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 discontinuation of temporary methods. The 2009 MDHS included a number of questions designed to assess whether women who were using family planning at the time of the survey had received sufficient information to make informed choices. Current users were asked whether they had been told about other methods, told about side effects, or given advice about what to do about side effects by the provider from whom they obtained their method. If they were not told about other methods or about side effects during that consultation, they were asked if they had ever received information from a provider about these topics. Caution must be exercised in interpreting the responses to these questions since they are subjective. In addition, they also suffer from an unknown degree of recall error, that is, many users had gone to the provider months or even years before the MDHS interview and may not accurately have remembered the encounter. Nevertheless, the results of these questions provide some insight into the nature of the family planning counselling received by the users. Table 5.10 presents information on the informed choice indicators for current users who adopted the method in January 2003 or later. In general, the information exchange between many current users and their provider is limited. Less than half of users were told about side effects and only 43 percent were told what to do if they experienced side effects. Just over half of users were provided information about other family planning methods they might use. Table 5.10 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods that they could use, by method and source; and among sterilized women, the percentage who were informed that the method is permanent, by initial source of method, Maldives 2009 Among women who started last episode of modern contraceptive method within five years preceding the survey: Among women who were sterilized: Method/source Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Percentage who were informed that sterilization is permanent1 Number of women Method Female sterilization 18.2 14.8 30.7 262 75.8 262 Pill 57.4 53.6 64.9 242 na na Injectables 73.6 72.9 68.4 68 na na Initial source of method2 Public sector 49.5 47.0 58.3 522 74.4 208 Indhira Gandhi Memorial hospital 47.2 46.4 58.8 151 83.8 87 Government regional hospital 32.3 28.4 46.9 98 67.2 68 Government atoll hospital 30.2 28.4 41.5 75 69.2 52 Government health centre 65.5 62.6 67.6 171 * 1 Government health post * * * 16 na na Community/family health worker * * * 9 na na Other public * * * 1 na na Private medical sector 31.8 27.1 36.5 97 (81.3) 54 Total3 45.3 42.6 53.7 643 75.8 262 Note: Table excludes users who obtained their method from friends/relatives. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates the figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Among women who were sterilized in the five years preceding the survey 2 Source at start of current episode of use 3 Total includes users of other modern methods and users of other sources for which results are not presented separately due to the small numbers of unweighted cases. Family Planning | 61 Table 5.10 also shows that the proportions of users receiving the information needed to make an informed choice vary markedly with both the method adopted and the type of clinical providers. Female sterilization users generally reported receiving less information than users of other methods. Looking at the differentials by provider type, users obtaining their method from a public sector source were somewhat better informed than users relying on medical providers in the private sector. 5.10 REASONS FOR DISCONTINUATION OF CONTRACEPTIVE USE Table 5.11 looks in greater detail at the reasons the 2009 MDHS respondents gave for discontinuing contraceptive use. The table shows the percent distribution of all discontinuations in the five-year period prior to the survey by the main reason for discontinuing use, according to the specific method. Table 5.11 Reasons for discontinuation Among all discontinuations of methods in the five years preceding the survey, the percent distribution by main reason for discontinuation, according to method, Maldives 2009 Reason Pill Injectables Male condom Periodic abstinence Withdrawal All methods1 Became pregnant while using 7.6 1.1 13.4 21.5 30.7 13.8 Wanted to become pregnant 17.3 11.9 33.4 38.7 35.0 28.3 Husband disapproved 2.0 0.7 1.8 2.0 0.3 1.6 Side effects 18.8 41.6 4.4 0.0 0.6 10.4 Health concerns 14.8 18.8 3.0 0.6 0.0 6.8 Access/availability 0.3 0.0 0.3 0.0 0.0 0.2 Wanted a more effective method 3.2 1.0 3.1 5.5 7.1 3.6 Inconvenient to use 2.3 2.9 5.9 0.0 0.3 3.5 Infrequent sex/husband away 8.8 3.9 8.8 5.8 4.4 7.2 Fatalistic 0.8 1.3 0.0 0.0 0.0 0.3 Difficult to get pregnant/menopausal 0.9 0.0 0.1 0.0 0.0 0.3 Marital dissolution/separation 0.5 3.3 1.5 0.4 0.8 1.1 Other 11.0 7.7 8.1 1.4 2.6 7.2 Don't know 0.0 0.0 1.0 0.0 0.3 0.5 Missing 11.7 5.7 15.4 24.3 18.0 15.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 389 107 756 160 232 1,722 1 All methods include other modern methods for which results are not presented separately due to the small number of unweighted cases. More than one-quarter of all discontinuations during the five-year period before the survey occurred because the user wanted to have a child. Among modern contraceptive methods, this reason was given most often in the case of condom discontinuations. Fourteen percent of all discontinuations were the result of method failure; that is, the woman became pregnant while using a method. Method failure was most often mentioned as a reason for discontinuations of use of periodic abstinence (22 percent) and withdrawal (31 percent). Side effects and health concerns accounted for 17 percent of all discontinuations. They were cited most often as the reasons for discontinuations of injectables (60 percent) and the pill (33 percent). Smaller proportions of users cited other reasons for discontinuations. Infrequent sex or marital dissolution were reasons in the case of 8 percent of discontinuations. Dissatisfaction with the method, including concerns about its effectiveness or convenience, were given as reasons for 7 percent of discontinuations. Husband’s disapproval was rarely cited as a main factor affecting the decision to discontinue use (2 percent), and problems in getting the method were almost never cited as reasons for discontinuation. 62 | Family Planning 5.11 INTENTION TO USE CONTRACEPTION IN THE FUTURE To obtain information about potential demand for family planning services, all currently married women who were not using contraception at the time of the survey were asked about their intention to adopt family planning methods in the future. Table 5.12 shows the percent distribution of nonusers by their intention to use a method in the future, according to number of living children. Table 5.12 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method, by intention to use in the future, according to number of living children, Maldives 2009 Number of living children1 Intention to use in the future 0 1 2 3 4+ Total Intends to use 25.9 29.3 26.7 25.2 22.8 26.4 Unsure 24.0 19.0 20.1 14.8 11.7 17.9 Does not intend to use 49.2 50.5 52.3 58.9 63.6 54.5 Missing 1.0 1.3 1.0 1.1 1.9 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 607 1,281 925 561 868 4,242 1 Includes current pregnancy The results suggest that there is only limited interest among nonusers in adopting a family planning method in the future. The majority of nonusers (55 percent) did not plan to use in the future, and 18 percent were unsure about their intentions. Only one in four nonusers said that they definitely planned to use in the future. The intention to use varied somewhat with the number of living children the nonuser has. The proportion saying that they did not plan to use in the future increased from 49 percent among women with no children to 64 percent among women with four or more children. 5.12 REASONS FOR NON-USE Table 5.13 presents the distribution of currently married non-users who do not intend to use contraceptive methods in the future by the main reason they gave for not using. The reasons for non-use are of interest to the family planning program because they help to identify areas for potential interventions to support the adoption of contra- ception by non-users. Opposition to use was given as the main reason for non-use by more than four in ten women. In most of these cases, the woman cited her own disapproval (39 per- cent) rather than that of the husband or others or a religious concern. Method-related reasons were cited by a significant proportion of non-users; 12 percent had health concerns, and 6 percent mentioned fear of side effects. Table 5.13 Reason for not intending to use contra- ception in the future Percent distribution of currently married women age 15-49 who are not using contraception and who are not intending to use in the future, by main reason for not intending to use, Maldives 2009 Reason Percent distribution Fertility-related reasons 19.7 Infrequent sex/no sex 2.9 Menopausal/had hysterectomy 1.4 Subfecund/infecund 8.3 Wants as many children as possible 7.1 Opposition to use 45.3 Respondent opposed 38.8 Husband/partner opposed 5.5 Others opposed 0.2 Religious prohibition 0.8 Lack of knowledge 0.4 Knows no method 0.4 Method-related reasons 19.1 Health concerns 12.0 Fear of side effects 5.5 Lack of access/too far 0.1 Cost too much 0.2 Inconvenient to use 0.7 Interfere with body's normal process 0.6 Other 6.0 Don't know 8.8 Missing 0.7 Total 100.0 Number of women 2,311 Family Planning | 63 Around one in five non-users had fertility-related reasons for not planning to adopt contra- ception. These reasons included a perceived lack of need for contraception because the woman was subfecund or infecund (8 percent), menopausal, or had had a hysterectomy (1 percent), or was not sexually active, or had sex infrequently (3 percent). Seven percent of the non-users mentioned a desire to have as many children as possible. 5.13 PREFERRED METHOD Non-users who planned to use family planning in the future were asked about the method they would prefer to use. Table 5.14 shows that 34 percent of all non-users who planned to use preferred the condom, and the pill was preferred by 21 percent. Nine percent said they would use periodic abstinence, and 5 percent would rely on injectables. Four percent preferred female sterilization, and a similar percentage said they planned to use withdrawal. Fifteen percent of non-users intending to use a method in the future were unsure which method they prefer. Table 5.14 Preferred method of con- traception for future use Percent distribution of currently mar- ried women age 15-49 who are not using a contraceptive method but who intend to use in the future, by preferred method, Maldives 2009 Method Percent distribution Female sterilization 4.3 Male sterilization 0.0 Pill 20.9 IUD 1.8 Injectables 4.8 Implants 3.5 Condom 34.4 Diaphragm 0.6 Periodic abstinence 8.9 Withdrawal 3.9 Other 1.2 Unsure 15.1 Missing 0.6 Total 100.0 Number of women 1,119 5.14 EXPOSURE TO FAMILY PLANNING MESSAGES The 2009 MDHS obtained information on the types of media (television, radio, newspaper, or magazine) through which women had recently received family planning information. Table 5.15 shows that radio and television are the primary sources of family planning information for women in the Maldives. Forty-six percent of ever-married women age 15-49 had seen a recent family planning message on radio, and 42 percent reported seeing a message on television. Newspapers and magazines reached far fewer women; around one-quarter of women had read about family planning in a newspaper or magazine. Thirty-eight percent of women had not seen or heard anything any family planning message recently. The proportion of women who had not been exposed to any family planning message decreased with the woman’s age. Somewhat surprisingly, fewer women living in urban areas have seen a family planning message within the few months before the MDHS compared with those living in rural areas. Exposure to a family planning message through the three media sources generally decreases with the woman’s educational level and wealth quintile. 64 | Family Planning Table 5.15 Exposure to family planning messages Percentage of ever-married women age 15-49 who heard or saw a family planning message on the radio or television or in a newspaper in the past few months, according to background characteristics, Maldives 2009 Background characteristic Radio Television Newspaper/ magazine None of these three media sources Number Age 15-19 34.3 35.4 18.7 45.0 119 20-24 39.3 36.1 26.5 40.6 1,268 25-29 41.5 35.8 25.1 40.3 1,539 30-34 44.7 41.4 23.2 37.7 1,287 35-39 52.4 45.4 25.2 34.7 1,185 40-44 49.5 46.4 24.4 35.1 1,013 45-49 55.1 50.9 25.0 32.7 721 Residence Urban 34.7 37.0 32.6 42.5 2,368 Rural 51.5 43.7 20.9 35.1 4,763 Region Malé 34.7 37.0 32.6 42.5 2,368 North 52.4 38.4 18.7 37.0 1,067 North Central 51.0 45.6 20.0 34.6 1,038 Central 54.5 46.5 15.4 35.6 615 South Central 54.3 46.0 17.9 31.6 853 South 47.3 43.8 28.7 36.0 1,190 Education No formal education 54.5 49.1 19.3 33.3 1,668 Primary 53.1 46.3 24.9 31.9 2,464 Secondary 37.0 35.0 27.3 43.3 2,584 More than secondary 22.0 23.1 30.5 53.8 333 Wealth quintile Lowest 55.6 41.5 18.6 34.9 1,300 Second 52.5 44.7 18.0 34.9 1,396 Middle 50.4 45.3 22.7 35.1 1,488 Fourth 39.4 41.4 29.5 38.4 1,447 Highest 33.2 34.7 34.0 43.9 1,499 Total 15-49 45.9 41.5 24.8 37.5 7,131 Note: Total includes 81 women with information missing on level of education. 5.15 CONTACT OF NONUSERS WITH OUTREACH WORKERS/HEALTH CARE PROVIDERS The 2009 MDHS collected information on contacts non-users may have had with family planning workers or other health care providers in which family planning had been discussed during the 12 months prior to survey. Table 15.16 presents the data on both the proportion of currently married non-users who had any contact with a family planning fieldworker and the proportion who discussed family planning with another health care provider during the 12 months prior to the survey. Relatively few women had been reached by fieldworkers, with only 9 percent of non-users reporting that they had been visited at home by a fieldworker who discussed family planning. Table 15.16 also looks at the extent to which non-users had an opportunity to discuss family planning during their visits to health facilities. Overall, 85 percent of non-users had visited a health facility during the 12-month period before the survey. Only about one in eight of these women—10 percent of all nonusers—had discussed family planning during a visit they had made to a health Family Planning | 65 facility during the 12 months before the MDHS. Overall, at least eight in ten of the nonusers in every population subgroup shown in Table 15.16 reported that they had never discussed family planning with a health provider or fieldworker during the year before the survey. Although the results in Table 15.16 suggest that there are many “missed” opportunities for informing and motivating nonusers about family planning, caution must be exercised in drawing such conclusions. Not all visits to health providers present appropriate opportunities for offering family planning information or services, and not all non-users are interested in/or in need of family planning when they visit a facility. Nevertheless, health workers should be taking more advantage of visits that women make to facilities to offer family planning information. Table 5.16 Contact of non-users with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the last 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who neither discussed family planning with a fieldworker nor at a health facility, by background characteristics, Maldives 2009 Background characteristic Percentage of women who were visited by fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who Percentage of women who neither discussed family planning with a fieldworker nor at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 9.8 11.9 57.2 82.2 102 20-24 7.9 13.8 71.3 80.9 990 25-29 7.5 12.5 73.0 82.0 1,103 30-34 10.4 13.0 75.4 79.8 861 35-39 8.8 6.4 80.3 86.5 709 40-44 8.7 4.9 80.8 87.5 589 45-49 10.7 5.8 74.9 86.1 463 Residence Urban 7.6 10.5 72.2 83.5 1,628 Rural 9.4 10.4 76.4 82.9 3,189 Region Malé 7.6 10.5 72.2 83.5 1,628 North 8.5 9.9 76.1 84.4 665 North Central 9.0 10.1 78.0 83.2 669 Central 10.1 10.7 76.1 81.3 373 South Central 10.2 11.3 75.4 81.3 600 South 9.7 10.1 76.2 83.3 881 Education No formal education 12.0 6.7 80.0 83.9 997 Primary 9.1 9.8 75.0 83.6 1,626 Secondary 7.3 12.7 72.8 82.3 1,915 More than secondary 7.5 12.6 68.3 79.9 228 Wealth quintile Lowest 8.1 10.4 77.2 84.2 862 Second 10.3 10.5 76.0 81.9 931 Middle 10.3 9.1 77.8 83.3 1,010 Fourth 10.4 11.1 72.7 80.6 997 Highest 4.9 10.8 71.5 85.6 1,016 Total 8.8 10.4 75.0 83.1 4,817 Note: Total includes 50 women with information missing on level of education Other Proximate Determinants of Fertility | 67 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter addresses the principal factors, other than contraception, which affect a woman’s risk of becoming pregnant. These factors include marriage, sexual activity, postpartum amenorrhoea, abstinence from sexual activity, and onset of menopause. The time when exposure to pregnancy begins and the level of exposure throughout a woman’s life are also reported in this chapter. 6.1 CURRENT MARITAL STATUS Marriage is a primary indication that a woman will be exposed regularly to the risk of pregnancy. Therefore, knowledge of when marriage typically occurs in a population is important to the understanding of fertility. Populations that have a low age at first marriage tend to have early childbearing and high fertility rates. Table 6.1 presents the percent distribution of women, by current marital status. Respondents who are currently married, divorced, separated, or widowed are referred to as ’ever married.’ The data indicate that 31 percent of women have never been married, 63 percent are currently married, 5 percent are divorced, and less than 1 percent each are separated or widowed. The percentage of women never married decreases rapidly from 95 percent among teenagers (age 15-19) to 41 percent among women age 20-24. By age 35-39 all but 2 percent of women have been married. The proportion of women who are divorced increases steadily with age, from 3 percent of women age 20-24 to 10 percent of women age 40-44, and then to 11 percent of women age 45-49. The proportion who are widowed also increases with age, reaching a high of 4 percent among women age 45-49. Table 6.1 Current marital status Percent distribution of women age 15-49, by current marital status, according to age, Maldives 2009 Marital status Age Never married Married Divorced Separated Widowed Total Number of women 15-19 94.5 5.2 0.4 0.0 0.0 100.0 2,156 20-24 41.3 55.0 3.2 0.2 0.3 100.0 2,161 25-29 11.4 83.2 5.2 0.1 0.1 100.0 1,737 30-34 5.2 87.9 6.4 0.2 0.4 100.0 1,357 35-39 2.4 87.8 8.6 0.1 1.2 100.0 1,213 40-44 1.5 86.0 10.0 0.2 2.4 100.0 1,028 45-49 1.9 83.3 10.6 0.0 4.2 100.0 735 Total 31.4 62.6 5.2 0.1 0.8 100.0 10,388 6.2 AGE AT FIRST MARRIAGE Marriage correlates with exposure to risk of conception and is consequently associated with fertility. The duration of exposure to the risk of pregnancy depends primarily on the age at which women first marry. Women who marry early in life can be expected to have their first child early and thus give birth to more children, contributing to higher fertility rates. Table 6.2 shows the proportions of women who marry at specific ages and the median age at marriage for successive age groups. The median is defined as the age by which 50 percent of all women in the age group were married. This measurement of central tendency is preferred over the mean, because, unlike the mean, it can be estimated for all cohorts where at least half of the women 68 | Other Proximate Determinants of Fertility are ever married at the time of survey. In drawing conclusions concerning trends, the data for the oldest cohorts in Table 6.2 should be interpreted with caution because these women may not recall marriage dates or ages with accuracy. There has been a notable increase in the age at which women first marry across cohorts. For example, 16 percent of women age 45-49 were married by age 15 compared with only 8 percent of women age 35-39 and with less than 2 percent of women age 25-29. Similarly, more than eight in ten women age 45-49 were married by age 20, while one in four women age 20-24 were married by that same age. Overall, the median age at first marriage increases rapidly across cohorts, from 16.9 years among women age 45-49 to 21.6 years among women age 25-29. Table 6.2 Age at first marriage Percentage of women age 15-49 who married by age and median age at first marriage, according to current age, Maldives 2009 Percentage never married Median age at first marriage Percentage first married, by exact age: Current age 15 18 20 22 25 Number 15-19 0.0 na na na na 94.5 2,156 a 20-24 0.3 3.9 25.4 na na 41.3 2,161 a 25-29 1.6 16.8 34.6 53.4 80.6 11.4 1,737 21.6 30-34 8.7 32.5 53.3 66.2 81.9 5.2 1,357 19.7 35-39 8.4 45.3 67.3 79.6 91.1 2.4 1,213 18.3 40-44 15.5 57.2 75.2 84.5 91.7 1.5 1,028 17.3 45-49 16.3 63.0 84.0 89.1 94.9 1.9 735 16.9 20-49 6.5 29.4 49.6 65.3 79.3 14.8 8,232 20.0 25-49 8.7 38.4 58.2 71.1 86.6 5.4 6,070 19.0 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner na = Not applicable due to censoring a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Table 6.3 shows the median age at first marriage according to residence, level of education, and wealth quintile. Because of the small number of married respondents interviewed, the data for women age 15-24 have been omitted. Urban women age 25-49 marry almost two years later than rural women (20.4 years and 18.5 years, respectively). There are large variations in the age at first marriage across regions, ranging from 17.7 among women in the Central region to 20.4 years among women in Malé (Figure 6.1). Age at first marriage increases as the woman’s level of education and wealth status also increase. Among women with secondary and higher education, the median age at first marriage is 23.8 years, almost seven years older than the age of first marriage among women with no education (17.0 years). Similarly, the richest women marry almost three years later than women in the poorest quintile (21.1 years compared with 18.2 years). Figure 6.1 presents the median age at marriage for women in Maldives in comparison with their median age in countries in South Asia and Southeast Asia for which comparable data are available. Figure 6.1 shows that, on average, women in Maldives marry later in life than women in Bangladesh, Nepal, and India, at about the same age as women in Pakistan, and earlier in life than women in Southeast Asia. Other Proximate Determinants of Fertility | 69 Table 6.3 Median age at first marriage Median age at first marriage among women, by five-year age groups and age 25-49, 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 22.4 21.6 19.5 18.5 17.5 20.4 Rural 21.1 18.8 17.9 16.9 16.8 18.5 Region Malé 22.4 21.6 19.5 18.5 17.5 20.4 North 20.9 19.0 17.7 17.7 17.8 18.9 North Central 21.9 19.2 18.5 17.3 16.9 18.7 Central 20.2 17.8 17.3 16.3 15.8 17.7 South Central 21.0 18.5 17.8 16.9 17.0 18.3 South 21.3 19.0 17.8 16.4 16.2 18.4 Education No formal education 19.8 17.9 17.3 16.9 16.7 17.0 Primary 18.8 18.3 18.1 17.2 17.0 18.2 Secondary 22.5 22.4 22.4 22.0 19.4 22.4 More than secondary 24.0 24.4 22.4 22.7 15.7 23.8 Wealth quintile Lowest 20.5 18.7 17.1 17.2 16.8 18.2 Second 21.1 18.3 18.0 16.8 17.0 18.3 Middle 21.2 18.8 18.3 16.9 16.3 18.6 Fourth 21.8 20.3 19.0 17.8 17.5 19.6 Highest 22.6 22.5 19.9 18.6 16.7 21.1 Total 21.6 19.7 18.3 17.3 16.9 19.0 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner Figure 6.1 Median Age at First Marriage in South and Southeast Asia 15.0 17.0 17.4 19.0 19.1 19.8 20.1 21.1 22.2 Bangladesh (2007) Nepal (2006) India (2005-06) Maldives (2009) Pakistan (2006-07) Indonesia (2007) Cambodia (2005) Vietnam (2002) Philippines (2008) 0.0 5.0 10.0 15.0 20.0 25.0 Median age at first marriage for women age 25-49 Source: Macro International Inc, 2010. MEASURE DHS STATcompiler 70 | Other Proximate Determinants of Fertility 6.3 AGE AT FIRST SEXUAL INTERCOURSE Although age at first marriage often marks first exposure to intercourse, the two events do not necessarily occur at the same time. Women and men sometimes engage in sexual relations before marriage. In the 2009 MDHS, women were asked how old they were when they first had sexual intercourse. The age at first sexual intercourse varies throughout the age cohorts. For example, 16 percent of women age 45-49 were sexually active by age 15 compared with 8 percent of women age 35-39 and 1 percent of women age 25-29 (Table 6.4). Similarly, whereas almost all women age 45-49 have had sexual intercourse, 95 percent of women age 15-19 are not sexually active. Overall, the median age at first intercourse has increased from 17.0 years among women 45-49 to 21.8 years among women age 25-29. Table 6.4 Age at first sexual intercourse Percentage of women age 15-49 who had first sexual intercourse by specific exact age, percentage who never had intercourse, and median age at first intercourse, according to current age, Maldives 2009 Percentage who never had intercourse Median age at first intercourse Percentage who had first sexual intercourse by exact age: Current age 15 18 20 22 25 Number 15-19 0.1 na na na na 94.5 2,156 a 20-24 0.3 3.1 25.7 na na 41.4 2,161 a 25-29 1.2 15.7 33.9 51.7 77.1 11.6 1,737 21.8 30-34 7.1 27.9 48.3 63.0 76.3 5.2 1,357 20.2 35-39 7.8 41.9 60.7 72.7 81.6 2.4 1,213 18.7 40-44 13.6 52.2 67.4 75.5 81.3 1.5 1,028 17.8 45-49 15.6 59.5 76.5 81.9 85.9 1.9 735 17.0 20-49 5.8 26.8 46.1 61.3 73.6 14.9 8,232 20.5 25-49 7.7 35.2 53.3 na na 5.4 6,070 19.6 15-24 0.2 na na na na 67.9 4,318 a na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Differentials in age at first sex by background characteristics are shown in Table 6.5. Urban women had first sexual intercourse two years later than rural women (20.9 years compared with 18.9 years). Women in Malé had first sexual intercourse at a later age than women in other regions, and women in the Central region had the youngest median age for first intercourse. The median age at first sexual intercourse for women with secondary and higher education is 23.8 years, 6.5 years later than the median age for women with no education (17.3 years). The median age at first sexual intercourse increases with wealth status; women in the highest wealth quintile have a median age of 21.3 years compared with 18.5 years for women in the lowest wealth quintile. Figure 6.2 shows the median age at first sexual intercourse for countries in South Asia and Southeast Asia for which comparable data are available. Women in Maldives had their first sexual encounter about two years later in life than women in Nepal and India, at about the same age as women in Indonesia and Cambodia, and earlier in life than women in the Philippines. Other Proximate Determinants of Fertility | 71 Table 6.5 Median age at first intercourse Median age at first sexual intercourse among women by five-year age groups and age 25-49, 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 22.6 21.8 20.1 19.2 18.1 20.9 Rural 21.3 19.2 18.3 17.2 16.9 18.9 Region Malé 22.6 21.8 20.1 19.2 18.1 20.9 North 21.3 19.8 18.3 18.2 18.0 19.6 North Central 22.1 19.3 18.8 17.2 17.0 18.8 Central 20.3 18.2 18.2 16.6 15.8 18.2 South Central 21.4 19.0 18.2 17.2 17.1 18.7 South 21.3 19.5 18.1 16.7 16.4 18.7 Education No formal education 20.3 18.3 17.7 17.2 16.8 17.3 Primary 19.0 18.7 18.2 17.9 17.6 18.5 Secondary 22.6 22.3 22.9 20.9 19.5 22.5 More than secondary 24.0 23.7 23.1 22.8 15.7 23.8 Wealth quintile Lowest 20.9 18.8 17.5 17.3 17.0 18.5 Second 21.2 18.8 18.2 17.2 17.0 18.6 Middle 21.5 19.6 18.7 17.3 16.6 19.1 Fourth 21.8 21.0 19.7 18.1 18.0 20.1 Highest 22.8 22.5 20.2 20.0 16.9 21.3 Total 21.8 20.2 18.7 17.8 17.0 19.6 Figure 6.2 Median Age at First Sexual Intercourse in South and Southeast Asia 17.0 17.6 19.6 19.7 20.4 21.5 Nepal (2006) India (2005-06) Maldives (2009) Indonesia (2007) Cambodia (2005) Philippines (2008) 0.0 5.0 10.0 15.0 20.0 25.0 Median age at first sexual intercourse for women age 25-49 Source: Macro International Inc, 2010. MEASURE DHS STATcompiler 1 Among ever-married women 1 1 72 | Other Proximate Determinants of Fertility 6.4 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea refers to the interval between childbirth and the return of menstruation. The length and intensity of breastfeeding influence the duration of amenorrhoea, which offers protection from conception. Postpartum abstinence refers to the period between childbirth and the time when a woman resumes sexual activity. Delaying the resumption of sexual relations can also prolong protection. Women are considered to be insusceptible to pregnancy if they are not exposed to the risk of conception, either because their menstrual period has not resumed since a birth or because they abstain from intercourse after childbirth. Table 6.6 shows the percentage of births in the three years preceding the survey for which the mother is postpartum amenorrhoeic, abstaining, or insusceptible. The estimates in Table 6.6 are based on current status data; they refer to the woman’s situation at the time of the survey. The data are grouped in two-month intervals to minimize fluctuations in the estimates. The duration of postpartum amenorrhea for Maldivian women is relatively short, a median of 4.7 months. The median duration of postpartum abstinence is 3 months. Examining the two factors together, the median duration of postpartum insusceptibility to pregnancy is 5.6 months. Table 6.6 shows that all women in Maldives are insusceptible to pregnancy in the first two months following a birth, mostly due to the contribution of abstinence. However, the proportion of women who abstain from sexual intercourse decreases rapidly from the second month after birth. The decrease in the protective effect of amenorrhea is less rapid; 73 percent of women are still amenorrhoeic at 2 to 3 months after birth, 32 percent are still amenorrhoeic at 6 to 7 months, and 7 percent are still amenorrhoeic at 12 to 13 months. Table 6.6 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, insusceptible, by number of months since birth, and median and mean durations, Maldives 2009 Months since birth Percentage of births for which the mother is: Number of births Amenorrhoeic Abstaining Insusceptible1 < 2 93.2 100.0 100.0 77 2-3 73.4 63.5 83.1 166 4-5 47.8 25.4 56.9 164 6-7 32.4 13.4 40.6 159 8-9 18.6 7.9 24.1 141 10-11 11.8 4.6 14.4 143 12-13 7.1 2.1 9.2 138 14-15 6.0 8.3 14.3 116 16-17 1.0 5.7 6.6 132 18-19 0.8 3.6 4.4 152 20-21 1.6 6.0 7.6 160 22-23 0.2 0.8 1.1 125 24-25 0.0 3.2 3.2 119 26-27 0.0 2.1 2.1 110 28-29 0.0 2.1 2.1 113 30-31 3.4 2.6 5.9 113 32-33 0.0 2.3 2.3 107 34-35 0.0 0.1 0.1 127 Total 16.6 13.2 21.3 2,362 Median 4.7 3.0 5.6 na Mean 6.2 5.3 7.8 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth Other Proximate Determinants of Fertility | 73 Table 6.7 shows the median durations of postpartum amenorrhoea, abstinence, and insusceptibility by background characteristics. There are slight variations of about one month in the median duration across subgroups of women. Table 6.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Maldives 2009 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 4.2 2.7 5.2 30-49 5.7 3.6 6.5 Residence Urban 4.1 2.6 5.2 Rural 4.9 3.2 5.8 Region Malé 4.1 2.6 5.2 North 5.3 3.2 5.5 North Central 5.0 3.5 6.2 Central 5.4 2.3 5.9 South Central 4.1 2.3 5.1 South 4.7 4.3 5.9 Education No formal education 4.5 4.4 6.3 Primary 5.3 2.7 5.9 Secondary 4.2 3.0 5.4 More than secondary 5.7 2.4 5.7 Wealth quintile Lowest 4.9 2.7 6.0 Second 4.9 2.7 5.7 Middle 4.4 3.5 5.4 Fourth 5.1 2.4 6.0 Highest 3.9 3.4 5.0 Total 4.7 3.0 5.6 Note: Medians are based on the status at the time of the survey (current status) 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth 6.5 MENOPAUSE Another factor influencing the risk of pregnancy among women is menopause. In the context of the available survey data, women are considered menopausal if they are neither pregnant nor postpartum amenorrhoeic and have not had a menstrual period in the six months preceding the survey (Table 6.8). As expected, the proportion of women who are menopausal or who have had a hysterectomy increases with age. Less than 2 percent of women age 30-34 years are menopausal compared with 23 percent of women age 48-49 years. Table 6.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Maldives 2009 Age Percentage menopausal1 Number of women 30-34 1.5 1,287 35-39 2.3 1,185 40-41 5.4 432 42-43 6.9 389 44-45 8.4 340 46-47 11.6 336 48-49 23.0 238 Total 5.2 4,205 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 75 FERTILITY PREFERENCES 7 Insight into the fertility desires of a population is important, both for estimating the potential unmet need for family planning and for predicting future fertility. This chapter presents data from the 2009 MDHS on the fertility intentions of women, the need for family planning services, and the ideal family size as envisioned by women in Maldives. It also considers the potential effect on fertility of efforts to prevent unwanted pregnancies. 7.1 DESIRE FOR MORE CHILDREN To obtain information on current fertility preferences, all married non-sterilized women were asked the following question in the MDHS: “Would you like to have (a/another) child or would you prefer not to have any (more) children?” For pregnant women, the question was prefaced by the wording, “After the child you are expecting. . . .” Women who wanted more children were then asked how long they would like to wait before the birth of their next child. Sterilized women who were not asked the question about fertility preference are considered to want no more children for purposes of the tabulations in this chapter. Table 7.1 and Figure 7.1 show the reproductive preferences of currently married women in the Maldives. Nearly half of married women do not want any more children (37 percent) or have been sterilized (11 percent). Among those wanting another child, the majority—26 percent of all currently married women—either want to wait two years or more to have the next birth or are unsure about their childbearing intentions. Slightly less than half of the women who want another child—18 percent of all currently married women—want a child soon (within two years). Both the desire for a child and the timing desired for the next birth are strongly related to the number of children. As expected, the majority (75 percent) of women who have no children want a birth soon. However, there is interest in controlling the timing of the first birth among some childless women; 17 percent expressed a desire to delay having a child for at least two years. Interest in delaying births is even more evident among women with one child; half want to wait two years or more to have the next birth. Among women with more than one child, the proportion wanting to limit childbearing increases rapidly, from 47 percent among women with two children to 96 percent among women with six or more children. Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women 15-49 by number of living children, according to desire for children, Maldives 2009 Number of living children1 Total 15-49 Desire for children 0 1 2 3 4 5 6+ Have another soon2 75.4 22.9 11.2 4.2 3.5 1.7 0.1 17.8 Have another later3 16.5 50.6 21.7 10.7 2.4 2.2 0.3 21.5 Have another, undecided when 5.6 8.1 4.0 2.9 1.0 0.5 0.1 4.1 Undecided 1.0 7.2 14.2 9.9 5.7 1.2 0.9 7.1 Want no more 0.5 10.2 43.8 57.3 65.1 67.1 57.2 37.2 Sterilized4 0.0 0.2 3.4 13.3 20.0 24.5 38.6 10.5 Declared infecund 0.8 0.2 1.1 0.8 1.0 1.5 1.7 0.9 Missing 0.1 0.6 0.6 0.9 1.4 1.3 1.0 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 730 1,683 1,371 954 591 443 728 6,500 1 The number of living children includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 76 | Fertility Preferences Table 7.2 shows that, among all married women, the proportion that wants no more children varies markedly with education. Higher proportions of women with primary or no education want no more children compared with women with secondary or higher education. Among currently married women with four or more children, there are only minor differences in the proportions that want to limit childbearing. However, among women with three or fewer children, fertility preferences vary more markedly across subgroups. For example, among women with two children, 60 percent in urban areas want to stop childbearing compared with 38 percent in rural areas. Figure 7.1 Fertility Preferences among Currently Married Women Age 15-49 Undecided 7% Want child soon 18% Want child later 22% Infecund 1% Want no more children 37% MDHS 2009 Have another, undecided when 4% Sterilized 11% Fertility Preferences | 77 Table 7.2 Desire to limit childbearing Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Maldives 2009 Background characteristic Number of living children1 0 1 2 3 4 5 6+ Total Residence Urban 0.6 17.2 59.5 78.2 89.6 (92.1) 94.9 47.9 Rural 0.5 6.5 38.0 66.7 83.7 91.4 96.0 47.7 Region Malé 0.6 17.2 59.5 78.2 89.6 (92.1) 94.9 47.9 North 0.0 4.2 34.6 71.1 82.0 90.8 98.5 46.2 North Central 0.0 3.7 45.4 61.1 80.3 91.0 94.4 47.3 Central 1.2 6.5 36.1 60.7 87.1 93.0 93.3 47.4 South Central 1.1 8.1 40.6 66.2 88.2 93.4 93.4 49.2 South 0.8 10.0 34.4 71.8 81.9 89.6 98.4 48.5 Education No formal education (0.0) 31.9 61.7 74.9 87.6 92.5 94.9 82.6 Primary 0.0 12.5 39.6 67.2 83.7 91.6 99.3 55.1 Secondary 0.6 9.3 52.6 75.1 (86.8) * * 24.2 More than secondary 0.8 3.4 41.6 (54.9) * * * 16.0 Wealth quintile Lowest 0.7 7.1 38.7 65.9 81.2 85.6 96.0 52.2 Second 0.1 5.8 37.7 61.3 85.3 92.4 96.6 48.6 Middle 0.4 6.7 40.7 71.6 84.5 95.9 96.0 46.6 Fourth 1.6 12.8 50.6 77.7 86.5 89.9 95.3 46.7 Highest 0.0 16.5 58.6 74.4 (90.6) * (93.8) 45.4 Total 0.5 10.3 47.2 70.6 85.1 91.5 95.9 47.8 Note: Women who have been sterilized are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates the figure is based on fewer than 25 unweighted cases and has been suppressed. 1 The number of living children includes the current pregnancy. 7.2 NEED FOR FAMILY PLANNING One of the major concerns of family planning programs is to define the size of the potential demand for contraception and to identify women who are the most in need of contraceptive services. Table 7.3 presents estimates of unmet and met need for family planning services. Women with an unmet need for family planning (shown in columns 1-3 of Table 7.3) include the following: (1) Currently married women who are in need of family planning for spacing purposes. This group includes (a) pregnant women whose pregnancy is mistimed (i.e., wanted later); (b) amenorrhoeic women whose last birth was mistimed; and (c) non-users who are neither pregnant nor amenorrhoeic and who either want to delay the next birth at least two or more years, are unsure whether they want another child, or want another child but are unsure when to have the birth. (2) Currently married women who are in need of family planning for limiting purposes. This group includes: (a) pregnant women whose pregnancy is unwanted; (b) amenorrhoeic women whose last child was unwanted; and (c) non-users who are neither pregnant nor amenorrhoeic and who want no more children. Menopausal and infecund women are excluded from the unmet need category as are pregnant or amenorrhoeic women who became pregnant while using a contraceptive method. Pregnant women whose pregnancy is mistimed or amenorrhoeic women whose last birth was mistimed are considered to be in need of better contraception. 78 | Fertility Preferences Women with a met need for family planning (shown in columns 4-6 of Table 7.3) include women who are currently using contraception. The total demand for family planning (shown in columns 7-9 of Table 7.3) represents the sum of unmet need and met need. The total demand also includes pregnant and amenorrhoeic women who became pregnant while using a family planning method. The percentage of the total demand that is satisfied is shown in column 10 in Table 7.3. Table 7.3 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage for the demand for contraception that is satisfied, by background characteristics, Maldives 2009 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 36.3 0.0 36.3 15.0 0.0 15.0 57.3 0.0 57.3 36.6 111 20-24 26.3 5.2 31.5 20.2 3.0 23.2 47.6 8.4 56.0 43.7 1,188 25-29 25.3 8.8 34.2 19.2 10.8 30.0 45.7 19.7 65.3 47.7 1,446 30-34 13.5 16.6 30.2 13.4 21.7 35.1 27.6 38.6 66.2 54.5 1,193 35-39 6.1 18.1 24.2 7.1 36.9 44.0 13.5 55.3 68.9 64.8 1,065 40-44 2.4 20.8 23.2 2.5 42.8 45.3 4.9 63.8 68.8 66.3 884 45-49 0.3 15.7 16.0 0.4 39.2 39.7 0.7 54.9 55.6 71.3 612 Residence Urban 14.0 12.2 26.2 12.1 21.5 33.6 26.9 33.9 60.8 56.9 2,122 Rural 15.3 13.7 29.1 12.3 23.0 35.3 28.4 36.9 65.2 55.4 4,378 Region Malé 14.0 12.2 26.2 12.1 21.5 33.6 26.9 33.9 60.8 56.9 2,122 North 13.5 11.8 25.4 15.6 23.8 39.4 30.4 36.0 66.4 61.8 1,009 North Central 14.4 12.6 27.1 13.8 23.6 37.4 28.5 36.4 64.8 58.3 967 Central 13.3 11.8 25.1 14.0 28.0 42.0 27.7 40.0 67.7 62.9 563 South Central 14.7 15.9 30.5 11.4 20.3 31.7 26.8 36.3 63.0 51.5 789 South 19.6 16.0 35.6 7.5 20.9 28.4 27.9 36.9 64.9 45.2 1,051 Education No formal education 3.9 19.8 23.8 3.2 40.4 43.6 7.3 60.5 67.8 64.9 1,488 Primary 12.2 15.3 27.4 10.1 26.8 36.9 22.6 42.2 64.8 57.6 2,216 Secondary 23.7 8.4 32.1 18.0 9.3 27.3 43.1 17.9 61.1 47.4 2,409 More than secondary 18.4 6.8 25.2 23.6 9.1 32.7 43.1 15.8 58.9 57.3 316 Wealth quintile Lowest 14.2 14.6 28.8 11.1 25.9 36.9 26.0 40.8 66.8 56.9 1,167 Second 15.8 13.6 29.4 11.8 23.7 35.4 28.2 37.4 65.6 55.2 1,278 Middle 14.4 14.3 28.7 12.7 21.6 34.3 27.9 36.0 63.8 55.1 1,363 Fourth 15.9 12.8 28.7 12.3 21.1 33.4 28.8 34.0 62.8 54.4 1,311 Highest 14.3 11.1 25.4 13.1 20.9 33.9 28.3 32.1 60.4 57.9 1,381 Total 14.9 13.2 28.1 12.2 22.5 34.7 27.9 35.9 63.8 55.9 6,500 Note: Total includes 72 women with information missing on education level. 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed; amenorrhoeic women who are not using family planning and whose last birth was mistimed, or whose last birth was unwanted but now say they want more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and who say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted; amenorrhoeic women who are not using family planning, whose last child was unwanted and who do not want any more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and who want no more children. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. Fertility Preferences | 79 According to Table 7.3, the total unmet need among currently married women in Maldives is 28 percent; 15 percent are in need of family planning because of a desire to space the next birth, and the remainder are in need due to an interest in limiting births. Although the drop is not uniform, the level of unmet need tends to decline with age. Unmet need is slightly higher among rural women than urban women and varies from a level of 25 percent in the North and Central regions to 36 percent in the South. The total met need for family planning (i.e., the proportion of married women currently using contraception) is 35 percent. Around two-thirds of users—23 percent of all married women—are limiters. Overall, the total demand for family planning comprises 64 percent of married women in Maldives. Fifty-six percent of that demand is satisfied. The level of satisfied demand rises with age. It is similar among urban and rural women. Married women in the Central and North regions have the highest level of satisfied demand, and women in the South region have the lowest level (63 percent, 62 percent, and 45 percent, respectively). 7.3 IDEAL NUMBER OF CHILDREN In the first part of this chapter, the discussion of fertility preferences focused on women’s desires with respect to future childbearing. A woman’s future childbearing intentions obviously are influenced by the number of children she already has. The 2009 MDHS tried to obtain a measure of fertility preferences that was less dependent on current family size by asking about the respondent’s ideal number of children. This question required the respondent to perform the difficult task of considering the number of children she would choose to have in her whole life regardless of the number (if any) that she had already borne. Respondents had problems with the abstract nature of the question, and so some respondents gave non-numeric responses. In considering the results from the question on the ideal number of children, it is important to remember that, for several reasons, the ideal number tends to be fairly closely associated with the actual number of children a woman has. First, women who want a large family tend to have more children than other women. Second, women may rationalize their ideal family size so that as the actual number of children increases, their preferred family size also increases. Furthermore, women with large families are on average older than women with small families and may actually prefer a large family size because of attitudes that they acquired 20 to 30 years ago. Table 7.4 presents the distribution of ever-married women by their ideal number of children. The table shows that 13 percent of women gave non-numeric responses to a question about their ideal number of children. The proportion giving non-numeric answers rises steeply with the number of children, exceeding 20 percent among women with four and five children and peaking at 40 percent among women with 6 or more children. As a result, caution should be exercised in interpreting the information on family size preferences among higher parity women. Table 7.4 shows that an ever-married woman in Maldives prefers a moderate-size family. Less than one-third of ever-married women want a two-child family, 23 percent consider a three-child family to be ideal, and almost the same proportion prefer to have four children. Nine percent want five or more children. The mean ideal number of children among ever-married women who gave numeric responses is 2.9 children. As expected, higher parity women expressed a preference for more children; the mean ideal number ranges from 2.6 among women with one child to 4.4 among women with six or more children. The results in Table 7.4 indicate that some women in Maldives are having more children than they would prefer. For example, 19 percent of women with four children say they would have preferred to have three or fewer children, and 43 percent of the women with six of more children considered a smaller family to be ideal. 80 | Fertility Preferences Table 7.4 Ideal number of children Percent distribution of ever-married women, by ideal number of children and by mean ideal number of children, for ever- married women and for currently married women, according to number of living children, Maldives 2009 Number of living children1 Ideal number of children 0 1 2 3 4 5 6+ Total 0 0.1 0.2 0.1 0.2 0.1 0.3 0.9 0.2 1 2.4 5.0 1.4 0.5 0.1 0.7 0.3 2.0 2 50.3 46.1 40.3 16.8 9.2 9.6 6.8 30.8 3 24.5 29.7 25.7 29.9 9.3 11.4 9.1 22.9 4 14.0 11.7 22.9 30.3 49.0 20.5 21.5 22.1 5 1.8 1.4 2.6 6.0 6.4 24.9 4.5 4.8 6+ 0.7 1.0 0.9 2.8 5.2 8.0 17.5 3.9 Non-numeric responses 6.1 5.0 6.3 13.7 20.8 24.4 39.5 13.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 822 1,827 1,500 1,049 648 493 791 7,131 Mean ideal number of children2: Ever-married 2.6 2.6 2.9 3.4 3.9 4.2 4.4 3.1 Number 772 1,736 1,406 906 513 372 479 6,185 Currently married 2.6 2.6 2.9 3.4 3.9 4.2 4.5 3.1 Number 687 1,597 1,282 825 476 336 432 5,635 1 The number of living children includes current pregnancy for women 2 Means are calculated excluding respondents who gave non-numeric responses. Table 7.5 shows how the mean ideal number of children for ever-married women varies among subgroups. As expected, the mean increases with the woman’s age and is higher among rural women (3.3 children) compared with urban women (2.8 children). The mean ideal number of children among women with no education is 4.0 children, nearly 50 percent higher than the ideal number among women with more than secondary education (2.7 children). Similarly, family size preferences decline with increasing wealth, from 3.4 children among women in the lowest wealth quintile to 2.8 children in the highest quintile. 7.4 UNPLANNED AND UNWANTED FERTILITY Information obtained in the 2009 MDHS on fertility preferences can be used to derive several indicators of the level of unwanted fertility. First, responses to a question about the planning status of recent births, i.e., whether a birth was planned (wanted then), unplanned (wanted later), or not wanted at all, provide some indication of the extent of un- wanted childbearing. In interpreting these data, it is important to remember that women may rationalize mistimed or un- wanted pregnancies, declaring them as wanted only after the children are born. Table 7.6 presents the information on the planning status of recent births. The results indicate that around one- quarter of all births in the five-year period before the MDHS were unplanned; 16 percent were not wanted at all at the time they were conceived, and 10 percent were mistimed, i.e., their mothers would have preferred to delay the birth by at least two years. The proportion of births that were not wanted at the time of conception increases directly with birth order. Forty- seven percent of all fourth and higher order births were not Table 7.5 Mean ideal number of children Mean ideal number of children for ever- married women age 15-49 by background characteristics, Maldives 2009 Background characteristic Mean Number of women Age 15-19 2.6 109 20-24 2.6 1,217 25-29 2.8 1,455 30-34 3.1 1,181 35-39 3.4 1,008 40-44 3.8 751 45-49 4.1 463 Residence Urban 2.8 2,128 Rural 3.3 4,057 Region Malé 2.8 2,128 North 3.2 890 North Central 3.3 867 Central 3.4 518 South Central 3.4 756 South 3.3 1,025 Education No formal education 4.0 1,183 Primary 3.3 2,174 Secondary 2.6 2,438 More than secondary 2.7 315 Wealth quintile Lowest 3.4 1,071 Second 3.3 1,193 Middle 3.2 1,275 Fourth 3.0 1,275 Highest 2.8 1,371 Total 3.1 6,185 Note: Total includes 72 women with informa- tion missing on education level. Means are based on number of women who gave a numeric response Fertility Preferences | 81 wanted at all, compared with only about 11 percent of second order births. The planning status of births is also affected by the age of the mother. In general, the older the mother, the higher is the percentage of children that are unwanted at conception. A second approach to assessing unwanted fertility considers what the fertility rate would be in Maldives if women had avoided recent births they did not want. The wanted fertility rate is calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. Unwanted births are defined as births that exceed the number considered ideal by the respondent. For purposes of calculating the wanted fertility rate, women who did not report a numeric ideal family size are assumed to have wanted all their births. To the extent that women are unwilling to report an ideal family size that is lower than their actual family size, the wanted fertility rate may be overestimated. Table 7.6 Fertility planning status Percent distribution of births to ever-married women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother's age at birth, Maldives 2009 Planning status of birth Birth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 88.7 5.9 4.6 0.8 100.0 1,769 2 73.7 14.4 11.3 0.6 100.0 1,085 3 69.1 13.5 17.0 0.5 100.0 603 4+ 43.2 9.5 46.9 0.5 100.0 800 Mother's age at birth <20 69.5 10.6 17.8 2.2 100.0 179 20-24 78.5 12.2 8.7 0.6 100.0 1,484 25-29 77.6 10.6 11.3 0.5 100.0 1,281 30-34 71.7 7.8 20.1 0.4 100.0 836 35-39 57.4 3.4 38.2 1.0 100.0 364 40-44 33.3 4.6 61.3 0.8 100.0 109 45-49 * * * * 100.0 5 Total 73.5 9.8 16.0 0.7 100.0 4,258 Note: An asterisk indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. 82 | Fertility Preferences Table 7.7 presents total wanted fertility rates and total fertility rates for the three-year period before the survey. Overall, the wanted fertility rate is 2.2 births per woman, which is 12 percent lower that the total fertility rate (2.5 births). The gap between actual and wanted fertility is smallest among women with a secondary or higher education and among women in the highest wealth quintile. Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Maldives 2009 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 1.9 2.1 Rural 2.4 2.8 Region Malé 1.9 2.1 North 2.3 2.7 North Central 2.2 2.5 Central 2.4 2.8 South Central 2.6 3.0 South 2.5 2.9 Education No formal education 2.4 2.8 Primary 2.2 2.7 Secondary 2.5 2.6 More than secondary 2.6 2.7 Wealth quintile Lowest 2.3 2.8 Second 2.5 2.9 Middle 2.4 2.7 Fourth 2.1 2.4 Highest 2.0 2.1 Total 2.2 2.5 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Infant and Child Mortality | 83 INFANT AND CHILD MORTALITY 8 This chapter presents levels, trends, and differentials in neonatal, postneonatal, infant, child, and perinatal mortality. The information is relevant both for understanding population trends—for example, the mortality rates can be used in population projections—and for the planning and evaluation of health policies and programs. Information on child mortality serves the needs of the health sector by identifying population groups that are at high risk. In the Maldives, mortality statistics are routinely collected and reported to the Ministry of Health through the Vital Registration System (VRS). In addition, every five years, the Population and Housing Census, conducted by the Ministry of Planning and National Development (MPND), generates mortality estimates. These two methods provide an opportunity to compare and address any discrepancy that may exist between the two methods of estimation. The 2009 Maldives DHS provides yet another set of estimates. The data for mortality estimation were collected in the birth history section of the Women’s Questionnaire. The birth history section begins with questions about the respondent’s experience with childbearing (i.e., the number of sons and daughters living with the mother, the number living elsewhere, and the number who have died). These questions are followed by a retrospective birth history in which each respondent is asked to list each of her births, starting with the first birth. For each birth, data are obtained on sex, month and year of birth, survivorship status, and current age, or if the child had died, age at death. This information is used to directly estimate mortality. Age-specific mortality rates are categorised and defined as follows: Neonatal mortality (NN): the probability of dying within the first month of life Postneonatal mortality (PNN): the difference between infant and neonatal mortality Infant mortality (1q0): the probability of dying before the first birthday Child mortality (4q1): the probability of dying between the first and fifth birthday Under-five mortality (5q0): the probability of dying between birth and the fifth birthday All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. 8.1 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Infant and under-5 mortality rates from the 2009 MDHS are presented in Table 8.1. Under-5 mortality was 17 deaths per 1,000 live births for the five-year period preceding the survey (circa 2005-2009), implying that about one in every 60 children born in the Maldives during that period died before reaching a fifth birthday. The infant mortality rate during the five-year period was 14 deaths per 1,000, and the neonatal mortality rate was 10 deaths per 1,000. Thus, more than 80 percent of child deaths during 2005-2009 took place during the first year of the child’s life, and seven in ten of those infant deaths occurred during the neonatal period, that is, within the first month of life. 84 | Infant and Child Mortality The trend in early childhood mortality in the mid-1990s and later, can be examined by looking at changes in the mortality rates over the three successive five-year periods prior to the survey. The results indicate that mortality among young children has declined significantly in the 15 years prior to the survey, and that decline has occurred much faster in the most recent five years. For example, under-5 mortality in 2000-2004 was 14 percent lower than in 1995-1999, while the rate in the 2005-2009 period (17 deaths per 1,000) is less than half the level estimated for the 2000-2004 period (38 deaths per 1,000). Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Maldives 2009 Years preceding the survey Approximate calendar year1 Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 2005-2009 10 4 14 3 17 5-9 2000-2004 23 9 32 6 38 10-14 1995-1999 25 11 35 9 44 1 Data collection took place between January and October 2009. The period 0-59 months prior to the survey spans a period between February 2004 and October 2009. 2 Computed as the difference between the infant and neonatal mortality rates In the Population and Housing Censuses (PHC) of Maldives, the infant mortality rate was calculated data based on infant deaths among live births that occurred during the year preceding the census. This type of data does not permit direct estimation of child mortality. Therefore an indirect technique was employed to arrive at estimates of childhood mortality rates using information on children surviving among children ever born. Based on the 2006 PHC (referring to 2005), the IMR is estimated as 18 deaths per 1,000 live births (MPND, 2008). The Vital Registration System’s estimate for 2006 is 16 deaths per 1,000 live births (MOH, 2007). The low level of childhood mortality in Maldives should be viewed with caution and sampling variability should be considered. Figure 8.1 is presented to show that the infant mortality rate in Maldives is lower than in any other country in South Asia and Southeast Asia where comparable data are available. Among these countries, Pakistan has the highest rate, with 78 deaths per 1,000 births. Vietnam (18 deaths per 1,000 births) has the second lowest infant mortality rate, and ranks directly after Maldives. Figure 8.1 Infant Mortality Rate for Five-Year Period Before the Survey for Selected Countries in South and Southeast Asia 78 66 57 52 48 34 25 18 14 Pakistan (2006-07) Cambodia (2005) India (2005-06) Bangladesh (2007) Nepal (2006) Indonesia (2007) Philippines (2008) Vietnam (2002) MALDIVES (2009) 0 20 40 60 80 100 Source: ICF Macro, 2010. MEASURE DHS STATcompiler. http://www.measuredhs.com, June 9 2010. Deaths per 1,000 live births Infant and Child Mortality | 85 8.2 DATA QUALITY Because of the decline in infant and child mortality, a thorough review of the MDHS data was conducted. The quality of mortality estimates calculated from retrospective birth histories depends upon the completeness with which births and deaths are reported and recorded. One factor that affects childhood mortality estimates is the quality of reporting of age at death, which may distort the age pattern of mortality. If age at death is misreported, it will bias the estimates, especially if the net effect of the age misreporting results in transference from one age bracket to another. For example, a net transfer of deaths from under 1 month to a higher age bracket will affect the estimates of neonatal and postneonatal mortality. To minimise errors in reporting of age at death, interviewers were instructed to record age at death in days if the death took place in the month following the birth, in months if the child died before age 2, and in years if the child was at least age 2. They also were asked to probe for deaths reported at age 1 to determine a more precise age at death in terms of months. Examination of the reporting of age at deaths in months for deaths under age 2 years show that reporting is accurate even for events that took place in a distant past, where deaths are more likely to be reported at ages in multiples of six months (see Appendix Table C.6). Another potential data quality problem is the selective omission from the birth histories of infants who did not survive, which can lead to underestimation of mortality rates. When selective omission of childhood deaths occurs, it is usually more severe for deaths occurring early in infancy. One way such omissions can be detected is by examining the proportion of neonatal deaths to infant deaths. Generally, if there is substantial underreporting of deaths, the result is an abnormally low ratio of neonatal deaths to infant deaths. Appendix Table C.5 shows that the ratio declines from 93 percent in the 0-4 years preceding the survey to 82 percent in the 10-15 years before the survey. Data quality is also affected by displacement of birth dates, which may cause a distortion of mortality trends. This can occur if an interviewer knowingly records a death as occurring in a different year; the purpose is to cut down on overall work because live births occurring during the five years preceding the interview are the subject of a lengthy set of additional questions. In the 2009 MDHS questionnaire, the cut-off year for these questions was 2003. Data in Appendix Table C.4 show that there is no evidence of shifting of births outside the reference period; in fact, the number of births in calendar year 2003 is less than in 2004. 8.3 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY A number of socioeconomic, environmental, and biological factors influence infant and child mortality. In a framework developed for the study of child mortality in developing countries, Mosley and Chen (1984) outlined various proximate determinants and socioeconomic factors related to infant mortality. The proximate determinants, which are factors that affect mortality directly, include maternal characteristics such as age, parity, and birth interval; environmental contamination; nutrition; injury; and personal illness. Socioeconomic factors operate through the proximate determinants. This section discusses differentials in early childhood mortality by the socioeconomic and biodemographic characteristics of the mother. The socioeconomic determinants include place of residence, mother’s educational attainment, and wealth index quintile. The biodemographic determinants include sex of child, age of mother, parity, birth interval, and child’s birth weight. Mortality differentials by place of residence, region, educational level of the mother, and household wealth are presented in Table 8.2. Period-specific rates are presented for the ten-year period preceding the survey (approximately 2000 to 2009) to capture a sufficient number of births to study mortality differentials across population subgroups. 86 | Infant and Child Mortality There seems to be no difference in infant mortality between children born to mothers living in urban areas and those born to women in rural areas. However, the neonatal mortality rate in urban areas is 33 percent higher than that in rural areas (20 per 1,000 live births compared with 15 per 1,000 live births), and the postneonatal rate in the rural areas is more than double the rate in the urban areas (8 and 3 deaths per 1,000 live births, respectively). Infant mortality rates vary by region, ranging from 13 deaths per 1,000 live births in the North region to 32 deaths per 1,000 in the South Central region. The two regions also show the lowest and highest under-age-5 mortality (21 and 41 deaths per 1,000 live births, respectively). The 2009 MDHS data show that as a mother’s educational attainment goes up, the childhood mortality levels decline; children of less educated mothers generally have higher mortality rates than those born to more educated mothers. For instance, the infant mortality rate for children whose mothers had no education is 41 deaths per 1,000 live births compared with 13 deaths per 1,000 live births for children whose mothers have a secondary education. There are no large differentials and no clear patterns in childhood mortality by the wealth status. Some rates are highest among children in the middle wealth quintile. Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by background characteristic, Maldives 2009 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 20 3 23 1 23 Rural 15 8 22 6 28 Region Malé 20 3 23 1 23 North 10 3 13 8 21 North Central 17 7 24 6 30 Central 19 11 30 4 34 South Central 23 10 32 9 41 South 10 9 19 4 23 Mother's education No formal education 32 9 41 6 47 Primary 17 6 23 5 28 Secondary 7 6 13 1 14 Wealth quintile Lowest 12 9 21 7 28 Second 20 5 25 6 31 Middle 21 8 28 5 33 Fourth 10 7 16 3 19 Highest 18 2 21 0 21 1 Computed as the difference between the infant and neonatal mortality rates 8.4 DEMOGRAPHIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY The demographic characteristics of both mother and child have been found to play an important role in the survival probability of children. Table 8.3 presents early childhood mortality rates by demographic characteristics (i.e., sex of child, mother’s age at birth, birth order, previous birth interval, and birth size). The rates for males are consistently slightly higher than those for females. A mother’s age at birth can affect a child’s chances of survival. Neonatal mortality rates and infant mortality rates exhibit the expected U-shaped relationship with mother’s age—high for women in the young age groups, low for women in the middle age groups, and high for women in the older age groups. For example, the infant mortality rate for women under age 20 when they gave birth is 29 Infant and Child Mortality | 87 deaths per 1,000 live births. The rate decreases for women who give birth at age 20-29 and at age 30- 39 (20 and 26 deaths per 1,000 live births, respectively) and then rises to 48 deaths per 1,000 live births for women who give birth at age 40-49 years. The higher rates for younger and older women may relate to biological factors that lead to complications during pregnancy and delivery. The 2009 MDHS results show that the risk of dying increases with higher order births. For example, although the infant mortality rate for first-order births is 17 deaths per 1,000 live births, the rate for seventh-order births or higher is 47 deaths per 1,000 live births. As expected, childhood mortality rates decline as the birth interval increases. For example, the infant mortality rate for children born fewer than two years after a previous birth is more than two times higher than the rate for children born after an interval of four or more years (52 deaths per 1,000 live births compared with 22 deaths per 1,000 live births). A child’s size at birth has been shown to be strongly associated with the risk of dying during infancy, particularly during the first months of life. In the 2009 MDHS, for all children born in the five years preceding the survey, mothers were asked whether the child was very small, small, average size, large, or very large at birth. Although subjective, the mother’s judgment has been shown to correlate closely with the actual birth weight. Results show that mortality levels are higher among children perceived by their mother to have been small or very small at birth compared with other children. Infant mortality rates for infants who were judged by their mothers to be small or very small at birth are, for example, twice as high as those for infants who were reported by their mothers to be average or large at birth (20 deaths per 1,000 live births compared with 10 deaths per 1,000 live births). Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by demographic characteristics, Maldives 2009 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child's sex Male 18 7 24 5 29 Female 15 6 21 5 25 Mother's age at birth <20 25 4 29 8 36 20-29 13 7 20 2 22 30-39 20 5 26 7 33 40-49 26 22 48 20 67 Birth order 1 12 4 17 2 19 2-3 13 7 20 3 23 4-6 25 5 30 7 37 7+ 30 17 47 11 57 Previous birth interval2 <2 years 37 15 52 5 57 2 years 12 6 18 8 25 3 years 13 6 19 3 22 4+ years 16 6 22 6 28 Birth size3 Small/very small 11 9 20 - - Average or larger 7 3 10 - - 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey 88 | Infant and Child Mortality 8.5 PERINATAL MORTALITY In the 2009 MDHS, women were asked to report all pregnancy losses that occurred in the five years preceding the survey. For each such pregnancy, the duration was recorded. Pregnancy losses occurring after seven completed months of gestation (stillbirths) plus deaths to live births within the first seven days of life (early neonatal deaths) constitute perinatal deaths. The distinction between a stillbirth and an early neonatal death may be a fine one, often depending on observing and then remembering sometimes faint signs of life after delivery. The causes of stillbirths and early neonatal deaths are closely linked, and examining just one or the other can understate the true level of mortality around delivery. For this reason deaths around the time of delivery are combined into the perinatal mortality rate. When the number of perinatal deaths is divided by the total number of pregnancies reaching seven months of gestation, the perinatal mortality rate is derived. The perinatal mortality rate is a useful indicator of the state of delivery services, both in terms of the use of these services and of their ability to ensure delivery of healthy babies. Table 8.4 presents the number of stillbirths and early neonatal deaths, and the perinatal mortality rate, for the five-year period preceding the survey. The data show that, overall, 34 stillbirths and 35 early neonatal deaths were reported in the survey, resulting in a perinatal mortality rate of 18 per 1,000 pregnancies. Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Maldives 2009 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 0 8 47 165 20-29 18 16 14 2,433 30-39 15 9 23 1,071 40-49 0 3 26 101 Previous pregnancy interval in months4 First pregnancy 15 14 21 1,426 <15 0 1 9 160 15-26 5 4 19 470 27-38 3 2 13 365 39+ 10 14 18 1,348 Residence Urban 10 15 22 1,133 Rural 24 21 17 2,637 Region Malé 10 15 22 1,133 North 9 2 18 587 North Central 3 5 14 542 Central 4 1 13 346 South Central 3 8 23 456 South 6 5 16 707 Mother's education No education 4 5 20 453 Primary 14 17 22 1,382 Secondary 15 13 17 1,719 More than secondary 0 0 0 173 Wealth quintile Lowest 8 4 16 717 Second 10 12 27 812 Middle 4 7 14 787 Fourth 5 6 14 760 Highest 7 7 21 693 Total 34 35 18 3,770 1 Stillbirths are foetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months' duration, expressed per 1000. 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. Infant and Child Mortality | 89 Perinatal mortality is highest among births to women who gave birth before age 20 and lowest among births to women age 20-29. First pregnancies have the highest proportions resulting in stillbirths or early neonatal death. Perinatal mortality rates are higher in urban than in rural areas (22 and 17 per 1,000 pregnancies, respectively). There is no clear pattern in the relationship between perinatal mortality and education or perinatal mortality and household wealth. 8.6 HIGH-RISK FERTILITY BEHAVIOUR Findings from scientific studies have confirmed that there is a strong relationship between children’s chances of dying and certain fertility behaviours. Typically, the probability of dying in early childhood is much greater if children are born to mothers who are too young or too old, if they are born after a short preceding birth interval, or if they are high-parity births. Very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. Older women may also experience age-related problems during pregnancies and delivery. In this analysis, a mother is considered to be too young if she is less than age 18 and “too old” if she is above 34 years at the time of delivery. A “short birth interval” is a birth occurring within 24 months of a previous birth. Table 8.5 shows the distribution of children born in the five years preceding the survey by risk category. Although first births to women age 18-34 are considered an unavoidable risk, they are included in the analysis and are shown as a separate risk category. The first column in Table 8.5 shows the percentages of births in the five years preceding the survey that fall into the various risk categories. Twenty-eight percent of births have an elevated risk of death that is avoidable, another 41 percent are first births for which risk is considered unavoidable, and 31 percent are not in any high- risk category. Among those who are at risk, 18 percent of births are in only one of the high-risk categories, but 10 percent are in multiple high-risk categories (due to combinations of mother’s age, birth order, and birth interval). Column 2 shows risk ratios for births in various high-risk categories relative to births not having any high-risk characteristics. The single high-risk category with the largest percentage of births is birth order three or higher, which constitutes 9 percent of births. The mortality of this category is 1.56 times that of births with no elevated mortality risk. The multiple high-risk category with the largest percentage of births is children with birth order three or higher born to mothers age 34 or older (8 percent). Compared with births with no elevated risk, these births have an 84 percent greater risk of death in early childhood. The multiple high-risk category with the highest risk ratio consists of the following combination: age more than 34 years, birth interval less than 24 months, and birth order three or higher. Less than 1 percent of children fall in this category, in which children are almost eight times more likely to die than children who have no elevated mortality risk. The last column in Table 8.5 looks to the future and addresses the question of how many currently married women have the potential for having a high-risk birth. The results were obtained by simulating the risk category into which a birth to a currently married woman would fall if she were to become pregnant at the time of the survey. The results show that more than half of currently married women are in the “any avoidable risk” category, 25 percent face a single risk, and 27 percent are in multiple risk categories. 90 | Infant and Child Mortality Table 8.5 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Maldives 2009 Births in the 5 years preceding the survey Percentage of currently married women1 Risk category Percentage of births Risk ratio Not in any high risk category 31.2 1.00 34.2a Unavoidable risk category First-order births between ages 18 and 34 years 40.6 0.90 13.5 Single high-risk category Mother's age <18 0.5 10.08 0.0 Mother's age >34 3.0 1.42 8.3 Birth interval <24 months 5.2 0.56 10.6 Birth order >3 9.2 1.56 6.0 Subtotal 17.9 1.48 25.0 Multiple high-risk category Age <18 and birth interval <24 months2 0.0 0.00 0.0 Age >34 and birth interval <24 months 0.1 0.00 0.5 Age >34 and birth order >3 7.6 0.84 23.0 Age >34 and birth interval <24 months and birth order >3 0.6 7.77 1.4 Birth interval <24 months and birth order >3 1.9 0.87 2.5 Subtotal 10.3 1.25 27.4 In any avoidable high-risk category 28.2 1.40 52.4 Total 100.0 na 100.0 Number of births/women 3,736 na 6,500 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women Maternal Health │ 91 MATERNAL HEALTH 9 This chapter presents findings on important areas of maternal health: antenatal, delivery, and postnatal care. This information, in combination with data on mortality, is useful in formulating programs and policies to improve maternal and child health services. 