Namibia - Demographic and Health Survey - 1993

Publication date: 1993

Namibia REPUBLIC OF NAMIBIA Namibia Demographic and Health Survey 1992 Puumue Katjiuanjo Stephen Titus M~azuu Zauana J. Ties Boerma Ministry of Health and Social Services Windhoek, Namibia Macro International Inc. Columbia, Maryland USA May 1993 This report summarises the findings of the 1992 Namibia Demographic and Health Survey (NDHS) conducted by the Ministry of Health and Social Services, in collaboration with the Central Statistical Office. Macro International Inc. provided technical assistance. Funding was provided by the World Bank through a grant from the Government of Japan. Additional information about the NDHS may be obtained from the Ministry of Health and Social Services, Epidemiology Unit, Harvey Street, Pr. Bag 13198, Windhoek, Namibia (Telephone (061) 2032320/2032307; Fax (061) 227607. Additional information about the DHS programme may be obtained by writing to: DHS, Macro International Inc., 8850 Stanford Boulevard, Suite 4000, Columbia, MD 21045, USA (Telephone (410) 290 2800; Fax (410) 290 2999). CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xili Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Map of Namibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx CHAFFER 1 INTRODUC'TION 1.1 Geography, History, and Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.3 Population and Family Planning Policies and Pmgrammes . . . . . . . . . . . . . . . . . . 3 1.4 Health Priorities and Pmgrammes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.5 Objectives and Organisation of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 2.1 Characteristics of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.2 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.3 Background Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . 16 CHAPTER 3 FERTILITY 3.1 Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.2 Children Ever Born and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.3 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.4 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.5 Teenage Pregnancy and Motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 CHAFFER 4 FERTILITY REGULATION 4.1 Knowledge of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 4.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 4.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 4.4 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . 37 4.5 Knowledge of the Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 4.6 Sources of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.7 Intention to Use Family Planning Among Nonusers . . . . . . . . . . . . . . . . . . . . . . 41 4.8 Approval of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 4.9 Attitudes of Couples Toward Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 45 i i i CHAPTER 5 Page PROXIMATE DETERMINANTS OF FERTIL ITY 5.1 Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 5.2 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 5.3 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 5.4 Age at First Sexual Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5.5 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . . . . . . . . . . . . . . . . 54 5.7 Termination of Exposure m Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 CHAPTER 6 FERTIL ITY PREFERENCES 6.1 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 6.2 Demand for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 6.3 Ideal and Actual Number of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 6.4 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 CHAPTER 7 INFANT AND CHILD MORTAL ITY 7.1 Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 7.2 High-Risk Fertility Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 7.3 Causes of Death in Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 CHAPTER 8 MATERNAL MORTAL ITY 8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 8.2 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 8.3 Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 8.4 Direct Estimates of Adult Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 8.5 Direct Estimates of Matemal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 8.6 Indirect Estimates of Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 8.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 CHAPTER 9 MATERNAL AND CHILD HEALTH 9.1 Antenatal Care and Delivery Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 9.2 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 9.3 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 9.4 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 9.5 Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 iv CHAFFER 10 Page MATERNAL AND CHILD NUTRITION 10.1 Breasffeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 10.2 Bilth Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 10.3 Nutritional Status of Chi ld ren . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 10.4 Mother's Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 CHAPTER 11 AVAILABILITY OF HEALTH SERVICES 11.1 Distance and Time to Nearest Health Facility . . . . . . . . . . . . . . . . . . . . . . . . . . 130 11.2 Availability of Various Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 11.3 Antenatal and Delivery Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 11.4 Immunisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 11.5 Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 APPENDICES Appendix A Persons Involved in the Namibia Demographic and Health Survey. . . 143 Appendix B Survey Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Appendix C Estimates of Sampling Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Appendix D Data Quality Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Appendix E Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Table 1.1 Table 2.1 Table 2.2 Table 2.3.1 Table 2.3.2 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 TABLES Page Result of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Educational level of the female household population . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Educational level of the male household population . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Median age at first birth by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 26 Teenage pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Knowledge of contraceptive methods and source for methods . . . . . . . . . . . . . . . . . . . . 30 Knowledge of modem contraceptive methods and source for methods . . . . . . . . . . . . . 31 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Current use of contraception by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . . . . . 35 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Time to source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . 40 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 vii Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 5.11 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 7.6 Table 7.7 Page Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Acceptability of the use of mass media for disseminating family planning messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Attitudes of couples toward family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Current marital status by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Current marital status by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Age at first sexual intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Recent sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Postpartum amenorrhoea, abstinence and insusceptibility by age . . . . . . . . . . . . . . . . . 54 Postpartum amenorrhoea, abstinence and insusceptibility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Fertility preference by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . . . . . . 63 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . 70 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . 72 High-risk fertility behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Causes of death according to mothers' reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Presence of conditions and symptoms among deaths during the neonatal period . . . . . 76 Presence of symptoms among deaths after the neonatal period . . . . . . . . . . . . . . . . . . . 77 viii Table 7.8 Table 7.9 Table 7.10 Table 7.11 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 9.9 Table 9.10 Table 9.11 Table 9.12 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 10.6 Table 10.7 Table 10.8 Table 10.9 Table 11.1 Table 11.2 Page Diagnostic criteria considered to ascertain a probable cause of death . . . . . . . . . . . . . . 78 Agreement in probable cause of death between mothers' reported cause and symptoms-based diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Probable causes of death among children under 5 years . . . . . . . . . . . . . . . . . . . . . . . . . 80 Place of death and type of assistance sought during illness that led to death . . . . . . . . . 82 Sibling data for estimating maternal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Estimates of age-specific mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Direct estimates of maternal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Indirect estimates of maternal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Amenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Ass is tance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Vaccinations in the first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . . . . . . . 105 Prevalence and treatment of fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Prevalence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Knowledge and use of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Treatment of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Breastfeeding and supplementation by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Birth weight data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Mean birth weight and incidence of low birth weight . . . . . . . . . . . . . . . . . . . . . . . . . 121 Nutritional status by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Anthropometric indicators of materoal nutritional status . . . . . . . . . . . . . . . . . . . . . . . 126 Differentials in matemal anthropometric indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Number of health facilities and population served . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Proximity to health facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 ix Table 11.3 Table 11.4 Table 11.5 Table 11.6 Table 11.7 Table 11.8 Table 11.9 Table B.1 Table B.2 Table C.1 Table C.2 Table C.3 Table C.4 Table C.5 Table C.6 Table C.7 Table D. 1 Table D.2 Table D.3 Table D.4 Table D.5 Table D.6 Page Distance and time to nearest health facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Distance and time to nearest hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Availability of health services at nearest health facility/hospital . . . . . . . . . . . . . . . . . 134 Distance and time of nearest facility providing antenatal care . . . . . . . . . . . . . . . . . . . 136 Distance and time to nearest facility providing delivery cam . . . . . . . . . . . . . . . . . . . . 138 Distance and time to nearest facility providing vaccination services . . . . . . . . . . . . . . 139 Distance and time to nearest facility providing family planning services . . . . . . . . . . 139 Sample allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Sample implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 List of selected variables for sampling errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Sampling errors, entire sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Sampling errors, urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Sampling errors, rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Sampling errors, Northwest Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Sampling errors, Northeast Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Sampling errors, Central and South Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Blahs by calendar year since birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 X Figure 2.1 Figure 2.2 Figure 2.3 Figure 3.1 Figure 3.2 Figure 3.3 Figure 4.1 Figure 4.2 Figure 6.1 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure8.1 Figure8.2 Figure 8.3 Figure 8.4 Figure9.1 Figure 9.2 Figure 9.3 Figure 9.4 Figure 9.5 Figure9.6 FIGURES Page Population pyramid of Namibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Median number of years of education by sex and age . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Housing characteristics by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Total fertility rate among women 15-44 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Age-specific fertility rates by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Percentage of teenagers who have begun childbearing by age . . . . . . . . . . . . . . . . . . . . 28 Distribution of currently married women by method currently used . . . . . . . . . . . . . . . 34 Current use of family planning methods among currently married women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Fertility preferences of currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . 57 Childhood mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Age-specific mortality rates for five-year periods prior to the survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Under-five mortality for the ten-year period preceding the survey by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Leading causes of death in childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Percent distribution of sister deaths (age 15+) and maternal deaths by time of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Age-specific mortality rates for males and females . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Mortality rates among adults 15-49 by sex and region . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Relative risk of maternal death by parity and maternal age . . . . . . . . . . . . . . . . . . . . . . 89 Number and timing of antenatal visits for births in the last five years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Percentage of births attended by medical professionals in the five years preceding the survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Vaccination status of children 12-23 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Trends in vaccination coverage for measles and DPT by age 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Utilisation of curative health services among children with ARI in the two weeks preceding the survey by distance to health facility . . . . . . . . . . . . . . 106 Feeding practices among children under five with diarrhoea in the two weeks preceding the survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 xi Figure 10.1 Figure 10.2 Figure 10.3 Figure 10.4 Figure 10.5 Figure 11.1 Page Timing of initiation of breastfeeding for births in the five years preceding the survey by region and place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . 115 Breasffeeding status by age of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Growth of children under live years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Nutritional status of children under five years of age by region . . . . . . . . . . . . . . . . . 125 Nutritional status of children under live . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Travel time to nearest facility providing antenatal care for women 15-49 by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 xii ACRONYMS ARI BCG BMI CBR CDC CDD DHS DPT EPI GDP IEC ISSA IUD MCH/FP MOHSS NDHS NACP NCHS NIP ORS ORT PHC SD TBA "l'l~R UNICEF UN WHO Acute respiratory infections BaciUe Bili6 de Calmette et Gu6rin (vaccine) Body mass index Crude birth rate Centers for Disease Control Control of Diarthoeal Diseases Demographic and Health Surveys Diphtheria - poliomyelitis - tetanus (vaccine) Expanded Programme on Immunisation Gross domestic product Information, education and communication Integrated System for Survey Analysis Intra-uterine device Maternal and child health/family planning Ministry of Health and Social Services Namibia Demographic and Health Survey National AIDS Control Programme National Center for Health Statistics Nutrition Improvement Programme Oral rehydration salts Oral rehydration therapy Primary health care Standard deviation Traditional birth attendant Total fertility rate United Nations Children's Fund United Nations World Health Organisation xiii PREFACE The Namibia Demographic and Health Survey (NDHS) was a nationwide sample survey of women of reproductive age designed to provide information on fertility, family planning, child mortality, and maternal and child health. The survey was conducted by the Ministry of Health and Social Services (MOHSS) in collaboration with the Central Statistical Office (CSO) as part of the worldwide Demographic and Health Surveys programme which is being administered by Macro International Inc., Columbia, Maryland, USA. Funding for the NDHS was provided by the World Bank through a grant from the Government of Japan. The NDHS is the first national survey in Namibia, since independence was achieved in March 1990. The survey provides essential data for the planning, implementation, and monitoring and evaluation of health and family planning programmes in Namibia. Until recently, such data had been fragmented and lacking for many regions of the country and not available at the national level. The NDHS results are a very valuable source of data for Namibia's efforts to achieve health for all and to redress inequities in health status and health care existing within the country. Programme efforts need to be targeted towards more disadvantaged populations and further studies of special high-risk groups may be required. The substantial achievement of completing the NDHS and publishing this volume is due to the tireless efforts and contributions of many individuals and organisations. Within the Ministry of Health and Social Services the Epidemiology Unit constituted the heart of the survey. Under the survey directorship of Dr. Nestor Shivute (Director Primary Health Care Services) all staff members of the Epidemiology Unit worked very hard for more than a year to complete the survey. Without the contributions of Puumue Katjiuanjo, Stephen Titus, Maazuu Zauana, and Elisabeth Matroos the survey would still have been in its planning stages. Regarding the financial management of the survey we owe a special thanks to Mr. Abraham George, Senior Accountant in the MOHSS. At the Central Statistical Office we thank Philemon Kanime, Joseph Minnaar and Rebecca Appiah for their continuing support during the survey, and particularly regarding the sample selection. In the regions we wish to acknowledge the regional medical directors and their teams for the moral, technical and logistical support during the survey. Technical assistance during the survey was provided by Macro Intemational Inc. We thank the support of Ties Boerma, Jeanne Cushing, Thanh Le, and Kate Stewart in their various fields of expertise. Their assistance contributed to the further development of the technical skills of our staff and enhanced our capability to conduct surveys in Namibia. Thanks are also due to the reviewers of the NDHS report. These include George Bicego, Arm Blanc, Anne Cross, Melissa McNiff, Kaye Mitchell, Sidney Moore, and Jerry Sullivan. We also wish to record our gratitude to Joy Debeyer of the World Bank who has been instrumental in ensuring funding for the survey and has been supportive throughout the exercise. Dr. S.N. Amatihila Permanent Secretary Ministry of Health and Social Services XV SUMMARY OF FINDINGS The 1992 Namibia Demographic and Health Survey (NDHS) is a nationally representative survey conducted by the Ministry of Health and Social Services, assisted by the Central Statistical Office, with the aim of gathering reliable information on fertility, family planning, infant and child mortality, maternal mortality, maternal and child health and nutrition. Interviewers collected information on the reproductive histories of 5,421 women 15-49 years and on the health of 3,562 children under the age of five years. According to the NDHS, fertility is high in Namibia; at current fertility levels, Namibian women will have an average of 5.4 children by the end of their reproductive years. This is lower than most countries in sub-Saharan Africa, but similar to results from DHS surveys in Botswana (4.9 children per woman) and Zimbabwe (5.4 children per woman). Fertility in the South and Central regions is considerably lower (4.1 children per woman) than in the Northeast (6.0) and Northwest regions (6.7). About one in four women uses a contraceptive method: 29 percent of married women currently use a method (26 percent use a modem method), and 23 percent of all women are current users. The pill, injection and female sterilisation are the most popular methods among married couples: each is used by about 7 to 8 percent of currently married women. Knowledge of contraception is high, with almost 90 percent of all women age 15-49 knowing of any modem method. Certain groups of women are much more likely to use contraception than others. For example, urban women are almost four times more likely to be using a modem contraceptive method (47 percent) than rural women (13 percent). Women in the South and Central regions, those with more education, and those living closer to family planning services are also more likely to be using contraception. Levels of fertility and contraceptive use are not likely to change until there is a drop in desired family size and until the idea of reproductive choice is more widely accepted. At present, the average ideal family size (5.0 children) is only slightly lower than the total fertility rate (5.4 children). Thus, the vast majority of births are wanted. On average, Namibian women have their first child when they are about 21 years of age. The median age at first marriage is, however, 25 years. This indicates that many women give birth before marriage. In fact, married women are a minority in Namibia: 51 percent of women 15-49 were not married, 27 percent were currently married, 15 percent were currently living with a man (informal union), and 7 percent were widowed, divorced or separated. Therefore, a large proportion of children in Namibia are born out of wedlock. The NDHS also provides inlbrmation about maternal and child health. The data indicate that 1 in 12 children dies before the fifth birthday. However, infant and child mortality have been declining over the past decade. Infant mortality has fallen from 67 deaths per 1,000 live births for the period 1983-87 to 57 per 1,000 live births for the period 1988-92, a