling errors: Kasungu District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.068 0.030 897 497 3.512 0.435 0.009 0.127 Literate 0.604 0.033 897 497 2.041 0.055 0.538 0.671 No education 0.203 0.023 897 497 1.690 0.112 0.157 0.248 Secondary education or higher 0.139 0.028 897 497 2.402 0.199 0.084 0.195 Net attendance ratio for primary school 0.875 0.016 1,223 674 1.542 0.019 0.842 0.908 Never married 0.163 0.021 897 497 1.664 0.126 0.122 0.204 Currently married/in union 0.776 0.021 897 497 1.487 0.027 0.734 0.817 Married before age 20 0.805 0.023 717 397 1.572 0.029 0.758 0.851 Currently pregnant 0.125 0.012 897 497 1.118 0.099 0.100 0.149 Children ever born 3.475 0.132 897 497 1.347 0.038 3.210 3.739 Children surviving 2.720 0.090 897 497 1.194 0.033 2.541 2.900 Children ever born to women age 40-49 7.360 0.185 126 74 0.811 0.025 6.991 7.729 TFR (0-3 years) 6.964 0.340 na 1,390 1.257 0.049 6.285 7.644 Knows any contraceptive method 0.980 0.005 695 385 0.888 0.005 0.970 0.989 Ever used any contraceptive method 0.683 0.022 695 385 1.247 0.032 0.639 0.727 Currently using any contraceptive method 0.384 0.019 695 385 1.039 0.050 0.345 0.422 Currently using a modern method 0.273 0.025 695 385 1.484 0.092 0.223 0.324 Currently using pill 0.030 0.007 695 385 1.070 0.229 0.016 0.044 Currently using IUD 0.000 0.000 695 385 na na 0.000 0.000 Currently using condom 0.016 0.007 695 385 1.529 0.452 0.002 0.031 Currently using female sterilization 0.059 0.010 695 385 1.165 0.177 0.038 0.080 Currently using periodic abstinence 0.007 0.004 695 385 1.128 0.506 0.000 0.014 Obtained method from public sector source 0.756 0.040 201 111 1.307 0.052 0.677 0.836 Want no more children 0.419 0.022 695 385 1.168 0.052 0.375 0.462 Want to delay birth at least 2 years 0.413 0.023 695 385 1.235 0.056 0.366 0.459 Ideal family size 4.157 0.078 851 468 1.341 0.019 4.000 4.314 Neonatal mortality (0-4 years) 56.217 8.640 1,785 978 1.357 0.154 38.938 73.496 Postneonatal mortality (0-4 years) 61.265 6.593 1,792 983 1.103 0.108 48.079 74.451 Infant mortality (0-4 years) 117.482 12.250 1,792 983 1.453 0.104 92.981 141.983 Child mortality (0-4 years) 84.888 7.519 1,814 994 0.817 0.089 69.851 99.926 Under 5 mortality (0-4 years) 192.398 13.655 1,821 999 1.265 0.071 165.087 219.708 Mothers received tetanus injection for last birth 0.779 0.019 602 330 1.121 0.024 0.741 0.817 Mothers received medical assistance at delivery 0.430 0.039 968 525 2.006 0.090 0.352 0.507 Child had diarrhoea in two weeks prior to survey 0.278 0.013 866 471 0.842 0.046 0.252 0.303 Treated with oral rehydration salts (ORS) 0.483 0.039 245 131 1.144 0.080 0.406 0.560 Taken to a health provider 0.229 0.033 245 131 1.192 0.146 0.163 0.296 Vaccination card seen 0.746 0.043 207 116 1.428 0.058 0.660 0.832 Received BCG 0.846 0.042 207 116 1.700 0.050 0.761 0.931 Received DPT (3 doses) 0.754 0.035 207 116 1.150 0.046 0.685 0.824 Received polio (3 doses) 0.727 0.038 207 116 1.223 0.052 0.650 0.803 Received measles 0.646 0.045 207 116 1.355 0.070 0.556 0.737 Fully immunized 0.534 0.052 207 116 1.514 0.098 0.429 0.639 Height-for-age (below -2SD) 0.561 0.016 816 447 0.886 0.029 0.528 0.594 Weight-for-height (below -2SD) 0.040 0.006 816 447 0.915 0.154 0.028 0.052 Weight-for-age (below -2SD) 0.213 0.020 816 447 1.329 0.095 0.172 0.253 BMI <18.5 0.086 0.017 742 410 1.615 0.194 0.052 0.119 Has heard of HIV/AIDS 0.990 0.003 897 497 0.976 0.003 0.984 0.997 Knows condoms reduce HIV/AIDS 0.496 0.013 897 497 0.764 0.026 0.471 0.522 Knows limiting partners reduces HIV/AIDS 0.707 0.021 897 497 1.403 0.030 0.664 0.749 HIV Positive 0.055 0.014 233 116 0.940 0.257 0.026 0.083 MEN Urban residence 0.077 0.037 313 156 2.441 0.478 0.003 0.151 Literate 0.800 0.021 313 156 0.937 0.027 0.757 0.842 No education 0.103 0.016 313 156 0.915 0.153 0.072 0.135 Secondary education or higher 0.183 0.028 313 156 1.285 0.153 0.127 0.240 Never married 0.314 0.031 313 156 1.167 0.098 0.253 0.375 Currently married/in union 0.658 0.031 313 156 1.151 0.047 0.596 0.720 Married before age 20 0.247 0.024 250 125 0.886 0.098 0.199 0.296 Knows any contraceptive method 0.997 0.003 207 103 0.811 0.003 0.991 1.000 Want no more children 0.406 0.045 207 103 1.316 0.111 0.316 0.496 Want to delay birth at least 2 years 0.485 0.045 207 103 1.296 0.093 0.395 0.576 Ideal family size 4.171 0.134 289 141 1.160 0.032 3.902 4.439 Has heard of HIV/AIDS 0.994 0.004 313 156 0.985 0.004 0.985 1.000 Knows condoms reduce HIV/AIDS 0.816 0.030 313 156 1.388 0.037 0.755 0.877 Knows limiting partners reduces HIV/AIDS 0.878 0.020 313 156 1.078 0.023 0.838 0.918 HIV Positive 0.028 0.011 238 116 1.059 0.405 0.005 0.051 na = Not applicable Appendix B | 311 Table B.10 Sampling errors: Machinga District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.086 0.016 772 427 1.551 0.182 0.054 0.117 Literate 0.513 0.023 772 427 1.268 0.045 0.467 0.558 No education 0.386 0.021 772 427 1.201 0.055 0.344 0.428 Secondary education or higher 0.083 0.018 772 427 1.771 0.212 0.048 0.119 Net attendance ratio for primary school 0.790 0.016 1,013 572 1.112 0.021 0.757 0.823 Never married 0.122 0.011 772 427 0.971 0.094 0.099 0.145 Currently married/in union 0.742 0.014 772 427 0.919 0.020 0.713 0.771 Married before age 20 0.765 0.024 621 344 1.415 0.032 0.716 0.813 Currently pregnant 0.106 0.007 772 427 0.638 0.067 0.092 0.121 Children ever born 3.301 0.124 772 427 1.273 0.038 3.053 3.548 Children surviving 2.760 0.097 772 427 1.183 0.035 2.566 2.954 Children ever born to women age 40-49 6.197 0.274 119 66 1.066 0.044 5.649 6.744 TFR (0-3 years) 7.009 0.286 na 1,198 1.261 0.041 6.437 7.580 Knows any contraceptive method 0.996 0.003 574 317 1.190 0.003 0.990 1.002 Ever used any