9.1 ANTENATAL CARE The health care that a mother receives during pregnancy and at the time of delivery is important for the survival and well-being of both the mother and the child. Antenatal care (ANC) coverage is described according to the type of provider, number of visits, stage of pregnancy at the time of the first and last visits, and services and information provided during visits. It is also recommended that women receive two doses of tetanus toxoid vaccine, adequate amounts of iron and folic acid tablets, and iron syrup to prevent and treat anaemia while at their ANC visits. Blood pressure checks and procedures to detect pregnancy complications are also part of ANC coverage. A well-designed and carefully implemented ANC program facilitates detection and treatment of prob- lems, such as anaemia and infections, and also provides an opportunity to disseminate health care messages to women and their families. Information on ANC coverage was obtained from women who had given birth in the five years preceding the survey. For women with two or more live births during the five-year period, data on antenatal care refer to the most recent birth only. 9.1.1 Source of Antenatal Care Table 9.1 shows the percent distribution of women age 15-49 who had a live birth in the five years prior to the survey. Although mothers of live births may have received antenatal care from more than one type of provider, this report uses the best qualified provider cited by the women. Almost all women (99 percent) received antenatal care from a skilled provider. Most women saw a gynaecologist (92 percent) for antenatal care, while 7 percent of the remaining women report that they received care from a doctor other than a gynaecologist, and less than 1 percent report that they received care from a trained nurse or midwife, a community health worker, or a traditional birth attendant. There is little variation by background characteristics in the percentage receiving antenatal care from a skilled provider (gynaecologist, doctor, nurse, midwife, and community/family health worker). However, antenatal care received from a gynaecologist is less common among mothers who are age 35-49 at the birth of the child. It is more common among mothers with a first-order birth, those residing in urban areas, those with more than secondary education, and those belonging to the highest wealth quintile. 92 │ Maternal Health Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Maldives 2009 Background characteristic Gynae- cologist Doctor Nurse/ midwife Community/ family health worker Traditional birth attendant No one Missing Total Percentage receiving antenatal care from a skilled provider1 Number of women Mother's age at birth <20 92.4 7.6 0.0 0.0 0.0 0.0 0.0 100.0 100.0 111 20-34 92.9 6.3 0.1 0.1 0.1 0.2 0.2 100.0 99.3 2,682 35-49 86.7 11.2 0.0 0.4 0.5 0.6 0.6 100.0 97.9 397 Birth order 1 94.6 5.1 0.1 0.0 0.0 0.0 0.2 100.0 99.8 1,263 2-3 92.8 6.6 0.0 0.2 0.2 0.1 0.2 100.0 99.3 1,275 4-5 86.7 11.3 0.2 0.3 0.1 1.2 0.2 100.0 98.2 411 6+ 85.3 10.8 0.5 0.6 1.2 1.0 0.5 100.0 96.6 241 Residence Urban 97.5 2.1 0.0 0.0 0.0 0.0 0.4 100.0 99.6 964 Rural 89.8 9.0 0.1 0.2 0.3 0.4 0.1 100.0 99.0 2,227 Region Malé 97.5 2.1 0.0 0.0 0.0 0.0 0.4 100.0 99.6 964 North 88.8 9.8 0.2 0.4 0.0 0.7 0.2 100.0 98.8 489 North Central 85.5 12.5 0.2 0.2 1.0 0.4 0.2 100.0 98.2 466 Central 92.4 6.3 0.1 0.4 0.4 0.2 0.2 100.0 98.8 293 South Central 81.5 17.5 0.0 0.3 0.1 0.6 0.0 100.0 99.1 390 South 98.3 1.4 0.1 0.0 0.0 0.0 0.2 100.0 99.8 589 Mother's education No formal education 84.9 11.8 0.4 0.1 1.2 0.7 0.9 100.0 97.2 396 Primary 89.4 9.3 0.0 0.4 0.1 0.5 0.3 100.0 98.7 1,143 Secondary 95.5 4.4 0.1 0.0 0.0 0.0 0.0 100.0 100.0 1,456 More than secondary 99.5 0.5 0.0 0.0 0.0 0.0 0.0 100.0 100.0 156 Wealth quintile Lowest 87.1 10.9 0.3 0.3 0.6 0.8 0.0 100.0 98.3 595 Second 88.6 9.9 0.2 0.4 0.2 0.4 0.4 100.0 98.6 677 Middle 91.5 7.7 0.0 0.1 0.2 0.1 0.3 100.0 99.3 677 Fourth 95.1 4.9 0.0 0.0 0.0 0.0 0.0 100.0 100.0 643 Highest 98.7 0.9 0.0 0.0 0.0 0.0 0.4 100.0 99.6 599 Total 92.1 6.9 0.1 0.2 0.2 0.3 0.2 100.0 99.2 3,190 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. Total includes 39 cases for which information on mother’s formal education level is missing. 1 Skilled provider includes gynaecologist, doctor, nurse, midwife, and community/family health worker 9.2 NUMBER OF ANC VISITS, TIMING OF FIRST VISIT, AND SOURCE WHERE ANC RECEIVED Antenatal care is most beneficial in preventing adverse pregnancy outcomes when it is sought early in the pregnancy and is continued throughout the pregnancy. Health professionals recommend that the first antenatal visit should occur within the first three months of the pregnancy and further visits should continue on a monthly basis through week 28 of pregnancy and fortnightly up to week 36 (or until birth). If the first antenatal visit is made at the third month of pregnancy and as regularly as recommended, there will be a total of at least 12 to 13 antenatal visits. The Master Plan 2006-2015 of the Ministry of Health in Maldives highlights reproductive and maternal health as one of its priority areas (Ministry of Health 2006). The plan aims to provide four ANC checkups by a trained health professional to all pregnant women by 2015 and to ensure that Maternal Health │ 93 more than 95 percent of pregnant women are attended to by a gynaecologist at least once during the third trimester by 2015. Table 9.2 presents information on the number of antenatal visits and the timing of the first antenatal visit for the most recent birth in the five years preceding the survey. Eighty-five percent of women who had a live birth in the five years preceding the survey reported visiting antenatal clinics at least four times during pregnancy, and 2 percent reported two or three antenatal visits during their last pregnancy. Less than 1 percent did not receive any antenatal care. Table 9.2 shows that the majority of women (90 percent) had their first antenatal visit in the first trimester of pregnancy; another 7 percent had their first ANC visit during the fourth and fifth months of pregnancy. The median number of months of pregnancy at the first ANC visit is 1.8 months. Women in urban areas do not make four or more ANC visits as often as women in rural areas (80 and 88 percent, respectively). Urban women started ANC earlier than rural women, however; the median number of months pregnant at first visit is 1.6 and 1.9 months, respectively. Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Maldives 2009 Number and timing of ANC visits Residence Urban Rural Total Number of ANC visits None 0.0 0.4 0.3 1 0.2 0.3 0.3 2-3 1.2 1.7 1.5 4+ 79.6 87.5 85.1 Don't know/missing 19.0 10.2 12.8 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 0.0 0.4 0.3 <4 95.8 87.9 90.3 4-5 2.9 9.3 7.3 6-7 0.9 1.6 1.4 8+ 0.0 0.4 0.3 Don't know/missing 0.4 0.5 0.5 Total 100.0 100.0 100.0 Number of women 964 2,227 3,190 Median months pregnant at first visit (for those with ANC) 1.6 1.9 1.8 Number of women with ANC 960 2,215 3,175 9.3 COMPONENTS OF ANTENATAL CARE The content of antenatal care is an essential component of the quality of ANC services received. Focused antenatal care hinges on the principle that every pregnancy is at risk of complications. Therefore, apart from receiving basic care, every pregnant woman should be monitored for complications. Screening for complications in addition to providing information concerning pregnancy complications should be routinely included in all antenatal care visits. To assess ANC services, the 2009 MDHS respondents were asked a number of questions about the care they received during pregnancy for their most recent live birth. 94 │ Maternal Health Table 9.3 presents information on the content of ANC services, including the percentage of women who took iron tablets, who took intestinal parasite drugs, who were informed of the symptoms of pregnancy complications, and who received selected routine services during ANC visits for their most recent birth in the past five years. Eighty-seven percent of women take iron supplements during pregnancy. A higher proportion of mothers age 20 or older take iron supplements compared with younger women. A lower proportion of women with four or more children take iron supplements (82 percent) than women having three or fewer children (87-90 percent). There are no variations by urban-rural residence or by region. The percentage of women who take iron supplements increases with level of education and wealth quintile. Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Maldives 2009 Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Among women who received antenatal care for their most recent birth in the past five years, the percentage with selected services: Background characteristic Took iron tablets Took intestinal parasite drugs Number of women with a live birth in the past five years Informed of signs of pregnancy compli- cations Weighed Blood pressure measured Urine sample taken Blood sample taken Number of women with ANC for their most recent birth Mother's age at birth <20 81.5 17.7 111 53.8 97.0 97.8 95.9 96.6 111 20-34 87.8 13.9 2,682 52.5 99.7 99.7 97.2 98.7 2,672 35-49 84.6 18.9 397 47.0 99.4 99.8 95.0 96.5 392 Birth order 1 90.1 11.8 1,263 57.2 99.6 99.6 98.0 99.0 1,261 2-3 86.9 12.9 1,275 47.6 99.7 99.7 97.0 98.3 1,272 4-5 82.3 20.5 411 46.7 99.4 99.5 95.8 97.2 405 6+ 81.6 28.2 241 55.5 99.2 99.8 92.3 97.2 237 Residence Urban 88.7 6.8 964 49.4 99.7 99.7 96.6 99.1 960 Rural 86.5 18.0 2,227 53.0 99.5 99.6 97.0 98.1 2,215 Region Malé 88.7 6.8 964 49.4 99.7 99.7 96.6 99.1 960 North 88.5 12.3 489 59.1 100.0 99.8 97.1 98.6 485 North Central 89.9 23.9 466 54.7 98.8 98.8 95.5 95.7 463 Central 88.1 21.2 293 45.1 99.7 99.7 96.5 97.2 292 South Central 84.0 18.4 390 48.8 99.8 99.8 96.8 98.3 388 South 83.1 16.3 589 53.2 99.4 99.8 98.6 99.8 588 Mother's education No formal education 80.0 23.7 396 42.1 99.1 99.2 93.6 96.7 390 Primary 83.5 19.7 1,143 51.6 99.7 99.6 96.9 98.0 1,134 Secondary 91.1 9.3 1,456 54.4 99.6 99.7 98.0 98.9 1,456 More than secondary 95.7 6.4 156 55.6 100.0 100.0 94.1 100.0 156 Wealth quintile Lowest 84.1 22.4 595 52.2 99.5 99.5 95.5 97.3 590 Second 86.1 20.2 677 56.0 99.3 99.5 97.3 98.3 671 Middle 87.9 15.0 677 50.8 99.7 99.7 98.1 98.3 674 Fourth 87.0 10.5 643 50.1 100.0 99.9 97.0 99.1 643 Highest 90.9 4.7 599 50.1 99.5 99.6 96.5 98.8 597 Total 87.2 14.6 3,190 51.9 99.6 99.6 96.9 98.4 3,175 Note: Total includes 39 cases for which information on mother’s formal education level is missing. Maternal Health │ 95 As a component of antenatal care, the administration of intestinal antiparasitic drugs is less common than the administration of iron supplements because administration of intestinal anti- parasitic drugs is not part of the national ANC program in Maldives. Fifteen percent of women took drugs to combat intestinal parasites during their last pregnancy. There is variation in the use of de- worming mediations during pregnancy by background characteristics. Administration of intestinal antiparasitic drugs is lower among mothers who were age 20-34 at the birth of the child and among mothers of third- or lower-order births. Fewer women in urban areas (7 percent) took intestinal drugs than women in rural areas (18 percent). By region, women taking intestinal parasitic drugs ranged from 7 percent in Malé to 24 percent in the North Central region. The percentages were lowest for women with more than secondary education (6 percent) and women who are in the highest wealth quintile (5 percent). More than half of the women (52 percent) who received antenatal care during their last pregnancy were informed of the symptoms of pregnancy complications. A smaller proportion of women in urban areas receive such information compared with women in rural areas (49 percent compared with 53 percent). The percentage of women informed of complications ranges from 45 percent in the Central region to 59 percent in the North region. Also, mothers with no formal education have the lowest rates of having been informed of signs of pregnancy complications. Almost all women who received antenatal care were weighed (100 percent), had their blood pressure measured (100 percent), had urine and blood samples taken (97 percent), and had their blood tested (98 percent). Blood testing is of particular importance in the screening for maternal syphilis, HIV, anaemia, and Hepatitis B. 9.4 TETANUS TOXOID INJECTIONS Neonatal tetanus is a leading cause of neonatal death in developing countries where a high proportion of deliveries take place at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) injections are given to women during pregnancy to prevent infant deaths from neonatal tetanus. Neonatal tetanus can result if sterile procedures are not followed in cutting the umbilical cord after delivery. In the 2009 MDHS, information was collected on the number of TT doses the mother received during pregnancy for her most recent birth in the five years preceding the survey. If the mother did not receive at least two TT injections during the pregnancy, additional questions were asked about the number and timing of TT injections that she may have received prior to that pregnancy. If a pregnant woman has not received any previous TT injections, she needs two doses of TT during pregnancy to be fully protected. However, if a woman was immunised before she became pregnant, she may require one or no TT injections during her pregnancy, depending on the number of injections she has received in the past and the timing of the last injection. Five lifetime tetanus toxoid doses are required to provide protection from neonatal tetanus. The Maldives’ Health Master Plan 2006-2015 aims to improve TT vaccination coverage among mothers from a baseline of 65 percent in 2005 to 90 percent by 2015 (Ministry of Health 2006). Table 9.4 shows the percentage of women with a live birth in the five years preceding the survey who reported receiving TT injections during the pregnancy for the last live birth. Also shown is whether the last birth was fully protected against neonatal tetanus. An infant is considered fully protected if any of the following criteria are met: (1) the mother had two tetanus toxoid injections during the pregnancy; (2) the mother had two lifetime injections, with the last injection received within three years of the last birth; (3) the mother had three lifetime injections, with the last injection received within five years of the last birth; (4) the mother had four lifetime injections, with the last injection received within 10 years of the last birth; or (5) the mother had at least five lifetime injections. 96 │ Maternal Health Six in ten women received two or more TT injections during the pregnancy. Three in four women in urban areas received two doses of TT during pregnancy compared with 52 percent of those in rural areas. By region, the percentage of women who received two or more TT injections during the last pregnancy ranges from 32 percent in the Central region to 77 percent in Malé. More than four in five women with more than secondary education received two or more TT injections during the last pregnancy compared with 54 percent of women with no formal education. Women in the lowest wealth quintile (48 percent) have lower rates of TT injections compared with women in the highest wealth quintile (78 percent). Overall, 82 percent of women’s last births were protected against neonatal tetanus. Higher proportions of women age 20-34 were protected (83 percent) compared with older women and younger women (79 percent). The South region had the highest proportion of women whose last birth was protected against neonatal tetanus (87 percent), while the Central region had the lowest pro- portion (77 percent). Women with more than secondary education and those in the highest wealth quintile had the highest rates of protection against tetanus for their last birth compared with other women. Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Maldives 2009 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother's age at birth <20 59.1 78.8 111 20-34 59.5 82.7 2,682 35-49 59.0 79.0 397 Birth order 1 61.7 83.6 1,263 2-3 59.5 82.6 1,275 4-5 53.1 79.4 411 6+ 58.1 76.5 241 Residence Urban 76.6 84.4 964 Rural 52.0 81.1 2,227 Region Malé 76.6 84.4 964 North 49.6 79.0 489 North Central 50.0 79.8 466 Central 32.2 77.2 293 South Central 43.7 79.8 390 South 71.1 86.8 589 Mother's education No formal education 53.8 78.1 396 Primary 50.3 77.2 1,143 Secondary 65.9 85.8 1,456 More than secondary 84.4 94.3 156 Wealth quintile Lowest 48.4 77.7 595 Second 48.8 80.9 677 Middle 55.0 83.0 677 Fourth 68.3 82.4 643 Highest 77.9 86.6 599 Total 59.4 82.1 3,190 Note: Total includes 39 cases for which information on mother’s formal education level is missing. 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth. Maternal Health │ 97 9.5 PLACE OF DELIVERY Increasing the percentage of births delivered in health facilities is an important factor in reducing deaths arising from the complications of pregnancy. The expectation is that if a complication arises during delivery, a skilled health worker can manage the complication or refer the mother to the next level of care. Table 9.5 shows the percent distribution of all live births in the five years preceding the survey by place of delivery and by the percentage of births delivered in a health facility. The majority of births (95 percent) in the five years preceding the survey were delivered in a health facility; 85 percent were delivered in a public facility, and 10 percent were delivered in a private health facility. By age, women 20-34 most often deliver in a health facility (96 percent). Women having their first baby have higher rates of delivering in a health facility than other women; the proportion of births occurring in a health facility decreases as birth order increases. Women in urban areas are more likely than rural women to deliver in a health facility (98 percent compared with 94 percent). Across regions, Malé and the South Central region have the highest proportion of institutional deliveries (98 percent), while the North Central region has the lowest (90 percent). Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and by percentage delivered in a health facility, according to background characteristics, Maldives 2009 Health facility Percentage delivered in a health facility Background characteristic Public sector Private sector Home Other Missing Total Number of births Mother's age at birth <20 84.9 7.3 4.1 3.1 0.5 100.0 92.3 165 20-34 85.1 10.8 2.7 1.1 0.2 100.0 95.9 3,148 35-49 84.0 6.8 5.6 3.0 0.5 100.0 90.8 423 Birth order 1 84.7 12.8 0.8 1.5 0.2 100.0 97.5 1,552 2-3 84.2 10.7 3.2 1.5 0.4 100.0 94.9 1,459 4-5 87.0 3.8 8.0 1.0 0.2 100.0 90.8 460 6+ 87.3 2.6 7.6 2.0 0.5 100.0 89.9 265 Residence Urban 74.5 23.4 0.2 1.5 0.4 100.0 97.9 1,123 Rural 89.5 4.5 4.3 1.4 0.3 100.0 94.0 2,613 Region Malé 74.5 23.4 0.2 1.5 0.4 100.0 97.9 1,123 North 93.0 1.3 4.3 1.3 0.2 100.0 94.3 578 North Central 86.2 4.0 9.0 0.5 0.3 100.0 90.3 539 Central 83.6 8.2 7.4 0.7 0.1 100.0 91.8 343 South Central 93.8 4.0 1.2 0.8 0.2 100.0 97.8 453 South 89.3 6.0 1.3 3.0 0.5 100.0 95.2 700 Mother's education No formal education 83.5 3.3 10.8 1.6 0.8 100.0 86.8 449 Primary 89.6 4.6 4.4 1.0 0.5 100.0 94.2 1,368 Secondary 83.3 14.7 0.4 1.5 0.0 100.0 98.1 1,703 More than secondary 67.0 28.2 0.6 4.1 0.0 100.0 95.2 173 Antenatal care visits1 None * * * * * * * 8 1-3 77.1 5.2 17.7 0.0 0.0 100.0 82.3 57 4+ 86.1 10.3 2.6 1.0 0.0 100.0 96.4 2,715 Don't know/missing 81.8 13.3 1.5 1.9 1.5 100.0 95.1 410 Wealth quintile Lowest 88.0 2.4 7.8 1.8 0.0 100.0 90.5 709 Second 90.5 3.0 4.8 1.2 0.4 100.0 93.6 802 Middle 91.2 5.1 2.1 0.9 0.7 100.0 96.3 783 Fourth 84.3 14.0 0.9 0.9 0.0 100.0 98.2 756 Highest 69.1 28.1 0.0 2.5 0.3 100.0 97.2 686 Total 85.0 10.2 3.1 1.5 0.3 100.0 95.1 3,736 Note: Total includes 43 cases for which information on mother’s formal education level is missing. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes only the most recent birth in the five years preceding the survey 98 │ Maternal Health Delivery in a health facility increases with the woman’s education. For example, 87 percent of women with no formal education delivered in a health facility compared with 95 percent of women with more than secondary education. The proportion of births occurring in a health facility increases with increasing wealth status, from 91 percent of births in the lowest quintile to 97 percent among those in the highest quintile. Poorer women are more likely than richer women to deliver in a public facility, while richer women tend to give birth in a private facility. For example, 88 percent of births to mothers in the lowest wealth quintile occur in a public health facility compared with 69 percent of births to women in the highest wealth quintile. 9.6 ASSISTANCE DURING DELIVERY In addition to place of birth, assistance during childbirth is an important variable influencing the birth outcome and the health of the mother and infant. The skills and performance of the person providing assistance during delivery determine whether complications are managed and hygienic practices are observed. Table 9.6 shows the percent distribution of live births in the five years preceding the survey by person providing assistance at delivery and by the percentage of births attended by a skilled health worker. If the respondent mentioned more than one person attending during delivery, only the most qualified person is presented in the table. Table 9.6 also presents data on the prevalence of births by caesarean section (C-section). According to Table 9.6, 95 percent of births in the five years preceding the survey were assisted by a skilled health worker (gynaecologist, doctor, nurse, midwife, or community/family health worker); 71 percent by a gynaecologist; 9 percent by a doctor other than a gynaecologist, and 14 percent by a nurse or midwife. Very few births (1 percent) were assisted at delivery by a community/family health worker. In the absence of a skilled health worker, a traditional birth attendant was the next most common person assisting at a delivery (4 percent). First births have higher rates of assistance from a skilled health professional (99 percent) than subsequent births. Urban women receive assistance from a trained health professional during childbirth more often than rural women (99 percent and 93 percent, respectively). Six percent of rural women receive assistance during birth from a traditional birth attendant. In all regions, the proportion of births assisted by a trained health professional ranges from 89 percent in North Central and Central regions to 99 percent in Malé. As expected, a mother’s education and wealth status have a positive relationship with the delivery of care. For example, educated women have higher rates of delivery assistance from a health professional than women with no formal education (92-99 percent compared with 85 percent). Delivery assistance by gynaecologists varies according to background characteristics of the mother. The percentage of births delivered by a gynaecologist decreases with age of the mother at birth and increases with the mother’s level of education and wealth status. The percentage of births delivered by a gynaecologist decreases with increasing birth order and is higher in urban areas than in rural areas. Table 9.6 shows that 32 percent of births in the five years preceding the survey were delivered by C-section. Caesarean births are slightly more common among first births (39 percent) and births to women in urban areas (38 percent). Rates of C-section deliveries increase with the mother’s education and wealth status. The percentage of women with no formal education who give birth by C-section is 22 percent, which compares with 27-39 percent or more among educated women. The percentage who deliver by C-section increases from 25 percent among women in the lowest wealth quintile to 41 percent among women in the highest wealth quintile. Maternal Health │ 99 Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider, and percentage delivered by caesarean-section, according to background characteristics, Maldives 2009 Person providing assistance during delivery Background characteristic Gynae- cologist Doctor Nurse/ midwife Community/ family health worker Traditional birth attendant Relative/ other Don't know/ missing Total Percentage delivered by a skilled provider1 Percentage delivered by C- section Number of births Mother's age at birth <20 74.6 10.4 7.4 0.0 7.0 0.0 0.5 100.0 92.5 30.1 165 20-34 71.6 8.9 14.8 0.6 3.7 0.2 0.3 100.0 95.3 32.5 3,148 35-49 67.3 10.8 14.3 0.5 6.4 0.0 0.6 100.0 92.5 32.5 423 Birth order 1 79.7 6.0 12.8 0.2 1.1 0.0 0.2 100.0 98.5 39.2 1,552 2-3 67.7 10.2 15.6 0.9 4.9 0.3 0.4 100.0 93.4 30.3 1,459 4-5 58.5 14.6 16.6 0.8 9.2 0.0 0.4 100.0 89.7 20.9 460 6+ 63.4 12.8 13.7 0.6 9.0 0.0 0.5 100.0 89.9 23.4 265 Place of delivery Health facility 73.8 9.6 15.0 0.3 1.3 0.1 0.0 100.0 98.3 34.0 3,555 Elsewhere 23.3 1.7 2.6 6.8 65.0 0.5 0.2 100.0 27.6 0.0 170 Residence Urban 75.3 5.0 18.7 0.2 0.2 0.2 0.4 100.0 99.0 38.3 1,123 Rural 69.5 11.0 12.6 0.7 5.8 0.1 0.3 100.0 93.0 29.8 2,613 Region Malé 75.3 5.0 18.7 0.2 0.2 0.2 0.4 100.0 99.0 38.3 1,123 North 69.2 10.9 10.9 1.4 7.4 0.0 0.2 100.0 91.1 20.0 578 North Central 62.1 12.1 14.8 0.8 9.7 0.3 0.3 100.0 88.9 28.3 539 Central 65.2 9.3 15.0 0.6 9.4 0.2 0.3 100.0 89.5 32.9 343 South Central 65.1 22.2 9.3 1.0 2.0 0.1 0.3 100.0 96.6 32.7 453 South 80.4 3.7 13.2 0.0 2.3 0.0 0.5 100.0 97.3 35.8 700 Mother's education No formal education 63.3 11.7 10.2 0.9 12.7 0.3 0.9 100.0 85.2 21.7 449 Primary 64.0 13.1 14.9 1.1 6.2 0.1 0.5 100.0 92.1 27.1 1,368 Secondary 77.8 6.5 14.8 0.1 0.7 0.1 0.0 100.0 99.0 38.5 1,703 More than secondary 85.0 0.0 14.3 0.0 0.6 0.0 0.0 100.0 99.4 39.3 173 Wealth quintile Lowest 63.0 13.2 12.4 1.3 9.9 0.1 0.0 100.0 88.6 25.4 709 Second 66.3 13.0 13.3 0.8 5.9 0.2 0.5 100.0 92.6 26.6 802 Middle 74.3 8.8 12.3 0.2 3.6 0.1 0.7 100.0 95.4 32.3 783 Fourth 75.4 5.1 18.0 0.5 0.9 0.2 0.0 100.0 98.4 37.8 756 Highest 77.5 5.5 16.2 0.0 0.4 0.0 0.3 100.0 99.3 40.6 686 Total 71.2 9.2 14.4 0.6 4.2 0.1 0.3 100.0 94.8 32.4 3,736 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Total includes 11 cases for which information on mother’s place of delivery and 43 cases for which information on mother’s formal education level is missing. 1 Skilled provider includes gynaecologist, doctor, nurse, midwife and community/family health worker Table 9.7 shows the percent distribution of women age 15-49 giving birth in the 5 years preceding the survey, according to assistance at delivery and by place of delivery. Eight in ten deliveries at home were assisted by traditional birth attendants, and 9 percent were assisted by community/family health workers. Public sector health facilities in Maldives include Indhira Gandhi Memorial Hospital (IGMH), Regional Hospital, Atoll Hospital, Health Centre, and Health Post. In IGMH, Regional Hospital, and Atoll Hospital, high proportions of deliveries are assisted by gynaecologists (69 percent, 82 percent, and 85 percent, respectively). A nurse or midwife plays an important role at IGMH (25 percent) and at Health Centre (22 percent). At Health Centre, doctors provide assistance during delivery half of the time. Almost all deliveries (97 percent) in the private sector are assisted by a gynaecologist. 100 │ Maternal Health Table 9.7 Assistance at delivery by place of delivery Percent distribution of women age 15-49 giving birth in the 5 years preceding the survey according to assistance at delivery by place of delivery, Maldives 2009 Person providing assistance during delivery Place of delivery Gynaecologist Doctor Nurse/ midwife Other health worker Traditional birth attendant Relative/ other Don't know/ missing Total Number Home 2.1 2.0 3.8 8.5 83.0 0.7 0.0 100.0 116 Public sector 71.0 10.5 16.7 0.3 1.4 0.1 0.0 100.0 3,175 IGMH 68.8 6.2 24.7 0.1 0.0 0.1 0.0 100.0 1,316 Regional hospital 81.7 6.8 11.2 0.0 0.3 0.0 0.0 100.0 912 Atoll hospital 85.4 7.2 7.0 0.0 0.2 0.0 0.1 100.0 659 Government health centre 10.9 49.6 21.5 3.1 14.3 0.6 0.0 100.0 259 Government health post/ other public (43.0) (39.4) (5.4) (2.5) (9.8) (0.0) (0.0) 100.0 30 Private medical sector 97.0 2.0 0.8 0.0 0.0 0.2 0.0 100.0 380 Other 68.9 1.0 0.0 3.1 26.4 0.0 0.6 100.0 54 Total 71.2 9.2 14.4 0.6 4.2 0.1 0.3 100.0 3,736 Note: Total includes 11 cases for which information on mother’s place of delivery is missing. Figures in parentheses are based on 25-49 unweighted cases. 1 Indhira Gandhi Memorial Hospital 9.7 POSTNATAL CARE Postnatal care (PNC) is important for the welfare of the mother and the child. It provides an opportunity to treat complications arising from the delivery, and it provides the mother with important information on how to care for herself and her infant. The postnatal period is defined as the time between delivery of the placenta and 42 days (6 weeks) following delivery. The timing of postnatal care is important because the first two days after delivery are critical; most maternal and neonatal deaths occur during this period. Table 9.8 shows the timing of the first postnatal checkup for women who had a birth in the past five years. Table 9.8 shows that only 6 percent of women did not receive any postnatal care; however, 24 percent responded that they did not know the timing or there was information missing, 67 percent received a postnatal checkup within two days of delivery, and 3 percent of women had a checkup 3 to 41 days after delivery. Mother’s age relates to the likelihood of receiving postnatal care within two days of delivery; younger women have higher rates of checkup after delivery than older women. There are only slight differences in postnatal care coverage and timing between women in rural and urban areas. By region, the highest percentage of women who receive postnatal care within the first two days after delivery is found in the Central and the South regions (74 percent and 73 percent, respectively). The lowest percentage of women receiving postnatal care services is in the South Central and North regions (63 percent and 62 percent, respectively). As expected, postnatal coverage increases with women’s level of education and wealth status. For example, 14 percent of mothers with no formal education and 11 percent of mothers in the lowest wealth quintile had no postnatal care. Maternal Health │ 101 Table 9.8 Timing of first postnatal checkup Percent distribution of women age 15-49 with a birth in the five years preceding the survey by timing of first postnatal checkup (for the last live birth), according to background characteristics, Maldives 2009 Timing of first postnatal checkup (time since delivery) Background characteristic Less than 4 hours 4-23 hours 2 days 3-41 days Don't know/ missing No postnatal checkup1 Total Number of women Mother's age at birth <20 52.1 16.2 6.0 1.7 20.0 3.9 100.0 111 20-34 46.3 12.1 9.2 2.5 24.6 5.2 100.0 2,682 35-49 44.0 9.4 8.3 3.3 23.3 11.7 100.0 397 Birth order 1 45.4 14.9 10.0 2.9 23.2 3.6 100.0 1,263 2-3 47.0 11.1 8.5 2.2 25.6 5.6 100.0 1,275 4-5 46.7 7.0 8.0 3.9 23.0 11.4 100.0 411 6+ 45.3 9.0 8.4 1.2 25.2 11.0 100.0 241 Residence Urban 45.7 11.0 9.7 2.8 28.1 2.8 100.0 964 Rural 46.5 12.4 8.7 2.5 22.6 7.3 100.0 2,227 Region Malé 45.7 11.0 9.7 2.8 28.1 2.8 100.0 964 North 37.8 16.8 7.6 2.9 26.7 8.3 100.0 489 North Central 50.9 7.6 7.2 2.6 23.8 8.0 100.0 466 Central 50.6 10.6 12.8 1.7 15.3 9.0 100.0 293 South Central 41.0 13.1 8.9 3.9 28.7 4.3 100.0 390 South 51.6 12.8 8.8 1.7 17.9 7.2 100.0 589 Education No formal education 39.8 8.1 10.2 1.4 26.7 13.7 100.0 396 Primary 46.3 9.7 8.9 3.0 24.2 7.9 100.0 1,143 Secondary 47.5 14.0 8.3 2.4 25.2 2.7 100.0 1,456 More than secondary 48.3 18.5 13.5 3.4 12.4 4.0 100.0 156 Wealth quintile Lowest 42.4 10.5 8.1 2.9 25.0 11.1 100.0 595 Second 46.8 13.3 9.7 2.4 20.4 7.5 100.0 677 Middle 46.7 14.1 8.2 2.0 23.3 5.5 100.0 677 Fourth 47.8 10.0 9.5 2.4 27.3 3.0 100.0 643 Highest 47.0 11.4 9.6 3.4 25.7 2.9 100.0 599 Total 46.2 11.9 9.0 2.6 24.3 6.0 100.0 3,190 Note: Total includes 39 cases for which information on mother’s formal education level is missing. 1 Includes women who received a checkup after 41 days Table 9.9 presents information on the type of health provider performing the first postnatal checkup. This information is important because the skills of a provider determine the ability to diagnose problems and to recommend appropriate treatment or referral. The majority of women (92 percent) received a postnatal checkup from a gynaecologist, doctor, nurse/midwife, or community/ family health worker. The role of community/family health worker and traditional birth attendant in providing postnatal care is very limited (1 percent). Mothers who are less than age 20 and mothers who gave birth to their first child have the highest rates of receiving postnatal care from a gynaecologist, doctor, nurse, or midwife (95 percent, each). Health professionals provide postnatal care more often to mothers in urban than rural areas (96 percent versus 90 percent). Women who live in Malé (96 percent) have the highest rate of care from a gynaecologist, doctor, nurse, or midwife. Mothers with no formal education (81 percent) and women in the lowest wealth quintile (85 percent) receive the lowest rates of postnatal care from a trained health professional compared with other women. 102 │ Maternal Health Table 9.9 Provider of first postnatal checkup Percent distribution of women age 15-49 with a birth in the five years preceding the survey by provider of mother's first postnatal checkup (for the last live birth), according to background characteristics, Maldives 2009 Type of health provider of mother's first postnatal checkup Background characteristic Gynae- cologist Doctor Nurse/ midwife Community/ family health worker Traditional birth attendant Other Don't know/ missing No postnatal checkup1 Total Number of women Mother's age at birth <20 64.8 15.3 14.9 0.7 0.0 0.0 0.4 3.9 100.0 111 20-34 67.0 16.1 9.7 0.5 0.8 0.3 0.4 5.2 100.0 2,682 35-49 57.8 19.8 6.2 1.1 1.9 1.3 0.3 11.7 100.0 397 Birth order 1 70.7 14.3 10.3 0.3 0.1 0.5 0.1 3.6 100.0 1,263 2-3 66.1 16.5 9.1 0.6 1.1 0.3 0.7 5.6 100.0 1,275 4-5 53.4 22.2 9.6 0.8 1.6 0.4 0.5 11.4 100.0 411 6+ 59.5 18.5 6.7 1.3 2.5 0.6 0.0 11.0 100.0 241 Residence Urban 68.9 15.0 12.2 0.3 0.0 0.8 0.0 2.8 100.0 964 Rural 64.5 17.2 8.3 0.7 1.3 0.2 0.5 7.3 100.0 2,227 Region Malé 68.9 15.0 12.2 0.3 0.0 0.8 0.0 2.8 100.0 964 North 70.3 12.2 6.9 0.3 2.1 0.0 0.0 8.3 100.0 489 North Central 46.1 31.4 11.1 1.0 1.4 0.3 0.7 8.0 100.0 466 Central 57.0 23.4 7.7 0.3 1.5 0.5 0.6 9.0 100.0 293 South Central 60.3 23.8 9.8 1.0 0.2 0.3 0.4 4.3 100.0 390 South 80.6 2.6 6.5 0.7 1.2 0.3 0.9 7.2 100.0 589 Education No formal education 57.2 15.8 7.9 1.4 2.8 0.8 0.4 13.7 100.0 396 Primary 60.8 20.8 7.9 1.0 1.0 0.4 0.3 7.9 100.0 1,143 Secondary 70.1 14.4 11.4 0.1 0.4 0.4 0.5 2.7 100.0 1,456 More than secondary 81.3 8.4 6.3 0.0 0.0 0.0 0.0 4.0 100.0 156 Wealth quintile Lowest 60.2 17.4 7.4 1.0 2.0 0.4 0.5 11.1 100.0 595 Second 61.8 18.3 9.1 0.8 1.5 0.2 0.7 7.5 100.0 677 Middle 69.4 15.6 7.6 0.5 0.7 0.3 0.4 5.5 100.0 677 Fourth 69.1 16.5 10.5 0.4 0.3 0.0 0.2 3.0 100.0 643 Highest 68.4 14.6 12.9 0.0 0.0 1.2 0.0 2.9 100.0 599 Total 65.8 16.5 9.5 0.6 0.9 0.4 0.4 6.0 100.0 3,190 Note: Total includes 39 cases for which information on mother’s formal education level is missing. 1 Includes women who received a checkup after 41 days 9.8 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers some women face in seeking care during pregnancy and at the time of delivery. In the 2009 MDHS, women were asked about various problems they face in accessing health care. The women were asked whether each of the following factors would be a big problem in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to health facility, taking transport, not wanting to go alone, concern there may not be a female provider or any health provider, and concern that drugs may not be available. Table 9.10 shows that 83 percent of women reported having one or more problems in accessing health care for themselves. The main problem in accessing health care was the concern that there would be no drugs available (72 percent). Two-thirds of women were concerned that there would be no provider, and 57 of women were concerned that there would be no female provider available at the health facility. More than a quarter of women reported that distance to the health facility and having to take transport was a problem (26 percent and 28 percent, respectively). Maternal Health │ 103 Older women, women with more children, women who are no longer married, those who are employed but not for cash, those who live in rural areas, those who live in the North Central region, women with no formal education, and women from the poorest households report higher rates of problems in accessing health care than other women. Women who are not currently married mention problems related to lack of money for treatment more often than women who are married. As expected, rural women cite access and availability of health services more often than others as a problem (distance to the health facility, availability of female provider, availability of provider, and lack of drugs). Table 9.10 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Maldives 2009 Problems in accessing health care Background characteristic Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern no female provider available Concern no provider available Concern no drugs available At least one problem accessing health care Number of women Age 15-19 1.6 10.5 18.5 20.2 30.7 57.1 64.2 71.7 80.7 119 20-34 1.6 7.4 22.9 24.0 22.9 54.5 64.6 70.1 82.1 4,093 35-49 3.2 16.9 30.6 34.5 24.6 60.5 68.9 75.2 84.3 2,918 Number of living children 0 2.3 5.9 21.7 20.5 27.2 53.2 63.7 71.6 82.2 1,040 1-2 1.4 8.1 22.7 24.8 21.0 53.1 62.0 67.0 79.9 3,183 3-4 2.8 13.0 27.4 31.3 22.9 58.8 69.4 75.7 84.5 1,636 5+ 3.6 21.9 36.1 39.2 28.7 67.3 75.6 81.1 89.2 1,272 Marital status Married 1.9 9.8 25.5 27.1 23.1 56.7 66.6 72.4 82.5 6,500 Divorced/separated/widowed 5.6 27.8 31.3 39.8 29.6 60.4 64.4 69.6 88.1 631 Employed past 12 months Not employed 2.3 11.5 25.0 26.6 23.2 56.4 64.9 71.5 82.3 3,753 Employed for cash 2.3 11.3 26.8 30.0 24.0 57.2 67.7 72.8 83.4 3,279 Employed not for cash 1.0 11.2 33.0 28.7 35.9 76.0 76.2 81.9 93.1 85 Residence Urban 1.3 10.2 14.9 24.3 18.1 35.0 44.7 51.2 68.4 2,368 Rural 2.7 12.0 31.5 30.2 26.5 67.9 77.2 82.6 90.2 4,763 Region Malé 1.3 10.2 14.9 24.3 18.1 35.0 44.7 51.2 68.4 2,368 North 2.0 10.1 28.1 25.9 23.4 66.4 72.3 80.3 85.2 1,067 North Central 2.8 10.7 31.4 31.6 27.9 69.0 89.0 92.2 96.8 1,038 Central 3.2 12.4 23.0 22.8 24.9 73.1 82.7 86.9 93.3 615 South Central 3.2 11.1 46.6 44.4 33.7 73.7 74.0 84.9 92.7 853 South 2.6 15.2 28.3 26.4 23.8 61.5 70.6 72.5 85.6 1,190 Education No formal education 3.8 19.0 33.9 37.7 28.2 69.1 76.7 82.3 89.6 1,668 Primary 2.3 12.9 29.5 30.2 24.4 60.6 69.1 75.5 85.8 2,464 Secondary 1.2 6.1 19.8 21.1 21.5 49.1 60.4 65.5 78.5 2,584 More than secondary 2.3 5.0 10.6 21.6 14.2 34.2 45.1 51.0 64.7 333 Wealth quintile Lowest 3.2 16.8 39.1 37.4 31.6 75.8 81.4 88.3 92.8 1,300 Second 2.7 11.7 32.6 31.5 25.9 67.8 77.0 81.9 90.5 1,396 Middle 2.5 11.1 27.9 26.8 24.4 64.4 75.2 81.1 89.7 1,488 Fourth 1.2 10.0 17.4 23.4 20.0 46.0 56.0 61.5 77.1 1,447 Highest 1.8 7.9 14.9 23.4 17.8 33.9 44.8 50.7 66.4 1,499 Total 2.3 11.4 26.0 28.2 23.7 57.0 66.4 72.2 83.0 7,131 Note: Total includes 14 cases for which information on woman’s employment status and 81 cases for which information on woman’s formal education level is missing. Child Health | 105 CHILD HEALTH 10 This chapter presents information and findings in several areas of importance to child survival: birth weight and size, vaccination coverage, and treatment practices for the two most common childhood diseases: fever and diarrhoea. Many early childhood deaths can be prevented by immunising children against preventable diseases and by ensuring that children receive prompt and appropriate treatment when they become ill. Results are presented on the prevalence of fever and treatment of fever. The prevalence of and treatment of diarrhoeal diseases with oral rehydration therapy (including increased fluids) is useful in assessing programmes that recommend such treatment. Information is also presented on the manner of disposal of children’s faecal matter because appropriate sanitary practices help prevent and reduce the severity of diarrhoeal disease. 10.1 CHILD’S SIZE AT BIRTH Birth weight is an important indicator for assessing child health in terms of early exposure to childhood morbidity and the risks of mortality. Children whose birth weight is less than 2.5 kilograms, or children reported to be ‘very small’ or ‘smaller than average,’ are considered to have a higher than average risk of early childhood death. In the 2009 MDHS, for births in the five years preceding the survey, birth weight was recorded in the Women’s Questionnaire based on either a written record or the mother’s report. The mother’s estimate of the infant’s size at birth was also obtained because birth weight may not be known for many infants. Although the mother’s estimate is subjective, it can be a useful proxy for the child’s weight. Table 10.1 presents information on child’s weight and size at birth. Table 10.1 shows that availability of birth weight information was almost universal (98 percent), and 11 percent of these infants had low birth weight (less than 2.5 kg). There are small variations in prevalence of low birth weight across groups of children by mother’s age at birth, birth order, and mother’s smoking status. Those who live in rural areas have lower birth weights. Among the regions, Malé has the lowest proportion of low birth weight infants (8 percent) and the South and South Central regions have the highest (13 percent, each). There is no systematic pattern in the relationship between low birth weight and mother’s education and household wealth quintile. Table 10.1 also includes information on the mother’s assessment of the baby’s size at birth. In the absence of birth weight a mother’s subjective assessment of the size of the baby at birth may be useful. However, this assessment may vary among respondents because it is based on the mother’s own perception of what is small, average, or large for a baby and not on a uniform definition. Eighty- seven percent of births were considered by their mothers to be of average or larger than average size. Nine percent were perceived as smaller than average, and 4 percent were considered very small. This indicator is important mostly in countries where it is not common for infants to be weighed at birth; however, this is not the case in Maldives. 106 | Child Health Table 10.1 Child's weight and size at birth Percent distribution of live births in the five years preceding the survey with reported birth weight by birth weight; percentage of all births with a reported birth weight; percent distribution of all live births in the five years preceding the survey by mother's estimate of baby's size at birth, according to background characteristics, Maldives 2009 Percentage of all births with a reported birth weight1 Distribution of births with reported birth weight1 Distribution of births by mother’s estimate of size of child at birth Background characteristic Less than 2.5 kg 2.5 kg or more Total Number of births Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 12.8 87.2 100.0 156 94.6 9.1 11.1 77.8 2.0 100.0 165 20-34 10.2 89.8 100.0 3,111 98.8 3.7 8.7 87.2 0.4 100.0 3,148 35-49 12.2 87.8 100.0 411 97.2 4.9 9.4 85.0 0.8 100.0 423 Birth order 1 11.3 88.7 100.0 1,534 98.8 4.6 9.4 85.6 0.4 100.0 1,552 2-3 9.1 90.9 100.0 1,443 98.9 3.3 7.9 88.3 0.5 100.0 1,459 4-5 11.4 88.6 100.0 449 97.7 4.6 8.9 85.9 0.6 100.0 460 6+ 12.6 87.4 100.0 253 95.3 4.6 10.6 83.6 1.2 100.0 265 Mother's smoking status Smokes cigarettes/tobacco 8.7 91.3 100.0 165 95.3 5.0 6.8 87.7 0.5 100.0 173 Does not smoke 10.6 89.4 100.0 3,508 98.6 4.0 9.0 86.5 0.5 100.0 3,557 Residence Urban 7.9 92.1 100.0 1,109 98.8 3.1 6.3 90.0 0.6 100.0 1,123 Rural 11.7 88.3 100.0 2,569 98.3 4.5 9.9 85.1 0.5 100.0 2,613 Region Malé 7.9 92.1 100.0 1,109 98.8 3.1 6.3 90.0 0.6 100.0 1,123 North 10.0 90.0 100.0 577 99.8 3.5 18.1 78.3 0.2 100.0 578 North Central 10.5 89.5 100.0 531 98.5 4.8 6.1 88.2 0.9 100.0 539 Central 12.2 87.8 100.0 342 99.6 6.7 11.6 81.2 0.5 100.0 343 South Central 12.7 87.3 100.0 444 98.0 5.8 6.8 86.5 0.9 100.0 453 South 13.1 86.9 100.0 675 96.4 3.1 7.4 89.4 0.1 100.0 700 Mother's education No formal education 13.1 86.9 100.0 435 96.9 6.8 11.8 80.3 1.2 100.0 449 Primary 10.3 89.7 100.0 1,341 98.0 4.3 8.6 86.3 0.8 100.0 1,368 Secondary 10.0 90.0 100.0 1,687 99.0 3.5 8.6 87.7 0.2 100.0 1,703 More than secondary 11.7 88.3 100.0 173 100.0 1.2 6.6 92.2 0.0 100.0 173 Wealth quintile Lowest 12.4 87.6 100.0 703 99.2 4.6 12.5 82.6 0.3 100.0 709 Second 11.9 88.1 100.0 780 97.2 4.5 8.5 86.2 0.8 100.0 802 Middle 12.6 87.4 100.0 770 98.3 3.7 10.0 85.6 0.6 100.0 783 Fourth 6.9 93.1 100.0 746 98.7 3.5 6.1 90.2 0.1 100.0 756 Highest 8.7 91.3 100.0 679 99.0 4.1 7.2 88.1 0.7 100.0 686 Total 10.5 89.5 100.0 3,678 98.4 4.1 8.9 86.6 0.5 100.0 3,736 Note: Totals include cases for which information on mother’s smoking status and mother’s formal education level is missing. 1 Based on either a written record or the mother's recall 10.2 VACCINATION COVERAGE According to the World Health Organisation, a child is considered fully vaccinated if he or she has received a BCG vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertussis, and tetanus (DPT); at least three doses of polio vaccine; and one dose of measles vaccine. These vaccinations should be received during the first year of life. Maldives achieved universal immunization status in 1989, and to maintain these high rates, the Ministry of Education has made immunization an essential requirement for entry into government schools (Ministry of Health, 2004). Prevention against measles and hepatitis B were later added to the immunisation programme, and these infections are expected to have relatively lower coverage. Child Health | 107 The 2009 MDHS collected information on coverage for these vaccinations among all children born in the five years preceding the survey. In the 2009 MDHS, information on vaccination coverage was obtained in two ways—from health cards and from mothers’ verbal reports. All mothers were asked to show the interviewer the health cards in which immunisation dates are recorded for all children born since January 2003. If a card was available, the interviewer recorded onto the questionnaire the dates of each vaccination received by the child. If a child never received a health card, or the mother was unable to show the card to the interviewer, or a particular vaccination was not recorded on the health card, the vaccination information for the child was based on the mother’s report. Questions were asked for each vaccine type. Mothers were asked to recall whether the child had received BCG, polio, DPT, measles, and hepatitis B vaccinations. If the mother indicated that the child had received the polio, DPT, or hepatitis B vaccines, she was asked about the number of doses that the child received. The mother was then asked whether the child had received other vaccinations that were not recorded on the card, and if she responded in the affirmative, they too were noted on the questionnaire. The results presented here are based on both health card information and, for children without a card, information provided by the mother. Table 10.2 shows vaccination coverage by source of information for children age 12-23 months, the age by which they should have received all vaccinations. The last row of Table 10.2 shows that 89 percent of children age 12-23 months were fully vaccinated by 12 months of age. Nearly all children had received the BCG vaccination (99 percent), and 91 percent had been vaccinated against measles. Because DPT and polio vaccines are often administered at the same time, their coverage rates are similar. Ninety-five percent or more of children received all doses of DPT and polio vaccine by age 12 months, and 92 percent of the children received all doses of hepatitis B vaccine. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Maldives 2009 All basic vaccina- tions2 No vaccina- tions Number of children Source of information DPT Polio Hepatitis BCG 1 2 3 01 1 2 3 Measles B1 B2 B3 Vaccinated at any time before survey Vaccination card 89.0 89.0 89.0 88.6 89.0 89.0 89.0 88.7 85.9 85.3 0.0 89.0 89.0 88.1 732 Mother's report 10.3 9.8 9.5 9.2 10.1 9.7 9.6 8.3 8.7 7.6 0.6 10.0 8.9 8.9 90 Either source 99.4 98.8 98.5 97.9 99.1 98.7 98.6 97.0 94.5 92.9 0.6 99.0 97.9 96.9 822 Vaccinated by 12 months of age3 99.2 98.7 98.3 96.2 99.0 98.6 98.4 95.4 91.3 88.9 - 98.7 97.5 91.9 822 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. Table 10.3 presents information on vaccine coverage among children age 12-23 months from the vaccination cards and mothers’ reports. This information may give some indication of the success of the immunization program in reaching out to all population subgroups. Vaccination cards were seen for 89 percent of children. There are no differences in vaccination coverage between male and female children. The percentage of children fully vaccinated is lowest in the Central region (88 percent) and highest in the North Central region (96 percent). There is no clear pattern between the mother’s education or wealth status and the children’s vaccination coverage. 108 | Child Health Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Maldives 2009 Percent- age with a vaccina- tion card seen All basic vaccina- tions2 No vaccina- tions Number of children Background characteristic DPT Polio BCG 1 2 3 01 1 2 3 Measles Sex Male 99.9 98.9 98.4 97.9 99.9 98.9 98.9 97.0 94.9 93.4 0.1 88.4 413 Female 98.8 98.7 98.7 97.9 98.4 98.5 98.4 97.1 94.2 92.3 1.2 89.7 409 Birth order 1 99.4 98.8 98.1 97.4 99.0 98.7 98.7 96.7 97.3 94.3 0.6 92.3 367 2-3 99.1 98.4 98.4 97.8 99.0 98.2 98.0 96.7 91.4 90.8 0.9 84.5 309 4-5 100.0 100.0 100.0 99.5 100.0 100.0 100.0 98.8 96.1 95.0 0.0 93.8 95 6+ 99.1 99.1 99.1 99.1 99.1 99.1 99.1 98.1 91.1 91.1 0.9 84.2 51 Residence Urban 100.0 99.2 99.2 98.2 100.0 99.2 99.2 95.7 93.5 91.4 0.0 85.2 243 Rural 99.1 98.7 98.3 97.7 98.8 98.5 98.4 97.6 95.0 93.5 0.9 90.6 579 Region Malé 100.0 99.2 99.2 98.2 100.0 99.2 99.2 95.7 93.5 91.4 0.0 85.2 243 North 99.0 99.0 99.0 98.4 98.4 99.0 99.0 99.0 94.0 94.0 1.0 97.8 145 North Central 100.0 100.0 100.0 100.0 100.0 99.3 99.3 99.3 96.2 95.5 0.0 96.1 105 Central 98.6 97.5 96.8 94.3 97.9 97.5 96.9 92.3 92.5 87.8 1.4 88.2 82 South Central 99.0 99.0 99.0 99.0 98.7 99.0 99.0 98.1 96.1 95.2 1.0 90.0 104 South 98.8 97.7 96.5 96.5 98.8 97.5 97.5 97.5 95.7 93.4 1.2 81.0 142 Mother's education No education 98.4 98.4 98.4 97.8 98.4 98.4 98.4 94.1 89.5 89.0 1.6 85.9 94 Primary 100.0 100.0 100.0 99.2 99.7 99.7 99.7 98.8 95.7 94.6 0.0 90.5 246 Secondary 99.1 98.4 97.8 97.2 98.9 98.0 97.9 97.5 94.8 93.4 0.9 89.5 424 More than secondary (100.0) (100.0) 100.0) 100.0) (100.0) 100.0) 100.0) (88.9) (94.5) (88.9) 0.0 86.4 49 Wealth quintile Lowest 99.3 99.0 98.6 97.7 99.3 99.0 99.0 97.7 96.0 94.7 0.7 91.5 154 Second 99.6 99.6 99.6 99.3 99.1 99.6 99.6 98.6 97.4 96.4 0.4 93.4 173 Middle 99.7 98.6 97.6 96.9 99.2 98.5 98.2 97.5 93.5 91.0 0.3 89.3 170 Fourth 98.1 98.1 98.1 98.1 98.1 97.6 97.6 94.1 92.1 89.9 1.9 85.8 164 Highest 100.0 98.7 98.7 97.3 100.0 98.7 98.7 97.0 93.7 92.2 0.0 84.9 161 Total 99.4 98.8 98.5 97.9 99.1 98.7 98.6 97.0 94.5 92.9 0.6 89.0 822 Note: Total includes 12 children with information missing on mother’s education. Figures in parentheses are based on 25-49 unweighted cases. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 10.3 TRENDS IN VACCINATION COVERAGE One way of measuring trends in vaccination coverage is to compare coverage among children of different ages within the same survey. Table 10.4 shows the percentage of children age 12-59 months who received vaccinations during the first year of life, by current age. The results show trends in vaccination coverage over the past five years. Despite the high immunization coverage, improvements in vaccination coverage have continued to take place over the past five years. The percentage of children who received all basic vaccinations by 12 months of age has increased from 83 percent among children age 48-59 months to 89 percent among children age 12-23 months. Overall, 86 percent of children age 12-59 months received all basic vaccinations on time, that is, by the time they were 12 months old. Vaccination cards were seen for 83 percent of the children. Child Health | 109 Table 10.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Maldives 2009 All basic vaccina- tions2 No vaccina- tions Percentage with a vaccination card seen Number of children Age in months DPT Polio Hepatitis BCG 1 2 3 01 1 2 3 Measles B1 B2 B3 12-23 99.2 98.7 98.3 96.2 99.0 98.6 98.4 95.4 91.3 88.9 0.8 98.7 97.5 91.9 89.0 822 24-35 98.6 98.1 96.3 95.1 97.7 97.8 96.8 94.6 89.9 87.2 1.4 98.4 96.8 48.7 84.8 686 36-47 96.8 96.8 94.6 91.8 95.0 96.4 95.9 91.4 88.2 83.5 2.8 96.7 95.2 84.5 78.7 678 48-59 97.8 97.7 97.2 94.2 96.9 97.6 97.3 89.5 89.5 82.7 2.2 97.3 96.4 89.9 77.9 649 Total 98.2 97.9 96.7 94.4 97.3 97.7 97.2 92.9 89.9 85.9 1.7 97.9 96.5 88.4 83.0 2,835 Note: Information was obtained from the vaccination card or if there was no written record, from the mother. For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 10.4 PREVALENCE AND TREATMENT OF ACUTE RESPIRATORY INFECTIONS AND FEVER 10.4.1 Acute Respiratory Infections In the 2009 MDHS, the prevalence of acute respiratory infection (ARI) was estimated by asking mothers whether their children under age 5 had been ill with a cough accompanied by short, rapid breathing and difficulty in breathing as a result of a problem in the chest, in the two weeks preceding the survey. These symptoms are compatible with ARI. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Less than 1 percent of children had symptoms of ARI in the two weeks preceding the survey, and there are no variations across subgroups of children (data not shown). 10.4.2 Fever The 2009 MDHS also asked mothers about fever, which is a primary manifestation of malaria and other acute infections in children. Table 10.5 shows the percentage of children under five with fever during the two weeks preceding the survey and the percentage receiving various treatments, by background characteristics. Twenty-nine percent of children under age 5 were reported to have had fever in the two weeks preceding the survey. The prevalence of fever varies with children’s age. Children age 6-11 months and 12-23 months have higher rates of fever (34 percent, each) compared with other children. There are no significant variations in the prevalence of fever by sex of the child or by urban-rural residence. There is some variation among regions in the prevalence of fever, ranging from 25 percent in the South region to 31 percent in the North, North Central, and Central regions. The prevalence of fever has no systematic relation to education and wealth status of mothers, except that children of mothers with more than secondary education are least likely to have fever during the two weeks preceding the survey (24 percent). Eighty-four percent of children with fever were taken to a health facility or health provider for treatment. Female children were slightly more likely to be taken to a health facility or provider. Children in the Central region (88 percent) were treated at a health facility or by a health provider more often compared with children in other regions. Children of mothers with secondary level education are more likely to receive treatment for fever (87 percent) than are those of mothers with no formal schooling (78 percent) and a primary level education (82 percent). Although they were not recommended, almost nine in ten children with fever were reported by their mothers to have been given antibiotic drugs. It should be noted that the mothers may not know the difference between antibiotic and other drugs. Children under 6 months take antibiotics (68 percent) less than older children. Use of antibiotic drugs is more common in the South Central region (92 percent) than in other regions. 110 | Child Health Table 10.5 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage of children for whom treatment was sought from a health facility or provider and the percentage who took antibiotic drugs, by background characteristics, Maldives 2009 : Children under age five with fever Percentage for whom advice or treatment was sought from a health facility or provider1 Among children under age 5 Percentage who took antibiotic drugs Number of children Background characteristic Percentage with fever Number of children Age in months <6 21.8 406 79.9 68.2 88 6-11 34.4 441 86.2 81.1 152 12-23 33.7 822 84.5 89.6 277 24-35 26.9 686 87.1 93.0 184 36-47 28.4 678 83.3 89.5 193 48-59 25.4 649 83.5 93.9 165 Sex Male 28.9 1,862 82.6 89.1 538 Female 28.7 1,820 86.3 86.5 522 Residence Urban 28.9 1,106 85.1 88.0 319 Rural 28.7 2,576 84.2 87.8 740 Region Malé 28.9 1,106 85.1 88.0 319 North 30.8 575 86.0 86.7 177 North Central 31.3 530 80.6 83.4 166 Central 30.8 339 88.2 90.4 104 South Central 27.3 442 86.0 91.9 121 South 25.0 691 82.1 88.6 173 Mother’s education No formal education 29.2 442 78.1 86.0 129 Primary 30.1 1,343 82.1 86.6 404 Secondary 28.2 1,682 87.4 89.1 474 More than secondary 23.7 173 (97.0) (92.1) 41 Wealth quintile Lowest 29.9 699 79.7 86.9 209 Second 30.1 786 87.4 84.7 237 Middle 27.8 773 84.2 87.9 215 Fourth 28.4 745 85.3 93.3 211 Highest 27.7 679 85.3 86.8 188 Total 28.8 3,682 84.4 87.9 1,060 Note: Total includes cases for which information on mother’s formal education level is missing. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner 10.5 DIARRHOEAL DISEASE Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children, although the condition can be easily treated with oral rehydration therapy (ORT). Exposure to diarrhoea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. The 2009 MDHS obtained information on the prevalence of diarrhoea among young children by asking mothers whether their children under age 5 had diarrhoea during the two weeks preceding the interview. When a child was identified as having had diarrhoea, information was collected on treatment and feeding practices during the diarrhoeal episode. The mother was also asked whether there was blood in the child’s stools. Diarrhoea with blood in the stools is indicative of cholera or other diseases that need to be treated differently from diarrhoea in which there is no blood in the stool. Mothers of children suffering from recent diarrhoea were asked about actions they had taken to treat Child Health | 111 the diarrhoea and about feeding practices during the diarrhoeal episode. Other information included the respondent’s knowledge of oral rehydration salt (ORS) packets or pre-packaged liquids for treatment of diarrhoea (oral rehydration therapy) and disposal of children’s stools. Table 10.6 shows the percentage of children under age 5 with diarrhoea in the two weeks preceding the survey, according to selected background characteristics. Overall, only 4 percent of all children under age 5 had diarrhoea, and less than 1 percent had diarrhoea with blood. The occurrence of diarrhoea varies by age of the child. Young children ages 6-11 and 12-23 months are more prone to have diarrhoea than children in the other age groups (7 percent). Children in this age group are being introduced to complementary foods. Diarrhoea is more common among children from households with a non-improved/shared toilet facility (8 percent) than among children from households with an improved toilet facility (4 percent). There are also variations in the prevalence of diarrhoea by region, ranging from 3 percent in the North Central region to 8 percent in the Central region. Lower diarrhoea prevalence is found in children of mothers living in households in the highest wealth quintile (2 percent). Table 10.6 Prevalence of diarrhoea Percentage of children under age 5 who had diarrhoea in the two weeks preceding the survey, by background characteristics, Maldives 2009 Diarrhoea in the two weeks preceding the survey Background characteristic All diarrhoea Diarrhoea with blood Number of children Age in months <6 2.5 0.0 406 6-11 6.9 0.3 441 12-23 6.7 0.3 822 24-35 4.4 0.3 686 36-47 2.5 0.6 678 48-59 3.2 0.0 649 Sex Male 4.6 0.3 1,862 Female 4.3 0.3 1,820 Source of drinking water1 Improved 4.7 0.3 3,135 Not improved 3.1 0.0 544 Toilet facility2 Improved, not shared 4.3 0.3 3,519 Non-improved or shared 7.7 0.0 156 Residence Urban 3.7 0.4 1,106 Rural 4.8 0.2 2,576 Region Malé 3.7 0.4 1,106 North 5.3 0.4 575 North Central 3.0 0.2 530 Central 7.8 0.3 339 South Central 5.3 0.1 442 South 3.8 0.2 691 Mother's education No formal education 3.4 1.1 442 Primary 6.3 0.1 1,343 Secondary 3.4 0.3 1,682 More than secondary 3.4 0.0 173 Wealth quintile Lowest 5.4 0.5 699 Second 5.1 0.2 786 Middle 4.3 0.0 773 Fourth 5.3 0.7 745 Highest 1.8 0.0 679 Total 4.4 0.3 3,682 Note: Total includes 3 cases for which information on source of drinking water, 7 cases for which information on toilet facility, and 41 cases for which information on mother’s formal education level is missing. 1 See Table 2.7 for definition of categories. 2 See Table 2.8 for definition of categories. 112 | Child Health Mothers of children who had diarrhoea in the two weeks preceding the survey were asked what they did to treat the illness. Eighty-four percent of the children with diarrhoea were taken to a health care facility or provider where advice or treatment was sought (data not shown). Information on oral rehydration therapy was requested. Eighty-four percent of children with diarrhoea were treated with oral rehydration therapy (ORT) or increased fluids. Fifty-seven percent were treated with ORS, a solution prepared from a packet of oral rehydration salts; 21 percent were given recommended home fluids, and 59 percent received increased fluids. Eleven percent of children were given antibiotic drugs and 33 percent received home remedies or other treatments. Six percent of children with diarrhoea did not receive any treatment at all (data not shown). When a child has diarrhoea, mothers are encouraged to continue feeding their child the usual amount of food and to increase the child’s fluid intake. These practices help to reduce dehydration and minimise the adverse consequences of diarrhoea on the child’s nutritional status. In the 2009 MDHS, mothers were asked whether they gave their child with diarrhoea less, the same amount, or more fluids and food than usual when their child had diarrhoea. Twenty-four percent of children with diar- rhoea were given the same amount of liquids as usual, and 59 percent were given more (data not shown). Eight percent of the children were given somewhat less to drink than usual, and 9 percent were given much less to drink during the diarrhoea episode. Twenty-five percent of children were given the same amount of food as usual, 29 percent were given some- what less, 18 percent were given much less food, and 15 percent were given more food. Five percent of children were not given any food during the diarrhoea episode. Overall, 45 percent of the children had increased fluid intake and continued feeding, and more than three in four children were given ORT, increased fluids, and continued feeding (data not shown). 10.6 KNOWLEDGE OF ORS PACKETS To ascertain respondents’ knowledge of ORS in Maldives, women are asked whether they knew about ORS packets. Table 10.7 presents information on the percentage of mothers with a birth in the five years preceding the survey who had heard about ORS packets. Overall, 96 percent of women know about ORS packets. Knowledge of ORS varies by region, from 99 percent among women in the North Central region to 88 percent among women in the South Central region. Knowledge of ORS is lower among mothers with no formal education and primary school- ing (94 percent, each) than among women with more than secondary schooling (98 percent). Table 10.7 Knowledge of ORS packets or pre-packaged liquids Percentage of mothers age 15-49 who gave birth in the five years preceding the survey who know about ORS packets or ORS pre-packaged liquids for treatment of diarrhoea by background characteristics, Maldives 2009 Background characteristic Percentage of women who know about ORS packets or ORS pre-packaged liquids Number of women Age 15-19 (96.6) 27 20-24 94.2 687 25-34 96.3 1,830 35-49 94.8 646 Residence Urban 96.6 964 Rural 95.1 2,227 Region Malé 96.6 964 North 96.9 489 North Central 98.5 466 Central 92.6 293 South Central 88.3 390 South 96.5 589 Education No formal education 93.6 396 Primary 94.2 1,143 Secondary 96.7 1,456 More than secondary 98.4 156 Wealth quintile Lowest 94.8 595 Second 93.8 677 Middle 95.5 677 Fourth 97.0 643 Highest 96.7 599 Total 95.5 3,190 Note: Total includes 39 cases for which information on mother’s formal education level is missing. ORS = Oral rehydration salts Child Health | 113 10.7 STOOL DISPOSAL When human faeces are left uncontained, disease can spread by direct contact or by animal contact with the faeces. Hence, proper disposal of children’s stools is extremely important in preventing the spread of disease. Table 10.8 shows stool disposal for children under age 5. Eighteen percent of children under age 5 use a toilet or latrine, 7 percent dispose of stool in a toilet or latrine, and 9 percent bury the children’s stools. Sixty-two percent are thrown into the garbage, and only 1 percent is left uncontained. It is important to note that in Maldives, where the water table is high, burying stool is not recommended. Stools that are thrown into the garbage may be contained in disposable diapers. There are pronounced differences in practices of stool disposal by background characteristics. A child’s use of the toilet or latrine increases with increasing age of the child and is higher in rural areas (20 percent) compared with urban areas (14 percent). Malé (14 percent) has the lowest proportion of children using a toilet or latrine, while the North Central region has the highest proportion (26 percent). Surprisingly, a mother’s level of education is negatively associated with a child’s use of the toilet or latrine, being highest for mothers with no formal education (24 percent). Also, it is lowest for women from the highest wealth quintile. Table 10.8 Disposal of children's stools Percent distribution of youngest children under age 3 living with the mother by the manner of disposal of the child's last faecal matter, according to background characteristics, Maldives 2009 Manner of disposal of children's stools Background characteristic Child used toilet or latrine Put/rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Rinsed away Other Missing Total Number of mothers Age in months <6 1.4 1.4 11.0 0.2 81.1 1.3 3.5 0.2 100.0 401 6-11 4.3 4.7 7.1 0.3 78.0 1.5 3.9 0.2 100.0 437 12-23 13.4 5.9 9.3 0.1 66.8 1.8 2.7 0.1 100.0 792 24-35 46.3 13.3 7.6 0.6 29.4 1.1 1.5 0.2 100.0 593 Toilet facility Improved, not shared1 18.1 6.7 8.7 0.3 61.9 1.4 2.7 0.1 100.0 2,126 Non-improved or shared 20.2 7.1 9.2 0.0 56.3 2.9 4.3 0.0 100.0 92 Residence Urban 14.0 3.0 0.0 0.0 83.0 0.0 0.0 0.0 100.0 685 Rural 20.1 8.5 12.6 0.4 52.1 2.1 4.0 0.2 100.0 1,538 Region Malé 14.0 3.0 0.0 0.0 83.0 0.0 0.0 0.0 100.0 685 North 17.0 16.5 19.4 0.0 42.1 0.3 4.6 0.0 100.0 348 North Central 26.4 0.3 15.1 0.4 51.5 2.9 3.0 0.5 100.0 303 Central 13.9 5.2 7.2 0.3 67.0 2.9 3.2 0.2 100.0 205 South Central 22.6 1.4 18.0 0.3 51.1 3.5 2.7 0.4 100.0 279 South 19.2 14.3 3.9 0.9 54.4 1.6 5.6 0.0 100.0 404 Education No formal education 23.7 12.9 14.1 0.0 45.9 1.2 2.0 0.2 100.0 220 Primary 20.7 7.1 12.2 0.3 53.8 1.9 3.9 0.1 100.0 714 Secondary 15.6 6.3 6.4 0.4 67.6 1.3 2.4 0.2 100.0 1,135 More than secondary 16.8 1.0 1.6 0.0 79.6 0.4 0.7 0.0 100.0 129 Wealth quintile Lowest 18.3 9.1 19.7 0.2 46.7 2.6 3.2 0.2 100.0 393 Second 20.9 8.5 13.2 0.5 50.4 2.2 4.1 0.2 100.0 473 Middle 21.9 8.1 9.8 0.3 54.2 1.1 4.2 0.3 100.0 471 Fourth 15.8 4.8 1.8 0.4 74.0 1.4 1.9 0.0 100.0 445 Highest 13.6 3.5 0.0 0.0 82.5 0.0 0.4 0.0 100.0 441 Total 18.2 6.8 8.7 0.3 61.6 1.4 2.8 0.1 100.0 2,223 Note: Total includes 5 cases for which information on toilet facility and 26 cases for which mother’s formal education level is missing. 1 Non-shared facilities that are of the types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; and pit latrine with a slab Nutrition of Children and Women | 115 NUTRITION OF CHILDREN AND WOMEN 11 This chapter on nutrition covers concerns about children and women. The section on children addresses anthropometric assessment of the nutritional status of young children; infant and young child feeding practices, including breastfeeding and feeding with solid/semi-solid foods; diversity of foods; frequency of feeding; and micronutrient status, supplementation, and fortification. The section on women covers nutritional status of ever-married women 15-49 years of age; the diversity of foods eaten by mothers of children under age 3; and micronutrient status, supplementation, and fortification. Adequate nutrition is critical to child development. The period from birth to age 2 is important to optimal growth, health, and development. This period is one that may be marked by growth faltering, micronutrient deficiencies, and common childhood illnesses, such as diarrhoea and acute respiratory infections (ARIs). Optimal feeding practices reported in this chapter include early initiation of breastfeeding, exclusive breastfeeding during the first 6 months of life, continued breastfeeding until age 2 and beyond, timely introduction of complementary feeding at 6 months of age, frequent feeding of solid/semi-solid foods, and feeding of diverse food groups to children between 6 and 23 months of age. A summary indicator that describes the quality of infant and young child (age 6-23 months) feeding (IYCF) practices is included. A woman’s nutritional status has important implications for her health as well as for the health of her children. Malnutrition in women results in reduced productivity, increased susceptibility to infections, retarded recovery from illness, and heightened risk of adverse pregnancy outcomes. A woman who has a poor nutritional status as indicated by a low body mass index (BMI), short stature, and presence of anaemia or other micronutrient deficiency faces a greater risk of obstructed labour, low birth weight, poor quality breast milk, illness for herself and her baby, and death from postpartum haemorrhage. 11.1 NUTRITIONAL STATUS OF CHILDREN Anthropometric data on height and weight collected in the 2009 MDHS permit the measurement and evaluation of the nutritional status of young children in Maldives. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. However, marked differences, especially with regard to height-for-age, weight-for-height, and weight-for-age measures are often seen among subgroups of children. 11.1.1 Measurement of Nutritional Status among Young Children The 2009 MDHS collected data on the nutritional status of children by measuring the height and weight of all children under age 5, regardless of whether their mother was interviewed in the survey. Data were collected to calculate three indices—namely, height-for-age, weight-for-height, and weight-for-age. Weight measurements were obtained using lightweight, SECA mother-infant scales with a digital screen, designed and manufactured under the guidance of the United Nations Children’s Fund (UNICEF). Height measurements were carried out using a measuring board produced by Shorr Productions. Children younger than 24 months were measured lying down on the board (recumbent length), while standing height was measured for older children. For the 2009 MDHS, the nutritional status of children is calculated using new growth standards published by the World Health Organization (WHO) in 2006. These new growth standards were generated using data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). The study, with a sample size of 8,440 children from six countries around the world, was designed to 116 | Nutrition of Children and Women describe how children should grow under optimal conditions. The WHO Child Growth Standards can therefore be used to assess children everywhere regardless of ethnicity, social and economic influences, and feeding practices. Each of the three nutritional status indicators described below is expressed as standard deviation units from the median of the Multicentre Growth Reference Study sample. Each of these indices—height-for-age, weight-for-height, and weight-for-age—provides dif- ferent information about growth and body composition, which is used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period and is also affected by recurrent and chronic illness. Height-for age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) are considered thin (wasted) and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may result from inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) are considered severely wasted. The weight-for-height index can also be used to assess the extent to which children’s weight-for-height exceeds that considered normal. Children whose weight-for-height falls above plus two standard deviations (+2 SD) from the WHO reference population median are considered too heavy for their height. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. Children whose weight-for-age falls above plus two standard deviations (+2 SD) from the WHO reference population median are considered to be overweight. 