decline of about 15 percent. Mortality is higher in the Northeast region than elsewhere in Namibia. The leading causes of death are diarrhoea, undemutrition, acute respiratory infection (pneumonia) and malaria: each of these conditions was associated with about one-fifth of under-five deaths. Among neonatal deaths low birth weight and birth problems were the leading causes of death. Neonatal tetanus and measles were not lbund to be major causes of death. xvii Maternal mortality was estimated from reports on the survival status of sisters of the respondent. Maternal mortality was 225 per 100,000 live births for the decade prior to the survey. NDHS data also show considerable excess male mortality at ages 15-49, which may in part be related to the war of independence during the 1980s. Utilisation of maternal and child health services is high. Almost 90 percent of mothers received antenatal care, and two-thirds of children were bom in health facilities. Traditional birth attendants assisted only 6 percent of births in the five years preceding the survey. Child vaccination coverage has increased rapidly since independence. Ninety-five percent of children age 12-23 months have received at least one vaccination, while 76 percent have received a measles vaccination, and 70 percent three doses of DPT and polio vaccines. Children with symptoms of possible acute respiratory infection (cough and rapid breathing) may have pneumonia and need to be seen by a health worker. Among children with such symptoms in the two weeks preceding the survey two-thirds were taken to a health facility. Only children of mothers who lived more than 30 km from a health facility were less likely to be taken to a facility. About one in five children had diarrhoea in the two weeks prior to the survey. Diarrhoea prevalence was very high in the Northeast region, where almost half of children reportedly had diarrhoea. The dysentery epidemic contributed to this high figure: diarrhoea with blood was reported for 17 percent of children under five in the Northeast region. Among children with diarrhoea in the last two weeks 68 percent were taken to a health facility, and 64 percent received a solution prepared from ORS packets. NDHS data indicate that more emphasis needs to put on increasing fluids during diarrhoea, since only I 1 percent mothers of children with diarrhoea said they increased the amount of fluids given during the episode. Nearly all babies are breastfed (95 percent), but only 52 percent are put on the breast immediately. Exclusive breastfeeding is practiced for a short period, but not for the recommended 4-6 months. Most babies are given water, formula, or other supplements within the first four months of life, which both jeopardises their nutritional status and increases the risk of infection. On average, children are breastfed for about 17 months, but large differences exist by region. In the South region children are breastfed lor less than a year, in the Northwest region for about one and a half years and in the Northeast region for almost two years. Most babies are weighed at birth, but the actual birth weight could be recalled for only 44 percent of births. Using these data and data on reported size of the newborn, for all births in the last five years, it was estimated that the mean birth weight in Namibia is 3048 grams, and that 16 percent of babies were low birth weight (less than 2500 grams). Stunting, an indication of chronic undemutrition, was observed for 28 percent of children under five. Stunting was more common in the Northeast region (42 percent) than elsewhere in Namibia. Almost 9 percent of children were wasted, which is an indication of acute undemutrition. Wasting is higher than expected for Namibia and may have been caused by the drought conditions during 1992. Matemal height is an indicator of nutritional status over generations. Women in Namibia have an average height of 160 cm and there is little variation by region. The Body Mass Index (BM1), defined as weight divided by squared height, is a measure of current nutritional status and was lower among women in the Northwest and the Northeast regions than among women in the South and Central regions. xviii On average, women had a health facility available within 40 minutes travel time. Women in the Northwest region, however, had to travel more than one hour to reach the nearest health facility. At a distance of less than 10 km, 56 percent of women had access to antenatal services, 48 percent to maternity services, 72 percent to immunisation services, and 49 percent to family planning services. Within one hour of travel time, fifty-two percent of women had antenatal services, 48 percent delivery services, 64 percent immunisation services and 49 percent family planning services. Distance and travel time were greatest in the Northwest region. xix NAMIBIA NORTHWEST ANGOLA L& • CENTRAL • • • •A • NORTHEAS~I ~A ZAMBIA ~~Z [M BABWE ATLANTIC OCEAN t6EA= A==• • I t WINDHOEK % • SOUTH BOTSWANA • EnumeralJon Area (EA) SOUTH AFRICA XX CHAPTER 1 INTRODUCTION 1.1 Geography, History, and Economy Geography Namibia has a surface area of 824,295 km2 and ranks as Africa's fifteenth largest country. It is located in the southwestem part of the continent and shares borders with Angola and Zambia on the north, Zimbabwe at the eastem end of the Caprivi Strip, Botswana to the east, and South Africa in the south and southeast. Geographically, Namibia is divided into three major regions, the Namib Desert, the Central Plateau and the Kalahari Desert. The Namib Desert is in the westem part of the country, stretching approximately 1,400 km along the Atlantic coast. Its width varies between 97 and 160 kin. Despite the barrenness of the Namib, it is endowed with rich mineral deposits. The Central Plateau, which forms part of the Central African Plateau, lies between the two deserts. The plateau, comprising over 50 percent of the total land area of Namibia, stretches from the northern to the southern border. It is the most fertile area in the country and most suitable for human settlement. To some extent this area is suitable for cattle-raising and crop cultivation. The mountain ranges of the plateau are endowed with rich mineral deposits. The Kalahari is a semi-desert covering the southeastern part of the country; it consists mainly of terrestrial sands and limestones. Unlike the Namib Desert, vegetation grows in the Kalahari. The northern parts of the Kalahari are most suited to cultivation, while the southem part is suitable for sheep-raising and the eastern part is suitable for cattle, goats and to lesser extent, sheep. Rainfall is the main factor influencing the climate of Namibia. The average annual rainfall for the country is only 270 mm and 92 percent of the land is categorised as extremely arid (22 percent), arid (33 percent) or semi-arid (37 percent), while the remainder is sub-humid. History On 21 March 1990, following the successful implementation of United Nations General Assembly Resolution 435, Namibia became the 1 ast colony in Africa to attain its independence after more than 100 years of colonialism. Designated South West Africa, it was a German colony from 1884 until World War I. The territory was invaded and occupied by the Union of South Africa during the war, and then became the responsibility of the League of Nations. In 1920, the mandate of Namibia was handed over to South Africa under category "C" status, in which South Africa was expected to promote to the utmost the material and moral well-being and social progress of the inhabitants of the territory. To the contrary, the government of South Africa pursued a policy of exploitation and armexation of the territory. Following the refusal by the United Nations Assembly in 1946 to allow South Africa to incorporate the territory into its union, the South African government declared it would administer the territory without United Nations jurisdiction and shortly afterwards began to introduce its apartheid system. In 1971 the lntemational Court of Justice declared South Africa's occupation of Namibia illegal. Following the recommendations of the apartheid-oriented Odendaal Commission in 1964, Namibia was divided into a number of ethnic "homelands," which made up forty percent of the land in Namibia. Forty-four percent was reserved for whites, and the remaining 16 percent consisted of game reserves, diamond mining areas, etc. In the early 20th century, Namibians fought bloody wars against the German occupation (e.g., Nama and Herero wars). In 1960, the South West Africa People's Organisation (SWAPO), under the leadership of Sam Nujoma, was established and led the liberation struggle against the South African oppressors. Guerilla warfare took place from 1966 until independence, principally in northern Namibia. Thousands of Namibians fled to camps in Angola, Botswana, and Zambia. In tile seventies and eighties, the warfare increased, resulting in an estimated 10,000 civilian deaths. After independence in March 1990, Namibia set about redesigning the national infrastructure, administrative bodies, and basic services. The Government of the Republic of Namibia operates under a multi-party system. There is an executive branch comprised of the President and Cabinet, and a legislalive branch made up of the National Assembly. The country is divided into 13 regions and the election of Regional Councils took place in 1992. The Ministry of Health and Social Services administers four health regions, which were used in the Namibia Demographic and Health Survey. The Northwest health region includes Oshana, Omusati, Ohanguena, and Oshikoto regions; the Northeast health region includes Okavango and Caprivi; the Central health region comprises Kunene, Otjozondjupa, Erongo and Omaheke; and the South region includes Khomas, Hardap and Karas regions. Economy Namibia is one of the wealthier, more resource-rich countries on the continent. It is the fifth largest mineral producer in Africa and its fishing grounds are among the richest in the world. However, the national economy inherited by the Namibian government is fragile, dependent, and has an over-extended public sector. In its own interest, Namibia has decided to stay in the South African Customs Union and it still operates in the Rand Monetary Area and Bank of Namibia System. Namibia's economy is heavily dependent on a few prim ary commodity exports--diamonds, uranium, copper, other base metals, lead and mercury and livestock, followed by the Karakul (Persian lamb) pelt industry. The balance is made up by fish, manufactured products, and the tourist industry. Mining accounts for about two-thirds of all export earnings. Namibia depends on South Africa for about 75 percent of all imports. The majority of the population are dependent for their livelihood on livestock, i.e. cattle, sheep, goats and pigs. Per capita income varies greatly. The gross domestic product (GDP) was estimated at US$100 per year in mral areas, US$305 in the semi-urban areas, and US$580 in Katutura (a former black residential area in Windhoek, the capital city), while the annual GDP for whites was estimated at US$14,650 (UNICEF, 1990). 1.2 Population The last comprehensive population census, which was conducted in October 1991, reported a total population of 1,401,711 with an annual growth rate of 3 percent (Central Statistical Office, 1992). Despite the small size of its population, Namibia has a rich diversity of ethnic groups including Ovambo, Herero, Nama, Damara, Kavango, Caprivians, San, Twana, and Whites, Coloureds and Basters. 2 The population of Namibia is concentrated in the northern part of the country (60 percent); the south is least populated (7 percent); and the remainder are in the central part of the country. As a consequence of the apartheid policy, which reserved nearly 60 percent of the land for whites (who constituted less than 10 percent of the total population), ethnic distinctions were reinforced and different subgroups were encouraged to live in separate regions and, in urban areas, in separate localities. The majority of the black population is now concentrated in restricted rural areas, previously called "homelands." Overall, about one-third of the population lives in urban areas (in 57 "towns"), while 67 percent live in rural areas, including communal areas and commercial farms. At less than two persons per square kilometre, population density for the country as a whole is low. However, there are substantial regional differences in population density. For instance, Oshakati and Ondangwa districts in Northwest region exceed 11 persons per square kilometre. 1.3 Population and Family Planning Policies and Programmes Although population growth has been considerable during the last decade, the Government of the Republic of Namibia has yet to formulate an explicit population policy. However, population issues have received some attention, and different sectors of the govemment have come to realise the intersectoral impact of population issues, and of the importance of integrating population issues into a holistic planning perspective. Several surveys and needs assessment missions have indicated the need for information and understanding on the relationship between population and development, and a need for organised and coordinated population/health information, education and communication activities. Although family planning services in Namibia are underdeveloped and far from meeting the needs of the population, 191 (79 percent) of the 242 health facilities are providing family planning services. However, there are substantial differences in the availability and accessibility of family planning services. In the Northwest region, where nearly 50 percent of the population resides, only 43 percent of the health facilities are providing such services. One of the major components of primary health care (PHC) in the Ministry's Development Programme is the Maternal and Child Health/Family Planning (MCH/FP) programme. Its tasks, as stipulated in the draft policy, include: The promotion and improvement of MCH/FP services at all levels where such services are provided; To increase knowledge and access to family planning services, especially for distant communities; Identification of high-risk groups among pregnant women, mothers, and children, and to provide appropriate intervention; and To decrease morbidity and mortality associated with pregnancy. 1.4 Health Priorities and Programmes Namibia inherited a health structure that was segregated along racial lines and based entirely on curative health services. The administrative structure for delivery of health services was based on the Representative Authorities proclamation of 1980 (Proclamation AG8 of 1980), which created a two-tier system, resulting in an unequal allocation of resources and services. The ethnic-based second-tier was poody funded and administrators could not raise the necessary income to provide basic health care services. As a result, there were large inequalities in the delivery of health care services in the country. 3 Shortly after independence, major changes occurred in all sectors, many of which have been restructured to meet the challenges facing the new nation in the post-apartheid era. The Government of Namibia declared its commitment to the equitable distribution of resources and to equity of access to basic services for those who are socially or economically disadvantaged (i.e., the impoverished and underprivileged). The Ministry of Health and Social Services has adopted a "Primary Health Care" (PHC) strategy for achieving health for all Namibians. Its objective is to attain this goal for women and children in the 1990s. The PHC approach is used to guide the restructuring of the health sector in an independent Namibia. The Ministry of Health and Social Services has, in particular, made progress in streamlining and restructuring what was a curative-based health system to be a more community oriented system. The Minister of Health and Social Services has described this policy in the document "Towards Achieving Health for All Namibians" (Ministry of Health and Social Services, 1992). The National PHC/Community-based Health Care Guidelines were announced on February 22, 1992 by the President of the Republic. This gave the Ministry of Health and Social Services a mandate to design, develop and implement programmes which focus on promotion of health at the community level. The PHC guidelines also provide a solid base for decentralised planning and intersectoral collaboration with joint identification and prioritisation of needs at the community level by all sectors. Health regions were now able to plan and prioritise programmes according to their immediate needs. The Ministry of Health and Social Services also emphasised other PHC components: Immunisation against the major infectious diseases, i.e., poliomyelitis, diphtheria, tuberculosis, measles, tetanus and whooping cough; Maternal and child health care, which encompasses family planning; The promotion of proper nutrition, a safe water supply, and basic sanitation to secure an environment conducive to the well-being of all Namibians; and Education and training regarding prevailing health problems in communities, as well as prevention and control measures. During restructuring of the Ministry of Health and Social Services many national health programmes came into being, namely, Mother and Child Health and Family Planning Programme (MCH/FP), Expanded Programme on lmmunisation (EPI), Control of Diarrhoeal Diseases (CDD), Acute Respiratory Infections (AR1), lnlormation, Education and Communication (IEC), National AIDS Control Programme (NACP), National Nutrition Improvement Programme (NIP), School/Adolescent Health Programme, National Malaria Control Programme, Tuberculosis Control Programme, Rehabilitation Programme, National Vector-borne Diseases Control Programme, National Tuberculosis Control Programme, and Health Training Programme. 1.5 Objectives and Organisation of the Survey Objectives The Namibia Demographic and Health Survey (NDHS) is a national sample survey of women of reproductive age designed to collect data on mortality and fertility, socioeconomic characteristics, marriage patterns, breastfeeding, use of contraception, immunisation of children, accessibility to health and family planning services, treatment of children during episodes of illness, and the nutritional status of women and children. More specifically, the objectives of NDHS are: To collect data at the national level which will allow the calculation of demographic rates, particularly fertility rates and child mortality rates, and maternal mortality rates; 4 To analyse the direct and indirect factors which determine levels and trends in fertility and childhood mortality, Indicators of fertility and mortality are important in planning for social and economic development; To measure the level of contraceptive knowledge and practice by method, region, and urban/rural residence; To collect reliable data on family health: immunisations, prevalence and treatment of diarrhoea and other diseases among children under five, antenatal visits, assistance at delivery and breastfeeding; • To measure the nutritional status of children under five and of their mothers using anthropometric measurements (principally height and weight). Organisation The Namibia Demographic and Health Survey was conducted by the Ministry of Health and Social Services, with the assistance of the Central Statistical Office of the National Planning Commission. The survey was funded by the World Bank through a grant from the Government of Japan and the Namibian Government. Technical support was provided by Macro International Inc., located in Columbia, Maryland, USA. Questionnaires Two questionnaires were used in the main tieldwork for the NDHS: the household questionnaire and the individual questionnaire. The two questionnaires were adapted from the DHS model B questionnaire, which was designed for use in countries with low contraceptive prevalence. The questionnaires were developed in English, and then translated into five of the major Namibian languages: Oshiwambo, Herero, Lozi, Kwangali, and Afrikaans. English versions of the questionnaires are reproduced in Appendix E. All usual members and visitors in the selected households were listed on the household questionnaire. For each person listed, information was collected on age, sex, education, and relationship to the head of household. The household questionnaire was used to identify women eligible for the individual questionnaire. The individual questionnaire was administered to women age 15-49 who spent the night preceding the household interview in the selected household. Information in the following areas was obtained during the individual interview: 1. Background characteristics of the respondent 2. Health services utilisation and availability 3. Reproductive behaviour and intentions 4. Knowledge and use of contraception 5. Breastfeeding, health, and vaccination status of children 6. Marriage 7. Fertility preferences 8. Husband's background and woman's work 9. Height and weight of children under five and their mothers 10. Causes of death in childhood 11. Maternal mortality Sample The sample for the NDHS was designed to be nationally representative. The design involved a two- stage stratified sample which is self-weighting within each of the three health regions for which estimates of fertility and mortality were required--Northwest, Northeast, and the combined Central/South region. In order to have a sufficient number of cases for analysis, oversampling was necessary for the Northeast region, which has only 14.8 percent of the population. Therefore, the sample was not allocated proportionally across regions and is not completely self-weighting. In the first stage of sampling, a total of 175 sampling points were selected from the 1991 census frame with probability proportional to size. The sample points corresponded to enumeration areas, and the measure of size used in the selection process was the number of households in the census enumeration areas. Lists of household heads for the selected enumeration areas were then obtained from the census office and the sample households were selected from these lists. A more detailed description of the sample design is presented in Appendix B. Fieldwork The NDHS field staff consisted of seven teams, each composed of four female interviewers, one female editor, and one male or female supervisor. The interviewers and editors were newly recruited for the survey, while supervisors were from the Ministry of Health and Social Services. Fieldwork was conducted from July to November 1992. The persons involved in the survey are listed in Appendix A. A more complete description of the fieldwork is presented in Appendix B. Table 1.1 Result of the household and individual interviews Number of households, number of interviews, and response rates, Namibia 1992 Result Urban Rural Total Households sampled 1642 3364 5006 Households found 1501 3011 4512 Households interviewed 1350 2751 4101 Household response rate 89.9 91.4 90.9 Table 1.1 is a summary of results Eligible women 2057 3790 5847 from the household and the individual Eligible women interviewed 1891 3530 5421 interviews. A total of 5,006 households Eligible women response rate 91.9 93A 92.7 were selected; of these,4,101 were success- fully interviewed. The shortfall is largely due to households being absent. This includes nine clusters not interviewed in Northeast region. One team in this region had experienced multiple problems and lagged considerably behind the other teams. In the interviewed households 5,847 eligible women were identified and 5,421 were successfully interviewed, for a response rate of 93 percent. More detailed information on the reasons for nonresponse are given in Appendix Table B.2. 