contraceptive method 0.495 0.027 574 317 1.290 0.054 0.441 0.549 Currently using any contraceptive method 0.280 0.020 574 317 1.079 0.072 0.239 0.320 Currently using a modern method 0.238 0.021 574 317 1.156 0.087 0.196 0.279 Currently using pill 0.003 0.003 574 317 1.313 1.007 0.000 0.009 Currently using IUD 0.004 0.003 574 317 1.159 0.726 0.000 0.011 Currently using condom 0.015 0.006 574 317 1.167 0.393 0.003 0.027 Currently using female sterilization 0.037 0.008 574 317 1.041 0.223 0.020 0.053 Currently using periodic abstinence 0.001 0.001 574 317 0.924 1.002 0.000 0.004 Obtained method from public sector source 0.824 0.033 156 84 1.089 0.040 0.757 0.890 Want no more children 0.321 0.019 574 317 0.979 0.060 0.282 0.359 Want to delay birth at least 2 years 0.413 0.025 574 317 1.232 0.061 0.362 0.464 Ideal family size 4.376 0.113 743 411 1.706 0.026 4.150 4.602 Neonatal mortality (0-4 years) 32.744 4.761 1,435 793 0.970 0.145 23.223 42.266 Postneonatal mortality (0-4 years) 44.796 4.992 1,435 792 0.904 0.111 34.812 54.780 Infant mortality (0-4 years) 77.540 5.538 1,436 793 0.773 0.071 66.465 88.616 Child mortality (0-4 years) 57.029 6.602 1,450 800 0.968 0.116 43.824 70.233 Under 5 mortality (0-4 years) 130.147 7.515 1,452 802 0.793 0.058 115.117 145.178 Mothers received tetanus injection for last birth 0.824 0.026 513 284 1.557 0.032 0.771 0.876 Mothers received medical assistance at delivery 0.550 0.034 799 441 1.653 0.062 0.482 0.618 Child had diarrhoea in two weeks prior to survey 0.193 0.015 732 405 1.019 0.076 0.164 0.222 Treated with oral rehydration salts (ORS) 0.570 0.044 136 78 1.061 0.078 0.481 0.658 Taken to a health provider 0.303 0.039 136 78 1.002 0.129 0.224 0.381 Vaccination card seen 0.833 0.028 174 97 1.006 0.034 0.776 0.889 Received BCG 0.873 0.025 174 97 0.978 0.028 0.823 0.922 Received DPT (3 doses) 0.814 0.025 174 97 0.847 0.031 0.764 0.864 Received polio (3 doses) 0.800 0.033 174 97 1.098 0.042 0.733 0.866 Received measles 0.727 0.035 174 97 1.019 0.048 0.657 0.796 Fully immunized 0.611 0.032 174 97 0.868 0.053 0.546 0.676 Height-for-age (below -2SD) 0.448 0.027 677 376 1.326 0.060 0.394 0.501 Weight-for-height (below -2SD) 0.060 0.008 677 376 0.789 0.128 0.045 0.076 Weight-for-age (below -2SD) 0.214 0.017 677 376 1.022 0.080 0.180 0.248 BMI <18.5 0.114 0.012 643 356 0.965 0.106 0.090 0.139 Has heard of HIV/AIDS 0.995 0.003 772 427 1.279 0.003 0.988 1.001 Knows condoms reduce HIV/AIDS 0.549 0.024 772 427 1.327 0.043 0.501 0.596 Knows limiting partners reduces HIV/AIDS 0.563 0.017 772 427 0.930 0.029 0.530 0.597 HIV Positive 0.149 0.023 194 99 0.901 0.155 0.102 0.196 MEN Urban residence 0.104 0.022 198 114 1.013 0.211 0.060 0.148 Literate 0.773 0.032 198 114 1.077 0.042 0.709 0.837 No education 0.180 0.030 198 114 1.095 0.166 0.120 0.240 Secondary education or higher 0.224 0.055 198 114 1.863 0.247 0.113 0.334 Never married 0.352 0.038 198 114 1.119 0.108 0.276 0.429 Currently married/in union 0.616 0.037 198 114 1.054 0.059 0.543 0.689 Married before age 20 0.155 0.022 153 85 0.748 0.142 0.111 0.199 Knows any contraceptive method 0.987 0.014 129 70 1.381 0.014 0.959 1.015 Want no more children 0.407 0.048 129 70 1.100 0.117 0.311 0.503 Want to delay birth at least 2 years 0.345 0.046 129 70 1.085 0.132 0.254 0.437 Ideal family size 4.000 0.112 177 103 0.957 0.028 3.776 4.224 Has heard of HIV/AIDS 0.996 0.004 198 114 0.901 0.004 0.988 1.000 Knows condoms reduce HIV/AIDS 0.768 0.038 198 114 1.276 0.050 0.691 0.845 Knows limiting partners reduces HIV/AIDS 0.854 0.034 198 114 1.366 0.040 0.786 0.923 HIV Positive 0.082 0.026 144 86 1.118 0.312 0.030 0.135 na = Not applicable 312 | Appendix B Table B.11 Sampling errors: Mangochi District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.083 0.018 774 599 1.842 0.220 0.046 0.119 Literate 0.427 0.033 774 599 1.869 0.078 0.360 0.493 No education 0.436 0.030 774 599 1.705 0.070 0.376 0.497 Secondary education or higher 0.080 0.016 774 599 1.613 0.196 0.049 0.112 Net attendance ratio for primary school 0.677 0.029 1,075 855 1.593 0.043 0.618 0.735 Never married 0.116 0.019 774 599 1.633 0.162 0.078 0.153 Currently married/in union 0.730 0.018 774 599 1.108 0.024 0.695 0.766 Married before age 20 0.779 0.018 632 485 1.104 0.023 0.743 0.816 Currently pregnant 0.100 0.012 774 599 1.096 0.118 0.077 0.124 Children ever born 3.321 0.139 774 599 1.438 0.042 3.043 3.598 Children surviving 2.714 0.107 774 599 1.307 0.039 2.499 2.928 Children ever born to women age 40-49 6.525 0.394 112 85 1.408 0.060 5.738 7.312 TFR (0-3 years) 7.178 0.410 na 1,720 1.213 0.057 6.358 7.998 Knows any contraceptive method 0.971 0.007 568 437 0.996 0.007 0.957 0.985 Ever used any contraceptive method 0.465 0.025 568 437 1.208 0.054 0.415 0.516 Currently using any contraceptive method 0.205 0.023 568 437 1.383 0.114 0.158 0.252 Currently using a modern method 0.171 0.016 568 437 0.995 0.092 0.140 0.203 Currently using pill 0.023 0.007 568 437 1.139 0.309 0.009 0.038 Currently using IUD 0.002 0.002 568 437 0.997 0.987 0.000 0.005 Currently using condom 0.006 0.004 568 437 1.127 0.626 0.000 0.013 Currently using female sterilization 0.020 0.005 568 437 0.848 0.247 0.010 0.030 Currently using periodic abstinence 0.007 0.005 568 437 1.369 0.666 0.000 0.017 Obtained method from public sector source 0.629 0.047 108 88 1.000 0.074 0.536 0.723 Want no more children 0.287 0.025 568 437 1.298 0.086 0.238 0.336 Want to delay birth at least 2 years 0.431 0.024 568 437 1.157 0.056 0.383 0.480 Ideal family size 4.527 0.128 736 570 1.483 0.028 4.271 4.783 Neonatal mortality (0-4 years) 45.084 8.711 1,456 1,134 1.411 0.193 27.661 62.506 Postneonatal mortality (0-4 years) 59.337 5.161 1,461 1,137 