Maldives - Demographic and Health Survey - 2010

Publication date: 2010

Maldives Demographic and Health Survey 2009 Republic of Maldives Maldives Demographic and Health Survey 2009 Ministry of Health and Family Malé, Maldives ICF Macro Calverton, Maryland, USA October 2010 The 2009 Maldives Demographic and Health Survey (MDHS) was implemented by the Ministry of Health and Family (MOHF) from January 2009 through October 2009. ICF Macro, an ICF International Company, provided technical assistance to the project. Additional information about the 2009 MDHS may be obtained from: Ministry of Health and Family Street address: Ameenee Magu, Malé 20379, Maldives Telephone: (960) 332-8887 Fax: (960) 332 8889 Email: moh@health.gov.mv Information about the DHS programme may be obtained from: MEASURE DHS Project, ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA Telephone: 301-572-0200 Fax: 301-572-0999 E-mail: reports@measuredhs.com, Internet: http://www.measuredhs.com. Recommended citation: Ministry of Health and Family (MOHF) [Maldives] and ICF Macro. 2010. Maldives Demographic and Health Survey 2009. Calverton, Maryland: MOHF and ICF Macro. Contents | iii CONTENTS Page TABLES AND FIGURES . ix MAP OF MALDIVES . xvi CHAPTER 1 INTRODUCTION . 1 1.1 Geography, History, and Economy . 1 1.2 Population . 2 1.3 Health Services and Health Care Challenges . 3 1.4 Objectives of the Survey . 4 1.5 Organization of the Survey . 5 1.6 Sample Design . 5 1.7 Questionnaires . 6 1.8 Pre-test . 7 1.9 Training . 7 1.10 Fieldwork . 7 1.11 Data Processing . 9 1.12 Data Collection . 9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS . 11 2.1 Characteristics of the Household Population . 11 2.1.1 Age and Sex Composition . 11 2.1.2 Household Composition . 12 2.2 Orphaned and Vulnerable Children . 13 2.2.1 Children’s Living Arrangements and Orphanhood . 13 2.3 Education of the Household Population . 14 2.3.1 School Attendance Rates . 16 2.3.2 Grade Repetition and Dropout Rates . 18 2.4 Household Environment . 19 2.4.1 Drinking Water . 20 2.4.2 Household Sanitation Facilities . 21 2.4.3 Housing Characteristics . 21 2.5 Household Possessions . 23 2.6 Wealth Index . 23 2.7 Birth Registration . 24 2.8 Early Childhood Education Attendance . 25 2.9 Disability . 25 iv │ Contents 2.9.1 Young Child Disability . 27 2.10 Children in Economically Productive Labour . 27 2.11 Care and Support for Older Adults . 28 2.12 Health Expenditures . 30 2.13 Tsunami . 32 CHAPTER 3 CHARACTERISTICS OF FEMALE RESPONDENTS . 35 3.1 Characteristics of Survey Respondents . 35 3.2 Educational Attainment by Background Characteristics . 35 3.3 Access to Mass Media . 36 3.4 Employment . 38 3.5 Occupation . 39 3.6 Earnings and Type of Employment . 40 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS . 43 4.1 Introduction . 43 4.2 Current Fertility . 43 4.4 Fertility Trends . 46 4.5 Children Ever Born and Living . 46 4.6 Birth Intervals . 48 4.7 Age at First Birth . 49 4.8 Teenage Pregnancy and Motherhood . 51 CHAPTER 5 FAMILY PLANNING . 53 5.1 Knowledge of Family Planning Methods . 53 5.2 Ever Use of Family Planning . 54 5.3 Current Use of Family Planning . 55 5.4 Trends in Current Use of Family Planning . 57 5.5 First Use of Family Planning . 57 5.6 Knowledge of Fertile Period . 58 5.7 Timing of Sterilization . 58 5.8 Sources for Modern Family Planning Methods . 59 5.9 Informed Choice . 60 5.10 Reasons for Discontinuation of Contraceptive Use . 61 5.11 Intention to Use Contraception in the Future . 62 5.12 Reasons for Non-use . 62 5.13 Preferred Method . 63 5.14 Exposure to Family Planning Messages . 63 5.15 Contact of Nonusers with Outreach Workers/Health Care Providers . 64 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY . 67 6.1 Current Marital Status . 67 6.2 Age at First Marriage . 67 6.3 Age at First Sexual Intercourse . 70 6.4 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 72 6.5 Menopause . 73 Contents | v CHAPTER 7 FERTILITY PREFERENCES . 75 7.1 Desire for More Children . 75 7.2 Need for Family Planning . 77 7.3 Ideal Number of Children . 79 7.4 Unplanned and Unwanted Fertility . 80 CHAPTER 8 INFANT AND CHILD MORTALITY . 83 8.1 Levels and Trends in Infant and Child Mortality . 83 8.2 Data Quality . 85 8.3 Socioeconomic Differentials in Infant and Child Mortality . 85 8.4 Demographic Differentials in Infant and Child Mortality . 86 8.5 Perinatal Mortality . 88 8.6 High-Risk Fertility Behaviour . 89 CHAPTER 9 MATERNAL HEALTH . 91 9.1 Antenatal Care . 91 9.1.1 Source of Antenatal Care . 91 9.2 Number of ANC Visits, Timing of First Visit, and Source Where ANC Received . 92 9.3 Components of Antenatal Care . 93 9.4 Tetanus Toxoid Injections . 95 9.5 Place of Delivery . 97 9.6 Assistance during Delivery . 98 9.7 Postnatal Care . 100 9.8 Problems in Accessing Health Care . 102 CHAPTER 10 CHILD HEALTH . 105 10.1 Child’s Size at Birth . 105 10.2 Vaccination Coverage . 106 10.3 Trends In Vaccination Coverage . 108 10.4 Prevalence and Treatment of Acute Respiratory Infections and Fever . 109 10.4.1 Acute Respiratory Infections . 109 10.4.2 Fever . 109 10.5 Diarrhoeal Disease . 110 10.6 Knowledge of ORS Packets . 112 10.7 Stool Disposal . 113 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN . 115 11.1 Nutritional Status of Children . 115 11.1.1 Measurement of Nutritional Status among Young Children . 115 11.1.2 Results of Data Collection . 116 11.2 Initiation of Breastfeeding. 119 vi │ Contents 11.3 Breastfeeding Status by Age . 121 11.4 Duration and Frequency of Breastfeeding . 122 11.5 Types of Complementary Foods . 124 11.6 Infant and Young Child Feeding (IYCF) Practices . 125 11.7 Micronutrient Intake among Children. 127 11.8 Nutritional Status of Women . 129 11.9 Foods Consumed by Mothers . 131 11.10 Micronutrient Intake among Mothers . 132 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR . 135 12.1 HIV/AIDS Knowledge, Transmission, and Prevention Methods . 135 12.1.1 Awareness of HIV/AIDS . 135 12.1.2 Methods of HIV Prevention . 136 12.1.3 Rejection of Misconceptions about HIV/AIDS . 137 12.2 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 138 12.3 Attitudes towards People Living with AIDS . 140 12.4 Knowledge of a Source for HIV Testing . 141 12.5 Self-Reporting of Sexually Transmitted Infections . 141 12.6 Prevalence of Medical Injections . 142 12.7 HIV/AIDS Knowledge and Sexual Behaviour among Youth . 145 12.7.1 HIV/AIDS-Related Knowledge among Young Adults . 145 12.7.2 Knowledge of Condom Sources among Young Adults . 146 12.7.3 Trends in Age at First Sex . 146 CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 147 13.1 Employment and Form of Earnings . 147 13.1.1 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s Earnings . 147 13.1.2 Control over Husband’s Earnings . 149 13.1.3 Control over Women’s and Husband’s Cash Earnings by Magnitude of Women’s Earnings . 150 13.2 Women’s Empowerment . 150 13.2.1 Women’s Participation in Household Decision Making . 151 13.2.2 Attitudes Towards Wife Beating . 153 13.3 Women’s Empowerment Indicators . 155 13.4 Current Use of Contraception By Women’s Empowerment Status . 156 13.5 Ideal Family Size and Unmet Need by Women’s Status. 156 13.6 Women’s Status and Reproductive Health Care . 157 13.7 Early Childhood Mortality Rates by Women’s Status . 158 CHAPTER 14 DEMOGRAPHIC AND HEALTH INDICATORS ON MEN . 159 14.1 Response Rates For Men’s Survey . 159 Contents | vii 14.2 Characteristics of Survey Respondents . 160 14.3 Educational Attainment by Background Characteristics . 160 14.4 Access to Mass Media . 161 14.5 Employment . 162 14.6 Knowledge of Contraception . 164 14.7 Ideal Number of Children . 164 14.8 AIDS-related Knowledge, Attitudes, and Behaviour . 165 14.8.1 Awareness of HIV/AIDS . 165 14.8.2 Methods of HIV Prevention . 165 14.8.3 Comprehensive Knowledge about HIV/AIDS . 166 14.8.4 Attitudes towards People Living with AIDS . 168 14.8.5 Multiple sexual partners . 169 14.8.6 Knowledge of Place for HIV Testing . 169 14.9 Self-Reporting of Sexually Transmitted Infections . 170 14.10 Prevalence of Medical Injections . 171 14.11 Men’s Attitude towards Empowerment of Women . 173 14.11.1 Men’s View of Women’s Participation in Decision Making . 173 14.11.2 Attitudes towards Wife Beating . 175 14.11.3 Attitudes towards Refusing Sexual Intercourse with Husband . 176 CHAPTER 15 YOUTH-RELATED ISSUES . 179 15.1 Introduction . 179 15.2 Respondent’s Characteristics . 179 15.3 Current Activity . 180 15.4 Media Exposure . 181 15.5 Knowledge of the Fertile Period . 182 15.6 Knowledge of Family Planning Methods . 183 15.7 Decision about Marriage . 184 15.8 Decision on Number of Children . 185 15.9 Discussion on Reproductive Health . 186 15.10 Use of Tobacco . 187 15.11 Knowledge of AIDS . 188 15.12 Knowledge of HIV Prevention Methods . 188 CHAPTER 16 WOMEN’S OTHER HEALTH ISSUES . 191 16.1 Knowledge and Attitudes Regarding Tuberculosis . 191 16.2 Use of Tobacco . 193 16.3 Physical Activity . 194 16.4 Blood Pressure, Diabetes, Heart Attack, and Stroke . 194 REFERENCES . 197 APPENDIX A SAMPLE IMPLEMENTATION . 199 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 201 APPENDIX C DATA QUALITY TABLES . 213 viii │ Contents APPENDIX D PERSONS INVOLVED IN THE 2009 MALDIVES DEMOGRAPHIC AND HEALTH SURVEY . 219 APPENDIX E QUESTIONNAIRES . 223 APPENDIX F ESTIMATES OF SAMPLING ERRORS FOR SELECTED VARIABLES AT ATOLL-LEVEL . 337 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators . 3 Table 1.2 Results of the household and individual interviews . 9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 11 Table 2.2 Household composition . 13 Table 2.3 Children's living arrangements and orphanhood . 14 Table 2.4.1 Educational attainment of the female household population . 15 Table 2.4.2 Educational attainment of the male household population . 16 Table 2.5 School attendance ratios . 17 Table 2.6 Grade repetition and dropout rates . 19 Table 2.7 Household drinking water . 20 Table 2.8 Household sanitation facilities . 21 Table 2.9 Household characteristics . 22 Table 2.10 Household durable goods . 23 Table 2.11 Wealth quintiles . 24 Table 2.12 Birth registration of children under age 5 . 25 Table 2.13 Early childhood education attendance . 25 Table 2.14 Disability. 26 Table 2.15 Young child disability . 27 Table 2.16 Children in economically productive labour . 28 Table 2.17 Households with older adult population . 28 Table 2.18 Care and support of physical activities for older adults . 29 Table 2.19 Amount of care and support of physical activities for older adults . 29 Table 2.20 Health insurance coverage and utilization of inpatient and outpatient services . 30 Table 2.21 Quality of health expenditure data . 31 Table 2.22 Tsunami displacement . 32 Table 2.23 Current location of tsunami displaced . 32 Table 2.24 Number of people sheltered . 33 Table 2.25 Number of household members who received benefits . 33 Figure 2.1 Population Pyramid . 12 Figure 2.2 Percentage of Females and Males Currently Attending School, by Age . 18 CHAPTER 3 CHARACTERISTICS OF FEMALE RESPONDENTS Table 3.1 Background characteristics of female respondents . 35 Table 3.2 Educational attainment . 36 Table 3.3 Exposure to mass media . 37 Table 3.4 Employment status . 38 Table 3.5 Occupation. 40 Table 3.6 Type of employment . 41 x | Tables and Figures Figure 3.1 Women's Employment Status in the Past 12 Months . 39 Figure 3.2 Type of Earnings of Employed Women Age 15-49 . 41 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS Table 4.1 Current fertility . 43 Table 4.2 Fertility by background characteristics . 45 Table 4.3 Trends in age-specific fertility rates . 46 Table 4.4 Children ever born and living . 47 Table 4.5 Birth intervals . 48 Table 4.6 Age at first birth . 50 Table 4.7 Median age at first birth . 50 Table 4.8 Teenage pregnancy and motherhood . 51 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence . 44 Figure 4.2 Total Fertility Rates in Selected South Asia and Southeast Asia Countries . 44 Figure 4.3 Median Birth Interval in Selected South Asia and Southeast Asia Countries . 49 Figure 4.4 Teenage Pregnancy and Motherhood in Selected South Asia and Southeast Asia Countries . 52 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 54 Table 5.2 Ever use of contraception . 54 Table 5.3 Current use of contraception by age . 55 Table 5.4 Current use of contraception by background characteristics . 56 Table 5.5 Trends in use of specific contraceptive methods, Maldives 1999-2009 . 57 Table 5.6 Number of children at first use of contraception . 57 Table 5.7 Knowledge of fertile period . 58 Table 5.8 Timing of sterilization . 59 Table 5.9 Source of modern contraception methods . 59 Table 5.10 Informed choice . 60 Table 5.11 Reasons for discontinuation . 61 Table 5.12 Future use of contraception . 62 Table 5.13 Reason for not intending to use contraception in the future . 62 Table 5.14 Preferred method of contraception for future use . 63 Table 5.15 Exposure to family planning messages . 64 Table 5.16 Contact of non-users with family planning providers . 65 Figure 5.1 Trends in Contraceptive Use, Maldives 1999-2009 . 55 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 67 Table 6.2 Age at first marriage . 68 Table 6.3 Median age at first marriage . 69 Table 6.4 Age at first sexual intercourse . 70 Table 6.5 Median age at first intercourse . 71 Table 6.6 Postpartum amenorrhea, abstinence and insusceptibility . 72 Tables and Figures | xi Table 6.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 73 Table 6.8 Menopause . 73 Figure 6.1 Median Age at First Marriage in South and Southeast Asia . 69 Figure 6.2 Median Age at First Sexual Intercourse in South and Southeast Asia . 71 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 75 Table 7.2 Desire to limit childbearing . 77 Table 7.3 Need and demand for family planning among currently married women . 78 Table 7.4 Ideal number of children . 80 Table 7.5 Mean ideal number of children . 80 Table 7.6 Fertility planning status . 81 Table 7.7 Wanted fertility rates . 82 Figure 7.1 Fertility Preferences among Currently Married Women Age 15-49 . 76 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 84 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 86 Table 8.3 Early childhood mortality rates by demographic characteristics . 87 Table 8.4 Perinatal mortality . 88 Table 8.5 High-risk fertility behaviour . 90 Figure 8.1 Infant Mortality Rate for Five-Year Period Before the Survey for Selected Countries in South and Southeast Asia . 84 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 92 Table 9.2 Number of antenatal care visits and timing of first visit . 93 Table 9.3 Components of antenatal care . 94 Table 9.4 Tetanus toxoid injections . 96 Table 9.5 Place of delivery . 97 Table 9.6 Assistance during delivery . 99 Table 9.7 Assistance at delivery by place of delivery . 100 Table 9.8 Timing of first postnatal checkup . 101 Table 9.9 Provider of first postnatal checkup . 102 Table 9.10 Problems in accessing health care . 103 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth . 106 Table 10.2 Vaccinations by source of information . 107 Table 10.3 Vaccinations by background characteristics . 108 Table 10.4 Vaccinations in first year of life . 109 Table 10.5 Prevalence and treatment of fever . 110 Table 10.6 Prevalence of diarrhoea . 111 Table 10.7 Knowledge of ORS packets or pre-packaged liquids . 112 xii | Tables and Figures Table 10.8 Disposal of children's stools . 113 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN Table 11.1 Nutritional status of children . 118 Table 11.2 Initial breastfeeding . 120 Table 11.3 Breastfeeding status by age . 121 Table 11.4 Median duration and frequency of breastfeeding . 123 Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview . 124 Table 11.6 Infant and young child feeding (IYCF) practices . 126 Table 11.7 Micronutrient intake among children . 128 Table 11.8 Nutritional status of women . 130 Table 11.9 Foods consumed by mothers in the day and night preceding the interview 132 Table 11.10 Micronutrient intake among mothers . 133 Figure 11.1 Nutritional Status of Children by Age . 119 Figure 11.2 Infant Feeding Practices by Age . 122 Figure 11.3 Infant and Young Child Feeding (IYCF) Practices . 127 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 12.1 Knowledge of AIDS . 135 Table 12.2 Knowledge of HIV prevention methods . 136 Table 12.3 Comprehensive knowledge about AIDS . 138 Table 12.4 Knowledge of prevention of mother-to-child transmission of HIV . 139 Table 12.5 Accepting attitudes toward those living with HIV/AIDS . 140 Table 12.6 Knowledge of place for HIV testing . 141 Table 12.7 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 142 Table 12.8 Prevalence of medical injections . 143 Table 12.9 Comprehensive knowledge about AIDS and of a source of condoms among youth . 145 Table 12.10 Age at first sexual intercourse among youth . 146 Figure 12.1 Source of Last Medical Injection . 144 Figure 12.2 Safe Injection . 144 CHAPTER 13 WOMEN'S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 13.1 Employment and cash earnings of currently married women . 147 Table 13.2 Control over women's cash earnings and relative magnitude of women's earnings: Women . 148 Table 13.3 Control over men's cash earnings . 149 Table 13.4 Women's control over her own earnings and over those of her husband . 150 Table 13.5 Women's participation in decision-making . 151 Table 13.6 Women's participation in decision making by background characteristics . 153 Table 13.7 Attitude towards wife beating . 154 Table 13.8 Indicators of women's empowerment . 155 Table 13.9 Current use of contraception by women's status . 156 Tables and Figures | xiii Table 13.10 Women's empowerment and ideal number of children and unmet need for family planning . 157 Table 13.11 Reproductive health care by women's empowerment . 158 Table 13.12 Early childhood mortality rates by women's status . 158 Figure 13.1 Number of Decisions in Which Women Participate . 152 CHAPTER 14 DEMOGRAPHIC AND HEALTH INDICATORS ON MEN Table 14.1 Results of the household and individual interviews . 159 Table 14.2 Background characteristics of respondents . 160 Table 14.3 Educational attainment . 161 Table 14.4 Exposure to mass media: Men . 162 Table 14.5 Employment status . 163 Table 14.6 Knowledge of contraceptive methods . 164 Table 14.7 Ideal number of children . 164 Table 14.8 Knowledge of AIDS . 165 Table 14.9 Knowledge of HIV prevention methods . 166 Table 14.10 Comprehensive knowledge about AIDS . 167 Table 14.11 Accepting attitudes towards those living with HIV/AIDS: Men . 168 Table 14.12 Lifetime sexual partners . 169 Table 14.13 Knowledge of place for HIV testing . 170 Table 14.15 Prevalence of medical injections . 172 Table 14.16 Women's participation in decision making according to men . 173 Table 14.17 Men's attitude towards wives' participation in decision making . 174 Table 14.18 Attitude towards wife beating . 175 Table 14.19 Attitude towards refusing sexual intercourse with husband . 177 Table 14.20 Men's attitude towards a husband's rights when his wife refuses to have sexual intercourse . 178 Figure 14.1 Type of Facility Where Last Medical Injection Was Received . 173 CHAPTER 15 YOUTH-RELATED ISSUES Table 15.1 Results of the household and individual interviews . 179 Table 15.2 Background characteristics of respondents . 180 Table 15.3 Current activity . 181 Table 15.4 Exposure to mass media . 182 Table 15.5 Knowledge of the fertile period . 183 Table 15.6 Knowledge of contraceptive methods . 184 Table 15.7 Decision on whom to marry. 185 Table 15.8 Decision on number of children . 186 Table 15.9 Discussion of reproductive health . 187 Table 15.10 Cigarette smoking . 187 Table 15.11 Knowledge of AIDS . 188 Table 15.12 Knowledge of HIV prevention methods . 189 CHAPTER 16 WOMEN’S OTHER HEALTH ISSUES Table 16.1 Knowledge and attitude concerning tuberculosis . 191 Table 16.2 Knowledge of TB transmission modes . 192 xiv | Tables and Figures Table 16.3 Use of tobacco . 193 Table 16.4 Physical activity . 194 Table 16.5 Actions taken to lower blood pressure . 194 Table 16.6 Actions taken to lower diabetes . 195 Figure 16.1 Age When First Diagnosed with Diabetes . 195 APPENDIX A SAMPLING IMPLEMENTATION Table A.1 Sample implementation: Women . 199 Table A.2 Sample implementation: Men . 200 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 203 Table B.2 Sampling errors for National sample . 204 Table B.3 Sampling errors for Urban sample . 205 Table B.4 Sampling errors for Rural sample . 206 Table B.5 Sampling errors for Malé sample . 207 Table B.6 Sampling errors for North sample . 208 Table B.7 Sampling errors for North Central sample . 209 Table B.8 Sampling errors for Central sample . 210 Table B.9 Sampling errors for South Central sample . 211 Table B.10 Sampling errors for South sample . 212 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 213 Table C.2.1 Age distribution of eligible and interviewed women . 214 Table C.2.2 Age distribution of eligible and interviewed men . 214 Table C.3 Completeness of reporting . 215 Table C.4 Births by calendar years . 215 Table C.5 Reporting of age at death in days . 216 Table C.6 Reporting of age at death in months . 217 Table C.7 Nutritional status of children based on NCHS/CDC/WHO International Reference Population . 218 APPENDIX F ESTIMATES OF SAMPLING ERRORS FOR SELECTED VARIABLES AT ATOLL-LEVEL Table F.0 List of selected variables for sampling errors, atoll-level data . 339 Table F.1 Sampling errors for Malé sample . 339 Table F.2 Sampling errors for Haa Alif sample . 339 Table F.3 Sampling errors for Haa Dhaal sample . 340 Table F.4 Sampling errors for Shaviyani sample . 340 Table F.5 Sampling errors for Noonu sample . 340 Table F.6 Sampling errors for Raa sample . 341 Table F.7 Sampling errors for Baa sample . 341 Table F.8 Sampling errors for Lhaviyani sample . 341 Table F.9 Sampling errors for Kaafu sample . 342 Table F.10 Sampling errors for Alif Alif sample . 342 Table F.11 Sampling errors for Alif Dhaal sample . 342 Tables and Figures | xv Table F.12 Sampling errors for Vaavu sample . 343 Table F.13 Sampling errors for Meemu sample . 343 Table F.14 Sampling errors for Faafu sample . 343 Table F.15 Sampling errors for Dhaalu sample . 344 Table F.16 Sampling errors for Thaa sample . 344 Table F.17 Sampling errors for Lhaamu sample . 344 Table F.18 Sampling errors for Gaaf Alif sample. 345 Table F.19 Sampling errors for Gaaf Dhaal sample . 345 Table F.20 Sampling errors for Gnaviyani sample . 345 Table F.21 Sampling errors for Seenu sample . 346 xvi | Map of Maldivesa Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY, HISTORY, AND ECONOMY 1.1.1 Geography The Republic of Maldives is an archipelago in the Indian Ocean located 600 km south of India. Its islands extend from latitude 0° 42 ' 24 " S of the equator to 7 ° 6 ' 35 " N. It consists of 1,192 small islands that form a chain, about 820 km long and 120 km wide, within an area of 90,000 sq km. Only 196 of the islands are officially inhabited, although another 84 islands are used as resorts, and 14 islands serve an industrial purpose. The capital of Malé, with an area of about 2 sq km, accommodates one-third of the country's population of about 300,000. The total land area is estimated to be 300 sq km, of which only 10 percent are suitable for agriculture. For administrative purposes, the 26 natural atolls of the Maldives are classified into 20 groups, each of which is referred to as an administrative atoll. The islands are low lying, with an average elevation of 1.6 meters above main sea level. Only a few islands have a land area in excess of one sq km. The climate is tropical: warm and humid, with two pronounced monsoon seasons. Daily temperatures vary little throughout the year. The average maximum temperature is 31° Celsius, and the average minimum temperature is 26° Celsius. Relative humidity ranges from 73 percent to 85 percent. The average annual rainfall for the period 1996 to 2000 was 2,140 mm. Monthly variations in rainfall are significant, ranging from 22 mm in March to 258 mm in September (Ministry of Planning and National Development, 2008). 