11.1.2 Results of Data Collection Height and weight measurements were obtained for 2,513 children under age 5 who were present in MDHS households at the time of the survey. The following analysis focuses on the children for whom complete and credible anthropometric and valid age data were collected. Table 11.1 and Figure 11.1 show the percentage of children under age 5 classified as malnourished according to the three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for- age. Height-for-age Nineteen percent of children under age 5 are stunted, and 6 percent are severely stunted. Stunting is apparent even among children less than 6 months of age (15 percent). As shown in Figure 11.1, stunting increases with the age of the child through the first year of life (from 15 percent among children less than age 6 months to 24 percent among children age 9-11 months) before declining slightly to 22 percent between 12-17 months and then increasing to 25 percent for children age 18-23 months. A higher proportion of male children (20 percent) are stunted compared with female children (17 percent). Nutrition of Children and Women | 117 Stunting did not vary systematically with the length of the birth interval. Stunting levels were higher among children who were considered by the mother to be very small or smaller than average at birth than among children who were reported to be average or larger at birth. A larger percentage of children whose mothers were underweight (21 percent) were stunted than children of normal weight or overweight/obese mothers (18 percent). Rural children are more often stunted (20 percent) than urban children (16 percent). Regional variation in nutritional status of children is substantial, with stunting being highest in the North Central region (23 percent) and lowest in Malé and the North (16 percent). Education and wealth are both inversely related to stunting levels. For example, children born to mothers with primary education have higher rates of stunting (21 percent) compared with children born to mothers with more than secondary education (12 percent). A quarter of children born to mothers with no formal education are stunted. Weight-for-height Table 11.1 shows that the highest level of wasting is observed for children under age 6 months (16 percent) and children who were reported by the mother to have been very small at birth (20 percent). The proportion of wasting in children of thin mothers is almost twice that of children whose mothers have a normal BMI. The degree of wasting is less in urban than in rural areas (7 percent versus 12 percent). At the regional level, the North Central region reports the highest level of wasting (15 percent), and Malé reports the lowest level (7 percent). As with stunting, wasting decreases as the level of education increases. For example, children whose mothers have never attended school have the highest levels of wasting (15 percent), while children whose mothers have secondary or more than secondary education have the lowest levels of wasting (8 percent). There is no systematic relationship between wasting level and wealth quintile. Six percent of children under age 5 in Maldives are too heavy for their height, with Z-scores more than two standard deviations (+2 SD) above the median. Weight-for-age Reflecting the effects of both chronic and short-term malnutrition, 17 percent of children under age 5 are underweight for their age. Table 11.1 shows the highest proportions of underweight children are in the categories of children age 24-35 months (21 percent), children born less than 24 months after a sibling (26 percent), and children considered by their mother to have been very small or small at birth (43 percent). Children born to thin or underweight mothers are more often underweight than those born to mothers with a normal BMI (27 percent compared with 18 percent). There are substantial geographical variations. The proportion of children who are underweight is higher in rural areas than in urban areas. At the regional level, children in Malé are the least likely (11 percent) to be underweight, while children in the North Central and the South Central regions are the most likely (24 percent and 20 percent, respectively). As maternal education and wealth increase, the proportion of underweight children declines. 118 | Nutrition of Children and Women Table 11.1 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Maldives 2009 Height-for-age Weight-for-height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Number of children Age in months <6 7.8 14.8 (0.6) 6.0 15.5 8.8 (0.3) 3.9 17.2 2.3 (0.8) 222 6-8 8.6 18.5 (0.9) 4.7 8.9 4.9 (0.3) 2.7 9.7 2.2 (0.8) 156 9-11 9.6 24.4 (0.9) 4.1 13.8 5.0 (0.4) 4.5 19.1 2.2 (0.9) 156 12-17 7.5 21.9 (1.0) 1.8 6.6 3.9 (0.3) 1.3 13.8 1.7 (0.7) 269 18-23 8.0 25.1 (1.1) 1.5 6.7 6.3 (0.2) 0.6 14.1 2.4 (0.7) 261 24-35 6.6 19.4 (1.0) 2.4 10.0 4.1 (0.6) 4.8 21.2 1.3 (1.0) 472 36-47 5.2 18.1 (0.9) 2.2 10.9 7.7 (0.6) 4.1 19.1 3.0 (0.9) 499 48-59 3.4 14.2 (0.8) 1.2 12.5 6.1 (0.6) 3.0 17.3 2.5 (0.9) 477 Sex Male 7.9 20.3 (1.0) 2.6 10.7 6.0 (0.5) 3.2 17.6 2.2 (0.9) 1,266 Female 4.9 17.4 (0.9) 2.4 10.6 5.8 (0.4) 3.3 17.0 2.2 (0.8) 1,246 Birth interval in months2 First birth3 5.1 16.8 (0.8) 2.8 10.1 7.4 (0.3) 2.6 13.5 2.8 (0.7) 953 <24 8.1 20.5 (1.2) 3.0 11.9 3.6 (0.7) 5.8 25.7 1.4 (1.2) 172 24-47 6.9 21.0 (1.0) 1.3 9.2 4.2 (0.5) 3.4 16.1 1.2 (0.9) 399 48+ 5.4 17.8 (0.9) 2.4 12.7 4.7 (0.6) 3.2 20.2 2.1 (0.9) 758 Size at birth2 Very small 23.6 35.6 (1.9) 4.0 19.8 7.4 (0.7) 15.6 42.6 0.5 (1.6) 88 Small 6.3 27.4 (1.3) 4.7 15.2 2.7 (0.8) 3.3 27.4 0.7 (1.3) 211 Average or larger 4.9 16.4 (0.8) 2.1 10.1 5.9 (0.4) 2.6 14.9 2.4 (0.7) 1,978 Mother's interview status Interviewed 5.7 18.1 (0.9) 2.4 10.9 5.7 (0.5) 3.2 17.1 2.2 (0.8) 2,282 Not interviewed but in household 14.1 25.8 (1.2) 4.1 7.8 9.7 (0.4) 4.5 21.1 2.4 (0.9) 202 Not interviewed, and not in the household4 (3.1) (26.8) ((1.1)) (0.0) (6.3) (0.0) ((0.3)) (3.1) (6.3) (2.9) ((0.8)) 28 Mother's nutritional status5 Thin (BMI<8.5) 6.5 20.5 (1.2) 6.1 18.0 2.3 (1.0) 5.4 26.5 0.0 (1.3) 187 Normal (BMI 18.5- 24.9) 5.7 18.1 (0.9) 2.2 10.3 4.5 (0.5) 2.7 17.8 1.4 (0.9) 1,167 Overweight/obese (BMI ≥25) 6.7 18.4 (0.9) 2.2 9.8 7.7 (0.3) 3.1 15.1 3.2 (0.7) 959 Missing 8.7 22.8 (1.0) 2.6 10.8 11.6 (0.1) 4.4 16.4 3.8 (0.6) 156 Residence Urban 6.2 15.7 (0.7) 0.8 7.2 7.2 (0.2) 1.1 10.9 2.3 (0.5) 721 Rural 6.5 20.1 (1.0) 3.2 12.0 5.4 (0.6) 4.2 19.9 2.2 (1.0) 1,792 Region Malé 6.2 15.7 (0.7) 0.8 7.2 7.2 (0.2) 1.1 10.9 2.3 (0.5) 721 North 4.0 15.7 (0.9) 2.3 11.8 5.0 (0.6) 2.7 18.4 3.1 (0.9) 387 North Central 7.9 22.7 (1.1) 3.4 14.5 3.3 (0.7) 5.7 24.4 1.3 (1.2) 543 Central 8.5 20.9 (1.0) 5.7 14.1 5.7 (0.6) 4.8 18.0 1.3 (0.9) 235 South Central 7.7 20.9 (1.1) 2.6 10.2 5.8 (0.5) 3.7 19.9 2.6 (0.9) 280 South 4.7 19.9 (1.0) 2.8 8.4 8.6 (0.3) 3.4 15.9 2.9 (0.7) 346 Mother's education6 No formal education 8.9 24.9 (1.2) 2.3 14.8 5.5 (0.7) 5.2 27.1 2.7 (1.2) 321 Primary 7.0 20.8 (1.0) 3.4 12.0 4.7 (0.6) 4.7 21.0 1.4 (1.0) 937 Secondary 5.4 16.2 (0.8) 2.2 8.7 7.1 (0.3) 1.9 12.3 2.4 (0.6) 1,092 More than secondary 5.0 12.1 (0.5) 1.0 8.4 6.2 (0.3) 0.0 11.9 3.7 (0.4) 110 Wealth quintile Lowest 7.4 21.9 (1.2) 2.8 12.7 4.2 (0.7) 4.8 24.3 2.3 (1.1) 508 Second 7.3 23.1 (1.1) 3.8 11.4 6.8 (0.5) 5.0 19.0 1.6 (1.0) 533 Middle 4.9 17.6 (0.9) 3.3 12.8 4.8 (0.6) 3.7 19.3 1.8 (0.9) 519 Fourth 6.7 15.4 (0.8) 0.9 7.1 6.9 (0.2) 1.6 12.5 3.3 (0.6) 477 Highest 5.6 15.7 (0.7) 1.6 8.7 7.0 (0.3) 0.9 10.5 2.1 (0.6) 475 Total 6.4 18.9 (0.9) 2.5 10.6 5.9 (0.5) 3.3 17.3 2.2 (0.8) 2,513 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 1 case for which information on size at birth and 24 cases for which information on mother’s formal education level is missing. 1 Includes children who are below -3 standard deviations (SD) from the WHO Child Growth standards population median 2 Excludes children whose mothers were not interviewed 3 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 4 Includes children whose mothers are deceased 5 Excludes children whose mothers were not weighed and measured. Mother's nutritional status in terms of BMI (Body Mass Index) is presented in Table 11.8 6 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire Nutrition of Children and Women | 119 11.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the contraction of the uterus and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 11.2 shows the breastfeeding status and the timing of initial breastfeeding of all children born in the five years before the survey. It also considers the prevalence of the practice of prelacteal feeding, that is, giving the infant other liquids during the period between the birth and when the mother’s milk is flowing freely. This practice is discouraged because it limits the frequency of breastfeeding by the infant and exposes the baby to the risk of infection. Nearly all children (98 percent) born in the five years preceding the survey were breastfed regardless of their background characteristics. Slightly less than two-thirds of infants (64 percent) were put to the breast within one hour of birth, and 92 percent started breastfeeding within the first day. Although breastfeeding is widely practiced across all subgroups of women, the timing of initial breastfeeding varies by background characteristics. The proportion of children breastfed within one hour of delivery is higher in rural areas (66 percent) than in urban areas (60 percent). With respect to regions, the South Central region has the highest proportion (74 percent) of children breastfed within one hour of birth, while Malé and the North regions have the lowest proportion (60 percent). Children born to mothers with no formal education or with at least primary education are breastfed within one hour of birth more often than those born to mothers with secondary or higher education. The timing of initial breastfeeding varies according to the person who assisted at delivery and the place of delivery. Children whose mothers are assisted at birth by a health professional are less likely to be breastfed within one hour of birth (64 percent), and children whose mothers are assisted by a traditional birth attendant are breastfed more often (78 percent). Similarly, the proportion of children breastfed within one hour of birth is higher for children born at home (77 percent) than for those born at a health facility (64 percent). # # # # # # # # ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) <6 6-8 9-11 12-17 18-23 24-35 36-47 48-59 Age (months) 0 5 10 15 20 25 30 Percent Stunted Wasted Underweight) ( # MDHS 2009 Figure 11.1 Nutritional Status of Children by Age Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a five-month moving average 120 | Nutrition of Children and Women Only 12 percent of last-born children received a prelacteal feed. There are no marked differences in the proportions of children who received a prelacteal feed by the child’s sex. However, there are variations by residence, assistance at delivery, and place of delivery. Prelacteal feeding is practiced more in urban areas and in Malé (16 percent). It is also more common among children whose mothers were assisted by a health professional during delivery and those born in a health facility Children of mothers who have no formal education (6 percent) are least likely to receive prelacteal feeds; likewise, children born to mothers in the higher (fourth and highest) wealth quintiles (15 percent and 16 percent, respectively) are more likely to receive a prelacteal feed than children born to mothers in other wealth quintiles (9 percent). Table 11.2 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and for the last-born children born in the five years preceding the survey ever breastfed, the percentage who started breastfeeding within one hour and within one day of birth and the percentage who received a prelacteal feed, by background characteristics, Maldives 2009 Breastfeeding among children born in past five years Among last-born children ever breastfed: Background characteristic Percentage ever breastfed Number of children born in past five years Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 98.0 1,896 63.2 91.9 11.5 1,575 Female 98.0 1,840 65.4 92.2 11.8 1,560 Residence Urban 97.2 1,123 60.0 89.5 16.2 940 Rural 98.3 2,613 66.1 93.1 9.7 2,195 Region Malé 97.2 1,123 60.0 89.5 16.2 940 North 98.2 578 59.6 93.9 9.7 480 North Central 98.9 539 68.4 93.0 8.2 461 Central 99.4 343 70.8 93.7 12.1 292 South Central 97.5 453 74.2 92.3 11.2 382 South 98.1 700 62.1 92.8 8.8 579 Mother's education No formal education 97.4 449 69.2 91.0 6.0 385 Primary 98.7 1,368 69.2 93.7 9.3 1,132 Secondary 97.7 1,703 59.7 91.2 14.6 1,425 More than secondary 98.4 173 61.1 92.1 12.8 156 Assistance at delivery Health professional3 98.0 3,564 63.9 92.0 12.0 3,007 Traditional birth attendant 97.3 155 78.0 98.8 4.7 117 Other * 5 * * * 5 Place of delivery Health facility 98.1 3,555 64.1 92.1 12.0 3,009 At home 99.1 116 76.9 96.1 3.2 88 Other (87.9) 54 (61.3) (98.0) (8.4) 32 Wealth quintile Lowest 98.3 709 65.8 93.6 8.7 586 Second 97.9 802 68.8 93.6 9.4 664 Middle 98.4 783 65.1 92.2 9.3 668 Fourth 98.0 756 63.1 91.3 15.4 631 Highest 97.5 686 58.0 89.4 15.9 587 Total 98.0 3,736 64.3 92.0 11.7 3,135 Note: Table is based on births in the past five years whether the children are living or dead at the time of interview. Total includes cases for which information on mother’s formal education level, assistance at delivery and place of delivery is missing. 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. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, gynaecologist, nurse/midwife, or community/family health worker Nutrition of Children and Women | 121 11.3 BREASTFEEDING STATUS BY AGE Both UNICEF and WHO recommend that children be exclusively breastfed during the first six months of life and that children be given solid or semi-solid complementary foods in addition to continued breastfeeding from age 6 months to 24 months (or more) when the child is fully weaned. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for several reasons. First, it exposes infants to risk of infection. Second, it decreases infants’ intake of breast milk and therefore the frequency of breastfeeding, which reduces breast milk production. Third, in low resource settings, supplementary food is often nutritionally inferior. Table 11.3 and Figure 11.3 show the percent distribution of youngest children under age 3 living with the mother by breastfeeding status, according to age in months. Table 11.3 also presents the percentage of all children under age three who use a bottle with a nipple, by the child’s age. Exclusive breastfeeding is common but not universal in early infancy in Maldives. Table 11.3 shows that, among infants under age 2 months, 69 percent receive only breast milk, 2 percent consume breast milk and plain water, 4 percent drink non-milk liquids/juice, and 22 percent have other milk in addition to breast milk. Overall, only 48 percent of infants below age 6 months are exclusively breastfed, and the proportion exclusively breastfed drops off rapidly among older infants. By age 4-5 months, around three in four babies are receiving some form of supplementation and complementary foods. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under three years who are living with their mother by breastfeeding status; and the percentage currently breastfeeding; and the percentage of all children under three years using a bottle with a nipple, according to age in months, Maldives 2009 Percent distribution of youngest children under three living with their mother by breastfeeding status Breastfeeding and consuming: Percentage currently breast- feeding Number of youngest child under three years Number of children under three years Age in months Not breast- feeding Exclusively breastfed Plain water only Non- milk liquids/ juice Other milk Comple- mentary foods Total Percentage using a bottle with a nipple1 0-1 1.4 68.9 2.0 4.3 22.0 1.4 100.0 98.6 77 12.5 77 2-3 2.1 59.8 10.0 3.7 22.1 2.4 100.0 97.9 163 23.7 166 4-5 7.0 25.5 9.9 5.3 27.8 24.5 100.0 93.0 161 44.4 164 6-8 9.3 3.0 3.5 1.2 1.5 81.6 100.0 90.7 225 47.2 227 9-11 12.8 0.0 0.5 0.0 0.4 86.3 100.0 87.2 213 44.5 214 12-17 22.0 0.0 0.0 0.1 0.1 77.8 100.0 78.0 378 41.3 387 18-23 32.4 0.0 0.2 0.0 0.0 67.4 100.0 67.6 414 35.8 436 24-35 58.1 0.1 0.0 0.0 0.0 41.8 100.0 41.9 593 33.5 686 0-3 1.8 62.7 7.5 3.9 22.1 2.1 100.0 98.2 240 20.2 242 0-5 3.9 47.8 8.4 4.4 24.4 11.1 100.0 96.1 401 30.0 406 6-9 11.0 2.2 2.7 0.9 1.4 81.8 100.0 89.0 298 47.5 301 12-15 22.7 0.0 0.0 0.0 0.1 77.2 100.0 77.3 249 41.6 254 12-23 27.5 0.0 0.1 0.1 0.0 72.4 100.0 72.5 792 38.4 822 20-23 31.6 0.0 0.3 0.0 0.0 68.0 100.0 68.4 267 33.7 286 Note: Breastfeeding status refers to a 24-hour period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, so their percentages add to 100 percent. Children who receive breast milk and non-milk liquids and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years 122 | Nutrition of Children and Women After age 6 months, children need to start receiving foods in order to meet all of their nutritional requirements. As shown in Table 11.3, 82 percent of children age 6-9 months are breastfeeding and receiving complementary food. The use of a bottle with a nipple, regardless of the contents (breast milk, formula, or any other liquid), requires hygienic handling to avoid contamination that may cause infection in the infant. Table 11.3 shows that 30 percent of infants age 0-5 months are fed using a bottle with a nipple. 11.4 DURATION AND FREQUENCY OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding by selected background character- istics. The estimates of median and mean durations of breastfeeding are based on current status information, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The median duration of any breastfeeding in Maldives is 25.3 months, and the mean duration is 23.9 months. The median duration does not vary much by the child’s background characteristics. Children in households in the fourth wealth quintile are breastfed for the shortest duration (19.9 months), while other children are breastfed for 25-27 months. At the national level, the median duration of exclusive breastfeeding is 2.2 months. Median duration of exclusive breastfeeding in some other countries is as follows: Bangladesh (2007) 1.8 months, Cambodia (2005) 3.2 months, Egypt (2008) 2.7 months, India (2005-06) 2 months, Indonesia (2007) 0.7 months, Jordan (2007) 0.6 months, Nepal (2006) 2.6 months, and Philippines (2008) 0.7 months (source: STATcompiler 2010). The median duration of predominant breastfeeding, which is defined as exclusive breast- feeding or breastfeeding in combination with plain water, water-based liquids, or juices, is 3.5 months in Maldives. There is little variation by subgroups of children. Figure 11.2 Infant Feeding Practices by Age 0-1 2-3 4-5 6-8 9-11 12-17 18-23 24-35 Age group in months 0 20 40 60 80 100 Exclusively breastfed Plain water only Non-milk liquids/juice Other milk Complementary foods Not breastfeeding MDHS 2009 Percent Nutrition of Children and Women | 123 Table 11.4 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, percentage of breastfeeding children under six months of age living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Maldives 2009 Median duration (months) of breastfeeding among children born in the past three years1 Frequency of breastfeeding among children under six months of age2 Background characteristic Any breast- feeding Exclusive breast- feeding Predomi- nant breast- feeding3 Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 25.2 2.2 3.5 96.6 9.3 9.3 172 Female 25.3 2.2 3.4 97.3 8.3 8.9 182 Residence Urban (23.3) (2.2) (3.3) (96.0) (7.3) (8.6) 104 Rural 25.6 2.2 3.6 97.4 9.4 9.3 249 Region Malé (23.3) (2.2) (3.3) (96.0) (7.3) (8.6) 104 North (29.1) (3.1) (4.1) (97.2) (10.1) (9.6) 49 North Central 27.1 3.2 4.3 95.9 10.7 11.0 48 Central 27.2 2.7 3.9 98.3 8.2 8.2 39 South Central 23.7 0.4 0.4 97.5 8.6 8.5 48 South 22.1 2.6 4.0 98.0 9.4 9.2 65 Mother's education No formal education (29.3) (1.6) (2.2) (100.0) (10.7) (10.6) 22 Primary 25.5 2.4 4.1 97.8 9.7 9.9 121 Secondary 25.5 2.0 3.3 96.3 8.5 8.7 181 More than secondary * * * * * * 29 Wealth quintile Lowest 26.7 1.3 3.0 98.1 11.4 10.5 61 Second 25.7 3.1 4.3 97.4 9.3 9.4 78 Middle 25.3 1.0 2.3 97.3 8.3 8.3 71 Fourth 19.9 2.3 3.7 98.3 8.2 9.0 81 Highest (14.4) (2.5) (3.4) (93.3) (7.0) (8.4) 62 Total 25.3 2.2 3.5 97.0 8.8 9.1 354 Mean for all children 23.9 3.5 4.3 na na na na Note: Median and mean durations are based on current status. Includes children living and deceased at the time of the survey. Total includes 1 case for which information on mother’s formal education level is missing. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding 2 Excludes children without a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only Almost all breastfeeding children less than six months of age (97 percent) were breastfed at least six times during the 24 hours preceding the survey, which meets the WHO/UNICEF recommendations for optimal breastfeeding. The mean number of daytime feeds is 8.8, and the mean number of nighttime feeds is 9.1. 124 | Nutrition of Children and Women 11.5 TYPES OF COMPLEMENTARY FOODS UNICEF and WHO recommend the introduction of solid food to infants around the age of 6 months because by that age breast milk alone is no longer sufficient to maintain a child’s optimal growth. In the transition to eating the family diet, children age 6 months and older should be fed small quantities of solid and semi-solid foods throughout the day. During this transition period (age 6-23 months), the prevalence of malnutrition increases substantially in many countries because of increases in infections and poor feeding practices. Table 11.5 provides information on the types of foods given on the day and night preceding the survey to youngest children under age 3 years living with their mother. As expected, the proportions of children who consumed foods or liquids included in the various groups shown in the table rises with the age of the child. The results show that, among all breastfeeding children under age 3, 36 percent consume infant formula and higher proportions receive other milk (55 percent) and other liquids (60 percent). Children age 6-23 months consume foods made from grains more often than foods from any other food group. Among breastfeeding children in this age group, 96 percent ate foods made from grains, and 64 percent ate fruits and vegetables rich in vitamin A during the day and night preceding the interview. Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview Percentage of youngest children under three years of age who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Maldives 2009 Solid or semi-solid foods Fruits and vege- tables rich in vitamin A4 Food made from roots and tubers Age in months Forti- fied baby foods Food made from grains3 Other fruits and vege- tables Food made from legumes and nuts Meat, fish, poultry, and eggs Cheese, yogurt, other milk product Any solid or semi- solid food Food made with oil, fat, and butter Sugary foods Number of children Liquids Infant formula Other milk1 Other liquids2 BREASTFEEDING CHILDREN 0-1 7.3 23.2 5.6 0.0 0.0 1.4 0.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 76 2-3 15.5 18.8 12.3 0.8 2.0 0.6 0.5 0.0 0.0 0.0 0.6 2.5 0.0 0.0 160 4-5 35.0 37.6 26.7 16.7 22.5 8.0 4.2 0.8 0.8 2.0 8.4 26.3 0.5 1.7 150 6-8 47.0 53.5 56.2 67.0 85.3 49.0 24.1 10.2 10.9 13.1 32.5 89.9 10.1 15.9 204 9-11 46.0 46.6 66.9 70.3 96.9 67.8 30.6 26.9 24.2 47.2 45.5 99.0 35.9 36.7 185 12-17 40.4 69.2 80.9 53.1 99.5 70.6 34.6 25.0 23.1 68.5 45.2 99.5 39.2 47.9 295 18-23 39.7 70.1 76.6 34.6 98.5 66.8 35.3 16.9 25.5 76.7 34.6 99.0 45.4 58.9 280 24-35 34.9 73.8 82.7 11.0 99.2 68.4 34.7 26.5 26.3 85.8 28.5 99.7 50.8 60.4 248 6-23 42.7 61.8 71.7 54.0 95.7 64.4 31.8 19.9 21.4 55.1 39.5 97.2 34.2 42.2 964 Total 36.3 55.3 60.1 35.9 75.5 50.4 25.0 16.2 17.1 46.8 29.1 76.9 28.6 35.0 1,597 NON-BREASTFEEDING CHILDREN 9-11 (80.8) (92.3) (85.7) (65.3) (98.8) (81.1) (54.7) (26.4) (31.9) (65.2) (58.5) (98.8) (39.9) (58.3) 27 12-17 70.6 88.5 74.0 47.0 99.1 79.2 45.0 31.3 39.4 64.7 52.4 100.0 45.0 39.6 83 18-23 54.3 85.4 78.9 33.7 96.8 61.6 41.3 15.8 32.2 67.7 47.8 99.2 40.6 37.8 134 24-35 32.1 78.2 85.1 11.9 99.2 79.5 41.5 21.4 29.5 82.7 33.6 100.0 53.3 60.1 345 6-23 64.7 86.8 76.9 44.5 97.9 69.3 42.9 21.3 33.6 64.1 50.3 99.5 40.4 40.4 266 Total 46.7 81.9 81.2 25.9 97.5 73.2 41.1 20.8 30.5 72.7 40.9 98.5 46.5 50.4 626 Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases. 1 Other milk includes fresh, tinned, and powdered cow or other animal milk 2 Does not include plain water 3 Includes fortified baby food 4 Includes pumpkin, orange or yellow squash, carrots, sweet potatoes, dark green leafy vegetables, mangoes, and papayas Nutrition of Children and Women | 125 Of particular concern is the fact that the majority (68-80 percent) of breastfed children age 6- 23 months did not consume any food made from roots and tubers, food made from legumes and nuts, or other fruits and vegetables during the 24-hour period before the survey. Roots and tubers include white potatoes, white yams, manioc, cassava, or any other foods made from roots. Legumes and nuts include beans, peas, lentils, or nuts. The majority of children age 6-23 months also did not consume cheese, yogurt, and other milk products or food made with oil, fat, or butter. The patterns are similar for non-breastfeeding children. Non-breastfeeding children consume milk other than breast milk more often than breastfeeding children (87 percent compared with 62 percent). 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Appropriate infant and young child feeding (IYCF) practices include timely initiation of feeding solid/semi-solid foods from age 6 months and increasing the amount and variety of foods and frequency of feeding as the child gets older while maintaining frequent breastfeeding. Guidelines have been established with respect to IYCF practices for children age 6-23 months (PAHO/WHO, 2003 and WHO, 2005). Table 11.6 presents a summary indicator of IYCF practices. The indicator takes into account the percentages of children for whom feeding practices met minimum standards with respect to food diversity (i.e., the number of food groups consumed) and feeding frequency (i.e., the number of times the child was fed), as well the consumption of breast milk or other milks or milk products. Breastfed children are considered fed by the minimum standards if they consume at least three food groups1 and receive foods other than breast milk at least twice per day in the case of infants 6-8 months and at least three times per day in the case of children 9-23 months. Non-breastfed children are considered to be adequately fed if they consume milk or milk products, eat from four food groups (including milk products), and are fed at least four times per day. Data in Table 11.6 show that 98 percent of youngest children age 6-23 months living with the mother received breast milk or breast milk substitutes during the 24-hour period prior to the survey. Seventy-two percent had an adequately diverse diet; that is, they had been fed foods from the appropriate number of food groups depending on their age and breastfeeding status. Seventy-four percent had been fed the minimum standard number of times appropriate for their age. Feeding practices for about 58 percent of children age 6-23 months met the minimum standard with respect to all three of these feeding practices (Figure 11.3). The proportion fed according to the guidelines is much higher among breastfed children (63 percent) than among those who are not breastfed (40 percent). Among breastfed children age 6-23 months, 74 percent receive foods from at least three food groups, while 80 percent are fed the minimum number of times or more. Among non-breastfed children age 6-23 months, 92 percent receive milk or milk products, 67 percent are fed foods from at least four food groups, and 50 percent are fed four or more times per day. 1 Food groups used in the assessment of minimum standard of feeding practices include milk other than breast milk, foods made from grains, roots, and tubers; fruits and vegetables rich in vitamin A; other fruits and vegetables; eggs; meat, poultry, fish, and shellfish (and organ meats); beans, peas, and nuts; and foods made with oil, fat, or butter. 126 | Nutrition of Children and Women Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based upon number of food groups and times they are fed during the day or night preceding the survey by breastfeeding status and background characteristics, Maldives 2009 Among breastfed children 6-23 months, percentage fed: Among non-breastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: Background characteristic 3+ food groups1 Mini- mum times or more2 Both 3+ food groups and minimum times or more Number of breastfed children 6-23 months Milk or milk products3 4+ food groups 4+ times or more With 3 IYCF practices4 Number of non- breastfed children 6-23 months Breast milk or milk products3 3+ or 4+ food groups5 Mini- mum times or more6 With all 3 IYCF practices Number of all children 6-23 months Age in months 6-8 43.5 74.7 39.8 204 * * * * 21 99.1 43.4 70.5 37.2 225 9-11 72.0 81.1 61.2 185 (94.2) (71.7) (59.3) (38.1) 27 99.3 72.0 78.3 58.3 213 12-17 83.8 82.0 69.7 295 95.6 74.6 48.3 40.1 83 99.0 81.8 74.5 63.2 378 18-23 85.4 82.1 72.3 280 90.1 66.0 52.5 44.5 134 96.8 79.1 72.5 63.3 414 Sex Male 75.4 74.5 59.5 475 89.8 65.1 48.7 35.7 146 97.6 73.0 68.4 53.9 621 Female 71.7 85.9 65.4 489 95.3 70.3 51.8 45.1 120 99.1 71.4 79.2 61.4 609 Residence Urban 64.4 82.6 55.2 264 (90.2) (74.9) (55.5) (53.4) 105 97.2 67.4 74.9 54.6 369 Rural 76.9 79.4 65.3 700 93.6 62.6 46.6 31.2 161 98.8 74.2 73.3 58.9 860 Region Malé 64.4 82.6 55.2 264 (90.2) (74.9) (55.5) (53.4) 105 97.2 67.4 74.9 54.6 369 North 82.9 80.5 70.0 185 * * * * 22 100.0 83.6 76.6 66.5 207 North Central 72.6 79.3 64.8 146 (96.6) (65.1) (46.1) (33.1) 23 99.5 71.6 74.8 60.5 169 Central 68.6 73.3 54.3 89 (89.5) (58.5) (50.0) (26.4) 22 97.9 66.6 68.6 48.8 111 South Central 80.2 81.2 69.8 117 94.1 56.1 52.8 37.2 30 98.8 75.2 75.4 63.1 147 South 76.3 80.4 63.1 162 91.5 56.8 43.5 27.0 63 97.6 70.8 70.0 53.0 226 Mother's education No formal education 74.1 75.6 59.3 101 (90.9) (64.6) (39.4) (25.7) 29 98.0 72.0 67.6 51.9 130 Primary 74.5 76.5 61.7 295 93.1 71.1 52.7 42.1 53 98.9 74.0 72.8 58.7 348 Secondary 72.5 82.1 62.5 523 93.3 63.9 46.9 37.6 150 98.5 70.6 74.3 56.9 673 More than secondary (73.8) (92.6) (71.8) 33 * * * * 33 93.6 77.7 82.2 66.5 65 Wealth quintile Lowest 73.5 77.5 62.5 196 (91.8) (63.9) (56.0) (38.1) 32 98.8 72.1 74.5 59.0 229 Second 74.4 80.7 62.0 215 92.8 57.9 45.6 24.7 46 98.7 71.5 74.5 55.4 262 Middle 79.6 80.1 67.9 207 93.4 62.9 43.8 30.4 54 98.6 76.1 72.6 60.1 262 Fourth 68.8 82.3 59.4 170 90.1 74.0 50.7 47.5 65 97.3 70.2 73.6 56.1 235 Highest 69.7 81.1 59.9 175 (93.4) (73.1) (54.9) (51.6) 68 98.1 70.7 73.8 57.6 243 Total 73.5 80.3 62.5 964 92.3 67.4 50.1 39.9 266 98.3 72.2 73.8 57.6 1,229 Note: Total includes cases for which information on mother’s formal education level is missing. 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. 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge, fortified baby food from grains; c. vitamin A-rich fruits and vegetables; d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts; h. foods made with oil, fat, butter. 2 At least twice a day for breastfed infants 6-8 months and at least three times a day for breastfed children 9-23 months 3 Includes commercial infant formula; fresh, tinned, and powdered animal milk; and cheese, yogurt, and other milk products 4 Non-breastfed children age 6-23 months are considered to be fed with a minimum standard of three Infant and Young Child Feeding practices if they receive other milk or milk products and are fed at least the minimum number of times per day with at least the minimum number of food groups. 5 3+ food groups for breastfed children and 4+ food groups for non-breastfed children 6 Fed solid or semi-solid food at least twice a day for infants 6-8 months, 3+ times a day for other breastfed children, and 4+ times for non-breastfed children Nutrition of Children and Women | 127 11.7 MICRONUTRIENT INTAKE AMONG CHILDREN Table 11.7 summarises information collected in the 2009 MDHS on the intake of food rich in vitamin A and iron by youngest children and on the receipt of a vitamin A supplement and de- worming medication by all children. Vitamin A is an essential micronutrient for the immune system that plays an important role in maintaining the epithelial tissue in the body. Severe Vitamin A Deficiency (VAD) can cause eye damage. Deficiency also can increase severity of infections, such as measles and diarrhoeal diseases in children, and can slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Periodic dosing (usually every six months) with vitamin A supplement is one method of ensuring that children at risk do not develop VAD. The MDHS collected information on the consumption of foods rich in vitamin A and on the coverage of supplements. Table 11.7 shows that 82 percent of last-born children living with the mother consumed foods rich in vitamin A in the 24-hour period before the survey. Consumption of foods rich in vitamin A increases from 53 percent among children age 6-8 months to 91 percent among children age 24-35 months. There is no gender difference in the consumption of foods rich in vitamin A. Not surprisingly, breastfeeding children (80 percent) consume foods rich in vitamin A much less frequently than non-breastfeeding children (87 percent). There is not much variation by urban-rural residence in the consumption of vitamin A-rich foods. With regard to regions, children living in the North region (88 percent) consume foods rich in vitamin A more often than children in other regions. Children of young mothers (15-19) consume food rich in vitamin A (86 percent) at higher rates than children of older mothers. No systematic relation is observed between children's consumption of vitamin A-rich food and the mother’s education or wealth status. 63 40 58 37 60 42 Breastfed children Non-breastfed children All children age 6-23 months 0 20 40 60 80 100 Percentage of all children 6-23 months Fed with all 3 IYCF practices Not fed with all IYCF practices Figure 11.3 Infant and Young Child Feeding (IYCF) Practices MDHS 2009 128 | Nutrition of Children and Women Table 11.7 Micronutrient intake among children Among youngest children age 6-35 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey, and among all children age 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, and who were given de-worming medication in the six months preceding the survey, by background characteristics, Maldives 2009 Among youngest children age 6-35 months living with the mother: Among all children age 6-59 months: Background characteristic Percentage who consumed foods rich in vitamin A in past 24 hours1 Percentage who consumed foods rich in iron in past 24 hours2 Number of children Percentage given vitamin A supplements in past 6 months Percentage given de- worming medication in past 6 months3 Number of children Age in months 6-8 53.2 15.4 225 11.9 7.0 227 9-11 76.2 49.5 213 46.7 23.9 214 12-17 85.4 67.6 378 59.0 58.8 387 18-23 85.3 73.8 414 46.3 78.1 436 24-35 90.8 84.0 593 49.6 83.9 686 36-47 na na 0 52.0 81.1 678 48-59 na na 0 50.0 74.9 649 Sex Male 81.1 64.6 917 48.9 66.9 1,668 Female 83.1 67.0 905 47.2 70.3 1,608 Breastfeeding status Breastfeeding 79.8 61.4 1,212 49.4 57.1 1,343 Not breastfeeding 86.7 75.2 600 47.3 76.8 1,872 Residence Urban 79.8 59.9 547 27.4 64.4 968 Rural 83.1 68.3 1,275 56.7 70.3 2,308 Region Malé 79.8 59.9 547 27.4 64.4 968 North 87.6 70.0 293 59.1 70.7 517 North Central 83.9 67.1 253 59.0 73.3 481 Central 79.2 69.4 163 63.5 81.7 296 South Central 81.9 69.7 228 59.7 70.7 390 South 81.2 66.3 337 47.9 62.1 624 Mother's education No formal education 81.8 68.5 193 58.4 75.1 415 Primary 81.3 67.1 578 55.0 72.4 1,204 Secondary 81.8 63.6 930 41.9 63.7 1,476 More than secondary 88.4 70.7 98 27.4 68.7 142 Mother's age at birth 15-19 85.9 73.8 65 37.0 62.6 147 20-29 82.0 65.4 1,187 47.0 69.0 2,115 30-39 82.3 66.0 521 51.5 68.0 926 40-49 78.9 61.4 48 54.6 72.6 88 Wealth quintile Lowest 80.6 66.7 329 59.0 74.1 633 Second 82.8 68.4 389 58.5 69.2 701 Middle 83.7 68.1 396 56.1 71.0 697 Fourth 82.1 67.7 353 35.5 65.5 652 Highest 81.0 57.7 356 28.4 62.4 593 Total 82.1 65.8 1,822 48.1 68.6 3,276 Note: Information on vitamin A and de-worming medication is based on the mother's recall. Total includes cases for which information on breastfeeding status and for which information on mother’s formal education level is missing. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mango, and papaya 2 Includes meat, (including organ meat) ,fish, poultry, and eggs 3 De-worming for intestinal parasites is commonly done for helminths and for schistosomiasis. Iron is essential for cognitive development. Low iron intake can contribute to anaemia. Iron requirements are greatest between age 6 and 11 months, when growth is most rapid. Table 11.7 shows that 66 percent of the youngest children age 6-35 months who live with their mother consumed foods rich in iron in the 24 hours preceding the interview. The proportion of children who are fed foods rich in iron increases with age, from 15 percent among children age 6-8 months to 84 percent among children age 24-35 months. Nutrition of Children and Women | 129 As expected, breastfeeding children (61 percent) consume iron-rich foods less often than those not breastfeeding (75 percent). Urban children (60 percent) are less likely than rural children (68 percent) to receive iron-rich foods. By region, the proportion of children who consume iron-rich foods ranges from 60 percent in Malé to 70 percent in the North and the South Central regions. Consumption of iron-rich foods is highest among children whose mothers were age 15-19 years at the time of their birth. The proportion of children who are fed foods rich in iron does not vary systematically with the mother’s level of education and wealth status. The 2009 MDHS also collected information on vitamin A supplementation. As shown in Table 11.7, almost half of the children (48 percent) age 6-59 months received vitamin A supplements in the six months preceding the survey. Children ages 6-8 months and urban children have low rates of vitamin A supplementation in the six months preceding the survey (12 percent and 27 percent, respectively). A mother’s level of education is negatively associated with children receiving vitamin A supplements; 58 percent of children of mothers with no formal education received vitamin A supplements in the past six months compared with 27 percent of children whose mothers have more than secondary education. The proportion of children who receive vitamin A supplements increased with mothers’ age at birth and decreased with household wealth status. The proportion of children in the lowest and second wealth quintile who received vitamin A supplement is 59 percent, compared with 28 percent of children in the highest wealth quintile. Infection with helminths or intestinal worms has been shown to have an adverse impact on the physical development of children and is associated with high levels of iron deficiency anaemia and other nutritional deficiencies. Regular treatment with de-worming medication is a simple, cost effective measure to address these infections. Table 11.7 shows that more than two-thirds of children age 6-59 months received de-worming medication during the six months preceding the survey. The proportion of children who receive de-worming medication increases with age, from 7 percent among children age 6-8 months to 84 percent among children age 24-35 months, before declining among children age 36 months and older. The proportion of children who receive de- worming medication is much higher among non-breastfeeding children (77 percent) than among those who are breastfeeding (57 percent). By region, the proportion of children who received de-worming medication is highest in the Central region (82 percent) and lowest in the South region (62 percent). The rate of de-worming medication decreases with increase in the mother’s level of education and household wealth quintile. 11.8 NUTRITIONAL STATUS OF WOMEN Anthropometric measurements of height and weight were collected for women age 15-49. In this report, two indicators of nutritional status based on these data are presented: the percentage of women with very short stature (less than 145 cm) and the body mass index (BMI). The body mass index (BMI), or the Quetelet index, is used to measure thinness and obesity. BMI is defined as weight in kilograms divided by height in metres squared (kg/m2). A cut-off point of 18.5 is used to define thinness or acute undernutrition, and a BMI of 25.0 or above usually indicates overweight or obesity. The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. Low pre-pregnancy BMI and short stature are risk factors for poor birth outcomes and obstetric complications. In developing countries, maternal underweight is the leading risk factor for preventable deaths and diseases. Table 11.8 shows the percentage of women with height under 145 cm, the mean BMI, and the proportion of women falling into high-risk categories, according to background characteristics. Respondents for whom there was no information on height or weight and for whom a BMI could not be estimated are excluded from this analysis. The data analysis of height is based on 5,694 women, and the analysis of BMI is based on 5,173 women. 130 | Nutrition of Children and Women Table 11.8 shows that 12 percent of women have short stature (below 145 cm). Short stature increases with age, is higher in rural areas, and decreases with increasing level of education and wealth status. The percentage of women with height under 145 cm ranges from 18 percent among women with no formal education to 6 percent among women with more than secondary education. Short stature ranges from 8 percent in the Central region to 18 percent in the South region. Table 11.8 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Maldives 2009 Body Mass Index1 Normal Thin Overweight/obese Background characteristic Mean Body Mass Index (BMI) 18.5- 24.9 (total normal) <18.5 (total thin) 17.0- 18.4 (mildly thin) <17 (moder- ately and severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of women Height Percent- age below 145 cm Number of women Age 15-19 8.4 88 21.9 52.7 23.7 11.1 12.6 23.5 20.7 2.8 69 20-29 8.0 2,211 23.4 54.2 13.4 8.1 5.3 32.4 23.6 8.8 1,877 30-39 11.6 2,012 25.3 46.7 4.0 2.8 1.2 49.3 36.1 13.3 1,863 40-49 19.6 1,383 26.3 37.5 3.2 1.8 1.4 59.3 40.0 19.3 1,364 Residence Urban 10.4 1,805 25.3 43.5 5.3 3.3 2.0 51.2 36.9 14.4 1,657 Rural 12.9 3,889 24.6 48.8 8.5 5.2 3.3 42.8 30.2 12.5 3,516 Region Malé 10.4 1,805 25.3 43.5 5.3 3.3 2.0 51.2 36.9 14.4 1,657 North 8.6 897 24.1 49.8 11.3 6.6 4.6 39.0 28.8 10.2 809 North Central 13.6 998 24.9 44.8 8.2 4.7 3.5 46.9 33.4 13.5 903 Central 7.8 496 24.9 47.1 6.9 4.0 2.9 46.0 32.4 13.6 440 South Central 14.4 657 24.5 51.5 8.6 5.7 2.9 40.0 28.4 11.6 604 South 18.3 841 24.7 51.2 6.7 4.4 2.3 42.1 28.2 13.9 761 Education No formal education 18.2 1,392 25.9 41.7 4.2 2.4 1.9 54.0 34.8 19.3 1,345 Primary 12.1 2,001 25.1 45.3 5.9 3.8 2.1 48.8 35.7 13.1 1,840 Secondary 8.6 2,003 23.7 53.2 11.4 7.3 4.1 35.4 26.6 8.9 1,724 More than secondary 5.5 233 24.2 47.0 9.1 2.3 6.9 43.9 35.5 8.3 203 Wealth quintile Lowest 14.4 1,055 24.4 49.1 10.4 6.3 4.0 40.6 28.4 12.1 963 Second 13.3 1,127 24.8 46.6 9.0 5.9 3.1 44.4 31.0 13.4 1,030 Middle 12.5 1,226 24.5 50.7 7.0 3.7 3.3 42.4 31.4 11.0 1,097 Fourth 10.5 1,130 25.3 42.7 5.5 2.9 2.6 51.8 37.0 14.9 1,027 Highest 9.9 1,156 25.1 46.3 5.7 4.3 1.5 48.0 33.8 14.2 1,057 Total 12.1 5,694 24.8 47.1 7.5 4.6 2.9 45.5 32.4 13.1 5,173 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). Total includes cases for which information on mother’s formal education level is missing. 1 Excludes pregnant women and women with a birth in the preceding 2 months Almost one in two women (47 percent) has a normal BMI. The proportion of women with a normal BMI decreases with age from 53 percent among women age 15-19 to 38 percent among women age 40-49. Small differences are found across other subgroups of women. Eight percent of women were found to be underweight (BMI less than 18.5), and 46 percent were overweight or obese (BMI 25 or higher). Women age 15-19 are the thinnest compared with older women. Higher rates of underweight women are found in rural areas than in urban areas (9 percent and 5 percent, respectively). Nutrition of Children and Women | 131 On the other hand, the percentage of overweight or obese women is higher in urban areas (51 percent) than in rural areas (43 percent). Malé (51 percent), North Central region (47 percent), and Central region (46 percent) have the highest percentages of overweight or obese women, and the North region has the lowest percentage (39 percent). Overweight and obesity decrease with increasing level of education. For example, 54 percent of women with no formal education are overweight or obese compared with 44 percent of women with more than secondary education. Women in the lowest wealth quintile also have the lowest rates of overweight or obesity. 11.9 FOODS CONSUMED BY MOTHERS The quality and quantity of foods consumed by mothers influence their health and that of their children, especially the health of breastfeeding children. The 2009 MDHS included questions on the types of food consumed by mothers with children under age 3 during the day and night preceding the interview. Table 11.9 shows that approximately nine in ten mothers of young children in Maldives consume foods made of grain and eat meat, fish, shellfish, poultry, or eggs. Two in three women eat vitamin A-rich fruits and vegetables; about one in two eats foods made with oil, fats, or butter; 44 percent of women consume sugary foods; 40 percent consume other solid or semi-solid food; and 35 percent consume other fruits and vegetables. One in four women consumes foods made of roots or tubers and legumes, and 13 percent consume cheese and yogurt. The consumption of foods varies according to background characteristics. Consumption of milk, other liquids, and other solid or semi-solid food decreases with age, and intake of tea/coffee, foods made from grains, and foods made from roots/tubers increases with age. The consumption of milk, tea/coffee, other solid or semi-solid food and food made with oil/fat/butter is higher in rural areas than in urban areas, while the consumption of other liquids, food made from roots/tubers, legumes, cheese/yogurt, and other fruits and vegetables is higher in urban areas. As women’s education increases, the consumption of legumes, cheese/yogurt, vitamin A-rich fruits and vegetables, other fruits and vegetables, other solid or semi-solid food, foods made with oil, fat, and butter, and sugary foods also increases. Finally, the rates of consumption of legumes, cheese/yogurt, and other fruits and vegetables increases with each wealth quintile. 132 | Nutrition of Children and Women Table 11.9 Foods consumed by mothers in the day and night preceding the interview Among mothers age 15-49 with a child under age three years living with them, the percentage who consumed specific types of foods in the day or night preceding the interview, by background characteristics, Maldives 2009 Solid or semi-solid foods Background characteristic Foods made from grains1 Foods made from roots/ tubers Foods made from legumes Meat/ fish/ shellfish/ poultry/ eggs Cheese/ yogurt Vitamin A-rich fruits/ vege- tables1 Other fruits/ vege- tables Other solid or semi- solid food Foods made with oil/ fat/ butter Sugary foods Number of women Liquids Milk Tea/ coffee Other liquids Age 15-19 * * * * * * * * * * * * * 25 20-29 59.4 62.1 75.5 90.5 22.7 23.8 86.9 14.2 66.9 34.2 42.5 48.3 44.7 1,356 30-39 55.4 67.2 71.7 92.3 24.7 26.3 85.2 12.4 68.0 35.4 36.0 50.9 40.9 737 40-49 44.0 72.7 63.2 95.3 30.7 25.7 91.5 11.7 64.8 42.6 31.4 38.8 45.7 105 Residence Urban 53.2 54.5 77.2 91.4 25.9 29.6 85.7 19.3 67.8 41.1 36.5 44.9 42.0 685 Rural 59.3 68.7 72.5 91.3 22.6 22.3 87.1 10.9 66.7 32.1 41.2 50.4 44.3 1,538 Region Malé 53.2 54.5 77.2 91.4 25.9 29.6 85.7 19.3 67.8 41.1 36.5 44.9 42.0 685 North 60.4 70.7 72.7 93.8 26.9 28.7 88.0 8.8 69.5 33.1 42.4 58.2 45.7 348 North Central 57.0 71.7 60.3 92.9 22.2 22.3 89.1 9.1 68.1 34.3 37.1 48.6 47.8 303 Central 57.6 63.8 77.5 91.6 17.3 18.1 86.8 12.9 61.5 31.7 49.3 45.6 46.3 205 South Central 55.2 65.5 77.4 89.9 22.5 16.4 88.7 5.8 60.6 30.2 30.5 50.5 30.8 279 South 63.9 69.6 75.5 88.9 21.9 23.0 83.7 16.4 70.1 31.3 46.4 47.2 48.7 404 Education No formal education 51.6 73.0 60.1 91.7 19.6 18.2 85.0 9.2 60.9 26.1 30.7 43.7 38.8 220 Primary 52.3 67.2 73.2 90.5 25.8 22.6 87.3 9.8 64.2 33.0 38.5 48.8 41.4 714 Secondary 61.9 60.8 76.7 91.5 21.5 25.4 86.3 14.6 69.0 36.5 40.1 48.2 44.8 1,135 More than secondary 53.1 63.7 75.7 94.4 35.7 39.6 88.6 31.5 75.5 48.1 57.2 57.2 53.9 129 Wealth quintile Lowest 50.4 71.8 70.2 92.5 23.7 20.5 88.9 8.0 63.2 27.4 36.5 48.0 39.1 393 Second 57.4 66.8 70.9 90.9 21.5 21.1 86.0 8.4 65.3 31.1 38.3 48.2 45.4 473 Middle 62.7 67.2 75.2 90.6 20.2 22.9 86.3 11.8 68.5 33.4 45.8 50.6 42.3 471 Fourth 58.6 60.6 77.1 90.3 24.1 27.1 86.4 16.4 71.4 40.8 38.7 48.6 44.5 445 Highest 56.9 56.0 76.0 92.7 28.9 31.1 86.0 22.5 66.4 41.4 38.7 47.6 45.9 441 Total 57.4 64.4 73.9 91.4 23.6 24.6 86.6 13.4 67.0 34.9 39.7 48.7 43.6 2,223 Note: Foods consumed in the past 24-hour period (yesterday and last night). Total includes cases for which information on mother’s formal education level is missing. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes pumpkin, orange or yellow squash, carrots, sweet potatoes, dark green leafy vegetables, mangoes, and papayas 11.10 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects mother and infant against anaemia. Anaemia may lead to an increased risk of premature delivery and low birthweight. Table 11.10 lists measures that help assess the extent to which women receive adequate intake of vitamin A and iron during pregnancy. About 93 percent of these mothers eat foods rich in vitamin A, and 87 percent eat iron-rich foods. In general the consumption of vitamin A and iron-rich foods is high and does not vary much by background characteristics. Nutrition of Children and Women | 133 Table 11.10 shows that 52 percent of women with children born in the five years preceding the survey received a dose of vitamin A in the first two months after the birth of the last child. Postpartum vitamin A supplementation is higher among rural women (55 percent) than among urban women (45 percent). By region, the proportion of women who received postpartum vitamin A supplementation ranges from 45 percent in Malé to 61 percent in the North Central region. Post- partum vitamin A supplementation is lowest among women with more than secondary education and women in the highest wealth quintile (32 percent and 44 percent, respectively). Table 11.10 Micronutrient intake among mothers Among women age 15-49 with a child under age three years living with her, the percentages who consumed vitamin A-rich and iron-rich foods in the 24 hours preceding the survey; among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child; among mothers age 15-49 who during the pregnancy of the last child born in the five years prior to the survey, the percentage who suffered from night blindness, the percentage who took iron tablets for specific numbers of days, and the percentage who took de-worming medication, by background characteristics, Maldives 2009 Women with children under three years living with them Women with children under five years Percentage of women who took de- worming medication during pregnancy for last birth Per- centage who received vitamin A dose post- partum3 Number of days iron tablets or syrup taken during pregnancy for last birth Percent- age con- sumed vitamin- A rich foods1 Percent- age con- sumed iron- rich foods2 Percentage who had night blindness during pregnancy for last birth Number of women 60-89 Don’t know/ missing Number of women Background characteristic None <60 Reported Adjusted4 90+ Age 15-19 * * 25 (61.6) (0.0) (0.0) (17.7) (6.9) (1.6) (60.2) (13.6) (12.6) 27 20-29 93.1 86.9 1,356 53.0 3.4 1.8 8.9 6.7 1.8 67.2 15.4 13.0 1,758 30-39 91.8 85.2 737 49.3 1.5 1.0 10.1 6.4 1.2 61.7 20.6 15.1 1,183 40-49 97.0 91.5 105 58.1 6.3 4.8 12.6 5.7 1.4 58.4 21.9 25.1 222 Residence Urban 92.0 85.7 685 45.1 3.0 1.8 8.8 4.4 0.8 61.8 24.2 6.8 964 Rural 93.3 87.1 1,538 55.1 2.7 1.7 10.0 7.4 1.9 65.6 15.0 18.0 2,227 Region Malé 92.0 85.7 685 45.1 3.0 1.8 8.8 4.4 0.8 61.8 24.2 6.8 964 North 96.1 88.0 348 48.9 1.8 0.9 9.0 6.2 1.6 62.6 20.6 12.3 489 North Central 93.9 89.1 303 61.3 3.7 2.1 7.5 10.6 2.4 69.3 10.2 23.9 466 Central 91.5 86.8 205 55.8 2.3 0.8 8.9 8.9 2.5 69.8 9.9 21.2 293 South Central 92.4 88.7 279 51.9 2.7 1.6 10.4 9.8 1.6 54.6 23.6 18.4 390 South 92.1 83.7 404 57.0 3.1 2.5 13.3 3.6 1.6 70.5 11.0 16.3 589 Education No formal education 92.2 85.0 220 53.6 4.6 3.8 15.2 6.9 1.6 52.9 23.5 23.7 396 Primary 93.0 87.3 714 55.8 2.5 1.1 11.9 7.7 1.8 61.5 17.1 19.7 1,143 Secondary 93.1 86.3 1,135 51.1 2.9 1.7 7.4 6.0 1.5 68.4 16.8 9.3 1,456 More than secondary 91.7 88.6 129 32.4 0.9 0.9 2.4 2.0 1.6 78.1 15.9 6.4 156 Wealth quintile Lowest 94.2 88.9 393 53.4 4.0 2.9 12.3 7.1 2.6 60.2 17.7 22.4 595 Second 92.1 86.0 473 55.2 2.8 1.6 10.0 7.9 1.5 66.0 14.6 20.2 677 Middle 94.5 86.3 471 55.3 2.3 1.1 8.5 7.9 1.8 67.1 14.7 15.0 677 Fourth 92.8 86.4 445 51.6 2.4 1.7 9.9 5.3 0.7 66.8 17.3 10.5 643 Highest 91.1 86.0 441 44.1 2.7 1.4 7.7 4.0 1.3 61.4 25.5 4.7 599 Total 92.9 86.6 2,223 52.1 2.8 1.7 9.7 6.5 1.6 64.5 17.8 14.6 3,190 Note: Total includes cases for which information on mother’s formal education level is missing. 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. 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, mango, and papaya 2 Includes meat (and organ meat), fish, poultry, eggs 3 In the first two months after delivery 4 Women who reported night blindness but did not report difficulty with vision during the day 5 De-worming for intestinal parasites is commonly done for helminths and for schistosomiasis 134 | Nutrition of Children and Women Only 3 percent of women said that they had experienced night blindness while pregnant with their youngest child. After adjusting this figure for women who also reported vision problems during the day, only 2 percent of women are estimated to have experienced VAD-related night blindness during pregnancy. To boost iron, 65 percent of women took iron supplements during pregnancy for 90 days or more. Seven percent took iron tablets for fewer than 60 days and 10 percent did not take any iron supplements at all. The percentage of women who took iron supplements for 90 days or more is highest among women age 20-29 (67 percent), rural women (66 percent), and those with more than a secondary level of education (78 percent). By region, this proportion ranges from 55 percent in the South Central region to 71 percent in the South region. To treat intestinal worms, 15 percent of the women took de-worming medication while pregnant with the last child in the five years preceding the survey. The use of de-worming medication during pregnancy is highest among women age 40-49 (25 percent), rural women (18 percent), women residing in the North central region (24 percent), women with no formal education (24 percent), and women in the lowest wealth quintile (22 percent). HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 135 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 12 Acquired Immune Deficiency Syndrome (AIDS) is caused by the human immunodeficiency virus (HIV). As the virus weakens the immune system, the body becomes susceptible to and unable to recover from other opportunistic diseases that may lead to death through secondary infection. The predominant mode of HIV transmission is through heterosexual contact, followed in frequency by perinatal transmission, in which the mother passes the virus to the child during pregnancy, delivery, or breastfeeding. Other modes of transmission are through infected blood and unsafe injections. The spread of the AIDS epidemic depends on a number of variables, including the level of HIV/AIDS-related knowledge among the general population; social stigmatization; risk behaviour modification; access to high-quality services for sexually transmitted infections (STIs); provision and uptake of HIV counselling and testing; and access to care and antiretroviral therapy (ART). The principal objective of this chapter is to establish the preva- lence of relevant knowledge, perceptions, and behaviours at the national level and also within geographic and socio- economic subpopulations. In this way, prevention pro- grammes can target those groups of individuals most in need of information and most at risk of HIV infection. In this chapter, HIV/AIDS knowledge and attitudes are discussed first. The level of self-reported prevalence of sexually transmitted diseases is then presented. The prevalence of non-sterile injections, which can increase the risk of infection with HIV and other diseases is considered next. The chapter then reviews several indicators for young ever-married women age 15-24 including HIV/AIDS awareness, knowledge of a source for condoms, and trends in the age at first sex. 12.1 HIV/AIDS KNOWLEDGE, TRANSMISSION, AND PREVENTION METHODS 12.1.1 Awareness of HIV/AIDS MDHS respondents were asked whether they had heard of HIV or AIDS. Those who reported having heard of HIV or AIDS were asked a number of questions about whether and how HIV/AIDS could be avoided. Table 12.1 shows that awareness of AIDS is nearly universal (97 per- cent) among ever-married women age 15-49 in the Maldives. At least 94 percent of respondents in all sub- groups shown in the table have heard of AIDS. Table 12.1 Knowledge of AIDS Percentage of ever-married women age 15-49 who have heard of AIDS, by background characteristics, Maldives 2009 Background characteristic Has heard of AIDS Number of women Age 15-24 96.7 1,387 15-19 98.2 119 20-24 96.6 1,268 25-29 97.6 1,539 30-39 97.5 2,471 40-49 95.4 1,734 Marital status Married 97.0 6,500 Divorced/separated/ widowed 95.3 631 Residence Urban 97.5 2,368 Rural 96.6 4,763 Region Malé 97.5 2,368 North 95.0 1,067 North Central 97.8 1,038 Central 97.7 615 South Central 97.0 853 South 96.0 1,190 Education No formal education 94.1 1,668 Primary 96.5 2,464 Secondary 98.5 2,584 More than secondary 100.0 333 Wealth quintile Lowest 95.3 1,300 Second 96.4 1,396 Middle 97.1 1,488 Fourth 97.0 1,447 Highest 98.3 1,499 Total 96.9 7,131 Note: Total includes 81 ever-married women with information missing on level of formal education 136 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 12.1.2 Methods of HIV Prevention AIDS prevention programmes focus their messages and efforts on three important aspects of behaviour: using condoms, staying faithful to one partner, and delaying first sexual intercourse in young persons (i.e., abstinence). Table 12.2 shows the percentage of women who, in response to prompted questions, agreed that specific actions would help an individual to avoid AIDS. Around eight in ten women age 15-49 recognize that using condoms and abstaining from sex are different methods of avoiding HIV infection. Limiting sex to one partner who is not HIV positive is recognized by 9 in 10 women (92 percent) as another way to avoid HIV exposure. Seventy-six percent of women recognize that using condoms and limiting sex to one partner who is not HIV positive are ways to prevent transmission of HIV. Table 12.2 Knowledge of HIV prevention methods Percentage of ever-married women age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is not infected and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Maldives 2009 Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Abstaining from sexual intercourse Number of ever- married women Age 15-24 75.5 91.6 72.5 76.2 1,387 15-19 59.7 90.8 57.1 75.0 119 20-24 77.0 91.7 74.0 76.3 1,268 25-29 82.3 91.5 77.9 79.3 1,539 30-39 82.2 93.3 79.4 82.8 2,471 40-49 75.2 90.0 71.7 80.4 1,734 Marital status Married 79.2 91.9 75.7 80.2 6,500 Divorced/separated/ widowed 80.2 90.5 77.4 80.3 631 Residence Urban 82.4 92.9 79.4 77.5 2,368 Rural 77.7 91.2 74.1 81.5 4,763 Region Malé 82.4 92.9 79.4 77.5 2,368 North 74.8 90.9 72.7 81.7 1,067 North Central 73.1 93.9 70.7 79.8 1,038 Central 81.9 91.0 76.8 82.1 615 South Central 79.4 89.1 73.1 81.4 853 South 80.8 90.7 77.7 82.6 1,190 Education No formal education 72.7 87.8 68.7 78.8 1,668 Primary 79.8 91.3 76.2 80.9 2,464 Secondary 81.4 93.9 78.3 80.3 2,584 More than secondary 88.2 96.5 85.3 80.3 333 Wealth quintile Lowest 74.5 89.1 70.4 79.1 1,300 Second 77.4 91.3 73.9 81.3 1,396 Middle 79.0 92.2 75.5 83.2 1,488 Fourth 79.1 92.2 76.5 79.4 1,447 Highest 85.5 93.7 82.2 77.8 1,499 Total 79.3 91.8 75.9 80.2 7,131 Note: Total includes 81 ever-married women with information missing on level of formal education 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 137 Overall, differentials in the levels of knowledge of the various modes of prevention are not large. The largest differentials tend to be observed across educational levels. For example, 85 percent of women with more than secondary education say that the risk of HIV transmission can be reduced by using condoms and limiting sex to one partner who is not HIV positive; this compares with only 69 percent of women with no formal education. Although knowledge of HIV prevention generally increases with education, there is no clear pattern for knowledge about abstention as a method of prevention. 12.1.3 Rejection of Misconceptions about HIV/AIDS Stigma and discrimination are two of the constraints in the prevention of HIV/AIDS. Stigma and discrimination usually arise from misconceptions about HIV/AIDS. For programme efforts to succeed, therefore, it is important that common misconceptions about HIV/AIDS are corrected. Common misconceptions about AIDS include the idea that HIV-infected people always appear ill and the belief that the virus can be transmitted through mosquito or other insect bites, by sharing food with someone who is infected, or by witchcraft or other supernatural means. Respondents were asked about each of these misconceptions, and the findings are presented in Table 12.3. Two in three women correctly said that a healthy-looking person can have an HIV infection. The highest rates of misconceptions are for mosquito bites (i.e., 74 percent of women say that HIV cannot be transmitted by mosquito bite) and sharing food with a person who has AIDS (i.e., 83 percent of women correctly report that AIDS cannot be transmitted by sharing food with a person who has AIDS). A woman’s level of education and household wealth strongly relate to accurate knowledge about the ways in which HIV can and cannot be transmitted; the level of accurate knowledge about HIV transmission increases with an increase in the level of education and the wealth quintile. Table 12.3 provides an assessment of the level of comprehensive knowledge of HIV prevention and transmission. Comprehensive knowledge is defined as (1) knowing that consistent use of condoms during sexual intercourse and having just one faithful, HIV-negative partner can reduce the chances of getting HIV, (2) knowing that a healthy-looking person can have HIV, and (3) rejecting the two most common local misconceptions about HIV transmission or prevention: that HIV can be transmitted by mosquito bites and by shared food with a person who has HIV or AIDS. The results show that the percentage of respondents with comprehensive knowledge of AIDS among ever- married women is 42 percent. 138 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 12.3 Comprehensive knowledge about AIDS Percentage of ever-married women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Maldives 2009 Percentage of women who say that: Percentage who say that a healthy- looking person can have the AIDS virus and who reject the two most common local misconceptions1 Background characteristic A healthy- looking person can have AIDS AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by super- natural means A person cannot become infected by sharing food with a person who has the AIDS virus Percentage with a comprehensive knowledge about AIDS2 Number of ever- married women Age 15-24 65.3 67.2 83.4 74.7 41.8 35.0 1,387 15-19 69.3 54.7 70.1 62.8 33.3 21.5 119 20-24 64.9 68.4 84.7 75.8 42.6 36.3 1,268 25-29 68.2 78.1 90.6 85.1 53.8 45.5 1,539 30-39 70.5 78.9 92.3 88.3 55.8 48.0 2,471 40-49 63.1 67.4 85.0 81.6 42.2 33.9 1,734 Marital status Married 67.4 73.9 88.6 83.5 49.6 41.5 6,500 Divorced/separated/ widowed 65.2 71.1 87.0 81.3 46.7 41.3 631 Residence Urban 72.3 82.1 92.4 88.5 60.0 50.8 2,368 Rural 64.6 69.5 86.4 80.8 44.0 36.9 4,763 Region Malé 72.3 82.1 92.4 88.5 60.0 50.8 2,368 North 60.3 67.9 84.2 80.2 41.0 35.1 1,067 North Central 69.2 65.1 85.4 79.1 43.9 34.7 1,038 Central 69.9 72.0 86.0 82.5 49.1 42.1 615 South Central 73.0 71.3 87.3 83.1 50.7 41.9 853 South 55.8 72.1 88.9 80.1 39.5 34.3 1,190 Education No formal education 61.1 63.4 82.2 78.0 37.8 29.3 1,668 Primary 65.0 74.4 89.1 83.4 49.6 42.1 2,464 Secondary 70.9 76.9 90.4 85.1 53.0 45.6 2,584 More than secondary 82.3 90.9 97.1 93.3 72.6 61.6 333 Wealth quintile Lowest 62.8 64.7 82.8 77.7 39.3 32.4 1,300 Second 65.0 67.9 86.4 79.4 43.7 36.9 1,396 Middle 66.0 72.6 88.7 82.6 47.3 39.3 1,488 Fourth 68.3 79.1 90.5 85.7 54.2 45.4 1,447 Highest 73.1 82.7 92.9 90.4 60.6 52.1 1,499 Total 67.2 73.7 88.4 83.3 49.3 41.5 7,131 Note: Total includes 81 ever-married women with information missing on level of formal education 1 Two most common local misconceptions: people can get AIDS from mosquito bites and sharing food with a person who has AIDS. 2 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 12.2 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing the level of general knowledge of transmission of HIV from mother to child and reducing the risk of transmission using antiretroviral drugs is critical to reducing mother-to-child transmission of HIV (MTCT). To assess MTCT knowledge, respondents were asked if the virus that causes AIDS can be transmitted from a mother to a child through breastfeeding and whether a mother with HIV can reduce the risk of transmission to the baby by taking certain drugs during pregnancy. To assess the extent of awareness of the ways in which AIDS can be transmitted from a mother to her child, MDHS respondents were asked if the virus that causes AIDS can be transmitted during pregnancy, at delivery, or when breastfeeding. As Table 12.4 shows, 85 percent of ever- married women age 15-49 know the virus can be transmitted from mother to child during pregnancy, HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 139 and 70 percent of the women are aware the virus can be transmitted during delivery. Women are less knowledgeable about HIV transmission by breastfeeding (64 percent). Differentials in the level of awareness of the modes of mother-to-child transmission are also shown in Table 12.4. Knowledge of pregnancy, delivery, and breastfeeding as potential modes of transmission for the HIV virus is generally higher among older women than among their younger counterparts. Awareness of HIV transmission during pregnancy and during delivery by place of residence varies within a small range. However, knowledge that HIV can be transmitted by breastfeeding varies widely by region, ranging from 58 percent in Malé to 70 percent in North Central. Although the pattern is not totally uniform, the level of awareness of pregnancy as a mode of mother-to-child transmission increases with a woman’s educational attainment and her wealth quintile. Knowledge of breastfeeding as a means of HIV transmission, on the other hand, decreases as the woman’s education and wealth increase. Table 12.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of ever-married women who know that HIV can be transmitted from mother to child during pregnancy, during delivery, and by breastfeeding, by background characteristics, Maldives 2009 Percentage who know that HIV can be transmitted: Number of ever-married women Background characteristic During pregnancy During delivery By breastfeeding Age 15-24 81.6 63.4 62.4 1,387 15-19 76.6 57.6 65.9 119 20-24 82.1 64.0 62.1 1,268 25-29 84.1 65.8 58.6 1,539 30-39 89.2 73.5 64.1 2,471 40-49 84.2 73.7 68.3 1,734 Marital status Married 85.7 70.1 63.7 6,500 Divorced/separated/widowed 82.6 68.6 63.1 631 Currently pregnant Pregnant 84.6 66.7 65.8 522 Not pregnant or not sure 85.5 70.2 63.4 6,609 Residence Urban 86.5 70.5 58.3 2,368 Rural 84.9 69.7 66.2 4,763 Region Malé 86.5 70.5 58.3 2,368 North 83.3 66.8 62.5 1,067 North Central 87.8 70.8 69.8 1,038 Central 82.5 70.6 67.1 615 South Central 85.6 69.7 66.3 853 South 84.5 70.9 66.0 1,190 Education No formal education 83.2 71.9 68.4 1,668 Primary 85.1 70.1 63.6 2,464 Secondary 86.1 67.2 61.0 2,584 More than secondary 91.3 77.7 58.4 333 Wealth quintile Lowest 84.1 71.0 68.2 1,300 Second 84.2 69.3 65.8 1,396 Middle 85.1 68.5 67.0 1,488 Fourth 85.6 69.8 59.5 1,447 Highest 87.6 71.2 58.1 1,499 Total 85.4 70.0 63.6 7,131 Note: Total includes 81 ever-married women with information missing on level of formal education 140 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 12.3 ATTITUDES TOWARDS PEOPLE LIVING WITH AIDS Widespread stigma and discrimination in a population can adversely affect both people’s willingness to be tested and their adherence to antiretroviral therapy. Reduction of stigma and discrimination in a population is, thus, an important indicator of the success of programmes targeting HIV and AIDS prevention and control. To assess the level of stigma, survey respondents who had heard of AIDS were asked if they would be willing to care for a relative sick with AIDS in their own households, if they would be willing to buy fresh vegetables from a market vendor who had HIV, if they thought a female or male teacher who has HIV but is not sick should be allowed to continue teaching, and if they would want to keep a family member’s HIV status secret. The results shown in Table 12.5 indicate that most women were willing to care for a relative with AIDS at home (86 percent), buy fresh vegetables from a shopkeeper with AIDS (79 percent), allow a female teacher with AIDS to keep teaching (61 percent), or allow a male teacher with AIDS to keep teaching (59 percent). Three in four women say that they would be open about having an HIV-positive family member. Thirty-seven percent of women express accepting attitudes on all four indicators, indicating that some degree of stigma is associated with HIV/AIDS within Maldivian society. Table 12.5 Accepting attitudes toward those living with HIV/AIDS Among ever-married women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with AIDS, by background characteristics, Maldives 2009 Percentage of women who: Background characteristic Are willing to care for a family member with the AIDS virus in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Say that a male teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Percentage expressing acceptance attitudes on all five indicators Number of ever- married women who have heard of AIDS Age 15-24 85.8 71.6 53.9 52.1 80.1 32.7 1,341 15-19 83.9 68.2 43.8 42.1 88.9 27.4 117 20-24 85.9 72.0 54.9 53.1 79.3 33.2 1,224 25-29 86.8 81.0 60.1 58.6 72.8 35.5 1,503 30-39 84.9 81.7 65.7 62.3 73.5 37.3 2,410 40-49 86.2 78.1 62.3 59.1 79.3 39.8 1,654 Marital status Married 85.6 78.5 61.4 58.9 75.9 36.6 6,307 Divorced/separated/ widowed 87.5 80.7 61.0 57.5 77.7 37.2 601 Residence Urban 84.0 82.6 62.0 59.8 66.8 35.3 2,309 Rural 86.7 76.7 61.1 58.2 80.7 37.3 4,599 Region Malé 84.0 82.6 62.0 59.8 66.8 35.3 2,309 North 84.9 76.3 62.1 59.7 79.3 36.2 1,013 North Central 84.7 74.4 58.8 56.0 77.8 33.1 1,015 Central 88.2 77.6 58.5 56.2 78.9 36.8 601 South Central 92.1 79.5 65.3 62.4 80.3 42.0 827 South 85.1 76.8 60.4 56.9 85.6 38.7 1,142 Education No formal education 86.1 75.0 61.3 58.6 82.1 38.8 1,571 Primary 85.8 79.4 62.7 59.2 79.5 38.6 2,377 Secondary 84.9 79.0 58.9 57.0 72.5 34.4 2,546 More than secondary 89.4 87.6 67.3 65.7 51.3 28.7 333 Wealth quintile Lowest 85.6 74.2 59.8 57.5 81.7 36.2 1,239 Second 86.6 75.9 60.3 57.1 82.7 37.8 1,346 Middle 86.9 79.5 63.4 60.5 79.8 39.4 1,444 Fourth 85.0 79.1 59.0 56.7 72.8 33.5 1,404 Highest 84.8 84.0 64.0 61.6 64.5 36.1 1,474 Total 85.8 78.7 61.4 58.8 76.0 36.6 6,908 Note: Total includes 81 ever-married women with information missing on level of formal education HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 141 12.4 KNOWLEDGE OF A SOURCE FOR HIV TESTING Another important aspect of AIDS awareness assessed in the 2009 MDHS is the level of knowledge of a place where HIV testing is available. Table 12.6 shows that 82 percent of women age 15-49 know where to go for an HIV test. Knowledge of a source where HIV testing is available is highest among currently married women, women living in urban areas, and Malé residents. Knowledge of a place for HIV testing is directly related to the woman’s level of education and wealth. For example, 76 percent of women in the lowest wealth quintile know where to obtain HIV testing compared with 90 percent of women in the highest wealth quintile. 12.5 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS In the 2009 MDHS, respondents who had ever had sex were asked if they had had a disease they had contracted through sexual contact in the previous 12 months or if they had had either of two symptoms associated with sexually transmitted infections (STIs)— a bad-smelling, abnormal discharge from the vagina or a genital sore or ulcer. Table 12.7 shows the self-reported prevalence of STIs and STI symptoms among ever- married women age 15-49. One percent of women who have ever been sexually active had an STI and/or an STI symptom in the 12 months preceding the survey, 7 percent reported having a bad-smelling genital dis- charge, and 12 percent had a genital sore or ulcer. The prevalence of an STI or STI symptom is 15 percent. The prevalence of a self-reported STI or STI symptom is higher among women under age 25 compared to older women and among married women compared with divorced/separated/widowed women. Across regions, the prevalence of STI and/or symptoms of STI ranges from 13 percent in Malé, North, and South regions to 19 percent in North Central and Central regions. Among women who report having an STI or symptoms of an STI, more than four in five sought help from a clinic, hospital, or private doctor/other health professional. About one in six did not seek advice or treatment (data not shown). Table 12.6 Knowledge of place for HIV testing Percentage of ever-married women age 15-49 who know where to get an HIV test, according to background characteristics, Maldives 2009 Background characteristic Percentage who know where to get an HIV test1 Number of ever-married women Age 15-24 83.2 1,387 15-19 77.6 119 20-24 83.7 1,268 25-29 85.1 1,539 30-39 83.9 2,471 40-49 76.6 1,734 Marital status Married 82.5 6,500 Divorced/separated/ widowed 79.9 631 Residence Urban 88.1 2,368 Rural 79.4 4,763 Region Malé 88.1 2,368 North 78.1 1,067 North Central 79.8 1,038 Central 74.6 615 South Central 78.0 853 South 83.6 1,190 Education No formal education 73.9 1,668 Primary 79.2 2,464 Secondary 88.7 2,584 More than secondary 94.3 333 Wealth quintile Lowest 75.7 1,300 Second 78.2 1,396 Middle 80.7 1,488 Fourth 85.9 1,447 Highest 89.8 1,499 Total 82.3 7,131 Note: Total includes 81 ever-married women with information missing on level of formal education 142 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 12.7 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms Among ever-married women age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Maldives 2009 Percentage of ever-married women who reported having in the past 12 months: Background characteristic STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer Number of ever-married women who ever had sexual intercourse Age 15-24 2.0 10.3 15.3 20.3 1,387 15-19 0.0 7.3 16.8 21.6 119 20-24 2.2 10.6 15.1 20.2 1,268 25-29 1.4 9.2 13.7 16.8 1,536 30-39 1.2 6.3 10.8 14.2 2,471 40-49 0.8 3.6 7.6 9.1 1,734 Marital status Married 1.3 7.3 11.9 15.1 6,500 Divorced/separated/ widowed 0.9 4.1 7.3 10.3 628 Residence Urban 1.4 7.5 10.7 13.2 2,365 Rural 1.2 6.9 11.9 15.5 4,763 Region Malé 1.4 7.5 10.7 13.2 2,365 North 0.5 5.4 10.3 12.9 1,067 North Central 1.2 7.4 16.0 19.0 1,038 Central 1.8 10.2 14.3 19.4 615 South Central 1.3 6.4 12.4 15.7 853 South 1.6 6.3 8.2 12.6 1,190 Education No formal education 1.0 5.1 10.0 12.3 1,668 Primary 1.2 6.9 11.7 14.7 2,464 Secondary 1.4 8.3 12.6 16.5 2,581 More than secondary 2.2 7.2 9.8 12.5 333 Total 1.3 7.1 11.5 14.7 7,128 Note: Total includes 81 ever-married women with information missing on level of formal education 12.6 PREVALENCE OF MEDICAL INJECTIONS Non-sterile injections can pose a risk of infection with HIV and other diseases. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2009 MDHS were asked if they had received at least one injection in the past 12 months, and if so, the number of injections altogether. The results indicate that more than 34 percent of women received a medical injection in the past 12 months. The average number of injections received per person during this period (including people who received no injections at all) is 4.7 injections per ever-married woman age 15-49. Women age 15-24 have the highest rates of injections. Women who received injections were further asked if the syringe and needle were taken from a new, previously unopened package. Table 12.8 shows that more than 90 percent of women who received injections in the previous 12 months were administered injections with a syringe and needle taken from a new, unopened package. This is observed across all subgroups of women. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 143 Table 12.8 Prevalence of medical injections Percentage of ever-married women age 15-49 who received at least one medical injection in the last 12 months, the average number of medical injections per person in the last 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Maldives 2009 Background characteristic Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of ever-married women For last injection, syringe and needle taken from a new, unopened package Number of ever- married women receiving medical injections in the past 12 months Age 15-24 43.8 4.6 1,387 93.2 607 15-19 46.4 2.2 119 98.2 55 20-24 43.5 4.8 1,268 92.7 552 25-29 33.9 4.7 1,539 93.2 522 30-39 31.5 4.7 2,471 95.4 779 40-49 30.4 4.6 1,734 89.5 527 Residence Urban 32.1 5.5 2,368 91.6 761 Rural 35.2 4.2 4,763 93.8 1,675 Region Malé 32.1 5.5 2,368 91.6 761 North 33.1 5.3 1,067 93.7 354 North Central 42.1 3.3 1,038 95.2 436 Central 39.4 4.2 615 94.0 242 South Central 34.4 2.9 853 91.0 293 South 29.4 5.1 1,190 94.4 349 Education No formal education 32.1 4.1 1,668 91.4 535 Primary 31.0 4.6 2,464 94.9 763 Secondary 38.2 5.4 2,584 92.8 988 More than secondary 34.1 3.2 333 93.0 114 Wealth quintile Lowest 33.5 5.0 1,300 93.8 436 Second 36.6 4.1 1,396 93.1 511 Middle 35.8 4.3 1,488 93.0 533 Fourth 32.6 6.2 1,447 95.5 472 Highest 32.3 3.8 1,499 90.2 485 Total 34.2 4.7 7,131 93.1 2,436 Note: Total includes 81 ever-married women with information missing on level of formal education. Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker Respondents who have had an injection in the past 12 months were asked where they obtained their last injection. The information is summarized in the Figure 12.1. Overall, 80 percent received the last injection in a public facility; 27 percent in a health centre, 24 percent in Indhira Gandhi Memorial Hospital, 14 percent in a regional hospital, and 13 percent in an atoll hospital. 144 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Kaye: Figure 12.1 please 1) combine Government health post and Community/family health worker/other public and call it “Other government facility/provider” = 2%, and 2) combine private doctor, dental office, other private medical and call it “Other private medical facility/provider” = 3%. Figure 12.2 confirms the findings shown in Table 12.8. Safe injection is generally practiced in public facilities. Overall, 94 percent of the women report that their last injection was administered with a new syringe and needle taken from an unopened package at a public facility. The practice is slightly less stringent in the private sector (90 percent). Figure 12.1 Source of Last Medical Injection 80 24 14 13 27 1 1 19 13 0 0 2 5 1 PUBLIC SECTOR Indhira Gandhi Memorial Hospital Government regional hospital Government atoll hospital Government health center Government health post Community/family health worker/other public PRIVATE MEDICAL Private hospital, clinic Private doctor Dental office Other private medical Hospital/clinic abroad OTHER PLACE AT HOME/OTHER 0 20 40 60 80 100 Percent MDHS 2009 Figure 12.2 Safe Injection 94 91 95 95 95 100 100 100 90 92 54 78 87 86 89 100 PUBLIC SECTOR Indhira Gandhi Memorial Hospital Government regional hospital Government atoll hospital Government health centre Government health post Community/family health worker Other public PRIVATE MEDICAL Private hospital, clinic Private doctor Dental office Other private medical Hospital/clinic abroad OTHER PLACE AT HOME OTHER 0 20 40 60 80 100 Percent MDHS 2009 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 145 12.7 HIV/AIDS KNOWLEDGE AND SEXUAL BEHAVIOUR AMONG YOUTH This section addresses HIV/AIDS-related knowledge and sexual behaviour among youth age 15-24. Special attention is paid to this group because it accounts for half of all new HIV infections worldwide (Ross et al., 2006). In addition to knowledge of HIV transmission, data are presented on age at first sex, condom use, age differences between sexual partners, sex related to alcohol use, and voluntary counselling and testing for HIV. 12.7.1 HIV/AIDS-Related Knowledge among Young Adults Young respondents were asked the same set of questions on facts and beliefs about HIV transmission as other respondents. Information on the overall level of knowledge of major methods of avoiding HIV exposure and the rejection of major misconceptions is shown in Tables 12.2 and 12.3. Table 12.9 shows the level of the composite indicator, “comprehensive knowledge,” among young people by background characteristics. In general, the results indicate 35 percent of ever-married women age 15-24 have a comprehensive knowledge of AIDS. The knowledge increases with the woman’s age. Women living in urban areas and in Malé are more knowledgeable than women living elsewhere. Comprehensive knowledge of AIDS positively relates to the woman’s education; increasing from 20 percent for women with primary education to 63 percent for women with more than secondary education. Table 12.9 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of ever-married women age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Maldives 2009 Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of ever-married women Age 15-19 21.5 78.0 119 15-17 * * 3 18-19 21.6 77.4 116 20-24 36.3 89.5 1,268 20-22 33.4 88.1 639 23-24 39.2 91.0 628 Residence Urban 43.4 90.0 384 Rural 31.8 88.0 1,003 Region Malé 43.4 90.0 384 North 32.9 91.6 226 North Central 31.2 85.8 212 Central 33.1 84.5 150 South Central 33.1 90.0 189 South 29.2 86.9 226 Education No formal education * * 10 Primary 19.5 77.6 218 Secondary 36.4 90.5 1,074 More than secondary 62.9 93.2 69 Wealth quintile Lowest 23.4 87.6 253 Second 32.8 85.2 291 Middle 34.1 90.4 321 Fourth 38.0 88.6 286 Highest 47.8 90.9 235 Total 35.0 88.5 1,387 Note: Total includes 16 ever-married women with information missing on level of formal education. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 1 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 12.2 and 12.3. 2 The following responses are not considered sources for condoms: friends, family members, and home 146 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 12.7.2 Knowledge of Condom Sources among Young Adults Condom use among young adults plays an important role in the prevention of transmission of HIV and other sexually transmitted infections as well as prevention of unwanted pregnancies. Knowledge of a source of condoms helps young adults to obtain and use condoms. Table 12.9 shows that the majority of women (89 percent) know of a place to obtain a condom. This percentage does not vary much across subgroups of women and generally follows the same pattern as differentials in comprehensive knowledge of AIDS. 12.7.3 Trends in Age at First Sex Age at first sexual intercourse marks the time at which most individuals risk being exposed to HIV. Table 12.10 shows the proportion of ever-married women in the 15-24 age cohort who had sex before age 15 and before age 18. Less than 1 percent of young women had sex by age 15, while 6 percent reported having sex by age 18. Most young women in Maldives, therefore, had their first sexual intercourse after age 18. The proportion of women who had sex before age 18 is high among women who live in urban areas and in Malé (8 percent) and low among women in North Central (3 percent). The rate of young women having sexual intercourse by age 18 decreases rapidly by their degree of education, from 14 percent among women with primary education to 5 percent among women with secondary education. Table 12.10 Age at first sexual intercourse among youth Percentage of ever-married women age 15-24 who had sexual intercourse before age 15 and percentage of ever-married women age 18-24 who had sexual intercourse before age 18, by background characteristics, Maldives 2009 Background characteristic Percentage who had sexual intercourse before age 15 Number of ever-married women age 15-24 Percentage who had sexual intercourse before age 18 Number of ever-married women age 18-24 Age 15-19 1.6 119 na na 15-17 * 3 na na 18-19 1.6 116 14.0 116 20-24 0.5 1,268 5.3 1,268 20-22 0.4 639 5.0 639 23-24 0.6 628 5.6 628 Knows condom source1 Yes 0.5 1,228 5.4 1,225 No 1.2 159 10.9 159 Residence Urban 0.5 384 8.4 382 Rural 0.7 1,003 5.2 1,002 Region Malé 0.5 384 8.4 382 North 1.1 226 4.3 226 North Central 0.7 212 2.7 212 Central 0.4 150 7.4 149 South Central 0.4 189 6.6 189 South 0.6 226 5.5 226 Education No formal education * 10 * 10 Primary 2.5 218 14.2 218 Secondary 0.3 1,074 4.5 1,071 More than secondary 0.0 69 0.0 69 Wealth quintile Lowest 0.5 253 6.6 252 Second 1.4 291 6.5 291 Middle 1.0 321 5.5 321 Fourth 0.0 286 6.9 286 Highest 0.0 235 4.5 233 Total 0.6 1,387 6.0 1,384 Note: Total includes 16 ever-married women with information missing on level of formal education. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. na = Not available 1 The following responses are not considered a source for condoms: friends, family members and home Women’s Empowerment and Demographic and Health Outcomes | 147 WOMEN'S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 13 The 2009 MDHS Ever-Married Women’s Questionnaire collected data on the general background characteristics (e.g., age, education, wealth quintile, and employment status) of female respondents and also data more specific to women’s empowerment, such as receipt of cash earnings, the magnitude of a woman’s earnings relative to those of her husband/partner, and control over the use of her own earnings and those of her husband/partner. This questionnaire also collected data on a woman’s participation in household decision- making, on the circumstances under which she feels that a woman is justified in refusing to have sexual intercourse with her husband, and her attitude towards wife beating. For this report, three separate indices of empowerment are developed based on the number of household decisions in which the respondent participates, her opinion on the number of circumstances for which a woman is justified in refusing to have sexual intercourse with her husband/partner, and her opinion on the number of reasons that justify wife beating. The ranking of women on these three indices is then related to selected demographic and health outcomes, including contraceptive use; ideal family size and unmet need for contraception; the receipt of health care services during pregnancy, childbirth, and the postnatal period; and survivorship of children. 13.1 EMPLOYMENT AND FORM OF EARNINGS Like education, employment can also be a source of empowerment for both women and men. It may be particularly empowering for women if it puts them in control of income. Currently married women were asked whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months that preceded the survey. Table 13.1 shows that 46 percent of currently married women in Maldives are currently employed and the majority (96 percent) are paid in cash. There are small variations in the level of employment across age groups. Older women are more likely than younger women to receive cash payment, whereas younger women are more likely to be unpaid. Table 13.1 Employment and cash earnings of currently married women Percentage of currently married women age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Maldives 2009 Currently married women: Percent distribution of currently married women employed in the past 12 months, by type of earnings Age Percentage employed Number of women Cash only Cash and in-kind In-kind only Not paid Missing Total Number of women 15-19 43.6 111 93.5 0.0 0.0 6.5 0.0 100.0 48 20-24 47.6 1,188 94.9 0.1 0.1 4.5 0.3 100.0 566 25-29 44.7 1,446 95.8 0.9 0.3 2.4 0.6 100.0 646 30-34 45.7 1,193 97.0 0.6 0.0 1.8 0.6 100.0 545 35-39 48.4 1,065 96.6 1.6 0.1 1.7 0.0 100.0 515 40-44 47.4 884 97.2 0.3 0.2 2.3 0.0 100.0 419 45-49 43.1 612 98.6 0.0 0.0 1.3 0.2 100.0 264 Total 46.2 6,500 96.4 0.7 0.1 2.5 0.3 100.0 3,004 13.1.1 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s Earnings Currently married and employed women who earn cash for their work were asked who the main decision-maker is with regard to the use of their earnings. In addition, they were asked the 148 | Women’s Empowerment and Demographic and Health Outcomes relative magnitude of their earnings compared with their husband/partner’s earnings. This information may provide some insight into women’s empowerment in the family and the extent of their control over decision-making in the household. It is expected that employment and earnings are more likely to empower women if women themselves control their earnings and perceive their earnings as significant relative to those of a husband/partner. Table 13.2 shows, for currently married women who earned cash in the past 12 months, their control over their own earnings and their perception of the magnitude of their earnings relative to those of a husband/partner. Two in three women report that they and their husband jointly decide on how their earnings are to be spent, and 29 percent report that they are the main decision-maker in the allocation of their cash income. Only 4 percent of women report that their husband makes the decision on how earnings are to be used. Table 13.2 Control over women's cash earnings and relative magnitude of women's earnings: Women Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife's cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Maldives 2009 Person who decides how the wife's cash earnings are used: Women's cash earnings compared with husband's cash earnings: Background characteristic Mainly wife Wife and husband jointly Mainly husband Other Missing Total More Less About the same Husband has no earnings Don't know/ Missing Total Number of women Age 15-19 25.0 62.7 8.8 3.5 0.0 100.0 6.9 73.7 14.1 2.9 2.4 100.0 45 20-24 20.6 73.0 3.1 3.3 0.0 100.0 13.6 64.0 16.5 3.6 2.3 100.0 538 25-29 25.1 71.2 2.3 1.3 0.1 100.0 15.9 65.1 15.4 1.4 2.3 100.0 625 30-34 31.2 64.3 3.7 0.8 0.1 100.0 13.8 70.1 12.6 1.2 2.3 100.0 533 35-39 33.2 62.5 3.5 0.8 0.0 100.0 15.6 74.0 7.4 1.9 1.1 100.0 506 40-44 36.9 58.6 4.2 0.3 0.0 100.0 13.2 72.5 9.6 3.3 1.3 100.0 409 45-49 25.7 67.9 5.7 0.0 0.7 100.0 13.7 71.3 9.5 2.8 2.7 100.0 260 Number of living children 0 23.8 69.3 3.3 3.6 0.0 100.0 14.7 62.8 16.2 3.7 2.6 100.0 554 1-2 28.9 67.0 3.0 1.0 0.1 100.0 15.1 66.1 14.4 2.2 2.2 100.0 1,270 3-4 29.6 66.9 3.1 0.4 0.0 100.0 14.3 75.1 8.4 0.8 1.3 100.0 598 5+ 31.2 62.1 5.9 0.4 0.4 100.0 11.9 76.5 7.5 2.7 1.4 100.0 492 Residence Urban 22.8 73.4 3.4 0.2 0.2 100.0 10.9 67.3 16.9 2.2 2.8 100.0 931 Rural 31.1 63.4 3.7 1.8 0.1 100.0 15.9 69.9 10.2 2.3 1.6 100.0 1,985 Region Malé 22.8 73.4 3.4 0.2 0.2 100.0 10.9 67.3 16.9 2.2 2.8 100.0 931 North 34.6 59.6 4.8 1.0 0.0 100.0 9.5 80.1 8.6 1.1 0.7 100.0 476 North Central 29.1 65.4 3.8 1.6 0.1 100.0 10.4 75.2 8.4 3.7 2.2 100.0 471 Central 20.9 72.4 4.8 1.9 0.0 100.0 16.4 69.3 10.6 2.6 1.1 100.0 243 South Central 28.2 66.6 2.4 2.7 0.2 100.0 30.5 57.8 10.0 0.9 0.8 100.0 402 South 38.5 56.7 2.7 2.0 0.0 100.0 15.2 64.2 14.4 3.3 3.0 100.0 393 Education No formal education 30.2 63.8 5.5 0.3 0.3 100.0 11.9 76.7 7.5 2.6 1.4 100.0 667 Primary 35.9 60.2 2.3 1.6 0.0 100.0 12.4 76.2 7.4 2.2 1.7 100.0 826 Secondary 25.7 69.2 3.4 1.7 0.1 100.0 15.1 64.7 15.4 2.4 2.4 100.0 1,150 More than secondary 10.6 84.3 4.0 1.1 0.0 100.0 22.0 44.9 29.5 1.2 2.3 100.0 221 Wealth quintile Lowest 32.4 62.2 3.9 1.5 0.0 100.0 10.7 77.8 6.8 2.8 1.9 100.0 540 Second 30.7 63.2 4.0 1.9 0.2 100.0 18.8 69.2 9.1 1.7 1.3 100.0 559 Middle 32.8 61.5 3.5 2.1 0.0 100.0 15.5 67.2 13.1 2.5 1.7 100.0 601 Fourth 24.9 70.5 3.6 1.0 0.0 100.0 16.7 64.3 16.0 2.1 0.9 100.0 555 Highest 22.4 74.3 3.0 0.0 0.3 100.0 10.5 67.6 15.9 2.3 3.7 100.0 660 Total 28.5 66.6 3.6 1.3 0.1 100.0 14.3 69.1 12.4 2.3 2.0 100.0 2,915 Note: Total includes 52 women with information missing on level of formal education Table 13.2 also shows that the majority of women in all subgroups report that they decide jointly with their husbands how the cash earnings they receive for the work they do will be used. The proportion reporting that decisions about how a woman’s earnings are used are made jointly with the husband is highest among women with more than secondary education (84 percent). Women from the Women’s Empowerment and Demographic and Health Outcomes | 149 South region are most likely to report that they themselves mainly control how they will use the cash they earn (39 percent), Women age 15-19 are most likely to report that the husband mainly decides how the woman’s cash income will be used (9 percent). With regard to the magnitude of woman’s earnings, Table 13.2 shows that 69 percent of women earn less than their husband, 12 percent earn about the same as their husband, and 14 percent earn more than their husband. Women are most likely to earn about the same or more than their husband if they live in the South Central region (41 percent) or have more than a secondary education (51 percent). 13.1.2 Control over Husband’s Earnings Table 13.3 looks at control over men’s cash earnings from the perspective of the woman. Among married women whose husbands earned cash, 77 percent report that they and their husbands decide jointly how the husband’s earnings are to be used, 15 percent report that mainly their husbands decide how their cash earnings are to be used, and 8 percent report that mainly they make the decision. Table 13.3 Control over men's cash earnings Percent distributions of currently married women 15-49 whose husbands receive cash earnings, by person who decides how men's cash earnings are used, according to background characteristics, Maldives 2009 Background characteristic Mainly wife Husband and wife jointly Mainly husband Other Missing Total Number Age 15-19 (0.0) (72.4) (27.6) (0.0) (0.0) 100.0 44 20-24 4.6 82.3 12.9 0.3 0.0 100.0 518 25-29 4.7 83.1 11.5 0.4 0.3 100.0 612 30-34 5.2 76.9 17.8 0.1 0.0 100.0 525 35-39 9.8 74.4 15.2 0.6 0.0 100.0 497 40-44 13.6 69.4 16.6 0.3 0.0 100.0 392 45-49 13.8 69.8 16.5 0.0 0.0 100.0 249 Number of living children 0 3.4 78.0 18.1 0.5 0.0 100.0 531 1-2 6.3 78.9 14.5 0.2 0.1 100.0 1,240 3-4 8.2 77.9 13.6 0.4 0.0 100.0 592 5+ 15.1 70.2 14.3 0.4 0.0 100.0 473 Residence Urban 6.6 77.1 15.9 0.4 0.0 100.0 903 Rural 8.1 77.1 14.5 0.2 0.1 100.0 1,934 Region Malé 6.6 77.1 15.9 0.4 0.0 100.0 903 North 8.6 71.7 19.5 0.2 0.0 100.0 470 North Central 9.0 75.9 14.8 0.3 0.0 100.0 452 Central 5.4 82.1 12.0 0.4 0.0 100.0 235 South Central 6.5 81.7 11.4 0.3 0.0 100.0 397 South 9.7 77.0 12.8 0.0 0.5 100.0 380 Education No formal education 12.6 73.3 13.8 0.3 0.0 100.0 643 Primary 9.2 73.9 16.5 0.4 0.0 100.0 807 Secondary 5.3 78.8 15.6 0.2 0.2 100.0 1,122 More than secondary 0.4 89.7 9.1 0.8 0.0 100.0 214 Wealth quintile Lowest 9.0 76.0 14.4 0.2 0.3 100.0 524 Second 9.7 77.4 12.5 0.4 0.0 100.0 548 Middle 7.2 77.2 15.5 0.1 0.0 100.0 586 Fourth 6.3 78.6 14.7 0.5 0.0 100.0 543 Highest 6.2 76.1 17.3 0.3 0.0 100.0 638 Total 7.6 77.1 15.0 0.3 0.1 100.0 2,837 Note: Total includes 52 women with information missing on level of formal education. Figures in parentheses are based on 25-49 unweighted cases. 150 | Women’s Empowerment and Demographic and Health Outcomes The majority of women in all subgroups report that they decide jointly with their husband how his cash earnings will be used. The groups in which women are most likely to say that they themselves mainly decide on how the husband’s earnings will be used include women age 40-49, women with 5 or more children, and women with no formal education (13-15 percent). Women are most likely to say that the husband mainly decides on how his earnings will be used if they are age 30- 34, are from the North region, or have no children (18-20 percent). 13.1.3 Control over Women’s and Husband’s Cash Earnings by Magnitude of Women’s Earnings Table 13.4 shows that husband and wife jointly are most likely to decide on the use of a wife’s cash earnings if the wife’s income is the same as the husband’s and least likely if the husband has no cash earnings or did not work (79 percent compared with 61 percent, respectively). Decisions about how the husband’s cash earnings will be used are most likely to be made jointly if the woman has the same income as the husband and least likely to be made jointly if the woman herself has no cash earnings (82 percent compared with 71 percent, respectively). Table 13.4 Women's control over her own earnings and over those of her husband Percent distribution of currently married women age 15-49 with cash earnings in the past 12 months by person who decides how the woman's cash earnings are used and of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband's cash earnings are used, according to the relation between woman's and husband's cash earnings, Maldives 2009 Person who decides how the wife's cash earnings are used: Person who decides how husband's cash earnings are used: Women's earnings relative to husband's earnings Mainly wife Wife and husband jointly Mainly husband Other Missing Total Number Mainly wife Wife and husband jointly Mainly husband Other Missing Total Number of women More than husband 22.8 72.2 3.4 1.7 0.0 100.0 417 7.1 77.4 15.3 0.2 0.0 100.0 412 Less than husband 31.1 63.8 3.8 1.3 0.0 100.0 2,014 8.1 76.6 15.0 0.3 0.0 100.0 2,013 Same as husband 17.3 78.6 3.6 0.5 0.0 100.0 360 3.7 81.8 13.8 0.7 0.0 100.0 356 Husband has no cash earnings/ did not work 36.2 61.1 2.1 0.6 0.0 100.0 66 na na na na na na 0 Woman has no cash earnings na na na na na na 0 13.3 71.4 13.5 1.8 0.0 100.0 89 Woman did not work in past 12 months na na na na na na 0 8.9 79.5 11.0 0.2 0.3 100.0 3,423 Don't know/missing (38.0) (52.9) (0.0) (3.5) (5.6) 100.0 57 (17.4) (59.5) (19.9) (0.0) (3.2) 100.0 56 Total1 28.5 66.6 3.6 1.3 0.1 100.0 2,915 8.4 78.3 12.8 0.3 0.2 100.0 6,349 Note: Total includes 52 women with information missing on level of formal education. Figures in parentheses are based on 25-49 unweighted cases. na = Not Applicable. 1 Excludes cases where a woman or her husband has no earnings and includes cases where a woman does not know whether she earned more or less than her husband/partner 13.2 WOMEN’S EMPOWERMENT In addition to educational attainment, employment status, and control over earnings, the 2009 MDHS collected information on some direct measures of women’s autonomy and status. Specifically, questions were asked about women’s participation in household decision-making, their acceptance of wife beating, and their opinions of the conditions under which a wife should be able to deny sex to her husband. Such information provides insight into women’s control over their environment and their attitudes towards gender roles, both of which are relevant to understanding women’s demographic and health behaviour. The first measure—women’s participation in decision-making—requires little explanation because the ability to make decisions about one’s own life is of obvious importance to women’s empowerment. The other two measures derive from the notion that gender equity is essential to empowerment. Responses that indicate a view that the beating of wives by husbands is justified Women’s Empowerment and Demographic and Health Outcomes | 151 reflect a low status of women. They signify acceptance of norms that give men the right to use force against women, which is a violation of women’s human rights. Similarly, beliefs about whether and when a woman can refuse to have sex with her husband reflect issues of gender equity regarding sexual rights and bodily integrity. Besides yielding an important measure of empowerment, information about women’s attitudes towards sexual rights is useful for improving and monitoring reproductive health programmes that depend on women’s willingness and ability to control their own sexual lives. 13.2.1 Women’s Participation in Household Decision Making To assess women’s decision-making autonomy, information was sought on women’s participation in three different types of household decisions: on the respondent’s own health care, on making major household purchases, and on making household purchases for daily needs. Having a final say in decision-making processes is the highest degree of autonomy. Women are considered to participate in a decision if they alone or jointly with their husband have the final say in that decision. Table 13.5 shows the percent distribution of currently married women according to the person in the household who usually makes decisions concerning these matters. Fifty-six percent of women say that they make decisions about their health care jointly with their husband, 23 percent say the husband mainly makes these decisions, and 20 percent say they themselves are mainly responsible for health care decisions. Forty-seven percent of married women say that decisions about major household purchases are shared between wife and husband, 32 percent say that the husband mainly makes the decision, and 11 percent say that they mainly make the decision. Six in ten women (60 percent) say that they are in charge of purchases of daily household needs; among the remaining women, the majority report making these decisions jointly with their husband. Table 13.5 Women's participation in decision-making Percent distribution of currently married women by person who usually makes decisions about three kinds of issues, Maldives 2009 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 20.4 55.6 22.7 0.8 0.3 0.2 100.0 6,500 Major household purchases 10.9 46.9 31.7 8.6 1.8 0.1 100.0 6,500 Purchases of daily household needs 59.8 18.3 10.0 9.5 2.1 0.2 100.0 6,500 Women may have a say in some decisions but not in others. To assess a woman’s overall decision-making autonomy, the decisions in which she participates—that is, in which she alone has the final say or does so jointly with her husband or partner—are added together. The total number of decisions in which a woman participates is a measure of her empowerment. Figure 13.1 shows the percentage of currently married women according to the number of decisions in which they participate, either alone or in conjunction with their husbands. Overall, 47 percent of women say that they participate in all decision-making regarding their household. At the other extreme, 8 percent of women say that they have no say in household decision-making. 152 | Women’s Empowerment and Demographic and Health Outcomes Table 13.6 shows how women’s participation in decision-making varies by background characteristics. There is no clear correlation between age and involvement in the specific decisions. The percentage of women participating in all three decisions increases from 34 percent among women age 15-19 to 52 percent among women age 30-44 and then declines to 45 percent among women age 45-49. Women who are employed for cash are slightly more likely to participate in all decisions. Women who live with their husbands and women with husbands who are at least five years younger have higher rates of participation in all household decision-making than other women. The likelihood that a married woman is involved in all decisions is highest among women with 3-4 living children. Urban woman are more likely than rural women to have a say in all of the decisions. Looking at regional variations, the proportion of currently married women participating in all decisions is highest in the Central and the South regions (53 percent). Participation in decision-making increases with an increase in a woman’s education, and 44 percent of women with no formal education participate in all specified decisions compared with 55 percent of women with more than secondary education. The proportion of currently married women who participate in all three decisions increases from 46 percent for women in the lowest wealth quintile to 56 percent for women in the highest wealth quintile). Figure 13.1 Number of Decisions in Which Women Participate 8 19 26 47 0 1 2 3 Number of household decisions 0 10 20 30 40 50 60 Percent MDHS 2009 Women’s Empowerment and Demographic and Health Outcomes | 153 Table 13.6 Women's participation in decision making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Maldives 2009 Background characteristic Own health care Making major household purchases Making purchases for daily household needs Percentage who participate in all three decisions Percentage who participate in none of the three decisions Number of women Age 15-19 68.9 43.0 66.7 33.6 9.3 111 20-24 75.6 51.2 65.2 38.4 10.4 1,188 25-29 78.6 59.2 74.4 47.1 7.7 1,446 30-34 80.7 59.9 81.4 51.6 6.3 1,193 35-39 75.3 60.4 85.7 49.3 5.6 1,065 40-44 73.8 60.8 86.6 51.8 7.5 884 45-49 67.2 56.4 82.3 45.3 10.2 612 Employment (past 12 months) Not employed 75.0 56.7 78.5 46.9 8.9 3,492 Employed for cash 77.5 59.1 78.2 47.1 6.1 2,915 Employed not for cash 70.1 54.6 65.8 43.3 17.6 79 Husband living with respondent Yes 76.1 58.9 78.9 48.0 7.8 5,226 No 75.9 52.9 75.0 42.7 7.8 1,260 Missing 68.7 50.3 84.1 42.5 15.9 14 Age difference with husband Husband 10+ years older 74.8 58.4 82.3 48.5 7.7 864 Husband 5-9 years older 76.2 55.7 80.2 45.7 7.2 1,817 Husband -/+ 4 years younger/older 77.0 58.5 76.0 47.3 8.1 3,557 Husband 5+ years younger 74.1 70.8 82.9 54.5 6.0 97 Don't know/missing 61.6 53.3 77.9 39.4 11.4 166 Number of living children 0 72.6 47.7 62.0 34.8 12.2 946 1-2 79.9 60.5 77.4 49.2 6.8 2,908 3-4 74.5 59.5 84.6 50.5 6.8 1,486 5+ 71.0 56.7 85.0 46.7 8.0 1,160 Residence Urban 78.4 64.7 79.0 53.0 7.4 2,122 Rural 74.9 54.4 77.8 44.0 8.0 4,378 Region Malé 78.4 64.7 79.0 53.0 7.4 2,122 North 73.0 52.6 80.3 41.6 7.1 1,009 North Central 74.7 49.8 73.7 39.2 9.4 967 Central 82.9 60.8 77.0 53.3 6.8 563 South Central 71.8 46.9 76.5 35.8 7.8 789 South 74.8 62.4 80.4 52.0 8.5 1,051 Education No education 70.0 56.1 83.5 45.8 9.3 1,488 Primary 75.8 56.7 82.3 46.7 6.6 2,216 Secondary 78.0 58.4 71.7 46.3 8.1 2,409 More than secondary 88.6 65.2 72.4 55.9 8.2 316 Wealth quintile Lowest 72.7 54.8 79.5 43.5 7.8 1,167 Second 74.3 54.4 79.1 44.3 8.6 1,278 Middle 77.8 54.2 77.4 45.1 7.4 1,363 Fourth 75.7 60.8 77.3 48.9 7.6 1,311 Highest 79.1 64.0 77.6 52.2 7.6 1,381 Total 76.0 57.8 78.1 46.9 7.8 6,500 Note: Total includes 72 women with information missing on level of formal education and 14 women with information missing on employment in past 12 months and husband’s residence. 13.2.2 Attitudes towards Wife Beating Violence against women has serious consequences for their mental and physical well-being, including their reproductive and sexual health (WHO, 1999). One of the most common forms of violence against women worldwide is abuse by a husband or partner (Heise et al., 1999). 154 | Women’s Empowerment and Demographic and Health Outcomes The MDHS gathered information on women’s attitudes towards wife beating, a proxy for women’s perception of their status. Women who believe that a husband is justified in hitting or beating his wife for any of the specified reasons may believe themselves to be low in status both absolutely and relative to men. Such a perception could act as a barrier to accessing health care for themselves and their children, affect their attitude towards contraceptive use, and influence their general well-being. Women were asked whether a husband is justified in beating his wife under a series of circumstances: if the wife burns the food, argues with him, goes out without telling him, neglects the children, or refuses sexual relations. Table 13.7 summarizes women’s attitudes towards wife beating in these five specific circumstances. The table also shows the percentage of women who agree that wife beating is justified in at least one of the circumstances. Acceptance of wife beating ranges from 6 percent (burn the food) to 19 percent (refuse to have sexual intercourse). Thirty-one percent of women agree with at least one of the specified reasons that purportedly justify a husband’s beating his wife. Table 13.7 Attitude towards wife beating Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Maldives 2009 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason Number Age 15-19 7.9 21.3 16.9 27.8 17.4 40.7 119 20-24 3.7 17.0 10.2 18.9 15.9 31.1 1,268 25-29 3.1 13.8 10.0 14.7 15.1 26.3 1,539 30-34 5.1 13.9 10.0 14.8 17.8 25.7 1,287 35-39 6.4 16.4 12.3 15.9 19.7 29.3 1,185 40-44 10.0 21.5 18.2 23.8 26.1 37.5 1,013 45-49 14.1 23.6 22.6 24.5 27.1 40.2 721 Employment (past 12 months) Not employed 6.6 17.3 13.0 18.4 19.0 30.9 3,742 Employed for cash 6.0 16.9 13.1 18.0 19.7 30.8 3,279 Employed not for cash 3.2 14.4 8.3 17.8 21.7 28.0 85 Marital status Married 6.2 17.0 13.0 18.2 19.2 30.6 6,500 Divorced/separated/widowed 7.0 17.6 13.1 18.2 20.7 32.9 631 Number of living children 0 4.7 16.9 12.5 17.9 16.3 30.7 1,040 1-2 3.6 13.4 8.8 14.3 14.9 25.4 3,183 3-4 7.6 17.9 14.3 18.2 22.3 32.6 1,636 5+ 12.6 25.0 22.1 27.9 28.9 41.7 1,272 Residence Urban 2.4 9.6 6.2 9.0 9.8 17.6 2,368 Rural 8.2 20.7 16.4 22.7 24.0 37.3 4,763 Region Malé 2.4 9.6 6.2 9.0 9.8 17.6 2,368 North 8.4 20.9 15.9 24.0 25.3 37.1 1,067 North Central 9.5 23.3 20.0 26.6 29.8 42.7 1,038 Central 6.3 15.0 13.7 17.9 21.3 32.6 615 South Central 6.0 17.9 13.6 18.3 21.3 32.2 853 South 9.5 23.3 16.9 23.8 21.2 39.0 1,190 Education No formal education 12.3 24.6 22.0 27.4 29.6 42.8 1,668 Primary 7.1 18.0 13.7 18.5 21.4 31.9 2,464 Secondary 2.6 12.8 8.2 13.7 12.6 24.7 2,584 More than secondary 0.6 6.1 2.0 5.7 6.2 10.2 333 Wealth quintile Lowest 9.2 22.6 20.5 24.9 26.0 40.1 1,300 Second 8.1 20.6 14.6 22.4 24.6 36.7 1,396 Middle 7.8 18.8 14.6 21.3 22.7 36.1 1,488 Fourth 5.1 15.9 10.9 15.4 15.4 27.2 1,447 Highest 1.8 8.2 5.4 7.9 8.9 15.3 1,499 Total 6.3 17.0 13.0 18.2 19.3 30.8 7,131 Note: Total includes 81 women with information missing on level of formal education and 25 women with information missing on employment in past 12 months. Women’s Empowerment and Demographic and Health Outcomes | 155 Acceptance of wife beating varies by the woman’s age. The youngest and oldest women are more likely than other women to agree that a husband is justified in beating a wife in any of the specified circumstances. However, women age 20 and older increasingly accept that a husband is justified in abusing his wife for all specified reasons. Acceptance of wife beating varies little by the woman’s employment or marital status. The proportion of women who justify wife beating in at least some circumstances increases with the number of living children. Rural women are more than twice as likely as urban women to justify wife beating (37 percent and 18 percent, respectively). As expected, the proportion of women agreeing with at least one of the given reasons for beating a wife varies by region, ranging from 18 percent in the Malé region to 43 percent in the North Central region. The likelihood that a woman perceives wife beating as justified in some circumstances decreases markedly with the woman’s level of education (from 43 percent for women with no education to 10 percent for women with more than secondary education). Women in the highest wealth quintile are the least likely to agree with the specified reasons for wife beating, while women in the lowest quintile are the most likely (15 percent and 40 percent, respectively). 13.3 WOMEN’S EMPOWERMENT INDICATORS The two sets of empowerment indicators, namely women’s participation in making household decisions and their attitude towards wife beating can be summarized into two separate indices. The first index shows the number of decisions (see Table 13.5 for the list of decisions) in which women participate alone or jointly with their husband/partner. This index ranges in value from 0 to 4 and is positively related to women’s empowerment. It reflects the degree of decision-making control that women are able to exercise in areas that affect their own lives and environments. The second index, which ranges in value from 0 to 5, is the total number of reasons (see Table 13.8 for the list of reasons) for which the respondent feels that a husband is justified in beating his wife. A lower score on this indicator is interpreted as reflecting a greater sense of entitlement and self- esteem and a higher status of women. Table 13.8 shows how these indicators relate to each other. In general, the expectation is that women who participate in making household decisions are also more likely to disagree with wife beating. This pattern is confirmed by the data; the percentage of women who disagree with reasons that justify wife beating increases with the number of decisions in which women participate. Similarly, the percentage of women who participate in all household decisions decreases as the number of reasons that justify wife beating increases. Table 13.8 Indicators of women's empowerment Percentage of women age 15-49 who participate in all decision making, and the percentage who disagree with all reasons for justifying wife-beating, by value on each of the indicators of women's empowerment, Maldives 2009 Empowerment indicator Percentage who participate in all decision making Number of women Percentage who disagree with all the reasons justifying wife beating Number of women Number of decisions in which women participate 0 na na 63.6 508 1-2 na na 66.6 2,941 3 na na 73.1 3,052 Number of reasons for which wife beating is justified 0 49.4 4,514 na na 1-2 42.2 1,197 na na 3-4 40.8 529 na na 5 38.4 261 na na na = Not applicable 1 See Table 13.5 for the list of decisions. 2 See Table 13.6 for the list of reasons. 156 | Women’s Empowerment and Demographic and Health Outcomes 13.4 CURRENT USE OF CONTRACEPTION BY WOMEN’S EMPOWERMENT STATUS A woman’s ability to control her fertility and the contraceptive method she chooses are likely to be affected by her status, self-image, and sense of empowerment. A woman who feels that she is unable to control other aspects of her life may be less likely to feel that she can make decisions regarding fertility. She may also feel the need to choose methods that are easier to conceal from her husband or that do not depend on his cooperation. Table 13.9 shows the relationship of each of the two indicators of women’s empowerment with current use of contraceptive methods among currently married women age 15-49 in Maldives. There are no significant variations in the use of contraception according to the number of decisions a woman participates in. Women who have no say in household decisions are slightly more likely to use temporary modern methods, and women who participate in 3 decisions are more likely to use female sterilization. It is interesting to note that the prevalence of female sterilization increases with an increase in the number of reasons a woman agrees to as justifying wife beating. On the other hand, use of male condoms decreases with the number of reasons that a woman accepts as justifying wife beating. Women who do not agree that a husband is justified to beat his wife for any of the specified reasons are almost twice as likely to use a male condom as women who that all of the five reasons for justify wife beating. Table 13.9 Current use of contraception by women's status Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women's status, Maldives 2009 Modern methods Empowerment indicator Any method Any modern method Female sterili- zation Male sterili- zation Temporary modern female methods Male condom Any traditional method Not currently using Total Number of women Number of decisions in which women participate 0 31.0 24.6 9.1 0.3 6.8 8.4 6.4 69.0 100.0 508 1-2 32.9 24.7 8.9 0.3 6.3 9.1 8.2 67.1 100.0 2,941 3 37.1 29.6 11.3 0.7 8.1 9.6 7.5 62.9 100.0 3,052 Number of reasons for which wife beating is justified 0 34.2 26.7 9.3 0.4 6.9 10.1 7.6 65.8 100.0 4,514 1-2 35.2 25.6 10.0 0.5 7.2 7.9 9.6 64.8 100.0 1,197 3-4 36.9 30.8 13.2 0.7 10.0 6.9 6.1 63.1 100.0 529 5 36.7 30.7 17.1 1.3 6.5 5.8 6.0 63.3 100.0 261 Total 34.7 27.0 10.1 0.5 7.2 9.3 7.8 65.3 100.0 6,500 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly and lactational amenorrhea method 2 See Table 13.5 for the list of decisions. 3 See Table 13.6 for the list of reasons. 13.5 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS Women’s fertility preferences are commonly lower than those of their partners. As a woman becomes more empowered to negotiate fertility decision-making, she has more control over contraceptive use and thus her chances of becoming pregnant and giving birth. Table 13.10 shows women’s ideal family size and their unmet need for family planning by the two indicators of women’s empowerment. The data indicate that there are small differences in the mean ideal number of children depending on the number of decisions in which a woman participates. However, the mean ideal number of children increases with the number of reasons the woman uses to justify wife beating; it is 3.1 children for women who disagree with any reason for a husband to abuse his wife and 3.5 children for women who agree with five reasons for wife beating. Women’s Empowerment and Demographic and Health Outcomes | 157 Table 13.10 Women's empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women's empowerment, Maldives 2009 Mean ideal number of children Percentage of currently married women with an unmet need for family planning Empowerment indicator Number of women For spacing For limiting Total Number of women Number of decisions in which women participate 0 3.1 435 17.1 12.5 29.7 508 1-2 3.1 2,551 14.4 12.7 27.2 2,941 3 3.1 2,649 15.0 13.8 28.8 3,052 Number of reasons for which wife beating is justified 0 3.1 4,357 14.6 13.1 27.8 4,514 1-2 3.2 1,140 18.4 11.6 30.0 1,197 3-4 3.3 477 13.8 14.8 28.6 529 5 3.5 210 5.9 19.1 25.0 261 Total 3.1 6,185 14.9 13.2 28.1 6,500 1 Mean excludes respondents who gave non-numeric responses. 2 See table 7.3.1 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 13.5 for the list of decisions. 4 See Table 13.6.1 for the list of reasons. Table 13.10 also shows that in general there is no clear pattern in the association between unmet need for family planning services and the two women empowerment indicators. Unmet need does not vary much by the number of decisions in which a woman participates. On the other hand, unmet need for spacing births among women who agree with no reason for wife beating is 15 percent in contrast with 6 percent for women who agree with five reasons. Unmet need for limiting births increases from 13 percent for women who disagree with any reason for wife abuse compared with 19 percent for women who agree with all reasons for wife beating. 13.6 WOMEN’S STATUS AND REPRODUCTIVE HEALTH CARE Table 13.11 examines whether women’s use of antenatal, delivery, and postnatal care services from health workers varies by their level of empowerment as measured by the three indicators of empowerment. In societies where health care is widespread, women’s empowerment may not affect their access to reproductive health services; in other societies, however, increased empowerment of women is likely to increase their ability to seek out and use health services to better meet their own reproductive health goals, including the goal of safe motherhood. Table 13.11 indicates that coverage of antenatal care and delivery assistance by a health professional varies little by the woman’s empowerment status. However, postnatal care attendance by a health professional in the first two days after delivery increases slightly with an increase in the number of household decisions in which women participate. Similarly, two in three women (67 percent) who were attended by a health professional for postnatal care agree with no reason for wife beating compared with 60 percent of women who agree with all 5 reasons. 158 | Women’s Empowerment and Demographic and Health Outcomes Table 13.11 Reproductive health care by women's empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance and postnatal care from health personnel for the most recent birth, by indicators of women's empowerment, Maldives 2009 Empowerment indicator Received antenatal care from health personnel Received delivery assistance from health personnel Received postnatal care from health personnel within the first two days since delivery Number of women with a child born in the past five years Number of decisions in which women participate 0 97.8 93.4 59.8 222 1-2 99.5 96.0 66.7 1,318 3 99.7 96.6 67.1 1,501 Number of reasons for which wife beating is justified 0 99.5 96.4 66.6 2,256 1-2 99.4 95.6 65.6 598 3-4 98.5 92.1 64.0 248 5 97.3 94.1 60.4 88 Total 99.3 95.9 66.0 3,190 Note: 'Health personnel' includes doctor, nurse, midwife, or auxiliary nurse or auxiliary midwife. 1 Includes deliveries in a health facility and not in a health facility 2 Restricted to currently married women. See Table 13.5 for the list of decisions. 3 See Table 13.6 for the list of reasons. 13.7 EARLY CHILDHOOD MORTALITY RATES BY WOMEN’S STATUS A woman is empowered if she has access to information, makes decisions, and acts effectively in her interest and in the interest of those who depend on her. In most cases women are the primary caretakers of their children, and children of empowered women are expected to have better health and chances of survival. Table 13.12 shows information on the impact of women’s empowerment on infant and child mortality. The data show that women’s participation in household decisions has a positive effect on their children’s survival; childhood mortality rates decrease with increasing numbers of decisions in which mothers participate. There is a clear pattern in the relationship between another indicator of women’s empowerment—reasons for justifying wife beating—and infant and under-5 mortality. For example, the under-5 mortality rate is lowest for children whose mother does not accept any reason for beating a wife (23 deaths per 1,000 live births) and highest for children whose mother accepts all reasons for wife beating (72 deaths per 1,000 live births). Table 13.12 Early childhood mortality rates by women's status Infant, child, and under-five mortality rates for the 10-year period preceding the survey, by indicators of women's status, Maldives 2009 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which women participate 0 27 7 34 1-2 22 5 27 3 22 3 26 Number of reasons for which wife beating is justified 0 20 3 23 1-2 26 6 32 3-4 18 8 25 5 57 16 72 1 Restricted to currently married women. 2 See Table 13.5 for the list of decisions. 3 See Table 13.6 for the list of reasons Demographic and Health Indicators on Men │ 159 DEMOGRAPHIC AND HEALTH INDICATORS ON MEN 14 In the Maldives DHS (MDHS), half of the households selected for the ever-married sample of women were also selected for a survey of men and youth. In these households, all ever-married men, never-married women age 15-24, 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 eligible to be interviewed. The survey was limited to Maldivian citizens; non-Maldivians were included in the survey only if they were the spouse, son, or daughter of a Maldivian. This chapter discusses the findings of a subset of interviews conducted only with ever-married men age 15-64. Results of interviews with never-married women and never-married men are presented in Chapter 15. 14.1 RESPONSE RATES FOR MEN’S SURVEY Table 14.1 shows response rates for the ever-married men’s survey component of the 2009 MDHS. A total of 3,752 households were selected in the sample for the men’s survey, of which 3,559 were found to be occupied at the time of data collection. The difference between the number of households selected and the number occupied usually occurs because some structures are found to be vacant or non-existent. A total of 3,204 occupied households were successfully interviewed, yielding a household response rate of 90 percent. In the MDHS households selected for the men’s survey, a total of 3,224 ever-married men age 15-64 were identified as eligible for the individual interview; interviews were completed with 1,727 men, yielding a male response rate of 54 percent. The urban response rate of 47 percent is lower than the 55 percent response rate among rural respondents. The low response rate suggests that the men who participated in the survey may not represent all ever-married men in Maldives, especially those in urban areas or Malé. Table 14.1 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 (Malé) Rural Total Households selected for male interview Households selected 601 3,151 3,752 Households occupied 566 2,993 3,559 Households interviewed 463 2,741 3,204 Household response rate1 0.82 0.92 0.90 Individual interviews: ever-married men 15-64 Number of eligible men 579 2,645 3,224 Number of eligible men interviewed 274 1,453 1,727 Eligible man response rate2 47.3 54.9 53.6 1 Household interviewed/household occupied 2 Respondents interviewed/eligible respondents 160 | Demographic and Health Indicators on Men 14.2 CHARACTERISTICS OF SURVEY RESPONDENTS The distribution of ever-married men age 15-49 by background characteristics is shown in Table 14.2. The largest proportions of men are in age group 30-34 and age group 35-39 (20 percent each). Nearly all men (95 percent) are currently married. Four in ten ever-married male MDHS respondents live in urban areas. The same pro- portion lives in the Malé region. The remaining respondents are distributed across the five other regions of the Maldives. After Malé, the regions with the largest proportions of respondents in the men’s survey are the South (15 percent) and North Central regions (14 percent). The Central region has the smallest proportion of respondents in the men’s survey. Overall, 22 percent of ever-married men have never received any formal education. Thirty- four percent of men have attended primary school (without having gone on to secondary school), and 34 percent have attended secondary school (without continuing to higher education). Seven percent of men have received education beyond secondary school. The percentage of men inter- viewed rises with the wealth quintile, suggesting that wealthier males may be somewhat over- represented among the men’s survey respondents. 14.3 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Table 14.3 presents a detailed distribution of educational attainment. The general pattern evident in Table 14.3 indicates a decrease in the proportion of men with no education from the oldest to the youngest cohorts. For example, only 1 percent of young men age 15-24 have no formal education compared with 59 percent of men age 45-49. Three in five men age 15-24 have acquired some secondary education compared with only 9 percent of men age 45-49. Overall, the median years of school completed for men age 15-49 is 6.7 years. The MDHS data indicate that educational opportunities vary by urban-rural residence. Urban men have higher rates of school attendance than their rural counterparts. Ten percent of urban men have not attended school compared with 30 percent of men in rural areas. Comparison of the median number of years of education completed shows that urban men have a median of 8.6 years of schooling compared with 6.3 years for rural men. Table 14.2 Background characteristics of respondents Percent distribution of ever-married men age 15-49 by selected background characteristics, Maldives 2009 Background characteristic Weighted percent Weighted Unweighted Age 15-19 0.2 3 5 20-24 8.3 115 132 25-29 18.4 255 248 30-34 19.9 276 271 35-39 19.6 272 251 40-44 17.5 243 236 45-49 16.1 224 225 Marital status Married 94.6 1,312 1,306 Divorced/separated 5.1 71 57 Widowed 0.3 4 5 Residence Urban 38.0 527 223 Rural 62.0 860 1,145 Region Malé 38.0 527 223 North 12.9 178 158 North Central 14.1 196 230 Central 9.0 125 254 South Central 11.2 156 299 South 14.8 205 204 Education No formal education 22.4 311 355 Primary 33.9 470 500 Secondary 33.9 470 410 More than secondary 7.3 101 63 Wealth quintile Lowest 14.9 206 264 Second 16.9 235 323 Middle 21.5 298 396 Fourth 20.3 282 228 Highest 26.4 366 157 Total 15-49 100.0 1,388 1,368 50-64 na 339 359 Total men 15-64 na 1,727 1,727 Note: Total includes 35 men with information missing on education level. Education categories refer to the highest level of education attended, whether or not that level was completed. na = not applicable Demographic and Health Indicators on Men │ 161 School attendance varies among ever-married men in Maldives. The lowest level is observed in North region, where 36 percent of the men have never attended school, while the highest is found in Malé, where only 10 percent of ever-married men have never gone to school. Educational attainment increases as household economic status increases. Four in ten men in the poorest households have no formal education compared with one in ten men in the richest households. Table 14.3 Educational attainment Percent distribution of ever-married men 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 primary Some secondary Completed secondary More than secondary Unknown - Certificate Total Median years completed Number of men Age 15-24 1.4 3.5 15.3 60.0 6.5 11.4 2.0 100.0 9.3 117 15-19 * * * * * * * 100.0 * 3 20-24 1.5 3.5 15.6 59.1 6.6 11.6 2.0 100.0 9.3 115 25-29 0.4 8.6 19.4 56.9 5.7 7.2 1.7 100.0 8.9 255 30-34 3.5 15.9 31.8 30.5 2.9 11.7 3.8 100.0 6.9 276 35-39 17.4 13.0 30.4 28.4 1.2 6.3 3.3 100.0 6.6 272 40-44 49.0 13.1 17.0 13.3 2.4 3.6 1.5 100.0 3.6 243 45-49 59.1 7.7 16.4 8.6 1.0 4.8 2.3 100.0 0.0 224 Residence Urban 9.7 8.3 19.9 39.4 5.8 15.2 1.8 100.0 8.6 527 Rural 30.2 12.9 24.5 25.7 1.3 2.4 3.0 100.0 6.3 860 Region Malé 9.7 8.3 19.9 39.4 5.8 15.2 1.8 100.0 8.6 527 North 36.1 10.7 23.3 22.8 0.5 3.0 3.6 100.0 6.1 178 North Central 24.8 12.6 25.3 26.3 2.6 2.6 5.7 100.0 6.4 196 Central 30.6 17.0 22.3 23.9 1.0 3.4 1.8 100.0 6.1 125 South Central 26.2 16.7 28.4 24.8 0.2 1.4 2.3 100.0 6.4 156 South 33.2 9.6 23.3 29.4 1.6 1.8 1.0 100.0 6.4 205 Wealth quintile Lowest 39.8 16.8 28.0 11.3 0.7 0.9 2.5 100.0 5.2 206 Second 29.6 17.2 24.0 24.3 0.1 1.8 2.8 100.0 6.2 235 Middle 23.6 9.9 24.9 33.4 2.5 2.6 3.2 100.0 6.7 298 Fourth 18.2 6.4 24.8 36.0 3.9 9.1 1.6 100.0 7.2 282 Highest 10.3 8.6 15.8 40.2 5.8 16.8 2.5 100.0 8.8 366 Total 15-49 22.4 11.1 22.8 30.9 3.0 7.3 2.5 100.0 6.7 1,388 50-64 71.1 5.9 7.4 9.8 0.6 2.7 2.5 100.0 na 339 Total men 15-64 32.0 10.1 19.8 26.8 2.5 6.4 2.5 100.0 6.5 1,727 Note: An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. na = not applicable 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level 14.4 ACCESS TO MASS MEDIA The 2009 MDHS collected information on the exposure of respondents to newspaper, television, radio, and the Internet (Table 14.4). Almost all ever-married men age 15-49 (97 percent) watch television at least once a week, 74 percent listen to the radio, 52 percent read a newspaper, and 39 percent use the Internet at least once a week. Exposure to radio increases with age while use of the Internet shows the opposite association. The rate of television watching does not vary across subgroups of men. In general, younger men, men in urban areas, and those men who live in Malé have higher rates of media exposure than other men. 162 | Demographic and Health Indicators on Men Exposure to mass media increases with men’s education and wealth status. For example, the percentage of men who were exposed to at least one of the three media (radio, television or newspaper) at least once a week ranges from 40 percent for men in the lowest wealth quintile to 68 percent for men in the highest wealth quintile . Table 14.4 Exposure to mass media: Men Percentage of ever-married men 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 Uses Internet at least once a week At least three media at least once a week1 No media at least once a week1 Number Age 15-19 * * * * * * 3 20-24 47.2 98.5 63.4 53.2 51.5 0.6 115 25-29 59.3 99.3 68.4 56.9 63.6 0.3 255 30-34 58.5 94.1 66.8 47.7 59.1 1.5 276 35-39 56.2 97.4 70.8 39.0 55.9 0.7 272 40-44 47.8 97.3 81.5 25.3 45.8 1.0 243 45-49 36.7 97.2 90.7 14.2 39.7 0.7 224 Residence Urban 68.4 97.0 60.1 58.7 66.6 0.4 527 Rural 41.6 97.2 82.5 26.7 45.0 1.1 860 Region Malé 68.4 97.0 60.1 58.7 66.6 0.4 527 North 49.4 94.3 89.1 27.5 52.5 1.7 178 North Central 40.9 99.7 86.0 23.1 44.0 0.3 196 Central 23.8 97.2 79.5 20.6 26.8 2.4 125 South Central 36.0 97.8 79.3 25.8 40.7 0.6 156 South 50.7 97.1 77.7 33.9 53.7 0.9 205 Education No education 31.1 95.0 90.8 3.5 28.7 1.3 311 Primary 47.9 96.9 78.9 22.5 48.1 1.3 470 Secondary 63.7 98.6 62.5 64.6 66.7 0.2 470 More than secondary 75.0 97.4 50.1 94.0 84.9 0.0 101 Wealth quintile Lowest 37.1 96.5 89.9 12.8 39.9 0.6 206 Second 36.9 97.6 84.1 18.5 38.0 0.8 235 Middle 44.5 97.1 77.6 33.0 48.0 1.6 298 Fourth 59.7 98.4 66.3 50.3 61.1 0.5 282 Highest 69.4 96.3 61.5 62.5 68.4 0.5 366 Total 15-49 51.8 97.2 74.0 38.9 53.2 0.8 1,388 50-64 44.8 94.3 89.9 15.6 44.9 1.3 339 Total men 15-64 50.4 96.6 77.1 34.3 51.6 0.9 1,727 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Education categories refer to the highest level of education attended, whether or not that level was completed. 1 Radio, television, or newspaper 14.5 EMPLOYMENT The 2009 MDHS asked ever-married men detailed questions about their employment status. Men who said that they were currently working and those who reported that they worked sometime during the 12 months preceding the survey are considered to have been employed. Additional information was collected on the type of work that the men did, the continuity of their work throughout the year, for whom they worked, and the form in which they received their earnings. Demographic and Health Indicators on Men │ 163 Overall, 93 percent of ever-married men were employed in the 12 months preceding the survey (Table 14.5). The variations in employment status across subgroups of men is generally small, with the exception that a much lower proportion of separated, divorced, or widowed men are currently employed than other men. Table 14.5 Employment status Percent distribution of ever-married men 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 Missing/ don't know Background characteristic Currently employed1 Not currently employed Total Number of men Age 15-19 * * * * 100.0 3 20-24 93.8 1.2 5.0 0.0 100.0 115 25-29 94.7 4.0 1.3 0.0 100.0 255 30-34 95.3 4.4 0.3 0.0 100.0 276 35-39 93.0 5.3 0.9 0.8 100.0 272 40-44 94.1 3.9 2.0 0.0 100.0 243 45-49 87.9 7.5 3.4 1.2 100.0 224 Marital status Married or living together 94.1 4.0 1.6 0.4 100.0 1,312 Divorced/separated/widowed 78.4 16.2 5.4 0.0 100.0 75 Number of living children 0 91.7 4.2 4.1 0.0 100.0 229 1-2 96.0 2.6 1.1 0.4 100.0 641 3-4 91.3 6.9 1.8 0.0 100.0 301 5+ 89.0 8.3 1.5 1.3 100.0 216 Residence Urban 96.4 1.5 1.2 0.9 100.0 527 Rural 91.3 6.6 2.1 0.0 100.0 860 Region Malé 96.4 1.5 1.2 0.9 100.0 527 North 89.6 7.0 3.3 0.0 100.0 178 North Central 90.6 6.2 3.2 0.0 100.0 196 Central 95.9 3.5 0.6 0.0 100.0 125 South Central 92.5 6.6 0.9 0.0 100.0 156 South 89.4 8.5 2.1 0.0 100.0 205 Education No formal education 90.9 6.0 2.2 0.9 100.0 311 Primary 92.5 5.4 2.1 0.0 100.0 470 Secondary 94.0 3.8 1.7 0.5 100.0 470 More than secondary 98.3 1.7 0.0 0.0 100.0 101 Wealth quintile Lowest 89.3 7.3 3.4 0.0 100.0 206 Second 91.0 6.1 2.9 0.0 100.0 235 Middle 92.9 5.5 1.6 0.0 100.0 298 Fourth 93.8 4.5 0.7 1.0 100.0 282 Highest 96.6 1.7 1.1 0.6 100.0 366 Total 15-49 93.2 4.7 1.8 0.4 100.0 1,388 50-64 89.8 2.9 6.8 0.5 100.0 339 Total men 15-64 92.5 4.3 2.8 0.4 100.0 1,727 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 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. 164 | Demographic and Health Indicators on Men 14.6 KNOWLEDGE OF CONTRACEPTION Table 14.6 shows that knowledge of family planning methods is virtually universal among all ever-married men and currently married men in Maldives. Almost all currently married men age 15-49 interviewed in the MDHS know at least one modern family planning method (99 percent). The male condom is the most widely recognized method (99 percent). More than 90 percent of men are also aware of the pill (94 percent) and female sterilization (93 percent), and 87-88 percent know about male sterilization and injectables. Almost eight in ten married men have heard of at least one traditional method of contraception. The mean number of methods known by men is 7.7. 14.7 IDEAL NUMBER OF CHILDREN In the 2009 MDHS, each ever-married man was asked to choose, regardless of his current situation, the number of children he would have if he could start anew. Overall, 16 percent of respondents did not give a response to the question, 28 percent stated that their ideal number of children is two, 21 percent said that they wanted three children, and 18 percent wanted to have four children. Table 14.7 shows that the number of living children and ideal family size are correlated; men who have a small number of children more often than other men want a small number of children. As parity increases, the ideal number of children also increases. Whereas men who have six or more children want to have 7.2 children, men with no children only want to have 2.6 children. Table 14.7 Ideal number of children Percent distribution of ever-married men 15-49 by ideal number of children, and mean ideal number of children for all ever- married men and for currently married men, according to number of living children, Maldives 2009 Number of living children1 Ideal number of children 0 1 2 3 4 5 6+ Total 0 0.0 0.3 1.3 2.2 0.6 0.0 0.8 0.8 1 3.1 3.3 0.0 0.0 1.2 0.0 0.0 1.4 2 57.5 38.9 35.4 11.3 4.9 0.4 2.4 27.7 3 18.5 29.7 24.2 23.9 10.1 10.7 4.7 20.9 4 8.8 11.7 18.7 27.5 39.8 17.4 12.1 17.9 5 2.4 3.9 6.5 12.6 12.1 39.4 2.3 8.1 6+ 2.7 0.2 1.9 3.3 6.2 18.7 41.3 7.1 Non-numeric responses 7.0 12.0 12.0 19.2 25.0 13.5 36.3 16.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 176 386 286 187 131 81 142 1,388 Mean ideal number children for:2 Ever-married men 15-49 2.6 2.7 3.0 3.7 4.1 5.2 7.2 3.5 Number 164 340 251 151 98 70 90 1,164 Currently married men 15-49 2.5 2.7 3.0 3.7 4.2 5.2 7.1 3.5 Number 140 329 242 140 90 67 85 1,092 Mean ideal number children for men 15-64:2 Ever-married men 15-64 2.6 2.7 3.1 3.6 4.2 5.2 6.8 3.7 Number 167.5 345.2 265.3 171.4 117.9 88.5 177.4 1,341.0 Currently married men 15-64 2.5 2.7 3.1 3.6 4.3 5.2 6.7 3.7 Number 143.0 334.7 255.5 160.1 109.6 85.7 172.3 1,260.9 1 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). 2 Means are calculated excluding respondents who gave non-numeric responses. Table 14.6 Knowledge of contraceptive methods Percentage of all ever married men and currently married men age 15-49 who know any contraceptive method, by specific method, Maldives 2009 Method All ever- married men Currently married men Any method 98.9 99.0 Any modern method 98.9 99.0 Female sterilization 92.1 93.2 Male sterilization 85.5 86.5 Pill 93.9 94.4 IUD 80.5 81.1 Injectables 88.1 88.4 Implants 58.8 59.7 Male condom 98.4 98.7 Emergency contraception 33.9 34.4 Any traditional method 76.2 76.8 Rhythm 67.9 68.6 Withdrawal 65.3 65.7 Folk method 2.4 2.0 Mean number of methods known by respondents 15-49 7.7 7.7 Number of respondents 1,388 1,312 Mean number of methods known by respondents 15-64 7.5 7.5 Number of respondents 1,727 1,634 Demographic and Health Indicators on Men │ 165 14.8 AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 14.8.1 Awareness of HIV/AIDS The 2009 MDHS respondents were asked whether they had heard of HIV or AIDS. Those who reported having heard of AIDS were asked a number of questions about whether and how HIV/AIDS could be avoided. Table 14.8 shows that awareness of AIDS is nearly universal (98 percent) among ever-married men age 15-49 in the Maldives. At least 95 percent of respondents have heard of AIDS in nearly all subgroups shown in the table. 14.8.2 Methods of HIV Prevention AIDS prevention programmes focus their mes- sages and efforts on three important aspects of be- haviour: condom use, staying faithful to one partner, and delaying first sexual intercourse in young persons (i.e., abstinence). Table 14.9 shows the percentage of ever- married men age 15-49 who, in response to prompted questions, agreed that specific actions would help an individual to avoid AIDS. More than eight in ten men recognize the use of condoms, abstaining from sex, and limiting sex to one partner who is not HIV positive as ways of avoiding AIDS. Three in four men recognize that using condoms and limiting sex to one partner who is not HIV positive are ways to prevent transmission of HIV. Overall, differentials in the levels of knowledge of the various modes of prevention are small. Among the largest differentials are the differences in the proportions who recognize condom use as a method of preventing HIV transmission by education; 81 percent of men with no formal education say that the risk of HIV trans- mission can be reduced by using condoms compared with 91 percent of men with more than secondary education. However, the educational differentials are not uniform, and no clear pattern is observed with regard to knowledge of other prevention methods. Table 14.8 Knowledge of AIDS Percentage of ever-married men age 15-49 who have heard of AIDS, by background characteristics, Maldives 2009 Background characteristic Has heard of AIDS Number of ever-married men Age 15-24 97.8 117 15-19 * 3 20-24 97.7 115 25-29 99.7 255 30-39 98.7 548 40-49 96.2 467 Marital status Married 98.2 1,312 Divorced/separated/ widowed 95.2 75 Residence Urban 97.7 527 Rural 98.2 860 Region Malé 97.7 527 North 97.4 178 North Central 98.6 196 Central 99.0 125 South Central 98.4 156 South 97.7 205 Education No formal education 95.6 311 Primary 97.7 470 Secondary 99.3 470 More than secondary 100.0 101 Wealth quintile Lowest 96.3 206 Second 98.7 235 Middle 97.8 298 Fourth 98.8 282 Highest 98.0 366 Total 15-49 98.0 1,388 50-64 91.6 339 Total men 15-64 96.7 1,727 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 166 | Demographic and Health Indicators on Men Table 14.9 Knowledge of HIV prevention methods Percentage of ever-married men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is not infected and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Maldives 2009 Background characteristic Using condoms Limiting sexual intercourse to one uninfected partner Using condoms and limiting sexual intercourse to one uninfected partner Abstaining from sexual intercourse Number of ever-married men Age 15-24 89.8 84.5 78.8 79.1 117 15-19 * * * * 3 20-24 89.5 84.4 78.6 78.9 115 25-29 88.8 85.9 75.8 88.4 255 30-39 87.4 83.3 74.7 85.9 548 40-49 83.7 84.9 74.9 85.6 467 Marital status Married 86.8 84.3 75.2 86.1 1,312 Divorced/separated/ widowed 84.1 86.9 77.3 78.7 75 Residence Urban 89.0 82.2 74.6 85.8 527 Rural 85.1 85.8 75.7 85.6 860 Region Malé 89.0 82.2 74.6 85.8 527 North 83.3 78.7 70.5 82.7 178 North Central 83.2 94.2 80.5 87.8 196 Central 88.1 85.3 77.3 86.7 125 South Central 87.2 90.3 80.9 87.2 156 South 85.3 80.9 70.7 84.2 205 Education No formal education 81.1 84.9 73.4 84.9 311 Primary 86.8 80.8 72.7 85.8 470 Secondary 88.5 86.6 77.5 85.8 470 More than secondary 91.0 91.0 82.0 84.2 101 Wealth quintile Lowest 85.4 85.5 77.1 90.0 206 Second 84.6 85.3 73.9 84.9 235 Middle 85.9 84.1 76.4 81.9 298 Fourth 86.7 86.4 75.4 89.6 282 Highest 89.1 82.0 74.2 83.9 366 Total 15-49 86.6 84.4 75.3 85.7 1,388 50-64 72.6 79.0 62.7 80.2 339 Total men 15-64 83.9 83.4 72.8 84.6 1,727 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 14.8.3 Comprehensive Knowledge about HIV/AIDS A person is considered to have comprehensive knowledge if she or he (1) knows that using condoms during sexual intercourse and having just one faithful, HIV-negative partner can reduce the chance of getting HIV, (2) knows that a healthy-looking person can have HIV, and (3) rejects the two most common local misconceptions about HIV transmission or prevention: that HIV can be transmitted by mosquito bites or by sharing food with a person who has HIV or AIDS. Table 14.10 shows that the majority of ever-married men age 15-49 were aware that AIDS cannot be transmitted by mosquito bites (72 percent), by sharing food with a person who has AIDS (86 percent) or by witchcraft or other supernatural means (88 percent). Seventy-eight percent of men correctly reported that a healthy-looking person can be infected HIV. Demographic and Health Indicators on Men │ 167 The results show that 44 percent of ever-married men age 15-49 have a comprehensive knowledge of AIDS. Urban men, those who live in Malé and the South Central region, men age 30-39, men who are divorced/separated or widowed, men with more than secondary education, and men who live in the wealthiest households are more knowledgeable about AIDS than other men. Table 14.10 Comprehensive knowledge about AIDS Percentage of ever-married men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Maldives 2009 Percentage who say that a healthy looking person can have the AIDS virus and who reject the two most common local miscon- ceptions1 Percentage of respondents who say that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Percentage with a compre- hensive knowledge about AIDS2 Number of men Age 15-24 71.9 65.2 82.3 70.3 46.9 40.3 117 15-19 * * * * * * 3 20-24 71.9 65.1 82.3 70.0 47.1 40.7 115 25-29 81.2 73.5 90.2 90.0 55.2 42.1 255 30-39 81.3 78.1 89.8 90.5 60.6 48.3 548 40-49 73.7 66.6 86.6 82.2 46.9 39.7 467 Marital status Married 77.7 72.0 88.4 86.0 53.4 43.1 1,312 Divorced/separated/ widowed 81.5 76.7 83.9 83.8 60.7 52.2 75 Residence Urban 83.6 75.9 88.7 88.3 59.1 47.6 527 Rural 74.5 70.1 87.9 84.4 50.6 41.1 860 Region Malé 83.6 75.9 88.7 88.3 59.1 47.6 527 North 80.1 67.2 84.2 87.3 51.4 39.7 178 North Central 73.8 74.3 92.5 84.1 53.6 46.0 196 Central 74.8 73.0 94.0 81.3 55.3 46.8 125 South Central 83.1 69.8 87.6 83.6 56.5 48.1 156 South 63.7 66.9 83.0 84.9 39.6 28.9 205 Education No formal education 69.9 59.8 82.1 76.9 39.0 35.7 311 Primary 76.9 72.3 91.3 87.2 55.2 42.9 470 Secondary 80.9 76.9 88.6 88.2 57.3 45.2 470 More than secondary 90.3 87.0 88.0 92.0 73.4 58.7 101 Wealth quintile Lowest 77.1 62.0 83.6 78.7 45.7 39.7 206 Second 70.7 72.7 90.3 86.4 51.7 43.6 235 Middle 74.8 70.0 89.7 85.9 53.2 43.2 298 Fourth 83.1 77.7 86.4 86.4 56.3 43.5 282 Highest 81.7 75.5 89.6 89.3 58.3 46.1 366 Total 15-49 77.9 72.3 88.2 85.9 53.8 43.6 1,388 50-64 72.5 47.1 75.3 70.3 31.5 21.5 339 Total men 15-64 76.9 67.3 85.7 82.8 49.4 39.3 1,727 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 1 Two most common local misconceptions are: people can get AIDS from mosquito bites and sharing food with a person who has AIDS. 2 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 168 | Demographic and Health Indicators on Men 14.8.4 Attitudes towards People Living with AIDS In the MDHS, to assess the level of stigma, survey respondents who had heard of AIDS were asked (1) if they would be willing to care for a relative sick with AIDS in their own households, (2) if they would be willing to buy fresh vegetables from a market vendor who had the AIDS virus, (3) if they thought a female or a male teacher who has the AIDS virus but is not sick should be allowed to continue teaching, and (4) if they would want to keep a family member’s infection with the AIDS virus a secret. The results shown in Table 14.11 indicate that most ever-married men age 15-49 are willing to care for a relative with the AIDS virus at home (92 percent), and 86 percent will buy fresh vegetables from a shopkeeper infected with the AIDS virus. Two in three men would allow a female teacher or a male teacher with the AIDS virus to keep teaching (66 percent each). Three in four men said that they would not keep secret the status of a family member infected by the AIDS virus, and 43 percent of men expressed accepting attitudes on all five indicators, indicating that some degree of stigma is associated with HIV/AIDS within Maldivian society. Table 14.11 Accepting attitudes towards those living with HIV/AIDS: Men Among ever-married men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes towards people with HIV/AIDS, by background characteristics, Maldives 2009 Percentage of respondents who: Background characteristic Are willing to care for a family member with the AIDS virus in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Say that a male teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Percentage expressing acceptance attitudes on all five indicators Number of respondents who have heard of AIDS Age 15-24 93.6 79.4 58.8 58.8 81.5 38.6 115 15-19 81.6 84.4 66.0 66.0 100.0 66.0 3 20-24 93.8 79.3 58.6 58.6 81.1 38.0 112 25-29 92.0 88.5 67.5 66.7 73.4 45.2 254 30-39 93.4 90.5 72.7 71.6 74.0 46.7 541 40-49 91.2 79.7 60.6 61.1 77.5 38.9 449 Marital status Married/Living together 92.9 85.2 67.0 66.7 75.8 43.7 1,288 Divorced/separated/widowed 84.8 93.0 57.8 56.2 73.5 34.3 72 Residence Urban 93.3 87.4 66.2 66.2 70.5 42.0 515 Rural 91.9 84.6 66.8 66.1 78.9 43.9 845 Region Malé 93.3 87.4 66.2 66.2 70.5 42.0 515 North 93.0 86.5 69.0 67.6 83.7 48.9 174 North Central 93.3 83.1 67.4 67.4 76.5 43.5 193 Central 93.8 80.8 70.8 70.4 76.7 47.2 124 South Central 92.6 83.7 65.7 65.2 80.1 44.8 153 South 87.8 87.2 62.8 61.6 77.4 37.1 201 Education No education 89.8 74.6 58.0 58.3 83.3 36.7 298 Primary 91.8 88.2 68.6 67.3 79.2 47.1 460 Secondary 93.7 88.8 67.4 67.3 68.6 41.6 467 More than secondary 94.8 88.1 78.8 78.8 71.8 53.2 101 Unknown - Certificate 97.8 97.1 65.2 65.2 70.5 39.5 35 Wealth quintile Lowest 94.0 84.5 61.0 60.4 84.5 41.6 199 Second 90.8 85.3 69.7 68.7 78.4 45.8 232 Middle 92.3 85.0 68.5 67.9 75.6 44.2 292 Fourth 89.2 84.3 66.5 66.9 75.3 41.5 279 Highest 95.2 88.1 66.2 65.7 69.4 42.8 359 Total 15-49 92.4 85.6 66.6 66.1 75.7 43.2 1,360 50-64 87.8 66.1 52.2 52.1 83.2 36.6 311 Total men 15-64 91.6 82.0 63.9 63.5 77.1 41.9 1,670 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Demographic and Health Indicators on Men │ 169 14.8.5 Multiple sexual partners Information on sexual behaviour is important in designing and monitoring inter- vention programmes to control the spread of HIV. The 2009 MDHS included questions about the respondent’s sexual partners over his lifetime. Table 14.12 shows, among ever- married men age 15-49 years who had sexual intercourse, the percentage who have had more than one sexual partner during their lifetime. The table also shows the mean number of lifetime sexual partners among these men. Thirty-six percent of men report having had sex with more than one partner in a lifetime. These men have on average 2.3 partners. The mean number of lifetime sexual partners increases with age from 1.7 among men age 15-24 to 2.9 among men age 40-49. The mean number of lifetime sexual partners is highest among men who are divorced, separated, or widowed (3.9). Urban men, men in the South, and men with no formal educa- tion have higher proportions of multiple part- ners compared with other men. 14.8.6 Knowledge of Place for HIV Testing Knowledge of HIV status helps HIV- negative individuals make specific decisions to reduce risk and increase safer sex practices so that they can remain disease free. For those who are HIV infected, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. To assess the awareness and coverage of HIV testing services, MDHS respondents were asked whether they knew a place where they could go to be tested. Table 14.13 presents the results of these questions. Overall, 84 percent of ever-married men age 15-49 know where to go to get an HIV test. This knowledge varies by the men’s characteristics. Married men, men who live in urban areas, and Malé residents are more knowledgeable than other men about the source for HIV testing. Knowledge of place for HIV testing increases with increasing education and wealth status. Table 14.12 Lifetime sexual partners Among ever-married men who have ever had sexual intercourse, the percentage who had 2 or more sexual partners during their lifetime and the mean number of sexual partners during their lifetime, by background characteristics, Maldives 2009 Among respondents who ever had sexual intercourse Background characteristic Percentage who had 2+ partners Mean number of sexual partners in lifetime Number of men Age 15-24 22.0 1.7 98 15-19 * * 2 20-24 22.0 1.8 96 25-29 29.9 2.0 219 30-39 31.2 2.2 463 40-49 48.4 2.9 388 Marital status Married 34.5 2.3 1,109 Divorced/separated/ widowed 62.3 3.9 59 Residence Urban 38.2 2.5 414 Rural 34.6 2.2 754 Region Malé 38.2 2.5 414 North 33.6 1.6 158 North Central 23.0 1.5 184 Central 26.1 1.7 110 South Central 38.0 3.2 134 South 50.8 3.3 169 Education No formal education 41.7 2.1 260 Primary 35.9 2.1 415 Secondary 35.8 2.9 380 More than secondary 21.5 2.0 82 Wealth quintile Lowest 33.2 2.3 180 Second 34.5 2.2 201 Middle 33.9 2.3 259 Fourth 41.0 1.9 244 Highest 36.0 2.8 283 Total 15-49 35.9 2.3 1,168 50-64 61.1 2.9 267 Total 15-64 40.6 2.4 1,435 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 170 | Demographic and Health Indicators on Men Table 14.13 Knowledge of place for HIV testing Percentage of ever-married men age 15-49 who know where to get an HIV test, according to background characteristics, Maldives 2009 Background characteristic Percentage who know where to get an HIV test Number of men Age 15-24 83.0 117 15-19 * 3 20-24 83.3 115 25-29 89.5 255 30-39 87.5 548 40-49 76.2 467 Marital status Married 84.1 1,312 Divorced/separated/ widowed 76.6 75 Residence Urban 91.9 527 Rural 78.7 860 Region Malé 91.9 527 North 75.3 178 North Central 80.5 196 Central 73.2 125 South Central 72.5 156 South 88.0 205 Education No formal education 67.8 311 Primary 83.5 470 Secondary 91.2 470 More than secondary 97.6 101 Wealth quintile Lowest 70.0 206 Second 76.3 235 Middle 83.5 298 Fourth 88.5 282 Highest 92.6 366 Total 15-49 83.7 1,388 50-64 67.2 339 Total men 15-64 80.4 1,727 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 14.9 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS In the 2009 MDHS, ever-married men were asked if they have had a disease they contracted through sexual contact in the past 12 months or if they have had symptoms associated with sexually transmitted infections (STIs): a bad-smelling, abnormal discharge from the penis or a genital sore or ulcer. Table 14.14 shows that 1 percent of ever-married men report having an STI and 1 percent of ever-married men age 15-49 report having STI symptoms. Men with more than secondary education report the highest infection rates (8 percent) followed by widowed, divorced, and separated men (5 percent). Demographic and Health Indicators on Men │ 171 Table 14.14 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms Among ever-married men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Maldives 2009 Percentage of men who reported having in the past 12 months: Background characteristic STI Bad- smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer Number of men who ever had sexual intercourse Age 15-24 0.9 2.3 1.3 3.2 117 15-19 * * * * 3 20-24 0.9 2.4 1.4 3.3 115 25-29 1.4 0.2 1.1 1.7 255 30-39 1.6 1.1 0.2 2.6 548 40-49 1.0 1.1 0.7 2.5 467 Marital status Married 1.4 0.8 0.7 2.3 1,312 Divorced/separated/ widowed 0.0 5.1 0.0 5.1 75 Residence Urban 1.4 0.9 0.7 2.6 527 Rural 1.2 1.1 0.6 2.3 860 Region Malé 1.4 0.9 0.7 2.6 527 North 0.0 0.9 0.9 0.9 178 North Central 2.2 0.4 0.5 2.6 196 Central 0.0 1.8 0.7 2.5 125 South Central 1.7 0.5 0.5 2.2 156 South 1.8 2.1 0.3 3.3 205 Education No formal education 1.2 1.2 0.5 2.3 311 Primary 0.4 0.6 0.3 1.1 470 Secondary 1.3 1.7 0.6 2.8 470 More than secondary 6.1 0.0 2.5 7.9 101 Total 15-49 1.3 1.0 0.6 2.4 1,388 50-64 0.2 1.5 0.2 1.7 339 Total men 15-64 1.1 1.1 0.5 2.3 1,727 Note: Total includes 35 men with information missing on education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 14.10 PREVALENCE OF MEDICAL INJECTIONS Non-sterile injections can pose a risk of infection with HIV and other diseases. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2009 MDHS were asked if they had received an injection in the past 12 months, and if so, the number of injections. Overall, 35 percent of ever-married men age 15-49 reported having had a medical injection in the past 12 months (Table 14.15). On average, men received 2.2 injections over the 12-month period. Respondents who had received an injection in the past 12 months were asked where they had obtained their last injection. Their responses are summarized in Figure 14.1. More than three in four men went to a public facility, and 22 percent went to a private medical facility. Among facilities in the public sector, the government health centre is the most often-used facility. When asked whether the last injection used a new syringe taken from an unopened package, 93 percent of men confirmed this was the case (Table 14.15). Hygienic compliance was most often reported by men who were attended by a community health worker and private doctor. Indhira Gandhi Memorial Hospital shows a lower compliance for maintaining sterility of medical instruments than other public sector sources (data not shown). 172 | Demographic and Health Indicators on Men Table 14.15 Prevalence of medical injections Percentage of ever-married men age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Maldives 2009 Background characteristic Percentage who received a medical injection in the past 12 months1 Average number of medical injections per person in the past 12 months Number of ever- married men For last injection, syringe and needle taken from a new, unopened package Number of men receiving medical injections in the past 12 months Age 15-24 34.3 1.4 117 (95.6) 40 15-19 * * 3 * 1 20-24 34.2 1.4 115 (95.4) 39 25-29 32.1 1.5 255 91.6 82 30-39 37.0 1.4 548 92.8 203 40-49 33.6 3.9 467 92.9 157 Residence Urban 30.9 2.4 527 89.9 163 Rural 37.0 2.2 860 94.4 319 Region Malé 30.9 2.4 527 89.9 163 North 38.6 2.2 178 96.9 69 North Central 34.9 2.3 196 92.5 68 Central 39.4 2.2 125 97.2 49 South Central 39.9 2.4 156 90.9 62 South 34.1 1.8 205 95.0 70 Education No formal education 34.4 4.1 311 92.7 107 Primary 35.1 2.5 470 94.3 165 Secondary 35.8 1.2 470 92.3 169 More than secondary 31.2 0.7 101 * 31 Wealth quintile Lowest 37.3 2.0 206 93.9 77 Second 40.9 2.6 235 93.6 96 Middle 34.3 1.8 298 97.2 102 Fourth 29.6 2.0 282 91.9 83 Highest 33.6 2.7 366 88.7 123 Total 15-49 34.7 2.2 1,388 92.9 482 50-64 35.1 2.6 1,727 92.3 607 Total 15-64 37.6 2.6 1,727 93.2 650 Note: Total includes 9 men with information missing on formal education level. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 1 Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. Demographic and Health Indicators on Men │ 173 14.11 MEN’S ATTITUDE TOWARDS EMPOWERMENT OF WOMEN The 2009 MDHS also obtained information from ever-married men on several measures of women’s status and empowerment. Specifically, men were asked questions about women’s partici- pation in specific household decisions, on their degree of acceptance of wife beating, and on their opinions about when a wife should be able to refuse sex with her husband. 14.11.1 Men’s View of Women’s Participation in Decision Making To assess women’s decision-making autonomy, information was collected on from men women’s participation in decisions concerning four areas: a respondent’s own health care, large household purchases, household purchases for daily needs, what to do with the money wife earns and how many children to have. Table 14.16 shows the distribution of currently married men age 15-49 by the person they think should have the final say in making specific decisions. The data show that, for household purchases for daily needs most men feel that wives should have a greater say, while one in ten men think that husbands should be the main decision maker. For the remaining decisions (major household purchases, what to do with the wife’s income, and how many children a couple should have) a large proportion of men think that wives and husbands should make the decision together. In fact, 82 percent of men think that family size should be decided jointly by a husband and his wife. Table 14.16 Women's participation in decision making according to men Percent distribution of currently married men 15-49 by person who they think should have a greater say in making decisions about four kinds of issues, Maldives 2009 Decision Wife Wife and husband equally Husband Don't know/ depends Missing Total Number of men Major household purchases 27.9 52.4 18.7 0.6 0.4 100.0 1,312 Purchases of daily household needs 60.4 28.9 9.5 0.8 0.4 100.0 1,312 What to do with the money wife earns 33.7 48.7 5.1 11.7 0.8 100.0 1,312 How many children to have 3.3 82.2 7.9 5.9 0.7 100.0 1,312 Figure 14.1 Type of Facility Where Last Medical Injection Was Received 76 19 12 12 27 5 1 22 11 0 3 7 1 1 TOTAL PUBLIC SECTOR Indhira Gandhi Memorial Hospital Government regional hospital Government atoll hospital Government health centre Government health post Community/family health worker Other public TOTAL PRIVATE MEDICAL Private hospital, clinic Private doctor Dental office Other private medical Hospital/clinic abroad Home Other location 0 20 40 60 80 Percent MDHS 2009 <1 <1 174 | Demographic and Health Indicators on Men Table 14.17 is presented to show the variations in married men’s attitudes towards their wife’s participation in specific household decisions. The results indicate that the majority of men (80 percent or higher) think that a wife, alone or jointly with her husband, should have a say in each of the four decisions. This is particularly true for purchasing daily household needs. Overall, 61 percent of married men age 15-64 agree that a wife should participate in all four of the specified decisions, and very few (4 percent) say that they should not participate in any of the decisions. There are small variations across subgroups of men. Interestingly, the degree of independence a woman should have in making household decisions, as perceived by men, declines with increasing age and wealth status. However, men with more than secondary education more often say that a wife should be involved in all the specified decisions than men with less education. Table 14.17 Men's attitude towards wives' participation in decision making Percentage of currently married men age 15-49 who think a wife should have the greater say alone or equal say with her husband on specific kinds of decisions, by background characteristics, Maldives 2009 Background characteristic Making major household purchases Making purchases for daily household needs What to do with the money the wife earns How many children to have All four decisions None of the four decisions Number of currently married men Age 15-19 * * * * * * 3 20-24 81.9 93.2 89.5 96.9 71.8 0.7 108 25-29 79.7 87.2 86.6 86.6 62.0 2.3 238 30-34 84.2 89.2 84.0 86.6 65.1 2.9 260 35-39 76.4 88.9 77.0 82.2 57.4 6.2 265 40-44 79.8 90.3 82.8 86.4 61.2 2.1 232 45-49 81.0 89.1 78.5 80.0 57.0 5.1 207 Employment (past 12 months) Not employed 71.0 74.7 100.0 95.3 71.0 0.0 21 Employed for cash 80.7 89.8 82.5 85.7 61.7 3.2 1,284 Number of living children 0 76.4 88.0 88.1 90.0 64.0 3.4 204 1-2 82.2 88.1 81.7 84.8 61.1 3.2 621 3-4 79.8 92.7 85.6 85.2 63.4 2.2 280 5+ 79.3 89.3 74.8 83.6 58.3 6.0 207 Residence Urban 83.0 88.3 80.2 84.8 60.5 3.2 491 Rural 78.7 89.9 83.8 85.9 62.2 3.6 821 Region Malé 83.0 88.3 80.2 84.8 60.5 3.2 491 North 78.1 95.6 85.4 84.4 59.3 0.0 168 North Central 63.9 80.3 78.7 79.3 53.0 10.0 191 Central 80.4 91.1 89.8 88.1 67.8 2.5 121 South Central 84.0 88.6 77.9 86.8 62.4 4.1 152 South 89.0 94.7 88.4 92.0 70.4 0.7 189 Education No education 79.7 89.3 84.1 83.0 59.7 4.4 303 Primary 77.6 89.0 80.8 85.5 59.0 3.1 436 Secondary 80.2 88.2 82.0 88.2 64.2 3.6 443 More than secondary 97.5 97.2 85.9 88.4 73.3 0.0 96 Wealth quintile Lowest 81.9 95.0 84.3 88.8 67.5 1.2 195 Second 77.3 88.0 84.0 83.3 58.7 4.2 216 Middle 78.2 89.7 82.3 87.1 63.7 4.5 290 Fourth 81.5 90.4 86.4 84.3 62.6 4.0 270 Highest 82.3 85.6 77.4 84.6 57.4 3.0 341 Total 15-49 80.3 89.3 82.4 85.5 61.6 3.5 1,312 50-64 79.6 90.5 80.4 80.3 57.2 4.2 321 Total men 15-64 80.2 89.5 82.0 84.5 60.7 3.6 1,634 Note: Total includes 9 men with information missing on employment. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Demographic and Health Indicators on Men │ 175 14.11.2 Attitudes towards Wife Beating To assess a women’s degree of acceptance of wife beating, the 2009 MDHS asked ever- married men, ‘Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations?’ The five situations presented to men for their opinion were: she burns the food, she argues with him, she goes out without telling him, she neglects the children, and she refuses to have sex with him. The first five columns in Table 14.8 show how men’s acceptance of wife beating varies in each situation. The last column shows the percentage of ever-married men who feel that a husband is justified in beating his wife for at least one of the specified reasons. Table 14.18 Attitude towards wife beating Percentage of ever-married men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Maldives 2009 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason Number Age 15-19 * * * * * * 3 20-24 1.0 8.0 2.0 11.4 1.8 14.9 115 25-29 1.0 6.1 2.2 7.4 2.9 12.4 255 30-34 2.5 9.2 4.6 9.3 4.4 12.8 276 35-39 3.0 10.0 5.9 9.8 7.4 15.1 272 40-44 0.0 6.5 6.3 10.0 2.8 16.8 243 45-49 4.4 8.4 7.8 12.3 6.1 14.6 224 Employment (past 12 months) Not employed 0.0 8.6 0.0 8.6 0.0 8.6 25 Employed for cash 2.1 8.1 5.1 9.9 4.6 14.5 1,355 Marital status Married 2.0 8.4 5.1 9.8 4.5 14.5 1,312 Divorced/separated/widowed 3.0 4.0 4.4 10.5 3.4 11.5 75 Number of living children 0 1.0 5.9 2.2 7.7 2.8 12.4 229 1-2 1.9 8.7 4.5 9.9 4.7 14.4 641 3-4 1.9 7.8 4.5 8.3 5.1 13.3 301 5+ 3.7 9.4 10.2 14.0 4.7 17.6 216 Residence Urban 2.7 7.9 3.9 7.9 5.5 12.8 527 Rural 1.7 8.2 5.7 11.0 3.8 15.3 860 Region Malé 2.7 7.9 3.9 7.9 5.5 12.8 527 North 1.6 9.2 8.1 15.8 6.2 20.0 178 North Central 2.4 9.7 7.7 10.6 3.5 17.5 196 Central 1.1 6.6 3.4 8.9 3.1 12.6 125 South Central 2.7 12.6 6.2 13.3 5.5 20.4 156 South 0.5 3.7 2.7 6.7 1.4 7.0 205 Education No formal education 2.3 9.3 8.6 15.2 3.6 18.5 311 Primary 3.2 8.5 6.1 9.4 5.6 13.8 470 Secondary 1.4 7.0 2.2 7.3 4.2 13.0 470 More than secondary 0.0 8.0 1.0 5.3 2.6 8.0 101 Wealth quintile Lowest 1.1 8.6 5.6 12.3 4.1 15.8 206 Second 2.9 9.2 4.9 11.3 3.7 15.4 235 Middle 1.2 7.1 7.0 9.5 3.6 14.1 298 Fourth 2.2 9.7 3.6 10.5 4.7 14.6 282 Highest 2.6 6.8 4.3 7.3 5.7 12.9 366 Total 15-49 2.1 8.1 5.0 9.8 4.5 14.3 1,388 50-64 3.2 7.0 7.0 9.3 6.2 11.5 339 Total men 15-64 2.3 7.9 5.4 9.7 4.8 13.8 1,727 Note: Total includes 9 men with information missing on employment and 35 men with information missing on formal education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker 176 | Demographic and Health Indicators on Men As shown in Table 14.18, very small percentages of ever-married men age 15-49 agree to each of the reasons justifying a husband beating his wife. Men most often agree that a husband has the right to beat his wife if she neglects the children (10 percent). Agreement with other reasons justifying a husband to beat his wife is 2 percent if she burns the food, 8 percent if the wife argues with her husband, 5 percent if she goes out without telling him, and 5 percent if she refuses to have sexual intercourse with him. The likelihood that a man justifies wife beating in at least one of the specified situations varies across age groups. Men with five or more living children have the highest rates of agreement with at least one reason justifying wife beating compared with men with 1-2 living children (18 percent compared with 12 percent). Residence appears to influence men’s attitudes towards wife beating. Men in rural areas agree with at least one reason justifying wife beating more often than men in urban areas. The proportions of men who agree with at least one reason for a husband to beat his wife are highest in the North and South Central regions (20 percent each) and lowest in the South region (7 percent). Education and wealth quintile have a negative relationship with men’s agreement with any reason for a husband to hit or beat his wife. 14.11.3 Attitudes towards Refusing Sexual Intercourse with Husband The extent of control women have over when and with whom they have sexual intercourse is an indicator of women’s empowerment and has implications for demographic and health outcomes. In the 2009 MDHS, ever-married men were asked whether a wife is justified in refusing to have sexual intercourse with her husband under three circumstances: she knows her husband has a sexually transmitted disease (STD); she is tired or not in the mood; and she knows her husband has sex with other women. Table 14.19 shows the percentage of ever-married men age 15-49 who believe that a wife is justified in refusing sexual intercourse with a husband in three specific circumstances. Most men (88 percent or higher) agree with each of the specified reasons for a wife to withhold sexual intercourse from her husband. Overall, 81 percent of men agree with all of the specified reasons for a wife to refuse sexual intercourse with her husband, and 3 percent agree with none of the reasons. Male agreement with any of the specified reasons for a wife to refuse sexual intercourse with her husband does not vary substantially and shows no uniform pattern. Demographic and Health Indicators on Men │ 177 Table 14.19 Attitude towards refusing sexual intercourse with husband Percentage of ever-married men age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Maldives 2009 Wife is justified in refusing intercourse with her husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of ever- married men Age 15-19 * * * * * 3 20-24 90.9 86.1 91.4 77.5 2.3 115 25-29 96.0 84.5 91.1 79.6 2.2 255 30-34 96.3 92.3 91.3 85.3 2.0 276 35-39 90.1 87.3 89.6 79.0 4.2 272 40-44 96.0 89.1 94.7 84.7 1.1 243 45-49 88.1 87.5 88.4 77.8 5.4 224 Employment (past 12 months) Not employed * * * * * 25 Employed for cash 93.6 88.3 91.5 81.4 2.5 1,355 Marital status Married 93.6 88.2 91.3 81.4 2.6 1,312 Divorced/separated/widowed 87.5 85.1 87.8 75.0 7.3 75 Number of living children 0 94.9 85.7 90.7 79.0 2.0 229 1-2 93.5 88.6 91.8 83.1 3.1 641 3-4 91.9 90.1 88.7 79.9 3.1 301 5+ 92.5 85.7 92.6 78.7 2.9 216 Residence Urban 94.4 89.1 92.7 84.6 3.1 527 Rural 92.5 87.3 90.1 78.8 2.8 860 Region Malé 94.4 89.1 92.7 84.6 3.1 527 North 91.9 86.7 91.5 78.1 2.3 178 North Central 96.2 89.1 94.3 84.1 0.5 196 Central 94.7 84.8 89.1 76.1 2.2 125 South Central 94.4 91.3 87.2 81.9 3.1 156 South 86.7 84.5 87.7 73.8 5.3 205 Education No formal education 90.4 87.3 90.2 77.8 3.6 311 Primary 94.4 89.4 91.6 82.8 2.4 470 Secondary 92.9 87.3 91.0 80.8 3.4 470 More than secondary 99.3 87.1 92.5 83.4 0.7 101 Wealth quintile Lowest 89.7 85.0 88.5 74.6 4.2 206 Second 91.9 87.6 92.9 82.0 4.2 235 Middle 96.0 91.2 89.5 81.7 0.4 298 Fourth 91.8 87.7 90.8 80.0 2.4 282 Highest 95.0 87.5 92.9 84.3 3.7 366 Total 15-49 93.2 88.0 91.1 81.0 2.9 1,388 50-64 94.0 88.2 89.3 81.3 3.8 339 Total men 15-64 93.4 88.0 90.7 81.1 3.1 1,727 Note: Total includes 8 men with information missing on employment and 40 men with information missing on formal education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Table 14.20 shows the percentage of ever-married men age 15-49 who think that a husband has the right to take certain actions when his wife refuses to have sexual intercourse with him when he wants her to. The four specified actions are: get angry and reprimand her, refuse her financial support, use force to have sexual intercourse, or have sexual intercourse with another woman. Overall, less than 1 percent of men agree that a man has the right to take all four of the specified actions if his wife refuses to have sexual intercourse with him, while 75 percent think that a man does not have the right to take any of the actions. Looking at specific actions, the highest proportion (20 percent) is for men who think that a husband has a right to get angry and reprimand his wife. 178 | Demographic and Health Indicators on Men Table 14.20 Men's attitude towards a husband's rights when his wife refuses to have sexual intercourse Percentage of ever-married men age 15-49 who consider that a husband has the right to certain behaviours when a woman refuses to have sex with him when he wants her to, by background characteristics, Maldives 2009 When a woman refuses to have sex with her husband, he has the right to: Background characteristic Get angry and reprimand her Refuse her financial support Use force to have sex Have sex with another woman Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of ever- married men Age 15-19 * * * * * * 5 20-24 18.2 6.1 0.8 1.5 0.0 78.0 132 25-29 15.3 8.1 1.6 2.8 0.0 78.6 248 30-34 21.0 11.1 3.3 2.2 0.7 75.3 271 35-39 23.5 15.9 3.6 3.6 0.8 70.5 251 40-44 19.5 9.7 2.1 3.4 0.4 76.7 236 45-49 20.9 10.7 4.4 5.3 0.4 73.3 225 Employment (past 12 months) Not employed * * * * * * 22 Employed for cash 20.3 10.8 2.9 3.3 0.4 74.8 1,337 Marital status Married 19.7 10.3 2.9 3.1 0.5 75.7 1,306 Divorced/separated/widowed 25.8 19.4 1.6 4.8 0.0 62.9 62 Number of living children 0 20.4 8.1 0.5 3.3 0.0 75.8 211 1-2 17.4 9.9 3.4 2.2 0.3 77.2 597 3-4 24.0 12.9 1.5 4.2 0.6 71.9 334 5+ 20.4 11.9 5.8 4.4 0.9 73.9 226 Residence Urban 20.6 9.9 0.9 5.8 0.9 74.0 223 Rural 19.8 10.8 3.2 2.7 0.3 75.4 1,145 Region Malé 20.6 9.9 0.9 5.8 0.9 74.0 223 North 25.9 15.2 5.1 3.8 0.6 70.3 158 North Central 14.8 7.8 1.7 3.0 0.4 80.9 230 Central 23.2 12.2 3.5 1.6 0.4 72.0 254 South Central 19.1 12.7 4.0 4.0 0.0 73.2 299 South 17.6 6.4 2.0 1.0 0.5 80.4 204 Education No education 21.1 10.4 3.9 4.5 0.6 75.5 355 Primary 21.4 12.6 3.4 2.8 0.8 72.8 500 Secondary 19.5 9.0 1.5 2.7 0.0 76.3 410 More than secondary 9.5 7.9 0.0 1.6 0.0 82.5 63 Wealth quintile Lowest 20.8 13.3 4.2 2.7 0.4 72.3 264 Second 22.6 11.8 4.0 3.4 0.3 73.7 323 Middle 18.7 9.3 2.5 2.8 0.5 77.3 396 Fourth 17.5 9.6 1.8 3.5 0.4 75.4 228 Highest 19.7 8.9 0.6 4.5 0.6 77.1 157 Total 15-49 20.0 10.7 2.9 3.2 0.4 75.1 1,368 50-64 24.8 8.9 5.6 3.6 1.7 71.3 359 Total men 15-64 21.0 10.3 3.4 3.3 0.7 74.3 1,727 Note: Total includes 9 men with information missing on employment and 40 men with information missing on formal education level. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. Youth-Related Issues | 179 YOUTH-RELATED ISSUES 15 15.1 INTRODUCTION One in four Maldivians belongs to the 15-24 age group. In number, they increased from 45,000 in 1995 to more than 75,000 in 2006 (MPND, 2006). In the immediate future, a steady increase in the number of persons entering the labour market and beginning their reproductive years can be expected. This group needs services to facilitate a successful transition to adulthood, including those services that specifically address reproductive and sexual health. Half of the households selected for the ever- married sample of women of the 2009 MDHS were selected for the male and young adults survey. In these households, all 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 eligible to be interviewed. The MDHS was limited to Maldivian citizens; non-Maldivians were included in the survey only if they were the spouse, son, or daughter of a Maldivian. The objective for involving the youth in the survey was to assess their knowledge and attitudes regarding issues of reproductive health, marriage and childbearing, sexual activity, and HIV/AIDS. The survey also collected information on tobacco, alco- hol, and drug use. Prior to conducting these inter- views, informed consent was obtained from the youth. For those who were under 18 years of age consent was obtained first from the youth’s parents or guardians. A total of 3,205 never-married women and men age 15-24 (youth) were identified as eligible for individual interview. Interviews were completed with 2,240 youth, comprising 1,213 women and 1,027 men. The response rate was higher for female youth (80 percent) than for male youth (61 percent). For both women and men, the response rate was slightly higher in rural than in urban areas. 15.2 RESPONDENT’S CHARACTERISTICS This section provides information on the demographic and socioeconomic characteristics of the young adult respondents in this survey. The main background characteristics that are used in subsequent chapters to distinguish subgroups of young adults by their knowledge, attitudes, and behaviour in the area of reproductive health are age, residence (urban-rural), and level of education. As shown in Table 15.2, the number of never-married women and men age 15-24 who have no formal education is fewer than 25, which prevents any estimates about this group from appearing in subsequent tables. Table 15.1 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 Households selected for youth survey Households selected 601 3,162 3,763 Households occupied 566 3,012 3,578 Households interviewed 481 2,758 3,239 Household response rate1 85.0 91.6 90.5 Interviews with women 15-24 Number of respondents 333 1,191 1,524 Number of eligible women interviewed 260 953 1,213 Eligible women response rate2 78.1 80.0 79.6 Interviews with men 15-24 Number of respondents 349 1,332 1,681 Number of eligible men interviewed 210 817 1,027 Eligible men response rate2 60.2 61.3 61.1 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents 180 | Youth-Related Issues There are more females than males in the sample; 54 percent and 46 percent, respectively. Seventy-three percent of the women and 69 percent of the men are in the younger age group (15-19). Respondents are more often found in rural areas (58 percent) than in urban areas (42 percent). Most of the respondents have a secondary or higher education (95 percent of women and 90 percent of men). Table 15.2 Background characteristics of respondents Percent distribution of never-married women and men age 15-24 by background characteristics, Maldives 2009 Women Men Background characteristic Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15 12.7 154 160 10.6 108 116 16 16.8 203 225 18.7 192 195 17 16.4 198 193 13.5 139 145 18 14.6 177 182 15.8 162 147 19 12.5 151 149 10.3 106 115 15-19 72.8 883 909 68.9 707 718 20 8.5 103 95 9.7 100 91 21 8.2 99 93 7.9 82 80 22 5.5 66 59 6.9 71 70 23 3.3 40 38 3.7 38 41 24 1.7 21 19 2.9 29 27 20-24 27.2 330 304 31.1 320 309 Residence Urban 41.9 508 260 42.2 433 210 Rural 58.1 705 953 57.8 594 817 Education No formal education 0.4 5 6 0.2 2 4 Primary 3.7 45 60 9.6 99 122 Secondary 89.0 1,080 1,088 87.4 897 875 More than secondary 5.6 68 47 2.1 21 18 Total 100.0 1,213 1,213 100.0 1,027 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. 15.3 CURRENT ACTIVITY In Table 15.3, young, never-married women and men are distinguished by the type of activity they were involved in during the seven days before the survey (i.e., going to school, holding a job, going to school and holding a job, or neither going to school nor holding a job). Thirty-six percent of never-married women age 15-24 and one in three never-married men age 15-24 attend school only, and one in three women and 39 percent of men work only. A small percentage of women and men go to school as well as hold a job (4 percent of women and 8 percent of men, respectively). A sizable proportion of women and men are neither attending school nor working (27 percent of women and 20 percent of men). As expected, the youngest respondents have the highest rates of school attendance, whereas the oldest respondents have the highest rates of working. Urban respondents are less often in school and more often at work than rural respondents. Better-educated women have higher rates of school attendance, while women with less education have higher rates of working. Among men, there is no clear pattern in the realtionship between level of education and school attendance. Better-educated men work less. The rate of women attending school while holding a job increases with increasing education level. Men show the opposite pattern. The proportion of women who are neither attending school nor working decreases with increasing education level; 36 percent of women with a primary education have stopped school and do not work compared with only 13 percent of women with more than secondary education. Men show the opposite pattern: 9 percent of men with primary education are neither attending school nor working, while the corresponding proportion for men with secondary education is 21 percent. Youth-Related Issues | 181 Table 15.3 Current activity Percent distribution of never-married women and men age 15-24 by current activity, according to background characteristics, Maldives 2009 Current activity Background characteristic Attending school only Working only Attending school and working Neither attending school nor working Other Total Number WOMEN Age 15-19 46.2 23.4 3.8 26.5 0.1 100.0 883 20-24 8.2 56.9 5.6 29.2 0.0 100.0 330 Residence Urban 29.7 35.1 6.1 29.1 0.0 100.0 508 Rural 40.3 30.6 3.0 25.9 0.1 100.0 705 Education No formal education * * * * * 100.0 5 Primary 46.3 16.5 0.0 35.8 1.4 100.0 45 Secondary 36.5 32.0 3.6 27.9 0.0 100.0 1,080 More than secondary (26.5) (41.3) (19.4) (12.8) (0.0) 100.0 68 Total 35.9 32.5 4.3 27.3 0.1 100.0 1,213 MEN Age 15-19 44.8 24.3 9.8 20.5 0.5 100.0 707 20-24 6.6 70.3 4.5 18.6 0.1 100.0 320 Residence Urban 22.6 42.9 8.9 25.1 0.4 100.0 433 Rural 40.4 35.5 7.6 16.1 0.4 100.0 594 Education No formal education * * * * * 100.0 2 Primary 29.5 50.1 11.0 9.4 0.0 100.0 99 Secondary 33.9 37.1 7.9 20.7 0.4 100.0 897 More than secondary * * * * * 100.0 21 Total 32.9 38.6 8.2 19.9 0.4 100.0 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.4 MEDIA EXPOSURE Table 15.4 shows that television is the most popular mass media among young people age 15-24; 98 percent of women and 96 percent of men report watching television at least once a week. Printed materials are the least popular (38 percent of women and 39 percent of men). Women more often than men listen to the radio at least once a week. However, use of the Internet is more popular among young men than among young women. Twelve percent of women and 15 percent of men are exposed at least once a week to the four media: radio, television, printed materials, and the Internet. In general, for both women and men, those who are older, those living in urban areas, and those who have completed secondary education have the most exposure to the media. 182 | Youth-Related Issues Table 15. 4 Exposure to mass media Percentage of never-married women and men age 15-24 who usually read a newspaper at least once a week, watch TV at least once a week, listen to the radio at least once a week, and use the Internet at least once a week, by background characteristics, Maldives 2009 Exposure to mass media Background characteristic Reads newspaper/ magazine at least once a week Watches TV at least once a week Listens to a radio at least once a week Uses the internet at least once a week All four media No media Number WOMEN Age 15-19 35.4 97.9 69.9 36.2 9.9 0.6 883 20-24 46.3 97.6 62.9 51.6 18.5 0.0 330 Residence Urban 45.7 97.2 54.8 62.6 18.7 0.0 508 Rural 33.1 98.3 77.6 24.3 7.5 0.8 705 Education No formal education * * * * * * 5 Primary 30.4 95.5 71.2 10.0 2.7 2.9 45 Secondary 37.3 98.0 68.6 38.3 11.2 0.4 1,080 More than secondary (57.2) (96.4) (56.7) (90.6) (32.2) (0.0) 68 Total 38.3 97.8 68.0 40.3 12.2 0.4 1,213 MEN Age 15-19 35.7 96.7 54.8 53.9 11.1 0.4 707 20-24 47.1 94.3 54.7 68.4 23.6 0.6 320 Residence Urban 56.5 92.7 43.3 84.5 23.2 0.4 433 Rural 26.6 98.4 63.1 39.3 9.0 0.5 594 Education No formal education * * * * * * 2 Primary 17.1 98.0 66.3 24.6 6.5 0.4 99 Secondary 40.3 95.8 54.0 61.7 15.4 0.5 897 More than secondary * * * * * * 21 Total 39.2 96.0 54.8 58.4 15.0 0.5 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.5 KNOWLEDGE OF THE FERTILE PERIOD Correct knowledge of a woman’s monthly reproductive cycle and the specific days when a woman is most likely to conceive leads to the success of the practice of periodic abstinence as a family planning method. Basic knowledge of the mechanisms of human reproduction is important. In the 2009 MDHS, all never-married respondents age 15-24 were asked about their knowledge of a woman’s fertile period in the menstrual cycle. First, they were asked whether there are certain days from one menstrual period to the next when a woman is more likely to become pregnant if she has sexual relations. Those who responded positively to this question were further asked when this time is; whether it is just before her period begins, during her period, right after her period has ended, or halfway between periods. Youth-Related Issues | 183 Data in Table 15.5 show that knowledge about the fertile period is deficient in young women as well as young men; more than half of the respondents age 15-19 cannot respond to the question (51 percent among women and 53 percent among men). Only 16 percent of women and 11 percent of men gave the correct response, that a woman has the greatest chance of becoming pregnant halfway between her periods. Older respondents are more knowledgeable about the fertile period than younger respondents. Only 8 percent of men age 15-19 gave the correct answer. Table 15.5 Knowledge of the fertile period Percent distribution of never-married women and men age 15-24 who know that there are certain days in a woman's menstrual cycle when she is more likely to become pregnant, by perceived fertile period, according to age, Maldives 2009 Women Men Perceived fertile period 15-19 20-24 Total 15-19 20-24 Total Just before period 6.4 5.1 6.1 3.9 4.3 4.0 During period 0.4 0.9 0.5 3.9 2.3 3.4 Right after period 15.2 26.3 18.3 12.1 20.1 14.6 Halfway between periods 14.7 19.4 16.0 8.2 16.9 10.9 At any time 8.3 9.6 8.6 14.3 13.2 14.0 Other 0.1 0.0 0.1 0.0 0.0 0.0 Don't know, missing 54.9 38.7 50.5 57.5 43.3 53.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 883 330 1,213 707 320 1,027 15.6 KNOWLEDGE OF FAMILY PLANNING METHODS In the 2009 MDHS data on knowledge of family planning methods were obtained by first asking the respondent to name the ways that a couple can delay or avoid a pregnancy. If the respondent did not spontaneously mention a particular contraceptive method, the interviewer probed by describing a method and asking the respondent if she or he recognized it. Descriptions were included in the questionnaire for ten modern family planning methods: female sterilization, male sterilization, the pill, the intrauterine device (IUD), injectables, implants, condom, periodic abstinence, withdrawal, and emergency contraception. Data in Table 15.6 indicate that knowledge of contraceptive methods is widespread among never-married young adults in Maldives; more than 90 percent of young women and men have heard of a method of family planning. Knowledge about contraceptive methods is equal among women and men (94 percent and 93 percent, respectively). Almost all never-married young adults who have heard of at least one contraceptive method have heard of modern methods. Knowledge of traditional methods is limited (44 percent of women and 51 percent of men). On average, never-married women and men know about 5.5 methods. The most commonly known methods among unmarried women age 15-24 are male condoms (86 percent), followed closely by female sterilization (85 percent). As expected, for unmarried men age 15-24, the most commonly known method is condoms (91 percent). Knowledge of the pill and female sterilization among men is also high (74 percent each). The least familiar family planning method among young women is emergency contraception (27 percent), possibly because it was only introduced in 2007. For men, the least known family planning method is implants (27 percent), also because it was only introduced in 2006 and only available in Malé. Implants were cited by 37 percent of women. Higher proportions of never-married women and men age 20-24 have heard of family planning methods compared with their younger counterparts (age 15-19). For example, knowledge of modern contraceptive methods among never-married women age 15-19 is 93 percent, compared with 96 percent for never-married women age 20-24. 184 | Youth-Related Issues Table 15.6 Knowledge of contraceptive methods Percentage of never-married women and men age 15-24 who know specific contraceptive methods by age, Maldives 2009 Women Men Contraceptive method 15-19 20-24 Total 15-19 20-24 Total Any method 92.6 96.0 93.5 92.0 95.4 93.1 Any modern method 92.6 96.0 93.5 92.0 95.4 93.1 Female sterilization 82.6 90.6 84.8 69.2 84.5 73.9 Male sterilization 50.3 64.8 54.2 53.7 70.2 58.9 Pill 75.3 85.7 78.2 69.7 83.4 73.9 IUD 42.4 60.5 47.3 35.6 55.0 41.7 Injectables 64.2 75.4 67.2 56.5 71.9 61.3 Implants 31.4 51.6 36.9 22.8 36.0 26.9 Male condom 83.2 92.6 85.8 88.7 94.8 90.6 Emergency contraception 25.0 32.8 27.1 25.9 37.0 29.3 Any traditional method 38.6 59.5 44.2 46.4 62.1 51.3 Rhythm 30.7 51.0 36.2 31.6 38.9 33.8 Withdrawal 24.3 39.6 28.4 37.5 54.7 42.8 Folk method 1.7 3.6 2.2 2.1 4.2 2.7 Number 883 330 1,213 707 320 1,027 Mean number of methods known 5.1 6.5 5.5 4.9 6.3 5.4 15.7 DECISION ABOUT MARRIAGE In the 2009 MDHS, never-married women and men age 15-24 were asked who is going to choose the person they are going to marry: their parents, themselves, or their parents together with them. These findings are presented in Table 15.7. Data in the table show that higher proportions of women compared with men say that they and their parents jointly are the primary decision-makers about their future husband (59 and 38 percent, respectively). On the other hand, more men than women say that they themselves will decide whom they will marry (58 and 36 percent, respectively). This may be because men do not need parental consent for marriage. Although parents still play a role in determining their future spouse, few respondents report that their parents alone will mainly decide whom their future spouse will be (4 percent for women and 3 percent for men). Women age 15-19 in higher proportions than women age 20-24 say that they, together with their parents, are going to make the decision about whom they will marry (61 percent compared with 51 percent). Men show a similar pattern (40 percent and 35 percent, respectively). The involvement of parents in making the decision about a future partner varies by the respondent’s residence and education; more urban respondents than rural residents say that they themselves will make a decision on whom to marry. Although a women’s education does not have a strong relationship with her attitude about who will make the decision about a marriage partner, men with secondary education more often than men with primary education say that they want to make the decision themselves. Youth-Related Issues | 185 Table 15.7 Decision on whom to marry Percent distribution of never-married women and men age 15-24 by who makes the decision on whom the respondent will marry, according to background characteristics, Maldives, 2009 Decision-maker Background characteristic Mainly parents Mainly self Parents and self jointly Other Don't know/ missing Total Number WOMEN Age 15-19 4.4 32.9 61.4 0.7 0.6 100.0 883 20-24 3.7 45.5 50.8 0.0 0.0 100.0 330 Residence Urban 3.4 41.0 54.0 0.9 0.7 100.0 508 Rural 4.8 32.9 61.8 0.2 0.3 100.0 705 Education No formal education * * * * * 100.0 5 Primary 9.5 36.5 54.0 0.0 0.0 100.0 45 Secondary 4.2 36.8 57.9 0.6 0.5 100.0 1,080 More than secondary (0.0) (32.8) (67.2) (0.0) (0.0) 100.0 68 Total 4.2 36.3 58.5 0.5 0.5 100.0 1,213 MEN Age 15-19 3.5 56.0 39.7 0.1 0.6 100.0 707 20-24 3.1 61.4 34.7 0.6 0.2 100.0 320 Residence Urban 2.1 62.9 34.7 0.0 0.4 100.0 433 Rural 4.3 53.9 40.6 0.5 0.6 100.0 594 Education No formal education * * * * * 100.0 2 Primary 2.2 50.6 47.2 0.0 0.0 100.0 99 Secondary 3.7 58.0 37.6 0.3 0.4 100.0 897 More than secondary * * * * * 100.0 21 Total 3.4 57.7 38.1 0.3 0.5 100.0 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.8 DECISION ON NUMBER OF CHILDREN The 2009 MDHS respondents were also asked, ‘Who do you think should mainly decide how many children a couple should have, the husband, the wife, or both together?’ Table 15.8 presents the findings. Overall, nearly all respondents say that husband and wife together should make the decision on the number of children they are going to have (97 percent of women and 97 percent of men). Individual decision-making on number of children is not popular among either women or men. For instance, only 2 percent each of women and men think that a husband alone should decide the number of children. Similarly, less than 1 percent each of women and men think that a wife alone should decide the number of children. There is little variation across age groups and residence. However, the variation is notable across education levels. The proportion of never-married women and men who say that husband and wife jointly should decide on the number of children that they will have increases with their education level. For instance, this opinion is expressed by 92 percent of women with primary education compared with 97 percent of women with more than secondary education. 186 | Youth-Related Issues Table 15.8 Decision on number of children Percent distribution of never-married women and men age 15-24 by who they think should make the decision on the number of children to have, according to background characteristics, Maldives, 2009 Decision-maker Background characteristic Mainly husband Mainly wife Wife and husband jointly Other Don't know/ missing Total Number WOMEN Age 15-19 1.4 0.5 96.8 0.4 0.9 100.0 883 20-24 2.6 1.5 95.9 0.0 0.0 100.0 330 Residence Urban 1.8 1.2 95.9 0.0 1.1 100.0 508 Rural 1.7 0.5 97.0 0.5 0.3 100.0 705 Education No formal education * * * * * 100.0 5 Primary 6.3 1.4 92.4 0.0 0.0 100.0 45 Secondary 1.5 0.6 96.8 0.4 0.7 100.0 1,080 More than secondary (0.0) (3.4) (96.6) (0.0) (0.0) 100.0 68 Total 1.7 0.8 96.6 0.3 0.6 100.0 1,213 MEN Age 15-19 1.7 1.1 96.3 0.3 0.6 100.0 707 20-24 1.3 0.4 98.0 0.0 0.3 100.0 320 Residence Urban 0.3 0.3 99.0 0.0 0.4 100.0 433 Rural 2.5 1.2 95.3 0.4 0.6 100.0 594 Education No formal education * * * * * 100.0 2 Primary 5.9 2.4 90.3 0.0 1.4 100.0 99 Secondary 1.2 0.7 97.6 0.2 0.3 100.0 897 More than secondary * * * * * 100.0 21 Total 1.6 0.9 96.8 0.2 0.5 100.0 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.9 DISCUSSION ON REPRODUCTIVE HEALTH One of the objectives of the 2009 MDHS was to find out the sources from which young adults in Maldives obtained information on reproductive health. In the survey, respondents were asked whether they had discussed with anyone issues related to human reproduction and sexuality. Table 15.9 shows that one in four women (25 percent) and 22 percent of men had not talked about reproductive health and sexuality with anyone. Among those who talked, respondents more often talked with friends of the same sex; 57 percent of female respondents talked with their female friends and 66 percent of male respondents talked with their male friends. In addition to friends, the majority of the women who discussed reproductive health issues more often talked with persons of the same sex (e.g., mothers or sisters). Men, on the other hand, are more open to talking about reproductive health with persons of the opposite sex, such as female friends or girlfriends (34-35 percent each). Youth-Related Issues | 187 Table 15.9 Discussion of reproductive health Percentage of never-married youth age 15-24 by person with whom they talked about reproductive health, by background characteristics, Maldives 2009 Discuss reproductive health with: Background characteristic Mother Father Brother Sister Male friend Female friend Boyfriend/ girlfriend Female teacher Male teacher Health provider No one Number WOMEN Age 15-19 24.6 0.6 1.7 32.1 6.0 53.8 12.9 34.9 12.2 17.3 27.4 883 20-24 22.3 1.6 1.4 44.0 12.5 66.2 40.6 40.6 16.0 29.7 19.9 330 Residence Urban 31.5 1.7 2.3 47.8 11.9 63.5 26.2 37.2 13.9 21.3 19.4 508 Rural 18.5 0.3 1.2 26.4 4.8 52.6 16.2 35.9 12.7 20.2 29.6 705 Education No education * * * * * * * * * * * 5 Primary 12.9 1.3 0.0 21.5 2.3 50.4 13.9 26.8 7.8 22.0 36.3 45 Secondary 23.3 0.9 1.6 33.7 7.0 55.8 18.8 35.5 12.7 19.4 25.8 1,080 More than secondary (40.9) (0.0) (4.1) (70.5) (24.7) (86.3) (52.3) (59.4) (28.5) (41.1) (4.6) 68 Total 23.9 0.9 1.7 35.3 7.8 57.2 20.4 36.4 13.2 20.6 25.3 1,213 MEN Age 15-19 3.3 2.3 11.5 3.9 60.8 26.8 24.1 20.0 31.2 8.3 25.1 707 20-24 1.5 1.3 11.3 4.7 78.1 49.9 58.3 16.6 29.3 21.8 15.0 320 Residence Urban 4.1 1.7 14.9 6.3 71.8 43.6 46.7 25.3 30.9 15.9 16.1 433 Rural 1.7 2.2 8.9 2.6 62.0 27.0 26.1 14.3 30.4 10.1 26.1 594 Education No education * * * * * * * * * * * 2 Primary 3.6 2.7 7.3 2.9 61.6 25.3 25.8 9.3 20.1 13.3 27.6 99 Secondary 2.4 1.9 11.5 4.2 66.7 34.5 35.7 19.8 31.8 11.7 21.0 897 More than secondary * * * * * * * * * * * 21 Total 2.7 2.0 11.5 4.2 66.1 34.0 34.8 19.0 30.6 12.5 21.9 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. The role of teachers in imparting knowledge about reproductive health is significant. Both men and women talked with teachers of the same sex more often than they talked with teachers of the opposite sex. More than one-third of young, never-married women reported talking with a female teacher while 13 percent had talked to a male teacher. Among young, never-married men, 31 percent had talked with a male teacher, and 19 percent had talked with a female teacher. Health service providers play a less significant role as a source of information on reproductive health (21 percent for women and 13 percent for men). Overall, for both women and men, the younger, rural, and less educated respondents dis- cussed reproductive health less often than other respondents. 15.10 USE OF TOBACCO Tobacco smoking is associated with major health problems. Information about smoking behaviour can be used to predict the prevalence of noncommunicable diseases such as cardiovascular diseases, diabetes, chronic obstructive pulmo- nary diseases, and cancer (Truelsen and Bonita, 2002). An understanding of the full impact of tobacco use on a population’s health requires data on frequency or level of exposure to tobacco smoke, duration of exposure, and quantity or magnitude of exposure. Data for female youth are not presented because fewer than 25 women reported to smoke. Table 15.10 provides information on smoking behaviour among young men. Table 15.10 Cigarette smoking Percentage of never-married men age 15-24 who are currently smoking by background characteristics, Maldives 2009 Background characteristic Percent Number Age 15-19 19.8 707 20-24 42.0 320 Residence Urban 22.7 433 Rural 29.6 594 Education No formal education * 2 Primary 39.8 99 Secondary 25.4 897 More than secondary * 21 Total 26.7 1,027 Note: Total includes 8 men with information missing on level of education. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 188 | Youth-Related Issues Comparison across subgroups of men reveals that smoking is more common among older men, rural men, and less educated men. 15.11 KNOWLEDGE OF AIDS Table 15.11 shows the percentages of never-married women and men age 15-24 who have heard of AIDS. Overall, 96 percent each of women and men say that they have heard of AIDS. Older respondents, those who live in urban areas, and those with higher education report higher rates of having heard of AIDS. Table 15.11 Knowledge of AIDS Percentage of never-married women and men age 15-24 by who have heard of AIDS, by background characteristics, Maldives, 2009 Women Men Background characteristic Has heard of AIDS Number Has heard of AIDS Number Age 15-19 95.1 883 95.0 707 20-24 97.2 330 98.5 320 Ever had sexual intercourse Yes 100.0 43 98.6 101 No 97.3 586 97.3 466 Residence Urban 99.6 508 99.3 433 Rural 92.8 705 93.7 594 Education No formal education * 5 * 2 Primary 83.3 45 88.7 99 Secondary 96.1 1,080 96.7 897 More than secondary (100.0) 68 * 21 Total 95.7 1,213 96.1 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.12 Knowledge of HIV Prevention Methods HIV is mainly transmitted through heterosexual contact between an infected partner and an uninfected partner. Consequently, HIV prevention programs focus their messages and efforts on three important aspects of behaviour: use of condoms, limiting the number of sexual partners or staying faithful to one partner, and delaying sexual debut for young persons (abstinence). To ascertain whether the programs have effectively communicated these messages, MDHS respondents were asked specific questions about whether it is possible to reduce the chances of getting HIV by using a condom at every sexual encounter, limiting sexual intercourse to one uninfected partner, and abstaining from sex. Table 15.12 shows the levels of knowledge of various HIV prevention methods by background characteristics. Six in ten never-married women age 15-24 and 76 percent of never- married men age 15-24 know that using condoms can reduce the risk of contracting HIV. This knowledge is higher for respondents in urban areas and those with higher education. Youth-Related Issues | 189 More than three in four young, never-married women and men say that limiting sexual intercourse to one uninfected partner can prevent them from getting the AIDS virus (78 percent and 77 percent, respectively). Fifty-one percent of women and 62 percent of men say that using condoms and limiting sexual intercourse to one uninfected partner can reduce the risk of getting HIV. Additionally, 73 percent of women and 78 percent of men say that not having sexual intercourse at all can reduce the risk of contracting HIV. Knowledge for all four prevention methods is highest among those age 20-24 and those with a high level of education. Table 15.12 Knowledge of HIV prevention methods Percentage of never-married youth 15-25 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one uninfected sex partner who has no other partners, and by abstaining from sexual intercourse, by background characteristics, Maldives 2009 Women Men Background characteristic Using condoms Limiting sexual intercourse to one uninfected partner Using condoms and limiting sexual intercourse to one uninfected partner Abstaining from sexual intercourse Number Using condoms Limiting sexual intercourse to one uninfected partner Using condoms and limiting sexual intercourse to one uninfected partner Abstaining from sexual intercourse Number Age 15-19 55.2 76.5 47.1 71.6 883 71.7 72.8 56.6 75.3 707 20-24 68.8 81.9 61.2 77.6 330 85.0 86.2 74.8 84.7 320 Ever had sexual intercourse Yes 77.2 85.7 68.0 84.6 43 89.5 83.9 75.3 85.5 101 No 63.4 84.0 57.5 75.7 586 81.3 81.7 68.7 82.7 466 Residence Urban 65.9 77.4 53.4 75.7 508 87.8 79.7 71.5 84.0 433 Rural 53.9 78.4 49.1 71.4 705 67.1 75.0 55.6 74.1 594 Education No formal education * * * * 5 * * * * 2 Primary 49.2 61.5 34.7 61.2 45 63.9 68.4 49.6 71.6 99 Secondary 57.8 78.8 50.6 73.0 1,080 76.5 77.5 62.9 78.3 897 More than secondary (86.6) (82.3) (68.9) (84.2) 68 * * * * 21 Total 58.9 78.0 50.9 73.2 1,213 75.8 77.0 62.3 78.3 1,027 Note: Total includes 15 women and 8 men with information missing on level of education. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Women’s Other Health Issues | 191 WOMEN’S OTHER HEALTH ISSUES 16 Respondents in the 2009 MDHS individual interviews were asked a series of questions designed to obtain information on knowledge, attitudes, and personal experiences regarding a variety of adult health issues: tuberculosis, tobacco use, exercise, diabetes, hypertension, heart attack, and stroke. 16.1 KNOWLEDGE AND ATTITUDES REGARDING TUBERCULOSIS Respondents were asked if they had ever heard of tuberculosis (TB), knew how TB was spread, and believed the disease was curable. Additionally, respondents were asked whether or not they would want other people to know if a family member had TB. Table 16.1 shows that knowledge of TB among women in Maldives is almost universal (96 percent, with small variations across background characteristics. Among ever-married women, knowledge of TB increases slightly with educational attainment. For example, 95 percent of women with no formal education have heard of TB compared with 99 percent of women with more than secondary education. Table 16.1 Knowledge and attitude concerning tuberculosis Percentage of ever-married women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentage who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Maldives 2009 Among all respondents Among respondents who have heard of TB, the percentage who Background characteristic Percentage who have heard of TB Number of ever- married women Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member's TB kept secret Number of women who have heard of TB Age 15-19 94.3 119 49.4 72.9 5.4 112 20-24 95.3 1,268 60.8 89.6 6.7 1,208 25-29 97.2 1,539 76.0 94.3 8.5 1,496 30-34 96.9 1,287 79.2 96.8 8.1 1,246 35-39 96.3 1,185 79.1 97.1 6.6 1,140 40-44 95.8 1,013 74.1 98.8 7.2 970 45-49 94.9 721 75.0 96.6 5.5 684 Residence Urban 95.8 2,368 80.4 95.3 8.6 2,268 Rural 96.3 4,763 70.3 94.7 6.6 4,589 Region Malé 95.8 2,368 80.4 95.3 8.6 2,268 North 96.1 1,067 71.7 96.6 5.4 1,025 North Central 97.8 1,038 63.9 94.4 8.3 1,015 Central 97.2 615 74.3 93.0 6.7 598 South Central 96.9 853 77.6 96.6 6.8 827 South 94.5 1,190 67.2 92.9 6.0 1,124 Education No formal education 95.0 1,668 72.5 97.5 6.0 1,585 Primary 95.2 2,464 73.9 95.1 6.6 2,346 Secondary 97.4 2,584 72.2 92.9 7.9 2,516 More than secondary 99.4 333 84.9 95.8 11.0 331 Wealth quintile Lowest 95.5 1,300 68.7 95.0 5.4 1,241 Second 96.6 1,396 71.1 94.5 5.7 1,349 Middle 96.5 1,488 71.9 95.6 7.5 1,436 Fourth 96.4 1,447 74.6 94.0 8.9 1,395 Highest 95.7 1,499 80.9 95.3 8.5 1,435 Total 96.2 7,131 73.6 94.9 7.3 6,858 Note: Total includes 79 cases for which information on woman’s formal education level is missing. 192 | Women’s Other Health Issues Three in four women (74 percent) who have heard of TB correctly say that TB is spread through the air when coughing or sneezing. Correct knowledge of how TB is spread generally increases with age. Knowledge varies across regions, ranging from 64 percent in the North Central region to 80 percent in Malé for women. Knowledge of the way TB is spread generally increases with educational attainment Sixty-nine percent of women in the lowest wealth quintile have correct knowledge compared with 81 percent of women in the highest wealth quintile. Overall, 95 percent of women believe that TB can be cured. Belief in the possibility that TB can be cured varies only by age. More than 95 percent of women age 30-49 believe that TB can be cured compared with 73 percent of women age 15-19. Wanting to keep a family member’s illness a secret is a sign of stigma against persons with TB. Only 7 percent of women and men in Maldives say they would want to keep secret a family member’s TB illness. Women living in urban areas and women with more than secondary education are slightly more likely to want to keep the illness a secret. Table 16.2 provides additional information on the modes by which women in Maldives believe TB can be transmitted. Among women who have heard of TB, 74 percent of women say TB is spread through the air by coughing, 43 percent say that TB is spread by sharing utensils, 10 percent say that TB is spread by touching a person with the disease; and 13 percent of women say that TB is spread through food. Table 16.2 Knowledge of TB transmission modes Among ever-married women age 15-49 who heard of tuberculosis, the percentage who cite specific TB transmission modes, by background characteristics, Maldives 2009 TB modes of transmission Background characteristic Through air when coughing By sharing utensils By touching a person with TB Through food Through sexual contact Through mosquito bites Through blood contact/ trans- fusions Other Don't know Number of women Age 15-19 49.4 23.0 11.3 9.1 7.3 3.6 2.4 0.0 42.8 112 20-24 60.8 26.3 6.9 7.6 4.6 1.6 0.7 1.7 27.1 1,208 25-29 76.0 36.1 7.9 10.7 2.9 1.2 0.7 1.6 15.6 1,496 30-34 79.2 43.8 9.6 12.2 2.7 0.8 1.0 1.4 12.0 1,246 35-39 79.1 50.0 12.6 16.6 2.9 1.6 1.0 1.1 8.4 1,140 40-44 74.1 55.9 12.8 19.6 4.5 2.0 0.5 1.5 7.7 970 45-49 75.0 58.8 13.6 18.6 4.1 1.7 0.0 0.4 8.4 684 Residence Urban 80.4 44.1 9.7 13.5 2.3 1.4 0.7 1.4 10.6 2,268 Rural 70.3 42.4 10.4 13.4 4.2 1.5 0.8 1.3 16.3 4,589 Region Malé 80.4 44.1 9.7 13.5 2.3 1.4 0.7 1.4 10.6 2,268 North 71.7 42.1 9.9 3.9 3.2 0.9 0.5 1.0 14.9 1,025 North Central 63.9 44.0 13.3 20.6 4.9 1.4 0.9 0.9 19.7 1,015 Central 74.3 43.1 9.4 12.1 3.7 1.6 0.8 1.3 15.8 598 South Central 77.6 43.1 12.1 17.6 5.7 2.8 0.5 2.0 11.3 827 South 67.2 40.1 7.4 13.2 3.7 1.2 1.1 1.4 18.3 1,124 Education No formal education 72.5 54.7 12.3 16.9 4.7 1.3 0.4 1.0 10.1 1,585 Primary 73.9 43.1 10.8 13.2 3.0 0.9 0.9 1.3 14.8 2,346 Secondary 72.2 35.0 8.2 11.4 3.7 2.2 0.8 1.6 17.6 2,516 More than secondary 84.9 44.1 8.3 14.4 0.7 0.6 0.9 1.4 9.3 331 Wealth quintile Lowest 68.7 41.7 9.4 11.1 4.3 0.8 0.6 1.2 17.0 1,241 Second 71.1 43.2 11.1 13.8 4.0 2.2 0.8 1.6 15.9 1,349 Middle 71.9 43.3 10.6 14.7 4.5 1.6 0.9 0.9 15.6 1,436 Fourth 74.6 42.0 8.7 13.4 3.4 0.9 0.4 1.4 14.8 1,395 Highest 80.9 44.3 10.8 13.9 1.8 1.8 0.9 1.7 9.2 1,435 Total 73.6 42.9 10.1 13.4 3.6 1.5 0.7 1.3 14.4 6,858 Note: Total includes 79 cases for which information on woman’s formal education level is missing. Women’s Other Health Issues | 193 16.2 USE OF TOBACCO Tobacco leaves are used in various ways. They are dried and rolled into cigarettes and cigars for smoking, shredded and inserted into pipes (also for smoking), and finely pulverised for inhalation as snuff. Smoking has been shown to have significant adverse health effects, including an increased risk of respiratory and cardiovascular illnesses, both for the individual smoker and for other people exposed to second-hand, or environmental, tobacco smoke (WHO, 2002). Information on women’s use of tobacco was collected during the 2009 MDHS. Table 16.3 shows that 91 percent of women do not use tobacco. Among women who use tobacco, 2 percent smoke cigarettes and 7 percent use other forms of tobacco. Tobacco use varies by background characteristics. For example, older women are much more likely to use tobacco than younger women. Tobacco use increases from 1 percent among women age 15-19 to 25 percent among women age 45-49. Tobacco use is also more common among women in the Central region, women with no formal education and women in the lowest wealth quintile than among other women. Less than 5 percent of women who are pregnant or breastfeeding report using cigarettes or other tobacco. Table 16.3 Use of tobacco Percentage of ever-married women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, according to background character- istics and maternity status, Maldives 2009 Background characteristic Cigarettes Other tobacco Does not use tobacco Number of women Age 15-19 0.6 0.8 98.6 119 20-24 0.9 0.7 98.3 1,268 25-29 1.0 0.9 98.1 1,539 30-34 2.4 4.2 93.7 1,287 35-39 2.7 8.8 88.7 1,185 40-44 3.7 .15.0 81.3 1,013 45-49 4.7 20.7 74.9 721 Residence Urban 3.3 3.9 92.7 2,368 Rural 1.7 8.2 90.3 4,763 Region Malé 3.3 3.9 92.7 2,368 North 0.9 6.6 92.6 1,067 North Central 0.6 9.8 89.6 1,038 Central 6.6 4.7 89.3 615 South Central 1.7 14.0 84.8 853 South 1.1 5.8 93.1 1,190 Education No formal education 3.8 18.3 78.1 1,668 Primary 2.4 6.7 91.1 2,464 Secondary 1.1 0.3 98.5 2,584 More than secondary 3.4 0.0 96.6 333 Maternity status Pregnant .1.0 2.6 96.7 522 Breastfeeding (not pregnant) 1.0 3.3 95.6 1,674 Neither 2.8 8.4 88.9 4,935 Wealth quintile Lowest 2.3 12.4 85.6 1,300 Second 1.7 9.2 89.3 1,396 Middle 1.8 5.5 92.7 1,488 Fourth 2.1 4.5 93.2 1,447 Highest 3.4 3.0 93.7 1,499 Total 2.3 6.8 91.1 7,131 Note: Total includes 81 cases for which information on woman’s formal education level is missing 194 | Women’s Other Health Issues 16.3 PHYSICAL ACTIVITY Table 16.4 shows that 61 percent of women did not walk, run, or engage in any physical activity for at least 20 minutes in the week before the survey. Among women who did engage in physical activity, 21 percent did it for five to seven days, 6 percent for three to four days, and 7 percent for one to two days. Physical activity increases with age. Urban women and women in Malé are engaged in physical activity more often than women in other areas. Women with the highest education and wealth status are engaged in physical activity more often than other women. Table 16.4 Physical activity Percent distribution of ever-married women 15-49, who walked, ran, or engaged in other physical activity for at least 20 minutes in the week before the survey, by number of days engaged in physical activity, according to background characteristics, Maldives 2009 Number of days engaged in physical activity Background characteristic 0 1-2 3-4 5-7 Don't know Missing Total Number of women Age 15-19 75.8 14.3 2.5 4.0 2.7 0.7 100.0 119 20-24 68.7 7.0 5.4 13.2 5.6 0.1 100.0 1,268 25-29 67.4 7.0 5.1 15.6 4.9 0.0 100.0 1,539 30-34 55.8 5.9 8.3 22.5 7.5 0.0 100.0 1,287 35-39 59.7 4.4 5.1 24.6 6.2 0.0 100.0 1,185 40-44 51.9 8.2 5.8 28.3 5.3 0.5 100.0 1,013 45-49 53.6 6.4 5.6 28.6 5.6 0.1 100.0 721 Residence Urban 50.6 7.8 7.4 21.9 12.0 0.2 100.0 2,368 Rural 65.9 6.0 5.0 20.3 2.7 0.1 100.0 4,763 Region Malé 50.6 7.8 7.4 21.9 12.0 0.2 100.0 2,368 North 66.3 6.9 4.0 20.0 2.8 0.1 100.0 1,067 North Central 71.1 5.9 6.8 15.6 0.6 0.0 100.0 1,038 Central 72.6 5.6 5.7 15.0 1.0 0.1 100.0 615 South Central 63.6 4.6 4.3 21.3 6.0 0.1 100.0 853 South 59.1 6.5 4.7 26.7 3.0 0.1 100.0 1,190 Education No formal education 59.7 5.4 5.2 25.4 4.1 0.2 100.0 1,668 Primary 60.5 5.5 5.9 22.0 5.9 0.1 100.0 2,464 Secondary 63.2 7.9 5.9 16.6 6.3 0.1 100.0 2,584 More than secondary 52.4 10.4 6.6 22.0 8.7 0.0 100.0 333 Wealth quintile Lowest 66.7 5.6 4.1 21.7 1.9 0.1 100.0 1,300 Second 66.9 5.9 5.3 18.6 3.2 0.1 100.0 1,396 Middle 64.5 5.9 4.4 21.9 3.3 0.1 100.0 1,488 Fourth 56.3 6.9 8.8 21.0 6.8 0.2 100.0 1,447 Highest 50.8 8.6 6.3 21.0 13.1 0.2 100.0 1,499 Total 60.8 6.6 5.8 20.8 5.8 0.1 100.0 7,131 Note: Total includes 81 cases for which information on woman’s formal education level is missing. 16.4 BLOOD PRESSURE, DIABETES, HEART ATTACK, AND STROKE The MDHS also includes information collected about the respondents’ experience with blood pressure, diabetes, heart attack, and stroke. Four percent of the ever-married women age 15-49 interviewed in the MDHS reported that they had been diagnosed with high blood pressure. Table 16.5 shows that among women who had been diagnosed with high blood pressure, more than half (56 percent) took medication and 82 percent cut down on salt consumption to lower blood pressure. Efforts to lower blood Table 16.5 Actions taken to lower blood pressure Percent distribution of ever-married women age 15-49 who were told by a doctor or health professional on two or more visits that she had high blood pressure, by various actions to treat the illness, Maldives 2009 Actions taken to lower blood pressure Percent Taking prescribed medication 56.0 Controlling weight/losing weight 72.3 Cutting down on salt in diet 81.8 Exercising 52.0 Stopped smoking 50.2 Number 280 Women’s Other Health Issues | 195 pressure included control or loss of weight (72 percent), exercise (52 percent), and smoking cessation (50 percent). Three percent of the MDHS respondents reported that they had been diagnosed with diabetes. Figure 16.1 shows that 45 percent of women were first diagnosed with diabetes when they were age 30-39, 28 percent were diagnosed at age 40 or later, and 21 percent were diagnosed at age 20-29. In the MDHS, women who had been diagnosed with diabetes were asked whether they were taking medication to treat the disease. Table 16.6 shows that 10 percent of the women reported taking insulin and 47 percent took pills to lower their blood sugar. Two percent of women indicated that they have been told by a doctor or other health professional that they had had a heart attack or myocardial infarction at some point prior to the survey, and 2 percent have been told that they have had a stroke (data not shown). 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Appendix A | 199 SAMPLE IMPLEMENTATION Appendix A Table A.1 Sample implementation: Women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall response rates, according to urban-rural residence and region, Maldives 2009 Residence Region Result Urban Rural Malé North North Central Central South Central South Total Selected households Completed (C) 78.5 87.1 78.5 84.4 88.5 89.8 89.3 83.1 85.7 Household present but no competent respondent at home HP) 8.2 4.4 8.2 5.9 2.7 2.6 3.6 7.5 5.0 Postponed (P) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 Refused (R) 5.8 3.2 5.8 2.7 2.9 3.0 2.2 5.0 3.6 Dwelling not found (DNF) 1.7 0.4 1.7 0.6 0.1 0.0 0.3 0.8 0.6 Household absent (HA) 1.6 2.7 1.6 3.2 2.8 2.7 3.2 1.8 2.6 Dwelling vacant/address not a dwelling (DV) 2.2 1.4 2.2 2.2 2.2 1.2 0.7 0.8 1.5 Dwelling destroyed (DD) 0.1 0.1 0.1 0.1 0.2 0.1 0.0 0.2 0.1 Other (O) 1.9 0.7 1.9 0.8 0.6 0.6 0.7 0.6 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 1,202 6,313 1,202 1,092 1,289 1,132 1,512 1,288 7,515 Household response rate (HRR)1 83.4 91.6 83.4 90.1 93.9 94.2 93.6 85.9 90.3 Eligible women Completed (EWC) 78.9 86.5 78.9 85.6 91.4 85.9 87.9 80.7 85.3 Not at home (EWNH) 8.9 6.0 8.9 7.3 2.2 5.9 6.1 8.5 6.4 Postponed (EWP) 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Refused (EWR) 11.0 5.8 11.0 5.7 5.7 6.2 4.0 8.2 6.6 Partly completed (EWPC) 0.5 0.2 0.5 0.3 0.1 0.1 0.1 0.4 0.2 Incapacitated (EWI) 0.5 0.9 0.5 0.6 0.5 0.9 1.1 1.2 0.8 Other (EWO) 0.2 0.7 0.2 0.4 0.1 0.9 0.8 1.1 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,320 7,042 1,320 1,121 1,378 1,501 1,755 1,287 8,362 Eligible women response rate (EWRR)2 78.9 86.5 78.9 85.6 91.4 85.9 87.9 80.7 85.3 Overall response rate (ORR)3 65.8 79.2 65.8 77.2 85.8 80.9 82.3 69.3 77.0 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C ——————————— C + HP + P + R + DNF 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * EWC ————————————————————————— EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 200 | Appendix A Table A.2 Sample implementation: Men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men and overall response rates, according to urban-rural residence and region, Maldives 2009 Residence Region Result Urban Rural Malé North North Central Central South Central South Total Selected households Completed (C) 77.0 87.0 77.0 83.5 87.7 90.1 89.3 83.8 85.4 Household present but no competent respondent at home (HP) 9.3 4.3 9.3 6.0 2.6 2.3 3.0 7.8 5.1 Postponed (P) 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.5 0.1 Refused (R) 6.2 3.3 6.2 3.1 3.6 2.8 2.1 5.0 3.8 Dwelling not found (DNF) 1.7 0.3 1.7 0.7 0.2 0.0 0.4 0.2 0.5 Household absent (HA) 1.8 2.8 1.8 3.3 2.8 2.7 3.8 1.4 2.7 Dwelling vacant/address not a dwelling (DV) 1.7 1.6 1.7 2.6 2.5 1.4 0.8 0.8 1.6 Dwelling destroyed (DD) 0.2 0.1 0.2 0.0 0.3 0.2 0.0 0.2 0.1 Other (O) 2.2 0.5 2.2 0.7 0.3 0.5 0.5 0.5 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 601 3,151 601 546 644 563 757 641 3,752 Household response rate (HRR)1 81.8 91.6 81.8 89.4 93.2 94.6 94.2 86.2 90.0 Eligible men Completed (EMC) 47.3 54.9 47.3 52.9 56.7 51.7 57.0 56.1 53.6 Not at home (EMNH) 36.6 25.8 36.6 34.5 18.1 23.9 28.2 26.0 27.8 Postponed (EMP) 0.5 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.1 Refused (EMR) 14.2 15.4 14.2 9.2 23.7 18.1 11.2 14.0 15.2 Partly completed (EMPC) 0.2 0.5 0.2 1.0 0.0 0.8 0.5 0.4 0.5 Incapacitated (EMI) 0.5 1.3 0.5 1.7 0.4 1.7 1.8 0.9 1.2 Other (EMO) 0.7 2.0 0.7 0.7 1.2 3.8 1.4 2.6 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 579 2,645 579 403 515 602 660 465 3,224 Eligible men response rate (EMRR)2 47.3 54.9 47.3 52.9 56.7 51.7 57.0 56.1 53.6 Overall response rate (ORR)3 38.7 50.3 38.7 47.3 52.9 48.9 53.6 48.4 48.2 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C ——————————— C + HP + P + R + DNF 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * EWC ————————————————————————— EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 Appendix B | 201 ESTIMATES OF SAMPLING ERRORS Appendix B The estimates from a sample survey are affected by two types of errors: nonsampling errors and sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the Maldives Demographic and Health Survey 2009 (2009 MDHS) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2009 MDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2009 MDHS sample is the result of a multistage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2009 MDHS is a Macro SAS procedure. This procedure used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = = ⎥⎦ ⎤⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ − − − == H h h h m i hi h h m zz m m x frvarrSE h 1 2 1 2 2 2 1 1)()( in which hihihi rxyz −= , and hhh rxyz −= where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. 202 | Appendix B The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample and calculates standard errors for these estimates using simple formulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2009 MDHS, there were 270 non-empty clusters. Hence, 270 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − = ∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 270 clusters, r(i) is the estimate computed from the reduced sample of 269 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, the design effect (DEFT) for each estimate is calculated, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error is due to the use of a more complex and less statistically efficient design. The relative standard error and confidence limits for the estimates are also calculated. Sampling errors for the 2009 MDHS are calculated for selected variables considered to be of primary interest. The results are presented in this appendix for the country as a whole, for urban and rural areas, for the three geographical regions, and for each of the six geographical/administrative regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 through B.10 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE) for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to child-bearing. The confidence interval (e.g., as calculated for children ever born to women aged 40-49) can be interpreted as follows: the overall average from the national sample is 4.985 and its standard error is 0.080. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 4.985±2×0.080. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 4.824 and 5.146. For the total sample, the value of the DEFT, averaged over all variables, is 1.276. This means that, due to multistage clustering of the sample, the average standard error is increased by a factor of 1.276 over that in an equivalent simple random sample. Appendix B | 203 Table B.1 List of selected variables for sampling errors, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Variable Estimate Base population –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion Ever-married women 15-49 No education Proportion Ever-married women 15-49 Secondary education or higher Proportion Ever-married women 15-49 Net attendance ratio Ratio Household population 6-12 years Currently married/in union Proportion All women 15-49 Married before age 20 Proportion All women 20-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women age 40-49 Mean All women 40-49 Knows any contraceptive method Proportion Currently married women 15-49 Knows a modern method Proportion Currently married women 15-49 Ever used any contraceptive method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently using a traditional method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using IUD Proportion Currently married women 15-49 Currently using condoms Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using female sterilization Proportion Currently married women 15-49 Currently using withdrawal Proportion Currently married women 15-49 Currently using periodic abstinence Proportion Currently married women 15-49 Using public sector source Proportion Current users of modern method Want no more children Proportion Currently married women 15-49 Want to delay birth at least 2 years Proportion Currently married women 15-49 Ideal family size Mean Ever-married women 15-49 Mothers protected against tetanus for last birth Proportion Women with a live birth in past five years Mothers received medical assistance at delivery Proportion Births occurring 1-59 months before survey Had diarrhoea in the past 2 weeks Proportion Children under 5 Treated with oral rehydration salts (ORS) Proportion Children under 5 with diarrhoea in past 2 weeks Taken to a health provider Proportion Children under 5 with diarrhoea in past 2 weeks Vaccination card seen Proportion Children 12-23 months Received BCG vaccination Proportion Children 12-23 months Received DPT vaccination (3 doses) Proportion Children 12-23 months Received polio vaccination (3 doses) Proportion Children 12-23 months Received measles vaccination Proportion Children 12-23 months Received all basic vaccinations Proportion Children 12-23 months Height-for-age (-2SD) Proportion Children under 5 who are measured Weight-for-height (-2SD) Proportion Children under 5 who are measured Weight-for-age (-2SD) Proportion Children under 5 who are measured BMI <18.5 Proportion Ever-married women 15-49 who were measured Has heard about HIV/AIDS Proportion Ever-married women 15-49 Knows about condoms to prevent AIDS Proportion Ever-married women 15-49 Knows about limiting partners to prevent AIDS Proportion Ever-married women 15-49 Comprehensive knowledge on HIV transmission Proportion Ever-married women 15-49 Total fertility rate (past 3 years) Rate Women-years of exposure to childbearing Neonatal mortality rate¹ Rate Children exposed to the risk of mortality Post-neonatal mortality rate¹ Rate Children exposed to the risk of mortality Infant mortality rate¹ Rate Children exposed to the risk of mortality Child mortality rate¹ Rate Children exposed to the risk of mortality Under-five mortality rate¹ Rate Children exposed to the risk of mortality –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 The mortality rates are calculated for 5 years and 10 years before the survey for the national sample and the domain samples, respectively. 