6 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Information on the background characteristics of the households interviewed in the survey and the individual survey respondents is essential for the interpretation of survey findings and provides a rough measure of the representativeness of the survey. This chapter presents this information in three sections: characteristics of the household population, housing characteristics, and background characteristics of survey respondents. 2.1 Characteristics of the Household Population The NDHS collected information on all usual residents and visitors who spent the previous night in the household. A household was defined as a person or group of persons living together and sharing a common source of food. Age The age distribution of the household population in the NDHS is shown in Table 2.1 and Figure 2.1 by five-year age groups. The distribution conforms to the pattern characteristic of high fertility populations, Table 2.1 Household population by age, residence and sex Percem distribution of the de facto household population by five-year age groups, according to urban-rural residence and sex, Namibia 1992 Age group Urban R~M To~ MMe Female Total MMe Female ~ MMe FemaM ~ml 0-4 14.1 5-9 10.6 10-14 9.6 15-19 9.8 20-24 9.6 25-29 9.8 30-34 7.9 35-39 7.0 40-44 5.2 45-49 3.8 50-54 3.3 55-59 1.8 60-64 2.0 65-69 0.8 70-74 0.7 75-79 0.3 80 + 0.3 Missing/Don't know 3.3 Total 100.0 Number 3564 12.6 13.4 18.7 16.5 17.6 17.3 15.3 16,3 11.1 10.9 17.0 14.9 15.9 15.0 13.7 14.3 10.4 10.1 13.6 13.1 13.4 12.4 12.3 12.3 10.6 10.2 12.5 10.5 11.4 11.7 10.5 11.1 12.1 10.9 8.0 8.0 8.0 8.5 9.3 8.9 10.4 10.1 5.1 6.0 5.6 6.6 7.3 7.0 8.2 8.0 3.6 4.7 4.2 4,9 5,8 5.4 6.7 6.8 2.8 3.8 3.3 4.1 4.7 4.4 4.6 4.9 2.7 3.9 3.3 3.5 4.1 3.8 3.6 3.7 2.2 2.6 2.4 2.7 2.9 2.8 2.5 2.9 2.3 3.5 2.9 2.6 3.2 2.9 2.0 1.9 1.7 2.1 1.9 1.8 2.1 1.9 1.8 1.9 2.4 3.0 2,7 2.3 2,6 2.5 1.2 1.0 1.7 2.5 2.1 1.4 2.1 1.8 0.9 0.8 2.2 2.0 2.1 1,7 1.7 1.7 0.5 0.4 1.3 1.1 1.2 1.0 0.9 0.9 0.3 0.3 1.0 1.4 1.2 0.8 I.I 0.9 0.5 1.8 1.1 0,5 0.8 1.8 0.5 1.1 100.0 100.0 100.0 100.0 1~.0 100.0 100.0 1~.0 3906 7484 7915 8823 16749 11~8 12729 24~3 7 Age 80+ 75-79 70-74 65-09 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 - 10 Figure 2.1 Population Pyramid of Namibla Male ~ Female S 0 5 10 Percent NDHS1992 i.e., a much higher proportion of the population in younger than in older age groups. There is some evidence of heaping in the female age group 50-54 years; more women are reported at 50-54 years than at 45-49 years. This heaping does not occur among males in the same age group, which suggests that some interviewers may have pushed women out of the age range eligible for the individual interview. The magnitude of the displacement, however, is small. Moreover, an assessment of this phenomenon by Rutstein and Bicego (1990), indicates that the effects of misreporting at the upper and lower boundaries (age 15 and 49) are minimal. Household Composition While the majority of households in Namibia are headed by males (69 percent), almost a third are headed by women (see Table 2.2). The average household size in Namibia is 6 persons. Most households have three or more related adults (42 percent), or two adults of the opposite sex (23 percent). One in eight households has only one adult. There are two characteristics worth noting when comparing urban and rural households. First, female-headed households are just as common in urban areas as in rural areas; and second, large households are more common in rural areas than in urban areas. As a result, average household size is larger in rural (6.6) than in urban (4.9) areas. Table 2.2 Household composition Percent distribution of households by sex of head of household, household size, household structure, and presence of foster children, according to urban-rural residence and region, Nemibia 1992 Residence Region Characteristic Urban Rural Northwest Northeast Central South Total Household headship Male 68.8 69.3 62.5 78.9 72.0 72.2 69.1 Female 31.2 30.6 37.4 21.1 28.0 27.8 30.8 Number of usual members 1 11.1 7.2 3.5 2.8 19.5 11.1 8.6 2 17.0 8.8 6.8 3.0 21.2 16.0 11.8 3 10.9 10.3 7.5 6.7 14.5 13.5 10.5 4 15.0 10.5 10.4 9.7 12.5 14.9 12.1 5 12.5 10.1 10.9 10.4 10.2 11.6 10.9 6 9.3 10.4 10.7 10.5 8.5 9.7 10.0 7 7.1 8.8 9,9 9.1 4.5 7.8 8.2 8 4.3 8.5 10.9 7.0 3.7 3.9 7.0 9+ 12.8 25.4 29.3 40.7 5.5 11.5 20.9 Mean size 4.9 6.6 7.1 8.8 3.8 4.8 6.0 Household structure One adult 14.8 12.6 9.8 6.1 25.7 13.8 13.4 Two related adults: Of opposite sex 25.8 21.8 16.8 16.5 29.3 30.3 23.2 Of same sex 5.7 5.4 6.2 4.7 6.3 4.5 5.5 Three or more related adults 35.1 45.1 50.6 57.2 23.5 34.2 41.5 Other 18.7 15.1 16.5 15.5 15.2 17,3 16.4 Foster children I 20.3 46.4 53.7 44.8 22.7 21.3 37.0 Note: Table is based on de jure members, i.e. usual residents. 1Foster children are those under age 15 living in households with neither their mother nor their father present. The composition of households differs by region. Female-headed households are more common in the Northwest region and least common in the Northeast. Households are largest, on average, in the Northeast (8.8 persons per household) and Northwest (7.1 persons per household) regions, and much smaller in the Central (3.8 per household), and South (4.8 persons per household) regions. Households with one adult are most common in the Central region (26 percent). Thirty-seven percent of households include one or more children under age 15 who have neither their natural mother nor natural father living with them. It is more common in rural areas (46 percent) than in the urban areas (20 percent). The highest proportion of households with fostered children is found in the Northwest (54 percent) region, followed by the Northeast (45 percent), and Central/South (23 percent) regions. Education The current education system in Namibia entails seven years of primary education (Sub A, Sub B and Standard 1 to 5), followed by four years of secondary education. The education system was changed in the early eighties, when the number of years of primary education was reduced from 8 to 7, i.e., Standard 6 was abolished. To classify the levels of education for the NDHS analysis, primary education was divided into incomplete and completed primary education. Primary education was considered incomplete if the person did not go beyond 6 years of primary education. A person was considered to have completed primary education, if he or she had at least 7 years of primary education, but did not go on to secondary education. In the NDHS, information on educational attainment was collected for every member of the household (see Tables 2.3.1 and 2.3.2). One-fifth of the population (aged 5 and over) has received no formal education; 20 percent of males and 21 percent of females have never been to school; 51 percent of males and 49 percent of females have attended but not completed primary school, whereas 5 percent of males and 6 percent of females completed primary. Nineteen percent of males and 21 percent of females have attended secondary school but did not go on to higher education. Only 1 percent of males and 1 percent of females have obtained higher education. Among men 30-39 years about 5 percent have received higher education, as opposed to 3 percent of women. Table 2.3.1 Educational le~tet of the female household population Percent distribution of the de facto female household population age five and over by highest level of education attended, according to selected background characteristics, Namibia 1992 Background Some Completed Not characteristic None primary primary Secondary Higher stated Total Number Median Age 5-9 19.7 76.1 0.1 0.1 0.0 4.1 100.0 1328 0.9 10-14 4.9 90.1 2.3 1.9 0.0 0.9 100.0 1424 2.9 15-19 6.6 62.4 9.2 21.3 0.0 0.3 100.0 1338 5.5 20-24 11.5 37.9 7.8 40.2 0.7 1.8 100.0 975 7,0 25-29 15.8 29.9 7.0 40.4 4.1 2.9 I00.0 755 7.4 30-34 21.2 26.3 9.0 34.5 4.1 4.9 100.0 563 7.0 35-39 21,1 26.7 7.6 32.4 6,3 6,0 100.0 474 6.9 40-44 28.4 31.5 5.7 28.4 3.5 2.5 100.0 396 4.9 45-49 31.0 37.0 5.8 19.6 2.4 4.1 100.0 311 4.2 50-54 39.8 29.7 4.0 21.1 3.0 2.4 100.0 297 3.5 55-59 45.7 28.9 3.6 15.3 0.6 6.0 100.0 202 1.1 60-64 49.9 26.4 2.5 13.0 0.9 7.3 100.0 263 0.9 65+ 63.9 24.3 1.5 6.7 0.0 3.6 100.0 567 0.0 Missing/Don't know 26.4 12.0 2.7 15.1 0.0 43.8 100.0 208 2.2 Residence Urban 12.0 37.1 6.6 35.3 3.5 5.5 100.0 2985 6.7 Rural 24.2 57.4 4.2 11.0 0.4 2.9 100.0 6116 2.5 Region Northwest 18.8 65.2 3.0 9.7 0.4 2.9 100.0 3845 2.4 Northeast 16.8 55.3 6.2 18.2 0.3 3.1 100.0 1513 4.0 Central 36.9 32.1 5.4 20.3 1.1 4.1 100.0 1144 3.4 South 17.0 34,9 7.0 32.6 3.5 5.1 100.0 2598 6.3 Total 20.2 50.7 5.0 19.0 1.4 3.7 100.0 9101 3.7 10 Table 2.3.2 Educational level of the male household population Percent distribution of the de facto male household population age five and over by highest level of education attended, according to selected background characteristics. Namibia 1992 Background Some Completed Not characteristic None primary primary Seconda~ Higher stated Total Number Median Age 5-9 16.8 79.7 0.0 0.0 0.0 3.5 100.0 1370 1.0 10-14 3.7 90.6 2.9 2.1 0.0 0.7 100.0 1563 3,5 15-19 4.3 52.4 11,3 31,6 0.0 0.4 100,0 1342 6.6 20-24 7.3 32.2 10.3 48.5 1.1 0,6 100,0 1184 7.8 25-29 12.7 28.6 9.5 44.6 3.1 1,6 100,0 935 7.8 30-34 17.9 36.8 7.8 33,4 3.4 0.8 100.0 737 6.5 35-39 21.1 37.2 10.8 26.7 2.8 1.4 100.0 594 6.0 40-44 33.7 40.3 6.0 16.2 2.7 1.1 100.0 523 4.2 45-49 36.2 36.0 4,9 19.3 2.5 1.1 100.0 369 3.7 50-54 50.1 29,4 4.6 11.4 1,5 3.0 100.0 404 0.0 55-59 52.4 29.3 3.1 12,6 0.9 1.7 100.0 261 0.0 60&4 56.7 29.1 2.9 8.1 0.0 3.2 100,0 330 0.0 65+ 69.2 18.7 1.4 7.2 0.0 3.5 100.0 722 0.0 Missing/Don't know 35.0 6.4 0.0 5,6 0.0 53.0 100.0 63 0.6 Residence Urban 11.3 37.2 8.6 38.0 2.8 2.2 100.0 3320 7.0 Rural 25.3 55.0 4.8 12,9 0.3 1.7 100.0 7079 2.9 Region Northwest 19.3 57.9 5.2 15,7 0.4 1.6 100.0 4805 3.4 Northeast 25.4 55.3 5,1 12.1 0.0 2.1 1(30.0 1744 3.1 Central 34.0 36,9 3.8 22.0 1.2 2,1 100.0 1108 3,9 South 15.3 35,4 9.0 35.1 3.0 2.1 100.0 2741 6.7 Total 20.8 49.3 6.0 20,9 1.1 1.9 100,0 10399 4.2 Figure 2.2 shows the median number of years of education males and females by age group. Both sexes show a rapidly increasing level of education for the more recent age cohorts to a median of about 7 years of education at 25-29 years. The levels of educmion of younger age groups (20-24 and 15-19 years) indicate a further increase will be achieved when these cohorts have completed their education. While males have more education in the older age groups, reflecting the situation a few decades ago, women have more education in the younger age groups (25-29 years and below). This suggests that the level of education among females has increased more rapidly than among males. The proportion of persons with no education is much higher in the rural areas than in urban areas, and this difference is seen for beth males and females. Rural residents are twice as likely to have never attended school (25 percent) as urban residents (11 percent). Overall, regional differences in education are small. The overall level of education is somewhat higher in the South region and the proportion with no schooling is higher in the Central region. However, children who started school in the Central and South regions were much more likely to finish primary education and continue at the secondary level. 11 Figure 2.2 Median Number of Years of Education by Sex and Age Median Years of Educat ion 10 6 4 2 0 5 - 10 - 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 9 14 19 24 29 34 39 44 49 54 59 64 Age NDHS 1992 Table 2.4 presents enrolment rates by age, sex and residence. Eighty-two percent of children age 6- 15 years are enrolled in school. The enrolment is equally high in urban and rural areas at age 6-15 years. Enrolment after age 15 drops, but 61 percent are still enrolled at 16-20 years and 23 percent at 21-24 years. The drop is greater in urban areas than in rural areas. Male/female differences are small; there is slightly higher female enrolment at 6-15 years. After age 15, however, male enrolment is clearly higher than female enrolment. Table 2.4 School enrolment Percentage of the de facto household population age 6-24 years enrolled in school, by age group, sex, and urban- rural residence, Namibia 1992 Age group Male Female Total Urban Rural Total Urban Rural Total Urban Rural Total 6-10 73.4 74.4 74.2 76.8 79.3 78.7 75.0 76.9 76.5 11-15 88.0 87.6 87.7 90.8 89.4 89.8 89.4 88.5 88.7 6-15 80.4 80.5 80.5 83.5 84.0 83.9 81,9 82.3 82.2 16-20 61.8 69.0 67.1 46.5 59.2 55.1 53.2 64.2 60.9 21-24 14.8 32.0 25.6 15.7 23.6 20.3 15.3 27.4 22.7 12 2.2 Housing Characteristics In order to assess the socioeconomic conditions under which respondents live, women were asked to give specific information about their household environment. Table 2.5 presents this information for all households in which women were interviewed, and Figure 2.3 displays selected results by region. (Although the questions on household characteristics were asked in the individual questionnaire, Table 2.5 has been tabulated to represent households; i.e., households with more than one eligible woman were still counted only once). Overall, 26 percent of households in Namibia have electricity. While electricity is available in the majority of urban households (66 percent), it is found in only a small number of rural households (4 percent). Electricity is rarely in households in the northern regions. Sources used by households to obtain drinking water differ greatly by area of residence. In urban areas, piped water is the primary source of drinking water: 82 percent have water piped into their residence or yard and 15 percent obtain water from a public tap. In rural areas, piped wateris used by about 35 percent of the households mostly from public taps. Water from a public well or well in the residence is the leading source of drinking water in rural areas (37 percent). Rivers and streams are used by 10 percent of rural households. While piped water is the most common source in the Central and South regions (76 and 87 percent, respectively), wells are the most common source in the Northwest (46 percent) region and rivers/streams are the leading source of drinking water in the Northeast (39 percent) region. Regarding sanitation facilities, four of five urban households have their own flush toilet; 11 percent have no facility and use the bush (i.e., natural landscape). In rural areas, use of the bush is most common: 84 percent of households have no sanitation facilities; 8 percent have a pit latrine; 6 percent have a flush toilet; and I percent use a bucket. Regionally, 85 percent of households in the Northwest have no sanitation facilities, 90 percent in the Northeast, 43 percent in the Central region, and 21 percent in the South. The flooring material of dwelling units is usually earth/sand (49 percent) or cement (25 percent). Dirt floors (earth/sand, palm/bamboo, or dung) were found in 10 percent of urban households, while 80 percent of rural households had earth/sand, dung or palm or bamboo floors. Dirt floors are less common in the Central and South regions (28 and 10 percent, respectively), but predominate in the other regions (93 percent in the Northwest and 86 percent in the Northeast). Information was collected on the number of rooms households use for sleeping (as a measure of crowding). On average, 2.3 persons sleep in one room in Namibia. There was little diversity according to residence and region. In approximately one-fifth of households three or four persons share a room for sleeping; however, in more than 70 percent of households the average is one or two persons. Sleeping density is highest in the Northeast region (2.9 persons per room) and lowest in the Northwest and Central regions (2.1 persons per room). 13 Table 2.5 Housin~ chaxacl~risflcs Percent distribution of households with eligible women by housing characteristics, according to urban-rural residence and region, Namibia 1992 Residence Region Chexact~ds fl¢ Urban Rural Northwest Northeast Central South Total Electricity Yes 66.0 4.2 3.6 6.6 41.8 53.6 26.4 No 33.7 95.5 96.1 93.1 57.5 46.2 73.2 Source of drinking water Piped into residence 81.8 13.0 6.0 9.1 50.0 80.8 37.7 Public tap 14.6 21.7 24.0 27.9 25.8 6.4 19.2 Well in residence 0.8 9.4 13.9 0.3 1.7 1.4 6.3 Public well 1.7 27.8 31.9 15.8 18.0 3.0 18.4 Spring 0.1 5.8 8.8 0.0 1.3 0.2 3.8 River, sla~am 0.4 10.4 5.3 38,8 0.2 0.7 6.8 Pond, lake 0.0 2.4 3.3 2.1 0.0 0.0 1.5 Dam 0.0 5.3 3.4 1.2 1.5 5.2 3.4 Rainwater 0.0 0.1 0.1 0.0 0.0 0.0 0.0 Tanker truck 0.0 0.9 0.6 0.4 1.2 0.4 0.6 Borehole 0.0 1.2 0.2 3.9 0.0 0.8 0.8 Other 0.4 1.7 2.2 0.0 0.2 1.0 1.2 Missing/Don 't know 0.3 0.2 0.3 0.5 0.2 0.2 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Sanitation facility Own flush toilet 82.8 5.6 3.5 8.0 50.2 70.5 33.4 Trad. pit toilet 2.7 7.8 10.6 1.4 5.2 2.2 5.9 Vent.imp.pit latrine 0.6 0.4 0.1 0.4 1.2 0.6 0.5 Bucket 2.5 1.8 0.2 0.3 0.7 5.8 2.1 No facility, bush 11.1 84.2 85.3 89.8 42.5 20.6 57.9 Other 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Missing/Don't know 0.3 0.2 0.2 0.2 0.3 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Flooring Earth, sand 8.5 72.3 93.3 60.1 18.5 7.6 49.3 Dung 1.1 5.9 0.0 23.0 6.7 1.1 4.1 Wood planks 1,8 0.4 0.2 1.6 0,3 1.9 0,9 Palm, bamboo 0.1 1.6 O. 1 2.9 2.2 1,1 1.1 Parquet, polished wd 0.3 0.1 0.0 0.0 0.2 0.4 0.2 Vinyl, asphalt strips 6.0 0.6 0.0 0.2 0.7 7.6 2.5 Ceranfic flies 11.7 0.4 0.9 1.5 9.2 7.6 4.5 Cement 38.7 16.9 4.3 8.7 45.7 4zL5 24.7 Carpet 30.9 1.4 0.8 1.1 16.0 27.7 12.0 Other 0.1 0.0 O. 1 0.0 0.0 0.1 O. 1 Missing/Don't know 0.8 0.3 0.3 1.0 0.7 0.4 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Persons per sleeping room 1-2 70.3 74.7 81.6 55.9 71.8 69.6 73.1 3-4 19.7 19.3 15.3 32.7 18.8 20.1 19.4 5-6 6.5 4.0 2.2 7.9 5.5 6.8 4.9 7 + 2.4 1.3 0.4 3.0 2.5 2.3 1.7 Missing/Don't know 1.1 0.7 0.5 0.5 1.3 1.2 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Mean 2.3 2.2 2.1 2.9 2.1 2,3 2.3 Number of households 1476 2625 1615 475 705 1307 4101 14 Figure 2.3 Housing Characteristics by Region Percent of Households 100 80 60 40 20 0 Electricity Piped Water Toilet Facilities Note: Piped water Includes public tap; toilet facilities Include flush, latrine and bucket. NDHS1992 Household Durable Goods Respondents were asked about ownership of particular household goods (radio, television and refrigerator) and modes of transportation (donkey cart, bicycle, motorcycle and car). The results presented in Table 2.6 indicate that 66 percent of households own a radio (78 percent in urban areas, 59 percent in rural areas) and 19 percent own a television (47 percent in urban areas, 3 percent in rural areas). Televisions and refrigerators are largely restricted to urban areas and the Central and South regions, due to the lack of electricity in rural areas and in the northem regions. Donkey carts are owned by 11 percent of households, mainly in the rural areas. One-fifth of households own a bicycle, and 2 percent own a motorcycle. Twenty- three percent of households own a car, including 40 percent of urban households and 13 percent of rural households. Slightly more male-headed households possess the durable goods listed in Table 2.6 than female-headed households, and twice as many male- as female-headed households have cars. Table 2.6 Household durable goods Percentage of households with eligible women possessing various durable consumer goods, by urban-rural residence and sex of head of household. Namibie 1992 Residence Head of household Possession Urb~m Rural Female Male Total Radio 78.4 58.7 60.5 68.2 65.8 Television 46,5 2.7 15.3 19,9 18.5 Refrigerator 56.8 5.0 20.4 25,1 23.6 Donkey cart 2.4 15.6 6.1 13,0 10.9 Bicycle 17.3 21.1 14.2 22,2 19.7 Motorcycle 2.9 0.8 0.7 1,9 1.5 Private car 39.6 13.4 13.2 27.1 22,8 Number of households 1476 2625 1265 2836 4101 15 2.3 Background Characteristics of Survey Respondents General Characteristics Women were asked two questions in the individual interview to assess their age: "In what month and year were you born?" and "How old were you at your last birthday?" Interviewers were trained in probing tech- niques for situations in which respondents did not know their age or date of birth; and as a last resort, interviewers were instructed to record their best estimate of the respondent's age. The five-year age distribution is shown in Table 2.7. The data in Table 2.7 indicate that 42 percent of NDHS respondents are currently in a union (27 married and 15 percent living to- gether), 51 percent have never been married, 5 percent are divorced or separated, and 1 percent are widowed. The percentage of women who are currently married or in union is low. In Namibia, various forms of relation- ships are found in which the partners do not live together. Marriage patterns are discussed in detail in Chapter 5. About one in seven respondents has never attended school (15 percent), 9 percent have completed only primary school, and 37 percent have some secondary schooling (in- cluding 2 percent who have gone for school- ing beyond the secondary level). Although urbanisation appears to be increasing, the population is still predomi- nantly rural; two-thirds of respondents live in rur~ areas. The data indicate that almost half of the respondents live in the Northwest region, 30 percent live in the South, 12 per- cent in the Central region, and 16 percent in the Northeast. Most women report themselves to be Christians; 72 percent are Protestants and 26 percent Roman Catholics. The most commonly spoken language is Oshiwambo; 48 percent of women said Oshiwambo was spoken in their household. 