0.824 0.087 49.016 69.659 Infant mortality (0-4 years) 104.421 9.366 1,461 1,137 1.086 0.090 85.690 123.152 Child mortality (0-4 years) 69.626 7.424 1,474 1,146 0.999 0.107 54.778 84.473 Under 5 mortality (0-4 years) 166.776 10.594 1,479 1,149 1.012 0.064 145.588 187.964 Mothers received tetanus injection for last birth 0.903 0.014 529 411 1.104 0.016 0.875 0.932 Mothers received medical assistance at delivery 0.522 0.045 820 636 2.212 0.087 0.431 0.612 Child had diarrhoea in two weeks prior to survey 0.250 0.014 735 566 0.847 0.055 0.223 0.278 Treated with oral rehydration salts (ORS) 0.595 0.047 174 142 1.250 0.079 0.500 0.689 Taken to a health provider 0.298 0.050 174 142 1.373 0.167 0.198 0.397 Vaccination card seen 0.686 0.032 182 138 0.909 0.046 0.622 0.750 Received BCG 0.925 0.021 182 138 1.057 0.023 0.883 0.967 Received DPT (3 doses) 0.825 0.027 182 138 0.955 0.033 0.770 0.879 Received polio (3 doses) 0.738 0.037 182 138 1.112 0.050 0.664 0.812 Received measles 0.769 0.040 182 138 1.270 0.052 0.688 0.850 Fully immunized 0.595 0.041 182 138 1.098 0.069 0.514 0.677 Height-for-age (below -2SD) 0.483 0.028 647 512 1.358 0.059 0.426 0.540 Weight-for-height (below -2SD) 0.025 0.006 647 512 0.938 0.228 0.014 0.037 Weight-for-age (below -2SD) 0.236 0.020 647 512 1.172 0.087 0.195 0.277 BMI <18.5 0.125 0.016 644 500 1.248 0.130 0.092 0.157 Has heard of HIV/AIDS 0.971 0.006 774 599 1.074 0.007 0.959 0.984 Knows condoms reduce HIV/AIDS 0.534 0.024 774 599 1.326 0.045 0.487 0.582 Knows limiting partners reduces HIV/AIDS 0.557 0.026 774 599 1.440 0.046 0.505 0.608 HIV Positive 0.214 0.039 185 136 1.287 0.182 0.135 0.294 MEN Urban residence 0.100 0.015 190 150 0.679 0.148 0.070 0.130 Literate 0.728 0.038 190 150 1.186 0.053 0.651 0.805 No education 0.202 0.037 190 150 1.266 0.183 0.128 0.276 Secondary education or higher 0.238 0.048 190 150 1.553 0.202 0.142 0.334 Never married 0.230 0.043 190 150 1.403 0.186 0.145 0.316 Currently married/in union 0.707 0.034 190 150 1.038 0.049 0.638 0.776 Married before age 20 0.266 0.029 155 125 0.822 0.110 0.207 0.324 Knows any contraceptive method 0.910 0.035 129 106 1.386 0.039 0.840 0.980 Want no more children 0.386 0.058 129 106 1.357 0.151 0.269 0.503 Want to delay birth at least 2 years 0.292 0.035 129 106 0.883 0.122 0.221 0.362 Ideal family size 4.181 0.169 174 138 1.199 0.040 3.844 4.518 Has heard of HIV/AIDS 0.996 0.004 190 150 0.837 0.004 0.989 1.000 Knows condoms reduce HIV/AIDS 0.789 0.028 190 150 0.946 0.036 0.732 0.845 Knows limiting partners reduces HIV/AIDS 0.851 0.029 190 150 1.128 0.034 0.792 0.909 HIV Positive 0.199 0.045 108 108 1.173 0.228 0.106 0.292 na = Not applicable Appendix B | 313 Table B.12 Sampling errors: Mzimba District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.212 0.015 953 778 1.115 0.070 0.182 0.241 Literate 0.827 0.014 953 778 1.115 0.017 0.799 0.854 No education 0.082 0.014 953 778 1.601 0.173 0.054 0.111 Secondary education or higher 0.226 0.017 953 778 1.267 0.076 0.192 0.261 Net attendance ratio for primary school 0.931 0.006 1,143 949 0.738 0.006 0.920 0.943 Never married 0.193 0.015 953 778 1.177 0.078 0.162 0.223 Currently married/in union 0.733 0.022 953 778 1.520 0.030 0.689 0.776 Married before age 20 0.783 0.016 726 596 1.044 0.020 0.751 0.815 Currently pregnant 0.117 0.010 953 778 0.951 0.085 0.097 0.137 Children ever born 2.964 0.076 953 778 0.880 0.025 2.813 3.115 Children surviving 2.556 0.063 953 778 0.869 0.025 2.430 2.682 Children ever born to women age 40-49 6.711 0.152 139 121 0.812 0.023 6.407 7.015 TFR (0-3 years) 5.528 0.264 na 2,179 1.114 0.048 5.000 6.056 Knows any contraceptive method 0.994 0.004 676 570 1.135 0.004 0.986 1.001 Ever used any contraceptive method 0.755 0.023 676 570 1.411 0.031 0.708 0.802 Currently using any contraceptive method 0.393 0.025 676 570 1.345 0.064 0.342 0.443 Currently using a modern method 0.278 0.022 676 570 1.297 0.080 0.234 0.323 Currently using pill 0.029 0.007 676 570 1.069 0.236 0.016 0.043 Currently using IUD 0.003 0.002 676 570 0.946 0.706 0.000 0.006 Currently using condom 0.067 0.012 676 570 1.214 0.175 0.043 0.090 Currently using female sterilization 0.065 0.009 676 570 0.979 0.143 0.047 0.084 Currently using periodic abstinence 0.006 0.003 676 570 1.106 0.555 0.000 0.012 Obtained method from public sector source 0.515 0.070 219 175 2.078 0.136 0.375 0.656 Want no more children 0.395 0.019 676 570 0.998 0.048 0.357 0.432 Want to delay birth at least 2 years 0.385 0.018 676 570 0.948 0.046 0.350 0.421 Ideal family size 4.061 0.064 929 753 1.129 0.016 3.934 4.188 Neonatal mortality (0-4 years) 38.272 7.234 1,478 1,246 1.261 0.189 23.803 52.741 Postneonatal mortality (0-4 years) 41.269 6.794 1,478 1,246 1.184 0.165 27.680 54.857 Infant mortality (0-4 years) 79.541 9.059 1,478 1,246 1.133 0.114 61.423 97.658 Child mortality (0-4 years) 35.526 6.160 1,488 1,255 1.072 0.173 23.206 47.847 Under 5 mortality (0-4 years) 112.241 11.107 1,488 1,255 1.137 0.099 90.028 134.454 Mothers received tetanus injection for last birth 0.850 0.020 553 464 1.332 0.023 0.810 0.890 Mothers received medical assistance at delivery 0.659 0.029 799 676 1.532 0.044 0.602 0.717 Child had diarrhoea in two weeks prior to survey 0.157 0.017 743 630 1.294 0.106 0.123 0.190 Treated with oral rehydration salts (ORS) 0.415 0.056 104 99 1.212 0.135 0.303 0.527 Taken to a health provider 0.132 0.026 104 99 0.847 0.199 0.080 0.184 Vaccination card seen 0.811 0.034 153 129 1.074 0.041 0.744 0.878 Received BCG 0.943 0.022 153 129 1.182 0.023 0.899 0.986 Received DPT (3 doses) 0.921 0.028 153 129 1.229 0.031 0.865 0.977 Received polio (3 doses) 0.843 0.041 153 129 1.377 0.049 0.760 0.925 Received measles 0.828 0.036 153 