204 | Appendix B Table B.2 Sampling errors for National sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.332 0.012 7131 7131 2.140 0.036 0.308 0.356 No education 0.234 0.006 7131 7131 1.177 0.025 0.222 0.246 Secondary education or higher 0.409 0.008 7131 7131 1.402 0.020 0.393 0.425 Net attendance ratio 0.825 0.006 5777 5504 1.179 0.007 0.814 0.837 Currently married/in union 0.626 0.021 10591 10388 1.130 0.033 0.584 0.668 Married before age 20 0.496 0.008 8294 8232 1.262 0.016 0.480 0.511 Currently pregnant 0.050 0.003 10591 10388 1.150 0.058 0.044 0.056 Children ever born 1.845 0.064 10591 10388 1.081 0.035 1.716 1.974 Children surviving 1.738 0.060 10591 10388 1.073 0.035 1.618 1.858 Children ever born to women age 40-49 4.985 0.080 1768 1762 1.369 0.016 4.824 5.146 Knows any contraceptive method 0.993 0.001 6558 6500 1.284 0.001 0.990 0.996 Knows a modern method 0.993 0.001 6558 6500 1.267 0.001 0.990 0.995 Ever used any contraceptive method 0.602 0.010 6558 6500 1.672 0.017 0.581 0.622 Currently using any method 0.347 0.008 6558 6500 1.369 0.023 0.331 0.363 Currently using a modern method 0.270 0.007 6558 6500 1.354 0.028 0.255 0.285 Currently using a traditional method 0.078 0.004 6558 6500 1.291 0.055 0.069 0.086 Currently using pill 0.046 0.003 6558 6500 1.273 0.071 0.040 0.053 Currently using IUD 0.008 0.002 6558 6500 1.351 0.182 0.005 0.011 Currently using condoms 0.093 0.004 6558 6500 1.253 0.048 0.084 0.102 Currently using injectables 0.012 0.002 6558 6500 1.311 0.146 0.009 0.016 Currently using female sterilization 0.101 0.005 6558 6500 1.297 0.048 0.091 0.110 Currently using withdrawal 0.042 0.003 6558 6500 1.281 0.075 0.036 0.049 Currently using periodic abstinence 0.034 0.003 6558 6500 1.287 0.084 0.029 0.040 Used public sector source 0.631 0.013 1871 1809 1.160 0.021 0.605 0.657 Want no more children 0.478 0.007 6558 6500 1.202 0.016 0.463 0.493 Want to delay birth at least 2 years 0.215 0.007 6558 6500 1.303 0.031 0.202 0.228 Ideal family size 3.127 0.024 6112 6185 1.421 0.008 3.080 3.174 Mothers protected against tetanus for last birth 0.821 0.008 3263 3190 1.251 0.010 0.804 0.838 Mothers received medical assistance at delivery 0.948 0.006 3817 3736 1.546 0.006 0.936 0.960 Had diarrhoea in the past 2 weeks 0.044 0.005 3761 3682 1.381 0.108 0.035 0.054 Treated with oral rehydration salts (ORS) 0.570 0.053 188 163 1.330 0.093 0.464 0.675 Taken to a health provider 0.836 0.033 188 163 1.103 0.039 0.770 0.902 Vaccination card seen 0.890 0.015 843 822 1.344 0.017 0.860 0.920 Received BCG vaccination 0.994 0.003 843 822 1.135 0.003 0.987 1.000 Received DPT vaccination (3 doses) 0.979 0.006 843 822 1.127 0.006 0.967 0.990 Received polio vaccination (3 doses) 0.970 0.008 843 822 1.293 0.008 0.955 0.986 Received measles vaccination 0.945 0.010 843 822 1.205 0.011 0.925 0.965 Received all basic vaccinations 0.929 0.011 843 822 1.231 0.012 0.906 0.952 Height-for-age (-2SD) 0.189 0.010 2577 2513 1.283 0.054 0.168 0.209 Weight-for-height (-2SD) 0.106 0.007 2577 2513 1.062 0.063 0.093 0.120 Weight-for-age (-2SD) 0.173 0.009 2577 2513 1.133 0.051 0.155 0.191 BMI <18.5 0.075 0.005 5144 5173 1.273 0.062 0.065 0.084 Has heard about HIV/AIDS 0.969 0.003 7131 7131 1.321 0.003 0.963 0.974 Knows about condoms to prevent AIDS 0.793 0.006 7131 7131 1.322 0.008 0.780 0.805 Knows about limiting partners 0.918 0.005 7131 7131 1.504 0.005 0.908 0.928 Comprehensive knowledge on HIV transmission 0.415 0.009 7131 7131 1.474 0.021 0.398 0.432 Total fertility rate (past 3 years) 2.542 0.058 na 31085 1.141 0.023 2.427 2.657 Neonatal mortality (past 0-4 years) 10.154 2.243 3836 3756 1.311 0.221 5.667 14.640 Post-neonatal mortality (past 0-4 years) 4.022 1.049 3829 3749 0.987 0.261 1.925 6.120 Infant mortality (past 0-4 years) 14.176 2.442 3837 3757 1.222 0.172 9.293 19.059 Child mortality (past 0-4 years) 2.817 0.788 3524 3462 0.844 0.280 1.241 4.392 Under-five mortality (past 0-4 years) 16.953 2.566 3844 3762 1.176 0.151 11.821 22.084 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 205 Table B.3 Sampling errors for Urban sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 1041 2368 na 0.000 1.000 1.000 No education 0.122 0.009 1041 2368 0.928 0.077 0.103 0.141 Secondary education or higher 0.581 0.017 1041 2368 1.123 0.030 0.547 0.616 Net attendance ratio 0.827 0.016 637 1349 1.072 0.020 0.794 0.860 Currently married/in union 0.551 0.078 1717 3851 0.925 0.142 0.394 0.708 Married before age 20 0.394 0.016 1313 2961 1.140 0.041 0.362 0.426 Currently pregnant 0.036 0.007 1717 3851 0.947 0.187 0.022 0.049 Children ever born 1.335 0.192 1717 3851 0.915 0.144 0.950 1.720 Children surviving 1.283 0.185 1717 3851 0.913 0.144 0.914 1.653 Children ever born to women age 40-49 3.747 0.135 259 595 1.052 0.036 3.477 4.018 Knows any contraceptive method 0.994 0.003 935 2122 1.089 0.003 0.989 1.000 Knows a modern method 0.993 0.003 935 2122 1.055 0.003 0.988 0.999 Ever used any contraceptive method 0.567 0.022 935 2122 1.357 0.039 0.523 0.611 Currently using any method 0.336 0.017 935 2122 1.088 0.050 0.303 0.370 Currently using a modern method 0.256 0.015 935 2122 1.039 0.058 0.227 0.286 Currently using a traditional method 0.080 0.008 935 2122 0.928 0.103 0.063 0.096 Currently using pill 0.018 0.004 935 2122 0.984 0.239 0.009 0.026 Currently using IUD 0.014 0.004 935 2122 1.053 0.289 0.006 0.022 Currently using condoms 0.101 0.008 935 2122 0.857 0.084 0.084 0.118 Currently using injectables 0.007 0.003 935 2122 1.093 0.431 0.001 0.013 Currently using female sterilization 0.101 0.010 935 2122 1.051 0.103 0.080 0.121 Currently using withdrawal 0.031 0.005 935 2122 0.956 0.175 0.020 0.042 Currently using periodic abstinence 0.047 0.007 935 2122 0.989 0.146 0.033 0.061 Used public sector source 0.396 0.030 255 570 0.985 0.076 0.336 0.457 Want no more children 0.479 0.015 935 2122 0.923 0.032 0.448 0.509 Want to delay birth at least 2 years 0.184 0.013 935 2122 1.029 0.071 0.158 0.210 Ideal family size 2.808 0.046 936 2128 1.113 0.016 2.716 2.900 Mothers protected against tetanus for last birth 0.844 0.019 423 964 1.053 0.022 0.807 0.881 Mothers received medical assistance at delivery 0.990 0.004 494 1123 0.984 0.004 0.981 0.999 Had diarrhoea in the past 2 weeks 0.037 0.012 487 1106 1.315 0.326 0.013 0.061 Treated with oral rehydration salts (ORS) 0.546 0.167 17 41 1.339 0.306 0.211 0.881 Taken to a health provider 0.939 0.062 17 41 1.088 0.066 0.815 1.063 Vaccination card seen 0.852 0.038 108 243 1.056 0.045 0.776 0.929 Received BCG vaccination 1.000 0.000 108 243 na 0.000 1.000 1.000 Received DPT vaccination (3 doses) 0.982 0.012 108 243 0.934 0.012 0.958 1.006 Received polio vaccination (3 doses) 0.957 0.021 108 243 1.054 0.022 0.915 0.999 Received measles vaccination 0.935 0.027 108 243 1.007 0.029 0.881 0.989 Received all basic vaccinations 0.914 0.029 108 243 0.983 0.032 0.856 0.973 Height-for-age (-2SD) 0.157 0.019 349 721 0.957 0.121 0.119 0.194 Weight-for-height (-2SD) 0.072 0.014 349 721 0.995 0.199 0.043 0.100 Weight-for-age (-2SD) 0.109 0.017 349 721 0.948 0.153 0.076 0.143 BMI <18.5 0.053 0.008 728 1657 0.945 0.148 0.037 0.069 Has heard about HIV/AIDS 0.975 0.005 1041 2368 1.053 0.005 0.965 0.985 Knows about condoms to prevent AIDS 0.824 0.012 1041 2368 1.052 0.015 0.800 0.849 Knows about limiting partners 0.929 0.010 1041 2368 1.287 0.011 0.909 0.950 Comprehensive knowledge on HIV transmission 0.508 0.020 1041 2368 1.264 0.039 0.469 0.547 Total fertility rate (past 3 years) 2.128 0.110 na 11276 0.961 0.052 1.907 2.348 Neonatal mortality (past 0-9 years) 19.642 6.573 877 2016 1.047 0.335 6.497 32.788 Post-neonatal mortality (past 0-9 years) 3.305 1.880 872 2003 0.943 0.569 0.000 7.066 Infant mortality (past 0-9 years) 22.948 7.564 877 2016 1.147 0.330 7.819 38.076 Child mortality (past 0-9 years) 0.503 0.504 808 1866 na 1.003 0.000 1.511 Under-five mortality (past 0-9 years) 23.439 7.546 877 2016 1.147 0.322 8.346 38.531 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 206 | Appendix B Table B.4 Sampling errors for Rural sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 6090 4763 na na 0.000 0.000 No education 0.290 0.007 6090 4763 1.169 0.023 0.276 0.303 Secondary education or higher 0.324 0.009 6090 4763 1.539 0.029 0.305 0.342 Net attendance ratio 0.825 0.006 5140 4155 1.119 0.007 0.813 0.836 Currently married/in union 0.648 0.022 8659 6754 1.035 0.034 0.604 0.693 Married before age 20 0.552 0.009 6760 5283 1.250 0.017 0.533 0.570 Currently pregnant 0.057 0.003 8659 6754 1.136 0.061 0.050 0.064 Children ever born 2.077 0.076 8659 6754 1.019 0.037 1.925 2.228 Children surviving 1.941 0.071 8659 6754 1.017 0.036 1.800 2.083 Children ever born to women age 40-49 5.614 0.087 1504 1168 1.376 0.015 5.441 5.787 Knows any contraceptive method 0.993 0.001 5623 4378 1.252 0.001 0.990 0.995 Knows a modern method 0.992 0.001 5623 4378 1.236 0.001 0.989 0.995 Ever used any contraceptive method 0.618 0.010 5623 4378 1.582 0.017 0.598 0.639 Currently using any method 0.353 0.009 5623 4378 1.357 0.025 0.335 0.370 Currently using a modern method 0.276 0.008 5623 4378 1.389 0.030 0.260 0.293 Currently using a traditional method 0.076 0.005 5623 4378 1.392 0.064 0.067 0.086 Currently using pill 0.060 0.004 5623 4378 1.357 0.071 0.052 0.069 Currently using IUD 0.006 0.001 5623 4378 1.096 0.196 0.003 0.008 Currently using condoms 0.089 0.005 5623 4378 1.393 0.059 0.078 0.099 Currently using injectables 0.015 0.002 5623 4378 1.364 0.149 0.010 0.019 Currently using female sterilization 0.101 0.005 5623 4378 1.271 0.051 0.090 0.111 Currently using withdrawal 0.048 0.004 5623 4378 1.370 0.082 0.040 0.056 Currently using periodic abstinence 0.028 0.003 5623 4378 1.270 0.099 0.023 0.034 Used public sector source 0.739 0.013 1616 1239 1.182 0.017 0.713 0.765 Want no more children 0.477 0.008 5623 4378 1.236 0.017 0.461 0.494 Want to delay birth at least 2 years 0.230 0.007 5623 4378 1.298 0.032 0.216 0.245 Ideal family size 3.295 0.026 5176 4057 1.475 0.008 3.243 3.347 Mothers protected against tetanus for last birth 0.811 0.009 2840 2227 1.229 0.011 0.793 0.829 Mothers received medical assistance at delivery 0.930 0.008 3323 2613 1.735 0.009 0.914 0.947 Had diarrhoea in the past 2 weeks 0.048 0.005 3274 2576 1.202 0.095 0.039 0.057 Treated with oral rehydration salts (ORS) 0.577 0.045 171 123 1.119 0.078 0.488 0.667 Taken to a health provider 0.801 0.035 171 123 1.079 0.044 0.730 0.872 Vaccination card seen 0.906 0.013 735 579 1.254 0.015 0.879 0.933 Received BCG vaccination 0.991 0.005 735 579 1.283 0.005 0.982 1.000 Received DPT vaccination (3 doses) 0.977 0.006 735 579 1.149 0.006 0.965 0.990 Received polio vaccination (3 doses) 0.976 0.007 735 579 1.156 0.007 0.963 0.989 Received measles vaccination 0.950 0.009 735 579 1.068 0.009 0.932 0.967 Received all basic vaccinations 0.935 0.011 735 579 1.181 0.011 0.913 0.956 Height-for-age (-2SD) 0.201 0.012 2228 1792 1.356 0.058 0.178 0.225 Weight-for-height (-2SD) 0.120 0.007 2228 1792 1.051 0.061 0.105 0.135 Weight-for-age (-2SD) 0.199 0.010 2228 1792 1.166 0.051 0.179 0.219 BMI <18.5 0.085 0.006 4416 3516 1.356 0.066 0.074 0.096 Has heard about HIV/AIDS 0.966 0.003 6090 4763 1.369 0.003 0.959 0.972 Knows about condoms to prevent AIDS 0.777 0.007 6090 4763 1.363 0.009 0.762 0.791 Knows about limiting partners 0.912 0.005 6090 4763 1.460 0.006 0.901 0.923 Comprehensive knowledge on HIV transmission 0.369 0.008 6090 4763 1.337 0.022 0.352 0.386 Total fertility rate (past 3 years) 2.764 0.062 na 20239 0.967 0.022 2.640 2.888 Neonatal mortality (past 0-9 years) 14.844 1.814 6334 5039 1.140 0.122 11.216 18.472 Post-neonatal mortality (past 0-9 years) 7.576 1.174 6337 5044 1.043 0.155 5.228 9.923 Infant mortality (past 0-9 years) 22.420 2.125 6337 5040 1.069 0.095 18.169 26.671 Child mortality (past 0-9 years) 6.104 1.050 6149 4892 0.997 0.172 4.005 8.203 Under-five mortality (past 0-9 years) 28.387 2.334 6348 5050 1.046 0.082 23.719 33.055 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 207 Table B.5 Sampling errors for Malé sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 1041 2368 na 0.000 1.000 1.000 No education 0.122 0.009 1041 2368 0.928 0.077 0.103 0.141 Secondary education or higher 0.581 0.017 1041 2368 1.123 0.030 0.547 0.616 Net attendance ratio 0.827 0.016 637 1349 1.072 0.020 0.794 0.860 Currently married/in union 0.551 0.078 1717 3851 0.925 0.142 0.394 0.708 Married before age 20 0.394 0.016 1313 2961 1.140 0.041 0.362 0.426 Currently pregnant 0.036 0.007 1717 3851 0.947 0.187 0.022 0.049 Children ever born 1.335 0.192 1717 3851 0.915 0.144 0.950 1.720 Children surviving 1.283 0.185 1717 3851 0.913 0.144 0.914 1.653 Children ever born to women age 40-49 3.747 0.135 259 595 1.052 0.036 3.477 4.018 Knows any contraceptive method 0.994 0.003 935 2122 1.089 0.003 0.989 1.000 Knows a modern method 0.993 0.003 935 2122 1.055 0.003 0.988 0.999 Ever used any contraceptive method 0.567 0.022 935 2122 1.357 0.039 0.523 0.611 Currently using any method 0.336 0.017 935 2122 1.088 0.050 0.303 0.370 Currently using a modern method 0.256 0.015 935 2122 1.039 0.058 0.227 0.286 Currently using a traditional method 0.080 0.008 935 2122 0.928 0.103 0.063 0.096 Currently using pill 0.018 0.004 935 2122 0.984 0.239 0.009 0.026 Currently using IUD 0.014 0.004 935 2122 1.053 0.289 0.006 0.022 Currently using condoms 0.101 0.008 935 2122 0.857 0.084 0.084 0.118 Currently using injectables 0.007 0.003 935 2122 1.093 0.431 0.001 0.013 Currently using female sterilization 0.101 0.010 935 2122 1.051 0.103 0.080 0.121 Currently using withdrawal 0.031 0.005 935 2122 0.956 0.175 0.020 0.042 Currently using periodic abstinence 0.047 0.007 935 2122 0.989 0.146 0.033 0.061 Used public sector source 0.396 0.030 255 570 0.985 0.076 0.336 0.457 Want no more children 0.479 0.015 935 2122 0.923 0.032 0.448 0.509 Want to delay birth at least 2 years 0.184 0.013 935 2122 1.029 0.071 0.158 0.210 Ideal family size 2.808 0.046 936 2128 1.113 0.016 2.716 2.900 Mothers protected against tetanus for last birth 0.844 0.019 423 964 1.053 0.022 0.807 0.881 Mothers received medical assistance at delivery 0.990 0.004 494 1123 0.984 0.004 0.981 0.999 Had diarrhoea in the past 2 weeks 0.037 0.012 487 1106 1.315 0.326 0.013 0.061 Treated with oral rehydration salts (ORS) 0.546 0.167 17 41 1.339 0.306 0.211 0.881 Taken to a health provider 0.939 0.062 17 41 1.088 0.066 0.815 1.063 Vaccination card seen 0.852 0.038 108 243 1.056 0.045 0.776 0.929 Received BCG vaccination 1.000 0.000 108 243 na 0.000 1.000 1.000 Received DPT vaccination (3 doses) 0.982 0.012 108 243 0.934 0.012 0.958 1.006 Received polio vaccination (3 doses) 0.957 0.021 108 243 1.054 0.022 0.915 0.999 Received measles vaccination 0.935 0.027 108 243 1.007 0.029 0.881 0.989 Received all basic vaccinations 0.914 0.029 108 243 0.983 0.032 0.856 0.973 Height-for-age (-2SD) 0.157 0.019 349 721 0.957 0.121 0.119 0.194 Weight-for-height (-2SD) 0.072 0.014 349 721 0.995 0.199 0.043 0.100 Weight-for-age (-2SD) 0.109 0.017 349 721 0.948 0.153 0.076 0.143 BMI <18.5 0.053 0.008 728 1657 0.945 0.148 0.037 0.069 Has heard about HIV/AIDS 0.975 0.005 1041 2368 1.053 0.005 0.965 0.985 Knows about condoms to prevent AIDS 0.824 0.012 1041 2368 1.052 0.015 0.800 0.849 Knows about limiting partners 0.929 0.010 1041 2368 1.287 0.011 0.909 0.950 Comprehensive knowledge on HIV transmission 0.508 0.020 1041 2368 1.264 0.039 0.469 0.547 Total fertility rate (past 3 years) 2.128 0.110 na 11276 0.961 0.052 1.907 2.348 Neonatal mortality (past 0-9 years) 19.642 6.573 877 2016 1.047 0.335 6.497 32.788 Post-neonatal mortality (past 0-9 years) 3.305 1.880 872 2003 0.943 0.569 0.000 7.066 Infant mortality (past 0-9 years) 22.948 7.564 877 2016 1.147 0.330 7.819 38.076 Child mortality (past 0-9 years) 0.503 0.504 808 1866 na 1.003 0.000 1.511 Under-five mortality (past 0-9 years) 23.439 7.546 877 2016 1.147 0.322 8.346 38.531 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 208 | Appendix B Table B.6 Sampling errors for North sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 960 1067 na na 0.000 0.000 No education 0.296 0.018 960 1067 1.190 0.059 0.261 0.331 Secondary education or higher 0.295 0.024 960 1067 1.636 0.082 0.246 0.343 Net attendance ratio 0.842 0.013 862 968 1.080 0.015 0.816 0.867 Currently married/in union 0.621 0.058 1473 1623 1.016 0.093 0.506 0.737 Married before age 20 0.495 0.028 1124 1244 1.070 0.057 0.438 0.552 Currently pregnant 0.059 0.009 1473 1623 1.136 0.154 0.041 0.077 Children ever born 1.852 0.188 1473 1623 1.026 0.102 1.475 2.228 Children surviving 1.749 0.179 1473 1623 1.037 0.103 1.390 2.108 Children ever born to women age 40-49 5.529 0.189 221 245 1.188 0.034 5.151 5.908 Knows any contraceptive method 0.991 0.004 909 1009 1.157 0.004 0.984 0.998 Knows a modern method 0.991 0.004 909 1009 1.157 0.004 0.984 0.998 Ever used any contraceptive method 0.659 0.024 909 1009 1.527 0.036 0.611 0.707 Currently using any method 0.394 0.023 909 1009 1.416 0.058 0.348 0.440 Currently using a modern method 0.282 0.024 909 1009 1.573 0.083 0.235 0.330 Currently using a traditional method 0.112 0.015 909 1009 1.437 0.135 0.082 0.142 Currently using pill 0.065 0.009 909 1009 1.158 0.146 0.046 0.084 Currently using IUD 0.009 0.003 909 1009 0.934 0.317 0.003 0.015 Currently using condoms 0.125 0.016 909 1009 1.471 0.129 0.092 0.157 Currently using injectables 0.024 0.007 909 1009 1.427 0.303 0.009 0.038 Currently using female sterilization 0.057 0.008 909 1009 0.979 0.133 0.042 0.072 Currently using withdrawal 0.067 0.012 909 1009 1.424 0.177 0.043 0.090 Currently using periodic abstinence 0.045 0.009 909 1009 1.243 0.190 0.028 0.062 Used public sector source 0.729 0.033 258 289 1.179 0.045 0.664 0.795 Want no more children 0.462 0.018 909 1009 1.088 0.039 0.426 0.498 Want to delay birth at least 2 years 0.250 0.016 909 1009 1.118 0.064 0.218 0.282 Ideal family size 3.218 0.071 798 890 1.636 0.022 3.076 3.360 Mothers protected against tetanus for last birth 0.790 0.024 440 489 1.247 0.031 0.741 0.839 Mothers received medical assistance at delivery 0.911 0.017 518 578 1.291 0.019 0.877 0.944 Had diarrhoea in the past 2 weeks 0.053 0.012 514 575 1.227 0.231 0.028 0.077 Treated with oral rehydration salts (ORS) 0.615 0.068 26 30 0.727 0.111 0.479 0.751 Taken to a health provider 0.887 0.053 26 30 0.877 0.060 0.781 0.994 Vaccination card seen 0.978 0.012 129 145 0.932 0.012 0.954 1.002 Received BCG vaccination 0.990 0.009 129 145 1.089 0.009 0.972 1.009 Received DPT vaccination (3 doses) 0.984 0.011 129 145 1.013 0.011 0.961 1.006 Received polio vaccination (3 doses) 0.990 0.009 129 145 1.089 0.009 0.972 1.009 Received measles vaccination 0.940 0.019 129 145 0.912 0.020 0.902 0.978 Received all basic vaccinations 0.940 0.019 129 145 0.912 0.020 0.902 0.978 Height-for-age (-2SD) 0.157 0.019 350 387 0.970 0.124 0.118 0.196 Weight-for-height (-2SD) 0.118 0.019 350 387 1.125 0.165 0.079 0.157 Weight-for-age (-2SD) 0.184 0.027 350 387 1.286 0.145 0.130 0.237 BMI <18.5 0.113 0.016 724 809 1.352 0.141 0.081 0.144 Has heard about HIV/AIDS 0.950 0.010 960 1067 1.378 0.010 0.931 0.969 Knows about condoms to prevent AIDS 0.748 0.019 960 1067 1.359 0.025 0.710 0.786 Knows about limiting partners 0.909 0.011 960 1067 1.171 0.012 0.887 0.931 Comprehensive knowledge on HIV transmission 0.351 0.018 960 1067 1.199 0.053 0.314 0.388 Total fertility rate (past 3 years) 2.683 0.152 na 4869 0.930 0.057 2.379 2.987 Neonatal mortality (past 0-9 years) 9.766 4.516 1004 1124 1.387 0.462 0.733 18.799 Post-neonatal mortality (past 0-9 years) 3.139 1.850 1010 1131 1.045 0.589 0.000 6.838 Infant mortality (past 0-9 years) 12.905 4.619 1005 1125 1.237 0.358 3.666 22.143 Child mortality (past 0-9 years) 7.712 2.484 990 1106 0.856 0.322 2.744 12.680 Under-five mortality (past 0-9 years) 20.517 4.953 1009 1130 1.127 0.241 10.612 30.423 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 209 Table B.7 Sampling errors for North Central sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 1259 1038 na na 0.000 0.000 No education 0.352 0.016 1259 1038 1.177 0.045 0.320 0.383 Secondary education or higher 0.295 0.016 1259 1038 1.259 0.055 0.263 0.328 Net attendance ratio 0.835 0.011 1054 938 1.022 0.013 0.814 0.857 Currently married/in union 0.644 0.046 1763 1501 0.983 0.071 0.553 0.736 Married before age 20 0.532 0.015 1423 1171 1.142 0.028 0.502 0.561 Currently pregnant 0.061 0.007 1763 1501 1.027 0.119 0.046 0.075 Children ever born 2.070 0.142 1763 1501 0.877 0.069 1.786 2.354 Children surviving 1.950 0.130 1763 1501 0.852 0.066 1.690 2.209 Children ever born to women age 40-49 5.684 0.157 343 280 1.227 0.028 5.371 5.997 Knows any contraceptive method 0.995 0.002 1173 967 1.104 0.002 0.990 1.000 Knows a modern method 0.995 0.002 1173 967 1.104 0.002 0.990 1.000 Ever used any contraceptive method 0.654 0.020 1173 967 1.460 0.031 0.613 0.694 Currently using any method 0.374 0.017 1173 967 1.201 0.045 0.340 0.408 Currently using a modern method 0.283 0.016 1173 967 1.197 0.056 0.251 0.314 Currently using a traditional method 0.092 0.010 1173 967 1.212 0.112 0.071 0.112 Currently using pill 0.075 0.011 1173 967 1.487 0.153 0.052 0.098 Currently using IUD 0.003 0.002 1173 967 1.505 0.796 0.000 0.008 Currently using condoms 0.080 0.010 1173 967 1.229 0.122 0.061 0.100 Currently using injectables 0.019 0.004 1173 967 1.022 0.215 0.011 0.027 Currently using female sterilization 0.103 0.010 1173 967 1.102 0.095 0.084 0.123 Currently using withdrawal 0.058 0.008 1173 967 1.205 0.142 0.042 0.075 Currently using periodic abstinence 0.033 0.005 1173 967 0.895 0.141 0.024 0.043 Used public sector source 0.787 0.024 341 280 1.060 0.030 0.740 0.834 Want no more children 0.473 0.014 1173 967 0.966 0.030 0.445 0.502 Want to delay birth at least 2 years 0.199 0.015 1173 967 1.295 0.076 0.169 0.229 Ideal family size 3.305 0.062 1055 867 1.550 0.019 3.181 3.429 Mothers protected against tetanus for last birth 0.798 0.018 558 466 1.069 0.023 0.762 0.835 Mothers received medical assistance at delivery 0.889 0.027 647 539 2.024 0.031 0.834 0.944 Had diarrhoea in the past 2 weeks 0.030 0.007 636 530 1.044 0.233 0.016 0.044 Treated with oral rehydration salts (ORS) 0.424 0.123 20 16 1.091 0.290 0.178 0.669 Taken to a health provider 0.759 0.118 20 16 1.210 0.155 0.523 0.994 Vaccination card seen 0.961 0.019 129 105 1.105 0.020 0.923 0.999 Received BCG vaccination 1.000 0.000 129 105 na 0.000 1.000 1.000 Received DPT vaccination (3 doses) 1.000 0.000 129 105 na 0.000 1.000 1.000 Received polio vaccination (3 doses) 0.993 0.007 129 105 0.936 0.007 0.979 1.007 Received measles vaccination 0.962 0.016 129 105 0.960 0.017 0.929 0.994 Received all basic vaccinations 0.955 0.017 129 105 0.925 0.018 0.921 0.989 Height-for-age (-2SD) 0.227 0.025 604 543 1.474 0.112 0.177 0.278 Weight-for-height (-2SD) 0.145 0.012 604 543 0.838 0.084 0.121 0.169 Weight-for-age (-2SD) 0.244 0.018 604 543 0.981 0.072 0.208 0.279 BMI <18.5 0.082 0.010 1095 903 1.212 0.122 0.062 0.102 Has heard about HIV/AIDS 0.978 0.004 1259 1038 0.965 0.004 0.970 0.986 Knows about condoms to prevent AIDS 0.731 0.017 1259 1038 1.389 0.024 0.697 0.766 Knows about limiting partners 0.939 0.007 1259 1038 1.013 0.007 0.926 0.953 Comprehensive knowledge on HIV transmission 0.347 0.019 1259 1038 1.420 0.055 0.309 0.385 Total fertility rate (past 3 years) 2.530 0.133 na 4503 0.835 0.053 2.264 2.797 Neonatal mortality (past 0-9 years) 17.440 3.538 1286 1074 0.936 0.203 10.364 24.517 Post-neonatal mortality (past 0-9 years) 6.576 2.140 1286 1075 0.942 0.325 2.295 10.857 Infant mortality (past 0-9 years) 24.017 3.788 1286 1074 0.888 0.158 16.440 31.593 Child mortality (past 0-9 years) 5.734 2.006 1255 1048 0.965 0.350 1.722 9.745 Under-five mortality (past 0-9 years) 29.613 4.449 1289 1076 0.957 0.150 20.714 38.511 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 210 | Appendix B Table B.8 Sampling errors for Central sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 1290 615 na na 0.000 0.000 No education 0.279 0.014 1290 615 1.113 0.050 0.252 0.307 Secondary education or higher 0.299 0.025 1290 615 1.970 0.084 0.249 0.349 Net attendance ratio 0.806 0.014 987 493 1.194 0.017 0.778 0.833 Currently married/in union 0.666 0.061 1842 845 0.946 0.092 0.544 0.788 Married before age 20 0.652 0.016 1357 649 1.282 0.024 0.620 0.684 Currently pregnant 0.063 0.009 1842 845 1.153 0.143 0.045 0.081 Children ever born 2.151 0.190 1842 845 0.870 0.088 1.772 2.531 Children surviving 2.001 0.176 1842 845 0.869 0.088 1.650 2.353 Children ever born to women age 40-49 5.893 0.163 288 132 1.190 0.028 5.567 6.219 Knows any contraceptive method 0.996 0.002 1186 563 1.045 0.002 0.992 1.000 Knows a modern method 0.996 0.002 1186 563 1.045 0.002 0.992 1.000 Ever used any contraceptive method 0.709 0.022 1186 563 1.692 0.031 0.664 0.754 Currently using any method 0.420 0.016 1186 563 1.117 0.038 0.388 0.452 Currently using a modern method 0.331 0.016 1186 563 1.172 0.048 0.299 0.363 Currently using a traditional method 0.089 0.010 1186 563 1.164 0.108 0.069 0.108 Currently using pill 0.054 0.008 1186 563 1.230 0.149 0.038 0.070 Currently using IUD 0.004 0.002 1186 563 0.975 0.458 0.000 0.007 Currently using condoms 0.114 0.012 1186 563 1.274 0.103 0.091 0.138 Currently using injectables 0.007 0.003 1186 563 1.229 0.439 0.001 0.012 Currently using female sterilization 0.137 0.014 1186 563 1.430 0.104 0.108 0.166 Currently using withdrawal 0.061 0.009 1186 563 1.312 0.150 0.043 0.079 Currently using periodic abstinence 0.026 0.006 1186 563 1.305 0.232 0.014 0.038 Used public sector source 0.630 0.023 405 192 0.970 0.037 0.584 0.677 Want no more children 0.474 0.013 1186 563 0.926 0.028 0.447 0.501 Want to delay birth at least 2 years 0.242 0.013 1186 563 1.078 0.055 0.215 0.269 Ideal family size 3.371 0.064 1088 518 1.553 0.019 3.243 3.500 Mothers protected against tetanus for last birth 0.772 0.030 612 293 1.744 0.038 0.713 0.831 Mothers received medical assistance at delivery 0.895 0.031 716 343 2.380 0.035 0.832 0.958 Had diarrhoea in the past 2 weeks 0.078 0.012 708 339 1.157 0.149 0.055 0.102 Treated with oral rehydration salts (ORS) 0.569 0.084 56 27 1.261 0.148 0.401 0.737 Taken to a health provider 0.726 0.071 56 27 1.187 0.098 0.584 0.868 Vaccination card seen 0.882 0.031 170 82 1.274 0.036 0.820 0.945 Received BCG vaccination 0.986 0.010 170 82 1.112 0.010 0.967 1.006 Received DPT vaccination (3 doses) 0.943 0.019 170 82 1.062 0.020 0.905 0.980 Received polio vaccination (3 doses) 0.923 0.025 170 82 1.229 0.027 0.873 0.973 Received measles vaccination 0.925 0.018 170 82 0.895 0.019 0.889 0.961 Received all basic vaccinations 0.878 0.035 170 82 1.416 0.040 0.807 0.949 Height-for-age (-2SD) 0.209 0.029 492 235 1.557 0.141 0.150 0.267 Weight-for-height (-2SD) 0.141 0.019 492 235 1.233 0.134 0.103 0.179 Weight-for-age (-2SD) 0.180 0.021 492 235 1.147 0.116 0.138 0.222 BMI <18.5 0.069 0.012 930 440 1.399 0.169 0.046 0.092 Has heard about HIV/AIDS 0.977 0.004 1290 615 1.012 0.004 0.969 0.986 Knows about condoms to prevent AIDS 0.819 0.014 1290 615 1.335 0.017 0.790 0.847 Knows about limiting partners 0.910 0.013 1290 615 1.576 0.014 0.885 0.935 Comprehensive knowledge on HIV transmission 0.421 0.018 1290 615 1.314 0.043 0.385 0.457 Total fertility rate (past 3 years) 2.819 0.135 na 2485 0.961 0.048 2.550 3.089 Neonatal mortality (past 0-9 years) 18.637 4.701 1311 640 1.149 0.252 9.235 28.040 Post-neonatal mortality (past 0-9 years) 11.400 2.893 1310 638 0.953 0.254 5.613 17.186 Infant mortality (past 0-9 years) 30.037 5.814 1311 640 1.124 0.194 18.410 41.665 Child mortality (past 0-9 years) 3.958 1.984 1262 621 1.161 0.501 0.000 7.925 Under-five mortality (past 0-9 years) 33.876 6.428 1311 640 1.168 0.190 21.021 46.732 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 211 Table B.9 Sampling errors for South Central sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 1543 853 na na 0.000 0.000 No education 0.309 0.012 1543 853 1.049 0.040 0.284 0.333 Secondary education or higher 0.316 0.020 1543 853 1.659 0.062 0.277 0.356 Net attendance ratio 0.838 0.009 1257 706 0.907 0.011 0.820 0.856 Currently married/in union 0.707 0.037 1983 1116 1.110 0.052 0.633 0.780 Married before age 20 0.580 0.017 1675 926 1.410 0.029 0.546 0.613 Currently pregnant 0.053 0.006 1983 1116 1.049 0.107 0.042 0.065 Children ever born 2.243 0.136 1983 1116 1.134 0.061 1.971 2.515 Children surviving 2.079 0.124 1983 1116 1.123 0.060 1.830 2.328 Children ever born to women age 40-49 5.370 0.140 400 222 1.209 0.026 5.089 5.651 Knows any contraceptive method 0.993 0.002 1437 789 1.088 0.002 0.988 0.998 Knows a modern method 0.992 0.002 1437 789 1.013 0.002 0.987 0.997 Ever used any contraceptive method 0.579 0.023 1437 789 1.777 0.040 0.532 0.625 Currently using any method 0.317 0.015 1437 789 1.184 0.046 0.288 0.346 Currently using a modern method 0.250 0.013 1437 789 1.169 0.053 0.223 0.277 Currently using a traditional method 0.067 0.008 1437 789 1.177 0.116 0.051 0.082 Currently using pill 0.069 0.009 1437 789 1.273 0.123 0.052 0.086 Currently using IUD 0.005 0.002 1437 789 1.144 0.408 0.001 0.010 Currently using condoms 0.074 0.009 1437 789 1.341 0.126 0.055 0.092 Currently using injectables 0.009 0.003 1437 789 1.067 0.300 0.004 0.014 Currently using female sterilization 0.086 0.009 1437 789 1.265 0.109 0.067 0.104 Currently using withdrawal 0.045 0.006 1437 789 1.116 0.136 0.033 0.057 Currently using periodic abstinence 0.022 0.004 1437 789 1.159 0.203 0.013 0.031 Used public sector source 0.790 0.026 379 200 1.232 0.033 0.739 0.842 Want no more children 0.492 0.015 1437 789 1.143 0.031 0.462 0.523 Want to delay birth at least 2 years 0.231 0.013 1437 789 1.189 0.057 0.204 0.257 Ideal family size 3.357 0.052 1336 756 1.456 0.015 3.254 3.461 Mothers protected against tetanus for last birth 0.798 0.016 720 390 1.078 0.021 0.765 0.830 Mothers received medical assistance at delivery 0.966 0.006 836 453 0.881 0.006 0.954 0.977 Had diarrhoea in the past 2 weeks 0.053 0.011 817 442 1.382 0.207 0.031 0.076 Treated with oral rehydration salts (ORS) 0.661 0.105 40 24 1.446 0.159 0.451 0.871 Taken to a health provider 0.831 0.077 40 24 1.331 0.092 0.678 0.984 Vaccination card seen 0.900 0.024 184 104 1.109 0.027 0.851 0.948 Received BCG vaccination 0.990 0.010 184 104 1.385 0.010 0.969 1.010 Received DPT vaccination (3 doses) 0.990 0.010 184 104 1.385 0.010 0.969 1.010 Received polio vaccination (3 doses) 0.981 0.013 184 104 1.307 0.013 0.954 1.007 Received measles vaccination 0.961 0.016 184 104 1.108 0.016 0.930 0.992 Received all basic vaccinations 0.952 0.017 184 104 1.112 0.018 0.917 0.987 Height-for-age (-2SD) 0.209 0.020 455 280 1.066 0.094 0.169 0.248 Weight-for-height (-2SD) 0.102 0.015 455 280 1.065 0.147 0.072 0.132 Weight-for-age (-2SD) 0.199 0.018 455 280 0.992 0.092 0.162 0.235 BMI <18.5 0.086 0.009 998 604 1.090 0.108 0.067 0.104 Has heard about HIV/AIDS 0.970 0.006 1543 853 1.445 0.007 0.957 0.982 Knows about condoms to prevent AIDS 0.794 0.014 1543 853 1.374 0.018 0.765 0.822 Knows about limiting partners 0.891 0.015 1543 853 1.852 0.017 0.861 0.920 Comprehensive knowledge on HIV transmission 0.419 0.016 1543 853 1.289 0.039 0.386 0.451 Total fertility rate (past 3 years) 2.962 0.136 na 3348 1.062 0.046 2.689 3.235 Neonatal mortality (past 0-9 years) 22.766 3.878 1570 864 0.978 0.170 15.010 30.522 Post-neonatal mortality (past 0-9 years) 9.716 3.352 1570 864 1.319 0.345 3.011 16.421 Infant mortality (past 0-9 years) 32.482 5.938 1572 864 1.257 0.183 20.605 44.359 Child mortality (past 0-9 years) 9.069 2.764 1533 846 1.087 0.305 3.540 14.598 Under-five mortality (past 0-9 years) 41.257 6.364 1575 867 1.154 0.154 28.528 53.985 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 212 | Appendix B Table B.10 Sampling errors for South sample, Maldives 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 1038 1190 na na 0.000 0.000 No education 0.221 0.013 1038 1190 0.993 0.058 0.196 0.247 Secondary education or higher 0.392 0.019 1038 1190 1.246 0.048 0.354 0.429 Net attendance ratio 0.800 0.014 980 1050 1.115 0.017 0.772 0.827 Currently married/in union 0.614 0.061 1577 1711 0.884 0.099 0.492 0.736 Married before age 20 0.553 0.016 1130 1293 1.141 0.030 0.520 0.586 Currently pregnant 0.050 0.007 1577 1711 0.956 0.145 0.035 0.064 Children ever born 2.099 0.222 1577 1711 0.900 0.106 1.655 2.544 Children surviving 1.950 0.206 1577 1711 0.901 0.106 1.537 2.362 Children ever born to women age 40-49 5.677 0.241 252 289 1.402 0.043 5.194 6.160 Knows any contraceptive method 0.990 0.004 918 1051 1.157 0.004 0.982 0.997 Knows a modern method 0.990 0.004 918 1051 1.157 0.004 0.982 0.997 Ever used any contraceptive method 0.528 0.022 918 1051 1.341 0.042 0.483 0.572 Currently using any method 0.284 0.019 918 1051 1.250 0.066 0.247 0.322 Currently using a modern method 0.255 0.017 918 1051 1.195 0.068 0.220 0.289 Currently using a traditional method 0.030 0.008 918 1051 1.465 0.277 0.013 0.046 Currently using pill 0.039 0.008 918 1051 1.226 0.202 0.023 0.054 Currently using IUD 0.005 0.002 918 1051 0.789 0.367 0.001 0.009 Currently using condoms 0.060 0.008 918 1051 0.992 0.129 0.045 0.076 Currently using injectables 0.011 0.004 918 1051 1.120 0.350 0.003 0.019 Currently using female sterilization 0.132 0.014 918 1051 1.296 0.110 0.103 0.161 Currently using withdrawal 0.015 0.006 918 1051 1.380 0.365 0.004 0.027 Currently using periodic abstinence 0.013 0.006 918 1051 1.455 0.411 0.002 0.025 Used public sector source 0.740 0.031 233 278 1.073 0.042 0.679 0.802 Want no more children 0.485 0.023 918 1051 1.384 0.047 0.440 0.531 Want to delay birth at least 2 years 0.234 0.018 918 1051 1.317 0.079 0.198 0.271 Ideal family size 3.268 0.040 899 1025 0.968 0.012 3.188 3.348 Mothers protected against tetanus for last birth 0.868 0.015 510 589 1.005 0.017 0.838 0.898 Mothers received medical assistance at delivery 0.973 0.008 606 700 1.061 0.008 0.957 0.988 Had diarrhoea in the past 2 weeks 0.038 0.008 599 691 0.984 0.213 0.022 0.054 Treated with oral rehydration salts (ORS) 0.561 0.116 29 26 1.048 0.206 0.330 0.793 Taken to a health provider 0.778 0.088 29 26 0.901 0.113 0.602 0.954 Vaccination card seen 0.810 0.045 123 142 1.270 0.055 0.721 0.900 Received BCG vaccination 0.988 0.013 123 142 1.278 0.013 0.962 1.013 Received DPT vaccination (3 doses) 0.965 0.019 123 142 1.137 0.020 0.927 1.003 Received polio vaccination (3 doses) 0.975 0.017 123 142 1.211 0.017 0.941 1.009 Received measles vaccination 0.957 0.021 123 142 1.161 0.022 0.914 0.999 Received all basic vaccinations 0.934 0.028 123 142 1.253 0.030 0.878 0.990 Height-for-age (-2SD) 0.199 0.031 327 346 1.372 0.154 0.138 0.260 Weight-for-height (-2SD) 0.084 0.016 327 346 1.027 0.195 0.051 0.117 Weight-for-age (-2SD) 0.159 0.025 327 346 1.197 0.157 0.109 0.209 BMI <18.5 0.067 0.012 669 761 1.238 0.180 0.043 0.091 Has heard about HIV/AIDS 0.960 0.007 1038 1190 1.185 0.008 0.945 0.974 Knows about condoms to prevent AIDS 0.808 0.013 1038 1190 1.070 0.016 0.782 0.834 Knows about limiting partners 0.907 0.013 1038 1190 1.437 0.014 0.881 0.933 Comprehensive knowledge on HIV transmission 0.343 0.018 1038 1190 1.220 0.053 0.307 0.379 Total fertility rate (past 3 years) 2.926 0.132 na 5133 0.875 0.045 2.662 3.190 Neonatal mortality (past 0-9 years) 10.108 3.480 1163 1336 1.209 0.344 3.147 17.068 Post-neonatal mortality (past 0-9 years) 8.928 2.733 1161 1337 0.942 0.306 3.462 14.394 Infant mortality (past 0-9 years) 19.035 3.954 1163 1336 0.942 0.208 11.127 26.943 Child mortality (past 0-9 years) 4.044 2.084 1109 1271 0.898 0.515 0.000 8.213 Under-five mortality (past 0-9 years) 23.002 4.271 1164 1337 0.892 0.186 14.460 31.545 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix C | 213 DATA QUALITY TABLES Appendix C Table C.1 Household age distribution Single-year age distribution of the de facto household population by sex (weighted), Maldives 2009 Women Men Age Number Percent Number Percent 0 485 2.3 518 2.7 1 458 2.2 453 2.4 2 383 1.8 377 2.0 3 384 1.8 386 2.0 4 351 1.7 381 2.0 5 359 1.7 361 1.9 6 304 1.4 309 1.6 7 348 1.7 373 2.0 8 380 1.8 417 2.2 9 420 2.0 427 2.3 10 363 1.7 387 2.0 11 407 1.9 404 2.1 12 468 2.2 502 2.6 13 493 2.4 532 2.8 14 496 2.4 517 2.7 15 474 2.3 444 2.3 16 521 2.5 545 2.9 17 549 2.6 494 2.6 18 562 2.7 521 2.7 19 535 2.5 445 2.3 20 510 2.4 391 2.1 21 481 2.3 363 1.9 22 522 2.5 385 2.0 23 514 2.4 336 1.8 24 444 2.1 306 1.6 25 458 2.2 331 1.7 26 422 2.0 293 1.5 27 376 1.8 308 1.6 28 389 1.9 301 1.6 29 375 1.8 258 1.4 30 369 1.8 331 1.7 31 284 1.4 179 0.9 32 386 1.8 245 1.3 33 283 1.3 215 1.1 34 262 1.3 226 1.2 35 318 1.5 231 1.2 36 301 1.4 216 1.1 37 315 1.5 201 1.1 38 291 1.4 225 1.2 39 229 1.1 224 1.2 40 283 1.3 247 1.3 41 171 0.8 138 0.7 42 248 1.2 202 1.1 43 238 1.1 170 0.9 44 213 1.0 136 0.7 45 189 0.9 207 1.1 46 184 0.9 131 0.7 47 195 0.9 144 0.8 48 171 0.8 209 1.1 49 103 0.5 154 0.8 50 262 1.3 214 1.1 51 152 0.7 94 0.5 52 165 0.8 123 0.7 53 130 0.6 116 0.6 54 86 0.4 102 0.5 55 121 0.6 134 0.7 56 89 0.4 90 0.5 57 73 0.3 56 0.3 58 90 0.4 92 0.5 59 65 0.3 73 0.4 60 71 0.3 59 0.3 61 44 0.2 48 0.3 62 54 0.3 63 0.3 63 89 0.4 79 0.4 64 53 0.3 52 0.3 65 204 1.0 200 1.1 66 79 0.4 89 0.5 67 103 0.5 115 0.6 68 60 0.3 67 0.4 69 38 0.2 37 0.2 70+ 440 2.1 602 3.2 Don't know 17 0.1 58 0.3 Total 20,977 100.0 18,965 100.0 214 | Appendix C Table C.2.1 Age distribution of eligible and interviewed women De facto household population of women age 10-54, interviewed women age 15-49, and percentage of eligible women who were interviewed (weighted), by five-year age groups, Maldives 2009 Household population of women age 10-54 Ever-married women age 10-54 Interviewed women age 15-49 Percentage of eligible women interviewed Age group Number Percent 10-14 2,228 0 na na na 15-19 2,641 140 119 1.7 85.0 20-24 2,470 1,517 1,270 18.3 83.7 25-29 2,020 1,800 1,482 21.4 82.4 30-34 1,585 1,503 1,223 17.6 81.4 35-39 1,454 1,420 1,191 17.2 83.9 40-44 1,154 1,139 982 14.2 86.2 45-49 843 829 671 9.7 80.9 50-54 796 787 na na na 15-49 12,167 8,347 6,938 100.0 83.1 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household schedule. na = Not applicable Table C.2.2 Age distribution of eligible and interviewed men De facto household population of men age 10-64, interviewed men age 15-59 and percent of eligible men who were interviewed (weighted), Maldives 2009 Household population of men age 10-64 Ever-married women age 10-64 Interviewed men age 15-59 Percentage of eligible men interviewed Age group Number Percent 10-14 1,141 0 na na na 15-19 1,251 5 3 0.2 59.4 20-24 898 248 129 7.5 52.0 25-29 719 526 251 14.5 47.7 30-34 573 535 290 16.8 54.2 35-39 526 509 260 15.0 51.1 40-44 442 430 228 13.2 52.9 45-49 392 388 217 12.6 56.0 50-54 309 308 154 8.9 49.9 55-59 210 208 119 6.9 57.3 60-64 139 139 na na na 15-59 5,320 3,156 1,727 100.0 54.7 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household schedule. na = Not applicable Appendix C | 215 Table C.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Maldives 2009 Subject Reference group Percentage with information missing Number of cases Birth date Births in past 15 years Month only 4.29 10,618 Month and year 1.48 10,618 Age at death Dead children born in past 15 years 0.60 349 Age/date at first union1 Ever-married women age 15-49 0.97 7,131 Ever-married men age 15-49 2.96 1,727 Respondent's education All women age 15-49 0.00 7,131 All men age 15-49 0.00 1,727 Diarrhoea in past 2 weeks Living children age 0-59 months 0.13 3,682 Anthropometry From Household Questionnaire Living children age 0-59 months Height 31.76 4,217 Weight 26.47 4,217 Height or weight 32.05 4,217 1 Both year and age missing Table C.4 Births by calendar years Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living (L), dead (D), and total (T) children (weighted), Maldives 2009 Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 Calendar year Living Dead Total Living Dead Total Living Dead Total Living Dead Total 2009 259 3 261 99.8 100.0 99.8 92.1 0.0 90.3 na na na 2008 840 11 850 00.0 89.8 99.9 103.0 40.0 101.9 na na na 2007 812 8 820 99.9 100.0 99.9 101.0 581.7 102.3 107.1 80.4 106.7 2006 677 9 685 99.9 89.6 99.8 94.7 304.1 95.9 93.1 98.1 93.1 2005 643 10 652 99.9 100.0 99.9 102.5 330.1 104.1 97.8 72.2 97.3 2004 638 18 656 99.7 81.4 99.2 118.9 207.4 120.6 103.4 158.1 104.4 2003 591 13 605 99.8 61.7 98.9 97.9 212.8 99.5 95.6 59.5 94.4 2002 599 27 626 95.9 65.2 94.6 107.3 136.2 108.4 99.1 134.0 100.2 2001 618 27 644 96.3 41.6 94.0 107.1 196.8 109.7 93.7 100.1 94.0 2000 719 26 745 93.7 42.2 91.9 103.3 52.6 101.0 114.7 84.8 113.3 2005- 2009 3,230 39 3,269 99.9 95.0 99.9 99.7 148.1 100.2 na na na 2000- 2004 3,164 111 3,276 97.0 56.3 95.6 106.7 133.1 107.5 na na na 1995- 1999 3,377 173 3,550 91.3 40.6 88.8 102.7 101.2 102.7 na na na 1990- 1994 3,716 230 3,946 85.9 27.7 82.5 99.1 110.8 99.8 na na na <1989 4,568 558 5,126 74.8 18.5 68.7 108.3 122.9 109.7 na na na All 18,055 1,111 19,166 88.5 30.4 85.2 103.5 118.4 104.3 na na na na = Not applicable 1 Both year and month of birth given 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x 216 | Appendix C Table C.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Maldives 2009 Age at death (days) Number of years preceding the survey 0-4 5-9 10-14 15-19 Total 0-19 <1 20 43 46 45 154 1 9 9 8 16 43 2 1 5 3 4 13 3 2 6 6 12 26 4 1 0 7 6 14 5 2 0 2 5 8 6 1 0 1 0 2 7 0 2 3 11 17 8 0 1 3 2 5 9 0 0 2 2 4 10 0 1 1 1 3 11 2 0 0 2 3 12 0 0 1 0 1 13 1 0 0 1 2 14 0 3 0 2 5 15 0 2 1 2 5 16 0 0 0 3 3 17 0 0 0 2 2 19 0 1 0 0 1 20 0 0 2 1 3 21 0 0 0 1 2 23 0 0 0 0 0 24 0 1 1 0 2 25 0 0 0 3 3 28 0 0 1 0 1 31+ 1 0 1 0 2 Total 0-30 38 73 90 120 321 Percent early neonatal1 92.6 85.7 82.1 73.2 80.8 1 ≤6 days / ≤30 days Appendix C | 217 Table C.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months and the percentage of infant deaths reported to occur at age under one month, for five-year periods of birth preceding the survey, Maldives 2009 Age at death (months) Number of years preceding the survey 0-4 5-9 10-14 15-19 Total 0-19 <1a 38 73 90 120 321 1 5 3 7 8 22 2 0 4 5 4 13 3 3 1 8 12 24 4 1 3 3 3 9 5 0 2 2 5 10 6 1 1 1 7 10 7 0 5 2 5 11 8 0 3 3 1 6 9 2 3 3 5 13 10 1 0 1 2 3 11 1 3 3 1 8 12 0 1 1 3 5 13 0 0 0 0 0 15 0 0 0 0 0 16 0 1 0 1 1 18 0 0 3 4 7 19 0 0 2 0 3 20 0 0 0 1 1 21 0 0 0 1 1 23 0 1 0 0 1 1 year 0 1 9 5 16 Total 0-11 52 101 127 171 450 Percent neonatal1 73.4 72.9 70.8 70.4 71.4 1 Under one month / under one year a Includes deaths under one month reported in days 218 | Appendix C Table C.7 Nutritional status of children based on NCHS/CDC/WHO International Reference Population Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Maldives 2009 Height-for-age Weight-for-height Weight-for-age Background characteristic Per- centage below -3 SD Per- centage below -2 SD1 Mean Z- score (SD) Per- centage below -3 SD Per- centage below -2 SD1 Per- centage above +2 SD Mean Z-score (SD) Per- centage below -3 SD Per- centage below -2 SD1 Per- centage above +2 SD Mean Z-score (SD) Number of children Age in months <6 2.3 10.4 (0.4) 0.8 4.8 6.2 0.1 0.3 4.7 3.5 (0.2) 223 6-8 5.5 14.8 (0.7) 0.9 6.9 5.4 (0.1) 2.2 7.1 3.1 (0.7) 156 9-11 8.8 23.9 (1.1) 1.1 12.5 4.4 (0.4) 4.2 26.2 1.9 (1.2) 155 12-17 6.8 25.3 (1.2) 0.9 6.4 3.9 (0.4) 2.4 24.8 1.8 (1.1) 267 18-23 8.2 26.3 (1.2) 1.8 9.0 5.5 (0.5) 1.7 19.6 2.6 (1.0) 261 24-35 4.1 14.2 (0.7) 0.9 10.5 2.5 (0.8) 5.2 28.1 1.7 (1.1) 474 36-47 3.7 14.5 (0.7) 1.2 9.3 5.5 (0.7) 3.7 23.8 3.2 (1.0) 497 48-59 3.3 13.3 (0.7) 0.2 10.8 5.0 (0.6) 2.6 21.1 2.9 (0.9) 478 Sex Male 5.8 16.8 (0.8) 1.0 9.3 4.7 (0.5) 2.7 20.3 2.5 (1.0) 1,270 Female 3.7 16.8 (0.8) 0.8 9.0 4.7 (0.5) 3.5 22.0 2.7 (0.9) 1,242 Birth interval in months2 First birth3 3.8 15.1 (0.7) 1.1 7.8 5.9 (0.4) 2.5 15.8 3.5 (0.8) 951 <24 6.5 19.3 (1.0) 1.1 10.2 2.8 (0.7) 4.7 28.3 2.2 (1.3) 174 24-47 4.6 18.5 (0.9) 0.8 8.3 4.0 (0.5) 2.6 21.3 1.2 (1.0) 399 48+ 3.8 15.2 (0.8) 0.5 11.7 3.6 (0.7) 3.1 24.7 2.2 (1.0) 758 Size at birth2,4 Very small 14.5 31.6 (1.6) 1.7 14.4 4.7 (0.6) 10.1 41.5 0.0 (1.6) 87 Small 5.0 25.1 (1.2) 3.1 14.3 1.5 (0.9) 4.7 32.4 0.7 (1.5) 213 Average or larger 3.6 14.4 (0.7) 0.6 8.6 4.9 (0.5) 2.4 18.5 2.9 (0.9) 1,977 Missing 0.0 0.0 (1.1) 0.0 0.0 0.0 (0.7) 0.0 0.0 0.0 (1.3) 1 Mother's interview status Interviewed 4.1 16.0 (0.8) 0.8 9.4 4.5 (0.5) 2.9 20.7 2.6 (0.9) 2,282 Not interviewed but in household 12.4 26.2 (1.1) 2.2 6.8 6.5 (0.5) 4.9 27.6 2.7 (1.1) 202 Not interviewed, and not in the household 3.1 11.1 (0.9) 0.0 7.3 0.0 (0.5) 3.1 16.1 2.9 (1.0) 28 Mother's nutritional status5 Thin (BMI<18.5) 5.5 20.1 (1.1) 1.9 13.8 1.8 (1.0) 5.4 29.9 0.0 (1.5) 185 Normal (BMI 18.5-24.9) 3.7 16.2 (0.8) 1.0 9.4 3.3 (0.6) 2.6 21.2 1.7 (1.0) 1,170 Overweight/ obese (BMI ≥25) 5.5 16.0 (0.8) 0.7 8.2 6.3 (0.4) 2.8 19.0 3.8 (0.8) 959 Missing 7.3 21.6 (0.8) 0.3 8.1 9.6 (0.2) 4.1 21.8 3.8 (0.7) 154 Residence Urban 3.5 14.2 (0.6) 0.0 5.9 5.5 (0.3) 0.7 13.2 2.5 (0.7) 722 Rural 5.3 17.9 (0.9) 1.3 10.4 4.3 (0.6) 4.0 24.4 2.6 (1.1) 1,791 Region Malé 3.5 14.2 (0.6) 0.0 5.9 5.5 (0.3) 0.7 13.2 2.5 (0.7) 722 North 3.7 14.1 (0.8) 0.5 9.4 4.3 (0.6) 2.6 22.5 3.6 (1.0) 387 North Central 6.5 21.0 (1.0) 1.8 13.3 2.4 (0.8) 5.1 29.1 1.7 (1.3) 542 Central 6.8 18.7 (0.8) 1.8 10.9 4.7 (0.6) 4.7 20.8 1.5 (1.0) 235 South Central 5.7 17.8 (0.9) 0.8 9.0 4.9 (0.5) 3.6 23.0 2.8 (1.0) 281 South 3.9 16.7 (0.8) 1.5 8.0 6.8 (0.4) 3.8 22.7 3.6 (0.8) 346 Mother's education6 No education 7.1 22.3 (1.1) 0.2 12.8 4.9 (0.7) 4.2 31.8 3.3 (1.3) 321 Primary 5.4 18.5 (0.9) 1.5 10.9 4.2 (0.7) 4.4 25.1 1.5 (1.1) 939 Secondary 3.7 14.8 (0.7) 0.8 6.8 4.7 (0.4) 2.0 16.0 2.8 (0.8) 1,085 More than secondary 4.8 10.3 (0.3) 0.0 8.3 8.5 (0.3) 0.0 11.1 6.2 (0.5) 115 Unknown - Certificate 6.3 6.3 (0.2) 0.0 3.6 3.1 (0.3) 0.0 11.6 6.4 (0.4) 24 Wealth quintile Lowest 5.9 20.0 (1.0) 1.4 11.3 4.1 (0.7) 5.2 27.3 2.4 (1.2) 509 Second 5.7 20.3 (1.0) 1.2 9.6 4.2 (0.5) 4.4 24.3 2.1 (1.1) 532 Middle 4.5 14.8 (0.8) 1.1 11.5 3.3 (0.7) 3.0 24.8 2.3 (1.0) 517 Fourth 4.0 13.5 (0.6) 0.4 5.8 5.8 (0.3) 1.9 15.2 3.9 (0.6) 477 Highest 3.6 14.9 (0.6) 0.3 7.2 6.1 (0.4) 0.4 13.1 2.4 (0.7) 477 Total 4.8 16.8 (0.8) 0.9 9.1 4.7 (0.5) 3.1 21.2 2.6 (1.0) 2,512 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the NCHS/CDC/WHO Child Growth Standards. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. 1 Includes children who are below -3 standard deviations (SD) from the International Reference Population median 2 Excludes children whose mothers were not interviewed 3 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 4 Includes children whose mothers are deceased 5 Excludes children whose mothers were not weighed and measured. Mother's nutritional status in terms of BMI (Body Mass Index) is presented in Table 11.10 6 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire Appendix D | 219 PERSONS INVOLVED IN THE 2009 MALDIVES DEMOGRAPHIC AND HEALTH SURVEY Appendix D Chief Coordinator Ms. Maimoona Aboobakur Pre-Testing Ms. Kia Reinis Turgay Ünalan, Consultant Mr. Ahmed Hisan Ms. Aiman Waheed Ms. Aminath Rishfa Ms. Hudha Haleem Ms. Maimoona Aboobakur Ms. Mariyam Azma Ms. Mariyam Nazviya Ms. Rasheeda Najeeb Enumerators Mr. Abdul Latheef Mr. Adam Ismail Mr. Ahmed Abdul Rahman Mr. Ahmed Hisan Mr. Ahmed Niyaz Mr. Ahmed Shafiu Mr. Ahmed Shaheel Mr. Ahmed Shiran Saeed Mr. Ali Aman Mr. Ali Iyad Mr. Ali Muaz Mr. Hussain Ahmed Didi Mr. Hussain Solah Mr. Hussain Yazeed Mr. Isham Abdul Azeez Mr. Iyaz Jadulla Naseem Mr. Mohamed Azheem Mr. Mohamed Hameem Mr. Mohamed Mifzal Mr. Mohamed Shirhan Saamee Mr. Mohamed Sobir Mr. Saeed Hassan Mr. Shabeeb Athif Ms. Mariyam Shama Mr. Wishan Waheed Ms. Aishath Aagil Ms. Aishath Abdulla Ms. Aishath Ahmed Ms. Aishath Humaidha Ms. Aishath Neena Ms. Aishath Nisha Ms. Aishath Shaufa Ms. Aishath Sofa Ms. Aishath Yooha Ms. Aishath Yooha Nadheem Ms. Aminath Hilala Ms. Aminath Ismail Ms. Aminath Leena Ms. Aminath Masha Ms. Aminath Meeza Saeed Ms. Aminath Shafaq Ms. Aminath Shizna Ms. Aminath Zifna Ms. Amira Ahmed Ms. Amira Ali Ms. Fathina Ahmed Khaleel Ms. Fathmath Hanaan Ms. Fathmath Leena Ms. Fathmath Maisa Ms. Fathmath Shuwaina Ms. Fathmath Ulya Moosa Ms. Fathmath Usha Ms. Hawa Riyasa Ms. Hawwa Hanaan Ms. Liusha Ali Ms. Maajidha Hassan Ms. Malaka Ibrahim Ms. Maleesa Yoosuf Ms. Mareena Yoosuf Ms. Mariyam Eema Ms. Mariyam Ismail Ms. Mariyam Shama Ms. Nadhira Abdul Qafoor Ms. Nayasheen Ahmed Rushdy Ms. Shamha Shareef Ms. Shazny Abdulla Ms. Sofoora Riza Ms. Mariyam Hamdha Field Editors Mr. Abdul Latheef Mr. Ahmed Shafiu Mr. Ali Muaz Mr. Alim Shakeel Mr. Athif Haneef Mr. Hassan Waheed Mr. Moosa Naeem Ms. Shifaza Rasheed Ms. Aishath Neena Ms. Aishath Sofa Ms. Aminath Ismail Ms. Aminath Masha Ms. Aminath Meeza Saeed Ms. Aminath Zifna Ms. Fathmath Leena Ms. Fathmath Maisa Ms. Liusha Ali Ms. Mariyam Shama Ms. Mariyam Shiuna Ms. Seema Adam Ms. Sofoora Riza Ms. Hudha Haleem 220 | Appendix D Supervisors Mr. Abdul Jaleel Ibrahim Mr. Ahmed Shafiu Mr. Alim Shakeel Mr. Hassan Waheed Mr. Hussain Farooq Gasim Mr. Iyaz Jadulla Naseem Mr. Sidhgy Abdulla Mr Ahmed Hisan Ms. Aminath Suiza Ms. Fathmath Saba Ms. Nashiya Abdul Qafoor Office Editors Ms. Fathmath Shifza Ms. Moomina Abdul Rahman Ms. Zahidha Hussain Data Entry Coordinators Mr. Abulla Sham Zahir Mr. Hussain Aneel Mr. Ibrahim Latheef Data Entry Officers Mr. Afzal Mohamed Mr. Ahmed Imad Saeed Mr. Ameen Abdul Kareem Mr. Hassan Zameer Mr. Hussain Nashath Mr. Ismail Shafeeu Mr. Mazhar Riyaz Mr. Mushad Rasheed Mr. Yoosuf Rizmeen Ms. Aishath Niyaza Ms. Aminath Shuau Ms. Aminath Sithuna Ms. Aminath Viaama Ms. Bushra Jaufar Ms. Fathmath Maimoona Ms. Hanan Shiham Ms. Hawwa Maira Ms. Raushan Jaleel Ms. Yahma Hassan Contributors to the Report Writing Workshop Mr. Ahmed Khaleel Ministry of Health and Family/DSD Ms. Maimoona Aboobakur Ministry of Health and Family/DSD Mr. Mohamed Shaheed Ministry of Health and Family/QAID Ms. Aiman Waheedh Ministry of Health and Family/DSD Ms. Mariyam Nazviya Ministry of Health and Family/DSD Ms. Aishath Azla Ministry of Health and Family/DDPRS Ms. Aishath Ibahath Ministry of Health and Family/DGFPS Ms. Mariyam Shafia Ministry of Health and Family/QAID Ms. Moomina Abdul Rahman Ministry of Health and Family/DSD Ms. Selina Mohamed Ministry of Health and Family/DGFPS Dr. Niyasha Ibrahim IGMH Mr. Abdul Hameed Centre for Community Health and Disease Control Ms. Aishath Niyaf Centre for Community Health and Disease Control Ms. Aishath Suziya Centre for Community Health and Disease Control Ms. Aminath Shahidha Centre for Community Health and Disease Control Ms. Fathmath Saeedha Centre for Community Health and Disease Control Ms. Zarana Ibrahim Centre for Community Health and Disease Control Ms. Mariyam Najla Centre for Community Health and Disease Control Mr. Mohamed Zaid Faculty of Health Sciences Ms. Aishath Shaheen Ismail Faculty of Health Sciences Ms. Aminath Shafia Faculty of Health Sciences Ms. Ashiyath Rasheed Faculty of Health Sciences Ms. Asiya Ibrahim Faculty of Health Sciences Ms. Asrath Usman Faculty of Health Sciences Ms. Fathmath Muna Hassan Faculty of Health Sciences Ms. Fazeela Waheed Faculty of Health Sciences Ms. Mariyam Neerish Faculty of Health Sciences Appendix D | 221 Ms. Salma Hassan Faculty of Health Sciences Ms. Zeenaz Fahmy Faculty of Health Sciences Ms. Zubaidha Ali Faculty of Health Sciences Mr. Mohamed Shinah Ministry of Education Ms. Aishath Shifa Ministry of Education Ms. Fathmath Riyaza Ministry of Human Resources, Youth and Sports Ms. Fathmath Waheeda Ministry of Human Resources, Youth and Sports Ms. Mariyam Shafeeq National Social Protection Agency Mr. Ali Adhyb Journey Mr. Ali Sobah Journey Mr. Mohamed Shuaib Journey Ms. Aishath Amany Hamza Care Society Ms. Aminath Luha Care Society Ms. Khadheeja Hasaana Hassan Care Society Ms. Majidha Abubakur Care Society Ms. Nasha Ahmed Care Society Ms. Shina Wajeeh Care Society Ms. Aminath Nawal UNDP Ms. Aminath Rasheeda UNICEF Ms. Fathmath Zuhana UNFPA Ms. Kumiko Yoshida UNFPA Ms. Shadhiya Ibrahim UNFPA Ms. Sajidha Abdulla Manfa Centre Mr. Mohamed Zuhair ICF Macro Staff Ann Way MEASURE DHS Project Director Kia Reinis Survey Specialist Ruilin Ren Senior Sampling Expert Sri Poedjastoeti Survey Specialist Han Raggers Senior Data Processing Specialist Velma Lopez Report Reviewer Nancy Johnson Senior Editor Kaye Mitchell Report Production Christopher L. Gramer Cover Design ICF Macro Consultants Turgay Ünalan Consultant, Pretest Elizabeth Go Consultant, Main Training Anuja Jayaraman Consultant, Report-writing Workshop QUESTIONNAIRES Appendix E 223Appendix E | HOUSEHOLD QUESTIONNAIRE 1 7 D e c e m b e r 2 0 0 8 INTERVIEWER VISITS ISLAND NAME NEXT VISIT: HOUSEHOLD NAME Month Day INTERVIEWER'S NAME RESULT* INT. NUMBER RESULT 2 0 0 2 0 0 321 Hr : : DATE DATE TOTAL NUMBER OF VISITS TIME 1 COMPLETED 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 4 POSTPONED 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER_______________________________________ (specify) *RESULT CODES: FINAL VISIT NAME ID CODE DATE 2008 MALDIVES DEMOGRAPHIC AND HEALTH SURVEY IDENTIFICATION NAME OF HOUSEHOLD HEAD CLUSTER NUMBER HOUSEHOLD NUMBER ATOLL SUBSAMPLE: 1. EVER-MARRIED MEN 2. YOUTH AND YOUNG ADULT monthday year monthday year Year monthday year 2 0 0 monthday year 2 0 0 monthday year Min Hr Min TOTAL PERSONS IN THE HOUSEHOLD TOTAL ELIGIBLE EVER-MARRIED WOMEN TOTAL ELIGIBLE EVER-MARRIED MEN TOTAL ELIGIBLE NEVER-MARRIED YOUTH LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY VERIFIED BY NAME ID CODE ID CODE DATE ID CODE ID CODE 2 0 0 2 0 0 1 | 225Appendix E : Introduction and Consent SECTION 1 : GENERAL INFORMATION Hello. My name is _______________________________________ and I am working with Ministry of Health. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete. As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential and will not be shared with anyone other than the members of our survey team. Participation in the survey is completely voluntary. If we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope you will participate in the survey since your views are important. At this time, do you want to ask me anything about the survey? May I begin the interview now? Signature of interviewer:____________________________ Date: _______________________ RESPONDENT AGREES TO BE INTERVIEWED 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END RECORD THE TIME. HOUR MINUTES 2 226 | Appendix E 0 2 0 1 0 6 0 5 0 4 0 3 C O D E S F O R Q . 3 : R E L A T IO N S H IP T O H E A D O F H O U S E H O L D L IN E N U M B E R W h a t is t h e r e la ti o n s h ip o f (N A M E ) to t h e h e a d o f th e h o u s e h o ld ? S E E C O D E S B E L O W . Is ( N A M E ) m a le o r fe m a le ? D o e s (N A M E ) u s u a lly l iv e h e re ? P le a s e g iv e m e t h e n a m e s o f th e p e rs o n s w h o u s u a lly l iv e i n y o u r h o u s e h o ld a n d g u e s ts w h o s ta y e d h e re l a s t n ig h t, s ta rt in g w it h t h e h e a d o f th e h o u s e h o ld . A F T E R L IS T IN G T H E N A M E S A N D R E C O R D IN G T H E R E L A T IO N S H IP A N D S E X F O R E A C H P E R S O N , A S K Q U E S T IO N S 2 A -2 C T O B E S U R E T H A T T H E L IS T IN G I S C O M P L E T E . T H E N A S K Q U E S T IO N S 5 -5 4 F O R E A C H P E R S O N A S A P P R O P R IA T E . Is ( N A M E ) a M a ld iv ia n ? W h a t is (N A M E ’s ) c u rr e n t m a ri ta l s ta tu s ? 1 = M A R R IE D 2 = D IV O R C E D / S E P A R A T E D H o w o ld i s (N A M E ) ? E V E R -M A R R IE D W O M E N 1 5 -4 9 C IR C L E L IN E N U M B E R O F A L L E V E R -M A R R IE D W O M E N A G E 1 5 -4 9 M A R IT A L S T A T U S E L IG IB L E F O R I N T E R V IE W 3 = W ID O W E D 4 = N E V E R -M A R R IE D E V E R -M A R R IE D M E N 1 5 -6 4 N E V E R -M A R R IE D W O M E N A N D M E N 1 5 -2 4 Y E S 0 1 = H E A D 0 2 = W IF E O R H U S B A N D 0 3 = S O N O R D A U G H T E R 0 4 = S O N -I N -L A W O R D A U G H T E R -I N -L A W 0 5 = G R A N D C H IL D 0 6 = P A R E N T 0 7 = P A R E N T -I N -L A W 0 8 = B R O T H E R O R S IS T E R A D D T O T A B L E Y E S Y E S 2 A ) J u s t to m a k e s u re t h a t I h a v e a c o m p le te lis ti n g . A re t h e re a n y o th e r p e rs o n s s u c h a s s m a ll c h ild re n o r i n fa n ts t h a t w e h a v e n o t lis te d ? 2 B ) A re t h e re a n y o th e r p e o p le w h o m a y n o t b e m e m b e rs o f y o u r fa m ily , s u c h a s d o m e s ti c s e rv a n ts , lo d g e rs , o r fr ie n d s w h o u s u a lly l iv e h e re ? 2 C ) A re t h e re a n y g u e s ts o r te m p o ra ry v is it o rs s ta y in g h e re , o r a n y o n e e ls e w h o s ta y e d h e re l a s t n ig h t, w h o h a v e n o t b e e n l is te d ? C IR C L E L IN E N U M B E R O F A L L E V E R -M A R R IE D M E N A G E 1 5 -6 4 C IR C L E L IN E N U M B E R O F A L L N E V E R -M A R R IE D W O M E N A N D M E N A G E 1 5 -2 4 0 2 0 1 0 6 0 5 0 4 0 3 0 2 0 1 0 6 0 5 0 4 0 3 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 A D D T O T A B L E A D D T O T A B L E N O N O N O 0 9 = B R O T H E R O R S IS T E R -I N -L A W 1 0 = A U N T /U N C L E 1 1 = N IE C E /N E P H E W B Y B L O O D 1 2 = N IE C E /N E P H E W B Y M A R R IA G E 1 3 = O T H E R R E L A T IV E 1 4 = A D O P T E D /F O S T E R /S T E P C H IL D 1 5 = N O T R E L A T E D 9 8 = D O N 'T K N O W 0 2 0 1 0 6 0 5 0 4 0 3 1 2 1 2 1 2 1 2 1 2 1 2 T IC K H E R E I F C O N T IN U A T IO N S H E E T U S E D Is ( N A M E ) m a rr ie d t o a M a ld iv ia n o r is ( N A M E )a s o n o r d a u g h te r o f a M a ld iv ia n ? D id (N A M E ) s ta y h e re l a s t n ig h t? 1 2 G O T O 7 Y E S N O M A L E F E M A L E 2 1 2 1 Y E S N O 2 1 Y E S N O 2 1 Y E S N O 2 1 1 2 G O T O 7 1 2 G O T O 7 1 2 G O T O 7 1 2 G O T O 7 1 2 G O T O 7 1 2 G O T O N E X T P E R S O N 1 2 G O T O N E X T P E R S O N 1 2 G O T O N E X T P E R S O N 1 2 G O T O N E X T P E R S O N 1 2 G O T O N E X T P E R S O N 1 2 G O T O N E X T P E R S O N 1 2 G O T O N E X T P E R S O N 0 7 0 7 0 7 1 2 1 2 0 7 USUAL RESIDENTS AND RELATIONSHIP TO HEAD OF HHVISITORS SEX AGE RESIDENCE 1 2 3 8 9 1 0 1 14 75 IF AGE 15 OR OLDER 3 1 2 6 B 6 A6 1 2 G O T O 7 | 227Appendix E E L IG IB L E F O R H E IG H T A N D W E IG H T S U R V IV O R S H IP A N D R E S ID E N C E O F B IO L O G IC A L P A R E N T S 0 1 0 2 0 3 0 4 0 5 L IN E N U M B E R G O T O 1 5 Is ( N A M E )' s n a tu ra l m o th e r a liv e ? Is ( N A M E )' s n a tu ra l fa th e r a liv e ? D o e s ( N A M E )' s n a tu ra l m o th e r u s u a lly l iv e i n t h is h o u s e h o ld o r w a s s h e a g u e s t la s t n ig h t? IF Y E S : W h a t is h e r n a m e ? C IR C L E L IN E N U M B E R O F C H IL D R E N A G E 0 -5 D o e s ( N A M E )' s n a tu ra l fa th e r u s u a lly l iv e i n t h is h o u s e h o ld o r w a s h e a g u e s t la s t n ig h t? IF Y E S : W h a t is h is n a m e ? 0 1 0 2 0 3 0 4 0 5 0 6 1 2 8 G O T O 1 5 1 2 8 G O T O 1 5 1 2 8 G O T O 1 5 1 2 8 G O T O 1 5 IF N O : R E C O R D ‘ 0 0 ’ IF N O : R E C O R D ‘ 0 0 ’ 1 2 8 G O T O 1 7 1 2 8 G O T O 1 7 1 2 8 G O T O 1 7 1 2 8 G O T O 1 7 1 2 8 G O T O 1 7 R E C O R D M O T H E R ’S L IN E N U M B E R R E C O R D F A T H E R ’S L IN E N U M B E R Y E S N O D K Y E S N O D K 1 12 28 8 1 2 8 M O T H E R ’S L IN E N U M B E R F A T H E R ’S L IN E N U M B E R 0 6 0 7 1 2 8 G O T O 1 5 1 2 8 G O T O 1 5 1 2 8 G O T O 1 7 1 2 8 G O T O 1 7 0 7 1 2 1 4 1 5 1 6 IF AGE 0-17 YEARS IF AGE 0-5 YEARS _ _ _ _ _ _ 1 3 4 228 | Appendix E 1 2 3 8 1 20 1 0 2 0 3 0 4 L IN E N U M B E R D o e s ( N A M E ) h a v e a b ir th c e rt if ic a te ? H a s ( N A M E ) e v e r a tt e n d e d s c h o o l? S E E C O D E S B E L O W S E E C O D E S B E L O W W h a t is t h e h ig h e s t le v e l o f s c h o o l (N A M E ) h a s a tt e n d e d ? W h a t is t h e h ig h e s t g ra d e ( N A M E ) c o m p le te d a t th a t le v e l? D id ( N A M E ) a tt e n d s c h o o l o r p re s c h o o l a t a n y t im e d u ri n g t h is s c h o o l y e a r, t h a t is , d u ri n g 2 0 0 8 ? D u ri n g t h is s c h o o l y e a r, w h a t le v e l a n d g ra d e [ is /w a s ] (N A M E ) a tt e n d in g ? IF N O , P R O B E : H a s ( N A M E )' s b ir th e v e r b e e n r e g is te re d w it h t h e c iv il a u th o ri ty ? 1 = Y E S , H A S C E R T IF IC A T E 2 = N O C E R T IF IC A T E B U T R E G IS T E R E D 3 = N O C E R T IF IC A T E A N D N O T R E G IS T E R E D 8 = D O N 'T K N O W B IR T H R E G IS T R A T IO N E V E R A T T E N D E D S C H O O L C U R R E N T /R E C E N T S C H O O L A T T E N D A N C E L E V E L G R A D E S E E C O D E S B E L O W D id ( N A M E ) a tt e n d s c h o o l o r p re s c h o o l a t a n y ti m e d u ri n g t h e p re v io u s s c h o o l y e a r, t h a t is , d u ri n g 2 0 0 7 ? D u ri n g t h e 2 0 0 7 s c h o o l y e a r, w h a t le v e l a n d g ra d e d id ( N A M E ) a tt e n d ? S E E C O D E S B E L O W C O D E S F O R Q s . 1 9 , 2 1 , A N D 2 3 : E D U C A T IO N 0 0 = L E S S T H A N 1 Y E A R C O M P L E T E D (U S E '0 0 ' F O R Q . 1 9 O N L Y . T H IS C O D E I S N O T A L L O W E D F O R Q S . 2 1 A N D 2 3 ) 9 8 = D O N 'T K N O W 0 0 = N O N -F O R M A L E D U C A T IO N 0 1 = P R E S C H O O L 0 2 = P R IM A R Y 0 3 = 'O ' L E V E L 0 4 = 'A ' L E V E L 0 5 = D IP L O M A 0 6 = F IR S T D E G R E E 0 7 = M A S T E R 'S C E R T IF IC A T E /A B O V E 0 8 = C E R T IF IC A T E 9 8 = D O N 'T K N O W 1 2 3 8 1 2 3 8 1 2 3 8 1 2 G O T O 2 4 1 2 G O T O 2 4 1 2 G O T O 2 4 1 2 G O T O 2 4 G O T O 2 2 1 2 G O T O 2 2 1 2 G O T O 2 2 1 2 G O T O 2 2 1 2 G O T O 2 4 1 2 G O T O 2 4 1 2 G O T O 2 4 1 2 G O T O 2 4 0 5 0 6 1 2 3 8 1 2 3 8 1 2 G O T O 2 4 G O T O 2 4 1 2 G O T O 2 2 G O T O 2 2 1 2 G O T O 2 4 1 2 Y E S N O Y E S N O Y E S N O 2 2 2 1 1 1 1 2 L E V E L L E V E L L E V E L G R A D E G R A D E G R A D E 1 2 1 8 1 9 2 0 2 1 2 2 2 3 1 7 IF AGE 0-4 YEARS IF AGE 5 YEARS OR OLDER IF AGE 5 - 24 YEARS 0 7 1 2 3 8 1 2 G O T O 2 4 1 2 G O T O 2 2 G O T O 2 4 1 2 G O T O 2 4 5 | 229Appendix E 0 1 0 2 0 3 0 4 0 5 1 2 3 4 L IN E N U M B E R D o e s ( N A M E ) h a v e a n y d if fi c u lt y s e e in g ( e v e n w h e n ( h e /s h e ) is w e a ri n g g la s s e s o r c o n ta c t le n s e s )? D IS A B IL IT Y W o u ld y o u s a y t h a t (h e /s h e ) c a n s e e o n ly w it h s o m e d if fi c u lt y, a l o t o f d if fi c u lt y o r c a n (h e /s h e ) n o t s e e a t a ll? D o e s ( N A M E ) h a v e a n y d if fi c u lt y h e a ri n g ( e v e n w h e n ( h e /s h e ) is u s in g a h e a ri n g a id ? W o u ld y o u s a y t h a t (h e /s h e ) c a n h e a r o n ly w it h s o m e d if fi c u lt y, a l o t o f d if fi c u lt y o r c a n ( h e /s h e ) n o t h e a r a t a ll? D o e s ( N A M E ) h a v e a n y d if fi c u lt y c o m m u n ic a ti n g ( fo r e x a m p le u n d e rs ta n d in g o th e rs o r o th e rs u n d e rs ta n d in g ( h im /h e r) ) b e c a u s e o f a p h y s ic a l, m e n ta l o r e m o ti o n a l c o n d it io n ? W o u ld y o u s a y t h a t (h e /s h e ) c a n c o m m u n ic a te o n ly w it h s o m e d if fi c u lt y, a l o t o f d if fi c u lt y o r c a n ( h e /s h e ) n o t c o m m u n ic a te a t a ll? D o e s ( N A M E ) h a v e a n y d if fi c u lt y w it h r e m e m b e ri n g o r c o n c e n tr a ti n g ? D o e s ( N A M E ) h a v e a n y p h y s ic a l c o n d it io n t h a t m a k e s i t d if fi c u lt fo r (h im /h e r) ( w it h s e lf -c a re s u c h a s ) w a s h in g a ll o v e r o r d re s s in g ? W o u ld y o u s a y t h a t (h e /s h e ) c a n re m e m b e r o r c o n c e n tr a te o n ly w it h s o m e d if fi c u lt y, a l o t o f d if fi c u lt y o r c a n ( h e /s h e ) n o t re m e m b e r o r c o n c e n tr a te a t a ll? W o u ld y o u s a y t h a t (h e /s h e ) c a n w a s h a ll o v e r o r d re s s o n ly w it h s o m e d if fi c u lt y, a l o t o f d if fi c u lt y o r c a n ( h e /s h e ) n o t w a s h o r d re s s a t a ll? 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 N o p ro b le m w it h s e e in g S o m e d if fi c u lt y L o t o f d if fi c u lt y N o t s e e a t a ll 1 42 3 N o p ro b le m w it h h e a ri n g S o m e d if fi c u lt y L o t o f d if fi c u lt y N o t h e a r a t a ll 1 42 3 N o p ro b le m w it h c o m m u n ic a ti o n S o m e d if fi c u lt y L o t o f d if fi c u lt y C a n n o t c o m m u n ic a te a t a ll 1 42 3 N o p ro b le m w it h r e m e m b e ri n g o r c o n c e n tr a ti n g S o m e d if fi c u lt y L o t o f d if fi c u lt y C a n n o t re m e m b e r o r c o n c e n tr a te a t a ll 1 42 3 N o p ro b le m w it h w a s h in g a ll o v e r o r d re s s in g S o m e d if fi c u lt y L o t o f d if fi c u lt y C a n n o t w a s h a ll o v e r o r d re s s 1 42 3 D o e s ( N A M E ) h a v e a n y p h y s ic a l c o n d it io n t h a t m a k e s i t d if fi c u lt fo r (h im /h e r) t o w a lk o r c lim b in g s te p s ? W o u ld y o u s a y t h a t (h e /s h e ) c a n w a lk o r c lim b s te p s o n ly w it h s o m e d if fi c u lt y, a l o t o f d if fi c u lt y o r c a n ( h e /s h e ) n o t w a lk o r c lim b s te p s a t a ll? N o p ro b le m w it h w a lk in g o r c lim b in g s te p s S o m e d if fi c u lt y L o t o f d if fi c u lt y C a n n o t w a lk o r c lim b s te p s a t a ll 1 42 3 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 0 6 0 7 IF AGE 5 YEARS OR OLDER 2 4 2 5 2 7 2 9 IF Y E S : IF Y E S : IF Y E S : 2 6 IF Y E S : IF Y E S : 1 2 3 4 6 1 2 3 4 1 2 3 4 1 2 3 41 2 3 4 2 8 IF Y E S : 1 2 3 4 230 | Appendix E 0 1 0 2 0 3 0 4 0 5 L IN E N U M B E R 1 2 R E C O R D T H E L IN E N U M B E R O F T H E P E R S O N P R O V ID IN G T H E I N F O R M A T IO N I N Q U E S T IO N S 3 0 -5 4 C o m p a re d w it h o th e r c h ild re n , d o e s o r d id ( N A M E ) h a v e a n y s e ri o u s d e la y i n s it ti n g , s ta n d in g , o r w a lk in g ? C o m p a re d w it h o th e r c h ild re n , d o e s ( N A M E ) h a v e d if fi c u lt y s e e in g ,e it h e r in t h e d a y ti m e o r a t n ig h t? D o e s ( N A M E ) a p p e a r to h a v e d if fi c u lt y h e a ri n g (u s e s h e a ri n g a id ,h e a rs w it h d if fi c u lt y o r is c o m p le te ly d e a f? W h e n y o u t e ll (N A M E ) to d o s o m e th in g , d o e s h e /s h e s e e m t o u n d e rs ta n d w h a t y o u a re s a y in g ? D o e s ( N A M E ) h a v e d if fi c u lt y i n w a lk in g o r m o v in g h is /h e r a rm s , o r d o e s h e /s h e h a v e w e a k n e s s a n d /o r s ti ff n e s s i n t h e a rm s o r le g s ? Y O U N G C H IL D D IS A B IL IT Y C H IL D ’S C A R E T A K E R D o e s ( N A M E ) s o m e ti m e s h a v e f it s , b e c o m e r ig id , o r lo s e c o n s c io u s n e s s ? D o e s ( N A M E ) le a rn t o d o t h in g s l ik e o th e r c h ild re n o f h is /h e r a g e ? D o e s ( N A M E ) s p e a k a t a ll (C a n h e /s h e m a k e h im o r h e rs e lf u n d e rs to o d i n w o rd s ; c a n s a y a n y re c o g n iz a b le w o rd s )? Is ( N A M E )' s s p e e c h i n a n y w a y d if fe re n t fr o m n o rm a l (n o t c le a r e n o u g h t o b e u n d e rs to o d b y p e o p le o th e r th a n t h e i m m e d ia te f a m ily )? C a n ( N A M E ) n a m e a t le a s t o n e o b je c t (f o r e x a m p le , a n a n im a l, a t o y, a c u p , a s p o o n )? C o m p a re d w it h o th e r c h ild re n o f th e s a m e a g e , d o e s ( N A M E ) a p p e a r in a n y w a y m e n ta lly b a c k w a rd , d u ll o r s lo w ? 1 2 1 2 1 2 1 2 T h e f o llo w in g q u e s ti o n s r e la te t o y o u n g c h ild re n a n d s h o u ld b e a s k e d o f th e c h ild ’s p a re n t o r p ri m a ry c a re ta k e r. 1 12 2 Y E S N O Y E S N O 1 2 1 2 Y E S N O 1 2 Y E S N O 1 2 Y E S N O 1 2 Y E S N O 1 2 Y E S N O 1 2 Y E S N O 1 2 Y E S N O 1 2 Y E S N O 1 2 Y E S N O 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 0 6 3 0 3 1 3 2 3 3 3 4 3 5 3 6 3 7 3 8 3 9 4 0 0 7 7 IF AGE 2 YEARS IF AGE 3-9 YEARS IF AGE 2-9 YEARS IF AGE 2-14 YEARS 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 21 2 | 231Appendix E 0 2 0 3 0 4 0 5 A B C Y L IN E N U M B E R D o e s ( N A M E ) a tt e n d a n y o rg a n iz e d l e a rn in g o r e a rl y c h ild h o o d e d u c a ti o n p ro g ra m m e , s u c h a s a p ri v a te o r g o v e rn m e n t fa c ili ty i n c lu d in g k in d e rg a rt e n o r c o m m u n it y c h ild c a re ? R E C O R D A L L M E N T IO N E D F O L L O W IN G C O D E S R e a d b o o k s o r lo o k a t p ic tu re b o o k s w it h ( N A M E )? T e ll s to ri e s t o ( N A M E )? S in g s o n g s w it h ( N A M E )? T a k e ( N A M E ) o u ts id e t h e h o m e , c o m p o u n d , y a rd o r e n c lo s u re ? P la y w it h ( N A M E )? S p e n d t im e w it h ( N A M E ) n a m in g , c o u n ti n g ,a n d / o r d ra w in g t h in g s ? E A R L Y L E A R N IN G P R O G R A M M E S U P P O R T F O R E A R L Y L E A R N IN G A B C Y A B C Y A B C Y A B C Y A B C Y 1 2 8 A B C Y A B C Y A B C Y A B C Y A B C Y A B C Y 1 2 8 A B C Y A B C Y A B C Y A B C Y A B C Y A B C Y 1 2 8 A B C Y A B C Y A B C Y A B C Y A B C Y A B C Y 1 2 8 A B C Y A B C Y A B C Y A B C Y A B C Y A B C Y In t h e p a s t 3 d a y s , d id y o u o r a n y h o u s e h o ld m e m b e r o v e r 1 5 y e a rs o f a g e e n g a g e i n a n y o f th e f o llo w in g a c ti v it ie s w it h (N A M E )? W h o e n g a g e d i n t h e a c ti v it y w it h t h e c h ild - t h e c h ild 's m o th e r, f a th e r o r a n o th e r a d u lt m e m b e r o f th e h o u s e h o ld in c lu d in g t h e c a re ta k e r/ re s p o n d e n t) ? 0 1 1 2 8 1 2 8 Y E S N O D K A B C Y M O T H E R F A T H E R O T H E R A D U L T N O O N E 0 6 IF AGE 3-4 YEARS IF AGE 0 - 4 YEARS 4 1 4 2 A 4 2 B 4 3 4 4 4 5 4 6 4 7 A B C Y A B C Y A B C Y A B C Y A B C Y A B C Y 0 7 1 2 8 1 2 8 A B C Y A B C Y A B C Y A B C Y A B C Y A B C Y 8 IF Y E S : 232 | Appendix E C H IL D R E N 'S W O R K 0 1 0 2 0 3 0 4 0 5 0 6 321 321 IF Y E S : F o r p a y i n c a s h o r k in d ? D u ri n g t h e p a s t w e e k , d id ( N A M E ) d o a n y k in d o f w o rk f o r s o m e o n e w h o i s n o t a m e m b e r o f th is h o u s e h o ld ? G O T O 5 0 G O T O 5 1 S in c e l a s t (D A Y O F T H E W E E K ), a b o u t h o w m a n y h o u rs d id h e /s h e d o t h is w o rk f o r s o m e o n e w h o i s n o t a m e m b e r o f th is h o u s e h o ld ? S in c e l a s t (D A Y O F T H E W E E K ), a b o u t h o w m a n y h o u rs d id h e /s h e s p e n d d o in g t h e s e c h o re s ? D u ri n g t h e p a s t w e e k , d id ( N A M E ) d o a n y o th e r fa m ily w o rk ( o n th e f a rm o r in a b u s in e s s , o r s e lli n g g o o d s i n t h e s tr e e t) ? S in c e l a s t (D A Y O F T H E W E E K ), a b o u t h o w m a n y h o u rs d id h e /s h e s p e n d d o in g t h is w o rk ? A t a n y t im e d u ri n g t h e p a s t y e a r, d id ( N A M E ) d o a n y k in d o f w o rk f o r s o m e o n e w h o i s n o t a m e m b e r o f th is h o u s e h o ld ? D u ri n g t h e p a s t w e e k , d id ( N A M E ) h e lp w it h h o u s e h o ld c h o re s s u c h a s s h o p p in g , c o lle c ti n g f ir e w o o d , c le a n in g , fe tc h in g w a te r, o r c a ri n g f o r c h ild re n ? IF M O R E T H A N O N E J O B , IN C L U D E A L L H O U R S I N A L L J O B S . IF Y E S : F o r p a y i n c a s h o r k in d ? G O T O 5 3 1 2 N E X T L IN E 321 321 G O T O 5 0 G O T O 5 1 1 2 G O T O 5 3 1 2 N E X T L IN E 321 321 G O T O 5 0 G O T O 5 1 1 2 G O T O 5 3 1 2 N E X T L IN E 321 321 G O T O 5 0 G O T O 5 1 1 2 G O T O 5 3 1 2 N E X T L IN E 321 321 G O T O 5 0 G O T O 5 1 1 2 G O T O 5 3 1 2 N E X T L IN E 321 G O T O 5 0 G O T O 5 1 1 2 G O T O 5 3 1 2 N E X T L IN E L IN E N U M B E R Y E S F O R P A Y ( IN C A S H /K IN D ) Y E S , U N P A ID N O N o w I w o u ld l ik e t o a s k y o u a b o u t w o rk t h a t c h ild re n i n t h is h o u s e h o ld d o . 