'Fable 2.7 Background characteristics of respondents Percent distribution of women by seieoted background characteristics, Natrdbia 1992 Number of women Background Weighted Un- characteristic percent Weighted weighted Age 15-19 23.2 1259 1291 20-24 20.6 1119 1131 25-29 16.4 890 878 30-34 13.3 722 719 35-39 10.5 567 547 40-44 9.3 507 506 45-49 6.6 358 349 Marital status Never manned 51.3 2783 2708 Married 27.1 1471 1570 Living together 14.5 788 727 Widowed 1.4 77 84 Divorced 3.3 181 216 Separated 2.2 119 114 Education No education 14.5 785 799 Some primary 39.0 2113 2163 Completed primary 9.4 510 511 Secondary/Higher 37.1 2013 1948 Residence Urban 38.3 2077 1891 Rural 61.7 3344 3530 Region Northwest 41.4 2246 2149 Northeast 16.2 879 1360 Central 12.4 674 561 South 29.9 1622 1351 Religion Catholicism 25.9 1404 1451 Protestantism 72.3 3920 3874 No religion 1.3 69 69 Other religion 0.1 5 4 Not stated 0.4 24 23 Language spoken English 0.7 38 33 Afrikaans 11.4 615 516 Oshiwambo 48.2 2612 2451 Damara/nama 14.6 789 657 lierero 6.2 336 280 Kwangali 3.4 184 228 Lozi 2.9 158 307 'l'sw~ma 0.5 25 21 San 1.0 54 46 German 0.5 28 23 Other 10.6 575 852 Not stated 0.1 7 7 Head of household Female 30.0 1625 1589 Male 62,5 3389 3444 Visitor 7.5 407 388 Total 100.0 5421 5421 16 The second most common language is Damara/Nama (15 percent), followed by Afrikaans (11 percent), Herero (6 percent), Kwangali (3 percent) and Lozi (3 percent). Eleven percent of respondents spoke languages other than the ten precoded languages in Table 2.7. Differentials in Education Table 2.8 shows the distribution of the surveyed women by education, according to selected background characteristics. Education is inversely related to age; that is, older women are generally less educated than younger women. For example, 36 percent of women aged 45-49 have had no formal education, whereas only 4 percent of women aged 15-19 have never been to school. Twice as many rural women as urban women have not received any education (18 percent versus 9 percent). Only one-fourth of rural women go on for secondary schooling compared to over half of urban women. The Central region has the highest proportion of women with no education, although a higher proportion of women continue on to the secondary level than in the Northeast and Northwest regions. Over half of all respondents in the South have some secondary education. Table 2.8 Levelofeducation Percent distribution of women by highest level of education attended, according to selected background characteristics, Namibia 1992 Level of education Number Background Some Completed of characteristic None primary primary Secondary Tota l women Age 15-19 3.7 52.3 11.3 32.7 100.0 1259 20-24 7.0 33.6 9.9 49.5 100.0 1119 25-29 12.5 29.5 9.6 48.4 100.0 890 30-34 17.4 36.4 8.2 37.9 100.0 722 35-39 21.8 36.9 10.8 30.5 100.0 567 4044 33.5 40.5 6.7 19.3 100.0 507 45-49 36.3 38.7 4.6 20.4 100.0 358 Residence Urban 8.8 23.4 10.9 56.9 100.0 2077 Rural 18.0 48.7 8.4 24.8 100.0 3344 Region Northwest 11.2 49.0 8.8 31.0 100.0 2246 Northeast 18.6 49.5 9.2 22.8 100.0 879 Central 28.3 31.7 5.2 34.8 100.0 674 South 11.1 22.4 12.1 54.4 100.0 1622 Total 14.5 39.0 9.4 37.1 100.0 5421 17 Access to Mass Media Women were asked i f they usually listen to the radio or watch television at least once a week. This information is important to programme planners seeking to reach women with family planning and health messages through the media. Overall, four-fifths of women listen to the radio weekly and one-fifth watch television; about half of the women read the newspaper at least once a week (see Table 2.9). Media access differs little by age. Urban women have the greatest access, although 76 percent of rural women listen to the radio. A much higher proportion of educated women, women in urban areas, and women in the South watch television, listen to the radio and read the newspaper. Table 2.9 Access to mass media Percentage of women who usually read a newspaper once a week, watch television once a week, or listen to radio once a week, by selected background characteristics, Namibia 1992 Read Watch Listea~ to Number Background newspaper television radio of characteristic weekly weekly weekly women Age 15-19 56.7 22.0 78.5 1259 20-24 59.3 25.2 85.1 1119 25-29 57.1 26.3 83.8 890 30-34 52.3 31.1 79.7 722 35-39 48.8 27.5 80.7 567 40-44 42.6 19.3 75.0 507 45-49 43.5 22.9 77.9 358 Education No education 5.6 7.1 64.2 785 Some prlmary 43.0 11.6 74.6 2113 Completed primary 62.7 25.3 85.3 510 Secondary/Higher 81.5 45.9 92.5 2013 Residence Urban 72.9 54.4 88.9 2077 Rural 41.8 6.7 75.7 3344 Region Northwest 48.2 6.3 74.2 2246 Northeast 39.7 9.6 83.7 879 Central 44.2 30.1 78.8 674 South 73.0 57.0 89.1 1622 Total 53.7 25.0 80.8 5421 18 CHAPTER 3 FERTILITY The fertility measures presented in this chapter are based on the reported reproductive histories of women age 15-49 interviewed in the NDHS. Each woman was asked the number of sons and daughters living with her, the number living elsewhere, and the number who had died. She was then asked for a history of all her births, including the month and year each was born, the name, the sex, and if deceased, the age at death, and if alive, the current age and whether he/she was living with the mother. Based on this information, measures of completed fertility (number of children ever born) and current fe~lity (age-specific rates) are examined. These measures are also analysed in connection with various background characteristics. 3.1 Current Fertility The current level of fertility is the most important topic in this chapter because of its direct relevance to population policies and programmes. Three-year age-specific fertility rates are presented in Table 3.1. Three-year rates are calculated as a compromise between three criteria: to provide the most current information, to reduce sampling error, and to avoid problems noted in earlier DHS surveys of the displacement of births from five to six years preceding the survey. Numerators for the age-specific fertility rates in Table 3.1 are calculated by isolating live births which occurred during the period 1-36 months preceding the survey (determined from the date of interview and date of biV.h of the child), and classifying them by the age (in five- year age groups) of the mother at the time of birth (determined from the date of birth of the mother). The denominators for the rates are the number of woman-years lived in each of the specified five-year age groups during the period 1-36 months preceding the survey. The sum of the age-specific fertility rates, i.e., the total fertility rate (TFR), is used to Talile 3.1 Currant fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-rural residence, Namibia 1992 Residence Age group Urban Rural Total 15-19 110 108 109 20-24 172 231 207 25-29 192 279 241 30-34 154 249 208 35-39 114 204 166 40-44 46 135 105 45-49 10 53 37 TFR 15-49 4.0 6.3 5.4 TFR 15-44 4.0 6.0 5.2 GFR 143 197 176 CBR 43 42 42 TFR: Total fertility rate expressed prx woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased duo to truncation. summarise the current level of fertility. It can be interpreted as the number of children a woman would have by the end of her childbearing years if she passed through those years bearing children at the currently observed rates. If fertility remained constant at current levels, a Namibian woman would give birth to an average of 5.4 children. Figure 3.1 compares the total fertility rate in Namibia (among women 15-44 years) with 13 other countries in sub-Saharan Africa with DHS surveys. Total fertility rates range from about 5 to 7 children per woman, with the three surveys in southern Africa having the lowest fertility levels. 19 Figure 3.1 Total Fertility Rate among Women 15-44 DHS Surveys in Sub-Saharan Africa, 1986.1992 Botswana Namib ia Z imbabwe N iger ia Tanzan ia Ghana Togo Senega l Zambia L~berla Kenya Burund] Mal l Uganda • . . 4 .8 ' 5 .2 . . . - . . . ~ : . . 5 .3 . . . . . . . . . . - . . . . . 5.7 . . . . . . . . - - . - . - . . . . . . 9 . 1 ~ . . . " : . 6,1 L . . . . . . . ~, . . . . . . . 6.1 ~ f ~ . . \ . . . . . . s.4 i . . . . . . . . . : - - ' f ~. . . . . . . . . 9.5 ~" " ~ " . ~ " - - 6.9 • ~ - ~ . . , . . ~ 7.2 2 4 6 Total Fert i l i ty Rate Note : Rates are for the per iod 0-3 years preceding preceding the surveys. NDHS 1992 There are marked differences between urban and rural areas. Urban age-specific fertility rates are considerably lower for all age groups, except the young- est. The TFR for urban women is 3.9 (children per woman) compared with 6.3 children for rural women. The crude birth rate (CBR) presented in Table 3.1 is the annual number of births in a population per 1,0/X) persons. The CBR can be estimated from the birth history data and the age-sex distribution of the house- hold population. Overall, there were about 42 births per thousand population over the last three years, according to the NDHS. The 1991 census results indicated a popu- lation growth rate of 3.0 percent from 1981 to 1991. This would imply that the crude death rate in Namibia is approximately 12 per 1,000 population. Table 3.2 presents three-year total fertility rates by residence, region and the respondent's level of edu- cation. Large regional differences in the total fertility rate exist with the Central/South regions having a TFR Table 3.2 Fertiliv/bybackgroundcharaeterisfies Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 40-49, by selected background eharacterlsties, Namibia 1992 Mean number of children Total ever born Background fertility to women chareeteristic rate 1 age 40-49 Res idence Urban 4.0 4.7 Rural 6,3 6.2 Region Northwest 6.7 6.5 Northeast 6.0 6.6 Central/South 4.1 4.6 Educat ion No education 6.6 6.3 Some primary 6.1 6,1 Completed primary 5.2 5.5 Secondary/Higher 4.1 4, i Total 5.4 5.7 IWomen age 15-49 years 20 of 4.1, the Northwest 6.7 and the Northeast region 6.0. t The pattern of fertility by age varies by region (see Figure 3.2). Women in Northwest region have a high fertility plateau between age 25 and 39, women in Northeast region commence childbearing earlier than those in other regions, and women in Central and South regions have a much lower fertility rate from age 25 onward. Increasing level of education is associated with reduced fertility. The TFR is 6.6 among women with no education, 6.1 among women with less than 7 years of primary education (primary incomplete, up to standard 4), 5.2 among women with 7-8 years of primary education (completed Standard 5 or 6), and 4.1 among women with at least some secondary education. Figure 3.2 Age-Specific Fertility Rates by Region Births per 1000 Women 3SO 30O 250 200 150 IO0 50 0 15-10 20-24 25-29 30-34 35-39 40-44 45-49 NDHS1992 Fertility trends can be analyzed in different ways. One way is to compare NDHS data with previous surveys; however, no national data are available for the period before independence. At that time, the country was divided into administrative units by the South African colonial adminisU'ation, and no national survey was conducted. Fertility trends can also be estimated based on NDHS data alone. Table 3.2 shows the mean number of children ever born to women 40-49 years. These women have completed their childbearing years, or are near to doing so. The total number of children born to these women is a reflection of fertility levels in the past 20-25 years. In general, current fertility levels (indicated by the TFR) are slightly lower than the mean number of children born to women 40-49 years, suggesting a small fertility decline. The difference is greatest in urban areas, and in the Northeast and Central/South regions, but none of the differences between TFR and children ever born is larger than one child. The NDHS sample was designed to provide estimates of fertility and mortality for three regions in Namibia: Northwest, Northeast, and Central/South. 21 Table 3.3 shows the age-specific fer- tility rates for five-year periods preceding the survey. The fertility rates are declining in all age groups except the youngest. The trend in fertility during the past two decades can be estimated by considering fertility among women 15-34 years (since there are no older women in the more distant periods). Over the last 20 years there is a gradual decline in cumulative fertility among women 15-34 years from 4.6 to 3.7. Table 3.4 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. Childbearing early in marriage oRen remains resilient to change, even when fer- tility is declining, because fertility decline Table 33 Age.- speciflc far tltity rates Age-specific fertility ratas for five-year periods preceding the sutwey, by mother's age, NamJ.bla t992 Number of years preceding the survey Mother's age 0-4 5-9 10-14 15-19 15-19 101 96 107 t 14 20-24 197 210 226 271 25-29 236 243 262 274 30-34 197 226 245 [253] 35-39 171 188 [224] 40~14 99 [132] 45-49 [381 Note: Age-specific fertility rates are per 1,000 women. Estimates enclosed in brackets are truncated. usually begins at older ages (when women start to limit the number of births), not among young couples postponing births. However, Table 3.4 shows a recent decline in fertility, even formarriages of short duration. 3.2 Children Ever Born and Living In the NDHS questionnaire, the total number of children ever born was ascertained by a sequence of questions designed to maxi- mise recall. The distribution of women by number of children ever born is presented in Table 3.5 for all women and for currently married women. The mean number of chil- dren ever born for all women increases rapid- ly with age, so that by the end of her child- bearing years, a woman has given birth to six children. The distribution of women by num- ber of births indicates that almost one-fifth of teens have already borne a child, and more than one-third of women age 45 and over have borne at least eight children. Table 3.4 Fartility by marital duration Fertility rates for evez-married woman by duration (in years) since first marriage, for five-year periods preceding the survey, Namibia 1992 Marriage duration at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 0-4 278 300 322 362 5-9 225 272 286 299 t0-14 202 227 261 252 15-19 161 192 243 [346] 20-24 106 177 [201] 25-29 49 [96] Note: Fertility rates are per 1,000 women. Estimates enclosed in brackets are truncated. In Namibia, childbearing is not confined to marriage; more than half of the women 15-49 have never been married (see Table 2.7). The NDHS data indicate that women had on average one living child at age 20-24, three living children at 30-34 and five living children at 40-44 years. The parity distribution for older, currently married women also provides a measure of primary infertility. Voluntary childlessness is rare in most of Africa, and married women with no live births are most likely unable to bear children. The NDHS results suggest that about 2 to 3 percent of Namibian women are unable to bear children. 22 Table 3.5 Children ever born and living Percent distribution of all women and of currently married woman by number of chikh-en ever born (CEB) and mean number evez born and living, according to five-year age groups, Namibia 1992 Number of children ever born (CEB) Number Mean no. Mean no. Age of of of living group 0 1 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN 15-19 82.3 16.4 1.1 0.3 0.0 0.0 0,0 0.0 0.0 0.0 0.0 100.0 1259 0,19 0.18 20-24 36.7 36.7 17.3 6,4 2.4 0.5 0,1 0.0 0,0 0.0 0.0 100.0 1119 1.03 0.94 15-29 18.6 20.7 22,0 22.4 10,3 4.0 1.5 0.5 0.0 0,0 0.0 100.0 890 2.06 1.88 30-34 7.2 12.3 16.1 19.6 16.3 12.5 8,4 4.9 1.6 0.7 0.5 I00.0 722 3.39 3.07 35-39 4.4 6.4 10,9 12.8 16.1 13.1 14,3 9.5 5.9 4.8 1.8 100.0 567 4.5S 4,12 40-44 3.7 4,6 8,1 11.8 11,2 10.2 10,0 12.7 8,7 8.4 10 .7 100,0 507 5.62 4.97 45-49 3.4 5.5 8.9 8,1 11.3 9,8 9,4 10,4 11.8 8,1 13.4 100.0 358 5.83 5.13 Total 31.7 17.9 12.1 10.6 7.8 5,4 4,4 3,6 2.4 1.9 2.1 1OO.0 5421 2.44 2,19 CURRENTLY MARRIED WOMEN 15-19 37.3 55.5 5.7 1,5 0,0 0,0 0.0 0.0 0.0 0.0 0,0 100.0 86 0,71 0.68 20-24 13.0 36.8 27.9 15.3 5.7 0.9 0.3 0.0 0.0 0.0 0.0 100.0 307 1.68 1.52 25-29 10.9 18.2 22.8 28.9 11.1 5.6 2,1 0.3 0.0 0.0 0.0 1(30.0 414 2.38 2.18 30-34 4.7 8,8 13.7 20,4 16.7 15.7 10,5 6.2 1,7 1.0 0.5 100.0 459 3.78 3,43 35-39 3.1 7.2 10.9 11.8 14.8 14.1 14.7 9.9 6.7 4,8 1.9 100.0 397 4.69 4.22 40-44 1.9 2.6 8,4 11.2 10.1 10.4 9,6 13.8 8.9 9.8 13 ,3 100.0 345 6,05 5.41 45-49 2.6 3,8 8.6 8,0 11.0 8,6 7.9 12,4 13,2 9.3 14.7 100.0 251 6.16 5.44 Total 7.3 14,3 15.1 16,2 11.6 9.4 7,5 6.5 4,4 3.6 4.1 100.0 2259 3.89 3.50 3.3 Birth Intervals There has been a large amount of research to indicate that short birth intervals are deleterious to the healthofbabies. Thisispartieularlytrueforbabiesbomatintervalsoflessthan24months, Table 3.6shows the percent distribution of births in the five years preceding the survey by the number of months since the previous birth. More than one-fifth of births were born after an interval of less than 24 months. The median birth interval length is 33.5 months. Short birth intervals are more common if the previous child died early in life. The death of the child leads to truncation of breastfeeding, which leads to earlier resumption of fecundity. In addition, the parents often want another child quickly to replace the dead child. The proportion of births in the last five years with preceding births intervals of less than 24 months drops from 22 to 20 percent if children whose preceding sibling has died are excluded. Although the table indicates that a high proportion of births to teens were preceded by short intervals, this does not reflect the actual situation of most teen births because the table excludes first births (which are the majority of teen births). Birth intervals are somewhat longer in urban areas and in the Central/South region where the means are 38 and 37 months, respectively. This is due to a larger proportion of very long intervals (4 years or more) in these areas. 23 Table 3.6 Birth intervals Percent distribution of births in the five years preceding the survey by number of months since previous birth, according to demographic and soeineconomic characteristics, Namibia 1992 Number of months since previous birth Characteristic 7-17 18-23 24-35 36-47 48+ Median number of Number months since of Total previous birth births Age of mother 15-19 * * * * * * * 19 20-29 11.6 14.7 38.9 15.7 19.1 100.0 31.2 1143 30-39 8.3 10.7 35.7 16.8 28.5 100.0 35.0 1206 40 + 9.8 7.7 32.1 14.8 35.6 100.0 37.2 460 Birth order 2-3 8.6 12.3 33.9 17.0 28.2 100.0 35.0 1283 4-6 10.7 11.8 37.8 14.7 24,9 100.0 33.0 996 7 + 11.6 11.3 40,2 15.8 21.2 100.0 32.2 550 Sex of prior birth Male 10,0 12.1 36.3 15.9 25.6 100.0 33.5 1396 Female 9.8 11.8 36.6 15,9 25.8 100.0 33.6 1432 Survival of prior birth Living 8.0 11.8 37.3 16.4 26.5 100.0 34.1 2581 Dead 29.8 14.0 28.2 10.9 17.1 100.0 26.9 247 Residence Urban 10.8 10.4 25.8 15.5 37.4 100.0 38.2 877 Rural 9.5 12.7 41.3 16.1 20.4 100.0 32.2 1951 Region Northwest 8.8 13.2 43.6 14.8 19.7 100.0 31.6 1275 Northeast 8.0 10,7 39.4 19.9 22.0 100.0 34.6 534 Central 13.0 10,6 25.7 14.8 35.9 100.0 37.3 341 South 12.0 11.3 26.2 15.6 34.9 100.0 37.2 678 Education No education 9.8 11.9 35.3 15.7 27.3 100.0 353 592 Some primary 10.0 10.5 39.8 16.8 23.0 100.0 32,8 1221 Completed primary 9.9 13.0 38.6 15,7 22.8 100.0 32.1 276 Secondary/Higher 10.0 14.1 31.1 14.8 30.0 100.0 34.2 739 Total 9.9 12.0 36.5 15.9 25.7 100.0 33.5 2828 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. * Based on too few cases to show 24 3.4 Age at First Birth The age at which childbearing begins has important demographic consequences as well as important consequences for the mother and child. In many countries, postponement of first births, reflecting an increase in the age at marriage, has contribu~d greatly to overall fertility decline. Table 3.7 presents the distribution of Namibian women by age at first birth, according to their current age. Among women currently of age 20, about 40 percent became mothers before the age of 20, of which 2-3 percent gave birth before age 15, and 14-18 percent gave birth between age 15 and 17. There has been little change in the median age at first birth, which is about 21 years. Table 3.7 Age at fin'st birth Percent distribution of women 15-49 by age at flu-st birth, according to current age, Nan'tibia 1992 Current age Women Median with Age at first birth Number age at no of first births <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 82.3 1.0 10.1 6.6 NA NA NA 100.0 1259 a 20-24 36.7 1.6 16.2 23.8 15.6 6.1 NA 100.0 I110 a 25-29 18.6 1.7 15.0 22.2 16.7 18.2 7.6 100.0 890 21.2 30-34 7.2 3.8 18.5 22.2 17.0 17.0 14.3 100.0 722 20.5 35-39 4.4 2.6 15.7 21.3 23.6 16.2 16.4 100.0 567 20.7 40-44 3.7 3.1 16.9 17.9 21.4 18.2 18.9 100.0 507 21.1 45-49 3.4 3.0 12.1 12.9 21.8 22.4 24.5 100.0 358 22.0 NA = Not applicable aLess than 50 percent of the women in the age group x to x+4 have had a birth by age x 25 Table 3.8 summarises the median age at first birth for different cohorts and compares the entry age into parenthood for different subgroups of the population. (Medians for cohorts 15-19 and 20-24 could not be determined because most women have not yet had a birth.) Findings for older women should be interpreted with caution; for example, the higher medians for older women in Northwest may reflect omission or misdating of early births, rather than a genuine trend. There are only small differences between the various subgroups with two exceptions; women in the Northeast and Central/South regions have their first birth slightly earlier (means of 19.7 and 19.8 years, respectively), and women with at least some secondary education give birth for the first time somewhat later (mean 22.7 years). There is no evidence of a change in the age at first birth in Namibia during the past two decades. Table 3.8 Median age at first birth by background characteristics Median age at first birth among women age 20-49 years, by current age and selected b~kground characteristics, Namibia 1992 Current age Women Background age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 21.2 20.5 20.6 20.5 21.3 20.8 Rural 21.2 20.6 20.9 21.6 22.6 21.3 Region Northwest 23.1 22.1 21.6 22.4 23.5 22.6 Northeast 19.7 19.4 19.5 20.4 20.1 19.7 Central 19.5 19.5 20.5 20.0 20.8 19.8 South 21.2 20.6 20.5 20.4 21.5 20,8 Education No education 19.5 19.3 20.6 20,8 21.3 20.3 Some primary 19.9 19.8 20.5 20.9 21.8 20.4 Completed primary 20.5 19.6 20.6 (20.6) (21.7) 20.5 Secondary/Higher 23.5 22.4 21.1 21.9 24,1 22.7 Total 21.2 20.5 20.7 21.1 22.0 21.0 Note: The median for cohort 15-19 could not be determined because some women may still have a birth before reaching age 20. Figures in parentheses are based on a small number of cases. 