129 1.160 0.043 0.757 0.900 Fully immunized 0.723 0.050 153 129 1.393 0.070 0.622 0.823 Height-for-age (below -2SD) 0.468 0.018 717 614 0.923 0.039 0.432 0.504 Weight-for-height (below -2SD) 0.041 0.008 717 614 1.102 0.203 0.024 0.057 Weight-for-age (below -2SD) 0.179 0.014 717 614 0.994 0.081 0.150 0.208 BMI <18.5 0.084 0.012 802 653 1.255 0.147 0.059 0.109 Has heard of HIV/AIDS 0.998 0.001 953 778 0.956 0.001 0.995 1.001 Knows condoms reduce HIV/AIDS 0.703 0.016 953 778 1.089 0.023 0.671 0.735 Knows limiting partners reduces HIV/AIDS 0.869 0.017 953 778 1.541 0.019 0.836 0.903 HIV Positive 0.064 0.018 245 178 1.127 0.277 0.028 0.099 MEN Urban residence 0.219 0.028 274 212 1.106 0.127 0.163 0.274 Literate 0.812 0.027 274 212 1.148 0.033 0.757 0.866 No education 0.030 0.010 274 212 0.991 0.341 0.010 0.051 Secondary education or higher 0.301 0.028 274 212 1.018 0.094 0.244 0.357 Never married 0.369 0.028 274 212 0.964 0.076 0.313 0.425 Currently married/in union 0.607 0.032 274 212 1.083 0.053 0.543 0.671 Married before age 20 0.184 0.030 219 168 1.135 0.162 0.124 0.243 Knows any contraceptive method 1.000 0.000 165 129 na 0.000 1.000 1.000 Want no more children 0.354 0.030 165 129 0.800 0.084 0.294 0.414 Want to delay birth at least 2 years 0.499 0.031 165 129 0.784 0.061 0.438 0.560 Ideal family size 3.993 0.115 260 204 1.171 0.029 3.763 4.224 Has heard of HIV/AIDS 0.993 0.005 274 212 0.971 0.005 0.984 1.000 Knows condoms reduce HIV/AIDS 0.619 0.034 274 212 1.172 0.056 0.550 0.688 Knows limiting partners reduces HIV/AIDS 0.877 0.024 274 212 1.205 0.027 0.829 0.925 HIV Positive 0.039 0.013 216 157 0.999 0.337 0.012 0.066 na = Not applicable 314 | Appendix B Table B.13 Sampling errors: Salima District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.125 0.027 703 303 2.168 0.217 0.071 0.179 Literate 0.509 0.020 703 303 1.035 0.038 0.470 0.548 No education 0.340 0.021 703 303 1.152 0.061 0.299 0.381 Secondary education or higher 0.113 0.016 703 303 1.339 0.141 0.081 0.146 Net attendance ratio for primary school 0.788 0.020 1,084 465 1.353 0.026 0.747 0.828 Never married 0.139 0.017 703 303 1.325 0.125 0.104 0.173 Currently married/in union 0.761 0.021 703 303 1.333 0.028 0.718 0.803 Married before age 20 0.721 0.016 582 252 0.847 0.022 0.690 0.753 Currently pregnant 0.150 0.012 703 303 0.910 0.082 0.125 0.174 Children ever born 3.137 0.100 703 303 1.008 0.032 2.936 3.338 Children surviving 2.583 0.077 703 303 0.943 0.030 2.430 2.736 Children ever born to women age 40-49 6.495 0.284 95 40 0.989 0.044 5.927 7.063 TFR (0-3 years) 6.815 0.382 na 864 1.233 0.056 6.050 7.580 Knows any contraceptive method 0.984 0.004 532 230 0.770 0.004 0.976 0.993 Ever used any contraceptive method 0.441 0.027 532 230 1.256 0.061 0.387 0.495 Currently using any contraceptive method 0.207 0.017 532 230 0.975 0.083 0.173 0.242 Currently using a modern method 0.196 0.018 532 230 1.040 0.091 0.160 0.231 Currently using pill 0.009 0.003 532 230 0.741 0.336 0.003 0.015 Currently using IUD 0.004 0.004 532 230 1.344 0.962 0.000 0.011 Currently using condom 0.011 0.003 532 230 0.688 0.285 0.005 0.017 Currently using female sterilization 0.042 0.008 532 230 0.930 0.193 0.026 0.058 Currently using periodic abstinence 0.003 0.002 532 230 0.964 0.755 0.000 0.008 Obtained method from public sector source 0.690 0.045 122 50 1.073 0.065 0.599 0.780 Want no more children 0.402 0.023 532 230 1.081 0.057 0.356 0.448 Want to delay birth at least 2 years 0.411 0.023 532 230 1.069 0.056 0.365 0.456 Ideal family size 4.335 0.070 668 288 1.097 0.016 4.194 4.476 Neonatal mortality (0-4 years) 24.942 5.672 1,308 567 1.164 0.227 13.598 36.287 Postneonatal mortality (0-4 years) 59.139 10.117 1,313 569 1.391 0.171 38.906 79.373 Infant mortality (0-4 years) 84.082 12.517 1,313 569 1.420 0.149 59.047 109.116 Child mortality (0-4 years) 76.079 9.026 1,322 573 0.927 0.119 58.027 94.131 Under 5 mortality (0-4 years) 153.764 14.852 1,327 575 1.285 0.097 124.061 183.467 Mothers received tetanus injection for last birth 0.919 0.020 462 199 1.587 0.022 0.879 0.959 Mothers received medical assistance at delivery 0.459 0.035 716 312 1.561 0.076 0.390 0.529 Child had diarrhoea in two weeks prior to survey 0.288 0.025 647 281 1.416 0.088 0.238 0.339 Treated with oral rehydration salts (ORS) 0.659 0.030 188 81 0.827 0.045 0.600 0.719 Taken to a health provider 0.409 0.041 188 81 1.066 0.100 0.327 0.490 Vaccination card seen 0.603 0.045 159 69 1.163 0.075 0.512 0.694 Received BCG 0.941 0.018 159 69 0.941 0.019 0.906 0.976 Received DPT (3 doses) 0.713 0.040 159 69 1.103 0.056 0.633 0.793 Received polio (3 doses) 0.674 0.056 159 69 1.496 0.083 0.563 0.785 Received measles 0.772 0.036 159 69 1.080 0.047 0.700 0.844 Fully immunized 0.511 0.060 159 69 1.495 0.117 0.392 0.630 Height-for-age (below -2SD) 0.493 0.019 603 264 0.888 0.038 0.455 0.530 Weight-for-height (below -2SD) 0.052 0.009 603 264 0.960 0.165 0.035 0.069 Weight-for-age (below -2SD) 0.206 0.018 603 264 1.005 0.089 0.169 0.242 BMI <18.5 0.081 0.011 561 241 0.950 0.135 0.059 0.103 Has heard of HIV/AIDS 0.977 0.006 703 303 1.100 0.006 0.965 0.990 Knows condoms reduce HIV/AIDS 0.628 0.015 703 303 0.817 0.024 0.599 0.658 Knows limiting partners reduces HIV/AIDS 0.653 0.024 703 303 1.358 0.037 0.604 0.702 HIV Positive 0.095 0.023 194 74 1.100 0.245 0.048 0.142 MEN Urban residence 0.176 0.061 182 78 2.167 0.349 0.053 0.299 Literate 0.750 0.032 182 78 0.995 0.043 0.686 0.814 No education 0.102 0.023 182 78 1.011 0.223 0.056 0.147 Secondary education or higher 0.179 0.028 182 78 0.999 0.159 0.122 0.236 Never married 0.207 0.035 182 78 1.159 0.169 0.137 0.276 Currently married/in union 0.742 0.035 182 78 1.067 0.047 0.672 0.811 Married