1.1.2 History The Republic of Maldives has always been a sovereign and independent state except for brief periods of the 18th, 19th, and 20th centuries. The people of Maldives embraced Islam in the 12th century, and Maldives today remains solely a Muslim state. The Maldivians are homogenous in nature and traditions and converse in a common language called Dhivehi. During the 18th century, the Maldives became a protectorate of the Dutch rulers of Ceylon and later of the British who took control of Ceylon in 1796. In 1887, its status was formalized as an internally self-governing British protectorate. The first democratic constitution in 1932 proclaimed the sultanate, or office of the sultan, an elected position. The country was ruled by a sultan until 1953, when the Maldives became a republic within the Commonwealth, and Mohamed Amin served as its first president. The sultanate was restored after a short period, and the country gained full independence as a sultanate outside of the Commonwealth in 1965. In 1968, its status as a republic was reinstated after a referendum named Ibrahim Nasir to be president. In 1978, Maumoon Abdul Gayyoom became president and continued to serve for 30 years, after being elected for six consecutive terms. The republic rejoined the Commonwealth in 1982. In 2005, an important step toward democracy was taken when the parliament voted unanimously for a multiparty political system. In August 2007, voters opted for a presidential system of government. In August 2008, President Gayoom ratified the new constitution that paved the way for the first multiparty presidential election. In October 2008, President Gayoom was defeated by opposition leader Mohamed Nasheed. President Nasheed assumed office in November 2008 (www.themaldives.com). 2 | Introduction 1.1.3 Economy As an archipelago of many islands that are home to fewer than 500 inhabitants, Maldives has unique development problems. The population is extremely dispersed and fragmented. In addition, the survival of the country’s low-lying islands is threatened by the constant rise in sea level due to global warming. Over the past decade, the gross domestic product (GDP) grew at an annual rate of between 6 and 8 percent, driven by investment in tourism and low levels of inflation. In 2008, tourism accounted for 27 percent of GDP and about 29 percent of government revenue directly. Growth of the tourism sector also opens job opportunities which in 2008 accounted for approximately 24,000 jobs. To boost economic development to the entire country the Government expanded the tourism development, which used to be concentrated in the central region within the easy reach of the Malé International Airport, to other regions of the country. Along with tourism, the fishing industry generates revenues accounting for 6 to 7 percent of GDP and employment from the fishery sector represents 10 to 15 percent of the workforce (The Strategic Action Plan, 2009 -2013). Significant progress has also been achieved in human and social development over the past two decades. Credible macroeconomic and public investment policies as well as a largely favourable external environment have facilitated this progress, lifting Maldives from its status as one of the 20 poorest countries in the 1970s to one that shares characteristics of a lower middle-income country of today. The small size of its economy, which largely depends on tourism and fisheries, makes the Maldives vulnerable to external shocks, such as the economic recession following the tsunami of December 2004. In spite of the relatively low death toll after the tsunami, the country’s economy was badly shaken. According to one government assessment, the tsunami set back development by about 20 years. Financial damage was estimated at 62 percent of GDP, or $470 million, aggravated by a non-tsunami budget deficit of approximately $80 million in 2005 resulting from a significant fall in revenue from tourism. The country lacks land-based natural and mineral resources. As a result, virtually all economic production depends on imports, creating heavy dependence on foreign exchange earnings. Intensive agricultural production is limited because of the poor quality of the soil, which is porous and deficient in nitrogen and potassium, and the limited availability of fresh water. All staple foodstuffs, basic necessities, and items for the tourism industry are imported (Ministry of Economic Development, 2010) 1.2 POPULATION Little information is available on the ancient people and their way of life. Evidence suggests that the Maldives has been populated and thriving as early as the 4th century BC. It is argued that the earliest settlers migrated from Arabia, eastern Africa, and the Indian subcontinent among other places. Today, the Maldivians are a mixed race, but no ethnic identities exist. The population is homogeneous, follows the same religion (Islam), and speaks one language (Dhivehi). A large expatriate workforce is found in the country, generally unskilled and working in the area of construction and other unskilled jobs. Expatriates in professional jobs are found in the educational sector and the health sector. All expatriates work on a short-term contract basis, and when the contract expires, they must leave the country. The first population data, recorded in 1911, showed a population of only 72,237. It took about 60 years for the population to almost double (Census 2006 Analytical Report). In the 1950s, the annual population growth is 1 percent or less until 1958, when the rate was 5.28 percent. Thereafter, population growth slowed and underwent mild fluctuations. Between 1960 and 1980, the population Introduction | 3 grew an average of 3 percent annually. Significant declines in mortality during the 1980s and subsequent declines in fertility brought down the population growth rate. Although subsequent censuses recorded an increase in size of the population, the annual population growth rate decreased significantly, from 3.43 percent in 1985-1999 to 1.69 percent in 2000-2006. Between the 2000 and 2006 inter-census years, a 10 percent increase was seen in the total population. The 2006 population census puts the total population at 298,968, of which about 49 percent are women. The Maldives has recorded significant achievement in human development. The infant mortality rate declined from 63 deaths in 1986 to 11 deaths per 1,000 births in 2009 (Vital Registration data, 2009). The crude death rate declined from 17 deaths per 1,000 population in 1971 to 4 deaths per 1000 population. The crude birth rate, which was 49 births per 1,000 population in 1985, declined to 23 births per 1,000 population in 1996. In 1995, the average life expectancy at birth was 70.6 years, about 20 years higher than the life expectancy recorded in 1980. In 2009, the life expectancy at birth was 73 years for males and 74 years for females (Statistical Year Book of Maldives, 2009). Table 1.1 Basic demographic indicators Demographic indicators from selected sources Indicators 1995 2000 2006 Population 244,814 270,101 298,968 Sex ratio 104 103 103 Intercensal growth rate (percent) 2.73 1.96 1.69 Percent urban na 27% 35% Life expectancy at birth (years) Male 69.9 70.1 72.0 Female 71.6 70.1 73.2 Source: http://www.planning.gov.mv na = Not available 1.3 HEALTH SERVICES AND HEALTH CARE CHALLENGES The unique geographical nature of the country poses a challenge to service provision. Though the size of the population is comparatively small, it is geographically dispersed. Such isolated island communities require many facilities to provide service at a variety of locations. Health services in the Maldives are currently organized by a four tier referral system comprising of island, atoll, regional and central level services. The Indira Gandhi Memorial Hospital in Malé serves as a tertiary-level hospital at the central level of the referral system. At the regional level, health care is delivered by regional hospitals in six strategic locations across the island archipelago. Each of the six regional hospitals serves as the referral centre for 2 to 4 atolls, providing services in a number of specialty areas of medical care. At the atoll level, hospitals are found in 13 of the atolls in which a regional hospital is not located. Atoll hospitals were initiated in the early 2000s, with the primary objective being to bring emergency obstetric care closer to the community. Atoll health centres provide basic medical care, including obstetric services. The lowest level of the system consists of the island-level primary health care centres, health posts, and family health units. Currently the country has 3 island hospitals (including one private hospital), 6 regional hospitals, 13 atoll hospitals, and 176 health centres (including two in Malé). Medical services have expanded rapidly in the country during the last two decades. In 2005 the doctor to population ratio was 1:775, and the nurse to population ratio was 1:302. The nurse-to- doctor ratio was about 3:1. Medical services are provided to a large extent by an expatriate workforce, both in the public and the private sectors. The high turnover of professionals and strict recruitment process are among problems faced by the country in its effort to provide health care. 4 | Introduction The private sector in health care in the Maldives, although small, is vigorous and popular. There is one private tertiary facility located in Malé. A total of 62 clinics are distributed throughout the country, of which 73 percent are located in Malé. Pharmacy services are predominantly provided by the private sector, except for the pharmacy operated by the State Trading Organization (STO). Owing to the remote and small population in many islands, and the need to ensure access to drugs, the government supports committees of women or youth and NGOs to establish community pharmacies. The new government, which resumed office in November 2008, re-established the government’s health care mission— ‘to provide affordable, accessible and quality health care for all through establishing internationally accepted standards of health care, by improving the quality of health services; establishing better referral system and high quality regional centres; assuring health care training opportunities to Maldivians; reducing the costs of health care; setting up an inclusive social health insurance system; and encouraging private sector participation in health’ (Strategic Action Plan, 2009-2013). Under the government’s health care reform policies of decentralization, corporatization and privatization, the directive is to deliver health care services through Public Private Partnerships managed by corporate bodies at strategic local levels. Along with corporatization and privatization of delivery of health care, the government gives emphasis for revitalization of primary health care focusing on preventive health by empowering communities to make decisions related to healthy lifestyles and health services at island and atoll levels through political and administrative decentralization and supporting training of community based public health professionals. Health Care Challenges Notable achievements have been made in controlling many communicable diseases. However, acute respiratory infections and some vector-borne diseases such as dengue, chikungunya, scrub typhus, toxoplasmosis and leptospirosis have emerged due to environment and climate changes and have become endemic in various parts of the country. Although the prevalence of HIV/AIDS is low, certain risk behaviours such as sex work and intravenous drug use, which are seen to be increasing, pose increased risk of contracting HIV in these at-risk populations. Lifestyle changes associated with socio-economic development and chronic non-communicable diseases have emerged as the main cause of morbidity and mortality. Thalassaemia with an estimated carrier prevalence of 20 percent and increasing number of renal diseases are other chronic disease concerns. The demography in the Maldives suggests that adolescent sexual and reproductive health issues for the young, as well as health care for the growing number of elderly citizens need to be addressed. In addition, mental health and occupational health are MDG plus issues that the health sector has identified. 1.4 OBJECTIVES OF THE SURVEY The 2009 MDHS was designed to provide data to monitor the population and health situation in Maldives. Specifically, the MDHS collected information on fertility levels and preferences, marriage, sexual activity, knowledge and use of family planning methods, breastfeeding practices, nutrition status of women and young children, childhood mortality, maternal and child health, and awareness and behaviour regarding AIDS and other sexually transmitted infections. At the household level, the survey collected information on domains of physical disability among those age 5 and older, developmental disability among young children, support for early learning, children at work, the impact of the tsunami of 2004, health expenditures, and care and support for physical activity of adults age 65 and older. At the individual level, the survey assessed additional features of blood pressure, diabetes, heart attack, and stroke. Introduction | 5 1.5 ORGANIZATION OF THE SURVEY Maldives’ first Demographic and Health Survey (MDHS) was carried out by the Ministry of Health and Family (MOHF). The survey was funded by the government of Maldives, UNFPA, the United Nations Children’s Fund (UNICEF), and the World Health Organisation (WHO). Technical assistance was provided by ICF Macro. Conducting a demographic and health survey in the Maldives has been a long-felt need for internationally comparable information on the demographic and health situation of the Maldivian population. The survey also was intended to provide information for decision-makers to plan, monitor, and evaluate population, health, and nutrition programs. Because it was the first survey of its kind in the Maldives, external technical assistance was sought. The local planners at the Ministry of Health approached the MEASURE DHS program for technical assistance. Technical assistance from Macro International was received in April 2007 to develop the design of the survey and to identify (1) additional specific data needs; (2) primary design issues; and (3) development of key survey documents, including a draft work plan and the Household and Individual Questionnaires. A steering committee, representing stakeholder agencies, including the UN organizations, was formed to assist mainly in identifying data needs and to provide advice and facilitate the design process. A second technical support visit was made by Macro staff in June-July 2007, resulting in the development of the sample plan, selection of the sample points, and preparation of household listing documents and household selection materials. A subsequent visit by Macro staff in September 2007 allowed finalization of the MDHS plans. During the visit, the work plan and budget for the MDHS; the household and individual questionnaires; the supervisor’s and interviewer’s training manuals; and a training agenda for the pre-test training were finalized. 1.6 SAMPLE DESIGN The population of the republic of Maldives is distributed on 195 inhabited islands among a total of 202 inhabited islands; seven islands have no residents (MPND, 2008). Each inhabited island is an administrative unit with an island office that handles island-based affairs. The islands are regrouped to form atolls, a higher-level administrative unit with an atoll office and an atoll chief. There are 20 atolls in total in the republic. The capital city of Malé and the two surrounding islands, Villingili and Hulhumale, form a special atoll. The 21 atolls are regrouped to form six geographic regions according to their location. Malé atoll alone forms a region. In Maldives, there is no urban- rural designation for residential households within an atoll. All residential households in the 20 atolls outside of Malé are considered rural; all residential households in Malé are considered urban. The 2009 Maldives DHS is based on a probability sample of 7,515 households. The sample was designed to produce representative data on households, women, and children for the country as a whole, for urban and rural areas, for the six geographical regions, and for each of the atolls of the country. The male and youth surveys were designed to produce representative results for the country as a whole, for urban and rural areas, and for each of the six geographical regions. The 2006 Maldives Population and Housing Census provided the sampling frame for the 2009 MDHS. The MDHS sample was a stratified multistage sample selected in two stages from the census frame. In the first stage, 270 census blocks were selected using a systematic selection, with probability proportional to the number of residential households residing in the block. Stratification was achieved by treating each of the 21 atolls as a sampling stratum. Samples were selected independently in each stratum according to an appropriate allocation. 6 | Introduction In the second stage of sampling, residential households were selected in each of the selected census blocks. Household selection involved an equal probability systematic selection of a fixed number of households: 28 households per block. Households were selected from the household listings created in the census, but to allow all households an opportunity to be included in the sample, listings were sent to island offices for updating prior to making household selections for the MDHS. All ever-married women age 15-49 in the total sample of MDHS households, who were either usual residents of the household or visitors present in the household on the night before the survey, were eligible to be interviewed. In half of the households selected for the ever-married sample of women, all ever-married men age 15-64, who were either usual residents of the household or visitors present in the household on the night before the survey, were eligible to be interviewed. In the same half of households selected for the ever-married sample of men, never-married women and never- married men age 15-24, who were either usual residents of the household or visitors present in the household on the night before the survey, were also eligible to be interviewed. The MDHS was for the most part limited to Maldivian citizens; non-Maldivians were included in the survey only if they were the spouse, son, or daughter of a Maldivian. 1.7 QUESTIONNAIRES Four questionnaires were used for the 2009 MDHS: the Household Questionnaire, the Women’s Questionnaire, the Men’s Questionnaire, and the Youth Questionnaire. The contents of the Household, Women’s, and Men’s questionnaires were based on model questionnaires developed by the MEASURE DHS programme. The DHS model questionnaires were modified to reflect concerns pertinent to the Maldives in the areas of population, women and children’s health, family planning, and others. Questionnaires were translated from English into Dhivehi. The Household Questionnaire was used to list all the usual members and visitors in the selected households and to identify women and men who were eligible for the individual interview. Basic information was collected on the characteristics of each person listed, including their age, sex, education, and relationship to the head of the household. The Household Questionnaire was also designed to collect information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, water shortage, materials used for the floor and roof of the house, and ownership of various durable goods. In addition, height and weight measurements of ever-married women age 15-49 and children age 6-59 months were recorded in the Household Questionnaire to assess their nutritional status. Topics added to the Household Questionnaire to reflect issues relevant in the Maldives include physical disability among those age 5 and older, developmental disability among young children, support for early learning, children at work, the tsunami of 2004, health expenditures, and care and support for physical activities of adults age 65 and older. The Women’s Questionnaire was used to collect information from ever-married women age 15-49. These women were asked questions on the following topics: • Background characteristics (education, media exposure, etc.) • Reproductive history • Knowledge and use of family planning methods • Fertility preferences • Antenatal and delivery care • Breastfeeding and infant feeding practices • Vaccinations and childhood illnesses • Marriage and sexual activity • Woman’s work and husband’s background characteristics • Infant and child feeding practices Introduction | 7 • Childhood mortality • Awareness and behaviour about AIDS and other sexually transmitted infections (STIs) • Knowledge of blood pressure, diabetes, heart attack, and stroke The Men’s Questionnaire was administered to all ever-married men age 15-64 living in every second household in the MDHS sample. The Men’s Questionnaire collected much of the same information as the Women’s Questionnaire, but it was shorter because it did not contain questions on reproduction, maternal and child health, and nutrition. The Youth Questionnaire was administered to all never-married women and men age 15-24 living in every second household in the MDHS sample (the same one-half selected for the Men’s survey). The Youth Questionnaire focuses on priorities of the MOHF that pertain to young adults: reproductive health, knowledge and attitudes about HIV/AIDS, sexual activity, and tobacco, alcohol, and drug use. 1.8 PRE-TEST A pre-test was conducted in April-May 2008. The training team consisted of two consultants from ICF Macro and eight staff from the MOHF. The pre-test provided the opportunity to review questionnaire content and language, logistics, equipment needs, and general protocols for the survey. Lessons learned from the pre-test were used to finalize the survey instruments and logistical arrangements. The pre-test also served as training for the upcoming main survey. Pre-test fieldwork for the MDHS took place in Malé and Thinadhoo Islands. 1.9 TRAINING The first training course for field staff was conducted for four weeks in December 2008. The training team consisted of one consultant from ICF Macro and staff from the MOHF. A total of 58 trainees participated. Trainees were recruited on the basis of their education, prior experience as interviewers or supervisors in other surveys, interest and ability to travel to other islands, other related experience, and performance during the selection interview. The majority of trainees were graduates of ‘O’ level education (completed grade 10). Other staff members are community health workers who were recruited as supervisors. Two additional trainings of three weeks each were conducted in response to field staff dropouts occurring during data collection. An additional 21 recruits were trained in February 2009, and another 20 recruits were trained in April 2009. Each training was held for three weeks. In all, a total of 91 persons were trained for the survey. All participants were trained on interviewing techniques and the contents of the MDHS questionnaires. Participants were also trained to conduct anthropometric measurements. The training was conducted following the standard DHS training procedures, including class presentations, mock interviews, written tests, and field practice. At the start of the field work, six field teams were formed. The team of Malé region started data collection in the first week of January, and the atoll teams started fieldwork during the third week of January. 