26 3.5 Teenage Pregnancy and Motherhood Table 3.9 and Figure 3.3 show the percentage of women age 15-19 who are mothers or pregnant with their first child. About 36 percent of teenagers 18 years of age and 19 percent of teens 17 years of age have begun childbearing (have already given birth, or are pregnant with their first child). Early childbearing is common in the Northeast (35 percen0, Central (27 percent), and South (29 percent) regions, but not in the Northwest, where only 12 percent of the teenagers are mothers or pregnant. It is also much more common among teens with no education; almost half of these teenagers have a child or are pregnant, compared to 20 percent of teens with some education. Table 3.9 Teenage pregnancy and motherhood Percentage of women age 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Namibia 1992 Percentage who are: Percentage who have Pragnmat begun Number /]ackground with first child- of characteristic Mothers child bearing teenagers Age 15 0.9 0.4 1,3 267 16 5.4 0.9 6.3 229 17 14.7 4.1 18.7 262 18 29.5 6.5 36.0 250 19 38.5 6.9 45.4 251 Residence Urban 19.2 5.0 24.1 381 Rural 17.1 3.3 20.4 878 Region Northwest 9.6 2.4 12.0 620 Northeast 30.8 4.4 35.3 227 Central 21.0 6.0 27.0 120 South 23.5 5.3 28.8 292 Education No education (39.3) (10.3) (49.6) 46 Some primary 16.8 3.7 20.5 659 Completed primary 19.4 1.0 20.4 142 Secondary/Higher 16.2 4.1 20.3 411 Total 17.7 3.8 21.5 1259 Note: Hgures in parenthese are based on a small number of c~es. 27 Figure 3.3 Percentage of Teenagers Who Have Begun Childbearing by Age Percent 50 40 30 20 10 0 15 16 17 18 Age ln Years 19 NDHS1992 28 CHAPTER 4 FERTILITY REGULATION One of the key areas of the Ministry's Development Programme after independence was the improvement of maternal and child health and family planning services. This was in recognition of the fact that women of child bearing age and children under five years of age constitute about 40-45 percent of the population. These two groups are considered to be vulnerable because of their special health problems. In particular, the timing of births is known to have important effects on the health of women and their children. Pregnancies that are "too early, too late, too many or too close together" are associated with a higher-than- average health risk for both mother and child. The Ministry's implementation of the integrated Maternal and Child Health and Family Planning Programme (MCH/FP) aims to reduce both infant mortality and maternal mortality. The programme will also assist the government to reduce population growth, which was reported by the Central Statistics Office to be increasing rapidly at the rate of 3 percent annually. The rapid population growth compared to the economic growth rate of 2 percent has serious implications for the country's resources in terms of providing adequate education, health facilities, job opportunities, housing and other social amenities. Generally, family planning services in Namibia are underdeveloped and/or underutilised. This is indicated by the low level of family planning practice and the high dropout rate found by some studies. The prevision of family planning services in health facilities varies by region. Statistics presented during the National Safe Motherhood Conference showed that 79 percent of the 243 health facilities in the country are providing family planning services. However, in the Northwest region, which accounts for nearly 50 percent of the population, only 43 percent of the health facilities were reported to be providing family planning services; Some activities that have been undert~en to improve MCH/FP include assessment of needs, prevision of training and equipment, and preparation of management tools. Drafts of the Family Planning Policy and the MCH/FP service protocols have been prepared and will be published in 1993. 4.1 Knowledge of Contraception Determining the level of knowledge of contraceptive methods and of services was a major objective of the NDHS, since knowledge of specific methods and of the places where they can be obtained is a precondition for use. Information about knowledge of contraceptive methods was obtained by asking the respondent to name all the different ways or methods that a couple could use to delay or avoid a pregnancy. If the respondent failed to mention a particular method spontaneously, the method was described by the interviewer and the respondent was asked if she recognised the method described. Eight modem methods--the pill, IUD, injection, vaginal methods (diaphragm, foaming tablets and jelly), condoms, female sterilisation and male sterilisatiorv--were described, as well as two traditional methods--periodic abstinence (rhythm method) and withdrawal. Any other methods mentioned by the respondent, such as herbs or breastfeeding, were also recorded as spontaneous answers. For each method recognised, the respondent was asked if she knew where a person could go to get the method. If she reported knowing about the rhythm method, she was asked if she knew where a person could obtain advice on how to use the method. 29 Table 4.1 gives the percent distribution of all women and currently married women by knowledge of contraceptive method and source. Nine of ten currently married women know at least one method of family planning, and the proportion is only slightly lower if all women are considered. Virtually all Namibian women age 15-49 who know a method, know at least one modem method of family planning. Among currently married women, only 41 percent knew a traditional method, while more than twice as many (90 percent) reported knowing a modem method. The most familiar methods were steroid injection, pill, and condom in that order, each of which was mentioned by more than half of all women interviewed. Following these, were female sterilisation, the IUD and male sterilisation, which were mentioned by 50, 36 and 21 percent, respectively. Other modem methods (foaming tablets and diaphragm) were less well-known. As for traditional methods, about 25 percent of all women knew about periodic abstinence, while 22 percent knew about withdrawal. The vast majority of women who knew a method of family planning also reported knowing where to obtain that method. Knowledge of a source where specific methods can be obtained is slightly higher among married women than among all women. Table 4.1 Knowledge of contraceptive methods and source for methods Percentage of all women and currently married women who know specific contraceptive methods and who know a source (for infomaation or services), by specific methods, Namibia 1992 Know method Know a source Currently Currently Contraceptive All married All married method women women women women Any method 88.6 90.4 77.5 82.1 Any modern method 88.5 90.4 77.3 8l .8 Modern method Fill 79.3 82.4 68.1 72.7 IUD 35.6 40.5 29.7 34.9 Injection 80.1 84.8 70.2 76.2 Diaphragm/foam/jelly 10.8 15.3 8.1 12.1 Condom 71.6 70.6 51.5 52.2 Female sterilisation 50.1 60.1 43.3 52.3 Male stezilisation 20.8 27.3 17.3 23.9 Any traditional method 33.0 40.7 NA NA Periodic abstinence 25.1 32.3 16.6 22.9 Withdrawal 22.8 29.5 NA NA Herbs 3.8 6.5 NA NA Other traditional methods 1.7 1.9 NA NA Number of women 5421 2259 5421 2259 NA = Not applicable 30 Table 4.2 shows the percent distribution of currently married women knowing at least one modem method and a source by selected background characteristics. Knowledge of at least one contraceptive method among currently married women is somewhat higher among women in their late twenties than among younger or older women. However, the level ofknowledge among women age 40-49 is somewhat lower than for other age groups. This may be attributed to the late introduction of formal education in Namibia. The majority of women in this age group are known to have received no formal education. This phenomenon is also reflected in the positive relationship between level of knowledge/source and level of education. Women with no education have the least knowledge of both method (79 percent) and source (67 percent). Levels of contraceptive knowledge rise steadily to 89 percent for women with some primary education, 96 percent for women with completed primary, and 98 percent for women with secondary/higher education. Knowledge of a source is 77 percent for women with some primary education, 89 percent for completed primary education, and 96 percent for those with secondary and higher education. Table 4.2 Knowledge of modem contraceptive methods and source for methods Percentage of currently man'ied women who know at least one modem contraceptive method and who know a source (for information or services). by selected background characteristics. Namibia 1992 Know a Know Know source for Number Background any a modem modem of characteristic method method 1 method women Age 15-19 88.0 88.0 83.5 86 20-24 93.0 92.7 84.8 307 25-29 94.4 94.3 87.5 414 30-34 92.2 92.2 83.8 459 35-39 89.7 89.7 80.7 397 40-44 85.1 85.1 75.0 345 45-49 86.8 86.8 75.8 251 Residence Urban 95.5 95.5 94.0 877 Rural 87.2 87.1 74.1 1382 Region Northwest 82.1 82.1 66,9 713 Northeast 95.5 95.2 82.2 476 Centr,.d 88.3 88.3 86.2 340 South 96.2 96.2 94.1 730 Education No education 79.0 79.0 67.3 509 Some primary 89.3 89.2 76.6 827 Completed primary 95.6 95.6 88.5 192 Secondary/Higher 98.3 98.3 96.1 730 Total 90.4 90,4 81.8 2259 ~Includas pill, IUD, injection, vagin',d methods (foaming tablets/diephragm/ foam/jelly), condom, female sterilisation, and male sterilisedon. 31 The variation in knowledge of a modem contraceptive method and a source for the method between urban and rural areas is moderate. For urban women, knowledge of a method is 96 percent while, for rural women, it is 87 percent. However, knowledge of a source for a modem method shows a slightly wider differential, with almost 94 percent of urban women knowing a source compared to 74 percent of rural women. Differences in contraceptive knowledge are also observed with respect to place of residence. The level of knowledge of married women who have heard of at least one family planning method is highest in the South and Northeast regions (96 percent), lower in the Central region (88 percent) and lowest in Northwest region (82 percent). This pattern is similar for knowledge of a source; the level of knowledge of a source is highest in the South (94 percent), followed by the Central region (86 percent), and the Northeast region (82 percent). As with knowledge of method, the Northwest region has the lowest level of knowledge of a source (67 percent), compared to the other regions. This could be explained by the fact that, although this region accounts for about 50 percent of the population, women in this region have less access to mass media family planning messages and to family planning services. 4.2 Ever Use of Contracept ion All women interviewed in the NDHS who said that they had heard of a method of family planning were asked if they had ever used it. Over half (52 percent) of currently married women have used a method of family planning at some stage in their life and 41 percent of all women have used a method (see Table 4.3). Table 4.3 Ever use of contraception Percentage of all women and of currently married women who have ever used any contraceptive method, by specific method and age, Namibia 1992 Modem methods Any modem Any meth- Age group method od Pill ALL WOMEN Traditional methods Dia- Female Male In phragm steri- steri- Any Number jec- f~am/ lisa- llsa- tiaLd. Absti- With- of IUD tion jelly Condom tion tion method n~ncc drawal Herbs Other women 15-19 17.2 15.8 5.4 0.1 11,6 0,2 2,4 0.1 0.0 3.9 2.7 2,2 1,1 0.0 1259 20-24 43.2 41.1 21.6 1 2 27,2 0.2 7.4 0.5 0.2 9.9 7.1 4.7 3,8 0.7 1119 25-29 54.6 52.4 32.7 5.0 32.9 0.9 8.2 1.5 0.1 11.1 7.6 5.3 3,6 0,4 890 30-34 54.0 52,5 35.4 8.9 31.9 0.3 7.5 3.9 0.9 13.7 9.4 5.7 3,8 1,0 722 35-39 50.3 48.8 28.4 9.3 31.9 1.2 5,0 9.4 0.6 10.2 6.6 5.7 2.4 0.4 567 40-44 40.9 39.3 18.9 4,7 26.0 0.9 4.7 10.6 0.0 8.4 5.8 3.8 2,8 0.7 507 45-49 39.3 37.0 16.2 5.3 16,1 1.7 1.7 15.2 1.0 11.3 6.5 5.0 2.8 2,1 358 To(al 40.8 39 0 21.6 4.1 24.8 0.6 5.5 3.9 0.3 9.2 6.2 4.4 2.8 0.6 5421 CUI(I~.EN'rLY MARI{IED WOMEN 15-19 43.3 38,6 18,6 0,0 24.3 0,0 5,8 0,0 0,0 18,0 13,3 6,3 8,5 0.0 86 20-24 61.8 59.2 31.9 2.1 38.5 0.4 7.4 1.5 0.2 16.0 13,0 6.1 10.9 0.7 307 25-29 58 9 56.8 35.1 6.2 35.0 1.0 7.4 2.2 0.3 13.2 8.6 6.9 5.3 0.3 414 30-34 55.3 53.5 36.3 9.1 30.8 0.5 6.1 5.1 1.0 13,4 10.1 5.1 4.6 0.8 459 35-39 49 7 47.9 28.2 10.3 30.4 1.8 4.8 10.4 0,9 10.7 7.4 5.9 2.6 0.3 397 40-44 41,3 39.4 18.8 4.7 24.9 0.7 4.5 13.1 0.0 7.2 5.6 2.8 2.7 0.3 345 45-49 42.7 40.0 19.5 6,6 15 5 1.9 1.4 17.7 1.4 13.1 8,7 4.9 3,3 2.1 251 Total 51.9 49.7 28.8 6.5 29.7 1.0 5.5 7.4 0.6 12,4 9.0 5.4 4.9 0.6 2259 32 Among currently married women, ever use of modem methods is almost four times higher (50 percent) than ever use of traditional methods (12 percent). Hormonal methods are the most common methods: 30 percent of currently married women have used injection to prevent pregnancy, and 29 percent have used the pill. The corresponding figures among all women are 25 and 22 percent, respectively. Periodic abstinence has been used by 9 percent of currently married women; 7 percent have used the IUD, 7 percent were sterilised; 6 percent used the condom; and 5 percent of currently married women have used withdrawal. Ever use of modem methods is lowest among all women aged 15-19 years, but increases with age to the highest level among women aged 25-34 years. It then decreases for women age 35-49 years. Among currently married women, the highest level of ever-use is observed for age group 20-24 years. 4.3 Current Use of Contracept ion Overall, only 23 percent of women in Namibia (or 29 percent of currently married women) are currently using a contraceptive method (see Table 4.4). Since it is customary to analyse contraceptive use among currently married women, this chapter focuses primarily on married women and women who are living with a partner. It needs to be kept in mind, however, that the majority of women in Namibia (58 percent) are not currently married. Table 4.4 Current use of contraception by age Percent distribution of all women and of currently married women by contraceptive method currently used, according to age, age, Narnibia 1992 Age Any modcm Any meth- method od Modern methods Traditional methods Dia- Female Male Pe~i- Not phragm, steri- steri- Any odie With- cur- Injec- foam, Con- lisa- lisa- trad. absti- draw- rently Pill IUD tion jelly dora tiwt tion m~hod n~rf.,e al Herbs Other using Total Number ALL WOMEN 15-19 10,7 9,8 2,5 0.1 6,9 0.0 0,3 0.0 0.0 0.9 0.3 0.1 0.5 0.1 89.3 1~30.0 1259 20-24 24.8 22.3 8.6 0.7 11.6 0.0 0.9 0.5 0,0 2.6 0.7 0.1 1.4 0.4 75.2 100.0 1119 25-29 31.3 28.7 11.2 2.2 13.3 0.1 0,5 1.4 0.0 2.6 0.9 0.2 1.5 0.0 68.7 1130.0 890 30-34 28.7 26,6 11,8 2.6 7.5 0.0 0.6 3,9 0.2 2.2 1.0 0.0 1.0 0-1 71.3 100.0 722 35-39 32.0 30.0 7.6 2.7 9.9 0.2 0.2 9.4 0.0 2.0 0.S 0,3 0.7 0-1 68.0 100.0 567 40-44 20.8 20.0 4.1 1.2 3.8 0-0 0.2 10.6 0.0 0.8 0.2 0,4 0.2 0,0 79.2 100,0 507 45-49 20.9 19.8 2.0 0.6 1.0 0.0 0.0 15.2 1.0 1.0 0.0 0.3 0.7 0.0 79.1 1130.0 358 Total 23.3 21.4 7.1 1.3 8.6 0.0 0,5 3.8 0.1 1,8 0.6 0.2 0.9 0.1 76,7 100.0 5421 CURRENTLY MARRIED WOMEN 15-19 20.5 16.5 7,2 0,0 9.3 0.0 0.0 0.0 0.0 3.9 0.0 0.0 2.9 1.0 79.5 1~O.0 86 20-24 30.6 25.7 10.5 1.4 12.4 0,0 0.0 1.5 0,0 4.9 0.2 0-0 4,5 0.3 69.4 I00.0 307 25-29 32.3 28.3 11.0 3.2 11.7 0.0 0.3 2.2 0.0 4.0 1.2 0.2 2,7 0-0 67.7 100.0 414 30-34 29.3 27.0 11.6 2.8 6.5 0.0 0.8 5.1 0,3 2.3 0.9 0.0 1.2 0.2 70.7 100.0 459 35-39 32.6 29.8 7.6 2.4 9.0 0.3 0.0 10.4 0.0 2.8 1.1 0.5 1.0 0.2 67.4 1GO.0 397 40-44 23.7 22.5 4.0 1,3 3.6 0.0 0.3 13.1 0.0 1.2 0.3 0.7 0,2 0-0 76.3 1(30.0 345 45-49 24.6 23.1 2.4 0.9 0.7 0-0 0,0 17.7 1.4 1.5 0.0 0.5 1,0 0.0 75.4 100,0 251 Total 28.9 26.0 8,3 2.1 7.7 0,1 0.3 7.4 0,2 2.9 0.7 0,3 1,8 0.1 71.1 1O0.0 2259 33 One in four married women in Namibia is currently using a method of contraception: 26 percent are using a modem method while 3 percent are using a traditional method. The most commonly used method is the pill (8 percent), followed by injection (8 percent) and female sterilisation (7 percent) (see Figure 4.1). The IUD is used by less than 2 percent of married women. The least used contraceptive methods are periodic abstinence, withdrawal, and condoms. Figure 4.1 Distribution of Currently Married Women by Method Currently Used IUD 7% Malo % Storlllsa Injection 27% ale Con IIIsatlon 26% Tradit ional Methods 10% NDHS 1992 Most contraceptive users are women 25-39 years; younger and older women are least likely to use a contraceptive method (see Table 4.4). The choice of method also varies by age; younger women are more likely to use the pill, injection or a traditional method, while women 35 years and over tend to use female sterilisation. About one in five women is cun'ently using a modem method. The distribution of methods among all women is similar to that among currently married women with one exception; female sterilisation is almost twice as common among currently married women, The order of preference differs slightly; the preferred method for all women is injection (9 percent). Traditional methods account for about 3 percent of the total use. While overall use of family planning is not widespread in Namibia, the NDHS data show that some women are much more likely to be using contraception than others (see Table 4.5 and Figure 4.2), Women in urban areas and women with secondary or higher education are much more likely to be using a modem method of contraception than rural women or women with no primary education. The association between place of residence and contraceptive use is very strong. The level of contraceptive use is almost three times higher in urban areas (46 percent) than in rural (16 percent) areas. However, use of traditional methods J,s higher in rural (4 percent) than in urban (2 percent) areas. This may be due to lack of accessibility and availability rather than preference. The most popular methods among both urban and rural women are the pill, injection and female sterilisation. 34 Table 4.5 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to selected background characteristics, Namibia 1992 Modem methods Traditional methods Any Background modem character- Any meth- istic method od Dia- Female Male Perl- Not ph-agm, steri- steri- Any odie With- cur- lnjec- foam, Con- lisa- lisa- trad. absti- draw- rcndy Num- Pill IUD tion jelly dorn tion tion method nenee al Herbs Other using Total bet Residence Urban 47.8 46.6 14.7 4.0 13.8 0.1 0.5 12.9 0.5 1.2 0.6 0.4 0.2 0.0 52.2 100.0 877 Rural 16.9 13.0 4.2 0.8 3.9 0.0 0.1 4.0 0.0 3.9 0.7 0.2 2.8 0.2 83.1 100.0 1382 Region Northwest 8.7 7.3 2.6 0.7 0.6 0.0 0.3 3.1 0.0 1.3 1.0 0.3 0.0 0.0 91.3 100.0 713 Northeast 21.5 10.9 4.8 0.1 4.2 0.0 0.0 1.7 0.0 10.6 1.1 0.4 8.4 0.7 78.5 1~0.0 476 Central 32.2 31.8 9.9 1.1 13.8 0.0 0.0 7.1 0.0 0.4 0.4 0.0 0.0 0.0 67.8 100.0 340 South 52.0 51.5 15.3 5.1 14.1 0.2 0.5 15.6 0.7 0.5 0.2 0.3 0.0 0.0 48.0 100.0 730 Level of education No education 16.8 14.2 2.5 0.2 5.9 0.0 0.0 5.6 0.0 2.6 0.6 0.2 1.7 0.2 83.2 100.0 509 Primary incomplete 19.2 15.0 4.3 0.3 5.3 0.0 0.0 5.1 0.0 4.3 0.7 0.2 3.0 0.3 80.8 100.0 827 Primary completed 29.5 27.6 72 1.2 9.5 0.0 0.5 8.0 0.6 1.9 0.3 0.0 1.6 0.0 70.5 100.0 192 Secondary/Higher 48.1 46.4 16.9 5.6 11.3 0.2 0.6 11.2 0.5 1.7 0.7 0.5 0.5 0.0 51.9 100.0 730 No. of Uvlng children 0 11.2 10.9 6,6 0.6 1,8 0.0 0.0 1,8 0,0 0.3 0.3 0.0 0.0 0.0 88.8 I00.0 197 1 29.3 26.0 11.7 2.2 10.3 0.4 0.3 1.2 0.0 3.3 0.6 0.4 2.1 0.2 70.7 100.0 342 2 38.4 34.1 13.5 3.7 8.1 0.0 0.3 7.9 0.6 4.3 1.3 0.3 2.5 0.2 61.6 100.0 394 3 36.2 33.0 6.4 2.3 13.0 0.0 0.6 10.4 0.3 3.2 0.4 0.3 2.3 0.2 63.8 100.0 371 4+ 25.6 23.1 6.0 1.6 5m8 0.0 0.1 9.5 0.1 2.5 0.6 0.3 1.5 0.1 74.4 100.0 955 Time to source (rain.) < 15 50.2 49.3 16.3 4.4 11.6 0.0 0.5 16.2 0.3 0.9 0.4 0.5 0.0 0.0 49.8 100.0 469 15-29 38.4 35.7 10.9 3.4 13.0 0.0 1.2 6.8 0.4 2.7 0.9 0.4 1.4 0.0 61.6 100.0 279 30-59 26.3 24.7 9.7 1.5 8.9 0.0 0.0 4.5 0.0 1.6 0.4 0.0 1.0 0.2 73.7 100.0 370 60-119 24.5 19.0 4.3 2.3 7.7 0.0 0.0 4.7 0.0 5.4 1.0 0.3 4.1 0.0 75.5 100.0 362 ~120 14.4 9.6 2.7 0.0 4.0 0.0 0.0 2.9 0.0 4.8 0.7 0.5 3.4 0.2 85.6 100.0 370 Missing/Don'tknow 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 100.0 1 Don'tknowsource 17.4 15.0 4.6 0.6 1.9 0.3 0.0 7.0 0.6 2.4 0.7 0.0 1.2 0.4 82.6 1O0.0 407 Distance to source (kin) 0-4 40.5 37.0 12.1 2.8 12.0 0.0 0.3 9.7 0.0 3.5 0.6 0.4 2.4 0.I 59,5 I00.0 1013 5-9 35.0 31.6 10.4 3.6 8.8 0.0 0,9 6.1 1.9 3.4 1.5 0.0 2.0 0.0 65.0 I00.0 129 10-19 22.8 19.0 8.4 2.8 2.2 0.0 0.7 5.0 0.0 3.8 0.5 0.5 2.7 0.0 77.2 100.0 158 20-29 IL9 10.5 1.7 1.0 3.0 0.0 0.0 4.8 0.0 1.4 0.7 0.0 0.7 0.0 88.1 100.0 120 30-59 15.6 12.3 3.6 0.5 4.3 0.0 0.0 3.9 0.0 3.3 1.1 0.5 1.3 0.4 84.4 100.0 198 60+ 20.3 20.3 4.1 2.1 7.7 0.0 0.0 6.3 0.0 0.0 0.0 0.0 0.0 0.0 79.7 1130.0 171 Missing/Don't know 16.8 15.4 3.8 1.9 8.1 0.0 0.0 1.6 0.0 1.3 0.0 0.0 1.3 0.0 83.2 100.0 63 Don'tknowsource 17.4 15.0 4.6 0.6 1.9 0.3 0.0 7.0 0.6 2.4 0.7 0.0 1.2 0.4 82.6 100.0 407 Total 28.9 26.0 8.3 2.1 7.7 0.1 0.3 7.4 0.2 2.9 0.7 0.3 1.8 0.1 71.1 100.0 2259 Regional differences in contraceptive prevalence are also observed. By far the highest contraceptive prevalence is found in the South region where 52 percent of married women are currently using a modem method of contraception. The overall level of use is lowest in the Northwest region (7 percent). Current use of modem methods in the Central region is 32 percent, while in the Northeast region it is 11 percent. In the South, 16 percent of women are using female sterilisation, 15 percent are using the pill, and 14 percent have chosen injection. Use of traditional methods is common in the Northeast region; 11 percent of currently married women are currently using traditional methods, principally herbs (8 percent). 35 Figure 4.2 Current Use of Family Planning Methods Among Currently Married Women 0 10 20 30 40 50 60 Percent NDHS 1992 Greater use of family planning among women with formal education--an association documented in many countries around the world--also occurs in Namibia. Prevalence increases from 17 percent among women with no education to 48 percent among women who have some secondary or higher education. At all educational levels, injection is the most popular method with the exception of women with secondary/higher education where the pill is the preferred method. Use of condoms is very low among women with no education. Current use of modern contraceptives is lowest for women with no children (11 percent). Iris highest among women with 2-3 children (36-38 percent). About 10 percent of women with at least three children are sterilised. Women in the NDHS were also asked about the nearest health facility and outreach services they were using. If the nearest health facility was not a hospital, questions were asked about the nearest hospital as well. For each service it was asked whether family planning services were available. A detailed analysis of the services availability data is presented in Chapter 11. Use of modem contraceptives declines with travel time to the source. Use is highest among women within 15 minutes of a source, and declines gradually to the lowest level among women 2 hours or more from a source of family planning. The association between current use and distance is somewhat less pronounced. Although this provides only a crude indication of the relationship between service availability and use, it generally suggests that increased availability is associated with increased contraceptive use for supply methods such as pills and injection. This relationship is explored further in Section 4.6 and Table 4.11. 