before age 20 0.270 0.033 150 65 0.905 0.122 0.204 0.336 Knows any contraceptive method 0.993 0.007 135 58 0.968 0.007 0.979 1.000 Want no more children 0.328 0.047 135 58 1.150 0.142 0.235 0.422 Want to delay birth at least 2 years 0.368 0.053 135 58 1.283 0.145 0.262 0.475 Ideal family size 4.455 0.120 173 75 0.821 0.027 4.216 4.694 Has heard of HIV/AIDS 1.000 0.000 182 78 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.834 0.028 182 78 0.997 0.033 0.779 0.889 Knows limiting partners reduces HIV/AIDS 0.887 0.026 182 78 1.118 0.030 0.834 0.939 HIV Positive 0.082 0.020 136 59 0.843 0.242 0.042 0.123 na = Not applicable Appendix B | 315 Table B.14 Sampling errors: Thyolo District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.031 0.002 820 618 0.322 0.063 0.027 0.035 Literate 0.561 0.026 820 618 1.475 0.046 0.510 0.612 No education 0.283 0.023 820 618 1.438 0.080 0.238 0.328 Secondary education or higher 0.093 0.015 820 618 1.491 0.163 0.062 0.123 Net attendance ratio for primary school 0.843 0.015 1,000 765 1.226 0.018 0.812 0.874 Never married 0.137 0.016 820 618 1.319 0.116 0.105 0.168 Currently married/in union 0.700 0.024 820 618 1.495 0.034 0.653 0.748 Married before age 20 0.780 0.017 657 497 1.047 0.022 0.746 0.814 Currently pregnant 0.144 0.013 820 618 1.069 0.091 0.117 0.170 Children ever born 3.067 0.125 820 618 1.369 0.041 2.816 3.317 Children surviving 2.436 0.108 820 618 1.464 0.044 2.221 2.652 Children ever born to women age 40-49 6.088 0.371 112 86 1.233 0.061 5.346 6.830 TFR (0-3 years) 5.727 0.294 na 1,738 1.128 0.051 5.139 6.314 Knows any contraceptive method 0.999 0.001 565 433 0.905 0.001 0.996 1.001 Ever used any contraceptive method 0.561 0.035 565 433 1.656 0.062 0.492 0.630 Currently using any contraceptive method 0.305 0.032 565 433 1.641 0.104 0.242 0.369 Currently using a modern method 0.282 0.031 565 433 1.653 0.111 0.220 0.345 Currently using pill 0.013 0.005 565 433 1.103 0.409 0.002 0.023 Currently using IUD 0.000 0.000 565 433 na na 0.000 0.000 Currently using condom 0.011 0.004 565 433 0.962 0.378 0.003 0.020 Currently using female sterilization 0.061 0.011 565 433 1.119 0.185 0.038 0.083 Currently using periodic abstinence 0.006 0.003 565 433 1.039 0.579 0.000 0.012 Obtained method from public sector source 0.536 0.048 201 150 1.369 0.090 0.440 0.633 Want no more children 0.403 0.022 565 433 1.063 0.054 0.359 0.447 Want to delay birth at least 2 years 0.418 0.021 565 433 0.991 0.049 0.377 0.460 Ideal family size 4.138 0.085 797 599 1.411 0.020 3.969 4.308 Neonatal mortality (0-4 years) 42.674 6.344 1,412 1,079 1.108 0.149 29.987 55.361 Postneonatal mortality (0-4 years) 76.131 7.699 1,419 1,085 1.049 0.101 60.733 91.530 Infant mortality (0-4 years) 118.806 10.151 1,419 1,085 1.098 0.085 98.504 139.107 Child mortality (0-4 years) 77.421 9.624 1,430 1,093 1.133 0.124 58.173 96.670 Under 5 mortality (0-4 years) 187.029 11.258 1,437 1,099 0.965 0.060 164.513 209.545 Mothers received tetanus injection for last birth 0.808 0.019 505 386 1.104 0.024 0.770 0.847 Mothers received medical assistance at delivery 0.512 0.042 749 575 1.919 0.082 0.428 0.595 Child had diarrhoea in two weeks prior to survey 0.274 0.019 670 514 1.110 0.070 0.236 0.312 Treated with oral rehydration salts (ORS) 0.802 0.040 181 141 1.365 0.050 0.722 0.882 Taken to a health provider 0.514 0.040 181 141 1.076 0.078 0.434 0.595 Vaccination card seen 0.747 0.038 146 116 1.092 0.051 0.671 0.824 Received BCG 0.979 0.013 146 116 1.086 0.013 0.954 1.004 Received DPT (3 doses) 0.884 0.037 146 116 1.431 0.042 0.810 0.958 Received polio (3 doses) 0.872 0.037 146 116 1.373 0.042 0.798 0.946 Received measles 0.870 0.028 146 116 1.021 0.032 0.815 0.926 Fully immunized 0.748 0.045 146 116 1.278 0.060 0.658 0.837 Height-for-age (below -2SD) 0.481 0.022 549 414 1.003 0.046 0.437 0.525 Weight-for-height (below -2SD) 0.087 0.017 549 414 1.357 0.195 0.053 0.121 Weight-for-age (below -2SD) 0.222 0.013 549 414 0.727 0.059 0.196 0.249 BMI <18.5 0.089 0.011 640 486 0.953 0.120 0.067 0.110 Has heard of HIV/AIDS 0.996 0.002 820 618 1.069 0.002 0.991 1.001 Knows condoms reduce HIV/AIDS 0.672 0.019 820 618 1.148 0.028 0.635 0.710 Knows limiting partners reduces HIV/AIDS 0.768 0.014 820 618 0.966 0.019 0.739 0.796 HIV Positive 0.231 0.038 200 145 1.280 0.166 0.154 0.309 MEN Urban residence 0.055 0.004 211 169 0.255 0.073 0.047 0.063 Literate 0.705 0.045 211 169 1.418 0.063 0.616 0.794 No education 0.125 0.025 211 169 1.096 0.200 0.075 0.176 Secondary education or higher 0.230 0.038 211 169 1.312 0.166 0.154 0.306 Never married 0.297 0.031 211 169 0.987 0.105 0.235 0.359 Currently married/in union 0.684 0.035 211 169 1.087 0.051 0.614 0.753 Married before age 20 0.351 0.040 169 137 1.086 0.114 0.271 0.431 Knows any contraceptive method 1.000 0.000 140 116 na 0.000 1.000 1.000 Want no more children 0.496 0.046 140 116 1.081 0.092 0.404 0.587 Want to delay birth at least 2 years 0.261 0.047 140 116 1.270 0.181 0.166 0.355 Ideal family size 4.044 0.152 210 168 1.257 0.038 3.740 4.347 Has heard of HIV/AIDS 1.000 0.000 211 169 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.762 0.036 211 169 1.228 0.047 0.689 0.834 Knows limiting partners reduces HIV/AIDS 0.854 0.017 211 169 0.717 0.020 0.819 0.889 HIV Positive 0.186 0.035 140 126 1.058 0.188 0.115 0.257 na = Not applicable 316 | Appendix B Table B.15 Sampling errors: Zomba District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.139 0.008 806 637 0.688 0.060 0.122 0.156 Literate 0.681 0.021 806 637 1.296 0.031 0.639 0.724 No education 0.153 0.021 806 637 1.666 0.138 0.111 0.195 Secondary education or higher 0.170 0.019 806 637 1.454 0.113 0.132 0.209 Net attendance ratio for primary