1.10 FIELDWORK Based on the experience from previous surveys, fieldwork was planned to be completed in four months. However, the 2009 MDHS is the first survey to cover a large number of islands. Furthermore, the high turnover of field staff lengthened the duration of fieldwork because two training sessions had to be conducted to replace staff dropouts. The main reason for the dropouts was the start of the school year when many of the interviewers returned to school. 8 | Introduction Fieldwork started with all six teams deployed in Malé on January 8, 2009, with the intent of familiarizing team members with fieldwork procedures and practices. Because of administrative constraints, other teams did not start data collection until January 21, 2009. Teams in atolls outside Malé completed fieldwork in 5 to 6 months. The team in North Central region was the first to complete fieldwork on June 7, 2009. In Malé, fieldwork was slower and had to be suspended for one month to observe fasting (August 22-September 19, 2009). All teams underwent a change of team members. In all, data collection took place over a period of 10 months, from January 2009 to October 2009. All interviews were conducted in Dhivehi. Field teams usually consisted of 8 members: 4 female interviewers, 2 male interviewers, 1 field editor, and 1 team supervisor. Team composition varied somewhat over time, but each team maintained having one supervisor, one field editor, and at least 2 female interviewers and 1 male interviewer at all times. Fieldwork launched with six teams being disbursed to six regions of the survey. Over time, one team was dismantled and dispersed among other teams that suffered staffing shortfalls. To ensure data quality in fieldwork, the following steps were followed: 1. Check the accuracy and quality of household listing. On arrival at the cluster, the field team updated the household list. This was done by visiting all households and checking the residential status of the households in the list, removing nonresidential ones, and adding new households to the list. The final revised number on the household list was then sent to the central office, which selected the households for interviews. 2. Observe interviews. The team supervisors observed some interviews to see that the right procedures for interviewing had been followed by the interviewers. 3. Edit all questionnaires. The team field editor checked completed questionnaires for completeness, legibility, and consistency of editing. Mistakes were corrected and, if necessary, the interviewer might have had to revisit the household to clarify or obtain the correct information from the respondent. The team supervisor also reviewed selected questionnaires. When completed questionnaires were received at the central office, all questionnaires were checked by office editors who also recorded the occupation codes. 4. Re-interview households. During the team’s visit to a cluster, the team supervisor or the field editor conducted a re-interview in selected households using parts of the Household Questionnaire. 5. Field-check tables. The performance levels of the field teams, including interview response rates, was monitored using field check tables produced by the data processing supervisor. 6. Monitoring fieldwork by the central office. Throughout the fieldwork, each team was visited by the survey coordinator one time. However, communication between the teams and the MOHF central office was carried out on a daily basis by mobile telephone. This mode of communication is possible because mobile telephone coverage is available in Maldives even in the most remote island. In these discussions, problems arising in the field were discussed and resolved immediately. These problems included logistics, accommodations, support from the community, administrative, and health authorities, and team member performance. During field supervision by the survey coordinator, the completed questionnaires were reviewed, and the performance of each team member and response rates were discussed with the teams. Introduction | 9 1.11 DATA PROCESSING Following completion of all fieldwork, completed questionnaires were sent to the MOHF central office by various means. All programs for processing the MDHS data were prepared using the Census and Survey Processing System (CSPro). Data entry was conducted at the Ministry of Health and Family in Malé. About nine data entry operators worked at any one time to enter and check the data; a total of 20 different data entry operators worked on data entry and processing through the data entry period. Additional data processing was performed to aggregate all data, complete secondary data editing and date imputation, compute sampling weights, and prepare the data files for analysis. This phase of the survey was completed in November 2009. 1.12 DATA COLLECTION Table 1.2 shows response rates for the 2009 MDHS. A total of 7,515 households were selected in the sample, of which 7,137 were found to be occupied at the time of data collection. The difference between the num- ber of households selected and the number occupied usually occurs because some struc- tures are found to be vacant or non-existent. The number of occupied households success- fully interviewed was 6,443, yielding a house- hold response rate of 90 percent. In the households interviewed in the survey, a total of 8,362 ever-married women were identified as eligible for the individual interview; interviews were completed with 7,131 women, yielding a female response rate of 85 percent. In the one-half sub-sample of MDHS households, a total of 3,224 ever- married men age 15-64 were identified as eli- gible for the individual interview; interviews were completed with 1,727 men, yielding a male response rate of 54 percent. In the same sub-sample of households, a total of 3,205 never-married women and men age 15-24 (youth) were identified as eligible for indi- vidual interview; interviews were completed with 2,240 youth, yielding a youth response rate of 70 percent. The response rate was higher for female youth (80 percent) than male youth (61 percent). The urban household response rate of 83 percent is lower than the 92 percent response rate among rural households. The same is true for individual interviews with ever-married respondents; response rates are somewhat lower among urban women (79 percent) and men (47 percent) than among their rural counterparts (87 percent and 55 percent, respectively). The difference in response rates between urban and rural youth is negligible. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Maldives 2009 Residence Result Urban Rural Total Household interviews Households selected 1,202 6,313 7,515 Households occupied 1,132 6,005 7,137 Households interviewed 944 5,499 6,443 Household response rate1 83.4 91.6 90.3 Interviews with ever-married women age 15-49 Number of eligible women 1,320 7,042 8,362 Number of eligible women interviewed 1,041 6,090 7,131 Eligible women response rate2 78.9 86.5 85.3 Household interviews for men and young adults Households selected 601 3,151 3,752 Households occupied 566 2,993 3,559 Households interviewed 463 2,741 3,204 Interviews with ever-married men age 15-64 Number of eligible men 579 2,645 3,224 Number of eligible men interviewed 274 1,453 1,727 Eligible men response rate2 47.3 54.9 53.6 Interviews with never-married women 15-24 Number of respondents 333 1,191 1,524 Number of eligible women interviewed 260 953 1,213 Eligible young women response rate2 78.1 80.0 79.6 Interviews with never-married men 15-24 Number of respondents 349 1,332 1,681 Number of eligible men interviewed 210 817 1,027 Eligible young men response rate2 60.2 61.3 61.1 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter provides a demographic and socioeconomic profile of the 2009 MDHS house- hold sample. Information is presented on the age, sex, and education of the household population as well as on their housing facilities and household possessions. Information at the household level is included on a variety of health care topics: physical disability among those age 5 and older, developmental disability among young children, support for early learning, children in the workplace, care and support for physical activities of adults age 65 and older, general health expenditures, and the effects on health of the 2004 tsunami. The profiles of the households provided in this chapter will help readers to place in context the results of the 2009 MDHS. In addition, the household information may prove useful for social and economic development planning. 2.1 CHARACTERISTICS OF THE HOUSEHOLD POPULATION The 2009 MDHS survey collected information from all usual residents of a selected household (de jure population) and from persons who stayed in the selected household the night before the interview (de facto population). The tabulations of the MDHS household data presented in this chapter are based on the de facto population, unless otherwise stated. 2.1.1 Age and Sex Composition Age and sex are important variables and are the primary basis of demographic classification. Table 2.1 presents the percent distribution of the household population by age according to urban- rural residence and sex. The table portrays the demographic context in which behaviours examined later in the report occur. The population spending the night before the survey in the households selected for the survey included 39,945 individuals, of which 47 percent were male and 53 percent were female. Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Maldives 2009 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 9.7 9.1 9.4 11.8 10.2 11.0 11.1 9.8 10.5 5-9 7.8 6.7 7.3 11.0 9.6 10.2 10.0 8.6 9.3 10-14 8.6 9.0 8.8 14.2 11.4 12.7 12.4 10.6 11.4 15-19 14.1 13.8 13.9 12.3 12.0 12.2 12.9 12.6 12.7 20-24 12.4 13.3 12.9 7.9 11.0 9.5 9.4 11.8 10.6 25-29 10.9 10.6 10.7 6.4 9.1 7.8 7.9 9.6 8.8 30-34 8.3 8.9 8.6 5.3 6.9 6.1 6.3 7.6 7.0 35-39 7.4 7.3 7.3 5.0 6.7 5.9 5.8 6.9 6.4 40-44 5.9 5.7 5.8 4.1 5.4 4.8 4.7 5.5 5.1 45-49 4.7 3.6 4.1 4.4 4.2 4.3 4.5 4.0 4.2 50-54 3.0 3.4 3.2 3.6 4.0 3.8 3.4 3.8 3.6 55-59 2.0 2.1 2.0 2.5 2.1 2.3 2.3 2.1 2.2 60-64 1.3 1.2 1.2 1.7 1.6 1.7 1.6 1.5 1.5 65-69 1.6 1.7 1.6 3.2 2.6 2.9 2.7 2.3 2.5 70-74 0.7 0.6 0.6 1.9 1.4 1.6 1.5 1.1 1.3 75-79 0.4 0.5 0.5 1.0 0.6 0.8 0.8 0.6 0.7 80 + 0.3 0.1 0.2 1.1 0.6 0.8 0.9 0.4 0.6 Don't know/missing 0.9 2.5 1.7 2.4 0.5 1.4 1.9 1.1 1.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 6,233 6,915 13,148 12,732 14,062 26,797 18,965 20,977 39,945 Note: Total includes 3 persons whose sex was not stated. 12 | Household Population and Housing Characteristics Fifty-eight percent of the women are in their reproductive years at ages 15-49. The majority of the household population (55 percent) is younger than age 25, and 31 percent of the population is under age 15. The proportion of the population under age 15 is higher in the rural areas (34 percent) than in the urban areas (26 percent). Overall, 5 percent of the population is age 65 or older. This proportion is higher in rural than in urban areas (6 percent compared with 3 percent). The age dependency ratio, calculated as the ratio of children under age 15 and adults age 65 and older to the working age population (age 15-64) is 58 percent. This figure is comparable to that reported in the 2006 Maldives population census (Ministry of Planning and National Development, 2006). The population pyramid shown in Figure 2.1 is constructed using the sex and age distribution of the 2009 MDHS household population. Maldives has a pyramid with a broad base but with a narrower band at the bottom, indicating declining fertility. 2.1.2 Household Composition Table 2.2 shows for urban and rural areas the distribution of households by the sex of the head of the household, by the number of household members, and by the percentage of households with orphans and foster children under age 18. These characteristics are important because they are associated with the welfare of the household. Female-headed households are, for example, typically poorer than male-headed households. In addition, the size and composition of the household affects the allocation of financial and other resources among household members, which in turn influences the overall well-being of these individuals. Household size is also associated with crowding in the dwelling, which can lead to unfavourable health conditions. Almost two in three households in Maldives are headed by men. Urban households are more often headed by women than rural households (40 and 33 percent, respectively). The average household size is 6.4 persons, with rural households (6.2 persons) having a smaller size than urban households (6.6 persons). Forty percent of the households in urban and rural areas have seven or more members. 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 MDHS 2009 Male Percent Female Age Household Population and Housing Characteristics | 13 Table 2.2 provides information on the proportion of households with foster children (that is, children who live in households with neither biological parent present), double orphans (children with both parents dead), and single orphans (children with one parent dead). Overall, 13 percent of the households contain foster children or orphans. Most of these households have foster children (11 percent), and 5 percent of the households have single orphans. Urban households have a higher proportion of foster children and orphans than rural households (19 percent compared with 11 percent). This is because children from other islands come to Malé for their education and live with family or relatives. Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18, according to residence, Maldives 2009 Residence Characteristic Urban Rural Total Household headship Male 60.5 67.0 65.0 Female 39.5 33.0 35.0 Total 100.0 100.0 100.0 Number of usual members 0 0.0 0.1 0.1 1 2.5 3.0 2.8 2 5.2 5.8 5.6 3 8.7 8.3 8.5 4 17.2 12.9 14.3 5 12.9 16.2 15.2 6 13.4 14.0 13.8 7 9.7 11.9 11.2 8 7.0 8.0 7.7 9+ 23.4 19.7 20.8 Total 100.0 100.0 100.0 Mean size of households 6.6 6.2 6.4 Percentage of households with orphans and foster children under 18 Foster children1 16.8 7.6 10.5 Double orphans 0.1 0.2 0.2 Single orphans 3.4 5.0 4.5 Foster and/or orphan children 18.5 11.1 13.4 Number of households 1,994 4,449 6,443 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2.2 ORPHANED AND VULNERABLE CHILDREN 2.2.1 Children’s Living Arrangements and Orphanhood The Household Questionnaire collected information on the living arrangements of all children under age 18 in the households included in the 2009 MDHS sample. Information was also collected on the survival status of the children’s parents. The results are presented in Table 2.3. Seventy-one percent of children under age 18 live with both of their parents. Six percent of children are not living with a biological parent. The percentage of children who do not live with a biological parent increases with age, from about 1 percent among children age 0-4 years to 15 percent among children age 15-17. There are urban-rural differences; 11 percent of urban children under age 18 do not live with a biological parent compared with 4 percent of rural children. Children in Malé (11 percent) and in the South region (5 percent) more often live in households with no biological parent than in other regions. Interestingly, children from wealthier households1 are more likely to live in households with no biological parent. 1 Note: For description of the construction of the wealth quintiles, see Section 2.6 14 | Household Population and Housing Characteristics Table 2.3 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Maldives 2009 Living with both parents Living with mother but not father Living with father but not mother Not living with either parent Missing infor- mation on father or mother Percent- age not living with a biologic al parent Percent- age with one or both parents dead1 Background characteristic Both alive Only father alive Only mother alive Both dead Total Number of children Father alive Father dead Mother alive Mother dead Age 0-4 74.7 22.5 0.4 0.6 0.1 1.0 0.0 0.1 0.0 0.6 100.0 1.1 0.6 4,192 <2 75.2 22.1 0.2 0.3 0.1 0.9 0.0 0.1 0.0 1.1 100.0 1.0 0.3 1,923 2-4 74.2 22.8 0.5 0.9 0.1 1.2 0.0 0.1 0.0 0.2 100.0 1.2 0.8 2,269 5-9 74.4 20.1 1.3 0.9 0.2 1.9 0.2 0.3 0.0 0.7 100.0 2.4 2.0 3,703 10-14 69.7 18.2 2.5 1.9 0.7 5.4 0.5 0.4 0.1 0.6 100.0 6.4 4.2 4,566 15-17 61.3 14.8 3.2 2.3 0.9 13.5 0.5 0.8 0.3 2.5 100.0 15.0 5.6 3,032 Sex Male 71.4 18.4 1.7 1.6 0.6 4.7 0.2 0.3 0.1 1.2 100.0 5.2 2.9 7,839 Female 69.7 20.0 1.8 1.2 0.3 5.3 0.4 0.5 0.0 0.8 100.0 6.2 3.0 7,651 Residence Urban 70.1 14.1 0.6 1.9 0.6 10.2 0.3 0.5 0.1 1.8 100.0 11.1 2.0 4,316 Rural 70.7 21.1 2.2 1.2 0.4 2.9 0.3 0.3 0.1 0.7 100.0 3.6 3.3 11,177 Region Malé 70.1 14.1 0.6 1.9 0.6 10.2 0.3 0.5 0.1 1.8 100.0 11.1 2.0 4,316 North 74.4 18.3 2.8 0.9 0.9 1.8 0.3 0.1 0.2 0.2 100.0 2.4 4.3 2,595 North Central 71.1 22.0 1.7 1.2 0.3 2.9 0.2 0.2 0.0 0.3 100.0 3.3 2.5 2,440 Central 73.7 18.3 1.5 2.3 0.0 2.5 0.5 0.3 0.1 0.7 100.0 3.4 2.4 1,381 South Central 72.9 18.9 1.7 1.3 0.4 2.9 0.3 0.4 0.1 1.1 100.0 3.7 3.0 1,889 South 64.3 25.7 2.7 0.9 0.3 4.3 0.3 0.5 0.0 1.1 100.0 5.1 3.8 2,872 Wealth quintile Lowest 69.4 21.5 3.1 1.1 0.4 2.5 0.4 0.4 0.1 0.9 100.0 3.5 4.5 3,427 Second 72.8 19.4 2.1 1.0 0.4 3.1 0.3 0.3 0.1 0.5 100.0 3.9 3.3 3,467 Middle 68.5 23.2 1.8 1.7 0.4 3.0 0.1 0.2 0.0 0.9 100.0 3.4 2.7 3,127 Fourth 69.9 17.4 0.8 1.5 0.8 7.6 0.3 0.5 0.0 1.2 100.0 8.4 2.4 2,907 Highest 72.3 12.8 0.5 1.8 0.2 10.0 0.4 0.3 0.1 1.7 100.0 10.8 1.4 2,565 Total <15 72.8 20.2 1.4 1.2 0.3 2.9 0.2 0.3 0.0 0.6 100.0 3.4 2.3 12,461 Total <18 70.5 19.2 1.8 1.4 0.4 5.0 0.3 0.4 0.1 1.0 100.0 5.7 3.0 15,493 Note: Table is based on de jure members, i.e., usual residents. Total includes 3 children whose sex was not stated. 2.3 EDUCATION OF THE HOUSEHOLD POPULATION The educational level of household members is among the most important characteristics of the household because education is associated with reproductive health behaviour, including use of contraception and the health of children. In Maldives, the official age for entry into primary school is 6 years. Primary school consists of 7 years of education, and secondary school consists of 5 years. Lower secondary level is defined as completion of grade 10 in secondary school. Maldives has already achieved the Millennium Development Goal of providing universal primary education, and steps are being taken to provide education free of cost and to improve the quality of education (Government of Maldives, 2009). Information on the educational level of the female and male population age 6 and above is presented in Tables 2.4.1 and 2.4.2. An examination of the education distributions for successive cohorts indicates positive changes over time in the educational attainment of women and men alike. Results show that about one in four women and men have never attended school. Improvements over time can be seen by comparing the percentage of the population that has never attended school: 1 percent for women age 20-24 compared with 59 percent for women age 40-44. A similar pattern is observed for men. One in five women and men have gone to primary school without completing it. Twenty-three percent of women and 18 percent of men have completed lower secondary education. Household Population and Housing Characteristics | 15 Table 2.4.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age 6 and over by highest level of schooling attended or completed and median grade completed, according to background characteristics, Maldives 2009 Background characteristic No education Some primary Completed primary1 Some lower secondary Completed lower secondary2 Completed higher secondary3 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 23.9 75.7 0.0 0.0 0.0 0.0 0.0 0.4 100.0 1,452 0.9 10-14 0.6 64.1 17.6 17.2 0.1 0.0 0.1 0.3 100.0 2,228 5.3 15-19 0.6 1.4 4.5 41.5 47.7 2.2 1.4 0.6 100.0 2,641 9.1 20-24 1.1 2.6 8.7 9.3 63.3 5.9 6.7 2.4 100.0 2,470 9.4 25-29 2.3 8.9 22.8 8.4 44.0 2.6 9.3 1.7 100.0 2,020 9.2 30-34 13.8 17.2 28.3 10.9 20.4 1.2 5.7 2.5 100.0 1,585 6.6 35-39 33.2 19.4 25.5 5.8 9.8 0.9 3.6 1.9 100.0 1,454 5.3 40-44 58.8 12.7 15.5 4.6 4.0 0.0 1.7 2.8 100.0 1,154 0.0 45-49 72.2 11.2 8.9 2.5 1.9 0.0 1.4 1.8 100.0 843 0.0 50-54 80.5 7.5 5.2 1.4 2.3 0.0 0.0 3.1 100.0 796 0.0 55-59 82.0 7.0 4.0 1.6 1.0 0.0 0.9 3.6 100.0 439 0.0 60-64 87.7 4.5 2.4 2.0 0.0 0.0 0.0 3.4 100.0 310 0.0 65+ 91.3 3.2 0.7 0.0 0.0 0.0 0.0 4.8 100.0 924 0.0 Don't know/missing 2.0 0.4 0.0 0.6 1.6 0.4 0.0 95.1 100.0 240 7.1 Residence Urban 14.9 15.8 10.6 13.3 29.8 3.6 7.5 4.5 100.0 6,174 8.1 Rural 29.4 22.3 13.6 11.4 19.6 0.6 0.9 2.3 100.0 12,382 5.5 Region Malé 14.9 15.8 10.6 13.3 29.8 3.6 7.5 4.5 100.0 6,174 8.1 North 28.4 23.0 12.0 13.4 20.6 0.2 0.6 1.9 100.0 2,905 5.6 North Central 31.7 20.7 14.9 10.2 20.1 0.5 0.8 1.1 100.0 2,757 5.5 Central 28.5 22.3 17.0 10.8 18.3 0.5 0.7 1.8 100.0 1,444 5.8 South Central 30.6 23.6 14.1 9.8 18.8 0.5 0.6 2.1 100.0 2,101 5.2 South 28.0 22.2 12.0 11.9 19.4 1.0 1.4 4.0 100.0 3,175 5.6 Wealth quintile Lowest 34.2 25.2 13.0 11.5 14.3 0.2 0.3 1.2 100.0 3,712 4.4 Second 28.6 23.7 13.5 12.1 18.8 0.3 0.7 2.3 100.0 3,649 5.4 Middle 27.4 19.6 14.9 10.9 22.4 0.8 1.2 2.8 100.0 3,618 6.1 Fourth 19.3 17.5 12.0 12.5 30.3 1.9 3.2 3.3 100.0 3,759 7.0 Highest 13.9 14.8 9.7 13.2 29.0 4.4 9.7 5.4 100.0 3,819 8.6 Total 24.6 20.1 12.6 12.0 23.0 1.6 3.1 3.0 100.0 18,556 6.3 1 Completed 7th grade at the primary level 2 Completed 10th grade at the lower secondary level 3 Completed 12th grade at the higher secondary level 16 | Household Population and Housing Characteristics Table 2.4.