36 4,4 Number of Children at First Use of Contraception It is assumed that in many cultures, family planning is used only when couples have already had as many children as they want. As the concept of planning families gains acceptance, however, couples may begin to use contraception for spacing births as well as for limiting family size. Moreover, unmarried young women may be particularly motivated to use family planning to avoid an unwanted pregnancy. Table 4.6 shows the number of children a woman had when she first used contraception. Most ever- users of contraception reported that they began using some form of contraception after they had their first child (19 percent of all ever married women), but 13 percent started using before they had their first child. From the age patterns, it is apparent that while older age cohorts waited until they had at least four children or more, younger age cohorts started to use a method of contraception before they had any children. For example, 24 percent of women age 15-19 used contraception before they had any children, compared to 4 percent of women age 40-44. Table 4.6 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at the time of first use of contraception, according to current age, Namibia 1992 Number of living children at time Never of l'lrst use of contraception Number Current used of age contraception 0 1 2 3 4+ Missing Total women 15-19 57.0 23.6 17.7 0.4 0.0 0.0 1.2 100.0 98 20-24 37.8 23.1 32.1 5.1 1.6 0.0 0.3 100.0 348 25-29 39.2 20.3 26.2 8.2 3.0 2.6 0.4 100.0 473 30-34 43.5 13.4 20.0 8.7 6.6 7.5 0.3 100.0 536 35-39 49.5 8.7 14.9 10.4 6.6 9.8 0.0 100.0 458 40-44 58.2 4.0 9.4 7.3 7.4 12.9 0.9 100.0 411 45-49 59.2 6.2 6.9 5.7 5.4 15.8 0.9 100.0 315 Total 47.7 13.1 18.5 7.6 5.0 7.6 0.5 100.0 2638 37 4.5 Knowledge of the Fertile Period Table 4.7 presents knowledge of the fertile period among all women and among those who have ever used periodic abstinence. Forty-five percent of 'all women did not know when conception was most likely to occur, while 21 percent said they thought it occurred after their period ended. Only 8 percent of women correctly identified the fertile period as being in the middle of the ovulatory cycle. Ever-users of periodic abstinence were more knowledgeable--16 percent correctly identified the fertile period--but 37 percent thought a woman had the greatest risk of becoming pregnant after her period. It appears, therefore, that women in Namibia generally have limited knowledge about theirovulatory cycle. Since basic knowledge on reproduction is important for the successful practice of coitus-related methods such as withdrawal, condoms, etc., more attention needs to be given to the physiological aspects of reproduction in formal education and family planning programmes. Table 4.7 Knowledge of fertile period Percent distribution of all women end of women who have ever used periodic abstinence by knowledge of the fertile period during the ovulatory cycle, Namibia 1992 EveY llSel~ Perceived All of periodic fertile period women abstinence During menstrual period 1.2 1.2 Right after period has ended 20.6 37.3 In the middle of the cycle 7,8 15.9 Just before period begins 2,5 3.9 Other 0.3 1.2 No particular time 22.5 20.9 Don't know 45.0 18,9 Missing 0.2 0.8 Total 100.0 100.0 Number 5421 338 38 4.6 Sources of Family Planning Methods Current users of modem methods of family planning were asked where they most recently obtained their method. Most women (86 percent) said that they obtained their method from a government health facility (government hospital, government health centre, or primary health care mobile clinic). The private sector, which provides 11 percent of modem contraceptives, plays a much smaller role in supplying contraceptive methods in Namibia (see Table 4.8). Table 4.8 Source of supply for modern contraceptive methods Percent distribution of current users of modem contraceptive methods by most receat source of supply, according to specific methods, Namibia 1992 Female lnjec- stelili- Source of supply Pill IUD lion Condom sation Total Public 84.7 54.8 97.1 (82.4) 78.6 86.4 Government hospital 22,5 40,1 26.7 (35.0) 78,6 35.5 Government health centre 61.5 14.7 68.0 (47.5) 0.0 49.7 PHC mobile clinic 0.6 0.0 2.4 (0.0) 0,0 1.2 Private (medical) 12,8 41.4 2.3 (9.4) 15,8 11.1 Private doctor 1.3 26.9 0.0 (4.7) 1.2 2.6 Private hc~pital/clinlc 2.9 14.5 2.3 (0.0) 14.6 5.5 Pharmacy 8.6 0.0 0.0 (4.7) 0.0 3,0 Other private 1.3 0.0 0.0 (8.2) 0.0 0.6 Shop 0.1 0.0 0.0 (0.0) 0,0 0.0 Friends/relatives 1.1 0.0 0.0 (8.2) 0.0 0.6 Other 0.3 0.0 0.0 (0.0) 1.2 0.3 Don't know 0.0 0.0 0.0 (0.0) 0.5 0.1 Missing 0.9 3.8 0.6 (0.0) 4.0 1.5 Total 109.0 100.0 100.0 1OO.0 100.0 100.0 Number 383 71 468 26 207 1162 Note: Figures in parentheses are based on a small number of eases. The sources for family planning methods depend on the type of method used. Injection and pills are primarily supplied by govemment health centres (97 and 85 percent, respectively), while most sterilisations are done in government hospitals. The private sector's largest share in the supply of contracept'tves is IUDs, for which it accounts for 41 percent of the total supply. Eighty-two percent of all condoms used for family planning are provided by the government, while private pharmacies supply only 5 percent. About one in 12 condoms is obtained from friends or relatives. No women reported the primary health care mobile clinics as a source of condoms. Among women who have been s~rilised more than half (56 percent) had the operation when they were in their thirties. Twenty-nine percent were sterilised before age 30, and 15 percent at age 40 and over. The median age at sterilisation is 32.5 years. 39 Current users of modem methods were asked how long it takes to travel from home to their source of supply. Nonusers of contraceptive methods were asked if they knew a place where they could obtain a modem method and if so how long it would take to get to the source of supply. The results are presented according to urban-rural residence in Table 4.9. Half of women who are currently using a modem method of contraception are 30 minutes from their source of supply, compared to 21 percent of nonusers, and 31 percent of women who know at least one modem method. There are marked differences by urban-rural residence. More than 60 percent of the current users of modem methods of family planning in urban areas are less than 30 minutes away from their source of supply, compared to 27 percent in the rural areas. Time to source does not appear to play an important role, since both users and nonusers are equally close to a source. However, 15 percent of nonusers in urban areas did not know a source. Rural users generally live further from a source of supply for modem methods: 45 percent of the rural users had to travel more than one hour to reach a source. Among rural nonusers the proportion having to travel more than one hour to a source is about 60 percent (31 percent of all rural nonusers, but 48 percent could not provide a source or time), indicating that distance may play a role in contraceptive use. More important, however, is the fact that 45 percent of rural nonusers did not know a source at all. These data suggest that increasing the availability of family planning services in mrai Namibia may have an impact on the use of modem methods. Increasing information, education, and communication (IEC) efforts may also have an impact in both rural and urban areas. Table 4.9 Time to source of supply for modem contraceptive methods Percent distribution of women who are currently using a modem contraceptive method, of women who are not using a modem method, and of women who know a method, by time to reach a source of supply, according to urban-rural residence, Nanlibia 1992 Women who are currently using a modern method Women who a.re not using a modem method Women who know a contraceptive method Minutes to source Urban Rural Total Urbma Rmal Total Urban Rural Total 0-14 36.7 16.0 30.7 29.8 3.6 11.3 33.6 5.6 17.3 15-29 22.1 7.7 17.9 17.7 4.6 8.5 19.9 5.8 11.7 30-59 19.8 16.4 18.8 19.2 10.6 13.2 19.6 12.9 15.7 60+ 11.3 45.4 21.2 10.4 31.0 24.9 10.8 37.3 26.2 Does not know time 0.0 0.0 0.0 5.2 3.0 3.7 3.1 2.9 3,0 Does not know source 0.0 0.0 0.0 14.6 44.5 35.7 6.9 30.9 20,9 Not stated 7.8 10.8 8.6 2.5 0.8 1.3 4.7 2.1 3.2 Not asked 2.4 3.7 2.7 0.6 1.9 1.5 1.3 2.4 2,0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 825 337 1162 1252 3007 4259 2000 2801 4801 40 4.7 Intention to Use Family Planning Among Nonusers Women who were not using any contraceptive method at the time of the survey were asked whether they would do something in future to avoid getting pregnant. Sixty percent of currently married women said they did not intend to use a contraceptive method in future, while 26 percent intend to use a method within 12 months (see Table 4.10). The intention to use within 12 months is highest among married women with 2-3 living children (31 percen0. Twenty-four percent of mothers with 4 or more children intend to use a contraceptive method within 12 months. The proportion of currently married nonusers of a contraceptive method who do not intend to use a contraceptive method is more than 50 percent, regardless of the number of living children. Table 4.10 Future use of contraception Percent distribution of currently married women who are not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living children, Namibia 1992 Past experience with contraception and future intentions Number of living children I 0 1 2 3 4+ Total Never used contraception Intend to use in next 12 months 7.1 12.6 9.9 7.9 11.3 10.4 Intend to use later 1.2 2.5 3.0 0.9 1.1 1.5 Unsure as to timing 0.0 0.0 0.0 0.0 0.4 0.2 Unsure as to intention 6.8 8.4 5.2 7.2 8.1 7.5 Do not intend to use 55.7 40.9 39.4 41.3 53.3 47.9 Missing 0.0 1.0 0.0 0.0 0.2 0.2 Previously used contraception Intend to use in next 12 months 6.9 15.0 21.4 23.0 12.9 15.5 Intend to use later 4.3 3.7 3.6 2.1 1.6 2.5 Unsure as to timing 0.0 0.0 0.9 0.5 0.3 0.3 Unsure as to intention 3.9 0.4 1.9 0.5 1.2 1.3 Do not intend to use 13.2 15.4 14.2 16.2 9.6 12.4 Missing 0.9 0.0 0.5 0.5 0.0 0.2 Total 100.0 100.0 100.0 100.0 I00.0 100.0 All currently married nonusers Intend to use in next 12 months 14.0 27.7 31.3 30.9 24.2 25.9 Intend to use later 5.5 6.2 6.6 2.9 2.7 4.0 Unsure as to timing 0.0 0.0 0.9 0.5 0.7 0.5 Unsure as to intention 10.7 8.7 7.1 7.7 9.3 8.8 Do not intend to use 68.9 56.4 53.6 57.5 62.9 60.3 Missing 0.9 1.0 0.5 0.5 0.2 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 139.0 233.0 233.0 245.0 756.0 1606.0 tIncludes current pregnancy 41 Nearly 50 percent of women who never used any contraceptive method do not intend to use a method in future, while 10 percent intend using a contraceptive method within 12 months, and only 2 percent intend to use at a later time. Among women who previously used a contraceptive method, 16 percent intend using a method within 12 months while 12 percent do not intend to use a contraceptive method in future. Women who were not using a contraceptive method and said they did not intend to use one in future were asked to give the main reason for not intending to use a contraceptive method. The results are presented in Table 4.11 by respondent's age. The main reason women gave for not using a contraceptive method was that they wanted more children: 66 percent of women under 30 years want more children while 47 percent of women 30 years and over want more children. Other reasons include: lack of knowledge (12 percent), "difficult to get pregnant" (8 percent), and that the woman was menopausal or had had a hysterectomy (6 percent). The latter was only cited by women more than 30 years of age. Only 3 percent of women are opposed to family planning. Health concerns and side effects were mentioned by 4 and 2 percent of women, respectively. Table 4.11 Reasons for not using contraception Percent distribution of women who are not using a contra- ceptive method and who do not intend to use in the future by main reason for not using, according to age, Namibia 1992 Age Reason for not using contraception 15-29 30-49 Total Want children 66.1 47.1 52.2 Lack of knowledge 9.5 13.2 12.2 Partner opposed 1,8 1.2 1.4 Cost too much 0.0 0.1 0.1 Side effects 3.9 1.3 2.0 Health concerns 1.8 4.2 3.6 Hard to get methods 1,4 1.5 1.5 Religion 0.5 1.8 1.4 Opposed to family p lan ing 4.9 2.9 3.4 Fatalistic 0,0 0.5 0.4 Infrequent sex 0.0 0.2 0.2 Difficult to be pregnant 4.7 9.4 8.2 Menopausal, had hysterectomy 0.0 8.4 6.1 Not martied 0.0 0.3 0.2 Other 1.3 2.4 2.1 Don't know 4.1 5.4 5.0 Missing 0.0 0.2 0.1 Total 100.0 100.0 100.0 Number 260 709 969 42 Currently married nonusers who intend using a method in the future were asked which method they preferred to use (see Table 4.12). Among those who intent to use in the next 12 months, thirty-nine percent said they preferred injection, 31 percent the pill, and 10 percent the IUD. Women who intend to use a method at a later time preferred the pill (36 percent) followed by injection (31 percent). Seven percent of nonusers who intend to use a method sometime preferred sterilisatlon; only 2 percent preferred the condom. Table 4.12 Preferred method of contraception for future use Percent distribution of currantly married women who are not using a contraceptive method but who intend to use in the future by preferred method, according to whether they intend ~ use in the next I2 months or later, Namibia 1992 Intend to use In next After Preferred method 12 12 of contraception months months Total t Pill 30.6 35.6 31.0 IUD 10.1 6.7 9.6 Injection 39.4 31.0 38.1 Diaphragn'dFoam/Jelly 0.7 1.8 0.8 Condom 2.3 1.8 2.2 Female sterilisation 6.7 7.7 6.7 Periodic abstinence 1.3 5.1 1.8 Withdrawal 0.0 1.3 0.2 Herbs 3.3 0.0 3.0 Other 0.7 0.0 0.6 Missing 4.9 9.0 6.0 Total 100.0 100.0 100.0 Number of women 416 65 492 lIncludes 9 women unsure as to timing and two missing. 43 4.8 Approval of Family Planning All women were asked if it was acceptable to them to have messages about family planning on radio and television (see Table 4.13). Three-quarters of respondents approved of the family planning messages, however, women over 40 years of age were less likely to approve than younger women. In the Northwest region mass-media family planning messages were not acceptable to 31 percent of women, while in the Central and South regions only 9 percent found them unacceptable. Women with secondary or higher education (85 percent) expressed more approval for family planning messages than women with no education (53 percent) and approval in urban areas was considerably higher than in rural areas (84 vs. 64 percent). Table 4.13 Acceptability of the use of mass media for disseminating family olanninz messages Percentage of women who believe that it is acceptable to have messages about family planning on radio or television, by selected background characteristics, Namibia 1992 Not Background Accept- accept- characteristic able able Missing Total Number Age 15-19 68.2 20.4 11.4 100.0 1259 20-24 76.0 18.3 5.7 100.0 1119 25-29 77.2 17.1 5.6 100.0 890 30-34 75.3 18.6 6.1 100.0 722 35-39 70.5 22.1 7.4 100.0 567 40-44 63,9 25.4 10.8 100.0 507 45-49 66.4 24.7 8,9 100,0 358 Residence Urban 84,4 10.3 5.3 100,0 2077 Rural 64.2 26,2 9.6 100,0 3344 Region Northwest 59.0 31.5 9.4 100.0 2246 Northeast 79.5 18.2 2.3 100.0 879 Central 76.5 9.4 14.1 100.0 674 South 83.9 9.8 6.3 100.0 1622 Education No education 53.4 28.7 17.9 100.0 785 Some primary 65.3 24.8 9.8 100.0 2113 Completed primary 76.9 18.2 4.9 100.0 510 Secondaryfdigher 84.9 12.3 2.8 100.0 2013 Total 72.0 20.1 7,9 100.0 5421 44 4.9 Attitudes of Couples Toward Family Planning Among currently married women who knew a contraceptive method and had not been sterilised almost half reported that they had not discussed family planning with their husbands in the past year; 31 percent had discussed it once or twice; and about one-fi fth had discussed family planning with their husbands more often. Respondents were asked whether they approved or disapproved of couples using a method to avoid pregnancy. Table 4.14 presents the responses of currently married women, who knew a contraceptive method and had not been sterilised. In 47 percent of couples, the wife reported that both she and her husband approved of family planning. Another 16 percent who approved of family planning said their husbands disapproved, and 10 percent did not know if their husbands approved or disapproved. Only 4 percent of the women did not approve of family planning while their husbands approved. Couples in urban areas are more likely to approve of family planning than rural couples (57 and 41 percent, respectively). Approval is higher among couples in the South and Northeast regions than among couples in the Northwest and Central regions. Also, couples with secondary or higher education (68 percent) are twice as likely to approve of family planning as couples with no education (33 percent). .T.able 4.14 Attitudes of couples toward family planning Among cun-ently married non-sterilised women who know a eon~aceptive method, the pereentage who approve of family planning, by their perception of their husband's attitude and selected background characteristics, Namibia 1992 Respondent approves Respondent disapproves Unsure Husband Backgrotmd Both Husband of Husband disapproves/ Both characteristic approve disapproves husband approves unsure disapprove Missing Percent Total Age 15-19 20-24 25-29 30-34 35-39 40-44 45 -49 Residence Urban Rural 40.9 Region Northwest 32.8 Northeast 54.2 Central 41.3 South 58.8 Education No education 32,7 Some primary 36.6 Completed primary46.8 Secondary/Higher 67.8 Total 47.3 42.8 22.7 12.1 2,3 2.7 12.7 4.7 100.0 76 50.1 19.0 10.3 4.1 3.9 11.0 1.7 100.0 281 56,3 13.8 8.8 3.0 2.7 12.9 2.6 100.0 382 51.2 13.2 8.8 5.7 6.1 11.9 3.2 100.0 398 45.4 i8.9 6.2 2.8 6,4 16.7 3.6 I00.0 315 34.7 16.8 13.2 4.3 8.7 21.0 1.4 100.0 248 37.3 13.4 11.8 3.4 9.9 21.9 2.3 100.0 170 57.5 14.5 6.4 4.0 3.6 10.7 3.4 100.0 720 17.0 11.6 3.8 7.0 17.6 2.2 100.0 1150 16.5 7.4 3.7 7.1 29.5 3.0 100.0 563 17.8 13.2 4.3 4.1 5.6 0.9 100.0 447 17.8 12.6 2.2 9.1 12.6 4.3 100.0 276 13.4 7.4 4.5 3.9 9.1 2.9 100.0 584 14.4 13.9 3.2 12.4 21.2 2.3 100.0 374 18,7 11.8 4.6 6.1 18.5 3,6 100,0 696 17,7 11.3 4.8 2.0 16.7 0.7 100.0 167 13.6 4.1 3.2 2.1 6.8 2.3 100.0 632 16,0 9.6 3.9 5.7 14.9 2.6 100,0 1870 45 CHAPTER 5 PROXIMATE DETERMINANTS OF FERTILITY This chapter addresses the principal factors, other than contraception, which affect a woman's risk of becoming pregnant: nuptiality and sexual intercourse, postpartum amenorthoea and abstinence from sexual relations, and secondary infertility (menopause, terminal infertility, and long-term abstinence). Several indicators of a woman's exposure to the risk of pregnancy can be used to help explain trends in fertility levels. Age at first marriage and age at first sexual intercourse are indicators used to assess the age at which women are first exposed to the risk of pregnancy. Populations in which age at first marriage is low are generally characterised by early childbearing and high fertility. Other measures of proximate determinants of fertility are also examined, including the duration of postpartum amenorrhoea and of postpartum abstinence, and secondary infertility. 5.1 Marital Status The term "married" refers to legal or formal marriage, while "living together" refers to informal unions. In subsequent tables, these two categories are combined and referred to collectively as "currently married" or "currently in union." Also, the categories "widowed", "divorced", "not living together" or "separated", and "currently married/in union" are collapsed into an "ever-married" or "ever in union" category. Although pregnancy is most apt to occur among women in union, women may be involved in long- term sexual relationships regardless of marriage or cohabitation, and be at risk of pregnancy. This confounds the relationship between marriage/union and exposure to pregnancy, therefore more direct measures of exposure to pregnancy must also be considered in conjunction with marital status. Current marital status at the time of the survey is shown in Table 5.1. In Namibia, 42 percent of women 15-49 were currently married, including 27 percent that were formally married and 15 percent that simply lived with their partner. More than half of the women interviewed had never been married. Nine of ~l'able 5.1 Current marital status by age Percent distribution of women by current marital status, according to age, Namibia 1992 Marital status Number Age Never Living Not living of group married Married together Widowed Divorced together Missing Total women 15-19 92.3 2.9 4.0 0.0 0.3 0.5 0.0 100.0 1259 20-24 68.9 15.0 12.4 0.1 1.1 2.3 0.1 100.0 1119 25-29 46.9 28.6 17.9 1.0 3.2 2.3 0.1 100.0 890 30-34 25.8 44.0 19.6 2.0 5.5 3.1 0.0 lOO.0 722 35-39 19.2 48.5 21.5 2.5 5.4 2.9 0.0 100.0 567 40-44 18.9 44.1 24.0 4.0 6.7 2.3 0.0 100.0 507 45-49 11.9 54.6 15.5 4.9 8.9 4.2 0.0 100.0 358 Total 51.3 27.1 14.5 1.4 3.3 2.2 0.0 100.0 5421 47 ten women 15-19 were unmarried, but the proportion decreases in older age cohorts. By age 25-29, 47 percent of women had never been married and 26 percent of women 30-34 were unmarried. Even at older ages it is not uncommon for women to be unmarried; one in six women 35 years and older had never been married. These data suggest that, although not marrying has been fairly common in Namibia, the practice appears to have increased. However, an increase in age at first marriage may have contributed to the higher proportion of women who were not married at the time of the survey. Overall, five percent of all women were divorced or were separated from their partner. As expected, the proportion of women who were widowed increases with age, reaching five percent among those 45-49 years. Table 5.2 presents women's marital status by various background characteristics. Women in the Northwest (64 percent) were more likely to have never been in union than women in the Central and South regions (47 percent) and women in the Northeast region (30 percent). Women's marital status varied by level of educational. Approximately half of women with some secondary/higher education have never been in union, compared to 24 percent of women with no education. Table 5.2 Current marital status by background characteristics Percent distribution of women by current marital status, according to background characteristics, Namlbia 1992 Marital status Number Background Never Curremly Previously of characteristic married married married Missing Total women Residence Urban 50.2 42.2 7.6 0.0 100.0 2077 Rural 52.1 41.3 6.6 0.1 10O.0 3344 Region Northwest 63.9 31.7 4.2 0.1 100.0 2246 Northeast 30.3 54.2 15.5 0.0 100.0 879 Central 47.2 50.4 2.3 0.0 100.0 674 South 47.0 45.0 8.0 0.0 100.0 1622 Education No education 24.1 64.8 11.1 0.0 100.0 785 Some primary 53.8 39.2 7.0 0.0 100.0 2113 Primary completed 54.6 37.7 7.7 0.0 100.0 510 Secondary/Higher 58.6 36.3 5.1 0.1 100.0 2013 Total 51.3 41.7 7.0 0.0 100,0 5421 5.2 Polygyny Polygamy is common in sub-Saharan Africa and may have an impact on fertility. Married women were asked whether their husbands had other wives, and if so, how many. One in eight currently married women was in a polygynous union (see Table 5.3). Older women were more likely to be in polygynous unions than younger women, as evidenced by the lower prevalence of polygyny among women 20-34 years, 48 Table 5.3 Polygyny Percentage of currently married women in a polygynous union, by age and selected background characteristics, Namibia 1992 Background Age of woman All characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 ages Residence Urban 7.7 7.4 6.1 7.6 8.6 5.8 7.2 7.2 Rural 6.6 14.0 16.6 13.4 18.5 20.0 16.3 16.1 Region Northwest * (9.8) 9.9 9.4 19.5 19.7 14.6 14.5 Northeast 12.6 20.2 24.5 26.5 29.4 36.6 27.7 25.1 Central * (2.4) 16.7 10.5 (5.6) (5.0) (12.1) 9.2 South * 6.0 2.8 4.5 5.8 1.4 5.7 4.3 Education No education * (4.4) 18.2 14.3 19.8 21.5 22.1 17.5 Some primary 9.2 I5.5 I2.9 13.1 I8.9 18.9 10.3 14.8 Completed primary * (10.2) (8.5) (6.6) (16.6) * * 10.6 Secondary/Higher * 10.0 10.1 8.1 4.6 1.5 5.6 7.3 Total 6.9 11.3 12.2 11.0 14.4 15.7 13.0 12.6 Note: Figures in parentheses are based on a small number of eases. *Based on too few cases to show compared with women 35-49 years. The prevalence of polygyny in rural areas was more than twice as high as in urban areas. Regional differences were also pronounced; women in the Northeast region were more than six times as likely to be in a polygynous union as women in the South region. Prevalence among women with different educational levels varies somewhat. Eighteen percent of women with no education were in a polygynous union, compared to 7 percent of women with at least some secondary education. In polygynous unions, the woman may have one or more co-wives. Approximately half of women in polygynous unions have one other co-wife, and the other half have two or more co-wives. 