Nepal - Demographic and Health Survey - 1997

Publication date: 1997

Nepal World Summit for Children Indicators: Nenal 1996 Value BASIC INDICATORS Childhood mortality [ Childhood malnutrition Clean water supply Sanitary excreta disposal Basic education Children in especially difficult situations Infant mar'tality rate (direct estimation) Under-five mortality rate Percent stunted Percent wasted Percent underweight Percent of households within 15 minutes of a safe water supply 2 Percent of households with flush toilets Percent of womea 15-49 with completed primary education Percent of men 15-49 with completed primary education Percent of glrls 6-12 attending school Percent of boys 6-12 attending school Percent of women 15-49 who are literate Percent of children who live in single adult households 79 per 1,000 118 per 1,000 48.4 11.2 46.9 61.1 2.7 17.9 46.6 56.4 75.7 21.2 5.4 SUPPORTING INDICATORS Women's Health Birth spacing Safe motherhood Family planning Nutrition Maternal nutrition Breastfeeding Iodine Child Health Vaccinations Diarrhoea control Acute respiratory infection Percent of non-first births within 24 months of a previous birth Percent of births with medical prenatal care 3 Percent of births with prenatal care in first trimester Percent of births with medical assistance at delivery 4 Percent of births in a medical facility Percent of births at high risk 24.1 39.3 12.7 10.1 7.6 56.1 Contraceptive prevalence rate (any method, currently married women) 28.5 Percent of currently married women with an unmet need for family planning 31.4 Percent of currently married women with an unmet need for family planning to avoid a high-risk birth 23.8 Percent of mntbers with low BMI 28.3 Percent of childrea under 4 months who are exclusively breastfed 81.8 Percent of households with iodized salt 93.2 Percent of children whose mothers received tetanus toxiod vaccination during pregnancy 46.0 Percent of children 12-23 months with measles vaccination 56.6 Percent of children 12-23 months fully vaccinated 43.3 Percent of children with diarrhoea in preceding 2 weeks who received oral rchydmtion therapy 28.6 Percent of children with acute respiratory infection in preceding 2 weeks who were seen by medical personnel 18.2 0-4 years before the survey; see Chapter 7 for details. z Piped and well water. 3 Includes doctor, unrsc/midwifc, maternal and child health (MCH) worker, village health worker, health assistants and health post staff 4 Includes doctor, nurse/midwife, MCH worker, village health worker, health assistant and health post staff. Nepal Family Health Survey 1996 Ajit Pradhan Ram Hari Aryal Gokarna Regmi Bharat Ban PavalavaIli Govindasamy Family Health Division Department of Health Services Ministry of Health His Majesty's Government Kathmandu, Nepal New ERA Kathmandu, Nepal Macro International Inc. Calverton, Maryland USA March 1997 This report represents the findings of the 1996 Nepal Family Health Survey (NFHS) conducted under the aegis of the Family Health Division, Department of Health Services, Ministry of Health, Nepal. The NFHS was funded by the U.S. Agency for International Development (USAID) through its mission in Nepal and was implemented by New ERA, a local research firm in Nepal. Technical support for the survey was provided by Macro International Inc., under its Demographic and Health Surveys Project. The 1996 Nepal Family Health Survey (NFHS) is part of the worldwide Demographic and Health Surveys (DHS) project. Information about the NFHS may be obtained from the Family Health Division, Department of Health Services, Ministry of Health, P.O. Box 2936, Teku, Kathmandu, Nepal (Telephone: 213541 or 212051; Fax: 223142) and New ERA, P.O. Box 722, Maharajgunj, Kathmandu, Nepal (Telephone: 410803 or 413603; Fax: 419562). Additional information about the DHS project may be obtained from Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA (Telephone: 301-572-0200; Fax: 301-572-0999; E-mail: reports@macroint.com; lnternet: http://www.macroint.com/dhs/). Recommended citation: Pradhan, Ajit, Ram Hari Aryal, Gokarna Regmi, Bharat Ban, and Pavalavalli Govindasamy. 1997. Nepal Family Health Survey 1996. Kathmandu, Nepal and Calverton, Maryland: Ministry of Health [Nepal], New ERA, and Macro International Inc. CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix 1996 Technical Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi List of Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv Map of Nepal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxx CHAPTER 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 CHAPTER 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 CHAPTER 3 3.1 3.2 3.3 3.4 3.5 3.6 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Geography and Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Population and Reproductive Health Policies and Programmes . . . . . . . . . . . . . . . . . . . . . 3 Objectives and Organization of the 1996 Nepal Family Health Survey . . . . . . . . . . . . . . . 