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age 6 and over by highest level of schooling attended or completed and median grade completed, according to background characteristics, Maldives 2009 Background characteristic No education Some primary Completed primary1 Some lower secondary Completed lower secondary2 Completed higher secondary3 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 26.0 72.8 0.0 0.0 0.0 0.0 0.0 1.2 100.0 1,527 0.0 10-14 0.7 68.5 16.8 13.5 0.1 0.0 0.0 0.4 100.0 2,342 5.2 15-19 1.2 3.7 9.9 45.7 35.7 2.6 0.7 0.5 100.0 2,449 8.7 20-24 1.5 4.7 11.8 11.7 52.1 8.4 7.3 2.4 100.0 1,781 9.4 25-29 2.8 8.0 20.0 12.4 38.8 5.1 8.9 4.0 100.0 1,492 9.1 30-34 8.7 10.4 25.4 12.7 24.1 3.7 8.6 6.5 100.0 1,195 7.4 35-39 24.9 13.5 20.1 9.0 16.1 1.3 6.5 8.6 100.0 1,096 6.4 40-44 46.7 9.2 15.6 6.5 9.2 0.4 3.4 9.0 100.0 892 0.0 45-49 61.5 5.6 9.7 3.4 4.2 0.9 3.4 11.3 100.0 846 0.0 50-54 69.6 4.9 8.0 3.2 3.9 0.6 3.4 6.4 100.0 650 0.0 55-59 75.4 5.3 3.8 3.8 2.5 0.0 1.9 7.2 100.0 445 0.0 60-64 78.4 3.5 4.7 4.4 1.1 0.0 1.6 6.4 100.0 300 0.0 65+ 88.3 1.4 1.5 0.8 0.6 0.0 0.0 7.5 100.0 1,109 0.0 Don't know/missing 5.0 0.0 3.1 0.0 0.8 0.0 0.0 91.1 100.0 367 0.0 Residence Urban 12.4 14.7 9.9 15.6 29.1 4.8 8.7 4.9 100.0 5,510 8.4 Rural 28.8 24.4 13.2 12.5 12.9 1.0 0.7 6.5 100.0 10,979 5.0 Region Malé 12.4 14.7 9.9 15.6 29.1 4.8 8.7 4.9 100.0 5,510 8.4 North 30.3 26.3 11.0 14.1 12.8 1.0 0.6 3.9 100.0 2,383 4.6 North Central 29.4 24.4 15.5 12.0 12.6 1.3 0.7 4.0 100.0 2,340 5.1 Central 27.0 23.1 16.8 10.1 14.2 0.6 0.7 7.5 100.0 1,474 5.4 South Central 30.9 24.8 13.3 11.7 13.7 0.7 0.5 4.4 100.0 1,893 4.7 South 26.7 23.3 11.4 13.4 11.8 1.0 0.8 11.6 100.0 2,889 5.0 Wealth quintile Lowest 33.5 27.3 12.7 12.0 8.8 0.6 0.3 4.9 100.0 3,268 4.1 Second 27.9 26.3 14.1 13.0 11.8 0.6 0.5 5.8 100.0 3,240 5.0 Middle 26.3 22.6 12.9 13.2 16.3 1.4 0.8 6.7 100.0 3,251 5.7 Fourth 17.6 16.4 11.6 15.0 24.5 3.5 3.9 7.5 100.0 3,308 7.0 Highest 12.1 13.8 9.5 14.5 29.4 4.9 10.8 5.1 100.0 3,423 8.9 Total 23.3 21.2 12.1 13.5 18.3 2.2 3.3 6.0 100.0 16,490 6.2 1 Completed 7th grade at the primary level 2 Completed 10th grade at the lower secondary level 3 Completed 12th grade at the higher secondary level As expected, women and men in urban areas have better education than those in rural areas. There is not much variation in educational attainment across regions except in Malé, which has a much better educated population than other regions. For example, only 15 percent of women in Malé do not attend formal education compared with 28 to 32 percent in other regions. For women and men, educational attainment increases with the wealth quintile. Fourteen percent of women in the lowest quintile have completed lower secondary education compared with 29 percent in the highest wealth quintile. A similar pattern is observed for men. 2.3.1 School Attendance Rates Data on net attendance ratios (NARs) and gross attendance ratios (GARs) by school level, sex, residence, region, and wealth quintile are shown in Table 2.5. The NAR indicates participation in primary schooling for the population age 6-12 and in secondary schooling for the population age 13- 18. The GAR measures participation at each level of schooling among the population age 6-24. The GAR is nearly always higher than the NAR for the same educational level because the GAR includes participation by those who may be older or younger than the official age range for that level. A NAR of 100 percent indicates that all persons in the official age range for the level attend school at that level. The GAR can exceed 100 percent if there is significant over-age or under-age participation. Over-age participation for a given level of schooling occurs when a student starts school at a younger age than peers, repeats one or more grades, or drops out of school and later returns. Household Population and Housing Characteristics | 17 Table 2.5 also shows the Gender Parity Index (GPI) for primary and secondary school. The GPI for primary school is the ratio of the primary school GAR for females to the GAR for males. The GPI for secondary school is the ratio of the secondary school GAR for females to the GAR for males. The gender parity index (GPI) assesses sex-related differences in school attendance rates and is calculated by dividing the GAR for females by the GAR for males. A GPI less than one indicates a gender disparity in favour of males (i.e., a higher proportion of males than females attends that level of schooling). A GPI greater than 1 indicates a gender disparity in favour of females. A GPI of one indicates parity or equality between participation rates for males and females. Table 2.5 shows that the overall NAR for primary schools is 83, although the GAR is 115. There is a small difference in the NAR between males and females at the primary school level (82 and 84 percent, respectively). This is also true for the GAR (118 percent for males and 113 percent for females). Table 2.5 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Maldives 2009 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 80.3 85.0 82.7 1.06 114.3 114.5 114.4 1.00 Rural 81.9 83.0 82.4 1.01 118.9 112.2 115.7 0.94 Region Malé 80.3 85.0 82.7 1.06 114.3 114.5 114.4 1.00 North 81.5 86.7 84.0 1.06 118.2 117.4 117.8 0.99 North Central 85.7 81.4 83.6 0.95 119.8 111.7 115.8 0.93 Central 80.3 81.4 80.8 1.01 119.9 109.2 114.9 0.91 South Central 82.9 84.8 83.8 1.02 117.8 115.5 116.7 0.98 South 78.9 80.7 79.8 1.02 118.8 107.1 113.2 0.90 Wealth quintile Lowest 80.8 83.4 82.0 1.03 120.7 115.7 118.3 0.96 Second 83.9 82.6 83.3 0.99 120.0 111.8 116.1 0.93 Middle 81.6 82.6 82.1 1.01 119.8 111.2 115.7 0.93 Fourth 81.3 84.7 83.1 1.04 116.2 111.9 114.0 0.96 Highest 78.8 84.9 82.0 1.08 107.9 112.9 110.5 1.05 Total 81.5 83.5 82.5 1.02 117.8 112.8 115.3 0.96 SECONDARY SCHOOL Residence Urban 57.4 60.1 58.8 1.05 71.3 75.0 73.2 1.05 Rural 50.6 60.8 55.7 1.20 59.1 68.9 64.0 1.17 Region Malé 57.4 60.1 58.8 1.05 71.3 75.0 73.2 1.05 North 48.1 62.1 55.5 1.29 57.0 67.6 62.6 1.19 North Central 53.1 60.9 57.2 1.15 60.7 70.3 65.7 1.16 Central 46.1 59.5 52.3 1.29 54.5 69.6 61.5 1.28 South Central 53.8 57.2 55.4 1.06 64.1 64.5 64.3 1.01 South 50.8 62.3 56.3 1.23 58.7 71.6 64.8 1.22 Wealth quintile Lowest 43.4 57.6 50.7 1.33 52.5 65.6 59.2 1.25 Second 52.4 60.3 56.2 1.15 60.1 69.4 64.6 1.15 Middle 53.5 61.2 57.2 1.14 61.1 69.4 65.1 1.14 Fourth 53.9 61.8 58.2 1.15 68.0 73.2 70.8 1.08 Highest 61.9 62.5 62.2 1.01 75.6 77.8 76.7 1.03 Total 52.7 60.6 56.7 1.15 62.9 70.9 66.9 1.13 1 The NAR for primary school is the percentage of the primary-school-age (6-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (13-18 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary- school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of over-age and under-age 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 NAR (GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. 18 | Household Population and Housing Characteristics The NAR and GAR at the secondary school level are significantly lower than at the primary level (57 and 67, respectively). The primary school GPI of 1.02 indicates gender parity at the primary level. The GPI at the secondary school level is 1.15, reflecting that a larger proportion of girls than boys attend secondary school. The analysis does not show much variation across residence, region, or wealth quintile. Figure 2.2 illustrates age-specific attendance rates for women and men (i.e., the percentage of a given age cohort who attend school, regardless of the level attended (primary, secondary, or higher). At age 6, only 12 percent of the girls attend school. The percentage jumps to 63 percent by age 7 and to 96 percent by age 8. For males, the proportion for age 6 is 8 percent. It increases to 54 percent by age 7 and to 95 percent by age 8. 2.3.2 Grade Repetition and Dropout Rates Repetition rates and dropout rates shown in Table 2.6 describe the flow of pupils through the educational system in Maldives at the primary level. The repetition rates indicate the percentage of pupils who attended a particular grade during the 2008 school year (January to November) who again attended that same class in the 2009 school year. The dropout rates show the percentage of pupils in a grade during the 2008 school year who no longer attended school in the 2009 school year. Table 2.6 shows that, overall, repetition is highest at grade 7 (8 percent). At grades 5 and 6 repetition rates are much higher among males and in rural areas than among females and in urban areas. The table also shows that repetition rates at grade 7 are highest among respondents in the lowest wealth quintile (13 percent) and lowest among children in the highest wealth quintile (3 percent). Dropout rates are small for all grades except grade 7. At this grade, the dropout rate for males is higher than for females (4 percent compared with 1 percent). Rural children more often drop out of school at grade 7 than urban children. Across regions, Grade 7 dropout rate ranges from 4 percent in the North Central and the Central regions to 2 percent in Malé. There is no uniform pattern for Grade 7 dropout rates across wealth quintiles. Figure 2.2 Percentage of Females and Males Currently Attending School, by Age # # # # # # # # # # # # # # # # # # # #, , , , , , , , , , , , , , , , , , , , 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 120 Percent Female Male, # MDHS 2009 Household Population and Housing Characteristics | 19 Table 2.6 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics, Maldives 2009 Background characteristic School grade 1 2 3 4 5 6 7 REPETITION RATE1 Sex Male 1.0 1.7 1.6 1.6 3.1 4.2 11.5 Female 1.0 0.1 2.3 1.0 2.4 2.4 4.4 Residence Urban 0.0 0.0 0.9 1.1 1.3 1.0 2.8 Rural 1.3 1.2 2.3 1.3 3.2 4.2 9.8 Region Malé 0.0 0.0 0.9 1.1 1.3 1.0 2.8 North 1.5 0.7 0.7 0.0 2.9 8.0 13.4 North Central 1.8 0.7 2.1 3.4 3.9 1.1 8.4 Central 2.3 1.9 3.4 0.0 3.0 5.6 13.4 South Central 0.3 0.3 1.3 1.8 3.0 2.8 6.3 South 1.2 2.3 4.3 0.9 3.2 4.4 7.9 Wealth quintile Lowest 2.3 0.9 2.2 1.8 4.9 3.5 13.3 Second 0.9 0.9 2.7 1.7 3.1 5.0 8.4 Middle 1.2 1.2 2.2 0.3 1.8 4.1 7.7 Fourth 0.0 1.5 0.3 0.5 1.0 1.6 4.0 Highest 0.0 0.0 1.6 1.6 2.4 1.9 3.4 Total 1.0 0.9 1.9 1.3 2.8 3.4 8.0 DROPOUT RATE2 Sex Male 0.0 0.0 0.0 0.3 0.3 0.3 3.8 Female 0.0 0.1 0.0 0.0 0.0 0.0 1.3 Residence Urban 0.0 0.0 0.0 0.0 0.0 0.0 1.7 Rural 0.0 0.1 0.0 0.2 0.2 0.2 2.9 Region Malé 0.0 0.0 0.0 0.0 0.0 0.0 1.7 North 0.0 0.0 0.0 0.0 0.0 0.0 2.5 North Central 0.0 0.0 0.0 0.0 0.5 0.0 3.9 Central 0.0 0.0 0.1 0.0 0.0 0.0 4.3 South Central 0.0 0.5 0.0 0.0 0.5 0.0 2.2 South 0.0 0.0 0.0 0.9 0.0 1.0 2.2 Wealth quintile Lowest 0.0 0.0 0.0 0.6 0.0 0.0 3.7 Second 0.0 0.3 0.0 0.0 0.3 0.3 3.2 Middle 0.0 0.0 0.1 0.0 0.3 0.6 1.8 Fourth 0.0 0.0 0.0 0.0 0.0 0.0 0.7 Highest 0.0 0.0 0.0 0.0 0.0 0.0 3.0 Total 0.0 0.1 0.0 0.2 0.1 0.2 2.6 1 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. 2 The drop-out rate is the percentage of students in a given grade in the previous school year who are not attending school. 2.4 HOUSEHOLD ENVIRONMENT The physical characteristics of the dwelling in which a household lives are important determinants of the health status of household members, especially children. Physical characteristics can also be used as indicators of the socioeconomic status of households. MDHS respondents were asked a number of questions about their household environment, including questions on the source of drinking water; type of sanitation facility; type of flooring, walls, and roof; and number of rooms in the dwelling. The results are presented both in terms of households and of the de jure population. 20 | Household Population and Housing Characteristics 2.4.1 Drinking Water Table 2.7 shows that 97 percent of households have access to improved sources of water. Rural households are slightly less likely to have access to improved water sources than urban households (97 percent compared with 99 percent). Rainwater is a more important source of drinking water in the rural areas (95 percent) than in the urban areas (5 percent). Fifty-two percent of urban households have piped water into their premises) but it is not the main source of water for drinking. Overall, 13 percent of the households use bottled water for cooking/washing (41 percent in urban areas and 1 percent in rural areas). Table 2.7 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and the de jure by treatment of drinking water, according to residence, Maldives 2009 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 98.6 97.0 97.4 98.8 97.4 97.7 Piped water into dwelling/yard/plot 52.0 0.5 16.4 56.6 0.7 18.7 Public tap/standpipe 0.3 0.3 0.3 0.3 0.4 0.3 Protected dug well 0.7 1.0 0.9 1.3 1.1 1.1 Bottled water, improved source for cooking/washing1 40.9 0.5 13.0 34.3 0.4 11.3 Rainwater 4.7 94.7 66.8 6.3 94.8 66.3 Non-improved source 0.7 0.4 0.5 0.6 0.4 0.4 Unprotected dug well 0.0 0.3 0.2 0.0 0.3 0.2 Bottled water, non-improved source for cooking/washing 0.7 0.1 0.3 0.6 0.1 0.2 Other 0.5 2.5 1.9 0.5 2.2 1.7 Missing 0.1 0.0 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 98.7 97.0 97.5 98.8 97.3 97.8 Time to obtain drinking water (round trip) Water on premises 98.8 91.3 93.6 99.0 91.7 94.1 Less than 30 minutes 0.5 6.8 4.9 0.6 6.3 4.4 30 minutes or longer 0.3 1.3 1.0 0.2 1.6 1.1 Don't know/missing 0.4 0.6 0.5 0.3 0.4 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 0.6 6.7 4.8 0.4 6.4 4.5 Adult male 15+ 0.6 1.1 0.9 0.5 1.0 0.8 Female child under age 15 0.0 0.4 0.2 0.0 0.4 0.2 Male child under age 15 0.0 0.2 0.1 0.0 0.2 0.1 Other 0.0 0.2 0.2 0.0 0.2 0.1 Water on premises 98.8 91.3 93.6 99.0 91.7 94.1 Missing 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 10.8 8.9 9.5 11.6 8.9 9.7 Bleach/chlorine 0.2 3.2 2.3 0.1 3.4 2.4 Strained through cloth 0.5 38.2 26.6 0.9 39.3 26.9 Ceramic, sand or other filter 8.0 3.6 5.0 7.9 3.5 4.9 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 Other 0.0 0.8 0.6 0.0 0.9 0.6 No treatment 80.8 45.8 56.7 79.6 44.3 55.7 Percentage using an appropriate treatment method3 18.9 47.6 38.7 20.0 48.7 39.5 Number 1,994 4,449 6,443 13,204 27,776 40,980 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. Household Population and Housing Characteristics | 21 Ninety-four percent of households have the water source on the premises (99 percent in urban and 91 percent in rural areas). Adult females collect drinking water (5 percent) more often than anyone else in the household. In urban areas, most households use water from desalinated plants. More than half of the households (57 percent) do not treat the water prior to drinking (81 percent in urban areas and 46 percent in rural areas). Among households that treat their drinking water; 39 percent use an appropriate method (19 percent in urban areas and 48 percent in rural areas). Straining through cloth (27 percent) and boiling (10 percent) are the most common methods used to treat water. 2.4.2 Household Sanitation Facilities A household is classified as having an improved toilet if the toilet is used only by members of one household (that is, not shared with members of other households) and if the toilet separates the waste from human contact (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004). Table 2.8 shows that rural households are somewhat less likely to have a non-improved toilet facility than urban households (7 percent and 3 percent, respectively).Flush toilets are the most common type of toilet in Maldives. Ninety-seven percent of households in urban areas use flush toilets to a piped sewer system. The most common type of toilet in rural areas is a flush toilet facility to a pit latrine. Only 2 percent of households have no toilet facility. Table 2.8 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Maldives 2009 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 96.5 17.2 41.7 96.9 18.3 43.6 Flush/pour flush to septic tank 0.8 34.8 24.3 0.6 35.4 24.2 Flush/pour flush to pit latrine 0.0 39.0 27.0 0.0 37.9 25.7 Ventilated improved pit (VIP) latrine 0.0 1.1 0.8 0.0 1.1 0.7 Pit latrine with slab 0.0 0.5 0.4 0.0 0.5 0.3 Non-improved facility Any facility shared with other households 2.6 1.9 2.1 2.4 1.7 1.9 Flush/pour flush not to sewer/septic tank/pit latrine 0.0 0.9 0.6 0.0 1.0 0.7 Pit latrine without slab/open pit 0.0 0.3 0.2 0.0 0.4 0.3 No facility/bush/field 0.0 2.2 1.5 0.0 1.4 1.0 Other 0.0 2.0 1.4 0.0 2.2 1.5 Missing 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,994 4,449 6,443 13,204 27,776 40,980 2.4.3 Housing Characteristics Table 2.9 presents information on a number of household dwelling characteristics and the proportion of households using various types of fuel for cooking. These characteristics reflect the household’s socioeconomic situation. They also may influence environmental conditions—for example, in the case of the use of biomass fuels, exposure to indoor pollution—that have a direct bearing on household members’ health and welfare. Electricity is universally available in Maldives. 22 | Household Population and Housing Characteristics Table 2.9 Household characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Maldives 2009 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 99.9 99.8 99.8 99.9 99.9 99.9 No 0.0 0.1 0.1 0.0 0.0 0.0 Missing 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 0.3 1.0 0.8 0.6 0.9 0.8 Wood/planks 0.4 0.0 0.1 0.3 0.0 0.1 Parquet or polished wood 10.4 58.1 43.3 10.3 57.1 42.0 Vinyl or asphalt strips 83.5 38.1 52.1 82.8 39.3 53.3 Ceramic tiles 2.8 2.3 2.5 2.8 2.2 2.4 Cement 0.4 0.0 0.1 0.6 0.0 0.2 Carpet 2.1 0.1 0.7 2.3 0.1 0.8 Other 0.0 0.2 0.2 0.0 0.2 0.2 Missing 0.2 0.2 0.2 0.4 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 23.4 13.9 16.9 13.9 8.0 9.9 Two 36.9 31.7 33.3 32.9 26.3 28.4 Three or more 39.6 53.9 49.5 53.2 65.3 61.4 Missing 0.1 0.4 0.3 0.1 0.4 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 91.1 32.9 50.9 91.4 31.0 50.5 In a separate building 6.5 63.1 45.6 7.3 66.2 47.2 Outdoors 0.8 2.2 1.7 0.7 2.1 1.6 Other 0.0 0.1 0.1 0.0 0.1 0.1 Missing 1.6 1.7 1.7 0.6 0.7 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 1.6 0.6 0.9 1.5 0.5 0.8 LPG/natural gas/biogas 96.6 88.7 91.2 97.7 89.5 92.2 Kerosene 0.2 0.7 0.5 0.1 0.5 0.4 Wood 0.0 8.3 5.7 0.0 8.8 6.0 No food cooked in household 1.4 1.6 1.5 0.4 0.5 0.5 Other 0.0 0.0 0.0 0.0 0.0 0.0 Missing 0.2 0.0 0.1 0.2 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 0.0 8.3 5.7 0.0 8.8 6.0 Number of households 1,994 4,449 6,443 13,204 27,776 40,980 LPG = Liquid petroleum gas 1 Includes wood More than half of the households (52 percent) use vinyl or asphalt strips for flooring material. These materials are more often used in urban areas than in rural areas (84 percent and 38 percent, respectively). In rural areas, 58 percent of the households use parquet or polished wood compared with 10 percent in urban areas. Almost half of the households in Maldives live in housing units with three or more bedrooms, and one in three households has two bedrooms. Households in rural areas typically have a larger number of rooms for sleeping compared with urban households. Household Population and Housing Characteristics | 23 Fifty-one percent of households cook inside the house, and 46 percent cook in a separate building. Nine in ten households in urban areas cook inside the house. In rural areas this proportion is only 33 percent. LPG, natural gas, or biogas is the most common fuel used for cooking, reported by 91 percent of households. Gas is more often used in urban areas (97 percent) than in rural areas (89 percent). Firewood is used for cooking in 6 percent of households, all of them in rural areas. 2.5 HOUSEHOLD POSSESSIONS The possession of durable consumer goods is a good indicator of a household’s socioeconomic status. Moreover, particular goods have specific benefits. For instance, having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs food storage; and a means of transport allows greater access to many services away from the local area. Table 2.10 shows that most households own the consumer goods asked about in the survey. Eighty-three percent own a radio (72 percent in urban areas and 88 percent in rural areas), and 96 percent own a television (97 percent in urban areas and 95 percent in rural areas). A mobile telephone is available in 97 percent of households (99 percent in urban areas and 97 percent in rural areas) and 24 percent of the households have non-mobile telephones (45 percent in urban areas and 15 percent in rural areas). Eighty-five percent of the households own a refrigerator (96 percent in urban areas and 80 percent in rural areas). Table 2.10 also shows that 40 percent of the households own a bicycle (15 percent in urban areas and 51 percent in rural areas), 42 percent own a motorcycle (70 percent in urban areas and 29 percent in rural areas), and only 5 percent own a car. Five percent of the households own a boat with a motor (3 percent in urban areas and 6 percent in rural areas). Bicycles and boats with a motor are more common in rural areas than in urban areas. Table 2.10 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Maldives 2009 Households Population Possession Urban Rural Total Urban Rural Total Household effects Radio 71.9 88.1 83.1 75.4 88.9 84.6 Television 97.3 95.0 95.7 98.2 97.3 97.6 Mobile telephone 98.9 96.6 97.3 99.6 98.2 98.7 Non-mobile telephone 44.6 14.8 24.0 48.2 16.2 26.5 Refrigerator 95.7 80.1 84.9 97.4 83.6 88.0 Means of transport Bicycle 14.7 51.2 39.9 18.1 55.3 43.3 Motorcycle/scooter 69.8 28.8 41.5 76.2 32.8 46.8 Car/truck 10.6 2.5 5.0 12.2 3.1 6.1 Boat with a motor 2.7 5.6 4.7 3.1 6.9 5.7 Number 1,994 4,449 6,443 13,204 27,776 40,980 2.6 WEALTH INDEX Information on household assets was used to create an index representing the wealth of the households interviewed in the MDHS. To construct the wealth index, each household asset for which information was collected in the survey was assigned a weight or factor score generated through principal components analysis, and the resulting asset scores were standardized. The MDHS households were then assigned a standardized score for each asset, where the score differed depending on whether or not the household owned that asset. The scores were summed by household. Individuals were ranked according to the total score of the household in which they resided and divided into population quintiles, i.e., five groups with the same number of individuals in each. 24 | Household Population and Housing Characteristics The wealth index has been compared with both poverty rates and gross domestic product per capita for India, and with expenditure data from household surveys in Nepal, Pakistan, Indonesia (Filmer and Pritchett, 1998), and Guatemala (Rutstein, 1999). The evidence from those studies suggests that the assets index is highly comparable to conventionally measured consumption expenditures. Table 2.11 shows the degree to which wealth is distributed across residence in Maldives. As expected, urban populations are wealthier than rural populations. This is shown by the small percentage of the population in the urban areas in the three lowest quintiles (less than 3 percent). On the other hand, almost six in ten rural populations are in the first two quintiles (59 percent). Across regions, 61 percent of the population in Malé belong to the highest wealth quintile compared with one percent or less in other regions. Table 2.11 Wealth quintiles Percent distribution of the jure population by wealth quintiles according to residence and region, Maldives 2009 Wealth quintile Number of population Residence/region Lowest Second Middle Fourth Highest Total Residence Urban 0.2 0.4 2.2 36.4 60.9 100.0 13,204 Rural 29.4 29.3 28.5 12.2 0.6 100.0 27,776 Region Malé 0.2 0.4 2.2 36.4 60.9 100.0 13,204 North 39.1 28.6 22.4 9.8 0.1 100.0 6,360 North Central 29.9 29.6 29.0 10.9 0.6 100.0 5,996 Central 22.4 29.0 34.2 13.9 0.4 100.0 3,561 South Central 29.6 35.6 27.5 7.1 0.2 100.0 4,726 South 23.7 25.7 31.1 18.1 1.4 100.0 7,133 Total 20.0 20.0 20.0 20.0 20.0 100.0 40,980 2.7 BIRTH REGISTRATION The registration of a birth is the inscription of the facts of the birth into an official log. A birth certificate is issued at the time of registration or later as proof of the registration of the birth. Birth registration is basic to ensuring a child’s legal status and, thus, basic rights and services (UNICEF, 2006; United Nations General Assembly, 2002). The registration of vital events in most developing countries is a function of a number of socioeconomic factors. Information on the registration of births was collected in the household interview by asking whether children under age 5 had a birth certificate. If the interviewer was told that the child did not have a birth certificate, the interviewer probed further to ascertain whether the child’s birth had been registered with the civil authority. Overall, 93 percent of children were registered, 89 percent had a birth certificate, and 3 percent were registered but did not have a birth certificate. Coverage of registration does not vary greatly across most background characteristics, as shown in Table 2.12. For instance, coverage varies between 86 percent in the South region and 97 percent in the North region. Household Population and Housing Characteristics | 25 Table 2.12 Birth registration of children under age 5 Percentage of de jure children under 5 years of age whose births are registered with the civil authorities, according to background characteristics, Maldives 2009 Percentage of children whose births are registered Background characteristic Had a birth certificate Did not have a birth certificate Total registered Number of children Age <2 86.3 5.4 91.7 1,923 2-4 91.8 1.3 93.2 2,269 Sex Male 89.8 3.0 92.8 2,112 Female 88.8 3.4 92.3 2,077 Residence Urban 90.4 2.2 92.6 1,233 Rural 88.8 3.6 92.4 2,960 Region Malé 90.4 2.2 92.6 1,233 North 94.2 2.8 96.9 672 North Central 92.9 2.4 95.3 639 Central 87.3 4.5 91.8 401 South Central 90.5 2.8 93.3 492 South 80.3 5.5 85.7 756 Wealth quintile Lowest 87.7 4.2 91.9 795 Second 89.6 3.9 93.5 888 Middle 90.4 3.0 93.5 893 Fourth 87.0 2.6 89.6 846 Highest 91.7 2.2 93.8 770 Total 89.3 3.2 92.5 4,192 Note: Total includes 3 children whose sex was not stated. 