5.3 Age at First Marriage Table 5.4 presents the percentage of women ever married by selected exact ages and median age at first marriage, according to current age. The table reveals a higher age at first marriage among younger women. The median age at first marriage among women 30-34 was 25, compared to 23 among women 45- 49. Table 5.5 presents age at first marriage for women by their current age and selected background characteristics. The median age at first marriage for women in the Northeast region (18.9 years) was substantially lower than for women in the three other regions. Educational level was not a differentiating factor in age at first marriage among women 45 -49, however there was greater disparity between educational levels among younger women. Analysis by age cohort shows that age at marriage had increased markedly among women with at least some secondary education, The other educational categories did not show such an increase. Overall, women with no education married about two years earlier than women with some education. 49 Table 5.4 Age at first marriage Percentage of women who were first married by exact age 15, 18, 20, 22, and 25, and median age at first marriage, according to current age, Namibia 1992 Current age 15 18 20 22 Percentage of women who were Percentage Median first married by exact age: who had Number age at never of first 25 married women marriage 15-19 1.1 NA NA NA NA 92.3 1259 a 20-24 1.6 11.5 20.1 NA NA 68.9 1119 a 25-29 2.0 11.2 20.4 30.2 44.8 46.9 890 a 30-34 3.8 14.7 24.7 34.8 50.4 25.8 722 24.9 35-39 4.2 14.4 26.3 40.1 54.9 19.2 567 24.0 40114 4.4 14.1 28.2 39.0 53.3 18.9 507 24.3 45-49 2.2 10.4 23.1 38.1 56.8 11.9 358 23.3 20-49 2.8 12.6 23.0 33.5 45.5 39.0 4162 a 25-49 3.2 13.0 24.1 35.5 50.8 28.0 3044 24.8 NA - Not applicable aOmitted because less than 50 percent of the women in the age group x to x+4 were first married by age x Table 5.5 Median age at first marriage Median age at first marriage among women age 25-49 years, by current age and selected background characteristics, Namibia 1992 Current age Women Background age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban a 26.4 26.3 27.8 24.3 a Rural a 23.7 22.3 23.3 22.8 24.0 Region Northwest a 26.8 23.6 24.4 23.2 a Northeast 19.3 18.6 18.2 19.6 18.6 18.9 Central a 27.9 b 26.3 27.0 a South a 26.2 26.1 c 25.5 a Education No education Some primary Completed primary Secondary/Higher 21.9 23.0 21.5 22.9 22.9 22.6 a 24.1 24.0 24.9 24.9 24.6 a 23.7 24.5 29.0 22.8 24.8 a 26.2 24.8 25.0 23.0 a Total a 24.9 24.0 24.3 23.3 24.8 aOmitted because less than 50 percent of the women in this age group were first married at age 25. bOmined because less than 50 percent of the women in this age group were first married at age 35. COmitted because less than 50 percent of the women in this age group were first married at age 40. 50 5.4 Age at First Sexual Intercourse Age at first marriage is commonly used as a proxy for exposure to pregnancy, but in the Namibian situation, where many young women never marry or marry in their mid-twenties, the value of this indicator is limited in fertility analysis. Women may engage in sexual relations prior to marriage, especially if they are postponing the age at which they marry. All women in the NDHS were asked to state the age at which they first had sexual intercourse (see Tables 5.6 and 5.7). The median age at first intercourse was 18.9 years among women 20-49, and appears to be fairly similar in all age groups. The proportion of women 20-49 who had been sexually active by age 15 was seven percent, increasing to 37 percent by age 18, and 61 percent by age 20. Women in the Northeast region reportedly had sexual intercourse at about 17 years. This was approximately two years earlier than women in the South region, and four years earlier than women in the Northwest region. Women with no education engaged in sexual relations about two years earlier than women with secondary/higher education. In recent decades, educational level has had an impact on the age at first marriage (see Table 5.5), but the same effect has not been seen regarding age at first sexual intercourse. Table 5.6 Age at first sexual intercourse Percentage of women who had first sexual intercourse by exact age 15, 18, 20, 22, mad 25, and median age at first intercourse, according to current age, Namibia 1992 Percentage of women who had first intercourse by exact age: Current ago 15 18 20 22 Percentage Median who Number age at never had of first 25 intercourse women intercourse 15-19 7.7 NA NA NA NA 57.6 1259 a 20-24 6.1 40.3 66.1 NA NA 18.4 1119 18.7 25-29 6.0 35.1 59.8 74.6 86.4 7.7 890 19.0 30-34 7.8 39.8 62.4 77.5 87.2 1.9 722 18.7 35-39 8.3 37.4 62.1 78.9 87.7 0.5 567 19.0 40-44 8.7 35.8 55.3 70.8 84.3 0.6 507 19.4 45-49 7.0 29.6 48.2 69.0 85.0 0.6 358 20.1 20-49 7.1 37.3 60.7 75.2 84.8 7.1 4162 18.9 25-49 7.4 36.1 58.7 74.8 86.3 3.0 3044 19.1 NA = Not applicable aOmitted because less than 50 percent of the women in the age group x to x+4 had had interco~se by age x 51 Table 5.7 Median age at first marriage Median age at first marriage among women age 20-49 years, by current age and selected background characteristics, Namibie 1992 Current age Women Women Background age age characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 Residence Urban 18.5 19.1 18,9 18.9 18.8 19.9 18.9 19.0 Rural 18.7 18.9 18.6 19.1 19.8 20.3 19.0 19.2 Region Northwest a 21.1 20.5 20.4 21.2 21,6 a 20.9 Northeast 16.8 16.8 16.6 16.6 17.8 17.6 16.8 16.8 Central 17.0 17.7 17.6 17.4 16.9 17.4 17.4 17.5 South 18.4 19.2 19.1 19.0 18.9 19.9 19.0 19.1 Education No education 16.8 16.8 17.3 17.7 18.9 18.7 18.0 18.1 Some primary 18.1 18.1 18.2 18,6 18.9 19.8 18.4 18.5 Primary completed 18.0 18,7 18.2 19.8 19.5 21.6 18.8 19.3 Secondary/Higher 19.4 20.4 20.2 19.6 20.6 21.7 20.0 20.3 Total 18.7 19,0 18.7 19.0 19.4 20.1 18.9 19.1 Note: Medians are not shown for women 15-19 because less than 50 percent have married by age 15 in all subgroups shown in the table. aOmitted because less than 50 percent of the women in the age group were first married by age 20. 5.5 Recent Sexual Activity Previous sections have shown that a substantial amount of sexual activity occurs before and outside of marriage. Therefore, in many instances, marriage is neither a valid indicator of recent and/or regular sexual activity nor exposure to pregnancy. Information in chapter 3 shows that fertility levels among all women and among currently married women are similar (see Table 3.5). Since the probability of pregnancy is related to the frequency of intercourse, barring effective contraception, a more direct and effective measure of exposure to pregnancy is recent sexual activity. According to Table 5.6, seven percent of women 20-49 have never had sexual intercourse. At the same time, not all women who have had intercourse are currently sexually active. Table 5.8 presents data on women's recent sexual activity by various background characteristics; the distributions are shown only for women who have had intercourse. Women were considered to be sexually active if they had intercourse at least once in the four weeks prior to the survey. Women who are not sexually active may be abstaining in the period following a birth, or may be abstaining for other reasons. Among women who have had sexual intercourse, 58 percent were sexually active in the month prior to the survey. Approximately one-fourth of women who have had sexual intercourse were currently abstaining for reasons other than being postpartum, whereas approximately 16 percent were postpartum abstaining. More women in the Central, South, and Northeast regions reported being sexually active (72, 62, and 61 percent respectively) than women in the Northwest region (48 percent). 52 Moreover, women in the Northwest were much more likely to be postpartum abstaining than women in the Central, South and Northeast regions. As expected, women who were using a method of family planning were more likely to be sexually active than those who were not. However, more than half of women who were sexually active in the four weeks prior to the survey did not use any contraception. Table 5.8 Recent sexual activity Percent distribution of women who have ever had sexual intercourse by sexual activity in the four weeks preceding the survey and the duration of abstinence by whether or not postpartum, according to selected background characteristics, Namibia 1992 Not sexualiy active in last 4 weeks Sexually Abstaining Abstaining active (postpartum) (not postpartum) Number Background in last of characteristic 4 weeks 0-1 year 2+ years 0-1 yeas 2+ years Missing Total women Age of mother 15-19 54.8 19.5 0.6 24.1 0.6 0,4 100.0 531 20-24 54.7 16,8 3.3 23.5 1.4 0.3 100,0 913 25-29 58.8 16.1 3.6 18.8 1.8 0.9 100.0 821 30-34 62.2 11.6 2.7 19.8 2.5 1.2 100.0 708 35-39 62.5 9.7 2.0 21.0 3.0 1.8 100.0 564 40-44 57.6 5.4 3.1 22.6 9.4 1.9 100.0 503 45-49 56.6 2.8 1.0 23.7 14.1 1.8 100.0 355 Duration of union 0-4 73.6 9.8 0.6 15.2 0.3 0.5 100.0 676 5-9 70.5 8.6 2.5 15.8 1.5 0.9 100.0 581 10-14 62.5 9.9 2.2 18.7 3.9 2.9 100.0 484 15-19 64.9 9.1 1.9 18.7 3.7 1.8 100.0 379 20-24 58.9 7.4 1.4 23.4 6.9 1.9 100.0 291 25+ 63.1 1.8 0.9 21.9 10.5 1.8 100.0 228 Never in union ,14.8 19.3 3.9 27.4 4.3 0.4 100.0 1758 Residence Urban 63.3 8.5 2.4 20.3 3.8 1.8 100.0 1796 Rural 54.6 15.8 2.6 22.7 3.7 0.6 100.0 2600 Region Northwest 48.2 19.2 2.5 26.3 3.5 0.2 100.0 1563 Northeast 60.5 13.2 3.3 18.6 3.9 0.7 100.0 801 Centxal 72.2 5.4 1.2 17.4 3.1 0.8 100.0 622 South 61.8 8.8 2.7 20.3 4.1 2.4 100.0 1410 Education No education 64.9 8.3 2.8 17.3 5.7 1.0 100.0 760 Some primary 55.1 15.3 2.9 22.3 4.2 0.4 100.0 1654 Primary completed 53.8 15.5 1.7 24.9 3.4 0.8 100.0 414 Secondaryf/qighur 59.3 11,6 2.3 22.4 2.4 1.9 100.0 1568 Current contraceptive method No method 54.8 14.4 2.6 22.8 4.7 0.7 100.0 3159 Pill 71.5 7.6 1.5 15.9 1.5 1.9 I00.0 378 IUD 73.3 6.3 1.7 13.6 0.0 5.0 100.0 71 Sterilisation 69.2 2.6 1.7 20.0 2.6 3.9 100.0 212 Periodic abstinence (53.4) (12.8) (6.5) (25.6) (1.7) (0.0) 100.0 32 Other 62.7 11.9 3.0 20.8 0.8 0.8 100.0 543 Total 58.2 12.8 2.5 21.7 3.7 1.1 100.0 4396 Note: Figures in parentheses are based on a small number of cases. 53 5.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility Postpartum protection from conception can be prolonged by breastfeeding, which can lengthen the duration of amenorrhoea (the period following a birth, but prior to the return of menses). Protection can also be prolonged by delaying the resumption of sexual relations. Table 5.9 presents the percentage of births whose mothers are postpartum amenorrhoeic and postpartum abstaining, as well as the percentage of births whose mothers are still postpartum insusceptible (due to either amenorrhoea or abstinence) since the last birth. In the absence of contraception, postpartum amenorrhoea and abstinence are the most important determinants of the interval between births. Table 5.9 Postpartum amenorrhoea t abstinence and insusceptibility by ase Percentage of births whose mothers are postpartum amanorrhoeie, abstaining and insusceptible, by number of months since birth, and median and mean durations, Namibia 1992 Number Months Amenor- Insus- of since bi.,'th rhoeie Abstaining eepfible births < 2 87.3 92.9 98.1 125 2-3 73.6 75.0 92.4 144 4-5 68.9 53.6 82.0 163 6-7 57.4 52.0 76.5 141 8-9 46.3 34.2 63.7 140 10-11 42.6 37.9 62.5 128 12-13 38.9 30.9 53.2 174 14-15 24.0 21.3 37.1 135 16-17 28.6 22.0 41.5 140 18-19 17.9 16.2 31.1 114 20-21 13.8 14.9 23.1 125 22-23 7.7 17.0 22.8 139 24-25 3.9 11.4 13.5 148 26-27 5.1 9.7 12.9 138 28-29 2.5 9.1 11.6 141 30-31 3.4 10.0 12.8 139 32-33 5.7 7.0 11.0 115 34-35 1.4 7.9 8.6 118 Total 30.2 29.6 42.9 2469 Median 8.3 6.0 12.8 Mean 10.9 10.7 15.3 Prev/lncidence Mean 10.7 10.5 15.2 Eighty-seven percent of Namibian women are amenorrhoeic for less than two months following a birth; 93 percent of women abstain from sexual relations during this time. However, approximately 6 months later (about 8 months after a birth), fewer than half the women are still amenorrhoeic (46 percen0, and only about one-third (34 percent) are still abstaining. Overall, approximately half of the women become susceptible to pregnancy within 12-13 months of giving birth. 54 Table 5.10 presents the median duration of insusceptibility by background characteristics of the mothers. The median duration of postpartum amenorrhoea is 8.3 months; the median duration of postpartum abstinence is 6 months. Women are protected by either abstinence or amenorrhoea for slightly more than one year. In the Northeast and Northwest women have substantially longer periods of amenorrhoea (15 months and 10 months respectively) than women in the Central (6 months) and South (3 months) regions; a similar pattern emerges for the duration of abstinence, but the differences are smaller. Women in the Northeast and Northwest regions have longer periods of postpartum insusceptibility than women in the Central and South regions. Women living in rural areas experience much longer periods of amenorrhoea and, to a lesser extent, shorter periods of insusceptibility than urban women. Table 5.10 Median duration of postpartum amanorrhoea) abstinence and insusceptibility by background characteristics Median number of months of postpartum amanorrhoea, postpartum abstinence and postpartum insusceptibility, by selected background characteristics, Namibia 1992 Number Background Amenor- Imus- of characteristics rhoeic Abstaining eeptible births Age <30 7.5 7.2 12.3 1449 30+ 11.1 4.4 13.4 1019 Residence Urban 3.3 5.6 9.5 792 Rural 10.3 6.2 14.5 1677 Region Northwest 10.0 8.7 14.7 1103 Northeast 15.2 6.1 17,0 466 Central 5.9 3.7 10.1 303 South 2.4 5.7 7.8 597 Edueatinn No education 12.4 4.2 14.2 414 Some primary 11.0 8.5 15.2 1004 Primary completed 8.2 7.8 10.5 249 Secondary/Higher 5.6 5.2 10.0 802 Total 8.3 6.0 12.8 2469 As will be seen in Chapter 8, duration of breastfeeding (which is linked to amenorrhoea) decreases as the mother's level of education increases. As a result, the duration of amenorrhoea for educated women is shorter. The median duration of amenorrhoea for women with no education is one year, and 6 months for women with secondary or more schooling. There is less variation among different educational levels in duration of abstinence than in duration of amenorrhoea. Women with no education abstained for approximately 4 months, whereas, women with secondary/higher levels of education abstain for 5 months. Women in female-headed households had longer durations of abstinence than women in male-headed 55 households. Use of contraception should be considered in conjunction with amenorrhoea and abstinence in order to assess the impact on fertility. 5.7 Termination of Exposure to Pregnancy Later in life, the risk of pregnancy begins to decline with age, typically beginning around age 30. While the onset of infecundity is diflicult to determine for any individual woman, there are ways of estimating it for a population. Table 5.11 presents two indicators of decreasing exposure to the risk of pregnancy for currently married women age 30 and above: menopause and long-term abstinence. Women may be described as menopausal if they are neither pregnant nor postpartum amenorrhoeic, but have not bad a menstrual period in the six months preceding the survey. Nineteen percent of women age 46-47 and 40 percent of women age 48-49 were menopausal. The second indicator is long-term abstinence, which measures lack of exposure to pregnancy due to lack of sexual activity (3 years) among currently married women. Only 0.5 percent of currently married women were found to be practicing long-term abstinence at the time of the survey. Table 5.11 Termination of exposure to the risk of pregnancy Indicators of menopause and long-term abstinence among currently married women age 30-49, by age, Namibia 1992 Long-term Menopause I abstinence 2 Age Percent N Percent N 30-34 6.1 288 0.5 459 35-39 10.4 283 0.6 397 40-41 7.1 106 0.0 148 42-43 11.5 103 0.0 131 44-45 18.3 117 0,8 131 46-47 19.1 87 0.0 96 48-49 39.6 85 1,2 89 Women 30-49 12.9 1071 0.5 1451 IPercentage of non-pregnant, non-amenorrhoeic currently married women whose last menstrual period occurred six or more months preceding the survey or who report that they are menopausal. ZPercentage of currently married women who did not have intercourse in the three years preceding the survey. 56 CHAPTER 6 FERTILITY PREFERENCES Tiff s chapter focuses on three indicators of the need for contraception: whether or not the respondent wants another child, the preferred time interval between children, and the number of children considered to be ideal. Analyses of these and similar issues reveal important implications for the implementation of family planning programs. The underlying rationale of most family planning programmes is to give couples the freedom and ability to bear the number of children they want and to achieve the spacing of births they prefer, The data make possible quantification of fertility preferences and, in combination with information on contraceptive use, allow for an estimation of demand for family planning. Questions regarding fertility preferences were asked of nonsterilised, currently married women; and all women were asked what they considered to be the ideal family size. 6.1 Desire for More Children Women were asked: "Would you like to have another child or would you prefer not to have any more children?" If they did indeed want anotber child, they were asked: "How long would you like to wait from now before the birth of another child?" These questions were appropriately phrased if the woman had not yet had any children; if the woman was pregnant, she was asked about her desire for more children in addition to the baby she was expecting. Figure 6.1 shows the percent distribution of currently married women by their fertility preferences and Table 6.1 shows the distribution according to the number of living children. Twenty-six percent Figure 6.1 Fertility Preferences of Currently Married Women 15.49 Undecidq Want • Child Soon 26% (<2 years) Sterl l lsed 8% Want a Chi ld Later 3( (>2 years) Infecund 3% t No More 26% NDHS 1992 57 Table 6.1 Fertility preference by number of living children Percent distribution of currently married women by desire for more children, according to number of living children, N amibia 1992 Number of living children 1 Desire for children 0 1 2 3 4 5 6+ Total Want another soon 2 61.9 36.6 20.6 24,4 19.2 19,1 19.2 25,9 Want another later 3 16.9 38.8 36.3 31.1 28.1 30,5 22.0 29.7 Want another, undecided when 2.5 1.4 0.6 2.1 1,4 1.4 1.4 1.5 Undecided 4.1 4,5 3.7 5.4 8.9 6,3 6.8 5.7 Want no more 6.0 13.6 25,9 24.8 31.5 28.5 36,6 25.8 Sterilised 2.2 1.3 8.7 10,5 7.1 12.0 9,1 7.7 Declared infecund 4,9 2,1 1.9 1,4 2.9 2,2 3.6 2,6 Missing 1.5 1.8 2.2 0.3 0.9 0.0 1.1 1.1 Total 100.0 100.0 100.0 100.0 100,0 100.0 100,0 100.0 Number of women 161 333 384 380 282 217 502 2259 llncludes current pregnancy 2Warn next birth within 2 years S~Vant to delay next birth for 2 or more years of women wanted another child soon, 30 percent wanted to wait two or more years before having a child and 26 percent did not want any more children at all. The desire for more children tended to decline as the number of living children increased. Sixty-two percent of women with no living children wanted to have a child soon (within the next two years), whereas only 19 percent of women with 4 or more living children wanted a child soon. Six pereent of women with no living children said they didn't want any children, and over one-third of women with six or more children said they didn't want any more. Although family size norms are large in Namibia, Table 6.1 indicates a considerable interest in controlling fertility and, therefore, a potential demand for family planning services, particularly among women with many children and women who want to delay child-bearing or to space their births. However, consideration must be given to whether the desire to limit or space births necessarily translates into actual utilisation of family planning services. Lack of available family planning services and women's hesitation to begin using contraception may limit the ability of women to achieve their fertility preferences. 