1 2 3 1 2 3 Y E S F O R P A Y ( IN C A S H /K IN D ) Y E S , U N P A ID N O Y E S N O Y E S N O 1 2 1 12 2 321 321 321 G O T O 5 0 G O T O 5 1 1 2 G O T O 5 3 1 2 N E X T L IN E 0 7 IF AGE 5-14 YEARS 4 8 5 0 4 9 5 1 5 2 5 3 5 4 9 | 233Appendix E 11 12 13 21 31 32 106 106 108 998 103 41 42 91 96 1 2 3 1 2 8 1 2 3 4 6 101 102 103 104 105 106 HOUSEHOLD CHARACTERISTICS NO. QUESTIONS AND FILTERS What is the main source of drinking water for members of your household? What is the main source of water used by your household for other purposes such as cooking and handwashing? CODING CATEGORIES PIPED WATER PIPED INTO DWELLING PIPED TO YARD/PLOT PUBLIC TAP/STANDPIPE DUG WELL RAINWATER TANK IN COMPOUND PUBLIC OR COMMUNITY TANK BOTTLED WATER OTHER (SPECIFY) TUBE WELL OR BOREHOLE PROTECTED WELL UNPROTECTED WELL SKIP 11 12 13 21 31 32 106 103 106 41 42 91 96 PIPED WATER PIPED INTO DWELLING PIPED TO YARD/PLOT PUBLIC TAP/STANDPIPE DUG WELL RAINWATER TANK IN COMPOUND PUBLIC OR COMMUNITY TANK BOTTLED WATER OTHER (SPECIFY) TUBE WELL OR BOREHOLE PROTECTED WELL UNPROTECTED WELL Where is that water source located? How long does it take to go there, get water, and come back? Who usually goes to this source to fetch the water for your household? Do you do anything to the water to make it safer to drink? IN OWN DWELLING IN OWN YARD/PLOT ELSEWHERE MINUTES DON'T KNOW YES NO DON'T KNOW ADULT WOMAN ADULT MAN FEMALE CHILD UNDER 15 YEARS OLD MALE CHILD UNDER 15 YEARS OLD OTHER (SPECIFY) 01 234 | Appendix E A B C D E F X Z 112 112 95 98 BOIL ADD BLEACH/CHLORINE STRAIN THROUGH A CLOTH USE WATER FILTER SOLAR DISINFECTION LET IT STAND AND SETTLE OTHER 1 2 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 1 2 8 11 12 13 14 15 21 22 23 61 96 107 108 109 110 111 112 0 NO. QUESTIONS AND FILTERS During the past six months, has your household ever experienced a shortage in drinking water? What kind of toilet facility do members of your household usually use? Do you share this toilet facility with other households? How many households use this toilet facility? Does your household have: Electricity? A radio? A television? Satellite/cable TV connection? A computer? Internet connection? A mobile telephone? A non-mobile telephone? A refrigerator? Air conditioner? Washing machine? ELECTRICITY RADIO TELEVISION SATELLITE/CABLE TV CONNECTION COMPUTER INTERNET CONNECTION MOBILE TELEPHONE NON-MOBILE TELEPHONE REFRIGERATOR AIR CONDITIONER WASHING MACHINE What do you usually do to make the water safer to drink? Anything else? RECORD ALL MENTIONED. CODING CATEGORIES SKIP DON'T KNOW (SPECIFY) YES NO DON'T KNOW FLUSH OR POUR FLUSH TOILET FLUSH TO PIPED SEWER SYSTEM FLUSH TO SEPTIC TANK FLUSH TO PIT FLUSH TO SOMEWHERE ELSE FLUSH, DON'T KNOW WHERE PIT LATRINE VENTILATED IMPROVED PIT LATRINE PIT LATRINE WITH SLAB PIT LATRINE WITHOUT SLAB/OPEN PIT NO FACILITY/BEACH OTHER (SPECIFY) YES NO YES NO NO. OF HOUSEHOLDS IF LESS THAN 10 10 OR MORE HOUSEHOLDS DON'T KNOW 11 | 235Appendix E 1 2 11 21 31 32 33 34 35 11 12 31 32 33 34 96 01 02 04 05 08 95 96 1 2 3 6 1 2 3 6 1 2 3 113 114 115 116 117 118 119 116 118 116 118 NO. QUESTIONS AND FILTERS What type of fuel does your household mainly use for cooking? In this household, is food cooked on an open fire, an open stove or a closed stove? Does this (fire/stove) have a chimney, a hood, or neither of these? CODING CATEGORIES ELECTRICITY LPG BIOGAS KEROSENE WOOD NO FOOD COOKED IN HOUSEHOLD OTHER OPEN FIRE OPEN STOVE CLOSED STOVE WITH CHIMNEY OTHER CHIMNEY HOOD NEITHER IN THE HOUSE IN A SEPARATE BUILDING OUTDOORS OTHER YES NO NATURAL ROOFING NO ROOF THATCH FINISHED ROOFING GALVANIZED SHEETS ROOFING TILES CONCRETE SHEETS WOOD OTHER OTHER NATURAL FLOOR SAND RUDIMENTARY FLOOR WOOD PLANKS FINISHED FLOOR CEMENT/SLAKE LIME TILES CONCRETE SHEET DURABLE WOOD CARPET SKIP Is the cooking usually done in the house, in a separate building, or outdoors? Do you have a separate room which is used as a kitchen? MAIN MATERIAL OF THE FLOOR REC0RD OBSERVATION. MAIN MATERIAL OF THE ROOF RECORD OBSERVATION. (SPECIFY) (SPECIFY) (SPECIFY) (SPECIFY) 96 (SPECIFY) 21 236 | Appendix E 11 21 120 129 122 126 1 1 1 1 1 1 1 2 2 2 2 2 2 2 1 2 3 4 5 NO. QUESTIONS AND FILTERS MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION CODING CATEGORIES SKIP NATURAL WALLS NO WALLS RUDIMENTARY WALLS THATCH AND STICK FINISHED WALLS WITH BRICKS, CEMENT AND LIME BRICKS UNPLASTERED THIN PLYWOOD/WOOD STICKS GALVANIZED TIN SHEETS DURABLE WOOD/SHEETS OTHER 96 31 32 33 34 35 (SPECIFY) How many members of this household received benefits after the tsunami? Does any member of this household own: Which type of shelters or houses are they living in now? Are they living in temporary shelters or in their own damaged house or their own but renovated/repaired houses or reconstructed new houses or are they living with host families? A watch? A bicycle? A motorcycle or motor scooter? A car or truck? A pickup/lorry? A fishing boat? Any other boat? WATCH BICYCLE MOTORCYCLE OR MOTOR SCOOTER CAR OR TRUCK PICKUP/LORRY FISHING BOAT ANY OTHER BOAT YES NO TEMPORARY SHELTER OLD DAMAGED HOUSE OWN RENOVATED/REPAIRED HOUSE RECONSTRUCTED NEW HOUSE LIVING WITH HOST FAMILIES 123 1 2 Does any member of this household have a bank account? YES NO 127 1 2 Due to the tsunami, did your household provide shelter to another family or household? YES NO 129 125 1 2 Were they displaced on this island or to another island? ON THIS ISLAND TO ANOTHER ISLAND 124 1 2 Were members of your household displaced due to the tsunami? YES NO 127 121 How many rooms in this household are used for sleeping? ROOMS 128 For how many people did this household provide shelter? DO NOT INCLUDE USUAL MEMBERS OF THE HOUSEHOLD NUMBER WHO RECEIVED BENEFITS NUMBER SHELTERED 31 | 237Appendix E 201 202 203 204 205 207 206 00 98 98 A B C D E X 203 SOCIAL SECURITY/ WORKER COMPENSATION UC CARD PRIVATE SELF-PURCHASED INSURANCE OTHER 1 2 1 2 1 2 205 212 208 NO. QUESTIONS AND FILTERS Were any members of this household currently covered by a health welfare plan or assistance at any time in the past year? To what type(s)of health welfare plan/assistance does (did) the household member(s) belong? During the past year, did any member of your household die? Before their death, was (were) the person(s) hospitalized at any time during the past year? Were any (other) persons who lived in this household hospitalized at any time during the past year? In total, how many separate times were members of your household hospitalized during the past year(including any times that the person(s) who died were hospitalized)? Now I am going to ask some questions about how much your household paid in total for (all of) the(se) hospital stays. Please include the amount charged by the hospital itself as well as any fees paid directly to the doctors or other health workers who provided care in the hospital and the costs for any laboratory tests, other medical tests or procedures, and medications during the hospital stay. PLEASE EXCLUDE ANY COSTS WHICH WERE PAID BY A HEALTH WELFARE PLAN/ASSISTANCE. Try to be as exact as possible. If you are not sure, however, please give me your best estimate of the total amount that was paid for (all of) the(se) hospital stay(s). CHECK 204 AND 205: CODE 1 (YES) IN QS. 204 AND/OR 205 ADMITTED IN THE HOSPITAL ATLEAST ONCE RECORD ALL MENTIONED. IF YES: How many household members were covered by a plan? HEALTH EXPENDITURES CODING CATEGORIES NUMBER OF HH MEMBERS COVERED NO ONE DON'T KNOW GOVERNMENT/OFFICIAL STATE ENTERPRISE PRIVATE EMPLOYER SKIP WAS NOT ADMITTED IN THE HOSPITAL CODE 2 (NO) IN BOTH QS. 204 AND 205 (SPECIFY) YES NO YES NO YES NO TOTAL NUMBER OF HOSPITALIZATIONS DON'T KNOW 41 99998 202A In total, how much do members of your household pay for the insurance premiums/contributions to the plan per month? TOTAL DON'T KNOW 238 | Appendix E 209 215 216 217 218 210 211 212 213 214 99998 99998 98 98 1 2 3 1 2 1 2 212 301 220 NO. QUESTIONS AND FILTERS How much in total was your household charged for the hospital stay(s) excluding any costs that may have been covered by a health welfare plan/assistance? CHECK 201: HAS HEALTH WELFARE/ ASSISTANCE CODING CATEGORIES TOTAL DON'T KNOW SKIP NO ONE HAS HEALTH WELFARE/ ASSISTANCE How much in total was your household charged for the hospital stay(s) ? Was (were) the hospital(s) on this island? In total, how much did your household pay for travel costs that were incurred due to the(se) hospital stays? Now I would like to ask you some questions about any health care expenses that your household has had during the past month. In answering these questions, please do not include expenses relating to a hospital stay. Did anyone in your household visit a health care provider during the past month for treatment of any illness or injury or for preventative care (e.g., an immunization or antenatal care)? Please include the cost of transporting the patient(s) to and from this island to the hospital and transport and accommodation costs for other household members who may have accompanied the patients(s). In total, how many visits did members of your household make to a health care provider during the past month? HAS HEALTH WELFARE NO HEALTH WELFARE CHECK 201: Did any member of your household have laboratory test(s) done? How much in total was your household charged for the(se) visit(s) excluding any costs that may have been covered by a health welfare plan? We would also like to know about other health care costs your household may have had during the past month, e.g., for laboratory tests, other medical tests or procedures, or prescription drugs. Please tell me about such costs only if they were paid for separately and not included in the fee for the provider visit(s) that you have just told me about. Do not include any expenses associated with a hospital stay or expenses that were paid by a health welfare plan How much in total was your household charged for ? the(se) visit(s) In total, how many times did members of your household have laboratory tests during the past month? YES, ON THIS ISLAND NO, ON ANOTHER ISLAND NO, ABROAD TOTAL DON'T KNOW TOTAL NUMBER OF VISITS DON'T KNOW YES NO TOTAL DON'T KNOW TOTAL NUMBER OF TIMES DON'T KNOW YES NO 51 9999998 | 239Appendix E 219 222 228 226 220 221 227 99998 99998 99998 98 98 1 2 1 2 223 229 NO. QUESTIONS AND FILTERS Did any member of your household have any other medical tests, e.g., an X-ray during the past month? In total, how many times did members of your household have other medical tests during the past month? CODING CATEGORIES SKIP CHECK 201: HAS HEALTH WELFARE NO HEALTH WELFARE How much in total was your household charged for the(se) lab test(s) excluding any costs that may have been covered by a health welfare plan? How much in total was your household charged for ) ?the(se) lab test(s) CHECK 201: Did any member of your household obtain non-prescription (over-the-counter) drugs during the last month? In total, how many times did members of your household obtain non-prescription (over-the-counter) drugs during the past month? HAS HEALTH WELFARE NO HEALTH WELFARE How much in total was your household charged for the(se) test(s) excluding any costs that may have been covered by a health welfare plan? How much in total was your household charged for ) ?the(se) test(s) CHECK 201: HAS HEALTH WELFARE NO HEALTH WELFARE How much in total was your household charged for the(se) non-prescription drugs excluding any costs that may have been covered by a health welfare plan? How much in total was your household charged for the(se) non-prescription drugs? TOTAL DON'T KNOW TOTAL NUMBER OF TIMES DON'T KNOW YES NO TOTAL DON'T KNOW YES NO TOTAL NUMBER OF TIMES DON'T KNOW TOTAL DON'T KNOW 61 223 1 2 226 Did any member of your household obtain prescription drugs during the past month? YES NO 224 98 In total, how many times did members of your household have prescriptions filled during the past month? TOTAL NUMBER OF TIMES DON'T KNOW 225 99998 CHECK 201: HAS HEALTH WELFARE NO HEALTH WELFARE How much in total was your household charged for the(se) prescription drugs any costs that may have been covered by a health welfare plan? excluding How much in total was your household charged for ?the(se) prescription drugs TOTAL DON'T KNOW 240 | Appendix E 231 99998 1 2 3 301 301 229 230 CHECK 213, 217, 220, 223, AND 226: Did members of your household obtain all of these health care services on this island, on another island, or abroad during the past month? In total, how much did members of your household pay for the transportation and accommodation they used in going for health care services on other islands? Please include the transport and accommodation costs for other household members who may have accompanied the persons who were receiving these services. HAD SOME TYPE OF HEALTH CARE SERVICE NO HEALTH CARE SERVICES YES, ON THIS ISLAND NO, ON ANOTHER ISLAND NO, ABROAD TOTAL DON'T KNOW 71 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP | 241Appendix E 305 303 304 317 301 317 305 306 307 308 309 310 311 2 3 4 1 2 3 4 1 2 1 2 3 1 2 1 2 1 NO. QUESTIONS AND FILTERS CHECK QUESTIONS 5 AND 7 IN THE HOUSEHOLD SCHEDULE LINE NUMBER FROM QUESTION 1 NAME FROM QUESTION 2 NOT ACTIVE AT ALL SOMEWHAT MODERATELY VERY ALWAYS MOST OF THE TIME SOMETIMES NEVER We are interested in learning about the types of care and support that adults age 65 and older are receiving in order to improve programs for the elderly. BEGIN WITH THE FIRST OLDER ADULT LISTED IN QUESTION 304 AND ASK ALL RELEVANT QUESTIONS BEFORE GOING ON TO THE NEXT OLDER ADULT. How would you describe (NAME)'s level of physical activity? Is he/she usually not active at all, somewhat active, moderately active or very active? Does (NAME) require assistance with personal care like bathing, dressing, and eating? IF YES: Does he/she need help always, most of the time, only sometimes? Does (NAME) need medical care, e.g., giving medications or changing dressings? Does (NAME) need help with household activities like cooking, doing laundry and cleaning? Does (NAME) need help to go outside the house? Does (NAME) need to be watched over because he/she may hurt him/herself or others? NAME AT LEAST ONE USUAL HOUSEHOLD MEMBER AGE 65 OR OLDER CHECK QUESTIONS 1, 2, 5 AND 7. RECORD THE NAME(S) AND LINE NUMBER(S) OF ALL USUAL HOUSEHOLD MEMBERS AGE 65 AND OLDER AT THE TOP OF THE TABLE BELOW. IF THERE ARE MORE THAN THREE OLDER ADULTS, USE ADDITIONAL QUESTIONNAIRE. CARE AND SUPPORT FOR OLDER ADULTS ALL USUAL HOUSEHOLD MEMBERS UNDER AGE 65 OLDER ADULT 1 LINE NUMBER OLDER ADULT 2 LINE NUMBER OLDER ADULT 3 LINE NUMBER NAME NAME YES NO YES NO NOT APPLICABLE YES NO YES NO 2 3 4 1 2 3 4 1 2 1 2 3 1 2 1 2 1NOT ACTIVE AT ALL SOMEWHAT MODERATELY VERY ALWAYS MOST OF THE TIME SOMETIMES NEVER YES NO YES NO NOT APPLICABLE YES NO YES NO 2 3 4 1 2 3 4 1 2 1 2 3 1 2 1 2 1NOT ACTIVE AT ALL SOMEWHAT MODERATELY VERY ALWAYS MOST OF THE TIME SOMETIMES NEVER YES NO YES NO NOT APPLICABLE YES NO YES NO 312 PERSON NEEDS SOME TYPE OF SUPPORT NO SUPPORT NEEDED (SKIP TO 314) CHECK 306-311: PERSON NEEDS SOME TYPE OF SUPPORT NO SUPPORT NEEDED (SKIP TO 314) PERSON NEEDS SOME TYPE OF SUPPORT NO SUPPORT NEEDED (SKIP TO 314) 81 242 | Appendix E 313 314 315 316 317 318 319 A B C D E X 2 1 2 1 2 1 2 Y Z : NO. QUESTIONS AND FILTERS CODING CATEGORIES LINE NUMBER FROM COLUMN 1 NAME FROM COLUMN 2 Does your household pay someone to come in and help care for (NAME)? Is (NAME)'s income adequate for his/her needs or does your household provide additional support? Are any members of your household providing care and assistance on a regular basis to elderly persons living elsewhere? (such as personal care, medical care, help with household activities, going out) Is this household providing financial assistance on a regular basis to elderly persons living elsewhere? RECORD THE TIME HOUR MINS Is (NAME) receiving any regular income? IF YES: From where does (NAME) receive income? RECORD ALL MENTIONED OLDER ADULT 1 LINE NUMBER OLDER ADULT 2 LINE NUMBER OLDER ADULT 3 LINE NUMBER NAME NAME NAME YES NO INCOME ADEQUATE INCOME INADEQUATE/ HOUSEHOLD HELPS OTHER HOUSEHOLD HELPS NOBODY HELPS EMPLOYEE/EMPLOYER PENSION INVESTMENT SOCIAL WELFARE RELATIVES OTHER NO REGULAR INCOME DON'T KNOW (SPECIFY) (SKIP TO 316) GO BACK TO 306 IN NEXT COLUMN; OR, IF NO MORE PERSONS, GO TO 317. YES NO YES NO A B C D E X 1 2 Y Z YES NO EMPLOYEE/EMPLOYER PENSION INVESTMENT SOCIAL WELFARE RELATIVES OTHER NO REGULAR INCOME DON'T KNOW (SPECIFY) (SKIP TO 316) GO BACK TO 306 IN NEXT COLUMN; OR, IF NO MORE PERSONS, GO TO 317. A B C D E X 1 2 Y Z YES NO EMPLOYEE/EMPLOYER PENSION INVESTMENT SOCIAL WELFARE RELATIVES OTHER NO REGULAR INCOME DON'T KNOW (SPECIFY) (SKIP TO 316) GO BACK TO 306 IN NEW QUESTIONNAIRE; OR, IF NO MORE PERSONS, GO TO 317. 91 3 4 1 2 INCOME ADEQUATE INCOME INADEQUATE/ HOUSEHOLD HELPS OTHER HOUSEHOLD HELPS NOBODY HELPS 3 4 1 2 INCOME ADEQUATE INCOME INADEQUATE/ HOUSEHOLD HELPS OTHER HOUSEHOLD HELPS NOBODY HELPS 3 4 1 | 243Appendix E C H E C K C O L U M N 1 2 . R E C O R D T H E L IN E N U M B E R A N D A G E F O R A L L E L IG IB L E C H IL D R E N 0 -5 Y E A R S I N Q U E S T IO N 4 0 2 . IF M O R E T H A N F IV E C H IL D R E N , U S E A D D IT IO N A L Q U E S T IO N N A IR E (S ). A F IN A L O U T C O M E M U S T B E R E C O R D E D F O R T H E W E IG H T A N D H E IG H T M E A S U R E M E N T I N 4 0 8 . N A M E F R O M C O L U M N 2 H E IG H T A N D W E IG H T M E A S U R M E N T S C H IL D R E N A G E 0 -5 C H IL D 3 R E S U L T O F W E IG H T A N D H E IG H T M E A S U R E M E N T L IN E N O . N A M E C H IL D 1 C H IL D 4 C H IL D 2 L IN E N O . N A M E L IN E N O . N A M E L IN E N O . N A M E L IN E N O . N A M E L IN E N U M B E R F R O M C O L U M N 1 2 Y E A R D A Y M O N T H Y E A R D A Y M O N T H Y E A R D A Y M O N T H Y E A R D A Y M O N T H Y E A R D A Y M O N T H IF M O T H E R I N T E R V IE W E D , C O P Y M O N T H A N D Y E A R F R O M B IR T H H IS T O R Y A N D A S K D A Y ; IF M O T H E R N O T I N T E R V IE W E D , A S K : W h a t is ( N A M E ’S ) b ir th d a te ? (G O T O 4 0 3 F O R N E X T C H IL D O R , IF N O M O R E , G O T O 4 1 0 ) (G O T O 4 0 3 F O R N E X T C H IL D O R , IF N O M O R E , G O T O 4 1 0 ) (G O T O 4 0 3 F O R N E X T C H IL D O R , IF N O M O R E , G O T O 4 1 0 ) (G O T O 4 0 3 F O R N E X T C H IL D O R , IF N O M O R E , G O T O 4 1 0 ) (G O T O 4 0 3 F O R N E X T C H IL D O R , IF N O M O R E , G O T O 4 1 0 ) C H E C K 4 0 3 : C H IL D B O R N I N J A N U A R Y 2 0 0 3 O R L A T E R ? C M . W E IG H T I N K IL O G R A M S K G . K G . K G . K G . K G . C M . C M . C M . C M . H E IG H T I N C E N T IM E T E R S 1 Y E S N O 2 1 Y E S N O 2 1 Y E S N O 2 Y E S N O 1 Y E S N O 2 3 R E F U S E D O T H E R 6 M E A S U R E D L Y IN G D O W N O R S T A N D IN G U P ? 1 L Y IN G D O W N S T A N D IN G U P 2 1 L Y IN G D O W N S T A N D IN G U P 2 1 L Y IN G D O W N S T A N D IN G U P 2 1 L Y IN G D O W N S T A N D IN G U P 2 L Y IN G D O W N S T A N D IN G U P 1 L Y IN G D O W N S T A N D IN G U P 2 1 M E A S U R E D N O T P R E S E N T 2 3 R E F U S E D O T H E R 61 M E A S U R E D N O T P R E S E N T 2 3 R E F U S E D O T H E R 61 M E A S U R E D N O T P R E S E N T 2 R E F U S E D O T H E R M E A S U R E D N O T P R E S E N T 3 R E F U S E D O T H E R 61 M E A S U R E D N O T P R E S E N T 2 G O B A C K T O 4 0 3 I N N E X T C O L U M N I N T H IS Q U E S T IO N N A IR E O R I N T H E F IR S T C O L U M N O F T H E A D D IT IO N A L Q U E S T IO N N A IR E (S ); IF N O M O R E C H IL D R E N , G O T O 4 1 0 . 4 0 1 4 0 2 4 0 6 4 0 8 4 0 9 4 0 7 4 0 5 4 0 4 C H IL D 5 4 0 3 1 2 4 0 7 1 2 3 61 2 02 244 | Appendix E C H E C K C O L U M N 9 . R E C O R D T H E L IN E N U M B E R A N D N A M E F O R A L L E L IG IB L E W O M E N I N 4 1 1 . IF T H E R E A R E M O R E T H A N F IV E W O M E N , U S E A D D IT IO N A L Q U E S T IO N N A IR E (S ). A F IN A L O U T C O M E M U S T B E R E C O R D E D F O R T H E W E IG H T A N D H E IG H T M E A S U R E M E N T I N 4 1 4 . N A M E ( C O L U M N 2 ) H E IG H T A N D W E IG H T M E A S U R M E N T S E V E R -M A R R IE D W O M E N 1 5 -4 9 W O M A N 3 R E S U L T O F W E IG H T A N D H E IG H T M E A S U R E M E N T L IN E N O . N A M E W O M A N 1 W O M A N 4 W O M A N 2 L IN E N O . N A M E L IN E N O . N A M E L IN E N O . N A M E L IN E N O . N A M E L IN E N U M B E R ( C O L U M N 9 ) C M . W E IG H T I N K IL O G R A M S K G . C M . C M . C M . C M . H E IG H T I N C E N T IM E T E R S 3 R E F U S E D O T H E R 61 M E A S U R E D N O T P R E S E N T 2 3 R E F U S E D O T H E R 61 M E A S U R E D N O T P R E S E N T 2 3 R E F U S E D O T H E R 61 M E A S U R E D N O T P R E S E N T 2 R E F U S E D O T H E R M E A S U R E D N O T P R E S E N T 3 R E F U S E D O T H E R 61 M E A S U R E D N O T P R E S E N T 2 G O B A C K T O 4 1 2 I N N E X T C O L U M N I N T H IS Q U E S T IO N N A IR E O R I N T H E F IR S T C O L U M N S O F A D D IT IO N A L Q U E S T IO N N A IR E (S ); IF N O M O R E W O M E N , G O T O 5 0 1 . K G . K G . K G . K G . 4 1 0 4 1 1 4 1 3 4 1 4 4 1 5 4 1 2 W O M A N 5 3 61 2 12 | 245Appendix E EVER-MARRIED WOMEN’S QUESTIONNAIRE 1 7 D e c e b e 2 0 0 8 m r INTERVIEWER VISITS HOUSEHOLD NAME NEXT VISIT: Month Day INTERVIEWER'S NAME RESULT* INT. NUMBER RESULT 2 0 0 2 0 0 321 Hr : : DATE DATE TOTAL NUMBER OF VISITS TIME FINAL VISIT NAME ID CODE DATE 2008 MALDIVES DEMOGRAPHIC AND HEALTH SURVEY IDENTIFICATION NAME OF HOUSEHOLD HEAD CLUSTER NUMBER HOUSEHOLD NUMBER ATOLL NAME AND LINE NUMBER OF ELIGIBLE WOMAN monthday year monthday year Year monthday year 2 0 0 monthday year 2 0 0 monthday year Min Hr Min SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY VERIFIED BY NAME ID CODE ID CODE DATE ID CODE ID CODE 2 0 0 2 0 0 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER_______________________________________ (SPECIFY) *RESULT CODES: ISLAND NAME 1 247Appendix E | Introduction and Consent SECTION 1 : RESPONDENT’S BACKGROUND Hello. My name is _______________________________________ and I am working with the Ministry of Health. We are conducting a national survey that asks women, men and youth about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 30 and 60 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than members of our survey team. Participation in this survey is voluntary, and if we should come to any question you don’t want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important. At this time, do you want to ask me anything about the survey? May I begin the interview now? Signature of interviewer:____________________________ Date: _______________________ RESPONDENT AGREES TO BE INTERVIEWED 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END INFORMED CONSENT NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 102 In what month and year were you born? 101 RECORD THE TIME : HOUR MINUTES 9998 YEAR DON'T KNOW YEAR 98 MONTH DON'T KNOW MONTH 103 How old were you at your last birthday? AGE IN COMPLETED YEARS COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT. 1 2 3 4 104 What is your current marital status? MARRIED WIDOWED DIVORCED SEPARATED 105 1 2 Have you ever attended school? YES NO 108 2 248 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 107 What is the highest (grade/form/year) you completed at that level? GRADE/FORM/YEAR 108 Do you read a newspaper or magazine almost everyday, at least once a week, less than once a week or not at all? 110 1 2 3 4 5 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL CANNOT READ 111 Do you watch television almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 109 Do you use the internet almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 110 Do you listen to the radio almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 3 00 01 02 03 04 05 06 07 08 106 What is the highest level of school you attended? NON-FORMAL EDUCATION PRESCHOOL PRIMARY ‘O’ LEVEL ‘A’ LEVEL DIPLOMA FIRST DEGREE MASTER’S CERTIFICATE/ABOVE CERTIFICATE 249Appendix E | SECTION 2. REPRODUCTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 206 Have you ever given birth to a boy or girl who was born alive but later died? 207 How many boys have died? How many girls have died? IF NO, PROBE: Any baby who cried or showed signs of life but did not survive? 1 2 YES NO Just to make sure that I have this right: you have had in TOTAL births during your life. Is that correct? 204 1 2 YES NO 202 Do you have any sons or daughters to whom you have given birth who are now living with you? 203 How many sons live with you? And how many daughters live with you? IF NONE, RECORD ‘00’. SONS AT HOME DAUGHTERS AT HOME 201 Now I would like to ask about all the births you have had during your life. Have you ever given birth? 1 2 YES NO 206 IF NONE, RECORD ‘00’. 205 How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? SONS ELSEWHERE DAUGHTERS ELSEWHERE IF NONE, RECORD ‘00’. BOYS DEAD GIRLS DEAD 208 1 2 YES NO 204 Do you have any sons or daughters to whom you have given birth who are alive but do not live with you? SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.208 IF NONE, RECORD ‘00’. TOTAL BIRTHS 210 226ONE OR MORE BIRTHS NO BIRTHS CHECK 208: 206 209 CHECK 208: YES NO PROBE AND CORRECT 201-208 AS NECESSARY. 4 250 | Appendix E N o w I w o u ld l ik e t o r e c o rd t h e n a m e s o f a ll y o u r b ir th s , w h e th e r s ti ll a liv e o r n o t, s ta rt in g w it h t h e f ir s t o n e y o u h a d . R E C O R D N A M E S O F A L L B IR T H S I N 2 1 2 . R E C O R D T W IN S A N D T R IP L E T S O N S E P A R A T E L IN E S . (I F T H E R E A R E M O R E T H A N 1 2 B IR T H S , U S E A N A D D IT IO N A L Q U E S T IO N N A IR E , S T A R T IN G W IT H T H E S E C O N D C O L U M N ). 0 1 0 2 0 3 1 2 0 4 0 5 0 6 L IN E N U M B E R IF A L IV E : H o w o ld w a s ( N A M E ) a t h is /h e r la s t b ir th d a y ? R E C O R D A G E I N C O M P L E T E D Y E A R S . W h a t n a m e w a s g iv e n t o y o u r (f ir s t/ n e x t) b a b y ? 1 2 1 2 1 2 1 2 1 2 W e re a n y o f th e s e b ir th s t w in s ? 1 2 1 2 1 2 1 2 1 2 Is ( N A M E ) a b o y o r a g ir l? In w h a t m o n th a n d y e a r w a s ( N A M E ) b o rn ? W h a t is h is /h e r b ir th d a y ? 1 2 G O T O 2 2 0 1 2 G O T O 2 2 0 1 2 G O T O 2 2 0 1 2 G O T O 2 2 0 1 2 G O T O 2 2 0 G O T O 2 2 0 (N E X T B IR T H ) Is ( N A M E ) s ti ll a liv e ? 1 2 1 2 1 2 1 2 1 2 W e re t h e re a n y o th e r liv e b ir th s b e tw e e n ( N A M E O F P R E V IO U S B IR T H ) a n d ( N A M E ), in c lu d in g a n y c h ild re n w h o d ie d a ft e r b ir th ? G O T O 2 2 1 G O T O 2 2 1 G O T O 2 2 1 G O T O 2 2 1 G O T O 2 2 1 IF A L IV E : R E C O R D H O U S E H O L D L IN E N U M B E R O F C H IL D (R E C O R D ‘ 0 0 ’ I F C H IL D N O T L IS T E D I N H O U S E H O L D ). IF A L IV E : Is ( N A M E ) liv in g w it h y o u ? A D D B IR T H N E X T B IR T H 1 2 A D D B IR T H N E X T B IR T H 1 2 A D D B IR T H N E X T B IR T H 1 2 A D D B IR T H N E X T B IR T H 1 2 IF D E A D : H o w o ld w a s ( N A M E ) w h e n h e /s h e d ie d ? IF ‘ 1 Y E A R ’, P R O B E : H o w m a n y m o n th s o ld w a s ( N A M E )? R E C O R D D A Y S I F L E S S T H A N 1 M O N T H ; M O N T H S I F L E S S T H A N T W O Y E A R S ; O R Y E A R S 2 31 1 2 S IN G L E M U L T IP L E (N A M E ) B O Y G IR L M O N T H Y E A R 1 2 A G E I N Y E A R S Y E S N O Y E S N O 1 2 L IN E N U M B E R Y E A R S D A Y S M O N T H S 2 31 2 31 2 31 2 31 2 31 Y E S N O 2 1 1 2 1 2 2 1 3 2 1 5 2 1 4 2 1 6 2 1 7 2 1 8 2 1 9 2 2 1 2 2 0 0 7 1 2 1 2 1 2 P R O B E : 1 21 2 G O T O 2 2 0 G O T O 2 2 1 1 2 A D D B IR T H N E X T B IR T H A D D B IR T H N E X T B IR T H 5 2 31 251Appendix E | 0 8 0 9 1 0 1 2 1 1 L IN E N U M B E R IF A L IV E : H o w o ld w a s ( N A M E ) a t h is /h e r la s t b ir th d a y ? R E C O R D A G E I N C O M P L E T E D Y E A R S . W h a t n a m e w a s g iv e n t o y o u r n e x t b a b y ? 1 2 1 2 1 2 1 2 W e re a n y o f th e s e b ir th s t w in s ? 1 2 1 2 1 2 1 2 Is ( N A M E ) a b o y o r a g ir l? In w h a t m o n th a n d y e a r w a s ( N A M E ) b o rn ? W h a t is h is /h e r b ir th d a y ? 1 2 G O T O 2 2 0 1 2 G O T O 2 2 0 1 2 G O T O 2 2 0 1 2 G O T O 2 2 0 IF D E A D : H o w o ld w a s ( N A M E ) w h e n h e /s h e d ie d ? IF ‘ 1 Y E A R ’, P R O B E : H o w m a n y m o n th s o ld w a s ( N A M E )? R E C O R D D A Y S I F L E S S T H A N 1 M O N T H ; M O N T H S I F L E S S T H A N T W O Y E A R S ; O R Y E A R S Is ( N A M E ) s ti ll a liv e ? 1 2 1 2 1 2 1 2 W e re t h e re a n y o th e r liv e b ir th s b e tw e e n (N A M E O F P R E V IO U S B IR T H ) a n d ( N A M E ), in c lu d in g a n y c h ild re n w h o d ie d a ft e r b ir th ? G O T O 2 2 1 G O T O 2 2 1 G O T O 2 2 1 G O T O 2 2 1 IF A L IV E : R E C O R D H O U S E H O L D L IN E N U M B E R O F C H IL D (R E C O R D ‘ 0 0 ’ I F C H IL D N O T L IS T E D I N H O U S E H O L D ). IF A L IV E : Is ( N A M E ) liv in g w it h y o u ? A D D B IR T H N E X T B IR T H 1 2 A D D B IR T H N E X T B IR T H 1 2 A D D B IR T H N E X T B IR T H 1 2 A D D B IR T H N E X T B IR T H 2 31 1 2 G O T O 2 2 0 1 2 G O T O 2 2 1 1 2 1 2 1 21 2 A D D B IR T H N E X T B IR T H S IN G L E M U L T IP L E (N A M E ) B O Y G IR L M O N T H Y E A R A G E I N Y E A R S Y E S N O Y E S N O L IN E N U M B E R Y E A R S D A Y S M O N T H S G O T O 2 2 0 2 31 2 31 2 31 2 31 2 31 Y E S N O 1 2 1 3 G O T O 2 2 1 P R O B E : 6 1 2 1 2 1 21 2 A D D B IR T H N E X T B IR T H 2 1 2 2 1 3 2 1 5 2 1 4 2 1 6 2 1 7 2 1 8 2 1 9 2 2 1 2 2 0 1 4 G O T O 2 2 0 1 2 G O T O 2 2 1 1 2 1 2 1 21 2 A D D B IR T H N E X T B IR T H 2 31 252 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1 2 YES NO 222 Have you had any live births since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE. 225 FOR EACH BIRTH SINCE JANUARY 2003, ENTER ‘B’ IN THE MONTH OF BIRTH IN THE FIRST COLUMN OF CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE ‘B’ CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD ‘P’ IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF ‘P’s MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED). 223 NUMBERS ARE SAME (PROBE AND RECONCILE) CHECK: FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED NUMBERS ARE DIFFERENT COMPARE 208 WITH NUMBER OF BIRTHS IN BIRTH HISTORY AND MARK: FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS. FOR EACH BIRTH SINCE JANUARY 2003: MONTH AND YEAR OF BIRTH ARE RECORDED FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED 224 CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2003 OR LATER. IF NONE, RECORD ‘00’ AND SKIP TO 226 C C 1 2 3 THEN LATER NOT AT ALL 228 At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all? 232 How many months pregnant were you when the last such pregnancy ended? RECORD NUMBER OF COMPLETED MONTHS. ENTER ‘T’ IN THE CALENDAR, IN THE MONTH THAT THE PREGNANCY TERMINATED AND ‘P’ FOR THE REMAINING NUMBER OF COMPLETED MONTHS. MONTHS 1 2 8 YES NO UNSURE 226 Are you pregnant now? 229 1 2 YES NO 233 Since January 2003, have you had any other pregnancies that did not result in a live birth? 235 230 When did the last such pregnancy end? YEAR MONTH 231 237LAST PREGNANCY ENDED IN JANUARY 2003 OR LATER LAST PREGNANCY ENDED BEFORE JANUARY 2003 CHECK 230: C 227 How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS. ENTER ‘P’s IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND EARLIER MONTHS TO EQUAL THE TOTAL NUMBER OF COMPLETED MONTHS. MONTHS 1 2 YES NO 229 Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth? 237 7 253Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 234 ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2003. ENTER ‘T’ IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND ‘P’ FOR THE REMAINING NUMBER OF COMPLETED MONTHS. C 994 995 996 1 2 IN MENOPAUSE/HAS HAD HYSTERECTOMY BEFORE LAST BIRTH NEVER MENSTRUATED 235 Did you have any miscarriages, abortions, or stillbirths that ended before 2003? 237 237 When did your last menstrual period start? YEARS AGO MONTHS AGO 236 When did the last such pregnancy that terminated before 2003 end? YEAR MONTH (DATE, IF GIVEN) WEEKS AGO DAYS AGO 4 3 1 2 YES NO 1 2 8 YES NO DON’T KNOW 238 From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations? 301 239 Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods? 1 2 3 4 6 8 JUST BEFORE HER PERIOD BEGINS DURING HER PERIOD RIGHT AFTER HER PERIOD HAS ENDED HALFWAY BETWEEN TWO PERIODS OTHER DON’T KNOW (SPECIFY) 8 254 | Appendix E SECTION 3. CONTRACEPTION 302 CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302. Have you ever used (METHOD)? Have you ever heard of (METHOD)? Which ways or methods have you heard about? FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: 301 Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. 07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse. 08 RHYTHM METHOD Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant. 09 WITHDRAWAL Men can be careful and pull out before climax. 10 EMERGENCY CONTRACEPTION As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within 5 days to prevent pregnancy. 1 2 YES NO 11 Have you heard of any other ways or methods that women or men can use to avoid pregnancy? 1 2 YES NO 01 FEMALE STERILIZATION Women can have an operation to avoid having any more children. 02 03 PILL Women can take a pill every day to avoid becoming pregnant. 04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse. 05 INJECTABLES Women can have an injection by a health provider that stops them from becoming pregnant for one or more months. 06 IMPLANTS Women can have several small rods placed in their upper arm by adoctor or nurse which can prevent pregnancy for one or more years. (SPECIFY) (SPECIFY) 1 2 YES NO MALE STERILIZATION Men can have an operation to avoid having any more children. 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO Have you ever had an operation to avoid having any more children? 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO Have you ever had a partner who had an operation to avoid having any more children? 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 303 307NOT A SINGLE “YES” (NEVER USED) AT LEAST ONE “YES” (EVER USED) CHECK 302: 9 255Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 306 What have you used or done? CORRECT 302 AND 303 (AND 301 IF NECESSARY) 309 320NOT PREGNANT OR UNSURE PREGNANT CHECK 226: 304 Have you ever used anything or tried in any way to delay or avoid getting pregnant? 1 2 YES NO 331305 ENTER ‘0’ IN COLUMN 1 OF THE CALENDAR IN EACH BLANK MONTH. 320 C 307 Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant. How many living children did you have at that time, if any? IF NONE, RECORD ‘00’. NUMBER OF CHILDREN 308 311AWOMAN NOT STERILIZED WOMAN STERILIZED CHECK 302 (01): 1 2 YES NO 310 Are you currently doing something or using any method to delay or avoid getting pregnant? A B C D E F G H I J K X 311A CIRCLE ‘A’ FOR FEMALE STERILIZATION. FEMALE STERILIZATION MALE STERILIZATION PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD WITHDRAWAL OTHER (SPECIFY) 306 331 Which method are you using? CIRCLE ALL MENTIONED. IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST. 311 314 317A 313 313 998 NUMBER DON’T KNOW 312 How many (pill cycles/condoms) did you get the last time? 9995 9998 FREE DON’T KNOW 313 The last time you obtained (HIGHEST METHOD ON LIST IN 311), how much did you pay in total, including the cost of the method and any consultation you may have had? COST 317A 10 256 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 314 In what facility did the sterilization take place? (NAME OF PLACE) (SPECIFY) 11 12 13 14 16 PUBLIC SECTOR GOVT. HEALTH CENTER 21 23 26 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PRIVATE DOCTOR’S OFFICE OTHER PRIVATE MEDICAL PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) 98DON’T KNOW (SPECIFY) 96OTHER 1 2 8 YES NO DON’T KNOW 315 CHECK 311/311A: CODE ‘A’ CIRCLED CODE ‘A’ NOT CIRCLED Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation? Before the sterilization operation, was your husband/ partner told that he would not be able to have any (more) children because of the operation? 9995 9998 FREE DON’T KNOW 316 How much did you/your husband pay in total for the sterilization, including any consultation you/he may have had? COST 317A In what month and year was the sterilization performed? Since what month and year have you been using (CURRENT METHOD) without stopping? PROBE: For how long have you been using (CURRENT METHOD) now without stopping? YEAR MONTH 317 318 NO GO BACK TO 317/317A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION). YES CHECK 317/317A, 215 AND 230: ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 317/317A? 11 257Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 319 YEAR IS 2002 OR EARLIER YEAR IS 2003 OR LATER CHECK 317/317A: ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2003. C ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDER AND IN EACH MONTH BACK TO THE DATE STARTED USING. 329THEN SKIP TO 320 I would like to ask you some questions about the times you or your husband may have used a method to avoid getting pregnant during the last few years. COLUMN 1- SEGMENTS OF CONTRACEPTIVE USE SINCE JANUARY 2003. USE CALENDER TO PROBE FOR EARLIER PERIODS OF USE AND NON-USE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2003. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS. RECORD PERIODS OF USE AND NON-USE IN COLUMN 1 OF THE CALENDAR. FOR EACH MONTH IN WHICH A METHOD WAS USED, ENTER THE CODE FOR THE METHOD; ENTER ‘0’ IN THOSE MONTHS WHEN NO METHOD WAS USED. ILLUSTRATIVE QUESTIONS FOR COLUMN 1 When was the last time you used a method? Which method was that? When did you start using that method? How long after the birth of (NAME)? How long did you use the method then? COLUMN 2- REASON FOR DISCONTINUATION FOR EACH PERIOD OF USE, ASK WHY SHE STOPPED USING THE METHOD AND RECORD THE REASON FOR DISCONTINUATION IN COLUMN 2 OF THE CALENDAR IN THE MONTH IN WHICH THE SEGMENT OF USE WAS TERMINATED. IF A PREGNANCY FOLLOWED, ASK IF SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR WHETHER SHE DELIBERATELY STOPPED USING THE METHOD TO GET PREGNANT. THE NUMBER OF CODES ENTERED IN COLUMN 2 MUST BE THE SAME AS THE NUMBER OF COMPLETE SEGMENTS OF CONTRACEPTIVE USE IN COLUMN 1. ILLUSTRATIVE QUESTIONS FOR COLUMN 2 Why did you stop using the (method)? Did you become pregnant while using (method), or did you stop to get pregnant, or stop for some other reason? C C 00 01 02 03 04 05 06 07 08 09 10 11 96 NO CODE CIRCLED FEMALE STERILIZATION MALE STERILIZATION PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD WITHDRAWAL OTHER METHOD CHECK 311/311A: CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST. 321 324 331 331 324 331 322A 12 258 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 322A Where did you learn how to use the rhythm method? (SPECIFY) 11 12 13 14 15 16 17 PUBLIC SECTOR COMMUNITY/FAMILY HEALTH WORKER 31 33 OTHER SOURCE SHOP FRIEND/RELATIVE INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) 96OTHER 322 Where did you obtain (CURRENT METHOD) when you started using it? (NAME OF PLACE) IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. GOVT. HEALTH CENTER GOVT. HEALTH POST 21 22 23 26 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) 03 04 05 06 07 08 09 10 PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD CHECK 311/311A: CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST. 323 327 333 330 327 1 2 YES NO 326 Were you told what to do if you experienced side effects or problems? 3261 2 YES NO 324 You obtained (CURRENT METHOD FROM 321) from (SOURCE OF METHOD FROM 314 OR 322) in (DATE FROM 317/317A). At that time, were you told about side effects or problems you might have with the method? 329 1 2 YES NO 325 Were you ever told by a health provider or community health/family planning worker about side effects or problems you might have with the method? 1 2 YES NO 327 CHECK 324: CODE ‘1’ CIRCLED CODE ‘1’ NOT CIRCLED At that time, were you told about other methods of family planning that you could use? When you obtained (CURRENT METHOD FROM 321) from (SOURCE OF METHOD FROM 314 OR 322) were you told about other methods of family planning that you could use? 327 13 259Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1 2 YES NO 331 Do you know of a place where you can obtain a method of family planning? 01 02 03 04 05 06 07 08 09 10 11 96 FEMALE STERILIZATION MALE STERILIZATION PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD WITHDRAWAL OTHER METHOD CHECK 311/311A: CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST. 329 333 333 (SPECIFY) 11 12 13 14 15 16 17 PUBLIC SECTOR COMMUNITY/FAMILY HEALTH WORKER 31 33 OTHER SOURCE SHOP FRIEND/RELATIVE INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) 96OTHER 330 Where did you obtain (CURRENT METHOD) the last time? GOVT. HEALTH CENTER GOVT. HEALTH POST 21 22 23 26 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) (NAME OF PLACE) PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. 333 1 2 YES NO 328 Were you ever told by a health or family planning worker about other methods of family planning that you could use? 333 14 260 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1 2 YES NO 334 In the last 12 months, have you visited a health facility for care for yourself (or your children)? (SPECIFY) A B C D E F G PUBLIC SECTOR COMMUNITY/FAMILY HEALTH WORKER L M OTHER SOURCE SHOP FRIEND/RELATIVE INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) XOTHER 332 Where is that? Any other place? GOVT. HEALTH CENTER GOVT. HEALTH POST H I J K PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) (NAME OF PLACE) PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. 401 1 2 YES NO 335 Did any staff member at the health facility speak to you about family planning methods? 1 2 YES NO 333 In the last 12 months, were you visited by a fieldworker who talked to you about family planning? 15 261Appendix E | SECTION 4. PREGNANCY AND POSTNATAL CARE 576ONE OR MORE BIRTHS IN 2003 OR LATER NO BIRTHS IN 2003 OR LATER CHECK 215: ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2003 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). Now I would like to ask you some questions about the health of all your children born in the last five years. (We will talk about each separately). 401 LINE NO. 407 402 CHECK 224: NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH Did you see anyone for antenatal care for this pregnancy? IF YES: Whom did you see? Anyone else? PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED. LINE NO. NAME LINE NUMBER FROM 212 LINE NO. NAME DEAD NAME LIVING DEADLIVING (SKIP TO 426) LIVING 404 FROM 212 AND 216 1 2 3 THEN LATER NOT AT ALL DEAD (SKIP TO 426) 1 2 MONTHS YEARS DON’T KNOW (SKIP TO 407) 1 2 3 THEN LATER NOT AT ALL (SKIP TO 407) 405 At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all? (SKIP TO 426) (SKIP TO 414) 1 2 3 THEN LATER NOT AT ALL (SKIP TO 426) 998 1 2 MONTHS YEARS DON’T KNOW 998 1 2 MONTHS YEARS DON’T KNOW 998 406 How much longer would you have liked to wait? A B C D E X Y HEALTH PERSONNEL GYNECOLOGIST DOCTOR NURSE/MIDWIFE/ COMMUNITY/ FAMILY HEALTH WORKER OTHER PERSON TRADITIONAL BIRTH ATTENDANT OTHER NO ONE (SPECIFY) 16 LAST BIRTH 403 262 | Appendix E NO. 413 Were you told where to go if you had any of these complications? NAMEQUESTIONS AND FILTERS NAMENAME A B HOME YOUR HOME OTHER HOME PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER (NAME OF PLACE(S)) LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH C D E F G H I J X (SPECIFY) (SPECIFY) (SPECIFY) NUMBER OF TIMES DON’T KNOW 98 408 Where did you receive antenatal care for this pregnancy? Anywhere else? PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. 409 How many months pregnant were you when you first received antenatal care for this pregnancy? MONTHS DON’T KNOW 98 1 1 1 1 1 1 2 2 2 2 2 2 Were you weighed? Was your blood pressure measured? Did you give a urine sample? Did you give a blood sample? Was a sonogram done? Were you counseled about HIV/AIDS? YES NO 410 How many times did you receive antenatal care during this pregnancy? 411 As part of your antenatal care during this pregnancy, were any of the following done at least once? 1 2 8 YES NO DON’T KNOW 412 During (any of) your antenatal care visit(s), were you told about the signs of pregnancy complications? 1 2 8 YES NO DON’T KNOW (SKIP TO 414) 17 WEIGHT BP URINE BLOOD SONOGRAM COUNSELED ON HIV/AIDS 263Appendix E | NO. 416 During this pregnancy, how many times did you get this tetanus injection? NAMEQUESTIONS AND FILTERS NAMENAME LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH 421 During this pregnancy, were you given or did you buy any iron tablets or iron syrup? 1 2 8 YES NO DON’T KNOW (SKIP TO 423) (SKIP TO 421) TIMES DON’T KNOW 8 2 OR MORE TIMES CHECK 415: OTHER 415 414 During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth? 1 2 8 YES NO DON’T KNOW (SKIP TO 417) 419 In what month and year did you receive the last tetanus injection before this pregnancy? YEAR 420 How many years ago did you receive that tetanus injection? YEARS AGO MONTH 9998DK YEAR (SKIP TO 421) 98DK MONTH 422 During the whole pregnancy, for how many days did you take the tablets or syrup? DAYS DON’T KNOW 998IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS. 417 At any time before this pregnancy, did you receive any tetanus injections, either to protect yourself or another baby? 1 2 8 YES NO DON’T KNOW (SKIP TO 421) 418 Before this pregnancy, how many other times did you receive a tetanus injection? TIMES DON’T KNOW 8 IF 7 OR MORE TIMES, RECORD ‘7’. 423 During this pregnancy, did you take any drug for intestinal worms? 1 2 8 YES NO DON’T KNOW 18 264 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME KG FROM RECALL NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH 425 During this pregnancy, did you suffer from night blindness? 1 2 8 YES NO DON’T KNOW 424 During this pregnancy, did you have difficulty with your vision during daylight? 1 2 8 YES NO DON’T KNOW 1 2 3 VERY LARGE LARGER THAN AVERAGE AVERAGE SMALLER THAN AVERAGE VERY SMALL DON’T KNOW 426 When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small? 4 5 8 1 2 3 VERY LARGE LARGER THAN AVERAGE AVERAGE SMALLER THAN AVERAGE VERY SMALL DON’T KNOW 4 5 8 1 2 3 VERY LARGE LARGER THAN AVERAGE AVERAGE SMALLER THAN AVERAGE VERY SMALL DON’T KNOW 4 5 8 428 2 How much did (NAME) weigh? RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE. 427 Was (NAME) weighed at birth? 1 2 8 YES NO DON’T KNOW (SKIP TO 429) 1 2 8 YES NO DON’T KNOW (SKIP TO 429) 1 2 8 YES NO DON’T KNOW (SKIP TO 429) LAST BIRTH KG FROM CARD 1 99.998DON’T KNOW KG FROM RECALL 2 KG FROM CARD 1 99.998DON’T KNOW KG FROM RECALL 2 KG FROM CARD 1 99.998DON’T KNOW 429 Who assisted with the delivery of (NAME)? Anyone else? PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY. A B C D E F X HEALTH PERSONNEL GYNECOLOGIST DOCTOR NURSE/MIDWIFE COMMUNITY/ FAMILY HEALTH WORKER OTHER PERSON TRADITIONAL BIRTH ATTENDANT RELATIVE/FRIEND OTHER (SPECIFY) A B C D E F X HEALTH PERSONNEL GYNECOLOGIST DOCTOR NURSE/MIDWIFE COMMUNITY/ FAMILY HEALTH WORKER OTHER PERSON TRADITIONAL BIRTH ATTENDANT RELATIVE/FRIEND OTHER (SPECIFY) NO ONE NO ONE NO ONE A B C D E F X HEALTH PERSONNEL GYNECOLOGIST DOCTOR NURSE/MIDWIFE COMMUNITY/ FAMILY HEALTH WORKER OTHER PERSON TRADITIONAL BIRTH ATTENDANT RELATIVE/FRIEND OTHER (SPECIFY) 19 Y YY 265Appendix E | NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 21 22 23 24 25 26 (NAME OF PLACE) 31 36 96 (SPECIFY) (SPECIFY) 430 Where did you give birth to (NAME)? PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. HOME YOUR HOME OTHER HOME PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER (SKIP TO 437) 11 12 (SPECIFY) (SKIP TO 438) 21 22 23 24 25 26 31 36 96 (SPECIFY) (SPECIFY) HOME YOUR HOME OTHER HOME PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER (SKIP TO 437) 11 12 (SPECIFY) (SKIP TO 437) 21 22 23 24 25 26 31 36 96 (SPECIFY) (SPECIFY) HOME YOUR HOME OTHER HOME PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER (SKIP TO 437) 11 12 (SPECIFY) (SKIP TO 438) 434 How long after delivery did the first check take place? 3 HOURS DAYS DON’T KNOW 998 WEEKS 1 2 432 Was (NAME) delivered by caesarean section? 1 2 YES NO 1 2 YES NO 1 2 YES NO 433 Before you were discharged after (NAME) was born, did any health care provider check on your health? 1 2 YES NO (SKIP TO 449) 1 2 YES NO (SKIP TO 436) 1 2 YES NO (SKIP TO 449) 3 HOURS DAYS DON’T KNOW 998 431 How long after (NAME) was delivered did you stay there? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. WEEKS 1 2 3 HOURS DAYS DON’T KNOW 998 WEEKS 1 2 3 HOURS DAYS DON’T KNOW 998 WEEKS 1 2 IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. 20 266 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 435 Who checked on your health at that time? PROBE FOR MOST QUALIFIED PERSON. 436 After you were discharged did any health care provider or a traditional birth attendant check on your health? 1 2 YES NO (SKIP TO 439) 1 2 YES NO (SKIP TO 447) 11 12 13 14 21 96 HEALTH PERSONNEL GYNECOLOGIST DOCTOR NURSE/MIDWIFE COMMUNITY/ FAMILY HEALTH WORKER OTHER PERSON TRADITIONAL BIRTH ATTENDANT OTHER (SPECIFY) 1 2 YES NO (SKIP TO 447) (SKIP TO 449)(SKIP TO 449) 437 Why didn’t you deliver in a health facility? PROBE: Any other reason? RECORD ALL MENTIONED. A B C D E F G H X COST TOO MUCH FACILITY NOT OPEN TOO FAR/NO TRANSPORTATION DON’T TRUST FACILITY/ POOR QUALITY SERVICE NO FEMALE PROVIDER AT FACILITY HUSBAND/FAMILY DID NOT ALLOW NOT NECESSARY NOT CUSTOMARY OTHER (SPECIFY) 438 After (NAME) was born, did any health care provider or a traditional birth attendant check on your health? 1 2 YES NO 1 2 YES NO (SKIP TO 443) 1 2 YES NO 439 How long after delivery did the first check take place? 3 HOURS DAYS DON’T KNOW 998 WEEKS 1 2 IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. 21 267Appendix E | NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 440 Who checked on your health at that time? PROBE FOR MOST QUALIFIED PERSON. 11 12 13 14 21 96 HEALTH PERSONNEL GYNECOLOGIST DOCTOR NURSE/MIDWIFE COMMUNITY/ FAMILY HEALTH WORKER OTHER PERSON TRADITIONAL BIRTH ATTENDANT OTHER (SPECIFY) 11 12 HOME YOUR HOME OTHER HOME PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER (NAME OF PLACE) 21 22 23 24 25 26 31 36 96 (SPECIFY) (SPECIFY) (SPECIFY) 441 Where did this first check take place? PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. 442 (SKIP TO 447) ASKED CHECK 436: NOT ASKED 443 In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health? 1 2 8 YES NO DON’T KNOW (SKIP TO 447) 444 How many hours, days, or weeks after the birth of (NAME) did the first check take place? DAYS AFTER 2 IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. BIRTH DON’T KNOW WEEKS AFTER BIRTH HRS AFTER BIRTH 998 3 1 22 268 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 445 Who checked on (NAME)’s health at that time? PROBE FOR MOST QUALIFIED PERSON. 11 12 13 14 21 96 HEALTH PERSONNEL PEDIATRICIAN DOCTOR NURSE/MIDWIFE COMMUNITY/ FAMILY HEALTH WORKER OTHER PERSON TRADITIONAL BIRTH ATTENDANT OTHER (SPECIFY) 11 12 HOME YOUR HOME OTHER HOME PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER (NAME OF PLACE) 21 22 23 24 25 26 31 36 96 (SPECIFY) (SPECIFY) (SPECIFY) 446 Where did this first check of (NAME) take place? PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. 447 In the first two months after delivery, did you receive a vitamin A dose (like this/any of these)? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS. 1 2 8 YES NO DON’T KNOW 448 Has your menstrual period returned since the birth of (NAME)? 1 2 YES NO (SKIP TO 450) (SKIP TO 451) 449 Did your period return between the birth of (NAME) and your next pregnancy? 1 2 YES NO (SKIP TO 453) 1 2 YES NO (SKIP TO 453) 23 269Appendix E | NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 455 How long after birth did you first put (NAME) to the breast? IF LESS THAN 1 HOUR, RECORD ‘00’ HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS. MONTHS DON’T KNOW 98 MONTHS DON’T KNOW 98 DAYS 000 2 458 (SKIP TO 460) CHECK 404: IS CHILD LIVING? LIVING 456 In the first three days after delivery, was (NAME) given anything to drink other than breast milk? 1 2 YES NO DEAD (SKIP TO 461) 450 For how many months after the birth of (NAME) did you not have a period? MONTHS DON’T KNOW 98 MONTHS DON’T KNOW 98 MONTHS DON’T KNOW 98 1 2 YES NO (SKIP TO 461) 1 2 YES NO (SKIP TO 458) 453 For how many months after the birth of (NAME) did you not have sexual intercourse? MONTHS DON’T KNOW 98 IMMEDIATELY HOURS 1 454 Did you ever breastfeed (NAME)? 1 2 YES NO (SKIP TO 461) 457 What was (NAME) given to drink? Anything else? RECORD ALL LIQUIDS MENTIONED. A B C D E F G H I X MILK (OTHER THAN BREAST MILK) PLAIN WATER SUGAR OR GLUCOSE WATER GRIPE WATER SUGAR-SALT-WATER SOLUTION FRUIT JUICE INFANT FORMULA TEA/INFUSIONS HONEY OTHER (SPECIFY) 451 (SKIP TO 453) CHECK 226: IS RESPONDENT PREGNANT? NOT PREGNANT PREGNANT UNSURE OR 452 Have you begun to have sexual intercourse again since the birth of (NAME)? 1 2 YES NO (SKIP TO 454) 24 270 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 459 Are you still breastfeeding (NAME)? 1 2 YES NO (SKIP TO 462) 465 GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501. 1 2 8 YES NO DON’T KNOW 460 For how many months did you breastfeed (NAME)? STILL BF 98 MONTHSMONTHS DON’T KNOW 98 MONTHS STILL BF 95 DON’T KNOW 98 95 DON’T KNOW 461 CHECK 404: IS CHILD LIVING? LIVING DEAD (SKIP TO 464) (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501) LIVING DEAD (SKIP TO 464) (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501) LIVING DEAD (SKIP TO 464) 463 How many times did you breastfeed yesterday during the daylight hours? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER. NUMBER OF DAYLIGHT FEEDINGS 462 How many times did you breastfeed last night between sunset and sunrise? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER. NUMBER OF NIGHT TIME FEEDINGS 1 2 8 YES NO DON’T KNOW 1 2 8 YES NO DON’T KNOW 464 Did (NAME) drink anything from a bottle with a nipple yesterday or last night? GO BACK TO 405 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE; OR IF NO MORE BIRTHS, GO TO 501. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501. 25 (GO TO 405 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE, OR IF NO MORE BIRTH, GO TO 501). 271Appendix E | SECTION 5. CHILD IMMUNIZATION AND HEALTH AND CHILD’S AND WOMAN’S NUTRITION 502 501 LAST BIRTH LINE NO. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2003 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LINE NO. NAME LINE NUMBER FROM 212 LINE NO. NAME DEAD NAME LIVING DEADLIVINGLIVING 503 FROM 212 AND 216 DEAD (SKIP TO 508) 1 2 3 YES, SEEN YES, NOT SEEN NO CARD (SKIP TO 506) 504 Do you have a card where (NAME’S) vaccinations are written down? IF YES: May I see it please? (GO TO 503 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE, OR IF NO MORE BIRTH, GO TO 573). (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 573). (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 573). (SKIP TO 508) 1 2 3 YES, SEEN YES, NOT SEEN NO CARD (SKIP TO 506) (SKIP TO 508) 1 2 3 YES, SEEN YES, NOT SEEN NO CARD (SKIP TO 506) 506 (1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. (2) WRITE ‘44’ IN ‘DAY’ COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED. (3) IF MORE THAN TWO VITAMIN ‘A’ DOSES, RECORD DATES FOR MOST RECENT AND SECOND MOST RECENT DOSES. 1 2 YES NO 1 2 YES NO (SKIP TO 508) (SKIP TO 508) 1 2 YES NO (SKIP TO 508) 505 Did you ever have a vaccination card for (NAME)? BCG POLIO 1 POLIO 2 POLIO 3 DPT 1 DPT 2 DPT 3 HepB 1 MEASLES HepB 2 HepB 3 VITAMIN A (2ND MOST RECENT) DAY MONTH YEAR LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH BCG PO P1 P2 P3 D1 D2 D3 H1 2 3 MEA VITA VITA H H DAY MONTH YEAR DAY MONTH YEAR BCG PO P1 P2 P3 D1 D2 D3 H1 2 3 MEA VITA VITA H H POLIO 0 (POLIO GIVEN AT BIRTH) VITAMIN A (MOST RECENT) 26 272 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 506A CHECK 506: ALL RECORDED OTHER (GO TO 512) BCG TO MEASLES ALL RECORDED OTHER (GO TO 512) BCG TO MEASLES ALL RECORDED OTHER (GO TO 512) BCG TO MEASLES 509C Was the first polio vaccine received in the first two weeks after birth or later? 507 Has (NAME) received any vaccinations that are not recorded on this card? RECORD ‘YES’ ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, AND/OR MEASLES VACCINES. (SKIP TO 512) 1YES (PROBE FOR VACCINATIONS AND WRITE ‘66’ IN THE CORRESPONDING DAY COLUMN IN 506) NO DON’T KNOW 2 8 (SKIP TO 512) (SKIP TO 512) 1YES (PROBE FOR VACCINATIONS AND WRITE ‘66’ IN THE CORRESPONDING DAY COLUMN IN 506) NO DON’T KNOW 2 8 (SKIP TO 512) (SKIP TO 512) 1YES (PROBE FOR VACCINATIONS AND WRITE ‘66’ IN THE CORRESPONDING DAY COLUMN IN 506) NO DON’T KNOW 2 8 (SKIP TO 512) 1FIRST 2 WEEKS LATER 2 1 2 8 YES NO DON’T KNOW 1 2 8 YES NO DON’T KNOW 1 2 8 YES NO DON’T KNOW 509A A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar? 509 Please tell me if (NAME) received any of the following vaccinations: 508 Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization campaign? 1YES NO DON’T KNOW 2 8 (SKIP TO 512) 1YES NO DON’T KNOW 2 8 (SKIP TO 512) 1YES NO DON’T KNOW 2 8 (SKIP TO 512) 509E A DPT vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops? 1YES NO DON’T KNOW 2 8 (SKIP TO 509G) 1YES NO DON’T KNOW 2 8 (SKIP TO 509G) 1YES NO DON’T KNOW 2 8 (SKIP TO 509G) 1FIRST 2 WEEKS LATER 2 1FIRST 2 WEEKS LATER 2 509F How many times was a DPT vaccination received? NUMBER OF TIMES NUMBER OF TIMESNUMBER OF TIMES 509B Polio vaccine, that is, drops in the mouth? 1YES NO DON’T KNOW 2 8 (SKIP TO 509E) 1YES NO DON’T KNOW 2 8 (SKIP TO 509E) 1YES NO DON’T KNOW 2 8 (SKIP TO 509E) 509D How many times was the polio vaccine received? NUMBER OF TIMES NUMBER OF TIMESNUMBER OF TIMES 27 273Appendix E | NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 519 When (NAME) had diarrhea, was there any blood in the stools? 1YES NO DON’T KNOW 2 8 509G A Hepatitis B vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as DPT and polio drops? 1YES NO DON’T KNOW 2 8 (SKIP TO 509J) 1YES NO DON’T KNOW 2 8 (SKIP TO 509J) (SKIP TO 517) 1YES NO DON’T KNOW 2 8 (SKIP TO 509J) 509H How many times was a Hep B vaccination received? NUMBER OF TIMES NUMBER OF TIMESNUMBER OF TIMES 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 512 CHECK 506: DATE SHOWN FOR VITAMIN ‘A’ DOSE ‘A’ DOSE OTHER (SKIP TO 514) DATE FOR MOST RECENT VITAMIN ‘A’ DOSE OTHER (SKIP TO 514) DATE FOR MOST RECENT VITAMIN ‘A’ DOSE OTHER (SKIP TO 514) DATE FOR MOST RECENT VITAMIN 518 Has (NAME) had diarrhea in the last 2 weeks? 1 2 8 YES NO DON’T KNOW (SKIP TO 515) (SKIP TO 517) 1 2 8 YES NO DON’T KNOW (SKIP TO 515) (SKIP TO 533) 1 2 8 YES NO DON’T KNOW 513 According to (NAME)’s health card, he/she received a vitamin ‘A’ dose (like this/any of these) in (MONTH AND YEAR OF MOST RECENT DOSE FROM CARD). Has (NAME) received another vitamin ‘A’ dose since then? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS. (SKIP TO 517) 1 2 8 YES NO DON’T KNOW (SKIP TO 515) (SKIP TO 533) 1 2 8 YES NO DON’T KNOW (SKIP TO 533) 1 2 8 YES NO DON’T KNOW 509J A measles injection or an MMR injection - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting measles? 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 515 Did (NAME) receive a vitamin ‘A’ dose within the last six months? 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 514 Has (NAME) ever received a vitamin ‘A’ dose (like this/any of these)? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS. (SKIP TO 517) 1 2 8 YES NO DON’T KNOW (SKIP TO 517) 1 2 8 YES NO DON’T KNOW (SKIP TO 517) 1 2 8 YES NO DON’T KNOW 517 Has (NAME) taken any drug for intestinal worms in the last six months? 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 28 274 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 521 When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat? IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less? 1 2 3 4 5 6 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE STOPPED FOOD NEVER GAVE FOOD DON’T KNOW 1 2 3 4 5 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE NOTHING TO DRINK DON’T KNOW 520 Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). Was he/she given less than usual to drink, about the same amount, or more than usual to drink? IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less? 1 2 3 4 5 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE NOTHING TO DRINK DON’T KNOW 1 2 3 4 5 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE NOTHING TO DRINK DON’T KNOW 522 Did you seek advice or treatment for the diarrhea from any source? 1 2 YES NO (SKIP TO 527) 1 2 YES NO (SKIP TO 527) 1 2 YES NO (SKIP TO 527) A B PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER SOURCE SHOP TRADITIONAL PRACTITIONER OTHER (NAME OF PLACE(S)) C D E F G H I J K X (SPECIFY) (SPECIFY) (SPECIFY) 523 Where did you seek advice or treatment? Anywhere else? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. A B PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER SOURCE SHOP TRADITIONAL PRACTITIONER OTHER C D E F G H I J K X (SPECIFY) (SPECIFY) (SPECIFY) A B PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER SOURCE SHOP TRADITIONAL PRACTITIONER OTHER C D E F G H I J K X (SPECIFY) (SPECIFY) (SPECIFY) 524 CHECK 523: (SKIP TO 526) ONLY ONE CIRCLEDTWO OR MORE CODES CIRCLED CODE (SKIP TO 526) ONLY ONE CIRCLEDTWO OR MORE CODES CIRCLED CODE (SKIP TO 526) ONLY ONE CIRCLEDTWO OR MORE CODES CIRCLED CODE 129 1 2 3 4 5 6 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE STOPPED FOOD NEVER GAVE FOOD DON’T KNOW 1 2 3 4 5 6 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE STOPPED FOOD NEVER GAVE FOOD DON’T KNOW 275Appendix E | NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 526 How many days after the diarrhea began did you first seek advice or treatment for (NAME)? IF THE SAME DAY, RECORD ‘00’. DAYS 525 Where did you first seek advice or treatment? USE LETTER CODE FROM 523. FIRST PLACE FIRST PLACEFIRST PLACE DAYSDAYS 527 Does (NAME) still have diarrhea? 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 1 1 1 8 8 8 FLUID FROM ORS PKT ORS LQD HOMEMADE FLUID DK 528 Was he/she given any of the following to drink at any time since he/she started having the diarrhea: a) A fluid made from a special ORS packet? b) A pre-packaged ORS liquid? c) A government-recommended homemade fluid? YES NO 2 2 2 1 1 1 8 8 8 FLUID FROM ORS PKT ORS LQD HOMEMADE FLUID DKYES NO 2 2 2 1 1 1 8 8 8 FLUID FROM ORS PKT ORS LQD HOMEMADE FLUID DKYES NO 2 2 2 529 Was anything (else) given to treat the diarrhea? 1YES NO DON’T KNOW 2 8 (SKIP TO 533) 1YES NO DON’T KNOW 2 8 (SKIP TO 533) 1YES NO DON’T KNOW 2 8 (SKIP TO 533) 530 what (else) was given to treat the diarrhea? Anything else? RECORD ALL TREATMENTS GIVEN. A B C PILL OR SYRUP ANTIBIOTIC ANTIMOTILITY ZINC OTHER(NOT ANTI- BIOTIC,ANTIMOTILITY, OR ZINC) UNKNOWN PILL OR SYRUP INJECTION ANTIBIOTIC NON-ANTIBIOTIC UNKNOWN INJECTION (IV) INTRAVENOUS HOME REMEDY/ HERBAL MEDICINE OTHER D E F G H I J X (SPECIFY) A B C PILL OR SYRUP ANTIBIOTIC ANTIMOTILITY ZINC OTHER(NOT ANTI- BIOTIC,ANTIMOTILITY, OR ZINC) UNKNOWN PILL OR SYRUP INJECTION ANTIBIOTIC NON-ANTIBIOTIC UNKNOWN INJECTION (IV) INTRAVENOUS HOME REMEDY/ HERBAL MEDICINE OTHER D E F G H I J X (SPECIFY) A B C PILL OR SYRUP ANTIBIOTIC ANTIMOTILITY ZINC OTHER(NOT ANTI- BIOTIC,ANTIMOTILITY, OR ZINC) UNKNOWN PILL OR SYRUP INJECTION ANTIBIOTIC NON-ANTIBIOTIC UNKNOWN INJECTION (IV) INTRAVENOUS HOME REMEDY/ HERBAL MEDICINE OTHER D E F G H I J X (SPECIFY) 531 CHECK 530: GIVEN ZINC? (SKIP TO 533) CODE ‘C’ CIRCLED CODE ‘C’ CIRCLED NOT (SKIP TO 533) CODE ‘C’ CIRCLED CODE ‘C’ CIRCLED NOT (SKIP TO 533) CODE ‘C’ CIRCLED CODE ‘C’ CIRCLED NOT 30 276 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 532 How many times was (NAME) given zinc? DON’T KNOW TIMESTIMES DON’T KNOW 98 TIMES DON’T KNOW 9898 533 Has (NAME) been ill with a fever at any time in the last 2 weeks? 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 1YES NO DON’T KNOW 2 8 536 Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose? 1CHEST ONLY NOSE ONLY BOTH OTHER DON’T KNOW 3 534 Has (NAME) had an illness with a cough at any time in the last 2 weeks? 1YES NO DON’T KNOW 2 8 (SKIP TO 537) 1YES NO DON’T KNOW 2 8 (SKIP TO 537) 1YES NO DON’T KNOW 2 8 (SKIP TO 538) 535 When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing? 1YES NO DON’T KNOW 2 8 (SKIP TO 538) 1YES NO DON’T KNOW 2 8 (SKIP TO 538) 1YES NO DON’T KNOW 2 8 (SKIP TO 538) 6 8 2 (SKIP TO 537) (SPECIFY) 1CHEST ONLY NOSE ONLY BOTH OTHER DON’T KNOW 3 (SKIP TO 538) 6 8 2 (SPECIFY) 1CHEST ONLY NOSE ONLY BOTH OTHER DON’T KNOW 3 (SKIP TO 538) 6 8 2 (SPECIFY) 537 CHECK 533: HAD FEVER? (GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 573) YES NO OR DK (GO BACK TO 503 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE; OR IF NO MORE BIRTHS, GO TO 573) YES NO OR DK (GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 573) YES NO OR DK 539 When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat? IF LESS PROBE: Was he/she given much less than usual to eat or somewhat less? 1 2 3 4 5 6 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE STOPPED FOOD NEVER GAVE FOOD DON’T KNOW 1 2 3 4 5 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE NOTHING TO DRINK DON’T KNOW 538 Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same amount, or more than usual to drink? IF LESS PROBE: Was he/she given much less than usual to drink or somewhat less? 1 2 3 4 5 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE NOTHING TO DRINK DON’T KNOW 1 2 3 4 5 8 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE NOTHING TO DRINK DON’T KNOW 8 1 2 3 4 5 6 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE STOPPED FOOD NEVER GAVE FOOD DON’T KNOW 8 1 2 3 4 5 6 MUCH LESS SOMEWHAT LESS ABOUT THE SAME MORE STOPPED FOOD NEVER GAVE FOOD DON’T KNOW 8 31 277Appendix E | NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 540 Did you seek advice or treatment for the illness from any source? 1 2 YES NO (SKIP TO 545) 1 2 YES NO (SKIP TO 545) 1 2 YES NO (SKIP TO 545) A B PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER SOURCE SHOP TRADITIONAL PRACTITIONER OTHER (NAME OF PLACE(S)) C D E F G H I J K X (SPECIFY) (SPECIFY) (SPECIFY) 541 Where did you seek advice or treatment? Anywhere else? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. A B PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER SOURCE SHOP TRADITIONAL PRACTITIONER OTHER C D E F G H I J K X (SPECIFY) (SPECIFY) (SPECIFY) A B PUBLIC SECTOR INDHIRA GANDHI MEMORIAL HOSPITAL GVT. REGIONAL HOSPITAL GVT. ATOLL HOSPITAL GVT. HEALTH CENTER GVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER OTHER PUBLIC PRIVATE MED. SECTOR PVT. HOSPITAL/CLINIC OTHER PRIVATE MED. OTHER SOURCE SHOP TRADITIONAL PRACTITIONER OTHER C D E F G H I J K X (SPECIFY) (SPECIFY) (SPECIFY) 542 CHECK 541: (SKIP TO 544) ONLY ONE CIRCLEDTWO OR MORE CODES CIRCLED CODE (SKIP TO 544) ONLY ONE CIRCLEDTWO OR MORE CODES CIRCLED CODE (SKIP TO 544) ONLY ONE CIRCLEDTWO OR MORE CODES CIRCLED CODE 544 How many days after the illness began did you first seek advice or treatment for (NAME)? IF THE SAME DAY, RECORD ‘00’. DAYS 543 Where did you first seek advice or treatment? USE LETTER CODE FROM 541. FIRST PLACE FIRST PLACEFIRST PLACE DAYSDAYS 545 Is (NAME) still sick with a (fever/ cough)? 1 2 3 4 8 FEVER ONLY COUGH ONLY BOTH FEVER AND COUGH NO, NEITHER DON’T KNOW 1 2 3 4 8 FEVER ONLY COUGH ONLY BOTH FEVER AND COUGH NO, NEITHER DON’T KNOW 1 2 3 4 8 FEVER ONLY COUGH ONLY BOTH FEVER AND COUGH NO, NEITHER DON’T KNOW 32 278 | Appendix E NO. NAMEQUESTIONS AND FILTERS NAMENAME NEXT-TO-LAST BIRTH SECOND-FROM LAST BIRTH LAST BIRTH 546 At any time during the illness, did (NAME) take any drugs for the illness? 1YES NO DON’T KNOW 2 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573) 1YES NO DON’T KNOW 2 8 (GO TO 503 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE; OR IF NO MORE BIRTHS, GO TO 573) 1YES NO DON’T KNOW 2 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573) 549 Did you already have (NAME OF DRUG FROM 547) at home when the child became ill? 8 HAD ANTIBIOTIC PILL/ SYRUP AT HOME NO ANTIBIOTIC PILL/SYRUP AT HOME 2 1 548 CHECK 547: CODE ‘A’ CIRCLED? (GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 573) YES NO (GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 573) YES NO (GO TO 503 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE; OR IF NO MORE BIRTHS, GO TO 573) YES NO X 547 What drugs did (NAME) take? Any other drugs? RECORD ALL MENTIONED. ANTIBIOTIC DRUGS PILL/SYRUP INJECTION OTHER DRUGS DON’T KNOW (SPECIFY) B Z A X ANTIBIOTIC DRUGS PILL/SYRUP INJECTION OTHER DRUGS DON’T KNOW (SPECIFY) B Z A X ANTIBIOTIC DRUGS PILL/SYRUP INJECTION OTHER DRUGS DON’T KNOW (SPECIFY) B Z A HAD ANTIBIOTIC PILL/ SYRUP AT HOME NO ANTIBIOTIC PILL/SYRUP AT HOME 2 1 HAD ANTIBIOTIC PILL/ SYRUP AT HOME NO ANTIBIOTIC PILL/SYRUP AT HOME 2 1 572 GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573. GO TO 503 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE BIRTHS, GO TO 573. GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573. 33 279Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 577NO CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID 575 CHECK 528(a) AND 528(b), ALL COLUMNS: 1 2 576 Have you ever heard of a special product called LONU packet or a pre-packaged ORS liquid you can get for the treatment of diarrhea? YES NO 601ONE OR MORE NONE 577 RECORD NAME OF YOUNGEST CHILD LIVING WITH HER (AND CONTINUE WITH 578) CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2005 OR LATER LIVING WITH THE RESPONDENT (NAME) (SPECIFY) 01 02 03 04 05 06 96 574 The last time (NAME FROM 573) passed stools, what was done to dispose of the stools? CHILD USED TOILET OR LATRINE PUT/RINSED INTO TOILET OR LATRINE PUT/RINSED INTO DRAIN OR DITCH THROWN INTO GARBAGE BURIED LEFT IN THE OPEN OTHER 576ONE OR MORE NONE 573 RECORD NAME OF YOUNGEST CHILD LIVING WITH HER (AND CONTINUE WITH 574) CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2005 OR LATER LIVING WITH THE RESPONDENT (NAME) 8 8 8 FORTIFIED BABY CEREAL OTHER PORRIDGE/GRUEL YES DK NO 1 1 1 81 578 Now I would like to ask you about liquids or foods (NAME FROM 577) had yesterday during the day or at night. Did (NAME FROM 577) (drink/eat): Plain water? Commercially produced infant formula? Any (BRAND NAME OF COMMERCIALLY FORTIFIED BABY FOOD. E.G., Cerelac)? Any (other) porridge or gruel? PLAIN WATER FORMULA 2 2 2 2 34 280 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP NO. QUESTIONS AND FILTERS CODING CATEGORIES MOTHERCHILD SKIP 579 Now I would like to ask you about (other) liquids or foods that (NAME FROM 577) and you may have had yesterday during the day or at night. I am interested in whether your child and you had the item even if it was combined with other foods. Did (NAME FROM 577) / you drink (eat): a) Milk such as tinned, powdered, or fresh animal milk? b)Tea or coffee? c) Any other liquids? d) Bread, rice, noodles, or other foods made from grains? e) Pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside? f) White potatoes, white yams, manioc, cassava, or any other foods made from roots? g) Any dark green, leafy vegetables? h) Ripe mangoes or papayas? i) Any other fruits or vegetables? j) Liver, kidney, heart or other organ meats? k) Any meat, such as beef, pork, lamb, goat, chicken, or duck? l) Eggs? m) Fresh or dried fish or shellfish? n) Any foods made from beans, peas, lentils or nuts? o) Cheese, yogurt or other milk products? p) Any oil, fats, or butter, or foods made with any of these? q) Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits? r) Any other solid or semi-solid food? ) (b) 1 2 8 YES DK NOYES DK NO 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 1 2 8 ( ) (c) (e) (a) (f) (g) ( ) (d) (j) (k) (l) (n) (h) (o) (p) (q) (m) r)( 601AT LEAST ONE “YES” NOT A SINGLE “YES” 580 CHECK 578 (LAST 2 CATEGORIES: BABY CEREAL OR OTHER PORRIDGE/GRUEL) AND 579 (CATEGORIES d THROUGH r FOR CHILD): 8 NUMBER OF TIMES DON’T KNOW 581 How many times did (NAME FROM 577) eat solid, semisolid, or soft foods yesterday during the day or at night? IF 7 OR MORE TIMES, RECORD ‘7’. 35 281Appendix E | SECTION 6. MARRIAGE AND SEXUAL ACTIVITY NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 601 607CURRENTLY MARRIED WIDOWED/DIVORCED/ SEPARATED CHECK 104: MARITAL STATUS 607 Have you been married only once or more than once? 1 2 ONLY ONCE MORE THAN ONCE 609B CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. 609C Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues. How old were you when you had sexual intercourse for the very first time? 95 AGE IN YEARS FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND 602 Is you husband living with you now or is he staying elsewhere? 1 2 LIVING WITH HER STAYING ELSEWHERE 00NEVER HAD INTERCOURSE 609 How old were you when you started living together with your (first) husband? AGE IN COMPLETED YEARS 603 RECORD THE HUSBAND’S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD ‘00’. NAME LINE NO. 608 CHECK 607: MARRIED ONLY ONCE MARRIED MORE THAN ONCE In what month and year did you start living together with your husband? Now I would like to ask about your first husband. In what month and year did you start living together with your first husband? 9998 YEAR DON’T KNOW YEAR 701 98 MONTH DON’T KNOW MONTH 1 2 610 Do you know of a place where a person can get condoms? YES NO 609B 36 282 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP (SPECIFY) A B C D E F G PUBLIC SECTOR COMMUNITY/FAMILY HEALTH WORKER L M OTHER SOURCE SHOP FRIEND/RELATIVE INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) XOTHER 611 Where is that? Any other place? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF PLACE. (NAME OF PLACE(S)) GOVT. HEALTH CENTER GOVT. HEALTH POST H I J K PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) 1 2 8 612 If you wanted to, could you yourself get a condom? YES NO DON’T KNOW/UNSURE 37 283Appendix E | SECTION 7. FERTILITY PREFERENCES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 704 708NO, NOT CURRENTLY USING YES, CURRENTLY USING CHECK 310: USING A CONTRACEPTIVE METHOD? 703 CHECK 226: NOT PREGNANT OR UNSURE PREGNANT How long would you like to wait from now before the birth of (a/another) child? After the birth of the child you are expecting now, how long would you like to wait before the birth of another child? 708 993 994 995 996 998 1 2 SOON/NOW SAYS SHE CAN’T GET PREGNANT AFTER MARRIAGE OTHER DON’T KNOW 702 CHECK 226: NOT PREGNANT OR UNSURE PREGNANT Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children? Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not have any more children? 708 1 2 3 4 5 HAVE (A/ANOTHER) CHILD NO MORE/NONE SAYS SHE CAN’T GET PREGNANT UNDECIDED/DON’T KNOW AND PREGNANT UNDECIDED/DON’T KNOW AND NOT PREGNANT OR UNSURE 705 704 704 MONTHS YEARS (SPECIFY) 701 708NEITHER STERILIZED HE OR SHE STERILIZED CHECK 311/311A: NOT ASKED 1 2 8 705 Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the future? YES NO DON’T KNOW 708 707 01 02 03 04 05 06 07 08 09 10 11 96 98 706 Which contraceptive method would you prefer to use? FEMALE STERILIZATION MALE STERILIZATION PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD WITHDRAWAL OTHER UNSURE (SPECIFY) 708 38 284 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 22 23 24 26 NOT MARRIED 11 FERTILITY-RELATED REASONS INFREQUENT SEX/NO SEX MENOPAUSAL/HYSTERECTOMY SUBFECUND/INFECUND WANTS AS MANY CHILDREN AS POSSIBLE OPPOSITION TO USE RESPONDENT OPPOSED HUSBAND OPPOSED OTHERS OPPOSED RELIGIOUS PROHIBITION LACK OF KNOWLEDGE KNOWS NO METHOD KNOWS NO SOURCE METHOD-RELATED REASONS HEALTH CONCERNS FEAR OF SIDE EFFECTS LACK OF ACCESS/TOO FAR COSTS TOO MUCH INCONVENIENT TO USE INTERFERES WITH BODY’S NORMAL PROCESSES OTHER DON’T KNOW (SPECIFY) 707 What is the main reason that you think you will not use a contraceptive method at any time in the future? 51 52 53 54 55 56 96 31 32 33 34 41 42 98 708 PROBE FOR A NUMERIC RESPONSE. HAS LIVING CHILDREN NO LIVING CHILDREN If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be? If you could choose exactly the number of children to have in your whole life, how many would that be? 96 NUMBER OTHER 00NONE 710 CHECK 216: (SPECIFY) 710 (SPECIFY) 709 How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter? 96 NUMBER OTHER BOYS EITHERGIRLS 710 1 1 1 2 2 2 In the last few months have you: Heard about family planning on the radio? Seen about family planning on the television? Read about family planning in a newspaper or magazine? RADIO TELEVISION NEWSPAPER OR MAGAZINE YES NO 711 OTHER CHECK 311/311A: 713CODE B,G, OR K CIRCLED 715NO CODE CIRCLED 39 285Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1 2 3 8 715 Does your husband want the same number of children that you want, or does he want more or fewer than you want? SAME NUMBER MORE CHILDREN FEWER CHILDREN DON’T KNOW 1 2 8 712 Does your husband know that you are using a method of family planning? YES NO DON’T KNOW 714 801NEITHER STERILIZED HE OR SHE STERILIZED CHECK 311/311A: 1 2 3 6 713 Would you say that using contraception is mainly your decision, mainly your husband’s decision, or did you both decide together? MAINLY RESPONDENT MAINLY HUSBAND JOINT DECISION OTHER (SPECIFY) 40 286 | Appendix E SECTION 8. HUSBAND’S BACKGROUND AND WOMAN’S WORK NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 801 803CURRENTLY MARRIED WIDOWED/DIVORCED/ SEPARATED CHECK 104: 802 How old was your husband on his last birthday? AGE IN COMPLETED YEARS 808 1 2 As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work? YES NO 806 98 0 1 2 3 4 5 6 7 8 804 What was the highest level of school he attended: primary, secondary, or higher? NON-FORMAL PRIMARY ‘O’ LEVEL ‘A’ LEVEL DIPLOMA FIRST DEGREE MASTER’S CERTIFICATE/ABOVE CERTIFICATE DON’T KNOW 811 811 What is your occupation, that is, what kind of work do you mainly do? GRADE DON’T KNOW 803 1 2 Did your (last) husband ever attend school? YES NO 806 809 1 2 Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, maternity leave or any other such reason? YES NO 811 810 1 2 Have you done any work in the last 12 months? YES NO 816 807 1 2 Aside from your own housework, have you done any work in the last seven days? YES NO 811 806 CURRENTLY MARRIED WIDOWED/ DIVORCED/ SEPARATED What is your husband’s occupation? That is, what kind of work does he mainly do? What was your (last) husband’s occupation? That is, what kind of work did he mainly do? CHECK 801: 805 What was the highest (grade/form/year) he completed at that level? 