5 Recruitment, Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Data Entry and Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Coverage of the Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 CHARACTERIST ICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l 1 Age and Sex Composition of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Educational Attainment of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Background Characteristics of Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Employment Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 FERT IL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Children Ever Born and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Adolescent Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 iii CHAPTER 4 Page KNOWLEDGE, USE AND ATTITUDES TOWARD FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.1 Knowledge of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.2 Ever Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.3 Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 4.4 Number of Children at First Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.5 Effect of Breastfeeding on Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.6 Timing of Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.7 Sterilization Regret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.8 Source of Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 4.9 Nonuse of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 4.10 Exposure to Family Planning Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 4.11 Family Planning Outreach Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.12 Discussion of Family Planning with Husband . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.13 Attitudes Toward Family Planning Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 CHAPTER 5 5.1 5.2 5.3 5.4 5.5 5.6 CHAPTER 6 6.1 6.2 6.3 6.4 CHAPTER 7 7.1 7.2 7.3 7.4 7.5 OTHER PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . . . . . 79 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Postpartum Amenorrhoea, Abstinence and Insusceptibility . . . . . . . . . . . . . . . . . . . . . . . 85 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 FERTIL ITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 INFANT AND CHILD MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Levels and Trends in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Socio-economic Differentials in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Demographic Differentials in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Perinatal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 High-Risk Fertility Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 iv Page CHAPTER 8 MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Delivery Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Vaccination of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Vitamin A and Iodine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 CHAPTER 9 INFANT FEEDING, CHILDHOOD AND MATERNAL NUTRIT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 9.1 9.2 9.3 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Nutritional Status of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Nutritional Status of Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 CHAPTER 10 MATERNAL MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 10.1 Data Quality Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 10.2 Adult Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 10.3 Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 CHAPTER 11 KNOWLEDGE OF AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 11.1 Knowledge of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 11.2 Source of Knowledge About AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 11.3 Knowledge of Prevention of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 11.4 Perceptions about AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 11.5 Knowledge and Use of Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 APPENDIX A APPENDIX B APPENDIX C APPENDIX D APPENDIX E SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 EST IMATES OF SAMPL ING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 DATA QUAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 SURVEY STAFF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 QUEST IONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 V Table 1.1 Table 1.2 Table 2.1 Table 2.2 Table 2.3 Table 2.4.1 Table 2A.2 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 2.11 Table 2.12 Table 2.13 Table 2.14 Table 2.15 Table 2.16 Table 2.17 Table 3.1 Table 3.2 Table 3.3 Table 3 A Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 TABLES Page Demographic indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Results of household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Educational level of the male household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Educational level of the female household population . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 School enrolment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Iodized salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 School attendance and reasons for leaving school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Employer and form of eamings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Decisions on use of earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Child care while working . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Trends in fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Age-specif ic fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Fertility rates by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Pregnancy outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 vii Table 3.11 Table 3.12 Table 4.1 Table 4.2 Table 4.3 Table 4A Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 4.19 Table 4.20 Table 4.21 Table 4.22 Table 4.23 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Page Adolescent pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Children born to adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Trends in knowledge of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Knowledge of contraceptive methods by background characteristics . . . . . . . . . . . . . . . . 