2.8 EARLY CHILDHOOD EDUCATION ATTENDANCE In the MDHS, information was collected if the child attended any organized learning or early childhood education programme, including kindergarten or community childcare, run either by a private or a public facility. Table 2.13 shows that 71 percent of children age 3-4 years attend some form of early childhood education. Girls attend this education more often than boys; 72 percent and 70 percent, respectively. The highest percentage of children attend- ing early education is reported in the North Central region (79 percent), and the lowest is in the South Central region (52 percent). 2.9 DISABILITY Each respondent to the household questionnaire was asked to report on the ability of household members to function within six domains. The domains inquired about are those recommended by the Washington Group on Disability Statistics (Washington Group on Disability Statistics, 2006) and include vision, hearing, communicating, remembering, mobility, and self-care. Respondents were asked to report for each household member age 5 years and older whether the person is able to perform those functions with no difficulty, only Table 2.13 Early childhood education attendance Percentage of children age 3-4 years who attend some form of organized early childhood education, by background characteristics, Maldives 2009 Background characteristic Number of children Percent Sex Male 69.5 782 Female 71.9 751 Region Malé 69.0 437 North 76.3 246 North Central 79.2 254 Central 75.4 148 South Central 51.6 165 South 69.6 284 Total 70.7 1,534 26 | Household Population and Housing Characteristics with some difficulty, with a lot of difficulty, or not at all. Table 2.14 presents the percentage of household members who are reported to have either some difficulty or a lot of difficulty functioning within each of the six domains. It also presents the percentage of household members reported as not being able to perform the function at all. In addition, the table presents the percentage of household members reported to have some difficulty functioning within at least one of the domains, the percentage having a lot of difficulty functioning within at least one of the domains, and the percentage who cannot perform at all in at least one of the six function domains. Each of the disability measures is presented for the entire household population age 5 years and older and for household members age 5-14 years, age 15-49 years, and age 50 years and older. Table 2.14 Disability Percentage of de-facto household members age 5 and above with a disability, by specific age groups, Maldives 2009 Level of functioning Some difficulty Lot of difficulty Cannot do at all ALL HOUSEHOLD MEMBERS AGE 5 AND ABOVE Function domain Vision 13.2 4.7 0.2 Hearing 4.0 1.5 0.2 Communicating 2.5 1.1 0.5 Remembering 6.4 2.3 0.4 Mobility 7.4 4.0 0.6 Self-care 1.6 1.1 0.6 Prevalence of at least one function being reported at the specified level of functioning 22.0 9.6 1.3 Number of household members 35,691 35,691 35,691 HOUSEHOLD MEMBERS AGE 5-14 Function domain Vision 6.9 2.1 0.1 Hearing 2.1 0.7 0.2 Communicating 3.3 1.2 0.4 Remembering 4.8 2.0 0.4 Mobility 1.3 0.7 0.2 Self-care 0.8 0.6 0.4 Prevalence of at least one function being reported at the specified level of functioning 13.9 5.0 0.7 Number of household members 8,269 8,269 8,269 HOUSEHOLD MEMBERS AGE 15-49 Function domain Vision 10.8 3.3 0.1 Hearing 2.9 1.0 0.2 Communicating 1.6 0.8 0.4 Remembering 4.4 1.3 0.3 Mobility 4.1 1.7 0.2 Self-care 0.7 0.4 0.2 Prevalence of at least one function being reported at the specified level of functioning 17.6 6.4 0.8 Number of household members 21,917 21,917 21,917 HOUSEHOLD MEMBERS AGE 50+ Function domain Vision 31.9 14.5 0.7 Hearing 11.5 4.6 0.4 Communicating 4.7 2.1 0.6 Remembering 16.8 6.6 0.9 Mobility 29.9 18.1 2.6 Self-care 6.6 4.3 2.2 Prevalence of at least one function being reported at the specified level of functioning 51.3 29.3 4.2 Number of household members 5,504 5,504 5,504 Household Population and Housing Characteristics | 27 Twenty-two percent of household members age 5 years and older have some difficulty functioning in at least one of the domains, 10 percent have a lot of difficulty in at least one of the domains, and 1 percent cannot function at all in at least one of the six domains. The disability reported most often is with vision (13 percent) followed by mobility (7 percent). The prevalence of functioning with some difficulty in at least one domain increases from 22 percent for persons age 5-14 to 51 percent for persons age 50 and older. Four percent of persons age 50 and older cannot function at all in at least one of the domains compared with less than one percent of household members in each of the other age groups. The proportion of household members reported to have at least one function impairment increases with age, from 33 percent among household members age 5-14 to 86 percent among household members age 50 and older. Vision is the domain in which increases in problems across age groups are greatest; the percentage reporting at least difficulty with vision increases from 9 percent among persons age 5-14 to 47 percent among persons age 50 and older. Next to vision, the domains in which household members age 50 and older have the greatest problems in functioning are mobility (51 percent) and remembering (24 percent). 2.9.1 Young Child Disability Questions relating to young children’s disability were asked to a child’s parent or primary caretaker. Respondents were asked to report whether the young children had any of the follow- ing disabilities: serious delay in sitting, standing, or walking, difficulty seeing, either in the daytime or at night, difficulty hearing, difficulty understanding what is being said, difficulty in walking or moving arms, having fits, becoming rigid or losing consciousness, not learning to do things like other children; and difficulty speaking/being understood. Table 2.15 shows that one in four children age 2-9 years was reported to have at least one difficulty. The disability reported most often is that the child does not learn to do things like other children (10 percent) followed by difficulty understanding what is being said (7 percent). Six percent of children were reported to have fits, become rigid, or lose consciousness, and 4 percent have a serious delay in sitting, standing, or walking and difficulty speaking or being understood. 2.10 CHILDREN IN ECONOMICALLY PRODUCTIVE LABOUR Information was collected in the survey on work done by children age 5-14 years. Economically productive work includes any work (paid and unpaid) for someone who is not a member of the household; help with household chores such as shopping, collecting firewood, cleaning, fetching water, or caring for children; and family work (on the farm or in a business or selling goods in the street). Table 2.16 shows that 34 percent of children age 5-14 are working in economically productive work, and most of them do domestic work (32 percent). Among children who work in domestic jobs, 22 percent work for less than 4 hours per day and 11 percent work for more than 4 hours per day. Older children (10-14 years), girls, and children in the South region are more likely to work than other children. Table 2.15 Young child disability Percentage of children aged 2-9 years who, compared to other children, have specific difficulties, according to type of difficulty, and the percentage of children with at least one disability, Maldives 2009 Disability Percent Serious delay in sitting, standing or walking 3.8 Difficulty seeing, either in the daytime or at night 3.1 Have difficulty hearing 2.9 Difficulty understanding what is being said 7.3 Difficulty in walking or moving arms 2.8 Have fits, become rigid or lose consciousness 5.5 Does not learn to do things like other children 9.7 Difficulty speaking/being understood 4.4 At least one disability 24.8 Number 6,050 28 | Household Population and Housing Characteristics Table 2.16 Children in economically productive labour Percentage of children age 5-14 years working in economically productive work, by selected background characteristics, Maldives 2009 Working for someone who is not a member of the household Domestic work Other family/ farm business Currently working Number of children Background characteristic Paid Unpaid Less than 4 hours 4 hours or more/day Age 5-9 0.1 2.2 18.5 5.3 0.5 25.5 3,735 10-14 0.4 3.0 24.1 14.8 1.3 41.2 4,631 Sex Male 0.4 2.8 19.4 7.6 0.8 29.3 4,278 Female 0.2 2.4 24.0 13.7 1.0 39.3 4,089 Region Malé 0.0 4.2 14.4 4.9 0.4 21.9 2,123 North 0.5 1.9 21.7 12.4 1.4 35.9 1,450 North Central 0.5 2.9 22.0 9.6 0.8 34.6 1,369 Central 0.4 0.7 22.2 6.2 1.3 29.7 739 South Central 0.2 3.9 9.7 15.8 0.9 27.9 1,061 South 0.4 1.1 38.1 15.7 1.1 54.5 1,625 Total 0.3 2.6 21.6 10.6 0.9 34.2 8,367 2.11 CARE AND SUPPORT FOR OLDER ADULTS Table 2.17 shows that overall, 31 percent of household members are under age 15, 64 percent are age 15-64, and 5 percent are age 65 or older. Malé has the highest proportion of people who belong to the productive group (age 15-64), and the South region has the lowest (71 percent and 58 percent, respectively). More than one in four households (26 percent) has at least one member who is 65 years or older. The proportion of households with a member age 65 or older ranges from 16 percent in Malé to 37 percent in the South region. Table 2.17 Households with older adult population Percent distribution of household population by specific age groups and the percentage of households with a usual member (de jure) age 65 or older, by region, Maldives 2009 Number of usual members of a household (de jure members) Percentage of households with a usual member age 65 or older Number of households Age Region 0-14 15-64 65+ Don’t know/ missing Total Malé 25.7 71.3 2.8 0.2 100.0 12,994 15.9 1,994 North 33.3 61.1 5.4 0.1 100.0 6,302 25.9 1,032 North Central 33.4 60.4 6.0 0.2 100.0 5,970 28.2 1,008 Central 32.1 63.3 4.6 0.1 100.0 3,515 26.5 480 South Central 32.6 60.9 6.4 0.0 100.0 4,698 30.0 780 South 34.0 57.9 7.6 0.5 100.0 6,963 37.2 1,150 Total 30.8 63.9 5.1 0.2 100.0 40,443 25.7 6,443 Household Population and Housing Characteristics | 29 To gauge the level of care and support that is provided by households for older adults, each respondent to the household questionnaire was asked to report on the care and support that the older members (age 65 and older) of their household require in five areas of physical activity. Respondents were asked to report whether household members age 65 and older require assistance with the following physical activities: personal care such as bathing, dressing, or eating; medical care such as giving medications or changing dressings; household activities such as cooking, laundry, and cleaning; going outside the house; and being watched over so as not to hurt themselves or others. The findings are presented in Table 2.18. Table 2.18 Care and support of physical activities for older adults Percentage of de-facto household members age 65 and older requiring care and support for specific physical activities, by region, Maldives 2009 Total number of household members age 65 and older Physical activities for which adults age 65 and older require care and support Region Personal care Medical care Household activities To go outside Watched over for safety Malé 22.0 39.2 20.8 28.6 17.4 382 North 27.4 46.4 24.7 20.4 18.6 338 North Central 21.8 33.0 20.3 16.8 19.7 343 Central 25.4 41.4 23.8 18.7 14.8 157 South Central 28.2 43.8 27.7 19.7 15.1 294 South 29.1 42.1 33.5 24.3 32.5 519 Total 25.8 40.9 25.8 22.1 21.3 2,033 About 4 in 10 older adults (41 percent) need assistance with medical care such as taking medications and changing dressings, or other medical requirements. About one in four older adults requires help with personal care, and the same proportion needs assistance with general household tasks. One in five older adults each must be assisted when leaving their home and must be watched over for safety reasons. To further assess the overall extent of care and support required by older adults, Table 2.19 presents the percentage of older adults who require assistance with one or more needs, two or more needs, three or more needs, four or more needs, or help with all five needs. Overall, 5 percent of the population age 65 and older need assistance with all five needs that were asked about, while 43 percent do not require assistance with any of the five activities. Table 2.19 Amount of care and support of physical activities for older adults Percentage of de-facto household members age 65 and older requiring care and support in one or more areas, by region, Maldives 2009 In how many areas of physical activity is care and support needed by household members age 65 and older? Total number of household members age 65 and older Region Require no support One or more Two or more Three or more Four or more All five1 Malé 42.9 57.1 34.3 20.7 12.5 3.5 382 North 38.1 61.9 37.7 22.6 10.4 5.0 338 North Central 55.2 44.8 31.4 20.1 12.0 3.2 343 Central 44.6 55.4 30.8 21.2 13.1 3.6 157 South Central 44.2 55.8 37.0 21.9 13.5 6.3 294 South 35.1 64.9 42.7 30.9 15.5 7.5 519 Total 42.5 57.5 36.6 23.7 13.0 5.1 2,033 1 Personal care, medical care, household activities, going outside, and watching over for safety. 30 | Household Population and Housing Characteristics 2.12 HEALTH EXPENDITURES The MDHS included a health expenditure module to determine how much money households paid for expenditures related to health care. Household respondents were asked to report on expenditures for health insurance premiums, hospital stays in the previous year, and for all health care related costs incurred in the previous month, including visits to health care providers, laboratory tests, other medical tests, prescription drugs, non-prescription drugs, and finally, travel and accommodation costs associated with obtaining care on other islands. Prior to asking specific expenditure questions, household respondents were asked to report on the frequency of the related health activity. Each household was asked whether any member of the household was covered by a health welfare or assistance plan at any time in the preceding year. Table 2.20 shows that 29 percent of households have at least one household member who was covered by a health welfare or assistance plan in the previous year. As many as 4 in 10 households in Malé had a member so covered. This is the highest percentage in the regions of Maldives. In contrast, only 17 percent of households in South Central have at least one member who is covered by a health welfare plan or assistance. Coverage with a health welfare or assistance plan is more common as the wealth level of the household rises. Only 18 percent of the poorest households have a member who has health coverage compared with 4 in 10 of the wealthiest households. Table 2.20 shows that hospitali- zation is more common in rural areas, and in the North, Central, and South regions. Admittance to a hospital de- clines as the education level and wealth status of the household head increases. For example, the proportion of house- holds with a member admitted to a hos- pital in households whose head has no education is 58 percent compared with 45 percent of households whose head has more than secondary education. The last column in Table 2.20 is shown to gauge the utilization of out- patient services. Overall, 61 percent of households had a member who visited a health care provider for treatment or preventive care in the month before the survey. Rural households had a slightly higher proportion of visits to a health care provider than urban households. There are small variations across re- gions. Visits to a health care provider decline as the education level of the household head increases. For example, 63 percent of households whose head has no education have a member who visited a health care provider compared with 52 percent of households whose head has more than secondary educa- tion. Table 2.20 Health insurance coverage and utilization of inpatient and outpatient services Percentage of households with at least one household member who was covered by a health welfare plan or assistance, was hospitalized during the year before the survey, or visited a health provider during the past month, by background characteristics, Maldives 2009 Percentage of households with at least one member who: Background characteristic Was covered by a health welfare plan/ assistance Had a hospital stay last year Visited a health provider during the last month Number of households Residence Urban (Malé) 40.2 42.9 59.8 1,994 Rural 23.2 60.3 61.8 4,449 Region Malé 40.2 42.9 59.8 1,994 North 22.9 61.2 62.1 1,032 North Central 21.0 58.7 62.0 1,008 Central 35.6 60.9 62.7 480 South Central 16.9 59.7 62.5 780 South 24.6 60.8 60.4 1,150 Education of the head of the household No education 25.9 58.4 62.6 3,731 Primary 24.4 51.0 61.1 1,293 Secondary 42.7 46.9 57.1 829 More than secondary 42.6 44.7 51.8 211 Wealth index quintile Lowest 17.5 56.5 60.9 1,523 Second 21.4 62.5 63.4 1,269 Middle 27.9 62.2 60.6 1,257 Fourth 37.0 51.4 62.3 1,232 Highest 42.2 40.3 58.5 1,162 Total 28.5 54.9 61.2 6,443 Note: Total includes 379 households with information missing on the level of formal education for the household head Household Population and Housing Characteristics | 31 Results of the specific expenditure questions are not included in this report because as can be seen in Table 2.21, a high percentage of household respondents reported that they did not know all the expenditure questions they were asked. Table 2.21 shows what percentage of households had a household member who experienced a health care service, but did not know the answer to the question on how much the service cost. For example, 38 percent of households had a member of the household admitted to a hospital in the previous year, but did not know how much the household was charged for the hospital stay (excluding costs covered by a health welfare or assistance plan). Similarly, thirty-two percent of households reported having a member of the household obtain laboratory tests, but did not know how much the household was charged for the laboratory tests (excluding costs covered by a health welfare or assistance plan). Due to the rather high percentage of “Don’t know” responses or missing data on costs, the cost data are not included in this report. Table 2.21 Quality of health expenditure data Percentage of households with at least one household member having a specific health service for which the response on the question relating to costs of the service was 'Don't know' or missing, Maldives 2009 Percentage “don't know” and missing on cost Background characteristic Hospital stay Provider visit Laboratory fees Other medical test Prescription drugs Non- prescription drugs Residence Urban (Malé) 47.2 33.1 44.4 45.8 45.6 35.6 Rural 35.1 18.4 25.3 36.6 25.4 17.5 Region Malé 47.2 33.1 44.4 45.8 45.6 35.6 North 32.2 10.7 19.8 31.0 22.5 17.9 North Central 30.4 11.1 22.8 34.9 21.5 11.6 Central 43.4 30.1 40.8 50.7 33.7 31.6 South Central 36.7 25.4 29.3 37.4 24.9 20.1 South 37.0 22.1 22.9 33.8 28.5 14.0 Atoll Malé 47.2 33.1 44.4 45.8 45.6 35.6 Haa Alif 20.2 7.9 11.3 (14.8) 13.2 (12.1) Haa Dhaal 35.7 10.5 20.8 (32.1) 22.5 (13.8) Shaviyani 39.9 14.6 27.9 (49.0) 33.2 (27.4) Noonu 32.6 10.8 19.5 (31.8) 23.3 * Raa 33.0 8.0 26.4 38.5 25.1 * Baa 31.0 11.9 29.3 (35.3) 17.7 6.9 Lhaviyani 20.7 15.5 10.7 (30.1) 18.5 (22.4) Kaafu 34.0 26.7 34.5 (53.3) 24.6 (31.5) Alif Alif 46.7 19.3 38.5 54.5 32.6 (27.9) Alif Dhaal 53.3 45.4 49.9 48.7 47.2 33.7 Vaavu 29.9 11.6 27.1 (26.0) 16.4 * Meemu 35.4 12.5 29.4 33.4 22.1 * Faafu 21.9 11.1 19.5 (33.9) 13.9 * Dhaalu 38.6 24.6 (26.6) (49.6) 26.6 * Thaa 35.0 26.9 33.3 (44.9) 20.1 * Lhaamu 43.3 35.1 30.3 32.2 31.9 (25.5) Gaaf Alif 49.1 27.4 24.8 41.1 32.0 (27.8) Gaaf Dhaal 38.5 15.5 23.3 (28.4) 34.6 (11.4) Gnaviyani 30.9 24.1 25.9 (38.5) 29.7 (13.2) Seenu 32.5 23.8 20.9 (32.4) 22.2 * Education of the head of the household No education 36.9 21.5 29.8 41.2 30.3 25.5 Primary 36.7 21.4 27.8 32.1 26.6 22.7 Secondary 43.5 27.6 38.5 40.8 38.5 31.6 More than secondary (33.2) 22.5 (29.7) * (35.8) * Certificate 43.0 16.9 (27.1) * 23.0 * Missing 45.7 35.5 52.3 68.1 47.7 (25.9) Wealth index quintile Poorest 38.5 18.2 29.1 36.3 27.6 14.8 Poorer 37.4 17.2 22.2 33.8 25.8 19.6 Middle 31.8 20.6 25.0 39.9 22.0 20.3 Richer 37.9 27.9 37.1 44.7 42.4 29.9 Richest 48.6 32.7 44.7 44.0 41.5 35.1 Total 38.0 22.8 31.6 40.1 31.3 25.2 Number 3,537 3,941 2,175 1,182 3,702 876 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 32 | Household Population and Housing Characteristics 2.13 TSUNAMI Nearly one in ten households report having a household member who has been displaced as a result of the tsunami (see Table 2.22). The most affected region is South Central, where one in four households report having a member displaced by the tsunami. The Central and North Central regions each have 20 percent and 11 percent of household members who were displaced. Table 2.22 indicates that, among households that have a household member who was dis- placed by the tsunami, 7 percent were displaced on the same island and 2 percent were displaced to another island. Nineteen percent of households in the South Central region and 13 percent in the Central region have a household member who was displaced on the same island. Table 2.22 Tsunami displacement Percentage of households who have a household member who was displaced because of the tsunami, and whether or not they were displaced to another island, by region, Maldives 2009 Displaced to where: Percentage of households who have a household member who was displaced Number of households Region Displaced on the same island Displaced to another island Not determined Malé 1.1 0.5 0.0 1.5 1,994 North 5.3 0.1 0.1 5.5 1,032 North Central 7.6 2.7 0.2 10.5 1,008 Central 13.3 5.1 0.7 19.1 480 South Central 18.5 6.7 0.0 25.2 780 South 7.5 0.7 0.4 8.5 1,150 Total 6.9 1.9 0.2 9.0 6,443 Households which have a household member who was displaced because of the tsunami were asked the location of those household members. Table 2.23 indicates that among those households with a household member who was displaced by the tsunami, 14 percent have a household member who is still living in temporary shelter. About half are living in their own house that has been reconstructed or repaired, and 16 percent are living in a new house. Another 10 percent live with a host family. The proportion of displaced persons who live in their own renovated or repaired house varies across regions, ranging from 43 percent in North Central to 64 percent in Central region. Three in ten displaced persons in North Central region live in a reconstructed new house. Table 2.23 Current location of tsunami displaced For those households who have a household member who was displaced because of the tsunami, the distribution of where those displaced members live now, by region, Maldives 2009 Where displaced members live now: Region Temporary shelter Old damaged house Own renovated/ repaired house Reconstructed new house Living with host family Not determined Total Number of households Malé * * * * * * 100.0 31 North 19.1 3.9 53.0 6.3 17.7 0.0 100.0 57 North Central 7.5 10.8 43.4 30.5 6.0 1.7 100.0 106 Central 6.8 9.4 64.1 8.8 10.4 0.6 100.0 92 South Central 17.6 10.2 48.8 16.1 7.3 0.0 100.0 197 South 12.2 6.0 52.2 7.8 15.3 6.5 100.0 98 Total 13.8 8.3 49.1 16.3 10.1 2.4 100.0 580 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Household Population and Housing Characteristics | 33 Table 2.24 shows that, among households that gave shelter after the tsunami, 3 in 10 provided shelter to 0-4 people, 36 percent sheltered 5-9 people, and 26 percent sheltered 10 or more people. Table 2.23 also shows some variations across regions. Table 2.24 Number of people sheltered Among households giving shelter after the tsunami, the percent distribution of number of people sheltered, by region, Maldives 2009 Number of people given shelter Region 0-4 5-9 10+ Don't know/ missing Total Number of households Malé (38.2) (33.7) (15.3) (12.7) 100.0 108 North 35.3 43.9 15.4 5.4 100.0 80 North Central 31.2 35.3 29.3 4.2 100.0 94 Central 26.4 48.1 16.1 9.3 100.0 65 South Central 25.7 31.7 35.7 6.9 100.0 178 South 26.4 29.0 35.1 9.6 100.0 65 Total 30.3 35.8 26.0 7.9 100.0 589 Note: Figures in parentheses are based on 25-49 unweighted cases. Households that gave shelter to tsunami victims were asked whether they received benefits after the tsunami. Table 2.25 shows that 70 percent of the households did not receive any benefits. Among households that received benefits, 11 percent received benefits for 1-4 persons, 14 percent for 5-9 people, and 4 percent received benefits for 10 or more people. Table 2.25 Number of household members who received benefits Among households giving shelter after the tsunami, the percent distribution of number of household members who received benefits after the tsunami, by region, Maldives 2009 Number of people given benefits Region 0 1-4 5-9 10+ Don't know/ missing Total Number of households Malé (80.4) (13.6) (4.2) (0.0) (1.8) 100.0 108 North 85.8 8.2 6.0 0.0 0.0 100.0 80 North Central 79.0 7.2 9.4 3.5 1.0 100.0 94 Central 62.2 9.2 22.4 6.2 0.0 100.0 65 South Central 57.2 13.3 22.5 5.2 1.8 100.0 178 South 60.1 14.5 15.8 6.3 3.2 100.0 65 Total 69.6 11.4 14.1 3.5 1.4 100.0 589 Note: Figures in parentheses are based on 25-49 unweighted cases. Characteristics of Female Respondents | 35 CHARACTERISTICS OF FEMALE RESPONDENTS 3 This chapter provides a demographic and socioeconomic profile of female respondents inter- viewed in the 2009 MDHS. Such background information is essential to the interpretation of findings and for understanding the results presented later in the report. Basic characteristics collected include age, level of education, marital status, religion, and wealth status. Exposure to mass media and literacy status were examined, and detailed information was collected on employment status, occupation, and earnings. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 presents the distribution of the ever-married women who were interviewed in the 2009 MDHS by age, marital status, urban or rural residence, region of residence, educational level, and wealth quintile. The findings show that approximately two-fifths of women are under age 30 and about one-fourth are age 40 or older. There are fewer women in the 15-19 and 20-24 age groups than in the 25-29 cohort. The majority of women (91 percent) are married, and the remainder are split between divorced or separated (8 percent) and widowed (1 percent). Thirty-three percent of women live in urban areas. Considering place of residence, 33 percent of the women are from Malé, 30 percent are from the North and the North Central regions combined, 9 percent from the Central region, 12 percent from the South Central region, and 17 percent from the South region. The majority of respondents have had some education. Approximately one-fourth of the women never attended school. Around one- third of women have only a primary education, while four in ten attended secondary school or higher. The women are fairly evenly distributed across the wealth quintiles, with the smallest percentage found in the lowest wealth quintile (18 percent). 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Table 3.2 presents a detailed distribution of ever-married women age 15-49 by educational attainment. The general pattern evident in Table 3.2 indicates a decrease in the proportion of women with no education from the oldest to the youngest cohort. For example, 1 percent of women age 15-24 have no formal education, compared with 57 percent of women age 40-44 and 72 percent of women Table 3.1 Background characteristics of female respondents Percent distribution of women age 15-49 by selected back- ground characteristics, Maldives 2009 Background characteristic Weighted percent Weighted Unweighted Age 15-19 1.7 119 129 20-24 17.8 1,268 1,381 25-29 21.6 1,539 1,528 30-34 18.0 1,287 1,184 35-39 16.6 1,185 1,169 40-44 14.2 1,013 1,004 45-49 10.1 721 736 Marital status Married 91.2 6,500 6,558 Divorced/separated 7.7 549 492 Widowed 1.2 82 81 Residence Urban 33.2 2,368 1,041 Rural 66.8 4,763 6,090 Region Malé 33.2 2,368 1,041 North 15.0 1,067 960 North Central 14.5 1,038 1,259 Central 8.6 615 1,290 South Central 12.0 853 1,543 South 16.7 1,190 1,038 Education No formal education 23.4 1,668 1,941 Primary 34.6 2,464 2,503 Secondary 36.2 2,584 2,384 More than secondary 4.7 333 216 Unknown - Certificate 1.1 81 87 Wealth quintile Lowest 18.2 1,300 1,578 Second 19.6 1,396 1,850 Middle 20.9 1,488 1,931 Fourth 20.3 1,447 1,112 Highest 21.0 1,499 660 Total 15-49 100.0 7,131 7,131 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. 36 | Characteristics of Female Respondents age 45-49. Similarly, 74 percent of women age 15-24 had some secondary education compared with only 8 percent of women age 40-44 and 5 percent of women age 45-49. Overall, the median years of school completed for women age 15-49 is 6.7 years. The MDHS data indicate that educational opportunities vary by urban-rural residence. Urban women have higher rates of school attendance than their rural counterparts. Twelve percent of urban women have not attended school compared with 29 percent of women in rural areas. Comparison of the median number of years of education completed shows that urban women have a median of 8.7 years of schooling and rural women have 6.3 years of education. Forty-four percent of urban women have attended some secondary school compared with 30 percent of rural women. Table 3.2 Educational attainment Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median grade completed, according to background characteristics, Maldives 2009 Highest level of schooling Background characteristic No formal education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Unknown - Certificate Total Median years completed Number of women Age 15-24 0.7 3.0 12.7 74.2 3.3 5.0 1.1 100.0 9.3 1,387 15-19 0.8 3.8 9.6 84.8 0.7 0.1 0.4 100.0 9.3 119 20-24 0.7 2.9 13.0 73.2 3.5 5.5 1.2 100.0 9.3 1,268 25-29 1.9 11.1 25.0 50.4 2.0 8.7 0.9 100.0 9.1 1,539 30-34 11.7 19.8 29.4 30.3 1.9 5.2 1.8 100.0 6.6 1,287 35-39 32.2 22.4 26.6 14.3 0.3 2.9 1.2 100.0 5.4 1,185 40-44 57.3 15.4 15.6 8.3 0.0 2.2 1.0 100.0 a 1,013 45-49 71.6 13.2 9.3 4.5 0.0 0.9 0.6 100.0 a 721 Residence Urban 12.2 10.9 17.6 43.9 3.3 11.0 1.1 100.0 8.7 2,368 Rural 29.0 15.3 22.3 30.3 0.5 1.6 1.1 100.0 6.3 4,763 Region Malé 12.2 10.9 17.6 43.9 3.3 11.0 1.1 100.0 8.7 2,368 North 29.6 15.7 24.7 28.6 0.2 0.7 0.5 100.0 6.2 1,067 North Central 35.2 12.4 21.8 28.1 0.4 1.1 1.1 100.0 6.2 1,038 Central 27.9 16.5 25.1 27.7 0.9 1.4 0.5 100.0 6.3 615 South Central 30.9 15.7 20.4 30.2 0.5 1.0 1.3 100.0 6.3 853 South 22.1 16.4 20.4 35.1 0.8 3.3 1.9 100.0 6.8 1,190 Wealth quintile Lowest 37.0 19.3 22.3 20.5 0.4 0.3 0.3 100.0 5.4 1,300 Second 29.2 16.7 22.1 29.9 0.1 0.9 1.1 100.0 6.3 1,396 Middle 24.5 13.3 24.2 34.2 0.6 2.0 1.3 100.0 6.6 1,488 Fourth 18.8 11.1 18.7 42.7 1.9 5.4 1.5 100.0 7.4 1,447 Highest 9.4 9.6 16.8 44.7 4.0 14.1 1.4 100.0 9.1 1,499 Total 23.4 13.8 20.8 34.8 1.5 4.7 1.1 100.0 6.7 7,131 a = Omitted because more than 50 percent of women had no formal schooling 1 Completed 7th grade at the primary level 2 Completed 12th grade at the secondary level Educational levels are lowest in the North Central region, where 35 percent of the women have never attended school. The highest educational level is found in Malé, where only 12 percent of women have never attended school. Educational attainment also increases as household economic status increases. For example, 37 percent of the women in the poorest households have no formal education compared with 9 percent of women in the most advantaged households. Forty-five of women in the highest wealth quintile have some secondary education compared with 21 percent of women in the lowest wealth quintile. 3.3 ACCESS TO MASS MEDIA The 2009 MDHS collected information on the exposure of respondents to broadcast and print media and the Internet (Table 3.3). This information is important because it indicates to what extent the mass media can be used to disseminate family planning, health, and other information. Access to Characteristics of Female Respondents | 37 mass media is relatively high in Maldives. Television is the most popular of the mass media among women (96 percent watch television at least once a week), followed by radio (78 percent of women listen to radio at least once a week). Readership of print media and use of the Internet is comparatively lower for women (36 percent and 21 percent, respectively). There is no strong relationship between access to the four types of media and age; however, women age 15-19 read a newspaper and listen to the radio once a week less than older women; in contrast, they use the Internet at least once a week at higher rates than older women. On the other hand, media use varies by residence. Women who live in urban areas read a newspaper and use the Internet at least once a week, much more than other women, whereas women living in rural areas listen to the radio at least once a week at higher rates than urban women. The percentage of women who read a newspaper or magazine at least once a week varied considerably, from 15 percent in the Central region to 59 percent in the Male region. The percentage who use the Internet at least once a week ranges from 44 percent in Malé to 6 percent in the North and the Central regions. Table 3.3 Exposure to mass media Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Maldives 2009 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week At least three media at least once a week1 No media at least once a week Uses Internet at least once a week Number of women Age 15-19 15.6 96.2 71.8 25.8 0.0 29.2 119 20-24 33.0 97.0 73.7 38.4 0.2 29.7 1,268 25-29 36.9 96.7 77.4 39.9 0.7 27.9 1,539 30-34 37.9 97.2 74.8 37.7 0.4 24.3 1,287 35-39 39.1 96.7 80.4 36.6 0.8 16.9 1,185 40-44 37.2 95.4 79.6 33.1 0.9 12.2 1,013 45-49 33.6 94.8 86.2 30.4 1.0 6.9 721 Residence Urban 59.1 96.7 66.4 59.3 0.4 44.0 2,368 Rural 24.6 96.3 83.6 25.2 0.7 10.2 4,763 Region Malé 59.1 96.7 66.4 59.3 0.4 44.0 2,368 North 17.8 95.7 89.8 18.9 0.6 6.2 1,067 North Central 23.6 96.4 79.8 23.0 0.9 8.6 1,038 Central 15.1 96.7 78.9 15.4 1.2 5.8 615 South Central 15.6 96.3 81.3 16.7 0.7 6.8 853 South 43.1 96.4 85.3 43.9 0.5 19.9 1,190 Education No formal education 23.7 94.6 84.6 20.9 1.2 1.8 1,668 Primary 33.6 96.9 81.7 31.1 0.7 9.0 2,464 Secondary 41.5 97.4 72.8 45.6 0.2 36.6 2,584 More than secondary 69.4 95.0 56.9 77.1 0.0 86.4 333 Wealth quintile Lowest 17.7 93.2 86.1 17.0 1.3 3.7 1,300 Second 19.7 96.8 84.8 20.3 0.6 5.9 1,396 Middle 30.9 97.8 82.3 30.9 0.4 11.8 1,488 Fourth 46.7 97.2 73.7 48.6 0.5 29.4 1,447 Highest 62.2 96.8 63.9 62.5 0.3 53.0 1,499 Total 36.1 96.4 77.9 36.5 0.6 21.4 7,131 Note: Total includes 81 cases for which information on woman’s formal education level is missing. 1 Refers to radio, television and newspaper The percentage of women who reported that they have been exposed to at least three media at least once a week is 37 percent. Women with more than secondary education and women in the highest wealth quintile have the highest rates of exposure to three media at least once a week (77 percent and 63 percent, respectively). 38 | Characteristics of Female Respondents 3.4 EMPLOYMENT Employment is a source of empowerment for women, given that they gain control over their own income. It is difficult to measure employment status because some work, especially work on family farms, in family businesses, or in the informal sector, is often not perceived as employment by women and men themselves, and hence not reported as such. The 2009 MDHS asked women detailed questions about their employment status to ensure complete coverage of employment in any sector, whether formal or informal. Women who reported that they were currently working and those who reported that they worked at some time during the 12 months preceding the survey are considered to have been employed. Additional information was collected on the type of work women were doing, whether they worked continuously throughout the year, for whom they worked, and the form in which they received their earnings. Tables 3.4 shows the percent distribution of women age 15-49 by employment status and according to background characteristics. Two in five women are currently employed. Seven percent reported that they worked at some point during the past 12 months but were not working at the time of the survey, and fifty-three percent did not work at all in the 12 months preceding the survey (Figure 3.1). Table 3.4 Employment status Percent distribution of women age 15-49 by employment status, according to background characteristics, Maldives 2009 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Total Number of women Age 15-19 27.3 18.5 54.2 100.0 119 20-24 37.1 10.5 52.3 100.0 1,268 25-29 37.8 7.5 54.6 100.0 1,539 30-34 41.6 5.4 53.0 100.0 1,287 35-39 43.2 6.4 50.4 100.0 1,185 40-44 42.7 5.4 51.3 100.0 1,013 45-49 40.4 7.1 51.9 100.0 721 Marital status Married 38.7 7.5 53.7 100.0 6,500 Divorced/separated/widowed 53.5 5.8 39.6 100.0 631 Number of living children 0 48.4 12.5 39.1 100.0 1,040 1-2 39.7 6.4 53.8 100.0 3,183 3-4 37.2 5.5 56.9 100.0 1,636 5+ 37.6 7.6 54.5 100.0 1,272 Residence Urban 40.3 6.1 53.3 100.0 2,368 Rural 39.9 7.9 52.1 100.0 4,763 Region Malé 40.3 6.1 53.3 100.0 2,368 North 40.9 9.2 49.6 100.0 1,067 North Central 41.3 9.8 48.9 100.0 1,038 Central 41.2 4.7 54.1 100.0 615 South Central 45.4 8.5 46.1 100.0 853 South 33.3 6.5 60.2 100.0 1,190 Education No formal education 39.5 7.9 52.3 100.0 1,668 Primary 34.4 6.1 59.2 100.0 2,464 Secondary 41.7 8.4 49.9 100.0 2,584 More than secondary 64.6 6.1 29.3 100.0 333 Wealth quintile Lowest 40.0 9.6 50.3 100.0 1,300 Second 39.1 7.4 53.4 100.0 1,396 Middle 38.1 8.1 53.6 100.0 1,488 Fourth 39.8 5.0 55.1 100.0 1,447 Highest 43.1 6.8 49.9 100.0 1,499 Total 40.0 7.3 52.5 100.0 7,131 Note: Total includes women with information missing on employment status who are not shown separately. Total includes 81 cases for which information on woman’s formal education level is missing. 1 "”Currently employed’ is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Female Respondents | 39 Women in the older age group have higher current employment rates than younger women. A higher proportion of women who are divorced, separated, or widowed (54 percent) are currently employed compared with other women (39 percent). In addition, higher rates of women with no children are also currently employed compared with those who have children. There is no difference by urban-rural residence in the proportion of women who are currently employed (40 percent). Levels of employment vary a little by region; for example, among women, current employment ranges from a low of 33 percent in the South to a high of 45 percent in the South Central region. Women with more than a secondary education had the highest rates of current employment at the time of the survey. For example, 40 percent of the women with no education are currently employed compared with 65 percent of the women with more than secondary education. There are no substantial variations in the proportion currently employed across wealth quintiles. 3.5 OCCUPATION Respondents who reported being currently employed or who worked in the 12 months preceding the survey were asked what type of work they normally do. Table 3.5 shows the distribution of women by occupation and according to background characteristics. The majority of women who are currently working are employed in non-agricultural occupations. Slightly less than one-third of working women (32 percent) hold skilled manual jobs, and 26 percent work in professional, technical, or managerial positions. An additional 21 percent work in sales and services, and 16 percent have clerical jobs. Only 4 percent of working women are involved in some type of agricultural activity. More women who are married are engaged in professional, technical, or managerial activities or skilled manual labour than divorced, separated, or widowed women. Higher proportions of women who are divorced, separated, or widowed are in sales and services positions. Residence has a significant effect on the type of occupation. Urban women have higher employment rates in professional, technical, or managerial and clerical jobs, while rural women have higher employment rates in skilled manual labour and agricultural work. About half of women (49 percent) with no formal education and in the lowest wealth quintile (53 percent) work as skilled manual labour. The majority of women with more than secondary education (85 percent) and women who belong to both the fourth and the highest wealth quintiles (32 percent each) hold professional, technical, or managerial jobs. MDHS 2009 Figure 3.1 Women's Employment Status in the Past 12 Months Currently employed 40% Did not work in past 12 months 53% Not currently employed but worked in past 12 months 7% 40 | Characteristics of Female Respondents Table 3.5 Occupation Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Maldives 2009 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Agriculture Missing Total Number of women Age 15-19 33.5 23.1 25.7 16.3 1.4 0.0 100.0 55 20-24 33.9 28.9 15.9 18.6 0.9 1.7 100.0 603 25-29 35.0 21.4 15.9 25.7 1.1 0.9 100.0 698 30-34 28.1 18.4 17.9 30.3 4.5 0.9 100.0 604 35-39 21.9 7.6 24.1 39.4 7.0 0.0 100.0 587 40-44 16.5 8.0 25.6 42.1 6.8 0.9 100.0 488 45-49 10.6 3.5 33.9 42.7 9.0 0.2 100.0 343 Marital status Married 27.0 16.0 19.3 32.4 4.5 0.8 100.0 3,004 Divorced/separated/widowed 19.0 16.8 35.1 25.3 3.1 0.7 100.0 374 Number of living children 0 38.9 26.9 17.5 14.4 0.9 1.3 100.0 634 1-2 34.2 21.1 16.6 25.7 1.8 0.6 100.0 1,470 3-4 14.0 7.9 26.2 44.4 6.8 0.7 100.0 700 5+ 6.3 1.2 30.2 50.0 11.6 0.8 100.0 574 Residence Urban 31.0 31.5 19.0 17.3 0.4 0.8 100.0 1,098 Rural 23.8 8.6 22.1 38.5 6.2 0.8 100.0 2,280 Region Malé 31.0 31.5 19.0 17.3 0.4 0.8 100.0 1,098 North 21.3 7.8 12.2 52.3 6.1 0.3 100.0 535 North Central 23.8 6.5 24.1 41.5 3.6 0.4 100.0 530 Central 23.9 7.2 33.1 27.8 5.9 2.1 100.0 282 South Central 21.4 7.3 24.8 36.7 9.4 0.3 100.0 460 South 28.9 14.1 21.6 27.6 6.4 1.5 100.0 473 Education No formal education 5.4 1.9 33.1 49.4 9.4 0.8 100.0 791 Primary 13.5 6.8 27.6 45.2 6.3 0.6 100.0 998 Secondary 35.7 32.5 13.1 17.1 0.7 0.9 100.0 1,295 More than secondary 85.1 12.1 0.7 0.8 0.0 1.4 100.0 236 Wealth quintile Lowest 14.3 3.5 21.8 52.6 7.3 0.6 100.0 646 Second 20.8 7.5 24.3 38.9 7.5 0.9 100.0 649 Middle 29.9 11.7 20.6 32.4 4.3 1.1 100.0 687 Fourth 32.3 23.3 22.2 18.6 3.1 0.5 100.0 648 Highest 32.3 32.0 17.0 17.7 0.1 0.9 100.0 748 Total 26.1 16.1 21.1 31.6 4.3 0.8 100.0 3,378 Note: Total includes 59 cases for which information on woman’s formal education level is missing. 3.6 EARNINGS AND TYPE OF EMPLOYMENT Table 3.6 shows the percent distribution of ever-married women who were employed during the 12 months preceding the survey by type of earnings received, type of employer, continuity of employment, and variations by type of employment (agricultural or non-agricultural). Ninety-seven percent of women received their earnings in cash; only 1 percent received payment in cash and in kind; and 2 percent receive no payment (Figure 3.2). Table 3.6 presents information separately for women engaged in agricultural work or non- agricultural work. Nine in ten women employed in agricultural work are paid in cash, 3 percent are paid in cash and in-kind, and 7 percent are not paid. The majority of women who work in the agricultural sector are self-employed (95 percent), and 69 percent work all year. Among women employed in the non-agricultural sector, 97 percent earn cash only, 58 percent are employed by a non- family member, and 82 percent work all year. Characteristics of Female Respondents | 41 Table 3.6 Type of employment Percent distribution of women age 15-49 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 non-agricultural), Maldives 2009 Employment characteristic Agricultural work Non-agricultural work Total Type of earnings Cash only 90.2 97.2 96.5 Cash and in-kind 3.1 0.5 0.6 In-kind only 0.2 0.1 0.1 Not paid 6.5 2.0 2.4 Missing 0.0 0.2 0.4 Total 100.0 100.0 100.0 Type of employer Employed by family member 2.9 1.6 1.7 Employed by non-family member 2.6 57.8 55.3 Self-employed 94.5 40.6 42.7 Missing 0.0 0.0 0.4 Total 100.0 100.0 100.0 Continuity of employment All year 69.1 81.7 80.9 Seasonal 25.4 13.2 13.6 Occasional 5.5 4.8 4.8 Missing 0.0 0.3 0.6 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 146 3,204 3,378 Note: Total includes women with information missing on type of employment who are not shown separately. MDHS 2009 Figure 3.2 Type of Earnings of Employed Women Age 15-49 Cash and in-kind 1% Cash only 97% Not paid 2% Fertility Levels, Trends, and Differentials | 43 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4 4.1 INTRODUCTION This chapter looks at a number of fertility indicators, including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women initiate childbearing. Information on current and cumulative fertility is essential in monitoring population growth. The data on birth intervals are important because short intervals are strongly associated with childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the mother and the child. Data on fertility were collected in several ways. Each woman was asked about all of the births in her lifetime. To ensure completeness of the responses, the duration, the month and year of termination, and the outcome were recorded for each pregnancy. In addition, the women were asked questions separately about sons and daughters who live with them, those who live elsewhere, and those who have died. Subsequently, a list of all births was recorded along with each child’s name, age if still alive, and age at death, if dead. Finally, information was collected on whether the women were pregnant at the time of the survey. 