1 2 3 4 5 812 Do you do this work for government, for a private company, for someone else, for a member of your family, or are you self-employed? FOR GOVERNMENT FOR PRIVATE COMPANY FOR SOMEONE ELSE FOR FAMILY MEMBER SELF-EMPLOYED 41 287Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1 2 813 Do you usually work at home or away from home? HOME AWAY 1 2 3 814 Do you usually work throughout the year, or do you work seasonally, or only once in a while? THROUGHOUT THE YEAR SEASONALLY/PART OF THE YEAR ONCE IN A WHILE 815 Are you paid in cash or kind for this work or are you not paid at all? 1 2 3 4 CASH ONLY CASH AND KIND IN KIND ONLY NOT PAID 817 820CODE 1 OR 2 CIRCLED OTHER CHECK 815: 816 825CURRENTLY MARRIED WIDOWED/DIVORCED/ SEPARATED CHECK 104: 819 Would you say that the money that you earn is more than what your husband earns, less than what he earns, or about the same? 1 2 3 4 8 MORE THAN HIM LESS THAN HIM ABOUT THE SAME HUSBAND DOESN’T BRING IN ANY MONEY DON’T KNOW 824 Who usually makes decisions about visits to your family or relatives? 2 821 818 Who usually decides how the money you earn will be used: mainly you, mainly your husband, or you and your husband jointly? 1 2 3 6 RESPONDENT HUSBAND RESPONDENT AND HUSBAND JOINTLY OTHER (SPECIFY) 820 Who usually decides how your husband’s earnings will be used: you, your husband, or you and your husband jointly? 1 2 3 4 6 RESPONDENT HUSBAND RESPONDENT AND HUSBAND JOINTLY HUSBAND HAS NO EARNINGS OTHER 3 4 61 (SPECIFY) 821 Who usually makes decisions about health care for yourself: you, your husband, you and your husband jointly, or someone else? 2 3 4 61 RESPONDENT = 1 HUSBAND = 2 RESPONDENT AND HUSBAND JOINTLY = 3 SOMEONE ELSE = 4 OTHER = 6 822 Who usually makes decisions about making major household purchases? 2 3 4 61 823 Who usually makes decisions about making purchases for daily household needs? 2 3 4 61 YES DK NO 2 2 825 Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations: If she goes out without telling him? If she neglects the children? If she argues with him? If she refuses to have sex with him? If she burns the food? GOES OUT NEGLECTS CHILDREN ARGUES REFUSES SEX BURNS FOOD 2 2 2 8 8 8 8 8 1 1 1 1 1 42 288 | Appendix E SECTION 9. HIV/AIDS NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 904 910 YES NO 1 2 Do you know of a place where people can go to get tested for the AIDS virus? 912 1 2 8 YES NO DON’T KNOW 902 Can people reduce their chances of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners? 1 2 8 YES NO DON’T KNOW 905 Can people get the AIDS virus by sharing food with a person who has AIDS? 1 2 8 YES NO DON’T KNOW 906 Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all? 1 2 8 YES NO DON’T KNOW 907 Can people get the AIDS virus because of witchcraft or other supernatural means? 1 2 8 YES NO DON’T KNOW 908 Is it possible for a healthy-looking person to have the AIDS virus? 1 2 8 YES NO DON’T KNOW 903 Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex? 1 2 8 YES NO DON’T KNOW 8By Breastfeeding? YES DK NO 2 82During pregnancy? During delivery? 909 Can the virus that causes AIDS be transmitted from a mother to her baby: 1 1 821 Can people get the AIDS virus from mosquito bites? 901 Now I would like to talk about something else. Have you ever heard of an illness called AIDS? YES NO 1 2 916 43 BREASTFEEDING DURING PREGNANCY DURING DELIVERY 289Appendix E | 911 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Where is that? Any other place? (NAME OF PLACE) (SPECIFY) A B C D E F G PUBLIC SECTOR GOVT. HEALTH POST GOVT. VCT SITE GOVT. HEALTH CENTER H I J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC/ PRIVATE DOCTOR PHARMACY OTHER PRIVATE MEDICAL PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) (SPECIFY) X OTHER 915A In your opinion, if a male teacher has the AIDS virus but is not sick, should he be allowed to continue teaching in the school? 1 2 8 SHOULD BE ALLOWED SHOULD NOT BE ALLOWED DK/UNSURE/DEPENDS 912 Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus? 1 2 8 YES NO DON’T KNOW 913 If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not? 1 2 8 YES, REMAIN A SECRET NO DK/UNSURE/DEPENDS 914 If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household? 1 2 8 YES NO DK/UNSURE/DEPENDS 915 In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school? 1 2 8 SHOULD BE ALLOWED SHOULD NOT BE ALLOWED DK/UNSURE/DEPENDS YES NO 918 1 2 916 CHECK 701: HEARD ABOUT AIDS NOT HEARD ABOUT AIDS Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact? Have you heard about infections that can be transmitted through sexual contact? 44 290 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 919 Sometimes women have a genital sore or a ulcer. During the last 12 months, have you had a genital sore or ulcer? 1 2 8 YES NO DON’T KNOW 917 Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact? 1 2 8 YES NO DON’T KNOW 920 1001HAS HAD AN INFECTION (ANY ‘YES’) HAS NOT HAD AN INFECTION OR DOES NOT KNOW CHECK 917,918, and 919: 921 YES NO 1 2 The last time you had (PROBLEM FROM 917 / 918 / 919), did you seek any kind of advice or treatment? 1001 922 Where did you go? Any other place? (NAME OF PLACE(S)) (SPECIFY) A B C D E F G PUBLIC SECTOR GOVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER GOVT. HEALTH CENTER L X OTHER SOURCE SHOP OTHER PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) H I J K PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) 918 Sometimes women experience a bad smelling abnormal genital discharge. During the last 12 months, have you had a bad smelling abnormal genital discharge? 1 2 8 YES NO DON’T KNOW 45 291Appendix E | SECTION 10. OTHER HEALTH ISSUES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1001 Have you ever heard of an illness called tuberculosis or TB? YES NO 1 2 1005 A B C D E F X Z 1002 How does tuberculosis spread from one person to another? PROBE: Any other ways? RECORD ALL MENTIONED. THROUGH THE AIR WHEN COUGHING OR SNEEZING THROUGH SHARING UTENSILS THROUGH TOUCHING A PERSON WITH TB THROUGH FOOD THROUGH SEXUAL CONTACT THROUGH MOSQUITO BITES OTHER DON’T KNOW (SPECIFY) 1003 Can tuberculosis be cured? 1 2 8 YES NO DON’T KNOW 1004 If a member of your family got tuberculosis, would you want it to remain a secret or not? 1 2 8 YES, REMAIN A SECRET NO DON’T KNOW/NOT SURE/DEPENDS 1006 Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker? IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. NUMBER OF INJECTIONS NONE 00 1009 1005 Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months? IF YES: How many injections have you had? IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. NUMBER OF INJECTIONS NONE 00 1009 46 292 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1007 The last time you had an injection given to you by a health worker, where did you go to get the injection? (NAME OF PLACE) PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. (SPECIFY) 11 12 13 14 15 16 17 PUBLIC SECTOR GOVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER GOVT. HEALTH CENTER 31 96 OTHER PLACE AT HOME OTHER INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) 21 22 23 24 26 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PRIVATE DOCTOR DENTAL OFFICE/CLINIC PHARMACY OTHER PRIVATE MEDICAL (SPECIFY) 1008 Did the person who gave you that injection take the syringe and needle from a new, unopened package? 1 2 8 YES NO DON’T KNOW IF NONE RECORD ‘00’. 98 NUMBER OF DAYS DON’T KNOW / UNSURE 1009 On how many days this week, did you walk, run, or engage in other various physical activity for at least 20 minutes? 1012 Do you currently smoke or use any other type of tobacco? YES NO 1 2 1014 In the last 24 hours, how many cigarettes did you smoke?1011 CIGARETTES 1010 Do you currently smoke cigarettes? YES NO 1 2 1012 1013 A B C D E F X HOOKA BIDI CIGAR PIPE CHEWING TOBACCO SNUFF OTHER (SPECIFY) What (other) type of tobacco do you currently smoke or use? RECORD ALL MENTIONED 47 293Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP PROBLEM 2 Getting permission to go? Getting money needed for treatment? The distance to the health facility? Having to take transport? Not wanting to go alone? Concern that there may not be a female health provider? Concern that there may not be any health provider? Concern that there may be no drugs available? 1014 Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not? 1 NOT A BIG PROBLEM BIG 21 21 21 21 21 21 21 48 PERMISSION TO GO GETTING MONEY DISTANCE TAKING TRANSPORT GO ALONE NO FEMALE PROVIDER NO PROVIDER NO DRUGS 294 | Appendix E SECTION 11. BLOOD PRESSURE, DIABETES, HEART ATTACK AND STROKE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1108 Are you taking insulin at this time? YES NO 1 2 1110 1103 Were you told on 2 or more different visits that you had hypertension or high blood pressure? 1 2 8 YES NO DON’T KNOW 1106 (Other than during pregnancy) Has a doctor or other health professional ever told you that you had diabetes? 1 2 8 YES NO DON’T KNOW/NOT SURE 1110 1104 To lower your hypertension or high blood pressure, are you now: YES N/A NO 1 1 1 1 1 2 2 2 2 2 a. taking prescribed medicine? b. controlling your weight or losing weight? c. cutting down on salt in your diet? d. exercising? e. stopping smoking? 3 3 3 3 3 1101 Have you ever heard of an illness called high blood pressure or hypertension? YES NO 1 2 1105 1102 (Other than during pregnancy) Have you ever been told by a doctor or other health professional that you had hypertension or high blood pressure? 1 2 8 YES NO DON’T KNOW 1105 1105 How old were you when you were FIRST told by a doctor or health professional that you had diabetes? 1107 AGE IN COMPLETED YEARS 1109 Are you taking pills to lower your blood sugar? YES NO 1 2 1110 Have you ever been diagnosed by a doctor or other health professional with heart attack or myocardial infarction? YES NO 1 2 1105 Have you ever heard of an illness called diabetes or high sugar? YES NO 1 2 1110 1111 Have you ever been diagnosed by a doctor or other health professional with a stroke? YES NO 1 2 YES NO 1 2 1112 :RECORD THE TIME HOUR MINS 49 TAKE MEDICINE CONTROL WEIGHT CUT DOWN SALT EXERCISE STOP SMOKING 295Appendix E | IINTERVIEWER’S OBSERVATIONS TO BE FILLED IN AFTER COMPLETING INTERVIEW COMMENTS ABOUT RESPONDENT: COMMENTS ON SPECIFIC QUESTIONS: ANY OTHER COMMENTS: SUPERVISOR’S OBSERVATIONS NAME OF SUPERVISOR: DATE: EDITOR’S OBSERVATIONS NAME OF EDITOR: DATE: 50 296 | Appendix E 2 0 0 4 2 0 0 4 CCALENDAR INSTRUCTIONS COL.1 BIRTHS, PREGNANCIES, CONTRACEPTIVE USE B BIRTHS P PREGNANCIES T TERMINATIONS 0 NO METHOD 1 FEMALE STERILIZATION 2 MALE STERILIZATION 3 PILL 4 IUD 5 INJECTABLES 6 IMPLANTS 7 CONDOM 8 DIAPHRAGM 9 FOAM OR JELLY J RHYTHM METHOD K WITHDRAWAL X OTHER (SPECIFY) COL.2 DISCONTINUATION OF CONTRACEPTIVE USE 0 INFREQUENT SEX / HUSBAND AWAY 1 BECAME PREGNANT WHILE USING 2 WANTED TO BECOME PREGNANT 3 HUSBAND DISAPPROVED 4 WANTED MORE EFFECTIVE METHOD 5 HEALTH CONCERNS 6 SIDE EFFECTS 7 LACK OF ACCESS / TOO FAR 8 COST TOO MUCH 9 INCONVENIENT TO USE F FATALISTIC A DIFFICULT TO GET PREGNANT / MENOPAUSAL D MARITAL SEPARATION X OTHER (SPECIFY) Z DON'T KNOW 08 07 06 05 04 03 02 01 AUG JUL JUN MAY APR MAR FEB JAN 2 0 0 9 2 0 0 9 01 02 03 04 05 06 07 08 12 11 10 09 08 07 06 05 04 03 02 01 DEC NOV OCT SEP AUG JUL JUN MAY APR MAR FEB JAN 57 58 59 60 61 62 63 64 65 66 67 68 2 0 0 8 2 0 0 8 12 11 10 09 08 07 06 05 04 03 02 01 DEC NOV OCT SEP AUG JUL JUN MAY APR MAR FEB JAN 09 10 11 12 13 14 15 16 17 18 19 20 2 0 0 7 2 0 0 7 12 11 10 09 08 07 06 05 04 03 02 01 DEC NOV OCT SEP AUG JUL JUN MAY APR MAR FEB JAN 21 22 23 24 25 26 27 28 29 30 31 32 2 0 0 6 2 0 0 6 12 11 10 09 08 07 06 05 04 03 02 01 DEC NOV OCT SEP AUG JUL JUN MAY APR MAR FEB JAN 33 34 35 36 37 38 39 40 41 42 43 44 2 0 0 3 2 0 0 3 12 11 10 09 08 07 06 05 04 03 02 01 DEC NOV OCT SEP AUG JUL JUN MAY APR MAR FEB JAN 69 70 71 72 73 74 75 76 77 78 79 80 2 0 0 5 2 0 0 5 12 11 10 09 08 07 06 05 04 03 02 01 DEC NOV OCT SEP AUG JUL JUN MAY APR MAR FEB JAN 45 46 47 48 49 50 51 52 53 54 55 56 51 297Appendix E | EVER-MARRIED MEN’S QUESTIONNAIRE 1 7 D e c e b e 2 0 0 8 m r INTERVIEWER VISITS HOUSEHOLD NAME NEXT VISIT: Month Day INTERVIEWER'S NAME RESULT* INT. NUMBER RESULT 2 0 0 2 0 0 321 Hr : : DATE DATE TOTAL NUMBER OF VISITS TIME FINAL VISIT NAME ID CODE DATE 2008 MALDIVES DEMOGRAPHIC AND HEALTH SURVEY IDENTIFICATION NAME OF HOUSEHOLD HEAD CLUSTER NUMBER HOUSEHOLD NUMBER ATOLL NAME AND LINE NUMBER OF ELIGIBLE MAN monthday year monthday year Year monthday year 2 0 0 monthday year 2 0 0 monthday year Min Hr Min SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY VERIFIED BY NAME ID CODE ID CODE DATE ID CODE ID CODE 2 0 0 2 0 0 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER_______________________________________ (specify) *RESULT CODES: 1 ISLAND NAME 299Appendix E | Introduction and Consent SECTION 1 : RESPONDENT’S BACKGROUND Hello. My name is _______________________________________ and I am working with the Ministry of Health. We are conducting a national survey that asks women, men and youth about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 15 and 20 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than members of our survey team. Participation in this survey is voluntary, and if we should come to any question you don’t want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important. At this time, do you want to ask me anything about the survey? May I begin the interview now? Signature of interviewer:____________________________ Date: _______________________ RESPONDENT AGREES TO BE INTERVIEWED 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END INFORMED CONSENT NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 102 In what month and year were you born? 101 RECORD THE TIME : HOUR MINUTES 9998 YEAR DON'T KNOW YEAR 98 MONTH DON'T KNOW MONTH 103 How old were you at your last birthday? AGE IN COMPLETED YEARS COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT. 2 1 2 3 4 104 What is your current marital status? MARRIED WIDOWED DIVORCED SEPARATED 105 1 2 Have you ever attended school? YES NO 108 300 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 107 What is the highest (grade/form/year) you completed at that level? GRADE/FORM/YEAR 00 01 02 03 04 05 06 07 08 106 What is the highest level of school you attended? NON-FORMAL EDUCATION PRESCHOOL PRIMARY ‘O’ LEVEL ‘A’ LEVEL DIPLOMA FIRST DEGREE MASTER’S CERTIFICATE/ABOVE CERTIFICATE 3 108 Do you read a newspaper or magazine almost everyday, at least once a week, less than once a week or not at all? 110 1 2 3 4 5 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL CANNOT READ 111 Do you watch television almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 109 Do you use the internet almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 110 Do you listen to the radio almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 301Appendix E | 44 SECTION 2. REPRODUCTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 206 Have you ever fathered a son or a daughter who was born alive but later died? 207 How many boys have died? How many girls have died? IF NO, PROBE: Any baby who cried or showed signs of life but did not survive? 212 1 2 8 YES NO DON’T KNOW 208 1 2 YES NO 210 Did all of the children you have fathered have the same biological mother? 204 1 2 YES NO 202 Do you have any sons or daughters that you have fathered who are now living with you? 203 How many sons live with you? And how many daughters live with you? IF NONE, RECORD ‘00’. SONS AT HOME DAUGHTERS AT HOME 201 Have you ever fathered any children with any woman? Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not living with you now. 1 2 8 YES NO DON’T KNOW 206 IF NONE, RECORD ‘00’. 205 How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? SONS ELSEWHERE DAUGHTERS ELSEWHERE IF NONE, RECORD ‘00’. 209 How many years old is your (youngest) child? 212 HAS HAD MORE THAN ONE CHILD HAS HAD ONLY ONE CHILD 214 CHECK 208: BOYS DEAD GIRLS DEAD AGE IN YEARS 301HAS NOT HAD ANY CHILDREN 206 1 2 YES NO 204 Do you have any sons or daughters that you have fathered who are alive but do not live with you? SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.208 IF NONE, RECORD ‘00’. TOTAL CHILDREN In all, how many women have you fathered children with?211 NUMBER OF WOMEN 215 301(YOUNGEST) CHILD IS AGE 0-3 YEARS (YOUNGEST) CHILD IS 4 YEARS OR OLDER CHECK 214: How old were you when your (first) child was born?212 AGE IN YEARS 213 301AT LEAST ONE LIVING CHILD NO LIVING CHILDREN CHECK 203 AND 205: 302 | Appendix E 55 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 216 What is the name of your (youngest) child? WRITE NAME OF (YOUNGEST) CHILD 1 2 PRESENT NOT PRESENT 218 Were you ever present during any of those antenatal check-ups? (NAME OF (YOUNGEST) CHILD 219 1 2 8 YES NO DON’T KNOW 217 When (NAME)’s mother was pregnant with (NAME), did she have any antenatal check-ups? 2211 2 HOSPITAL/HEALTH FACILITY OTHER 219 Was (NAME) born in a hospital or health facility? 01 02 03 04 05 06 07 08 09 96 98 220 What was the main reason why (NAME)’s mother did not deliver in a hospital or health facility? COST TOO MUCH FACILITY CLOSED TOO FAR/NO TRANSPORTATION DON’T TRUST FACILITY/POOR QUALITY SERVICE NO FEMALE PROVIDER NOT THE FIRST CHILD CHILD’S MOTHER DID NOT THINK IT WAS NECESSARY HE DID NOT THINK IT WAS NECESSARY FAMILY DID NOT THINK IT WAS NECESSARY OTHER DON’T KNOW (SPECIFY) 1 2 3 4 8 221 MORE THAN USUAL ABOUT THE SAME LESS THAN USUAL NOTHING TO DRINK DON’T KNOW When a child has diarrhea, how much should he or she be given to drink: more than usual, the same amount as usual, less than usual, or should he or she not be given anything to drink at all? 303Appendix E | SECTION 3. CONTRACEPTION 302 CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR METHODS 02,07,10 AND 11, ASK 302 IF 301 HAS CODE 1 CIRCLED. Have you ever used (METHOD)? Have you ever heard of (METHOD)? Which ways or methods have you heard about? FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: 301 Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. 07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse. 08 RHYTHM METHOD Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant. 09 WITHDRAWAL Men can be careful and pull out before climax. 10 EMERGENCY CONTRACEPTION As an emergency measure after sexual intercourse, women can take special pills at any time within 5 days to prevent pregnancy. 1 2 YES NO 11 Have you heard of any other ways or methods that women or men can use to avoid pregnancy? 1 2 YES NO 01 FEMALE STERILIZATION Women can have an operation to avoid having any more children. 02 03 PILL Women can take a pill every day to avoid becoming pregnant. 04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse. 05 INJECTABLES Women can have an injection by a health provider that stops them from becoming pregnant for one or more months. 06 IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years. (SPECIFY) (SPECIFY) 1 2 YES NO MALE STERILIZATION Men can have an operation to avoid having any more children. 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO Have you ever had an operation to avoid having any more children? 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 1 2 YES NO 6 304 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 310 Do you know of a place where a person can get condoms? 303 In the last few months have you: Heard about family planning on the radio? Seen about family planning on the television? Read about family planning in a newspaper or magazine? 1 1 1 2 2 2 RADIO TELEVISION NEWSPAPER OR MAGAZINE YES NO 1 2 YES NO 1 2 3 8 YES NO DEPENDS DON’T KNOW 307 Do you think that a woman who is breastfeeding her baby can become pregnant? 306 Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods? 1 2 3 4 6 8 JUST BEFORE HER PERIOD BEGINS DURING HER PERIOD RIGHT AFTER HER PERIOD HAS ENDED HALFWAY BETWEEN TWO PERIODS OTHER DON’T KNOW (SPECIFY) 307 1 2 8 YES NO DON’T KNOW 305 Now I would like to ask you about a woman’s risk of pregnancy. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations? 8 WOMAN MAY BECOME PROMISCUOUS AG- REE DK AGREE DIS- 1 81 308 I will now read you some statements about contraception. Please tell me if you agree or disagree with each one. a) Contraception is women’s business and a man should not have to worry about it. b) Women who use contraception may become promiscuous. CONTRACEPTION WOMAN’S BUSINESS 2 2 309 401YES NO CHECK 301 (07) KNOWS MALE CONDOM 304 In the last few months, have you discussed the practice of family planning with a health worker or health professional? 1 2 YES NO 401 311 Where is that? Any other place? (NAME OF PLACE) (SPECIFY) A B C D E F G PUBLIC SECTOR GOVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER GOVT. HEALTH CENTER L M X OTHER SOURCE SHOP FRIEND/RELATIVE OTHER PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) H I J K PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) 7 305Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 312 If you wanted to, could you yourself get a condom? 1 2 YES NO 8 306 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP SECTION 4. MARRIAGE AND SEXUAL ACTIVITY 1 2 1 2 3 4 ONLY ONCE MORE THAN ONCE 407 Have you been married only once or more than once? 410 CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. 401 407CURRENTLY MARRIED WIDOWED/DIVORCED/SEPARATED CHECK 104: MARITAL STATUS: 1 2 LIVING WITH HIM STAYING ELSEWHERE 402 Is your wife living with you now or is she staying elsewhere? IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER IS GREATER THAN 95, WRITE ‘95’. 98 NUMBER OF PARTNERS IN LIFETIME DON’T KNOW 413 In total, with how many different people have you had sexual intercourse in your lifetime? 408A How old were you when you first started living with her?409 AGE IN YEARS LINE NUMBER 403 RECORD THE WIFE’S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF SHE IS NOT LISTED IN THE HOUSEHOLD, RECORD ‘00’. NAME WEEKS AGO 412 When was the last time you had sexual intercourse? IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS. IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS. 410In what month and year did you start living with your first wife? 9998 YEAR DON'T KNOW YEAR 98 MONTH DON'T KNOW MONTH 408 In what month and year did you start living with your wife? 408A Now I would like to ask a question about your first wife. MONTHS AGO YEARS AGO DAYS AGO How old were you when you had sexual intercourse for the very first time? 95 AGE IN YEARS FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE 411 Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some important life issues. 9 307Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 501 1 2 8 YES NO DON’T KNOW 416 The last time you had sex did you or your wife use any method to avoid or prevent a pregnancy? A B C D E F G H I J X 417 What method did you or your wife use? PROBE: Did you or your wife use any other method to prevent a pregnancy? RECORD ALL MENTIONED. FEMALE STERILIZATION PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD WITHDRAWAL OTHER (SPECIFY) 01 415 501MAN NOT STERILIZED MAN STERILIZED CHECK 302: 414 501CURRENTLY MARRIED WIDOWED/DIVORCED/SEPARATED CHECK 104: MARITAL STATUS: 308 | Appendix E NO. QUESTIONS AND FILTERS SECTION 5. FERTILITY PREFERENCES CODING CATEGORIES SKIP 502 508MAN NOT STERILIZED MAN STERILIZED CHECK 302: 1 2 8 YES NO DON’T KNOW 503 Is your wife (Are any of your wives) currently pregnant? 501 508CURRENTLY MARRIED WIDOWED/DIVORCED/SEPARATED CHECK 104: 508 CHECK 203 AND 205: HAS LIVING CHILDREN NO LIVING CHILDREN If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be? If you could choose exactly the number of children to have in your whole life, how many would that be? PROBE FOR A NUMERIC RESPONSE. (NO) WIFE PREGNANT OR DON’T KNOW WIFE(WIVES) PREGNANT How long would you like to wait from now before the birth of (a/another) child? After the birth of the child you are expecting now, how long would you like to wait before the birth of another child? 1 2 3 4 8 HAVE (A/ANOTHER) CHILD NO MORE/NONE COUPLE INFECUND WIFE (WIVES) STERILIZED UNDECIDED/DON’T KNOW 508 504 CHECK 503: (NO) WIFE PREGNANT OR DON’T KNOW WIFE(WIVES) PREGNANT Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children? Now I have some questions about the future. After the child(ren) you and your wife(wives) are expecting now, would you like to have another child, or would you prefer not to have any more children? 2 993 994 996 998 MONTHS YEARS SOON/NOW COUPLE INFECUND OTHER DON’T KNOW 1 (SPECIFY) (SPECIFY) 506 CHECK 503: 96 NUMBER OTHER NONE 00 601 601 (SPECIFY) 509 How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter? 96 NUMBER OTHER BOYS EITHERGIRLS 11 508 309Appendix E | SECTION 6. EMPLOYMENT AND GENDER ROLES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 6041 2 YES NO 602 Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, or any other such reason? 604 What is your occupation, that is, what kind of work do you mainly do? 611 1 2 YES NO 603 Have you done any work in the last 12 months? 609 611CODE 1 OR 2 CIRCLED OTHER CHECK 607: 6041 2 YES NO 601 Have you done any work in the last seven days? 1 2 3 6 611 1 1 1 1 1 RESPONDENT WIFE (WIVES) RESPONDENT AND WIFE (WIVES) JOINTLY OTHER 607 Are you paid in cash or kind for this work or are you not paid at all? 1 2 3 606 Do you usually work throughout the year, or do you work seasonally, or only once in a while? THROUGHOUT THE YEAR SEASONALLY/PART OF THE YEAR ONCE IN A WHILE 1 2 3 4 CASH ONLY CASH AND KIND IN KIND ONLY NOT PAID 608 611CURRENTLY MARRIED WIDOWED/DIVORCED/SEPARATED CHECK 104: 1 2 3 4 5 605 Do you do this work for government, for a private company, for someone else, for a member of your family, or are you self-employed? FOR GOVERNMENT FOR PRIVATE COMPANY FOR SOMEONE ELSE FOR FAMILY MEMBER SELF-EMPLOYED (SPECIFY) 610 Who usually decides how the money you earn will be used: mainly you, mainly your (wife(wives)), or you and your (wife(wives)) jointly? HUSBAND WIFE BOTH EQUALLY DON’T KNOW/ DEPENDS In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife or both equally: a) Making major household purchases? b) Making purchases for daily household needs? c) Deciding about visits to the wife’s family or relatives? d) Deciding what to do with the money she earns for her work? e) Deciding how many children to have? 2 2 2 2 2 3 3 3 3 3 8 8 8 8 8 a) b) c) d) e) 21 310 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 616 Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to. a) Get angry and reprimand her? b) Refuse to give her money or other means of support? c) Use force and have sex with her even is she doesn’t want to? d) Go ahead and have sex with another woman? YES DEPENDS NO 1 1 1 1 2 2 2 2 GET ANGRY NO SUPPORT USE FORCE SEX WITH OTHER WOMAN 8 8 8 8 612 I will now read you some statements about pregnancy. Please tell me if you agree or disagree with them. a) Childbearing is a woman’s concern and there is no need for the father to get involved. b) It is crucial for the mother’s and child’s health that a woman have assistance from a doctor or nurse at delivery. 1 DOCTOR/NURSE’S AG- REE DK AGREE DIS- 2 1 2 CHILDBEARING WOMAN’S CONCERN 8 8 ASSISTANCE CRUCIAL 615 Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations: If she goes out without telling him? If she neglects the children? If she argues with him? If she refuses to have sex with him? If she burns the food? YES DK NO 1 1 1 1 1 2 2 2 2 2 GOES OUT NEGL. CHILDREN ARGUES REFUSES SEX BURNS FOOD 8 8 8 8 8 DK 31 311Appendix E | SECTION 7. HIV/AIDS and STIs NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 704 710 YES NO 1 2 Do you know of a place where people can go to get tested for the AIDS virus? 712 1 2 8 YES NO DON’T KNOW 702 Can people reduce their chances of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners? 1 2 8 YES NO DON’T KNOW 705 Can people get the AIDS virus by sharing food with a person who has AIDS? 1 2 8 YES NO DON’T KNOW 706 Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all? 1 2 8 YES NO DON’T KNOW 707 Can people get the AIDS virus because of witchcraft or other supernatural means? 1 2 8 YES NO DON’T KNOW 708 Is it possible for a healthy-looking person to have the AIDS virus? 1 2 8 YES NO DON’T KNOW 703 Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex? 1 2 8 YES NO DON’T KNOW 8BREASTFEEDING YES DK NO 2 82DURING PREGNANCY DURING DELIVERY 709 Can the virus that causes AIDS be transmitted from a mother to her baby: During pregnancy? During delivery? By breastfeeding? 1 1 821 Can people get the AIDS virus from mosquito bites? 701 Now I would like to talk about something else. Have you ever heard of an illness called AIDS? YES NO 1 2 716 41 312 | Appendix E 711 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Where is that? Any other place? (NAME OF PLACE) (SPECIFY) A B C D E F G PUBLIC SECTOR GOVT. HEALTH POST GOVT. VCT SITE GOVT. HEALTH CENTER H I J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC/ PRIVATE DOCTOR PHARMACY OTHER PRIVATE MEDICAL PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) (SPECIFY) X OTHER 715A In your opinion, if a male teacher has the AIDS virus but is not sick, should he be allowed to continue teaching in the school? 1 2 8 SHOULD BE ALLOWED SHOULD NOT BE ALLOWED DK/UNSURE/DEPENDS 712 Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person has the AIDS virus? 1 2 8 YES NO DON’T KNOW 713 If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not? 1 2 8 YES, REMAIN A SECRET NO DK/UNSURE/DEPENDS 714 If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household? 1 2 8 YES NO DK/UNSURE/DEPENDS 715 In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school? 1 2 8 SHOULD BE ALLOWED SHOULD NOT BE ALLOWED DK/UNSURE/DEPENDS YES NO 718 1 2 716 CHECK 701: HEARD ABOUT AIDS NOT HEARD ABOUT AIDS Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact? Have you heard about infections that can be transmitted through sexual contact? 51 313Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 719 Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis? 1 2 8 YES NO DON’T KNOW 717 Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact? 1 2 8 YES NO DON’T KNOW 724 Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood? 1 2 8 YES NO DON’T KNOW 720 723HAS HAD AN INFECTION (ANY ‘YES’) HAS NOT HAD AN INFECTION OR DOES NOT KNOW CHECK 717, 718 AND 719: 721 YES NO 1 2 The last time you had (PROBLEM FROM 717 / 718 / 719), did you seek any kind of advice or treatment? 723 722 Where did you go? Any other place? (NAME OF PLACE(S)) (SPECIFY) A B C D E F G PUBLIC SECTOR GOVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER GOVT. HEALTH CENTER L X OTHER SOURCE SHOP OTHER PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) H I J K PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) 718 Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis? 1 2 8 YES NO DON’T KNOW 725 Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women? 1 2 8 YES NO DON’T KNOW 723 Husband and wives do not always agree in everything. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him? 1 2 8 YES NO DON’T KNOW 61 314 | Appendix E SECTION 8. OTHER HEALTH ISSUES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 801 Have you ever heard of an illness called tuberculosis or TB? YES NO 1 2 805 A B C D E F X Z 802 How does tuberculosis spread from one person to another? PROBE: Any other ways? RECORD ALL MENTIONED. THROUGH THE AIR WHEN COUGHING OR SNEEZING THROUGH SHARING UTENSILS THROUGH TOUCHING A PERSON WITH TB THROUGH FOOD THROUGH SEXUAL CONTACT THROUGH MOSQUITO BITES OTHER DON’T KNOW (SPECIFY) 803 Can tuberculosis be cured? 1 2 8 YES NO DON’T KNOW 804 If a member of your family got tuberculosis, would you want it to remain a secret or not? 1 2 8 YES, REMAIN A SECRET NO DK/UNSURE/DEPENDS 806 Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker? IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. NUMBER OF INJECTIONS NONE 00 809 805 Now I would like to ask you some questions relating to health matters. Have you had an injection for any reason in the last 12 months? IF YES: How many injections have you had? IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. NUMBER OF INJECTIONS NONE 00 809 71 315Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 807 The last time you had an injection given to you by a health worker, where did you go to get the injection? (NAME OF PLACE) PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. (SPECIFY) 11 12 13 14 15 16 17 PUBLIC SECTOR GOVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER GOVT. HEALTH CENTER 31 96 OTHER PLACE AT HOME OTHER INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) 21 22 23 24 26 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PRIVATE DOCTOR DENTAL OFFICE/CLINIC PHARMACY OTHER PRIVATE MEDICAL (SPECIFY) 808 Did the person who gave you that injection take the syringe and needle from a new, unopened package? 1 2 8 YES NO DON’T KNOW IF NONE RECORD ‘00’. 98 NUMBER OF DAYS DON’T KNOW / UNSURE 809 On how many days this week, did you walk, run, or engage in other vigorous physical activity for at lease 20 minutes? 812 Do you currently smoke or use any other type of tobacco? YES NO 1 2 901 In the last 24 hours, how many cigarettes did you smoke?811 CIGARETTES 810 Do you currently smoke cigarettes? YES NO 1 2 812 813 A B C D E F X HOOKA BIDI CIGAR PIPE CHEWING TOBACCO SNUFF OTHER (SPECIFY) What (other) type of tobacco do you currently smoke or use? RECORD ALL MENTIONED 81 316 | Appendix E SECTION 9. BLOOD PRESSURE, DIABETES, HEART ATTACK AND STROKE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 908 Are you taking insulin at this time? YES NO 1 2 910 903 Were you told on 2 or more different visits that you had hypertension or high blood pressure? 1 2 8 YES NO DON’T KNOW 906 Has a doctor or other health professional ever told you that you had diabetes? 1 2 8 YES NO DON’T KNOW/UNSURE 910 904 To lower your hypertension or high blood pressure, are you now: a. taking prescribed medicine? b. controlling your weight or losing weight? c. cutting down on salt in your diet? d. exercising? e. stopping smoking? YES DK NO 1 1 1 1 1 2 2 2 2 2 TAKE MEDICINE CONTROL WEIGHT CUT DOWN SALT EXERCISE STOP SMOKING 8 8 8 8 8 901 Have you ever heard of an illness called high blood pressure or hypertension? YES NO 1 2 905 902 Have you ever been told by a doctor or other health professional that you had hypertension or high blood pressure? 1 2 8 YES NO DON’T KNOW 905 How old were you when you were FIRST told by a doctor or health professional that you had diabetes? 907 AGE IN COMPLETED YEARS 909 Are you taking pills to lower you blood sugar? YES NO 1 2 910 Have you ever been diagnosed by a doctor or other health professional with heart attack or myocardial infarction? YES NO 1 2 905 Have you ever heard of an illness called diabetes or high sugar? YES NO 1 2 910 911 Have you ever been diagnosed by a doctor or other health professional with a stroke? YES NO 1 2 905 Have you ever heard of an illness called diabetes or high sugar? YES NO 1 2 910 912 :RECORD THE TIME HOUR MINS 91 905 317Appendix E | IINTERVIEWER’S OBSERVATIONS TO BE FILLED IN AFTER COMPLETING INTERVIEW COMMENTS ABOUT RESPONDENT: COMMENTS ON SPECIFIC QUESTIONS: ANY OTHER COMMENTS: SUPERVISOR’S OBSERVATIONS NAME OF SUPERVISOR: DATE: EDITOR’S OBSERVATIONS NAME OF EDITOR: DATE: 02 318 | Appendix E YOUTH AND YOUNG ADULT QUESTIONNAIRE 2 1 7 D e c e m b e r 0 0 8 INTERVIEWER VISITS HOUSEHOLD NAME NEXT VISIT: Month Day INTERVIEWER'S NAME RESULT* INT. NUMBER RESULT 2 0 0 2 0 0 321 Hr : : DATE DATE TOTAL NUMBER OF VISITS TIME FINAL VISIT NAME ID CODE DATE 2008 MALDIVES DEMOGRAPHIC AND HEALTH SURVEY IDENTIFICATION NAME OF HOUSEHOLD HEAD CLUSTER NUMBER HOUSEHOLD NUMBER ATOLL NAME AND LINE NUMBER OF ELIGIBLE YOUTH/YOUNG ADULT monthday year monthday year Year monthday year 2 0 0 monthday year 2 0 0 monthday year Min Hr Min SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY VERIFIED BY NAME ID CODE ID CODE DATE ID CODE ID CODE SEX OF RESPONDENT: 1. MALE 2. FEMALE 2 0 0 2 0 0 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER_______________________________________ (specify) *RESULT CODES: 1 ISLAND NAME 319Appendix E | Introduction and Consent SECTION 1 : RESPONDENT’S BACKGROUND Hello. My name is _______________________________________ and I am working with the Ministry of Health. We are conducting a national survey that asks women, men and youth about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 15 and 20 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than the members of our survey team. Participation in this survey is voluntary, and if we should come to any question you don’t want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important. At this time, do you want to ask me anything about the survey? May I begin the interview now? Signature of interviewer:____________________________ Date: _______________________ RESPONDENT AGREES TO BE INTERVIEWED 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END INFORMED CONSENT NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 102 In what month and year were you born? 101 RECORD THE TIME : HOUR MINUTES 9998 YEAR DON'T KNOW YEAR 98 MONTH DON'T KNOW MONTH 103 How old were you at your last birthday? AGE IN COMPLETED YEARS COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT. 104 1 2 Have you ever attended school? YES NO 108 2 320 | Appendix E 01 02 03 04 05 06 07 08 96 108 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP What is the main reason you are not currently attending school? GRADUATED AND DID NOT NEED ADDITIONAL SCHOOLING DID NOT PASS EXAMS DID NOT LIKE SCHOOL/DID NOT WANT TO CONTINUE CARING FOR SIBLINGS/OTHER FAMILY MEMBERS HELP WITH FAMILY BUSINESS NEEDED TO EARN MONEY SCHOOL NOT ACCESSIBLE/TOO FAR COULD NOT PAY SCHOOL FEES OTHER 110 1 2 Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, or any other such reason? YES NO 112 1 2 3 4 5 114 Do you do this work for government, for a private company, for someone else, for a member of your family, or are you self-employed? FOR GOVERNMENT FOR PRIVATE COMPANY FOR SOMEONE ELSE FOR FAMILY MEMBER SELF-EMPLOYED (SPECIFY) 107 1 2 Are you currently attending school? YES NO 109 112 1 2 Have you done any work in the last 12 months? YES NO 120 111A 106 What is the highest (grade/form/year) you completed at that level? GRADE/FORM/YEAR 113 What is your occupation, that is, what kind of work do you mainly do? 109 1 2 Have you done any work in the last seven days? YES NO 111 111A How many hours do you usually work during a week? HOURS WORKED111 During the past seven days, about how many hours did you work? 9595 HOURS OR MORE 113 3 00 01 02 03 04 05 06 07 08 105 What is the highest level of school you attended? NON-FORMAL EDUCATION PRESCHOOL PRIMARY ‘O’ LEVEL ‘A’ LEVEL DIPLOMA FIRST DEGREE MASTER’S CERTIFICATE/ABOVE CERTIFICATE 321Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 125 1 2 Do you watch television almost every day, at least once a week, less than once a week or not at all? YES NO 120 During this past week did you help with household chores such as house cleaning, washing, shopping, caring for children, or fetching water? 1 2 3 4 117 Are you paid in cash or kind for this work or are you not paid at all? ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 1 2 3 115 Do you usually work throughout the year, or do you work seasonally, or only once in a while? THROUGHOUT THE YEAR SEASONALLY/PART OF THE YEAR ONCE IN A WHILE 120 1 2 3 4 CASH ONLY CASH AND KIND IN KIND ONLY NOT PAID 1 2 HELP WITH HOUSEHOLD EXPENSES KEEP ALL 120 118 Do you use the money you earn to help with household expenses or do you keep all of it? HOURS WORKED121 During the past seven days, about how many hours did you spend helping with household chores? 9595 HOURS OR MORE 119 About how much of the money that you earn do you give for household expenses, less than half, about half, more than half, nearly all or all? 1 2 3 4 LESS THAN HALF ABOUT HALF MORE THAN HALF NEARLY ALL/ALL 122 122 Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all? 124 1 2 3 4 5 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL CANNOT READ 123 Do you use the internet almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 124 Do you listen to the radio almost every day, at least once a week, less than once a week or not at all? 1 2 3 4 ALMOST EVERY DAY AT LEAST ONCE A WEEK LESS THAN ONCE A WEEK NOT AT ALL 4 322 | Appendix E NO. QUESTIONS AND FILTERS SECTION 2. KNOWLEDGE OF REPRODUCTIVE HEALTH ISSUES CODING CATEGORIES SKIP 202 Now I would like to talk about some issues relating to reproductive health. 204ATTENDED SCHOOL NEVER ATTENDED SCHOOL 201 CHECK 104: EVER ATTENDED SCHOOL 1 2 YES NO 204 Do you think that young people should be taught about human reproduction and sexuality in school? 1 2 8 YES NO DON’T KNOW 209 Do you think a girl can become pregnant the first time that she ever has sexual intercourse? 206 205 At what age do you think youth should first be taught about human reproduction and sexuality in school? AGE 207 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 Have you ever talked about anything relating to human reproduction and sexuality with any of the following persons: Mother? Father? Brother? Sister? Male Friend? Female Friend? Boyfriend / Girlfriend? Female Teacher? Male Teacher? Health Provider? YES NO 206 1 1 1 1 2 2 2 2 Have you ever seen or heard about anything relating to human reproduction and sexuality on: Television? Radio? Newspaper/Magazine? Internet? YES NO 1 2 YES NO 203 Were you ever taught about human reproduction and sexuality in school? 1 2 8 YES NO DON’T KNOW 210 From one menstrual period to the next, are there certain days when a women is more likely to become pregnant if she has sexual relations? Now I would like to ask you about a woman’s risk of pregnancy. 1 2 8 YES NO DON’T KNOW 208 Do you think that health providers should be more active in providing youth with information about human reproduction? 212 211 Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods? 1 2 3 4 6 8 JUST BEFORE HER PERIOD BEGINS DURING HER PERIOD RIGHT AFTER HER PERIOD HAS ENDED HALFWAY BETWEEN TWO PERIODS OTHER DON’T KNOW (SPECIFY) 5 MOTHER FATHER BROTHER SISTER MALE FRIEND FEMALE FRIEND BOYFRIEND/GIRLFRIEND FEMALE TEACHER MALE TEACHER HEALTH PROVIDER TELEVISION RADIO NEWSPAPER/MAGAZINE INTERNET 323Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Do you know about family planning, that is, the various ways or methods that a couple can use to delay or avoid a pregnancy. Which ways or methods have you heard about? 212 FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)? CIRCLE CODE 1 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. 1 2 YES NO 07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse. 1 2 YES NO 08 RHYTHM METHOD Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant. 1 2 YES NO 09 WITHDRAWAL Men can be careful and pull out before climax. 1 2 YES NO 10 EMERGENCY CONTRACEPTION As an emergency measure after sexual intercourse, women can take special pills at any time within 5 days to prevent pregnancy. 1 2 YES NO 11 Have you heard of any other ways or methods that women or men can use to avoid pregnancy? 1 2 YES NO 01 FEMALE STERILIZATION Women can have an operation to avoid having any more children. 1 2 YES NO 02 MALE STERILIZATION Men can have an operation to avoid having any more children. 1 2 YES NO 03 PILL Women can take a pill every day to avoid becoming pregnant. 1 2 YES NO 04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse. 1 2 YES NO 05 INJECTABLES Women can have an injection by a health provider that stops them from becoming pregnant for one or more months. 1 2 YES NO 06 IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years. (SPECIFY) (SPECIFY) 213 Would you say that using contraception should mainly be the woman’s decision, mainly the man’s decision, or they should both decide together? 1 2 3 6 MAINLY WOMAN MAINLY MAN JOINT DECISION OTHER (SPECIFY) 214 301KNOWS ONE OR MORE FAMILY PLANNING METHODS DOES NOT KNOW ANY FAMILY PLANNING METHOD CHECK 212: 6 324 | Appendix E 01 02 03 04 05 06 07 08 09 10 11 96 98 216 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP If a couple wants to plan their family what contraceptive do you think is best for a couple to use? FEMALE STERILIZATION MALE STERILIZATION PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD WITHDRAWAL OTHER UNSURE 301 (SPECIFY) 301 1 2 3 8 215 Contraceptive services should be available to unmarried couples. AGREE DISAGREE IT DEPENDS DON’T KNOW Please tell me if you agree or disagree with the following statement. 1 2 8 YES NO DON’T KNOW 218 What is the main reason that you think you will not use a contraceptive method at any time in the future? 22 23 24 26 51 52 53 54 55 41 42 FERTILITY-RELATED REASONS INFREQUENT SEX/NO SEX MENOPAUSAL/HYSTERECTOMY SUBFECUND/INFECUND METHOD-RELATED REASONS LACK OF KNOWLEDGE KNOWS NO METHOD KNOWS NO SOURCE WANTS AS MANY CHILDREN AS POSSIBLE HEALTH CONCERNS FEAR OR SIDE EFFECTS LACK OF ACCESS/TOO FAR COSTS TOO MUCH INCONVENIENT TO USE INTERFERES WITH BODY’S NORMAL PROCESSES 217 Do you think you will use a contraceptive method to delay or avoid pregnancy at any time after you are married if your (wife/husband) agrees? 31 32 33 34 OPPOSITION TO USE RESPONDENT OPPOSED HUSBAND MAY OPPOSE OTHERS OPPOSED RELIGIOUS PROHIBITION 56 98 7 DON’T KNOW (SPECIFY) 96OTHER 325Appendix E | SECTION 3. ATTITUDES ABOUT MARRIAGE AND CHILDBEARING NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 302 In your opinion, what is the best age for a boy to marry? IDEAL AGE FOR A BOY TO MARRY 98DON’T KNOW 301 In your opinion, what is the best age for a girl to marry? Now I am going to ask some questions about marriage and childbearing. IDEAL AGE FOR A GIRL TO MARRY 98DON’T KNOW 1 2 3 6 308 MAINLY HUSBAND MAINLY WIFE JOINT DECISION OTHER How long do you think a woman should wait after one birth before she has another birth? (SPECIFY) 00 305 How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter? PROBE FOR A NUMERIC RESPONSE. NONE NUMBER OTHER 96 (SPECIFY) 306 306304 If you could choose exactly the number of children to have in your whole life, how many would that be? 96 NUMBER OTHER (SPECIFY) BOYS EITHERGIRLS 1 2 3 6 303 MAINLY PARENTS MAINLY RESPONDENT JOINT DECISION WITH PARENT OTHER Who is going to choose the person you will marry, your parents, yourself, or will you decide together with your parents? (SPECIFY) 2 8DELAY FIRST BIRTH 306 Who do you think should mainly decide how many children a couple should have, the husband, the wife, or both together? MONTHS YEARS AG- REE DK AGREE DIS- 1 1 81 307 Please tell me if you agree or disagree with the following: Before they marry, a couple should date and spend some time alone together so they get to know each other well. After a couple marries, they should delay having their first child for at least one year. DATE/SPEND TIME ALONE TOGETHER 8 2 2 DON’T KNOW 98 326 | Appendix E NO. QUESTIONS AND FILTERS SECTION 4. SEXUAL ACTIVITY CODING CATEGORIES SKIP 401 501AGE 18 YEARS AND OLDER AGE 15 - 17 YEARS CHECK 103: Now I am going to ask you some questions about sexual relationships. Some of the questions will be personal. However, we promise that we will keep your answers confidential. Your responses will help us in understanding the situation of youth today in the Maldives and in planning youth health programs. Again your participation is voluntary. If we should come to any question you don’t want to answer, just let me know and I will go on to the next question. 402 CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. 407 1 2 3 4 The last time you had sexual intercourse, did you or your partner use anything to prevent pregnancy? YES NO 411 406 When did you last have sexual intercourse? DAYS AGO WEEKS AGO MONTHS AGO YEARS AGO 404 How old were you when you had sexual intercourse for the very first time? AGE IN YEARS 405 With how many different persons have you ever had sexual intercourse? TOTAL NUMBER OF SEXUAL PARTNERS 1 2 403 Have you ever had sexual intercourse? YES NO 411 1 2 03 04 05 06 07 08 09 10 11 96 98 408 What method did you use? PILL IUD INJECTABLES IMPLANTS CONDOM DIAPHRAGM FOAM/JELLY RHYTHM METHOD WITHDRAWAL OTHER UNSURE (SPECIFY) 409 Sometimes a woman becomes pregnant when she does not want to be. FEMALE MALE In the past, have you ever become pregnant when you did not want to be? In the past, has a woman with whom you were having sex ever become pregnant when you did not want her to be? YES NO 409 1 2 410 What happened with the (last such) pregnancy? 1 2 3 8 PREGNANCY CONTINUED HAD ABORTION HAD MISCARRIAGE DON’T KNOW 9 327Appendix E | 1 8 MEN WANT WIVES TO BE VIRGINS AG- REE DK AGREE DIS- 1 82 412 Do you agree or disagree with the following statements: It is becoming more common in the Maldives for couples to initiate sexual intercourse before marriage. Men still want their wives to be virgins at the time they marry. SEX BEFORE MARRIAGE MORE COMMON 2 411 Have any of your unmarried friends told you that they have initiated sexual activity? YES NO 1 2 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 01 328 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 504 SECTION 5. HIV/AIDS 510 YES NO 1 2 Do you know of a place where people can go to get tested for the AIDS virus? 512 1 2 8 YES NO DON’T KNOW 502 Can people reduce their chances of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners? 1 2 8 YES NO DON’T KNOW 505 Can people get the AIDS virus by sharing food with a person who has AIDS? 1 2 8 YES NO DON’T KNOW 506 Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all? 1 2 8 YES NO DON’T KNOW 507 Can people get the AIDS virus because of witchcraft or other supernatural means? 1 2 8 YES NO DON’T KNOW 508 Is it possible for a healthy-looking person to have the AIDS virus? 1 2 8 YES NO DON’T KNOW 503 Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex? 1 2 8 YES NO DON’T KNOW 8BREASTFEEDING YES DK NO 2 82DURING PREGNANCY DURING DELIVERY 509 Can the virus that causes AIDS be transmitted from a mother to her baby: During pregnancy? During delivery? By breastfeeding? 1 1 821 Can people get the AIDS virus from mosquito bites? 501 Have you ever heard of an illness called AIDS? YES NO 1 2 Now I would like to talk about something else. 517 11 329Appendix E | 511 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Where is that? Any other place? (NAME OF PLACE) (SPECIFY) A B C D E F G PUBLIC SECTOR GOVT. HEALTH POST GOVT. VCT SITE GOVT. HEALTH CENTER H I J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC/ PRIVATE DOCTOR PHARMACY OTHER PRIVATE MEDICAL PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) (SPECIFY) X OTHER 516 In your opinion, if a male teacher has the AIDS virus but is not sick, should he be allowed to continue teaching in the school? 1 2 8 SHOULD BE ALLOWED SHOULD NOT BE ALLOWED DK/UNSURE/DEPENDS 512 Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus? 1 2 8 YES NO DON’T KNOW 513 If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not? 1 2 8 YES, REMAIN A SECRET NO DK/UNSURE/DEPENDS 514 If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household? 1 2 8 YES NO DK/UNSURE/DEPENDS 515 In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school? 1 2 8 SHOULD BE ALLOWED SHOULD NOT BE ALLOWED DK/UNSURE/DEPENDS YES NO 601 1 2 517 CHECK 501: HEARD ABOUT AIDS NOT HEARD ABOUT AIDS Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact? Have you heard about infections that can be transmitted through sexual contact? 21 330 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 520 If a woman has a sexually transmitted disease, what symptoms might she have? RECORD ALL MENTIONED. A B C D E F G H I J K X ABDOMINAL PAIN GENITAL DISCHARGE/DRIPPING FOUL SMELLING DISCHARGE BURNING ON URINATION REDNESS/INFLAMMATION IN THE GENITAL AREA SWELLING IN THE GENITAL AREA GENITAL SORES/ULCERS GENITAL WARTS GENITAL ITCHING BLOOD IN URINE LOSS OF WEIGHT OTHER NO SYMPTOM Y 518 What other sexually transmitted diseases have you heard about? RECORD ALL MENTIONED. DON’T KNOW A B C D X SYPHILIS GONORRHEA HEPATITIS B HERPES SIMPLEX (HSV-2) OTHER (SPECIFY) (SPECIFY) Y Z DON’T KNOW/REMEMBER THE NAME DON’T KNOW 519 If a man has a sexually transmitted disease, what symptoms might he have? RECORD ALL MENTIONED. A B C D E F G H I J K X ABDOMINAL PAIN GENITAL DISCHARGE/DRIPPING FOUL SMELLING DISCHARGE BURNING ON URINATION REDNESS/INFLAMMATION IN THE GENITAL AREA SWELLING IN THE GENITAL AREA GENITAL SORES/ULCERS GENITAL WARTS GENITAL ITCHING BLOOD IN URINE LOSS OF WEIGHT OTHER NO SYMPTOM Y DON’T KNOW (SPECIFY) 521 YES NO 1 2 Do you know where a person can go to get treatment if they think they have a sexually transmitted disease? 601 31 Z Z 331Appendix E | 522 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Where can they go? Any other place? (NAME OF PLACE) (SPECIFY) A B C D E F G PUBLIC SECTOR GOVT. HEALTH POST COMMUNITY/FAMILY HEALTH WORKER GOVT. HEALTH CENTER L X OTHER SOURCE SHOP OTHER PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. INDHIRA GANDHI MEMORIAL HOSPITAL GOVT. REGIONAL HOSPITAL GOVT. ATOLL HOSPITAL OTHER PUBLIC (SPECIFY) H I J K PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC PHARMACY PRIVATE DOCTOR OTHER PRIVATE MEDICAL (SPECIFY) 41 332 | Appendix E NO. QUESTIONS AND FILTERS SECTION 6. SMOKING, DRINKING AND DRUGS CODING CATEGORIES SKIP 605 608 In the last month, how many days did you drink an alcohol-containing beverage? NUMBER OF DAYS 1 2 YES NO 601 Do you currently smoke cigarettes? 610 RECORD ‘00’ IF DID NOT USE DRUGS DURING LAST THREE MONTHS A B C D X SMOKED INHALED INJECTED DRUNK/SWALLOWED OTHER (SPECIFY) 609B YES NO 1 2 Have you ever used any other drugs that can be used to get high? In what ways have you ingested heroin or other drugs? Now I am going to ask you some questions about other behaviors in which youth sometimes engage. Your response will help us in understanding the situation of youth today in the Maldives and in planning youth health programs. Again your participation is voluntary. We promise to keep your answers confidential. If we should come to any question you don’t want to answer, just let me know and I will go on to the next question. 605 CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. 603 YES NO 1 2 Do you currently smoke or use any other type of tobacco? 605 602 In the last 24 hours, how many cigarettes did you smoke? CIGARETTES 611 How old were you when you first ingested any drugs that are used to get high? AGE RECORD ALL MENTIONED 606 YES NO 1 2 Have you ever drunk an alcohol-containing beverage? 609A 613 609A YES NO 1 2 There are other drugs like heroin that are used to get ‘high’. Have you ever used heroin? 609C 613USED HEROIN / OTHER DRUGS NEVER USED DRUGS CHECK 609A AND 609B: 604 A B C D E F X HOOKA BIDI CIGAR PIPE CHEWING TOBACCO SNUFF OTHER (SPECIFY) What (other) type of tobacco do you currently smoke or use? RECORD ALL MENTIONED 607 How old were you when you first drank an alcohol-containing beverage? AGE 612 In the last 3 months, on how many days did you use drugs? 000DID NOT USE DRUGS NUMBER OF DAYS RECORD ‘00’ IF DID NOT DRINK DURING LAST MONTH. 51 333Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP RECORD ‘00’ IF DID NOT USE DRUGS DURING LAST THREE MONTHS WITH ANYONE. 612A In the last 3 months, on how many occasions did you use drugs together with a family member, friend or someone else? 000ALWAYS USED ALONE NUMBER OF OCCASIONS 1 2 8 615 Drugs are easily available to young people in your school. AGREE DISAGREE DON’T KNOW Do you agree or disagree that: 614 616ATTENDING SCHOOL NOT IN SCHOOL CHECK 107: CURRENTLY ATTENDING SCHOOL 1 2 8 613 Drugs are easily available to young people in this community. AGREE DISAGREE DON’T KNOW Please tell me if you agree or disagree with the following statement. 616 What are the reasons that youth in the Maldives are using drugs? RECORD ALL MENTIONED. A B C D E X UNEMPLOYED/NOT IN SCHOOL BORED INFLUENCED BY PEERS INFLUENCED BY MEDIA NOT SUPERVISED BY PARENTS OTHER ZDON’T KNOW (SPECIFY) 617 :RECORD THE TIME HOUR MINS 61 334 | Appendix E IINTERVIEWER’S OBSERVATIONS TO BE FILLED IN AFTER COMPLETING INTERVIEW COMMENTS ABOUT RESPONDENT: COMMENTS ON SPECIFIC QUESTIONS: ANY OTHER COMMENTS: SUPERVISOR’S OBSERVATIONS NAME OF SUPERVISOR: DATE: EDITOR’S OBSERVATIONS NAME OF EDITOR: DATE: 71 335Appendix E | Appendix F | 337 ESTIMATES OF SAMPLING ERRORS FOR SELECTED VARIABLES AT ATOLL-LEVEL Appendix F Sampling errors for the 2009 MDHS are calculated for selected variables considered to be of primary interest. The results are presented in the national report for the country as a whole, for urban and rural areas, for the three geographical regions, and for each of the 6 geographical/administrative regions. This report presents sampling errors for selected variables for each of the atolls. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table F,0. The estimates from a sample survey are affected by two types of errors: non-sampling errors and sampling errors. Non-sampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the Maldives Demographic and Health Survey 2009 (2009 MDHS) to minimize this type of error, non-sampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2009 MDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2009 MDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2009 MDHS is a Macro SAS procedure. This procedure used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = = ⎥⎦ ⎤⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ − − − == H h h h m i hi h h m zz m m x frvarrSE h 1 2 1 2 2 2 1 1)()( 338 | Appendix F in which hihihi rxyz −= , and hhh rxyz −= where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2009 MDHS, there were 270 non-empty clusters. Hence, 270 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − = ∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 270 clusters, r(i) is the estimate computed from the reduced sample of 269 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, the design effect (DEFT) for each estimate is calculated, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. The relative standard error and confidence limits for the estimates are also calculated. Tables F.1 through F.21 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). The confidence interval (e.g., as calculated for Fully immunized, Haa Dhaal atoll, can be interpreted as follows: the overall percent from the Haa Dhaal sample is 89.5 and its standard error is 0.037. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 89.5±2×0.037. There is a high probability (95 percent) that the true proportion of children fully immunized in Haa Dhaal is between 82.1 percent and 96.9 percent. For the total sample, the value of the DEFT, averaged over all variables, is 1.276. This means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.276 over that in an equivalent simple random sample. Appendix F | 339 Table F.0 List of selected variables for sampling errors, atoll-level data, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Variable Estimate Base population –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education Proportion Ever-married women 15-49 Secondary education or higher Proportion Ever-married women 15-49 Currently married Proportion All women 15-49 Married before age 20 Proportion All women 20-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Knows any contraceptive method Proportion Currently married women 15-49 Knows a modern method Proportion Currently married women 15-49 Ever used any contraceptive method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Mothers protected against tetanus for last birth Proportion Women with a live birth in past five years Fully immunized Proportion Children 12-23 months Has heard about HIV/AIDS Proportion Ever-married women 15-49 Knows about condoms to prevent HIV/AIDS Proportion Ever-married women 15-49 Knows about limiting partners to prevent HIV/AIDS Proportion Ever-married women 15-49 Comprehensive knowledge on HIV transmission Proportion Ever-married women 15-49 Table F.1 Sampling errors for Male sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.122 0.009 1041 2368 0.928 0.077 0.103 0.141 Secondary education or higher 0.581 0.017 1041 2368 1.123 0.030 0.547 0.616 Currently married 0.551 0.078 1717 3851 0.925 0.142 0.394 0.708 Married before age 20 0.394 0.016 1313 2961 1.140 0.041 0.362 0.426 Currently pregnant 0.036 0.007 1717 3851 0.947 0.187 0.022 0.049 Children ever born 1.335 0.192 1717 3851 0.915 0.144 0.950 1.720 Children surviving 1.283 0.185 1717 3851 0.913 0.144 0.914 1.653 Knows any contraceptive method 0.994 0.003 935 2122 1.089 0.003 0.989 1.000 Knows a modern method 0.993 0.003 935 2122 1.055 0.003 0.988 0.999 Ever used any contraceptive method 0.567 0.022 935 2122 1.357 0.039 0.523 0.611 Currently using any method 0.336 0.017 935 2122 1.088 0.050 0.303 0.370 Currently using a modern method 0.256 0.015 935 2122 1.039 0.058 0.227 0.286 Mothers protected against tetanus for last birth 0.844 0.019 423 964 1.053 0.022 0.807 0.881 Fully immunized 0.914 0.029 108 243 0.983 0.032 0.856 0.973 Heard about HIV/AIDS 0.975 0.005 1041 2368 1.053 0.005 0.965 0.985 Knows about condoms to prevent HIV/AIDS 0.824 0.012 1041 2368 1.052 0.015 0.800 0.849 Knows about limiting partners 0.929 0.010 1041 2368 1.287 0.011 0.909 0.950 Comprehensive knowledge on HIV transmission 0.508 0.020 1041 2368 1.264 0.039 0.469 0.547 Table F.2 Sampling errors for Haa Alif sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.122 0.009 1041 2368 0.928 0.077 0.103 0.141 Secondary education or higher 0.581 0.017 1041 2368 1.123 0.030 0.547 0.616 Currently married 0.551 0.078 1717 3851 0.925 0.142 0.394 0.708 Married before age 20 0.394 0.016 1313 2961 1.140 0.041 0.362 0.426 Currently pregnant 0.036 0.007 1717 3851 0.947 0.187 0.022 0.049 Children ever born 1.335 0.192 1717 3851 0.915 0.144 0.950 1.720 Children surviving 1.283 0.185 1717 3851 0.913 0.144 0.914 1.653 Knows any contraceptive method 0.994 0.003 935 2122 1.089 0.003 0.989 1.000 Knows a modern method 0.993 0.003 935 2122 1.055 0.003 0.988 0.999 Ever used any contraceptive method 0.567 0.022 935 2122 1.357 0.039 0.523 0.611 Currently using any method 0.336 0.017 935 2122 1.088 0.050 0.303 0.370 Currently using a modern method 0.256 0.015 935 2122 1.039 0.058 0.227 0.286 Mothers protected against tetanus for last birth 0.844 0.019 423 964 1.053 0.022 0.807 0.881 Fully immunized 0.914 0.029 108 243 0.983 0.032 0.856 0.973 Heard about HIV/AIDS 0.975 0.005 1041 2368 1.053 0.005 0.965 0.985 Knows about condoms to prevent HIV/AIDS 0.824 0.012 1041 2368 1.052 0.015 0.800 0.849 Knows about limiting partners 0.929 0.010 1041 2368 1.287 0.011 0.909 0.950 Comprehensive knowledge on HIV transmission 0.508 0.020 1041 2368 1.264 0.039 0.469 0.547 340 | Appendix F Table F.3 Sampling errors for Haa Dhaal sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.320 0.035 315 440 1.316 0.108 0.250 0.389 Secondary education or higher 0.297 0.048 315 440 1.842 0.160 0.202 0.393 Currently married 0.593 0.110 503 699 1.020 0.186 0.372 0.813 Married before age 20 0.534 0.036 364 508 1.369 0.067 0.462 0.606 Currently pregnant 0.052 0.016 503 699 1.172 0.308 0.020 0.084 Children ever born 1.809 0.332 503 699 0.946 0.184 1.145 2.473 Children surviving 1.719 0.319 503 699 0.959 0.186 1.080 2.358 Knows any contraceptive method 0.990 0.005 296 414 0.964 0.006 0.980 1.001 Knows a modern method 0.990 0.005 296 414 0.964 0.006 0.980 1.001 Ever used any contraceptive method 0.648 0.049 296 414 1.758 0.076 0.549 0.746 Currently using any method 0.413 0.050 296 414 1.723 0.120 0.314 0.513 Currently using a modern method 0.285 0.049 296 414 1.847 0.171 0.188 0.383 Mothers protected against tetanus for last birth 0.879 0.033 150 210 1.234 0.037 0.813 0.945 Fully immunized 0.895 0.037 47 66 0.829 0.041 0.821 0.969 Heard about HIV/AIDS 0.959 0.019 315 440 1.670 0.019 0.922 0.997 Knows about condoms to prevent HIV/AIDS 0.784 0.033 315 440 1.413 0.042 0.718 0.850 Knows about limiting partners 0.907 0.022 315 440 1.350 0.024 0.863 0.951 Comprehensive knowledge on HIV transmission 0.371 0.038 315 440 1.406 0.104 0.294 0.447 Table F.4 Sampling errors for Shaviyani sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.269 0.025 338 300 1.027 0.092 0.219 0.318 Secondary education or higher 0.324 0.032 338 300 1.264 0.100 0.260 0.389 Currently married 0.668 0.077 490 437 0.992 0.115 0.515 0.821 Married before age 20 0.477 0.050 387 347 1.067 0.104 0.378 0.576 Currently pregnant 0.066 0.015 490 437 1.161 0.226 0.036 0.096 Children ever born 1.851 0.271 490 437 1.105 0.146 1.309 2.393 Children surviving 1.714 0.245 490 437 1.083 0.143 1.224 2.204 Knows any contraceptive method 0.994 0.006 329 292 1.374 0.006 0.983 1.006 Knows a modern method 0.994 0.006 329 292 1.374 0.006 0.983 1.006 Ever used any contraceptive method 0.649 0.035 329 292 1.323 0.054 0.579 0.719 Currently using any method 0.332 0.026 329 292 1.003 0.079 0.280 0.384 Currently using a modern method 0.286 0.037 329 292 1.462 0.128 0.213 0.360 Mothers protected against tetanus for last birth 0.720 0.044 166 147 1.246 0.061 0.633 0.808 Fully immunized 0.958 0.026 49 44 0.899 0.027 0.907 1.009 Heard about HIV/AIDS 0.959 0.014 338 300 1.298 0.015 0.930 0.987 Knows about condoms to prevent HIV/AIDS 0.740 0.020 338 300 0.855 0.028 0.699 0.781 Knows about limiting partners 0.913 0.017 338 300 1.090 0.018 0.880 0.947 Comprehensive knowledge on HIV transmission 0.352 0.021 338 300 0.813 0.060 0.310 0.395 Table F.5 Sampling errors for Noonu sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.312 0.023 325 286 0.895 0.074 0.266 0.358 Secondary education or higher 0.319 0.036 325 286 1.405 0.114 0.246 0.392 Currently married 0.714 0.044 423 375 0.822 0.061 0.627 0.801 Married before age 20 0.590 0.035 347 305 1.366 0.059 0.521 0.660 Currently pregnant 0.042 0.008 423 375 0.778 0.188 0.026 0.058 Children ever born 2.083 0.122 423 375 0.610 0.059 1.840 2.327 Children surviving 1.971 0.104 423 375 0.552 0.053 1.763 2.179 Knows any contraceptive method 0.997 0.003 304 268 1.022 0.003 0.990 1.003 Knows a modern method 0.997 0.003 304 268 1.022 0.003 0.990 1.003 Ever used any contraceptive method 0.676 0.044 304 268 1.647 0.066 0.587 0.765 Currently using any method 0.434 0.034 304 268 1.185 0.078 0.367 0.502 Currently using a modern method 0.333 0.027 304 268 0.999 0.081 0.279 0.388 Mothers protected against tetanus for last birth 0.849 0.035 151 133 1.203 0.041 0.779 0.919 Fully immunized 1.000 0.000 35 31 na 0.000 1.000 1.000 Heard about HIV/AIDS 0.991 0.005 325 286 0.908 0.005 0.981 1.000 Knows about condoms to prevent HIV/AIDS 0.672 0.043 325 286 1.635 0.064 0.587 0.758 Knows about limiting partners 0.966 0.010 325 286 0.992 0.010 0.946 0.986 Comprehensive knowledge on HIV transmission 0.317 0.036 325 286 1.385 0.113 0.245 0.389 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix F | 341 Table F.6 Sampling errors for Raa sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.376 0.031 341 334 1.187 0.083 0.314 0.439 Secondary education or higher 0.285 0.026 341 334 1.049 0.090 0.234 0.337 Currently married 0.611 0.090 509 511 1.031 0.148 0.431 0.792 Married before age 20 0.525 0.025 392 384 0.965 0.047 0.475 0.574 Currently pregnant 0.071 0.013 509 511 0.850 0.180 0.045 0.096 Children ever born 2.148 0.302 509 511 0.917 0.141 1.544 2.753 Children surviving 1.991 0.274 509 511 0.897 0.138 1.444 2.539 Knows any contraceptive method 0.997 0.004 319 313 1.068 0.004 0.989 1.004 Knows a modern method 0.997 0.004 319 313 1.068 0.004 0.989 1.004 Ever used any contraceptive method 0.648 0.038 319 313 1.433 0.059 0.571 0.725 Currently using any method 0.378 0.033 319 313 1.231 0.089 0.311 0.445 Currently using a modern method 0.242 0.033 319 313 1.384 0.137 0.176 0.309 Mothers protected against tetanus for last birth 0.834 0.029 156 153 0.970 0.035 0.777 0.892 Fully immunized 0.936 0.040 31 30 0.909 0.043 0.855 1.016 Heard about HIV/AIDS 0.980 0.007 341 334 0.893 0.007 0.966 0.993 Knows about condoms to prevent HIV/AIDS 0.727 0.031 341 334 1.283 0.043 0.665 0.789 Knows about limiting partners 0.945 0.014 341 334 1.155 0.015 0.916 0.973 Comprehensive knowledge on HIV transmission 0.308 0.034 341 334 1.355 0.110 0.240 0.376 Table F.7 Sampling errors for Baa sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.360 0.038 321 233 1.397 0.104 0.285 0.435 Secondary education or higher 0.286 0.038 321 233 1.507 0.133 0.210 0.362 Currently married 0.615 0.132 493 352 0.912 0.215 0.350 0.879 Married before age 20 0.351 0.088 493 352 1.043 0.250 0.176 0.526 Currently pregnant 0.063 0.020 493 352 1.191 0.317 0.023 0.103 Children ever born 1.939 0.467 493 352 0.988 0.241 1.004 2.874 Children surviving 1.856 0.454 493 352 1.002 0.244 0.949 2.763 Knows any contraceptive method 0.993 0.005 298 216 0.993 0.005 0.983 1.003 Knows a modern method 0.993 0.005 298 216 0.993 0.005 0.983 1.003 Ever used any contraceptive method 0.621 0.044 298 216 1.545 0.070 0.534 0.708 Currently using any method 0.299 0.032 298 216 1.222 0.109 0.234 0.364 Currently using a modern method 0.252 0.028 298 216 1.105 0.110 0.197 0.308 Mothers protected against tetanus for last birth 0.652 0.046 146 107 1.166 0.071 0.560 0.744 Fully immunized 0.966 0.034 32 23 1.056 0.035 0.899 1.034 Heard about HIV/AIDS 0.963 0.011 321 233 1.022 0.011 0.941 0.984 Knows about condoms to prevent HIV/AIDS 0.740 0.028 321 233 1.141 0.038 0.684 0.796 Knows about limiting partners 0.912 0.012 321 233 0.734 0.013 0.889 0.935 Comprehensive knowledge on HIV transmission 0.393 0.026 321 233 0.942 0.065 0.341 0.444 Table F.8 Sampling errors for Lhaviyani sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.358 0.033 272 184 1.141 0.093 0.291 0.424 Secondary education or higher 0.289 0.023 272 184 0.824 0.079 0.243 0.334 Currently married 0.685 0.096 362 249 1.344 0.140 0.494 0.877 Married before age 20 0.542 0.053 318 216 1.192 0.097 0.437 0.648 Currently pregnant 0.069 0.020 362 249 1.329 0.290 0.029 0.108 Children ever born 2.189 0.348 362 249 1.321 0.159 1.494 2.884 Children surviving 2.074 0.325 362 249 1.309 0.156 1.425 2.723 Knows any contraceptive method 0.992 0.008 252 171 1.361 0.008 0.977 1.007 Knows a modern method 0.992 0.008 252 171 1.361 0.008 0.977 1.007 Ever used any contraceptive method 0.669 0.015 252 171 0.521 0.023 0.638 0.700 Currently using any method 0.368 0.028 252 171 0.906 0.075 0.312 0.423 Currently using a modern method 0.314 0.032 252 171 1.077 0.100 0.251 0.377 Mothers protected against tetanus for last birth 0.844 0.023 105 73 0.656 0.027 0.799 0.890 Fully immunized 0.905 0.046 31 21 0.868 0.050 0.814 0.996 Heard about HIV/AIDS 0.975 0.011 272 184 1.134 0.011 0.954 0.997 Knows about condoms to prevent HIV/AIDS 0.821 0.026 272 184 1.101 0.031 0.769 0.872 Knows about limiting partners 0.923 0.019 272 184 1.162 0.020 0.886 0.961 Comprehensive knowledge on HIV transmission 0.404 0.056 272 184 1.880 0.139 0.292 0.517 342 | Appendix F Table F.9 Sampling errors for Kaafu sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.234 0.021 359 255 0.930 0.089 0.192 0.275 Secondary education or higher 0.279 0.042 359 255 1.759 0.150 0.196 0.363 Currently married 0.643 0.065 499 359 0.905 0.101 0.513 0.774 Married before age 20 0.677 0.027 374 266 1.161 0.040 0.623 0.731 Currently pregnant 0.061 0.017 499 359 1.316 0.273 0.028 0.094 Children ever born 2.125 0.199 499 359 0.744 0.094 1.726 2.524 Children surviving 1.981 0.176 499 359 0.706 0.089 1.630 2.333 Knows any contraceptive method 0.997 0.003 325 231 1.038 0.003 0.990 1.003 Knows a modern method 0.997 0.003 325 231 1.038 0.003 0.990 1.003 Ever used any contraceptive method 0.687 0.038 325 231 1.481 0.056 0.610 0.763 Currently using any method 0.426 0.025 325 231 0.912 0.059 0.376 0.476 Currently using a modern method 0.336 0.027 325 231 1.039 0.081 0.282 0.391 Mothers protected against tetanus for last birth 0.773 0.068 164 114 2.044 0.088 0.637 0.909 Fully immunized 0.948 0.035 42 30 1.014 0.037 0.878 1.017 Heard about HIV/AIDS 0.979 0.006 359 255 0.797 0.006 0.967 0.991 Knows about condoms to prevent HIV/AIDS 0.787 0.024 359 255 1.089 0.030 0.740 0.834 Knows about limiting partners 0.935 0.017 359 255 1.307 0.018 0.901 0.969 Comprehensive knowledge on HIV transmission 0.351 0.020 359 255 0.790 0.057 0.311 0.390 Table F.10 Sampling errors for Alif Alif sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.290 0.025 311 139 0.958 0.085 0.241 0.339 Secondary education or higher 0.284 0.048 311 139 1.858 0.168 0.189 0.380 Currently married 0.675 0.116 424 186 0.926 0.171 0.444 0.906 Married before age 20 0.684 0.039 323 145 1.522 0.056 0.607 0.761 Currently pregnant 0.069 0.015 424 186 0.838 0.216 0.039 0.099 Children ever born 2.235 0.398 424 186 0.915 0.178 1.440 3.031 Children surviving 2.029 0.368 424 186 0.935 0.181 1.293 2.765 Knows any contraceptive method 0.989 0.006 280 125 0.964 0.006 0.977 1.001 Knows a modern method 0.989 0.006 280 125 0.964 0.006 0.977 1.001 Ever used any contraceptive method 0.643 0.054 280 125 1.860 0.083 0.536 0.751 Currently using any method 0.371 0.036 280 125 1.230 0.096 0.300 0.442 Currently using a modern method 0.289 0.034 280 125 1.234 0.116 0.222 0.356 Mothers protected against tetanus for last birth 0.860 0.039 154 70 1.386 0.045 0.782 0.938 Fully immunized 0.909 0.035 44 20 0.808 0.039 0.839 0.979 Heard about HIV/AIDS 0.961 0.011 311 139 1.003 0.012 0.938 0.983 Knows about condoms to prevent HIV/AIDS 0.793 0.030 311 139 1.293 0.038 0.733 0.852 Knows about limiting partners 0.889 0.016 311 139 0.896 0.018 0.857 0.921 Comprehensive knowledge on HIV transmission 0.433 0.034 311 139 1.209 0.079 0.365 0.501 Table F.11 Sampling errors for Alif Dhaal sample, Maldives DHS 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– No education 0.325 0.027 384 197 1.127 0.083 0.271 0.379 Secondary education or higher 0.324 0.046 384 197 1.906 0.141 0.233 0.416 Currently married 0.719 0.068 502 255 0.941 0.095 0.583 0.855 Married before age 20 0.613 0.020 414 212 0.881 0.033 0.573 0.654 Currently pregnant 0.069 0.010 502 255 0.827 0.142 0.049 0.088 Children ever born 2.245 0.175 502 255 0.692 0.078 1.896 2.595 Children surviving 2.117 0.166 502 255 0.701 0.079 1.784 2.450 Knows any contraceptive method 1.000 0.000 358 183 na 0.000 1.000 1.000 Knows a modern method 1.000 0.00