51 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 First method used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Current method use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Trends in current use of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . . . . . . . 57 Number of children at filst use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Perceived contraceptive effect of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Timing of sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Sterilization regret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Source of supply for modern contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Exposure to family planning messages on radio and television . . . . . . . . . . . . . . . . . . . . 69 Heard specific family planning shows on radio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Acceptability of media messages on family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Family planning messages in print . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Contact of non-users with family planning providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Discussion of family planning with husband . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Wives' and husbands' attitudes toward family planning . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Never-married women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Recent sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 viii Table 5.7 Table 5.8 Table 5.9 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 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Table 8.7 Table 8.8 Table 8.9 Table 8.10 Table 8.11 Table 8.12 Table 8.13 Page Postpartum amenorrhoea, abstinence, and insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . 86 Median duration of postpartum insusceptibility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Desire to limit childbearing by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . 92 Need for family planning services among currently married women . . . . . . . . . . . . . . . . 94 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . . . . . . . 98 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Trends in infant mortality, 1969-1994 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Infant and child mortality by socioeconomic characteristics . . . . . . . . . . . . . . . . . . . . . 104 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . 105 Perinatal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 High-risk fertility behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 114 Tetanus toxoid vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Use of clean delivery kits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Delivery characteristics: caesarean section and birth size . . . . . . . . . . . . . . . . . . . . . . . 121 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Vaccinations in first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Treatment with Vitamin A and iodine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Prevalence and treatment of acute respiratory infection and prevalence of fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Prevalence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ix Table 8.14 Table 8.15 Table 8.16 Table 9.1 Table 9.2 Table 9.3 Table 9A Table 9.5 Table 9.6 Table 9.7 Table 10.1 Table 10.2 Table 11.1 Table 11.2 Table 11.3 Table 11.4 Table A. I Table A.2 Table B. 1 Table B.2 Table B.3 Table BA Table B.5 Table B.6 Table B.7 Table B.8 Table B.9 Table B.10 Table B. 11 Table B. 12 Table C. 1 Page Knowledge of diarrhoea care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Treatment of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Knowledge and use o f ORS and Jeevan Jal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Types o f food received by children in the preceding 24 hours . . . . . . . . . . . . . . . . . . . . 145 Nutritional status of children by demographic characteristics . . . . . . . . . . . . . . . . . . . . . 147 Nutritional status of children by background characteristics . . . . . . . . . . . . . . . . . . . . . . 148 Maternal nutritional status by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . 152 Adult mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Direct estimates of maternal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Knowledge o f AIDS and sources of information on AIDS . . . . . . . . . . . . . . . . . . . . . . . 161 Knowledge o f ways to avoid HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Awareness of AIDS-related health issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Knowledge and use of condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Sampling allocation by primary sampling units (PSUs) . . . . . . . . . . . . . . . . . . . . . . . . . 170 Sampling fractions and woman weights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 List of selected variables for sampling errors, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . 178 Sampling errols - Total sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Sampling errols - Urban sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Sampling errors - Rural sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Sampling errols - Mountain sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Sampling errols - Hill sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Sampling errols - Terai sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Sampling errors - Eastern sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Sampling errors - Central sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Sampling errors - Western sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Sampling errors - Mid-western sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Sampling errors - Far-western sample, Nepal 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 X Table C.2 Table C.3 Table CA Table C.5 Table CA Table C.7 Table C.8 Table C.9 Page Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Births by Nepali calandar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Data on siblings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Indicators on data quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Sibship size and sex ratio of siblings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 xi Figure 2.1 Figure 2.2 Figure 2.3 Figure 3.1 Figure 4.1 Figure4.2 Figure 4.3 Figure 5.1 Figure 6.1 Figure 6.2 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 8.1 Figure 8.2 Figure 9. l Figure 9.2 FIGURES Page Population Pyramid, Nepal, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Distribution of De Facto Household Population by Single Year of Age and Sex . . . . . . . 14 School Enrolment among Children Age 6-15 by Age, Sex, and Urban-Rural Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Age-specific Fertility Rates, Nepal 1976-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Trend in Knowledge of Modem Contraceptive Methods Nepal, 1976-1996 . . . . . . . . . . . 50 Trend in Current Use of Modem Contraceptive Methods among Currently Married Non-pregnant Women Age 15-49 Nepal, 1976-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Distribution of Current Users of Modem Contraceptive Methods by Source of Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Trends in the Proportion of Women Never Married, Age Groups 15-19 and 20-24, Nepal 1961-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Fertility Preference of Currently Married Women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . 90 Percentage of Currently Married Women With Two Children Who Want No More Children by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Trends in Infant Mortality Nepal, 1969-1994 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Under-Five Mortality by Place of Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Under-Five Mortality by Selected Demographic Characteristics . . . . . . . . . . . . . . . . . . 106 Perinatal Mortality by Selected Demographic Characteristics . . . . . . . . . . . . . . . . . . . . 108 Vaccination Coverage Among Children Age 12-23 Months . . . . . . . . . . . . . . . . . . . . . . 125 Prevalence of Diarrhoea and Bloody Diarrhoea by Age of Child . . . . . . . . . . . . . . . . . . 133 Distribution of Children by Breastfeeding Status According to Age . . . . . . . . . . . . . . . . 143 Level of Stunting among Children under Age 3 by Place of Residence and Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 xiii PREFACE In Nepal, censuses are conducted at an interval often years and demographic surveys have supplemented census data in providing more detailed information on health and family planning. Furthermore, demographic surveys not only allow comparisons with estimates obtained by censuses but also provide detailed information on health and population during the inter-censal period as well. Like many developing countries, Nepal suffers from a low level of reporting of vital events and the vital registration system is not sufficiently able to provide reliable information and estimates for use in the formulation of health and population related policies and programmes. Demographic surveys fill this void by providing much needed data on specific areas of interest to planners. It gives me tremendous pleasure in saying that the successful completion of the 1996 Nepal Family Health Survey has provided up-to-date information on the knowledge and use of contraception, fertility preferences, the level and pattern of fertility, maternal and child health, infant, child and adult mortality, and knowledge of AIDS. Moreover, the NFHS provides, for the first time in Nepal, an estimate of the nutritional status of children and their mothers from a nationwide survey of the height and weight of children under three years of age and their mothers. I am happy to note that the entire survey, including this report, has been on schedule and the findings of this survey will be an important source of information in formulating the 9th five-year development plan for the population, health and family planning, women and development, and education sectors of the economy. I highly appreciate and commend the dedicated efforts of all the persons and institutions involved in the successful completion of this survey. I would especially like to thank the members of the Technical Committee for the 1996 NFHS for their advice and recommendations throughout this survey. Dr. Kalyan Raj Pandey Director General Department of Health Services Ministry of Health His Majesty's Government Teku, Kathmandu, Nepal XV FOREWORD The 1996 Nepal Family Health Survey (NFHS), is the fifth in a series of demographic surveys. The NFHS was conducted under the aegis of the Family Health Division of the Ministry of Health. In addition to demographic information, the NFHS provides information on maternal and child health, infant, child and adult mortality, and knowledge of AIDS. This information is not only important in understanding the problems in the areas of population and health but also in monitoring and evaluating related development programmes. His Majesty's Government is in the process of formulating