4.2 CURRENT FERTILITY The level of current fertility is one of the most important topics in this report because of its direct relevance to population policies and programs. Current fertility can be measured using the age- specific fertility rate (ASFR), the total fertility rate (TFR), the general fertility rate (GFR), and the crude birth rate (CBR). The ASFR provides the age pattern of fertility, while the TFR refers to the number of live births that a woman would have had if she were subject to the current ASFRs throughout the repro- ductive ages (15-49 years). The GFR is expressed as the number of live births per 1,000 women of reproductive age, and the CBR is reported as the number of live births per 1,000 population. The measures of fertility presented in this chapter all refer to the period three years prior to the survey. This time span generates a sufficient number of births to provide robust and current estimates. Current estimates of fertility levels in Maldives are presented in Table 4.1 by urban-rural residence. The total fertility rate (TFR) indicates that if childbearing were to remain constant at the age-specific fertility rates measured for the 36-month period before the Maldives DHS (MDHS), a Maldivian woman who is at the beginning of her childbearing years would give birth to 2.5 children by the end of her childbearing years. The TFR among urban women is lower than that among rural women (2.1 births compared with 2.8 births per woman). The peak of childbearing for urban women is at age 25-29 and for rural women is at age 20-24, with 152 births per 1,000 women and 165 births per 1,000 women, respectively. At almost all age groups, the age-specific fertility rates for urban women are lower than those for rural women (Figure 4.1). Fertility Table 4.1 Current fertility Age-specific, total, and general fertility rates and the crude birth rate for the three years preceding the survey, by residence, Maldives 2009 Residence Age group Urban Rural Total 15-19 6 12 10 20-24 89 165 138 25-29 152 159 156 30-34 121 118 119 35-39 40 72 61 40-44 16 24 22 45-49 0 2 2 TFR 2.1 2.8 2.5 GFR 68 88 82 CBR 22.9 25.5 24.7 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population 44 | Fertility Levels, Trends, and Differentials declines with age somewhat more rapidly among urban women than among rural women, although the greatest absolute urban-rural difference in ASFRs (76 births per 1,000 women) is among women age 20-24. The GFR for rural women is much higher than for urban women (88 compared with 68 live births per 1,000 women). The crude birth rate (CBR) is 25 live births per 1,000 population. Figure 4.2 shows that the TFR of 2.5 births per woman in Maldives is higher only in comparison with the TFR in Vietnam of 1.9 births per woman and lower than the rate in any other country in South or Southeast Asia where comparable data are available. # # # # # # # ! ! ! ! ! ! ! ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 Births per 1,000 women Urban Rural Total) ! # MDHS 2009 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence 1.9 2.5 2.6 2.7 2.7 3.1 3.3 3.4 4.1 Vietnam 2002 MALDIVES 2009 Indonesia 2007 India 2005-06 Bangladesh 2007 Nepal 2006 Philippines 2008 Cambodia 2005 Pakistan 2006-07 0 1 2 3 4 5 Total fertility rate Figure 4.2 Total Fertility Rates in Selected South Asia and Southeast Asia Countries Source: ICF Macro, 2010. MEASURE DHS STATcompiler http://www.measuredhs.com, April 26 2010 Fertility Levels, Trends, and Differentials | 45 The Population and Housing Censuses (PHCs) of Maldives have routinely collected current and retrospective fertility data since 1977. Because the type of data collected in the census and the technique for fertility estimation used in the census differ from those used in the MDHS, fertility estimates from the census are not directly comparable to those from the MDHS. The TFR estimated from the 2006 PHC using direct and indirect techniques for 2006 is 2.15 births per woman. The Vital Registration System (VRS) in Maldives has collected and compiled reports of births and deaths since 1999. Data for 2006 show that the crude birth rate is 23 births per 1,000 population. For all measurements, the MDHS estimates are higher than estimates from the 2006 PHC and the VRS. Fertility is known to vary by a woman’s residence, education, and other background characteristics. Table 4.2 shows several different indicators of fertility, mainly the total fertility rate, the mean number of births to women age 40-49, and the percent of women age 15-49 currently pregnant. The mean number of births to women age 40-49 is an indicator of cumulative fertility; it reflects the fertility performance of older women who are nearing the end of their reproductive period. If fertility remains stable over time, the two fertility measures, total fertility rate (TFR) and children ever born (CEB), tend to be very similar. The percentage pregnant provides a useful additional measure of current fertility, although it is recognized that it may not capture all pregnancies in an early stage. Table 4.2 indicates that there are variations in the TFR by residence, region, and wealth quintile. Women in Malé have the smallest average number of children in the country, and women in the South Central region have the highest fertility, followed closely by women in the South and in the Central regions. Fertility varies little by the woman’s education. However, wealth quintile is inversely associated with fertility; the TFR is noticeably higher among women in the lowest three quintiles (2.8) than among women in the highest two quintiles. 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, Maldives 2009 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 2.1 3.6 3.7 Rural 2.8 5.7 5.6 Region Malé 2.1 3.6 3.7 North 2.7 5.9 5.5 North Central 2.5 6.1 5.7 Central 2.8 6.3 5.9 South Central 3.0 5.3 5.4 South 2.9 5.0 5.7 Education No formal education 2.8 2.5 5.5 Primary 2.7 5.7 4.5 Secondary 2.6 5.5 2.7 More than secondary 2.7 5.3 2.6 Wealth quintile Lowest 2.8 5.0 5.6 Second 2.9 4.9 5.8 Middle 2.7 6.8 5.3 Fourth 2.4 4.6 4.6 Highest 2.1 3.6 3.7 Total 2.5 5.0 5.0 Note: Total fertility rates are for the period 1-36 months prior to interview. 46 | Fertility Levels, Trends, and Differentials Table 4.2 also presents information on currently pregnant respondents. Five percent of women reported that they were pregnant at the time of the survey. This proportion is higher in rural areas than in urban areas. Women with no education are less than half as likely to be pregnant as educated women. The proportion pregnant by wealth quintile shows a curvilinear pattern, it is lower for women in the lowest and highest wealth quintiles and peaks for women in the middle quintile. Table 4.2 presents a crude assessment of trends in fertility if one compares current total fertility with a measure of completed fertility: the mean number of children ever born to women age 40-49. The mean number of children ever born to older women who are nearing the end of their reproductive years is an indicator of average completed fertility among women who began child- bearing approximately three decades preceding the survey. If fertility remained constant over time and the reported data on both children ever born and births during the three years preceding the survey are reasonably accurate, the TFR and the mean number of children ever born for women age 40-49 are expected to be similar. When fertility levels have been falling, the TFR will be substantially lower than the mean number of children ever born. The 2009 MDHS data show that the mean number of children ever born for women age 40-49 is much higher than the TFR for the three years preceding the survey (5.0 compared with 2.5 children per woman), indicating a recent substantial reduction in fertility. Fertility has declined in both urban and rural areas, at all educational levels except for women with more than secondary education, and for all wealth quintiles. The difference between current and completed fertility is highest in rural areas (2.8 births), among women in the North Central region (3.2 births), among women who have no formal education (2.8 births), and among women in the second wealth quintile (2.9 births). 4.4 FERTILITY TRENDS Table 4.3 uses information from the retrospective birth histories obtained from MDHS respondents to examine trends in age-specific fertility rates for succes- sive five-year periods before the survey. To calculate these rates, births were classified according to the period of time in which the birth occurred and the mother’s age at the time of birth. Because birth histories were not collected for women over age 50, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years or more prior to the survey, because women in that age group would have been 50 years or older at the time of the survey. Table 4.3 shows that over time the ASFRs in every age group have declined. The declines are steepest between the periods of 10-14 and 15-19 years preceding the survey. Although fertility has fallen in all age groups for the periods 5-9 and 0-4 years preceding the survey, the declines are less pronounced than in previous years, except in age group 15-19. 4.5 CHILDREN EVER BORN AND LIVING Table 4.4 presents the distribution of all women and currently married women by number of children ever born, according to five-year age groups. The table also shows the mean number of children ever born. Data on the number of children ever born reflect the accumulation of births to women over their entire reproductive years. They, therefore, have limited reference to current fertility levels, particularly when a country has experienced a decline in fertility. However, the information on Table 4.3 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, Maldives 2009 Mother's age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 12 29 69 125 20-24 135 138 188 274 25-29 146 142 180 264 30-34 114 113 155 [19] 35-39 59 79 [101] - 40-44 22 [32] - - 45-49 [1] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. Fertility Levels, Trends, and Differentials | 47 children ever born is useful for observing how average family size varies across age groups, and for observing the level of primary infertility. It reflects the cumulative number of births over the past 30 years among women interviewed in the MDHS. The data may be subject to some recall error, which typically is greater for older women than for younger women. The information on parity is useful for understanding a number of related issues. First, the results show how the average family size increases from one age group to the next. They also offer insight into the impact of marital status on women’s fertility. Because almost all Maldivian women are married by age 35 (see Table 6.1), differences in parity between ever-married women and currently married women represent primarily the effects of widowhood and divorce on fertility. In addition, the percentage of women in their forties who have never had children provides an indicator of the level of primary infertility,1 or the inability to bear children. Voluntary childlessness is rare in developing countries like Maldives; married women who are nearing the end of their childbearing years who have no live births are generally thought to be unable to bear children. Finally, a comparison of the mean number of children ever born and surviving children among women in their forties reflects the extent and impact of mortality on the population. Almost all women age 15-19 (99 percent) have never given birth. However, this proportion declines sharply to 10 percent for women age 30-34 and to less than 5 percent for women age 35 and older, indicating that childbearing among Maldivian women is nearly universal. Women nearing the end of their reproductive years have a parity of 5.5 children. Table 4.4 shows that, on average, women gave birth to less than one child before their mid- twenties, more than three children by their mid-thirties, and about five children by their mid- to late forties. The same pattern is found among currently married women, except that the mean number of children ever born is higher for currently married women (2.68 children) than for all women (1.85 children). The difference in the mean number of children ever born between all women and currently married women is due to a large proportion of young, unmarried women who, among all women, have lower fertility. Table 4.4 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Maldives 2009 Mean number of children ever born Mean number of living children Number of women Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total 15-19 98.7 1.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,156 0.01 0.01 20-24 67.6 25.9 5.8 0.6 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,161 0.40 0.39 25-29 24.7 39.7 24.6 7.8 2.5 0.6 0.1 0.0 0.0 0.0 0.0 100.0 1,737 1.26 1.24 30-34 10.1 18.8 30.4 22.8 10.7 4.4 1.3 0.7 0.5 0.2 0.0 100.0 1,357 2.32 2.24 35-39 4.8 10.0 19.0 21.5 17.8 13.0 7.7 3.3 1.7 0.5 0.6 100.0 1,213 3.43 3.25 40-44 3.3 6.0 7.9 17.6 13.6 15.7 14.9 10.0 6.0 2.4 2.7 100.0 1,028 4.65 4.32 45-49 3.5 4.5 7.6 10.1 10.2 13.0 13.7 14.1 11.8 4.7 6.7 100.0 735 5.46 4.92 Total 41.2 16.8 12.8 9.4 6.0 4.7 3.5 2.5 1.7 0.7 0.8 100.0 10,388 1.85 1.74 CURRENTLY MARRIED WOMEN 15-19 76.4 22.9 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 111 0.24 0.24 20-24 45.0 45.1 9.0 0.9 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,188 0.66 0.65 25-29 14.7 44.9 27.9 9.0 2.8 0.6 0.1 0.0 0.0 0.0 0.0 100.0 1,446 1.43 1.40 30-34 4.5 19.4 32.5 24.4 11.4 4.7 1.5 0.8 0.6 0.2 0.0 100.0 1,193 2.48 2.39 35-39 2.3 8.8 19.2 22.5 18.5 14.0 8.2 3.6 2.0 0.6 0.4 100.0 1,065 3.58 3.39 40-44 1.4 5.3 6.6 17.6 14.4 16.1 16.0 10.6 6.2 2.8 3.0 100.0 884 4.86 4.52 45-49 1.3 3.7 7.8 9.8 10.4 12.1 15.1 14.4 12.5 5.3 7.6 100.0 612 5.71 5.18 Total 14.3 24.7 18.6 13.6 8.7 6.6 5.2 3.5 2.4 1.0 1.2 100.0 6,500 2.68 2.53 1 It should be pointed out here that this estimate of primary infertility does not include women who may have had one or more births but who are unable to have more children (i.e., secondary infertility). 48 | Fertility Levels, Trends, and Differentials 4.6 BIRTH INTERVALS A birth interval is defined as the length of time between two live births. The study of birth intervals is important in understanding the health status of young children. Research has shown that short birth intervals are closely associated with poor health of children, especially during infancy. Children born too close to a previous birth, especially if the interval between the births is less than two years, are at increased risk of health problems and dying at an early age. Longer birth intervals, on the other hand, contribute to the improved health status of both mother and child. Table 4.5 presents the distribution of second and higher-order births in the five years preceding the survey by the number of months since the previous birth, according to background characteristics. The table also presents the median number of months since the preceding birth. Five percent of births are less than 18 months apart and 8 percent of births were born less than two years after the previous birth. Sixteen percent of births are 24-35 months apart, and 70 percent are at least three years apart. Table 4.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey, by number of months since preceding birth and by median number of months since preceding birth, according to background characteristics, Maldives 2009 Background characteristic Median number of months since preceding birth Number of non- first births Months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Total Age 15-19 * * * * * * 100.0 2 31.1 20-29 9.3 11.3 25.2 17.4 15.5 21.3 100.0 762 38.2 30-39 3.7 6.8 10.5 13.0 11.2 54.7 100.0 1,180 64.8 40-49 0.6 4.9 13.5 10.8 8.0 62.2 100.0 227 77.5 Birth order 2-3 5.9 7.8 16.4 14.7 14.0 41.2 100.0 1,446 52.1 4-6 4.7 8.8 15.1 12.5 7.9 51.0 100.0 567 61.9 7+ 2.9 9.3 15.6 17.3 13.4 41.5 100.0 158 52.5 Sex of preceding birth Male 4.9 7.6 17.1 13.2 14.1 43.2 100.0 1,104 54.7 Female 5.8 8.8 14.9 15.5 10.6 44.4 100.0 1,066 52.8 Survival of preceding birth Living 5.0 8.1 16.1 14.4 12.5 43.9 100.0 2,115 54.1 Dead 19.9 11.8 14.3 8.5 7.4 38.0 100.0 56 44.5 Residence Urban 4.2 7.6 16.2 15.6 12.0 44.4 100.0 607 54.3 Rural 5.8 8.4 16.0 13.8 12.5 43.5 100.0 1,564 53.9 Region Malé 4.2 7.6 16.2 15.6 12.0 44.4 100.0 607 54.3 North 4.7 8.5 17.7 14.0 12.2 43.0 100.0 347 53.4 North Central 6.2 8.4 14.7 11.4 16.1 43.2 100.0 327 53.9 Central 4.9 6.7 16.3 13.8 9.2 49.1 100.0 204 58.7 South Central 5.5 7.0 16.2 14.4 12.3 44.7 100.0 260 56.0 South 7.1 10.2 15.2 15.1 11.8 40.7 100.0 425 50.3 Education No formal education 2.8 4.9 12.3 10.1 13.3 56.7 100.0 424 68.6 Primary 4.6 9.0 14.4 13.8 11.4 46.9 100.0 1,057 56.4 Secondary 8.4 9.1 21.7 17.9 12.7 30.2 100.0 612 41.1 More than secondary (6.5) (9.4) (13.0) (17.3) (19.9) (33.8) 100.0 57 (49.9) Wealth quintile Lowest 5.4 8.4 16.5 14.1 14.5 41.2 100.0 485 52.4 Second 6.2 9.1 15.1 16.2 10.7 42.7 100.0 484 51.6 Middle 4.6 9.3 16.0 11.4 13.1 45.4 100.0 442 56.6 Fourth 6.6 8.8 13.5 13.7 8.8 48.5 100.0 416 57.7 Highest 3.6 4.4 19.7 16.3 15.1 40.8 100.0 343 51.4 Total 5.4 8.2 16.0 14.3 12.4 43.7 100.0 2,171 54.0 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. Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 21 births for which information on mother’s formal education level is missing. Fertility Levels, Trends, and Differentials | 49 The overall median birth interval is 54.0 months. The median number of months since the preceding birth increases substantially with age, from 31.1 months for births to women age 15-19 to 77.5 months for births whose mother is age 40-49. The median birth interval is longest for children of birth order 4 to 6 (61.9 months) and births to women with no education (68.6 months). There are no notable differences in the length of the median birth interval by sex of the preceding birth or by urban- rural residence. The 2009 MDHS confirms findings from previous studies that the death of a preceding child leads to a shorter birth interval than when the preceding child survives (e.g., Bicego and Ahmad, 1996). The median birth interval is ten months longer for births whose previous sibling is alive than for births whose previous sibling did not survive (54.1 months and 44.5 months, respectively). Compared with the median birth interval of other countries in South Asia and Southeast Asia where comparable data are available, the median birth interval in Maldives is one of the longest (Figure 4.3). It is one month shorter than in Indonesia (55 months) and longer than in most other Asian countries. In contrast, the median birth interval in Pakistan is only 29 months. 4.7 AGE AT FIRST BIRTH 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. Table 4.6 shows the percentage of women who have given birth by specific ages, according to age at the time of the survey. This cross-sectional data can be used to show the trend in age at first birth. The data indicate that women are gradually having children at an older age. The median age at first birth has increased from 19.3 years for women age 45-49 to 23.9 years for women age 25-29. The increase in age at first birth can also be observed from the increase in the proportion of women who have given birth at age 15 across age groups. Five percent of women age 45-49 had their first child by age 15 compared with less than 1 percent of women age 25-29. Another indicator shown in the table is the proportion of women who have never given birth, by age. Whereas 99 percent of women age 15-19 have never given birth, the corresponding proportion for women age 45-49 is 4 percent. 29 31 33 34 37 44 47 54 55 Pakistan 2006-07 India 2005-06 Philippines 2008 Nepal 2006 Cambodia 2005 Bangladesh 2007 Vietnam 2002 MALDIVES 2009 Indonesia 2007 0 10 20 30 40 50 60 70 Number of months Figure 4.3 Median Birth Interval in Selected South Asia and Southeast Asia Countries Source: ICF Macro, 2010. MEASURE DHS STATcompiler http://www.measuredhs.com, April 26 2010 50 | Fertility Levels, Trends, and Differentials Table 4.6 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Maldives 2009 Percentage who have never given birth Percentage who gave birth by exact age Number of women Median age at first birth Current age 15 18 20 22 25 15-19 0.0 na na na na 98.7 2,156 a 20-24 0.0 1.4 8.3 na na 67.6 2,161 a 25-29 0.5 6.6 18.2 32.9 59.6 24.7 1,737 23.9 30-34 2.4 17.6 34.8 50.9 69.0 10.1 1,357 21.9 35-39 3.4 27.0 48.8 65.7 81.3 4.8 1,213 20.1 40-44 4.8 35.2 59.8 73.6 84.6 3.3 1,028 19.1 45-49 4.6 34.4 58.6 76.3 87.8 3.5 735 19.3 20-49 2.0 16.1 31.7 na na 26.1 8,232 22.5 25-49 2.7 21.4 40.0 55.6 73.7 11.3 6,070 21.2 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.7 presents trends and differentials in the median age at first birth across age cohorts for key sub-groups. The measures are also presented for women age 25-49 to ensure that half of the women have already had a birth. Results of the 2009 MDHS indicate that the median age at first birth is 21.2 years. Urban women start childbearing 2.5 years later than their rural counterparts (22.9 years compared with 20.4 years). The median age at first birth increases as a woman’s level of education and wealth quintile also increase. The median age at first birth increases from 18.8 years for women with no education to 24.6 years for women with some secondary education. Women in the wealthiest households give birth 3.4 years later than women in poorer households (23.4 and 20.0 years, respectively). Table 4.7 Median age at first birth Median age at first birth among women age 25-49 years, according to background characteristics, Maldives 2009 Background characteristic Women age 25-49 Age 25-29 30-34 35-39 40-44 45-49 Residence Urban a 23.9 21.5 20.3 20.2 22.9 Rural 23.3 20.8 19.5 18.6 19.0 20.4 Region Malé a 23.9 21.5 20.3 20.2 22.9 North 23.3 20.8 19.3 19.1 19.8 20.8 North Central 23.6 21.6 19.9 18.7 19.0 20.6 Central 22.0 19.5 18.6 18.0 17.7 19.4 South Central 23.3 20.2 19.3 18.3 19.2 20.2 South 23.5 21.3 19.6 18.8 18.3 20.7 Education No formal education 22.4 19.6 18.6 18.5 19.0 18.8 Primary 20.7 20.0 20.0 19.2 19.5 20.1 Secondary 24.8 24.5 25.1 23.8 21.5 24.6 More than secondary a 26.8 24.7 24.9 17.7 a Wealth quintile Lowest 22.7 20.5 18.3 18.7 19.8 20.0 Second 23.5 19.8 19.6 18.5 19.3 20.2 Middle 23.1 21.1 20.1 18.8 18.3 20.7 Fourth 24.0 22.9 21.0 19.5 19.5 22.0 Highest a 24.4 22.0 20.3 19.9 23.4 Total 23.9 21.9 20.1 19.1 19.3 21.2 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group Fertility Levels, Trends, and Differentials | 51 4.8 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy is a major health concern because of its association with high morbidity and mortality for both the mother and child. Childbearing during the teenage years also frequently has adverse social consequences, particularly on female educational attainment because women who become mothers in their teens are more likely to curtail education. Table 4.8 shows that pregnancies among teenagers in Maldives are rare. Only 2 percent of adolescents have started childbearing, 1 percent are mothers, and less than one percent are pregnant with their first child. Very few teenagers have begun childbearing at age 18, while 7 percent have started at age 19 (4 percent had a live birth, and 3 percent are pregnant with their first child). The proportion of teenagers who have entered motherhood varies little across subgroups of women. Women in the South begin childbearing earlier than women in other regions. Although the differences are small, there is an inverse relationship between early childbearing and education. Looking at wealth status, the proportion of teenagers who have begun childbearing is highest among those living in households in the lowest wealth quintile (4 percent). Table 4.8 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child and percentage who have begun childbearing, by background characteristics, Maldives 2009 Percentage who: Background characteristic Have had a live birth Are pregnant with first child Percentage who have begun childbearing Number of women Age 17 0.0 0.6 0.6 167 18 0.5 0.2 0.7 1,462 19 3.8 2.8 6.5 527 Residence Urban 1.1 0.3 1.4 890 Rural 1.2 1.1 2.3 1,471 Region Malé 1.1 0.3 1.4 890 North 0.5 1.7 2.2 379 North Central 0.5 0.3 0.8 330 Central 1.1 1.4 2.5 196 South Central 1.5 1.0 2.5 190 South 2.1 1.1 3.2 418 Education No formal education * * * 20 Primary 2.1 2.2 4.3 164 Secondary 1.2 0.8 2.0 1,902 More than secondary 0.0 0.0 0.0 39 Wealth quintile Lowest 1.6 2.0 3.6 473 Second 0.4 0.7 1.1 475 Middle 1.7 0.7 2.4 376 Fourth 0.7 0.3 1.0 586 Highest 1.5 0.5 2.0 482 Total 1.3 0.9 2.1 2,156 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Total includes 1 woman with information missing on education. 