school 0.888 0.023 869 712 1.869 0.025 0.843 0.933 Never married 0.168 0.017 806 637 1.311 0.103 0.133 0.202 Currently married/in union 0.684 0.019 806 637 1.149 0.028 0.647 0.722 Married before age 20 0.754 0.022 639 505 1.283 0.029 0.710 0.798 Currently pregnant 0.121 0.012 806 637 1.046 0.099 0.097 0.145 Children ever born 2.786 0.098 806 637 1.079 0.035 2.590 2.981 Children surviving 2.291 0.090 806 637 1.217 0.039 2.111 2.471 Children ever born to women age 40-49 6.064 0.301 111 87 1.076 0.050 5.461 6.667 TFR (0-3 years) 5.306 0.372 na 1,806 1.382 0.070 4.561 6.050 Knows any contraceptive method 0.997 0.003 560 436 1.203 0.003 0.992 1.003 Ever used any contraceptive method 0.585 0.032 560 436 1.528 0.054 0.521 0.649 Currently using any contraceptive method 0.320 0.025 560 436 1.285 0.079 0.269 0.370 Currently using a modern method 0.282 0.027 560 436 1.408 0.095 0.229 0.336 Currently using pill 0.014 0.005 560 436 1.035 0.365 0.004 0.024 Currently using IUD 0.000 0.000 560 436 na na 0.000 0.000 Currently using condom 0.008 0.004 560 436 1.157 0.542 0.000 0.017 Currently using female sterilization 0.036 0.010 560 436 1.262 0.277 0.016 0.056 Currently using periodic abstinence 0.003 0.003 560 436 1.382 1.002 0.000 0.010 Obtained method from public sector source 0.828 0.035 183 143 1.256 0.042 0.758 0.898 Want no more children 0.382 0.019 560 436 0.934 0.050 0.343 0.420 Want to delay birth at least 2 years 0.361 0.019 560 436 0.929 0.052 0.323 0.399 Ideal family size 3.944 0.070 802 634 1.161 0.018 3.803 4.085 Neonatal mortality (0-4 years) 30.707 5.564 1,241 972 0.986 0.181 19.578 41.836 Postneonatal mortality (0-4 years) 53.053 6.698 1,243 973 0.990 0.126 39.658 66.448 Infant mortality (0-4 years) 83.760 10.460 1,243 973 1.209 0.125 62.839 104.680 Child mortality (0-4 years) 65.892 8.765 1,258 988 1.026 0.133 48.362 83.423 Under 5 mortality (0-4 years) 144.133 15.363 1,260 989 1.335 0.107 113.407 174.858 Mothers received tetanus injection for last birth 0.881 0.016 497 389 1.081 0.018 0.850 0.913 Mothers received medical assistance at delivery 0.655 0.029 699 544 1.435 0.044 0.598 0.713 Child had diarrhoea in two weeks prior to survey 0.240 0.017 639 498 0.983 0.069 0.207 0.273 Treated with oral rehydration salts (ORS) 0.689 0.045 156 120 1.171 0.066 0.598 0.780 Taken to a health provider 0.433 0.063 156 120 1.490 0.145 0.307 0.559 Vaccination card seen 0.810 0.032 141 108 0.937 0.040 0.746 0.875 Received BCG 0.934 0.027 141 108 1.264 0.029 0.880 0.988 Received DPT (3 doses) 0.913 0.028 141 108 1.178 0.031 0.856 0.970 Received polio (3 doses) 0.881 0.027 141 108 0.970 0.030 0.828 0.935 Received measles 0.847 0.032 141 108 0.995 0.037 0.784 0.911 Fully immunized 0.729 0.033 141 108 0.860 0.046 0.663 0.796 Height-for-age (below -2SD) 0.423 0.031 596 476 1.456 0.073 0.361 0.485 Weight-for-height (below -2SD) 0.076 0.013 596 476 1.191 0.176 0.049 0.103 Weight-for-age (below -2SD) 0.220 0.027 596 476 1.527 0.122 0.166 0.273 BMI <18.5 0.114 0.019 679 535 1.554 0.167 0.076 0.152 Has heard of HIV/AIDS 0.995 0.003 806 637 1.055 0.003 0.990 1.000 Knows condoms reduce HIV/AIDS 0.565 0.018 806 637 1.034 0.032 0.529 0.601 Knows limiting partners reduces HIV/AIDS 0.699 0.021 806 637 1.289 0.030 0.657 0.741 HIV Positive 0.246 0.037 188 134 1.179 0.151 0.171 0.322 MEN Urban residence 0.191 0.031 209 159 1.137 0.162 0.129 0.253 Literate 0.727 0.041 209 159 1.330 0.056 0.645 0.809 No education 0.142 0.027 209 159 1.119 0.191 0.088 0.196 Secondary education or higher 0.262 0.027 209 159 0.902 0.105 0.207 0.317 Never married 0.320 0.033 209 159 1.009 0.102 0.255 0.385 Currently married/in union 0.628 0.034 209 159 1.027 0.055 0.560 0.697 Married before age 20 0.271 0.037 166 125 1.071 0.137 0.197 0.345 Knows any contraceptive method 1.000 0.000 131 100 na 0.000 1.000 1.000 Want no more children 0.286 0.023 131 100 0.571 0.079 0.241 0.331 Want to delay birth at least 2 years 0.414 0.043 131 100 1.005 0.105 0.328 0.501 Ideal family size 3.859 0.179 198 150 1.173 0.046 3.500 4.218 Has heard of HIV/AIDS 1.000 0.000 209 159 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.804 0.046 209 159 1.685 0.058 0.711 0.897 Knows limiting partners reduces HIV/AIDS 0.808 0.025 209 159 0.905 0.031 0.759 0.857 HIV Positive 0.105 0.028 154 124 1.116 0.264 0.048 0.161 na = Not applicable Appendix B | 317 Table B.16 Sampling errors: Lilongwe District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.434 0.029 710 1,705 1.548 0.066 0.377 0.492 Literate 0.679 0.018 710 1,705 1.044 0.027 0.643 0.716 No education 0.215 0.017 710 1,705 1.085 0.078 0.182 0.249 Secondary education or higher 0.237 0.020 710 1,705 1.235 0.083 0.197 0.276 Net attendance ratio for primary school 0.820 0.021 953 2,260 1.484 0.025 0.778 0.861 Never married 0.204 0.027 710 1,705 1.806 0.134 0.149 0.258 Currently married/in union 0.689 0.033 710 1,705 1.912 0.048 0.622 0.755 Married before age 20 0.649 0.025 566 1,372 1.228 0.038 0.600 0.698 Currently pregnant 0.104 0.011 710 1,705 0.948 0.105 0.082 0.125 Children ever born 2.830 0.112 710 1,705 1.124 0.040 2.607 3.054 Children surviving 2.339 0.099 710 1,705 1.250 0.043 2.140 2.538 Children ever born to women age 40-49 6.535 0.310 98 209 1.121 0.047 5.915 7.154 TFR (0-3 years) 5.664 0.419 na 4,809 1.355 0.074 4.827 6.502 Knows any contraceptive method 0.971 0.011 497 1,175 1.415 0.011 0.950 0.993 Ever used any contraceptive method 0.604 0.023 497 1,175 1.050 0.038 0.558 0.651 Currently using any contraceptive method 0.363 0.024 497 1,175 1.107 0.066 0.315 0.411 Currently using a modern method 0.343 0.022 497 1,175 1.032 0.064 0.299 0.387 Currently using pill 0.024 0.007 497 1,175 0.994 0.286 0.010 0.037 Currently using IUD 0.000 