the 9th five-year plan, as well as the long-term health plan, both of which are scheduled to begin in the fiscal year 1997/1998, and I am happy to note that the information and findings of this survey can be utilised in the formulation of these and other plans and activities in the near future. I deeply appreciate the United States Agency for International Development in providing the funds for the survey and Macro International Inc. for their technical assistance. I would like to thank Dr. Kalyan Raj Pandey, Director General, Department of Health Services, Ministry of Health, for chairing the Technical Committee for the 1996 NFHS. My sincere appreciation also goes to New ERA and its staff for supervising the fieldwork and data entry process. Last but not least my sincere thanks goes to Mr. Ajit Pradhan, Demographer and Member Secretary for the Technical Committee for the 1996 NFHS, Dr. Gokarna Regmi, Demographer, Family Health Division (up to December 1995), and Mr. Bharat Ban, Project Director, New ERA for their intense and active involvement in the successful completion of the survey. Dr. Laxmi Raj Pathak Director Family Health Division Department of Health Services Ministry of Health His Majesty's Government Teku, Kathmandu, Nepal xvii ACKNOWLEDGEMENTS This study is an outcome of the dedicated efforts of many institutions and individuals. The 1996 Nepal Family Health Survey (NFHS) was conducted under the aegis of the Family Health Division, Department of Health Services, Ministry of Health of His Majesty's Government of Nepal. The NFHS was funded by the United States Agency for International Development (USAID) through its mission in Nepal and was implemented by New ERA, a local research firm. Technical support for the survey was provided by Macro International Inc. We would like to thank Mr. Ashoke Shrestha, Dr. Gokama Regmi, Ms. Anjushree Karmaeharya, Mr. Munishwor Shrestha, Mr. Matrika Chapagain, Mr. Rajendra Lal Singh, Ms. Sarita Vaidya, Mr. Kabi Raj Khanal and other field and data entry staff of New ERA who made significant contributions to the successful completion of this study. We appreciate the active involvement of Dr. Ram Hari Aryal, Under Secretary, who represented the Ministry of Population and Environment, both as a member of the Technical Committee for the 1996 NFHS and as an author of this report. Our sincere gratitude goes to all the members of the Technical Committee for the 1996 NFHS, for their time and valuable advice and feedback. Our deep appreciation also goes to the USAID mission in Nepal. We would like to express our sincere gratitude to Ms. Molly Gingerich, Chief, Office of Health and Family Planning, Ms. Pancha Kumari Manandhar, Population/Family Planning Specialist and Mr. Puma Chhetri, for their keen interest and active support throughout this survey. Special thanks goes to Dr. Shyam Thapa, Senior Scientist, Family Health International, and advisor to the Ministry of Health and Ministry of Population and Environment, for his valuable advice and support. The technical support provided by Macro International Inc. is highly acknowledged. Our special appreciation goes to Dr. Pavalavalli Govindasamy, the country monitor for Nepal, for her effort and contribution throughout the survey. We also wish to thank Ms. Anne Cross, the regional co-ordinator, Dr. Alfredo Aliaga, who served as the sampling expert and Mr. David Cantor, the data processing specialist. We are grateful to Mr. Muniswor Mool, Senior Public Health Officer, Planning and Foreign Aid Division, and other officials from the District Health Offices, District Police Offices, District Administrative Offices, Health Posts, Sub-Health Posts, and Village Development Committee Leaders who helped in various ways in the successful implementation of the fieldwork. Last but not least, we extend our deepest gratitude to all the supervisors, field editors and interviewers whose dedicated efforts ensured the timely completion of the survey, and to all the respondents who not only spared their valuable time but also maintained their patience during the interview and provided their personal and family information. We believe that this study has truly captured the facts related to the fertility, mortality and health situation in Nepal, as well as the knowledge, perception and behaviour pertaining to family planning and AIDS. It is hoped that this information will help in improving the quality of life of the Nepalese people. Bharat Ban Project Director New ERA Ajit Pradhan Demographer Family Health Division xix 1996 NFHS TECHNICAL COMMITTEE Dr. Kalyan Raj Pandey, Director General, Department of Health Services (Chairman) Dr. Laxmi Raj Pathak, Director, Family Health Division (Vice-chairman) Dr. Shyam P. Bhattarai, Director, National Health Education Information and Communication Centre Dr. Prakash Aryal, Director, National Centre for AIDS and STD Control Dr. Mahendra Bdr. Bista, Director, Child Health Division Dr. Hari Nath Acharya, Director, Planning and Foreign Aid Division, Dept. of Health Services Mr. Dharanidhar Gautam, Section Chief, MIS Section, Planning and Foreign Aid Division Mr. Muniswor Mool, Section Chief, Monitoring and Evaluation Section, Planning and Foreign Aid Division Dr. Pushpa Lal Joshi, UNFPA/Ministry of Population and Environment (Invitee) Dr. Shyam Thapa, Family Health International (Invitee) Dr. Ram Hari Aryal, Under Secretary, Ministry of Population and Environment Dr. Mahodadhi Shrestha, National Health Research Council Ms. Molly Gingerich, Chief, Office of Health and Family Planning, USAID/Nepal Ms. Pancha Kumari Manandhar, Population/Family Planning Specialist, USAID/Nepal