52 | Fertility Levels, Trends, and Differentials Figure 4.4 shows where Maldivian teenagers stand compared with teenagers from other countries in South Asia and Southeast Asia with regard to starting motherhood. Few teenagers in Maldives have begun childbearing (2 percent). In contrast, one in three women age 15-19 in Bangladesh are pregnant with their first child or have become a mother. 2 8 9 9 10 16 19 33 MALDIVES 2009 Cambodia 2005 Pakistan 2006-07 Indonesia 2007 Philippines 2008 India 2005-06 Nepal 2006 Bangladesh 2007 0 10 20 30 40 Percent Figure 4.4 Teenage Pregnancy and Motherhood in Selected South Asia and Southeast Asia Countries Source: Macro International Inc, 2010. MEASURE DHS STATcompiler http://www.measuredhs.com, May 4, 2010 Family Planning | 53 FAMILY PLANNING 5 A policy to implement programs in family planning in Maldives was adopted in 1986. By 1990 the programs had reached all islands. Most of the family planning outlets are in the public sector. Private pharmacies are registered to provide contraceptives prescribed by private physicians. Contraceptives are also available through the Society for Health Education, a non-government organization. Oral contraceptive pills, injectables, and male condoms are available in all government facilities. IUD insertion and removal and female and male sterilization are performed in all hospitals. Norplant, however, is available only in Malé. All contraceptive methods offered by government health facilities are provided free of charge. The data on family planning knowledge and use collected in the 2009 MDHS provide insight into one of the principal determinants of fertility. 5.1 KNOWLEDGE OF FAMILY PLANNING METHODS Awareness of family planning methods is crucial when deciding if one should use a contra- ceptive, and, if an affirmative decision is made, then selecting which method to use. To assess family planning knowledge, respondents were first asked an open-ended question about the methods a couple can use to delay or avoid pregnancy. All methods named spontaneously in response to this question were recorded as recognized family planning methods. If a respondent failed to mention any of the methods listed in the questionnaire, the inter- viewer would describe each method and ask whether the respondent had heard about it. Methods recognized by the respondent after the description was read were also recorded as known. Information was collected for seven modern methods (female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, and emergency contraception) and two traditional methods (periodic abstinence and withdrawal). In addition, provision was made in the questionnaire to record other methods that respondents mentioned spontaneously. No questions were asked to elicit information on depth of knowledge of these methods (e.g., the respondent’s understanding of how to use a specific method). Therefore, in the analysis that follows, knowledge of a family planning method is defined simply as having heard of a method. Table 5.1 shows that knowledge of family planning methods is virtually universal among married women in Maldives. Almost all currently married women age 15-49 interviewed in the MDHS knew at least one modern family planning method. The male condom was the most widely recognized method (98 percent), followed closely by the pill (96 percent). More than 90 percent were also aware of female sterilization and injectables, more than 80 percent knew about the IUD and male sterilization, and 71 percent had heard of implants. Implants were introduced in 2002 and only available in Malé. Emergency contraception, introduced in the Maldives in 2007, was the least widely recognized, with only 29 percent of married women aware of the method. Seven in ten married women had heard of at least one traditional method. The mean number of methods known by women was 7.7. 54 | Family Planning Table 5.1 Knowledge of contraceptive methods Percentage of ever-married women and currently married women age 15-49 who know any contraceptive method, by specific method, Maldives 2009 Method Ever-married women Currently married women Any method 99.2 99.3 Any modern method 99.2 99.3 Female sterilization 93.6 93.7 Male sterilization 81.3 81.8 Pill 95.7 96.1 IUD 86.4 86.4 Injectables 93.0 93.2 Implants 70.4 71.0 Male condom 97.3 97.6 Emergency contraception 29.0 28.9 Any traditional method 71.5 71.7 Rhythm 61.0 61.5 Withdrawal 56.8 56.8 Folk method 1.1 1.2 Mean number of methods known by respondents 15-49 7.7 7.7 Number of respondents 7,131 6,500 5.2 EVER USE OF FAMILY PLANNING Data on the level of ever use of family planning methods were obtained in the MDHS by asking respondents separately if they had ever used each of the family planning methods that they knew. Table 5.2 shows the percentages of ever-married women and currently married women who had ever used family planning, according to a woman’s age and the method used. Overall, 60 percent of currently married women had used a family planning method at some time. Across age groups, the highest level of ever use of any family planning method among currently married women was observed in the 40-44 age group (69 percent), while the lowest level is found among women age 15- 19 (42 percent). Table 5.2 Ever use of contraception Percentage of ever-married women and currently married women age 15-49 who have ever used any contraceptive method by method, according to age, Maldives 2009 Modern method Traditional method Age Any method Any modern method Female sterili- zation Male sterili- zation Pill IUD Inject- ables Implants Male condom Emer- gency contra- ception Any tradi- tional method Rhythm With- drawal Folk method Number of women EVER-MARRIED WOMEN 15-19 41.8 36.8 0.0 0.0 2.8 0.0 1.8 0.0 35.7 0.0 10.3 1.6 9.6 1.1 119 20-24 47.1 39.8 0.1 0.0 7.2 0.6 3.0 0.7 33.3 0.5 15.0 5.3 11.7 0.7 1,268 25-29 59.0 50.7 1.2 0.1 19.9 2.6 7.3 1.4 33.6 0.9 20.5 9.9 13.8 0.8 1,539 30-34 60.2 52.0 6.4 0.4 27.2 3.9 6.0 1.0 28.6 0.9 21.3 13.1 12.4 0.8 1,287 35-39 65.4 58.4 16.2 1.1 29.4 5.2 10.6 0.5 23.2 0.6 20.7 13.4 12.7 0.5 1,185 40-44 66.3 60.4 23.0 1.4 31.2 5.4 13.2 0.7 19.0 0.3 16.3 10.2 10.0 0.3 1,013 45-49 57.9 54.6 24.3 1.7 25.1 2.7 13.9 0.0 12.0 0.0 10.2 6.3 5.4 0.3 721 Total 58.8 51.8 9.8 0.7 22.4 3.3 8.3 0.8 26.7 0.6 17.9 9.8 11.5 0.6 7,131 CURRENTLY MARRIED WOMEN 15-19 41.5 36.1 0.0 0.0 2.3 0.0 1.9 0.0 34.9 0.0 9.9 1.8 9.3 1.1 111 20-24 47.7 40.1 0.1 0.0 7.0 0.6 2.8 0.8 33.9 0.5 15.5 5.5 12.0 0.7 1,188 25-29 60.5 51.9 1.3 0.1 20.1 2.7 7.8 1.5 34.5 1.0 21.0 10.3 14.0 0.8 1,446 30-34 60.6 52.5 6.4 0.5 27.7 3.8 6.3 1.1 29.0 0.7 21.8 13.5 12.9 0.8 1,193 35-39 67.2 60.3 17.3 1.3 30.8 4.9 11.4 0.6 23.8 0.5 21.2 14.1 12.6 0.6 1,065 40-44 69.3 63.0 24.2 1.6 34.3 4.9 14.2 0.8 19.4 0.4 17.1 10.6 10.5 0.3 884 45-49 60.5 56.9 26.1 1.8 27.3 2.6 12.1 0.0 13.0 0.1 11.0 6.9 5.7 0.3 612 Total 60.2 53.0 10.1 0.7 23.2 3.1 8.4 0.9 27.6 0.6 18.5 10.2 11.9 0.6 6,500 Family Planning | 55 Virtually all currently married women who had used a method had experience with modern methods. The most commonly used modern method was the male condom (28 percent), followed by the pill (23 percent). Around one-fifth of married women had used a traditional method. 5.3 CURRENT USE OF FAMILY PLANNING Overall, the MDHS results indicate that around one-third of currently married women in Maldives are using contraception (Figure 5.1). Female sterilization is the most widely used method, followed closely by the male condom (10 percent and 9 percent, respectively). Five percent of married women use the pill. Smaller proportions of women are using other modern methods; e.g., 1 percent use injectables. Eight percent of women reported use of traditional methods, with women somewhat more likely to have used withdrawal (4 percent) than rhythm (3 percent). Table 5.3 shows that current use levels rise rapidly with age, from a level of 15 percent among currently married women age 15-19 to a peak of 45 percent among women age 40-44. The male condom is the most popular method among women under age 40, with around one in ten women age 20-39 using the condom. Female sterilization is the widely used method among women age 35 and over; around one in four women age 40-49 report they use female sterilization. Table 5.3 Current use of contraception by age Percent distribution of currently married women by contraceptive method currently used, according to age, Maldives 2009 Modern method Traditional method Age Any method Any modern method Female sterili- zation Male sterili- zation Pill IUD Inject- ables Implants Male condom Any tradi- tional method Rhythm With- drawal Folk method Not currently using Total Number of women 15-19 15.0 9.6 0.0 0.0 1.6 0.0 1.2 0.0 6.8 5.4 0.7 4.7 0.0 85.0 100.0 111 20-24 23.2 16.8 0.1 0.0 3.5 0.4 1.0 0.6 11.3 6.4 1.8 4.6 0.0 76.8 100.0 1,188 25-29 30.0 20.8 1.3 0.0 4.1 1.2 2.0 0.7 11.6 9.2 3.7 5.4 0.2 70.0 100.0 1,446 30-34 35.1 26.5 6.4 0.2 7.1 1.2 1.0 0.6 10.1 8.6 4.1 4.2 0.2 64.9 100.0 1,193 35-39 44.0 35.1 17.3 0.7 5.2 0.8 1.5 0.0 9.5 8.9 4.9 4.0 0.0 56.0 100.0 1,065 40-44 45.3 38.4 24.2 1.2 5.3 0.9 0.6 0.7 5.5 7.0 3.1 3.8 0.1 54.7 100.0 884 45-49 39.7 34.8 26.1 1.7 2.0 0.3 0.8 0.0 3.9 4.9 3.2 1.7 0.0 60.3 100.0 612 Total 34.7 27.0 10.1 0.5 4.6 0.8 1.2 0.5 9.3 7.8 3.4 4.2 0.1 65.3 100.0 6,500 Note: If more than one method is used, only the most effective method is considered in this tabulation. 42 33 13 1 3 6 10 1 9 39 34 13 2 3 9 7 1 5 35 27 5 1 1 1 9 10 1 8 Any method Any modern method Pill IUD Injectables Implants Condom Female sterili- zation Male sterili- zation Tradi- tional methods 0 20 40 Percent RHS 1999 RHS 2004 MDHS 2009 Figure 5.1 Trends in Contraceptive Use, Maldives 1999-2009 u u u = Unknown 56 | Family Planning Table 5.4 shows the variation in current use levels with other background characteristics. The results indicate that some women in Maldives adopt contraception before having the first birth; 13 percent of childless women are current family planning users. Among women with more than one child, contraceptive use increases with the number of living children, peaking at 54 percent among women with five or more children. Table 5.4 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Maldives 2009 Modern method Traditional method Background characteristic Any method Any modern method Female sterili- zation Male sterili- zation Pill IUD Inject- ables Implants Male condom Any tradi- tional method Rhythm With- drawal Folk method Not currently using Total Number of women Number of living children 0 12.9 7.5 0.0 0.0 0.7 0.0 0.0 0.0 6.8 5.4 2.1 3.3 0.0 87.1 100.0 946 1-2 29.2 20.5 1.6 0.1 3.9 0.9 1.2 0.7 12.2 8.6 4.2 4.3 0.2 70.8 100.0 2,908 3-4 44.4 35.8 15.8 0.6 8.0 1.5 1.7 0.4 7.7 8.6 3.6 5.0 0.0 55.6 100.0 1,486 5+ 54.2 47.8 32.0 1.6 5.4 0.6 1.6 0.4 6.2 6.3 2.4 3.8 0.1 45.8 100.0 1,160 Residence Urban 33.6 25.6 10.1 0.4 1.8 1.4 0.7 1.2 10.1 8.0 4.7 3.1 0.2 66.4 100.0 2,122 Rural 35.3 27.6 10.1 0.5 6.0 0.6 1.5 0.1 8.9 7.6 2.8 4.8 0.0 64.7 100.0 4,378 Region Malé 33.6 25.6 10.1 0.4 1.8 1.4 0.7 1.2 10.1 8.0 4.7 3.1 0.2 66.4 100.0 2,122 North 39.4 28.2 5.7 0.3 6.5 0.9 2.4 0.0 12.5 11.2 4.5 6.7 0.0 60.6 100.0 1,009 North Central 37.4 28.3 10.3 0.1 7.5 0.3 1.9 0.1 8.0 9.2 3.3 5.8 0.0 62.6 100.0 967 Central 42.0 33.1 13.7 1.5 5.4 0.4 0.7 0.1 11.4 8.9 2.6 6.1 0.2 58.0 100.0 563 South Central 31.7 25.0 8.6 0.6 6.9 0.5 0.9 0.1 7.4 6.7 2.2 4.5 0.0 68.3 100.0 789 South 28.4 25.5 13.2 0.5 3.9 0.5 1.1 0.3 6.0 3.0 1.3 1.5 0.1 71.6 100.0 1,051 Education No formal education 43.6 36.2 21.5 1.3 5.8 0.6 1.0 0.2 5.7 7.4 3.7 3.7 0.1 56.4 100.0 1,488 Primary 36.9 29.2 12.0 0.5 5.5 0.8 1.5 0.6 8.4 7.6 3.1 4.5 0.0 63.1 100.0 2,216 Secondary 27.3 19.6 2.3 0.0 3.5 1.0 1.0 0.5 11.2 7.7 3.4 4.2 0.2 72.7 100.0 2,409 More than secondary 32.7 21.2 1.7 0.0 2.1 0.8 0.5 0.7 15.4 11.5 5.7 5.8 0.0 67.3 100.0 316 Wealth quintile Lowest 36.9 29.1 10.7 0.4 7.1 0.4 2.5 0.1 7.9 7.8 2.8 4.9 0.0 63.1 100.0 1,167 Second 35.4 27.0 9.3 0.7 6.6 0.5 1.2 0.1 8.7 8.4 2.6 5.7 0.1 64.6 100.0 1,278 Middle 34.3 27.4 10.5 0.3 5.3 0.7 1.2 0.5 8.8 7.0 2.8 4.2 0.0 65.7 100.0 1,363 Fourth 33.4 25.6 10.9 0.5 3.0 0.8 0.8 0.4 9.2 7.8 4.2 3.5 0.0 66.6 100.0 1,311 Highest 33.9 26.0 9.0 0.4 1.7 1.7 0.6 1.2 11.5 7.9 4.6 3.0 0.3 66.1 100.0 1,381 Total 34.7 27.0 10.1 0.5 4.6 0.8 1.2 0.5 9.3 7.8 3.4 4.2 0.1 65.3 100.0 6,500 Note: Total includes 72 women with information missing on level of education. If more than one method is used, only the most effective method is considered in this tabulation. The MDHS found, somewhat surprisingly, that rural women are slightly more likely than urban women to use family planning (35 percent and 34 percent, respectively). Use levels vary markedly by region, from 28 percent in the South to 42 percent in the Central region. Interestingly the level of use of female sterilization is similar in the South and Central regions (13 percent and 14 percent respectively) while the level of condom use among women in the Central region is nearly double the level in the South (11 percent and 6 percent, respectively). Use generally declines with education. This is largely attributable to a higher rate of use of female sterilization among less educated women; 22 percent of women with no formal education and 12 percent of women with only a primary education are using sterilization compared with only two percent of women with secondary or more than secondary education. Across wealth quintiles, there are only modest differences in the level of current family planning use; 37 percent of married women in the lowest wealth quintile are using family planning compared with 33-34 percent among women in the middle to highest quintiles. Family Planning | 57 5.4 TRENDS IN CURRENT USE OF FAMILY PLANNING Table 5.5 shows the trend in current use of con- traceptive methods among currently married Maldivian women during the period 1999-2009. Findings show that use of any method by currently married women has de- creased from 42 percent in the 1999 Reproductive Health Survey (RHS) to 35 percent in the 2009 MDHS. There has been a shift in the use of some modern methods. In 1999, the pill was used by 13 percent of currently married women; this rate has decreased steadily since, with only 5 percent of currently married women using the pill in the 2009 MDHS. Use of condoms has increased from 6 percent in 1999 to the current rate of 9 percent. The proportion of married women who were sterilized declined from 10 percent in 1999 to 7 percent in 2004 but increased to 10 percent in 2009. Use of traditional methods also declined slightly from 9 percent in 1999 to 8 percent in 2009, after dipping to 5 percent in 2004. While the pill was the most commonly used modern method in the 1999 and 2004 RHS surveys, female sterilization has become the most commonly used modern method in the 2009 MDHS. 5.5 FIRST USE OF FAMILY PLANNING Women who reported that they had used family planning methods at some time were asked about the number of children they had when they first used family planning. These data are useful in identifying the stage in the family-building process when women begin using family planning as well as highlighting their motivation for adopting family planning. Table 5.6 presents the percent distribution of ever-married women by the number of living children at the time of the first use of family planning. A substantial proportion of women used family planning to delay the first birth; around one-fifth of all women—nearly one-third of all ever users— started using family planning immediately after marriage while they were still childless. Sixteen percent of women began use of family planning after they had their first child, 9 percent started after they had two children, and 15 percent had three or more children before using family planning. Table 5.6 Number of children at first use of contraception Percent distribution of ever-married women age 15-49, by number of living children at the time of first use of contraception, according to current age, Maldives 2009 Never used Number of living children at time of first use of contraception Number of women Current age 0 1 2 3 4+ Missing Total 15-19 58.2 38.4 3.4 0.0 0.0 0.0 0.0 100.0 119 20-24 52.9 33.3 11.7 1.8 0.2 0.1 0.0 100.0 1,268 25-29 41.0 25.9 24.0 7.1 1.3 0.5 0.0 100.0 1,539 30-34 39.8 16.8 22.2 11.6 6.0 3.4 0.1 100.0 1,287 35-39 34.6 11.2 16.6 14.3 10.3 13.0 0.1 100.0 1,185 40-44 33.7 9.4 7.5 12.7 12.4 23.9 0.4 100.0 1,013 45-49 42.1 8.6 4.0 7.6 7.1 30.1 0.4 100.0 721 Total 41.2 19.3 15.6 8.9 5.6 9.3 0.2 100.0 7,131 Table 5.5 Trends in use of specific contraceptive methods, Maldives 1999-2009 Percentage of currently married women who are currently using a contraceptive method, by specific method, Maldives 1999-2009 Method RHS 1999 RHS 2004 MDHS 2009 Any method 42 39 35 Any modern method 33 34 27 Pill 13 13 5 IUD 1 2 1 Injectables 3 3 1 Implants u u 1 Condom 6 9 9 Female sterilization 10 7 10 Male sterilization 1 1 1 Traditional methods 9 5 8 Number of women 923 972 6,500 u = Not available 58 | Family Planning Looking at the age patterns, there has been a shift in the timing of the adoption of the first contraceptive method, with younger women initiating use of family planning methods at lower parities than older women. For example, one-third of women age 20-24 started family planning when they were childless compared with 9 percent of women age 40-49. 5.6 KNOWLEDGE OF FERTILE PERIOD An elementary understanding of reproductive physiology, particularly knowledge of when in the ovulatory cycle a woman is most likely to become pregnant, may be useful in ensuring success in the use of coitus-related methods such as the condom, vaginal methods, and withdrawal. Such knowledge is especially critical for the practice of periodic abstinence. To investigate women’s knowledge about their fertile period, respondents were asked in the 2009 MDHS whether there are certain days a woman is more likely to become pregnant if she has sexual intercourse. Those who responded affirmatively to that question were asked if this time is just before the period begins, during the period, right after the period ends, or halfway between two periods. Table 5.7 shows that understanding of the ovulatory cycle is limited among Maldivian women. Only around one-fifth of the ever-married women age 15-49 who were interviewed knew that a woman has a greater probability of becoming pregnant if she has sexual intercourse halfway between two periods. Women who had ever used the rhythm method were more knowledgeable than other women; nevertheless, only around one-third of rhythm users were aware that the chance of becoming pregnant was greatest for a woman if she has intercourse halfway between her periods. Table 5.7 Knowledge of fertile period Percent distribution of ever-married women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Maldives 2009 Perceived fertile period Users of rhythm method Nonusers of rhythm method Ever- married women Just before her menstrual period begins 1.8 2.2 2.2 During her menstrual period 0.6 0.4 0.4 Right after her menstrual period has ended 46.0 32.3 32.7 Halfway between two menstrual periods 34.7 20.1 20.6 Other 0.0 0.1 0.1 No specific time 3.4 11.7 11.4 Don't know 13.5 32.9 32.3 Missing 0.0 0.3 0.3 Total 100.0 100.0 100.0 Number of women 223 6,908 7,131 5.7 TIMING OF STERILIZATION Female sterilization is among the most widely used family planning methods in Maldives, with one in ten ever-married women having been sterilized. In countries like the Maldives where contraceptive sterilization is prevalent, there is interest in knowing the trend in the adoption of the method and in determining whether the age at which sterilization occurs is declining. To investigate these issues, information was collected in the 2009 MDHS from sterilized women on the month and year in which the sterilization took place. This information is used in Table 5.8 to look at the timing of adoption of sterilization among Maldivian women. The results indicate that most Maldivian women adopt sterilization when they are in their thirties. An examination of the variation in the median age at sterilization by the years since the operation has occurred indicates little change in the age pattern of adoption of sterilization. Family Planning | 59 Table 5.8 Timing of sterilization Percent distribution of sterilized women age 15-49, by age at the time of sterilization and by median age at sterilization, according to the number of years since the operation, Maldives 2009 Years since operation Age at time of sterilization Number of women Median age1 <25 25-29 30-34 35-39 40-44 45-49 Total <2 2.3 12.8 31.1 36.8 14.8 2.2 100.0 102 34.0 2-3 0.0 13.5 36.1 28.5 19.2 2.7 100.0 98 33.4 4-5 3.2 18.5 33.6 33.6 11.1 0.0 100.0 113 34.0 6-7 0.9 19.6 38.9 33.7 6.9 0.0 100.0 106 33.4 8-9 2.1 10.7 22.3 61.9 2.9 0.0 100.0 82 35.6 10+ 10.3 39.1 36.6 13.9 0.0 0.0 100.0 201 a Total 4.2 22.1 33.9 31.0 8.0 0.7 100.0 701 - a = Not calculated due to censoring 1 Median age at sterilization is calculated only for women sterilized before age 40 to avoid problems of censoring 5.8 SOURCES FOR MODERN FAMILY PLANNING METHODS In the MDHS, detailed information was collected from current users on sources from which family planning methods were obtained. Table 5.9 shows the distribution of current users by source. Overall, nearly two-thirds of current family planning users in the Maldives received their method from a governmental source. Private sector sources served the majority of users only in the case of the male condom; more than half of condom users said they got their condoms from a private sector source, principally pharmacies. Current users obtaining condoms from public sources were most likely to have gotten them from a government health centre (22 percent). Government health centres also served the majority of users of injectables (65 percent) and pill users (61 percent). Three in four female sterilization users went to a public hospital to be sterilized. Notably the Indira Ghandhi Memorial Hospital provided sterilization services for nearly four in ten sterilization users. Table 5.9 Source of modern contraception methods Percent distribution of current users of modern contraceptive methods age 15-49, by most recent source of method, according to method, Maldives 2009 Source Female sterilization Pill Injectables Male condom Total1 Public sector 76.6 81.1 89.2 32.3 63.1 Indhira Gandhi Memorial Hospital 39.0 2.8 5.7 2.1 19.7 Government regional hospital 23.9 5.3 6.1 3.5 12.7 Government atoll hospital 13.6 6.7 8.2 2.4 8.1 Government health centre 0.1 60.6 64.9 22.2 20.6 Government health post 0.0 4.2 3.3 1.6 1.4 Community/family health worker 0.0 1.3 0.0 0.3 0.5 Other public 0.0 0.1 1.0 0.2 0.1 Private medical sector 22.3 14.2 4.1 56.2 31.0 Private hospital, clinic 8.0 0.8 1.1 2.9 4.8 Private pharmacy 0.0 11.3 0.0 52.7 19.6 Private doctor 0.0 1.6 0.0 0.0 0.3 Other private medical 1.6 0.6 3.0 0.6 1.2 Hospital/clinic abroad 12.8 0.0 0.0 0.0 5.2 Other source 0.0 0.6 0.0 2.6 1.0 Shop 0.0 0.6 0.0 2.4 0.9 Friend/relative 0.0 0.0 0.0 0.2 0.1 Other 0.0 4.1 0.0 5.4 2.8 Don't know 0.2 0.0 0.0 0.0 0.1 Missing 0.9 0.0 6.8 3.5 2.0 Total 100.0 100.0 100.0 100.0 100.0 Number of women 701 303 80 607 1,809 1 Total includes other modern methods for which results are not presented separately due to the small number of unweighted cases. 60 | Family Planning 5.9 INFORMED CHOICE Ensuring that potential users have the information they need to make informed choices is a vital component of family planning programs. Users should be informed of the range of methods that are available in order to make decisions about the contraceptive method most appropriate for their personal situation. Family planning providers should also inform potential users of the side effects that may be experienced when using specific methods and what they should do if effects are encountered. This information both assists the user in coping with side effects and decreases unnecessary discontin

View the publication

You are currently offline. Some pages or content may fail to load.