0.000 497 1,175 na na 0.000 0.000 Currently using condom 0.014 0.004 497 1,175 0.823 0.307 0.006 0.023 Currently using female sterilization 0.073 0.014 497 1,175 1.157 0.185 0.046 0.101 Currently using periodic abstinence 0.003 0.002 497 1,175 0.898 0.719 0.000 0.008 Obtained method from public sector source 0.623 0.039 189 449 1.108 0.063 0.545 0.702 Want no more children 0.459 0.017 497 1,175 0.779 0.038 0.424 0.494 Want to delay birth at least 2 years 0.342 0.019 497 1,175 0.887 0.055 0.304 0.379 Ideal family size 3.627 0.067 680 1,632 1.076 0.018 3.493 3.760 Neonatal mortality (0-4 years) 20.681 5.078 1,109 2,633 0.989 0.246 10.526 30.837 Postneonatal mortality (0-4 years) 52.314 6.726 1,110 2,634 0.903 0.129 38.863 65.765 Infant mortality (0-4 years) 72.996 9.071 1,110 2,634 0.996 0.124 54.854 91.137 Child mortality (0-4 years) 77.747 9.925 1,129 2,677 1.043 0.128 57.898 97.597 Under 5 mortality (0-4 years) 145.068 13.248 1,130 2,678 1.023 0.091 118.571 171.564 Mothers received tetanus injection for last birth 0.853 0.019 412 1,013 1.128 0.023 0.814 0.892 Mothers received medical assistance at delivery 0.547 0.040 613 1,489 1.697 0.074 0.466 0.627 Child had diarrhoea in two weeks prior to survey 0.244 0.026 565 1,376 1.477 0.105 0.193 0.296 Treated with oral rehydration salts (ORS) 0.595 0.035 142 336 0.832 0.059 0.525 0.665 Taken to a health provider 0.249 0.034 142 336 0.941 0.137 0.180 0.317 Vaccination card seen 0.590 0.060 125 292 1.335 0.101 0.471 0.710 Received BCG 0.858 0.044 125 292 1.404 0.052 0.769 0.947 Received DPT (3 doses) 0.690 0.068 125 292 1.617 0.098 0.554 0.826 Received polio (3 doses) 0.653 0.042 125 292 0.962 0.064 0.569 0.736 Received measles 0.707 0.038 125 292 0.926 0.054 0.630 0.784 Fully immunized 0.525 0.062 125 292 1.369 0.119 0.400 0.649 Height-for-age (below -2SD) 0.523 0.039 400 952 1.464 0.075 0.444 0.601 Weight-for-height (below -2SD) 0.047 0.012 400 952 1.153 0.256 0.023 0.071 Weight-for-age (below -2SD) 0.245 0.030 400 952 1.320 0.122 0.185 0.305 BMI <18.5 0.060 0.012 478 1,119 1.087 0.199 0.036 0.084 Has heard of HIV/AIDS 0.962 0.009 710 1,705 1.220 0.009 0.944 0.979 Knows condoms reduce HIV/AIDS 0.439 0.025 710 1,705 1.328 0.056 0.390 0.489 Knows limiting partners reduces HIV/AIDS 0.563 0.026 710 1,705 1.413 0.047 0.510 0.615 HIV Positive 0.016 0.011 246 352 1.403 0.692 0.000 0.039 MEN Urban residence 0.444 0.069 228 542 2.094 0.156 0.306 0.582 Literate 0.811 0.030 228 542 1.161 0.037 0.750 0.871 No education 0.131 0.030 228 542 1.329 0.227 0.072 0.191 Secondary education or higher 0.325 0.038 228 542 1.211 0.116 0.250 0.400 Never married 0.390 0.044 228 542 1.358 0.113 0.302 0.478 Currently married/in union 0.594 0.045 228 542 1.367 0.075 0.505 0.683 Married before age 20 0.155 0.032 182 431 1.170 0.203 0.092 0.218 Knows any contraceptive method 0.994 0.006 136 322 0.896 0.006 0.982 1.000 Want no more children 0.534 0.042 136 322 0.987 0.079 0.450 0.619 Want to delay birth at least 2 years 0.277 0.035 136 322 0.914 0.127 0.207 0.348 Ideal family size 3.506 0.076 213 503 0.963 0.022 3.354 3.657 Has heard of HIV/AIDS 0.993 0.005 228 542 0.900 0.005 0.983 1.000 Knows condoms reduce HIV/AIDS 0.724 0.017 228 542 0.585 0.024 0.689 0.759 Knows limiting partners reduces HIV/AIDS 0.645 0.034 228 542 1.078 0.053 0.577 0.714 HIV Positive 0.055 0.025 96 398 1.066 0.455 0.004 0.106 na = Not applicable 318 | Appendix B Table B.17 Sampling errors: Mulanje District, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.062 0.010 777 512 1.182 0.165 0.041 0.082 Literate 0.592 0.030 777 512 1.679 0.050 0.533 0.652 No education 0.222 0.018 777 512 1.190 0.080 0.187 0.258 Secondary education or higher 0.104 0.016 777 512 1.457 0.154 0.072 0.136 Net attendance ratio for primary school 0.829 0.019 865 569 1.294 0.023 0.791 0.867 Never married 0.135 0.014 777 512 1.172 0.107 0.106 0.164 Currently married/in union 0.702 0.018 777 512 1.089 0.025 0.667 0.738 Married before age 20 0.788 0.017 631 416 1.070 0.022 0.753 0.823 Currently pregnant 0.136 0.016 777 512 1.308 0.118 0.104 0.168 Children ever born 3.161 0.096 777 512 0.994 0.030 2.969 3.354 Children surviving 2.440 0.071 777 512 0.929 0.029 2.299 2.582 Children ever born to women age 40-49 5.986 0.230 146 95 1.007 0.038 5.527 6.445 TFR (0-3 years) 5.565 0.285 na 1,432 1.141 0.051 4.996 6.135 Knows any contraceptive method 0.993 0.004 549 359 1.200 0.004 0.984 1.001 Ever used any contraceptive method 0.611 0.035 549 359 1.657 0.056 0.542 0.680 Currently using any contraceptive method 0.285 0.028 549 359 1.439 0.097 0.230 0.341 Currently using a modern method 0.246 0.022 549 359 1.169 0.087 0.203 0.289 Currently using pill 0.009 0.004 549 359 0.920 0.414 0.002 0.016 Currently using IUD 0.000 0.000 549 359 na na 0.000 0.000 Currently using condom 0.005 0.003 549 359 0.933 0.577 0.000 0.010 Currently using female sterilization 0.072 0.012 549 359 1.071 0.164 0.049 0.096 Currently using periodic abstinence 0.004 0.002 549 359 0.896 0.590 0.000 0.009 Obtained method from public sector source 0.524 0.049 152 101 1.196 0.093 0.427 0.622 Want no more children 0.443 0.019 549 359 0.894 0.043 0.405 0.481 Want to delay birth at least 2 years 0.317 0.019 549 359 0.949 0.060 0.279 0.354 Ideal family size 4.027 0.058 724 477 1.011 0.014 3.911 4.143 Neonatal mortality (0-4 years) 55.462 8.236 1,257 828 1.077 0.148 38.990 71.934 Postneonatal mortality (0-4 years) 89.191 9.777 1,261 831 1.088 0.110 69.637 108.744 Infant mortality (0-4 years) 144.652 14.033 1,262 831 1.170 0.097 116.587 172.717 Child mortality (0-4 years) 89.182 8.654 1,278 842 0.997 0.097 71.874 106.490 Under 5 mortality (0-4 years) 220.934 13.169 1,284 846 1.017 0.060 194.596 247.272 Mothers received