Dr. Pavalavalli Govindasamy, Country Monitor for Nepal, Macro International Inc. Mr. Ajit Pradhan, Demographer, Family Health Division (Member secretary) Mr. Bharat Ban, Project Director, NFHS 1996, New ERA Representative, Population Division, National Planning Commission Representative, Health and Social Sector Division, National Planning Commission Representative, Central Bureau of Statistics Representative, UNFPA/Nepal Representative, UNICEF/Nepal Representative, WHO/Nepal xxi LIST OF AUTHORS Ajit Pradhan, M.Sc., Demographer, Family Health Division, Department of Health Services, Ministry of Health, Kathmandu, Nepal. Mr. Pradhan authored Chapter 3 (Fertility), Chapter 5 (Other Proximate Determinants of Fertility) and Chapter 9 (Infant Feeding, Childhood and Maternal Nutrition). Ram Hari Aryal, Ph.D., Under Secretary, Ministry of Population and Environment, Kathmandu, Nepal. Dr. Aryal authored Chapter 4 (Knowledge, Use and Attitude Towards Family Planning), and Chapter 6 (Fertility Preferences) and co-authored Chapter 1 (Introduction). Gokarna Regmi, Ph.D., Technical Advisor, New ERA, Kathmandu, Nepal. Dr. Regmi authored Chapter 8 (Maternal and Child Health) and co-anthored Chapter 1 (Introduction). Bharat Ban, M.A., Project Director, New ERA, Kathmandu, Nepal. Mr. Ban authored Chapter 2 (Characteristics of Households and Respondents), Chapter 11 (Knowledge of AIDS) and co-authored Chapter 1 (Introduction). Pavalavalli Govindasamy, Ph.D., Demographic Specialist and Country Monitor for the NFHS, Macro International Inc., Calverton, Maryland, U.S.A. Dr. Govindasamy authored Chapter 7 (Infant and Child Mortality) and Chapter 10 (Maternal Mortality). xxiii SUMMARY OF FINDINGS The 1996 Nepal Family Health Survey (NFHS) is a nationally representative survey of 8,429 ever- married women age 15-49. The survey is the fifth in a series of demographic and health surveys conducted in Nepal since 1976. The main purpose of the NFHS was to provide detailed information on fertility, family planning, infant and child mortality, and matemal and child health and nutrition. In addition, the NFHS included a series of questions on knowledge of AIDS. Fertility Survey results indicate that fertility in Nepal has declined steadily from over 6 births per woman in the mid-1970s to 4.6 births per woman during the period of 1994-1996. Differentials in fertility by place of residence are marked, with the total fertility rate (TFR) for urban Nepal (2.9 births per woman) about two children less than for rural Nepal (4.8 births per woman). The TFR in the Mountains (5.6 births per woman) is about one child higher than the TFR in the Hills and Terai (4.5 and 4.6 births per woman, respectively). By development region, the highest TFR is observed in the Mid-western region (5.5 births per woman) and the lowest TFR in the Eastern region (4.1 births per woman). Fertility decline in Nepal has been influenced in part by a steady increase in age at marriage over the past 25 years. The median age at first marriage has risen from 15.5 years among women age 45-49 to 17.1 years among women age 20-24. This trend towards later marriage is supported by the fact that the proportion of women married by age 15 has declined from 41 percent among women age 45-49 to 14 percent among women age 15-19. There is a strong relationship between female education and age at marriage. The median age at first marriage for women with no formal education is 16 years, compared with 19.8 years for women with some secondary education. Despite the trend towards later age at marriage, childbearing begins early for many Nepalese women. One in four women age 15-19 is already a mother or pregnant with her first child, with teenage childbearing more common among rural women (24 percent) than urban women (20 percent). Nearly one in three adolescent women residing in the Terai has begun childbearing, compared with one in five living in the Mountains and 17 percent living in the Hills. Regionally, the highest level of adolescent childbearing is observed in the Central development region while the lowest is found in the Western region. Short birth intervals are also common in Nepal, with one in four births occurring within 24 months of a previous birth. This is partly due to the relatively short period of insusceptibility, which averages 14 months, during which women are not exposed to the risk of pregnancy either because they are amenorrhoeic or abstaining. By 12-13 months after a birth, mothers of the majority of births (57 percent) are susceptible to the risk of pregnancy. Early childbearing and short birth intervals remain a challenge to policy-makers. NFHS data show that children born to young mothers and those born after short birth intervals suffer higher rates of morbidity and mortality. Despite the decline in fertility, Nepalese women continue to have more children than they consider ideal. At current fertility levels, the average woman in Nepal is having almost 60 percent more births than she wants--the total wanted fertility rate is 2.9 births per woman, compared with the actual total fertility rate of 4.6 births per woman. Unplanned and unwanted births are often associated with increased mortality risks. More than half(56 percent) of all births in the five-year period before the survey had an increased risk of dying because XXV the mother was too young (under 18 years) or too old (more than 34 years), or the birth was of order 3 or higher, or the birth occurred within 24 months of a previous birth. Nevertheless, the percentage of women who want to stop childbearing in Nepal has increased substantially, from 40 percent in 1981 to 52 percent in 