58 Table 6.2 presents the percent distribution of currently married women by desire for children and age of respondent. Almost half of women under 25 years reported that they wanted to delay childbearing by at least two years. The proportion decreases in older age groups to 13 percent among women 45-49. A high proportion of women under 20 years said they wanted no more children (17 percent); however, consideration should be given to the small number of observations in this age group (86 women). Table 6.2 Fertility preferences by ago Percent distribution of currently married woman by desire for more children, according to age, Namibia 1992 Desire for Age of woman children 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Want another soon 1 28.1 30.3 31.1 25.0 24.0 26.1 15.6 25.9 Want another later 2 44.7 44.0 37.8 35.7 22.2 16.2 12.6 29.7 Want another, undecided when 2.6 0.6 1.5 2.4 1.4 1.9 0.0 1.5 Undecided 5.1 3.4 3.7 7.8 7.1 6.0 5.7 5.7 Want no more 16.7 18.4 21.8 21.0 31.2 29.2 40.3 25.8 Sterilised 0.0 1.5 2.2 5.3 10.4 13.1 19.1 7.7 Declared Irtfecund 0.0 0.6 1.3 0.9 2.4 6.7 5.8 2.6 Missing 2.8 1.2 0.5 1.8 1.2 0.7 0.9 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 86 307 414 459 397 345 251 2259 1Want next birth within 2 years 2Want to delay next birth for 2 or more years The desire to stop childbearing v aries greatly by background characteristics of respondents (see Table 6.3). Overall, one-third of currently married women (including women who had been stetilised) reported that they wanted no more children. Forty-five percent of urban women and 26 percent of rural women wished to cease childbearing. The differences by region are even more pronounced. The percentage of women wanting no more children was highest in the South region (57 percent) foUowed by the Northwest (19 percent), and the Northeast regions (16 percent). Of particular note was the high proportion of women who said they wanted no more children among women who had no children in the South and Central regions. The percentage of women wanting no more children is positively associated with education. Women with at least some secondary education were more likely to report that they wanted no more children than women with no education or primary education. Among women with secondary education, there is a sharp increase in the proportion who want to stop having children between those with one and those with two living children (14 percent and 48 percent, respectively). 59 Table 6.3 Desire to limit childbearing Percentage of currently married women who want no more children, by number of living children and selected background characteristics, Namibia 1992 Number of living children t Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 14.9 17.6 45.0 55.6 62.5 72.0 59.1 45.4 Rural 2.7 12.4 22.4 19.9 23.6 27.1 42.3 25.9 Region Northwest (0.0) 1.7 10.1 10.6 14.5 12.9 35.5 19.4 Northeast 0,0 4.7 6,5 9.7 15,9 23,2 43.4 16,1 Central (12.1) 22.6 (43.9) 46.0 (35.7) * (51.2) 37.1 South (17.5) 24.5 55.4 64.6 72.8 84.9 77.5 56.9 Education No education * 10.9 22.8 21.6 31.4 34.8 48.3 32.0 Some primary 3.9 15.6 19.7 16.2 28.0 37.0 44.4 27.0 Completed primm-y * (26.3) (28.8) (33.7) (48.6) (47.0) (44.5) 36.3 Secondary/Higher 14.4 13.6 47.6 59.1 58.7 49.9 43.7 41.1 Total 8.2 14.8 34.6 35.3 38.7 40.5 45.7 33.5 Note: Women who have been sterilised are considered small number of cases. *Based on too few cases to show 1Includes current pregnancy to want no more children. Figures hi paranthese are based on a 6.2 Demand for Family Planning Services Currently married women who report either that they do not want to have any more children (i.e., they want to limit their childbearing) or that they want to wait two or more years before having another child (i.e., they want to space their births), but are not currently using contraception, am defined as having an unmet need for family planning, l Women with unmet need for family planning and women currently using contraception constitute the total demand for family planning (see Table 6.4). The demand for family planning in Namibia includes over half of currently married women. Twenty- nine percent of currently married women were using contraception (modem or traditional methods) for purposes of spacing or limiting births, however, approximately 24 percent of women's contraceptive needs were not being met. Although the unmet need for spacing and for limiting births was low (16 and 8 percent of currently married women), younger women were more likely to need family planning for spacing purposes, and older women for limiting purposes. IThe calculation of unmet need, being a current status measure, is further refined by excluding women who are currently amenorrhoeic (nearly 30 percent of women) and, therefore, not in need of family planning at this point in time. For an exact description of the calculation, see footnote 1, Table 6.4. 60 Table 6.4 Need for family planning services Percentage of currently married women with unmet need for family planning, met need for family planning, and the total demand for family planning services, by selected background characteristics, Namibia 1992 Met need for Unmet need for family planning Total demand for Percentage family planning 1 (currently using) 2 fatr~y planning of demand Number For For For For For For sails- of spacing limiting Total spacing limiting Total spacing limiting Total fled women Background characteristic Age 15-19 24.2 7.7 31.9 15.3 5.1 20.5 39.5 12.9 52.4 39.1 86 20-24 18.1 4.5 22.6 20.2 10.5 30.6 38.2 15.0 53.2 57.6 307 25-29 19.9 4.7 24.6 17.9 14.3 32.3 37.9 19.0 56.9 56.7 414 30-34 17.5 5.9 23.3 14.3 15.0 29.3 31.7 20.9 52.6 55.7 459 35-39 13.7 8.3 22.0 6.1 26.5 32.6 19.7 34.9 54.6 59.7 397 40-44 13.1 10.1 23.2 2.8 20.9 23.7 15.9 31.0 46.9 50.5 345 45-49 6.6 16.8 23.3 1.6 23.1 24.6 8.1 39.8 48.0 51.4 251 Residence Urban 11.7 7.8 19.5 16.2 31.6 47.8 28.0 39.4 67.4 71.0 877 Rural 18.2 7.9 26.1 8.0 8.9 16.9 26.2 16.7 42.9 39.3 1382 Region Northwest 21.1 6.6 27.7 3.5 5.1 8.7 24.6 11.7 36.4 23.8 713 Northeast 16.9 5.1 22.0 17.8 3.7 21.5 34.7 8.8 43.5 49.4 476 Central 16.3 6.7 23.0 13.1 19.1 32.2 29.3 25.8 55.1 58.3 340 South 9.4 11.3 20.7 13.5 38.5 52.0 22.9 49.8 72.7 71.5 730 Education No education 16.5 9.5 26.0 5.5 11.3 16.8 22.0 20.8 42.8 39.2 509 Primary incomplete 15.5 9.1 24.6 8.6 10.6 19.2 24.1 19.7 43.9 43.8 827 Primary complete 18.5 7.7 26.1 12.2 17.3 29.5 30.6 25.0 55.6 53.0 192 Secondary/Higher 14.6 5.3 19.9 17.8 30.3 48.1 32.4 35.6 68.0 70.8 730 Total 15.7 7.8 23.5 11.2 17.7 28.9 26.9 25.5 52.4 55.1 2259 lUnmet need for spacing includes pregnant women whose pregnancy w~ mistimed, amenorrhoaic women whose last birth was mistimed, and women who are neither pregnant nor an~norrhoeic and who are not using any method of family planning and say they want to wait 2 or mo~ years for their next birth. ALso included in unmet need for spacing are women who are unsure whether they want another child or who want another child but are unsure when to have the birth. Unrnet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhoeie women whose last child was unwanted and women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and who want no mol~ children. 2Using 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. Total demand for family planning was greater in urban areas (67 percent) than in rural areas (43 percent). In addition, 71 percent of urban demand was satisfied, whereas only 39 percent of the demand in rural areas was satisfied. There are substantial regional differences inthe degree of demand satisfied. Total demand in the South region was 73 percent; 55 percent in the Central region; 44 percent in the Northeast; and 36 percent in the Northwest region. The proportion of demand satisfied was positively related to the size of demand; only 24 percent of the demand in the Northwest was satistied, versus 72 percent of satisfied demand in South region. Table 6.4 indicates that the demand for family planning was highest among the most educated women: 68 percent of those that completed secondary school had a demand for family planning, and approximately 71 percent of that need was satisfied. 61 6.3 Ideal and Actual Number of Children In order to ascertain what women considered to be the ideal number of children, they were asked: "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?" Table 6.5 shows the percent distribution of all women by ideal number of children, according to number of living children. Non-numeric responses were given by 8 percent of women, mostly women with higher numbers of living children. The mean ideal number of children between all women and currently married women was similar regardless of number of living children (5.0 and 5.7, respectively). Table 6.5 shows an association between the ideal number of children and the number of living children. There is usually a correlation between actual and ideal number of children, which, in Namibia, can be seen from the fact that the mean ideal number of children increases from about 4 among childless women to about 8 among those with six or more children. The reasons for this are, first, that women may successfully attain their desired family size (i.e., those who want more children have more), and, second, that women may rationalise and adjust their ideal number of children to match the actual number of children they have had. Table 6.5 Ideal number of children Percent distribution of all women by ideal number of children and mean ideal number of children for all women and for currently married women, according to number of living children, Namibia 1992 Number of living children I Ideal number of children 0 1 2 3 4 5 6+ Total 0 1.6 0.8 1.7 0.6 1.1 1.2 1.2 1.2 1 4.1 8.6 2.3 2.1 0.7 0.0 0.5 3.6 2 20.4 19.5 24.1 6.6 5.8 3.7 2.1 14.9 3 11.4 17.2 11.2 16.1 3.1 3.2 3.2 10.9 4 19.1 19.6 22.5 19.0 23.1 10.1 3.5 17.6 5 15.1 12.0 11.6 14.4 9.5 22.0 4.3 12.6 6+ 21.2 17.8 21.5 33.8 46.4 47.1 66.6 30.9 Non-numeric response 7.1 4.5 5.2 7.4 10.2 12.8 18.5 8.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1676 1033 723 605 434 300 649 5421 Mean ideal number 4.3 3.9 4.3 5.2 5.9 6.5 8.3 5.0 Number of women 1556 987 685 560 390 262 529 4969 Mean for women in union 4.6 4.0 4.2 5.3 5.9 6.7 8.4 5.7 Number of women in union 155 318 366 350 254 194 410 2046 Note: The means exclude women who gave non-numeric responses. llncludes current pregnancy 62 Table 6.6 presents the mean ideal number of children by age and selected background characteristics of the respondents. Typically, urban and more educated women have a smaller ideal family size. Among women with no education the mean ideal number of children was 6.6, and gradually decreased to 4.0 among the most educated women. In urban areas, the mean ideal number of children was 3.8, compared to 5.8 in rural areas. The difference between regions was also substantial. The ideal number of children among women in the two northern regions was approximately 6, whereas, 4.4 and 3.3 were the ideal numbers of children for women in the Central and South regions, respectively. Furthermore, there appears to be a trend toward smaller family size among younger women. Among women age 40-49, the ideal mean number of children was approximately seven, compared to four children among women 15-24. Table 6.6 Mean ideal number of children by background characteristics Mean ideal number of children for all women, by age and selected background characteristics, Namibia 1992 Age of women Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45~19 Total Residence Urban 2.6 3.3 3.7 4.4 4.5 4.8 5.1 3,8 Rural 4.7 5.0 5.7 6.2 7.4 7.9 7,9 5.8 Region Northwest 5.1 5.3 5.9 6.4 8.0 8.7 8,8 6,2 Northeast 4.3 5.1 6,1 6.8 6.9 8.4 8.2 5,8 Central 2.7 3.6 4.6 4.8 5.5 5.8 5.2 4,4 South 2.2 2.8 3.1 3.8 4.1 4.0 4.8 3,3 Education No education (4.0) 4.5 6.1 6.5 6.7 7.9 7.6 6,6 Some primary 4.4 5.1 5.6 6.2 7.0 7.2 7.1 5.6 Completed primary 4.0 4.1 4.4 5.1 5.6 (6.2) * 4.7 Secondary/Higher 3.5 3,8 4.2 4.1 4.7 4.8 4.4 4,0 Total 4.0 4.3 4.8 5.3 6.0 6.8 6.7 5,0 Note: Figures in parenthese are based on a small number of cases. • Based on too few cases to show 6.4 Fertility Planning Since the issue of mistimed and unwanted births is an important one, the NDHS asked women whether each birth in the five years preceding the survey was planned (wanted then), unplanned (wanted later), or not wanted at all (wanted no more). The responses give an indication of the degree to which couples are successfully controlling their fertility. This question was asked about every child 10om in the preceding five years and about the forthcoming expected child for women who were pregnant at the beginning of the survey. However, measures based on these questions have limitations. The respondent is required to recall accurately her wishes at one or more points in the last five years and to report them honestly. This type of recall information may be affected by memory problems. It is also likely that there will be underestimates because women with unplanned or unwanted births may rationalise such births and declare them as wanted after they are born. 63 Table 6.7 shows the percent distribution of births in the five years preceding the survey by fertility planning status, according to birth order and mother's age at birth. Over two-thirds of the births were perceived by the respondent as "wanted" at the time of conception, while one-fifth were wanted later, and 12 percent were not wanted at all. There was a positive relationship between birth order and the proportion of births that were wanted at the time they were conceived; the higher the birth order, the more likely it was that the respondent wanted the child at that time. Conversely, a negative relationship existed between birth order and the proportion of births declared not wanted. Almost half of first births were wanted then, one-third were wanted later, and 16 percent were not wanted at all. Women under 25 years were less likely to have wanted a birth at the time of conception than older women. The potential demographic impact of avoiding unwanted births can be estimated by calculating the wanted fertility rate. The wanted fertility rate is calculated in the same manner as the conventional age- specific fertility rates, except that births classified as unwanted are omitted from the numerator. For this calculation, unwanted births are defined as those which exceed the number considered ideal by the respondent. (Women who did not report an ideal family size were assumed to want all their births.) This rate represents the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been prevented. A comparison of the total wanted fertility rate and the actual total fertility rate suggests the potential demographic impact of the elimination of unwanted births. Table 6.7 Fertility planning status Percent distribution of births in the five years preceding the survey by fertility planning status, according to birth order and mother's age, Namibia 1992 Planning status of birth t Birth order Wanted Number and mother's Wanted Wanted no of age then later more Missing Total births Birth order 1 52.0 31.5 16.2 0.3 100.0 1138 2 64.6 22.8 11.9 0.7 100.0 803 3 68.1 19.1 11.0 1.7 100.0 647 4+ 72.8 15.0 10.5 1.7 100.0 1709 Age at birth <19 46.3 34.3 19.2 0.2 10O.0 669 20-24 58.4 27.9 12.6 1.1 100.0 1111 25-29 71.1 18.6 9.5 0.8 100.0 1026 30-34 73.8 15.4 9.3 1.5 100.0 713 35-39 74.9 10.9 12.0 2.3 100.0 498 40-44 75.2 8.1 15.3 1.4 100.0 239 45~49 (68.5) (16.7) (7.2) (7.6) (100.0) 41 Total 65.1 21.4 12.3 1.2 100.0 4297 Note: Figures in parentheses are based on a small number of cases. tIncludes current pregnancy 64 Table 6.8 presents a comparison of wanted fertility rates and total fertility rates by background characteristics. Overall, the difference between the wanted fertility rate and the total fertility rate is 0.6 child (5.4 versus 4.8). Consistent with other findings in this chapter, women in rural areas, women in the Northeast region, and women with less education had higher wanted and total fertility rates. However, the difference between wanted and total fertility was fairly constant/br all background characteristics. Table 6.8 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by selected background characteristics, Namibia 1992 Total wanted Total Background fertility f~tility characteristic rate rate Residence Urban 3,4 4.0 Rural 5.8 6.3 Region Northwest 6.3 6.7 Northeast 5.5 6.0 Central/South 3.4 4.1 Education No education 5.9 6.5 Some primary 5.6 6.1 Completed primary 4.3 5.1 Secondary/Higher 3.7 4.1 Total 4.8 5.4 Note: Rates are based on births to women 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 3.2. 65 CHAPTER 7 INFANT AND CHILD MORTALITY This chapter presents information on levels, trends and differentials in neonatal, posmeonatal, infant and child mortality. This information can be used as a means of identifying those sectors of the child population that are at high risk, for evaluation of health programmes, and for population projections. Mortality estimates are calculated from information that was collected in the birth history section of the individual questionnaire. The section began with questions about the aggregate childbearing experience of respondents (i.e., the number of sons and daughters who live in the household, those who live elsewhere, and those who died). These questions were followed by a retrospective birth history in which data were obtained on sex, date of birth, survivorship status, and current age or age at death of each of the respondents' live births. The rates presented here are defined as follows: Neonatal mortality: the probability of dying within the first month of life; Postneonatal mortality: the difference between infant and neonatal mortality; Infant mortality: the probability of dying before the first birthday; Child mortality: the probability of dying between the first and fifth birthday; Under-five mortality: the probability of dying before the fifth birthday. The accuracy of the mortality estimates is affected by the completeness of reporting of deaths, the degree of differential displacement of birth dates of surviving and dead children, and the extent to which age at death is accurately reported. Heaping of age at death at 12 months is a problem commonly identified in surveys. In the NDHS heaping at 12 months was moderate and very few deaths of this type were recorded at "1 year" (instructions required interviewers to record deaths under two years of age in months). An unknown fraction of these deaths may have actually occurred before the first birthday. Thus, the infant mortality rate may be biased downward somewhat and child mortality biased upward; under-five mortality would be unaffected. The magnitude of this bias in Namibia is small. It is seldom possible to establish, with confidence, mortality levels for a period more than 15 years before a survey) Even in the recent 15-year period considered here, apparent trends in mortality should be interpreted with caution. First, differences may exist in the completeness of death repotting related to the length of time preceding the survey. For example, it seems that underreporting of very early neonatal deaths (at 0-1 days) has occurred for the period 10-14 years prior to the survey. Second, the accuracy of reports of age at death and of date of birth may deteriorate with time. Thus, without a detailed evaluation of the quality of birth history data (which is not attempted in this report), conclusions regarding changes in mortality should be considered preliminary. ~Since the NDHS is a cross-sectional survey with respondents aged 15-49 years at the time of the interview, rates for periods earlier than 15 years preceding the survey do not adequately represent all births. 67 7.1 Infant and Child Mortality Neonatal, postneonatal, infant, child and under-five mortality rotes are shown in Table 7.l for five- year periods in the 15 years preceding the survey. For the most recent five-year period (1988-92), infant mortality is 57 per 1,000 live births, including 32 neonatal deaths per 1,000 live births, and 25 postneonatal deaths per 1,000 live births. Child mortality is 28 per 1,000 children aged one (or 26 per 1,000 live births), and under-five mortality is 83 per 1,000 live births. Thus, 38 percent of all under-five deaths occur in the neonatal period, 30 percent in the posmeonatal period, 68 percent during infancy, and 32 percent at ages 1-4 years. Table 7.1 Infant and chiM mortality Infant and child mortality rates by five-year periods preceding the survey, Namibia 1992 Years Neonatal Postneonatal Infant Child Under-five preceding mortality mortality mortality mortality mortality survey (NN) (PNN) (lqo) (4qz) (sqo) 0-4 31.5 25.2 56.6 28.1 83.2 5-9 39.9 27.4 67.3 36.8 101.6 10-14 29.2 43.1 72.2 41.0 110.3 Note: Month of interview excluded from analysis. Comparison of the NDHS mortality estimates with other Namibian sources is not possible since this is the first national estimate of child mortality. In 1988, a DHS-type survey was conducted among a selected population: the survey excluded all of Ovamboland, as well as coloured and white women. Infant mortality was estimated at 26 per 1,000 live births for 1983-87 (Rossouw and Van Tonder, 1989). The NDHS results indicate that this estimate seriously underestimated the level of mortality. Figure 7.1 compares child mortality in Namibia with other countries in sub-Saharan Africa where DHS surveys have been carried out. Botswana and Zimbabwe are the only countries with mortality lower than Namibia. Under-five mortality over the fifteen-year period has fallen slowly from 110 deaths per 1,000 live births during 1978-82 to 102 during 1983-87 and 83 per 1,000 for 1988-92 (see Figure 7.2). Mortality during the infant and 1-4 years age segments has declined. The decrease in infant mortality is largely due to a drop in postneonatal mortality. Neonatal mortality appears to rise slightly during this period; however, this is probably due to underreporting of neonatal deaths in the period 10-14 years prior to the survey. Infant mortality rates are subject to both sampling and non-sampling errors. The latter include underreporting of early childhood deaths, which would result in underestimates of mortality, and misreporting of age at death, which may distort the age pattem of under-five mortality. 68 Figure 7.1 Childhood Mortality Rates DHS Surveys in Sub-Saharan Africa, 1986-1992 Botswanal Zimbabwe Namlbla . Kenya . Cameroon . Tanzania Burundl Ghana Togo . ~ - Uganda Zambia , . Senegal . . Nigeria Llberlsl . Mall NIgerJ ,,, 0 50 100 150 200 250 300 Mortallty per 1,000 Live Births ['-ilnfant (<1 yr) QChild (1-4 yrs) Note: Rates are for the period 0-4 years preceding the surveys. 350 NDHS1992 Figure 7.2 Age-Specific Mortality Rates for Five-Year Periods Prior to the Survey Deaths per 1,000 Live Births 120 100 80 60 40 20 0 1981 1986 1990 1994 NDHS1992 69 Underreporting of deaths is generally more common for children who died shortly after birth than those who died later. If early neonatal deaths are selectively underreported, then an abnormally low ratio of deaths under seven days to all neonatal deaths and an abnormally low ratio of neonatal to infant mortality would be observed. Data presented in Appendix Tables D.5 and D.6 indicate that underreporting of deaths early in life has not occurred on a large scale in the NDHS. The proportion of first week deaths among all first months deaths was 77, 77 and 78 percent for the periods 0-4 years, 5-9 and 10-14 years preceding the survey (see Table D.5). The proportion of neonatal deaths among all infant deaths was 58, 60 and 41 percent for the three periods (see Table D.6). These results suggest that there is little underreporting for the decade prior to the survey, but considerable underreporting of neonatal deaths for the period 10-14 years preceding the survey. 2 Table 7.2 presents neonatal, postneonatal, infant, child and under-five mortality rates by selected background characteristics for the 10-year period (1983-1992) preceding the survey (see also Figure 7.3). A ten-year reference period is used to allow for adequate numbers of events in each population subgrou

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