tetanus injection for last birth 0.834 0.025 448 296 1.413 0.030 0.785 0.884 Mothers received medical assistance at delivery 0.598 0.044 661 437 1.979 0.073 0.511 0.686 Child had diarrhoea in two weeks prior to survey 0.221 0.018 568 375 1.028 0.083 0.184 0.258 Treated with oral rehydration salts (ORS) 0.575 0.056 125 83 1.230 0.098 0.462 0.688 Taken to a health provider 0.290 0.057 125 83 1.339 0.195 0.176 0.403 Vaccination card seen 0.859 0.025 128 81 0.803 0.029 0.809 0.910 Received BCG 0.944 0.023 128 81 1.102 0.024 0.898 0.990 Received DPT (3 doses) 0.839 0.049 128 81 1.483 0.059 0.740 0.937 Received polio (3 doses) 0.832 0.041 128 81 1.218 0.049 0.750 0.914 Received measles 0.812 0.049 128 81 1.385 0.060 0.714 0.910 Fully immunized 0.685 0.057 128 81 1.348 0.083 0.571 0.798 Height-for-age (below -2SD) 0.505 0.036 498 329 1.559 0.071 0.434 0.577 Weight-for-height (below -2SD) 0.060 0.014 498 329 1.253 0.228 0.032 0.087 Weight-for-age (below -2SD) 0.265 0.028 498 329 1.332 0.106 0.209 0.321 BMI <18.5 0.134 0.010 615 403 0.742 0.076 0.114 0.155 Has heard of HIV/AIDS 0.994 0.002 777 512 0.912 0.002 0.989 0.999 Knows condoms reduce HIV/AIDS 0.752 0.010 777 512 0.651 0.013 0.732 0.772 Knows limiting partners reduces HIV/AIDS 0.788 0.017 777 512 1.140 0.021 0.754 0.821 HIV Positive 0.233 0.038 184 117 1.214 0.163 0.155 0.310 MEN Urban residence 0.080 0.016 178 114 0.773 0.197 0.049 0.112 Literate 0.817 0.033 178 114 1.126 0.040 0.751 0.882 No education 0.073 0.027 178 114 1.356 0.362 0.020 0.126 Secondary education or higher 0.220 0.045 178 114 1.458 0.207 0.129 0.310 Never married 0.313 0.047 178 114 1.349 0.150 0.219 0.407 Currently married/in union 0.653 0.047 178 114 1.317 0.072 0.559 0.747 Married before age 20 0.300 0.037 138 88 0.953 0.124 0.225 0.375 Knows any contraceptive method 0.987 0.009 115 74 0.855 0.009 0.968 1.000 Want no more children 0.414 0.074 115 74 1.612 0.180 0.265 0.563 Want to delay birth at least 2 years 0.382 0.058 115 74 1.274 0.152 0.266 0.498 Ideal family size 4.130 0.110 178 114 0.894 0.027 3.910 4.351 Has heard of HIV/AIDS 1.000 0.000 178 114 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.544 0.034 178 114 0.908 0.062 0.477 0.612 Knows limiting partners reduces HIV/AIDS 0.766 0.037 178 114 1.151 0.048 0.693 0.839 HIV Positive 0.151 0.030 122 86 0.927 0.200 0.089 0.212 na = Not applicable Appendix B | 319 Table B.18 Sampling errors: Other Districts, Malawi 2004 Number of cases Confidence limits Variable Value (R) Standard Error (SE) Un- weighted (N) Weighted (WN) Design Effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.074 0.007 3,783 4,708 1.620 0.093 0.060 0.087 Literate 0.594 0.014 3,783 4,708 1.790 0.024 0.565 0.622 No education 0.248 0.011 3,783 4,708 1.519 0.043 0.227 0.270 Secondary education or higher 0.120 0.011 3,783 4,708 2.034 0.089 0.099 0.142 Net attendance ratio for primary school 0.804 0.009 5,025 6,144 1.441 0.011 0.785 0.822 Never married 0.169 0.007 3,783 4,708 1.076 0.039 0.156 0.182 Currently married/in union 0.707 0.009 3,783 4,708 1.179 0.012 0.689 0.724 Married before age 20 0.739 0.008 2,970 3,715 1.051 0.011 0.722 0.755 Currently pregnant 0.125 0.006 3,783 4,708 1.205 0.052 0.112 0.138 Children ever born 3.107 0.050 3,783 4,708 1.098 0.016 3.007 3.208 Children surviving 2.558 0.041 3,783 4,708 1.087 0.016 2.477 2.640 Children ever born to women age 40-49 6.816 0.116 578 726 1.021 0.017 6.585 7.047 TFR (0-3 years) 6.317 0.150 na 13,323 1.247 0.024 6.016 6.617 Knows any contraceptive method 0.989 0.002 2,682 3,326 1.100 0.002 0.985 0.994 Ever used any contraceptive method 0.598 0.012 2,682 3,326 1.308 0.021 0.573 0.622 Currently using any contraceptive method 0.321 0.011 2,682 3,326 1.261 0.035 0.298 0.343 Currently using a modern method 0.279 0.011 2,682 3,326 1.298 0.040 0.256 0.301 Currently using pill 0.020 0.003 2,682 3,326 1.028 0.140 0.014 0.025 Currently using IUD 0.001 0.001 2,682 3,326 1.134 0.609 0.000 0.003 Currently using condom 0.017 0.003 2,682 3,326 1.363 0.198 0.011 0.024 Currently using female sterilization 0.061 0.005 2,682 3,326 1.183 0.090 0.050 0.071 Currently using periodic abstinence 0.004 0.001 2,682 3,326 1.054 0.320 0.001 0.007 Obtained method from public sector source 0.711 0.026 817 1,019 1.649 0.037 0.658 0.763 Want no more children 0.417 0.013 2,682 3,326 1.369 0.031 0.390 0.443 Want to delay birth at least 2 years 0.388 0.011 2,682 3,326 1.146 0.028 0.367 0.410 Ideal family size 4.222 0.044 3,666 4,571 1.542 0.010 4.133 4.310 Neonatal mortality (0-4 years) 36.054 2.988 6,373 7,922 1.160 0.083 30.078 42.031 Postneonatal mortality (0-4 years) 54.915 3.419 6,384 7,936 1.107 0.062 48.077 61.752 Infant mortality (0-4 years) 90.969 4.489 6,384 7,936 1.128 0.049 81.991 99.947 Child mortality (0-4 years) 73.747 4.381 6,452 8,024 1.109 0.059 64.984 82.509 Under 5 mortality (0-4 years) 158.007 5.879 6,463 8,037 1.118 0.037 146.249 169.765 Mothers received tetanus injection for last birth 0.842 0.009 2,393 2,981 1.193 0.011 0.824 0.860 Mothers received medical assistance at delivery 0.559 0.017 3,543 4,414 1.755 0.031 0.524 0.593 Child had diarrhoea in two weeks prior to survey 0.214 0.008 3,189 3,992 1.158 0.039 0.197 0.231 Treated with oral rehydration salts (ORS) 0.613 0.024 676 854 1.226 0.039 0.565 0.661 Taken to a health provider 0.350 0.021 676 854 1.110 0.060 0.308 0.392 Vaccination card seen 0.767 0.017 709 901 1.072 0.023 0.732 0.801 Received BCG 0.917 0.012 709 901 1.161 0.013 0.892 0.942 Received DPT (3 doses) 0.809 0.016 709 901 1.049 0.019 0.778 0.841 Received polio (3 doses) 0.770 0.021 709 901 1.319 0.028 0.728 0.813 Received measles 0.792 0.017 709 901 1.105 0.022 0.758 0.826 Fully immunized 0.649 0.022 709 901 1.24