1991 and to 59 percent in 1996. According to the NFHS, 41 percent of currently married women age 15-49 say they do not want any more children, and an additional 18 percent have been sterilized. Furthermore, 21 percent of married women want to wait at least two years for their next child and only 13 percent want to have a child soon, that is, within two years. Family Planning Knowledge of family planning is virtually universal in Nepal, with 98 percent of currently married women having heard of at least one method of family planning. This is a five-fold increase over the last two decades (1976-1996). Much of this knowledge comes from media exposure. Fifty-three percent of ever-married women had been exposed to family planning messages on the radio and/or the television and 23 percent have been exposed to messages through the print media. In addition, about one in four women has heard at least one of three specific family planning programmes on the radio. There has been a steady increase in the level of ever use of modern contraceptive method over the past 20 years, from 4 percent of currently married women in 1976, to 27 percent in 1991 and 35 percent in 1996. Among ever-users, female sterilization and male sterilization are the most popular methods (37 percent), indicating that contraceptive methods have been used more for limiting than for spacing births. The contraceptive prevalence rate among currently married women is 29 percent, with the majority of women using modern methods (26 percent). Again, the most widely used method is sterilization (18 percent, male and female combined), followed by injectables (5 percent). Although current use of modern contraceptive methods has risen steadily over the last two decades, the pace of change has been slowest in the most recent years (1991-1996). Current use among currently married non-pregnant women increased from 3 percent in 1976 to 15 percent in 1986 to 24 percent in 1991 and to 29 percent in 1996. While female sterilization increased by only 3 percent from 45 percent of modern methods in 1986 to 46 percent in 1996, male sterilization declined by almost 50 percent from 41 percent to 21 percent over the same period. The level of current use is nearly twice as high in the urban areas (50 percent) as in rural areas (27 percent). Only 18 percent of currently married women residing in the Mountains are currently using contraception, compared with 30 percent and 29 percent living in the Hills and Terai regions, respectively. There is a notable difference in current contraceptive use between the Far-western region (21 percent) and all the other regions, especially the Central and Eastern regions (31 percent each). Educational differences in current use are large, with 26 percent of women with no education currently using contraception, compared with 52 percent of women who have completed their School Leaving Certificate (SLC). In general, as women's level of education rises, they are more likely to use modem spacing methods. The public sector figures prominently as a source of modem contraceptives. Seventy-nine percent of modem method users obtained their methods from a public source, especially hospitals and district clinics (32 percent) and mobile camps (28 percent). The public sector is the predominant source of sterilizations, 1UDs, injectables, and Norplant, and both the public and private sectors are equally important sources of the pill and condoms. Nevertheless, the public sector's share of the market has fallen over the last five years from 93 percent of current users in 1991 to 79 percent in 1996. xxvi There is considerable potential for increased family planning use in Nepal. Overall, one in three women has an unmet need for family planning--14 percent for spacing and 17 percent for limiting. The total demand for family planning, including those women who are currently using contraception, is 60 percent. Currently, the family planning needs of only one in two women is being met. While the increase in unmet need between 1991 (28 percent) and 1996 (31 percent) was small, there was a 14 percent increase in the percentage of women using any method of family planning and, over the same period, a corresponding increase of 18 percent in the demand for family planning. Maternal and Child Health At current mortality levels, one of every 8 children born in Nepal will die before the fifth birthday, with two of three deaths occurring during the first year of life. Nevertheless, NFHS data show that mortality levels have been declining rapidly in Nepal since the eighties. Under-five mortality in the period 0-4 years before the survey is 40 percent lower than it was 10-14 years before the survey, with child mortality declining faster (45 percent) than infant mortality (38 percent). Mortality is consistently lower in urban than in rural areas, with children in the Mountains faring much worse than children living in the Hills and Terai. Mortality is also far worse in the Far-western and Mid-western development regions than in the other regions. Maternal education is strongly related to mortality, and children of highly educated mothers are least likely to die young. For example, infant mortality is nearly twice as high among children of mothers with no education as among children of mothers with some secondary education. Neonatal mortality is expectedly higher among males than females. However, child mortality is 24 percent higher among females than males. First births, higher order births and births spaced less than 24 months apart also experience higher mortality. Perinatal mortality in Nepal has declined by 17 percent over the last 15 years from 63 deaths per 1,000 stillbirths and live births in the period 10-14 years before the survey to 52 deaths in the period 0-4 years before the survey. First pregnancies, high order pregnancies, pregnancies to women residing in rural areas, in the Terai, and in the Eastern region, are all at an increased risk of loss. One possible reason for the declining mortality is improvements in childhood vaccination coverage. The NFHS results show that about 76 percent of children age 12-23 months have been vaccinated against tuberculosis, DPT and polio. However, coverage declines after the first dose for DPT and polio, with one-third of children who start the series not completing it. Fifty-seven percent of children age 12-23 months were vaccinated against measles. Overall, two of five children had all the recommended vaccinations, and 36 percent were fully vaccinated before their first birthday. Diarrhoeal and respiratory illnesses are common causes of child deaths in Nepal. In the two weeks before the survey, 28 percent of children suffered from diarrhoea and 34 percent were ill with acute respiratory infections (AR1). However, use of health facilities is low in Nepal: only 14 percent of children with diarrhoea and 18 percent of children with ARI were taken to a health facility. Solution prepared from oral rehydration salts (ORS) was given to 26 percent of children with diarrhoea, and 4 percent received recommended home fluids (RHF). In addition, 35 percent of children with diarrhoea were given more to drink than before the diarrhoea. Over one-third of children with diarrhoea received no treatment at all. The care that a woman receives daring pregnancy and childbirth reduces the risk of illness and death for both mother and child. The NFHS data show that mothers received antenatal care from a doctor for only 13 xxvii percent of births in the three years preceding the survey, and from a nurse/midwife for I 1 percent of births. One of two women who received some antenatal care had fewer than 3 visits. For the majority of births (56 percent), mothers did not receive any antenatal care. An important component of antenatal care is protection against tetanus. Two or more doses of tetanus toxoid vaccines were received by mothers for about one-third of births, while 13 percent received one dose. For well over half of births, mothers did not receive a single dose. The majority of Nepalese children are born at home without assistance from trained medical personnel. Overall, only 8 percent of births are delivered in a health facility and 9 percent are delivered under the supervision of a doctor or nurse/midwife. Breastfeeding is nearly universal in Nepal and the average length of time that children are breastfed is relatively long (28 months). However, a significant minority of children (40 percent) are not breastfed within one day of birth. Bottle feeding is relatively rare in Nepal and less than 3 percent of children under three years of age were fed with a bottle using a nipple. Even though exclusive breastfeeding is recommended until 4-6 months of age, one-third of children age 4-5 months receive complementary foods. There is considerable malnutrition among children in Nepal. Forty-eight percent of children under age three are stunted, 11 percent are wasted, and 47 percent are underweight. Variation by place of residence is marked, with rural children, children living in the Mountains and in the Far-western regions of Nepal more likely to be malnourished than other children. Maternal nutritional status was also assessed from the NFHS data. Fit~een percent of Nepalese mothers of children born during the three years before the survey were less than 145 centimetres tall, the height below which a woman is considered to be at nutritional risk. Furthermore, more than one of four women fell below the cutoff of 18.5 for body mass index, which measures thinness, indicating that the level of chronic energy deficiency in Nepal is relatively high. Maternal deaths are high relative to developed countries. According to the NFHS data, maternal deaths accounted for 27 percent of all deaths to women age 15-49, with a maternal mortality ratio of 5 deaths per 1,000 live births. xxviii NEPAL FAR-WESTERN REGION MID-WESTERN REGION CHINA r,~CtE!,.l~tliRA WESTERN • REGION Ecological Regions Mountains Hills I I Terai SyII.NC.JA l~jid~LV~ ~ I RUpAIIOEItl { INDIA J'4 CENTRAL REGION EASTERN I l l ~ REGION S OLIJKIIU l l l I J BARA UOAyAPUR ' SAPTAR I <,d UN~ARI MORAEIG ,~IApA CHAPTER 1 INTRODUCTION 1.1 Geography and Economy Geography Nepal is a land-locked country nestled in the foothills of the Himalayas. It occupies an area from 26 ° 20' to 30* 10' north latitude and 800 15' to 88 ° 19' east longitude. It shares its northern border with the Tibetan region of the People's Republic of China, and its eastern, southern and western borders with India. Nepal is rectangular in shape and is approximately 80 miles (128 kilometres) wide and 550 miles (880 kilometres) long. The total land area of the country is 147,181 square kilometres and its population, according to the 1991 Census, is 18.5 million. Nepal is predominantly rural with only 9 percent of the population living in urban areas. Topographically, Nepal is divided into three distinct ecological regions. These are the Mountains, Hills, and Terai (or plains). The Mountain region ranges in altitude from about 4,800 metres to 8,839 metres above sea level and covers a land area of 51,817 square kilometres. Because of the harsh terrain, transportation and communication facilities in this region are very limited and only about 8 percent of the total population lives here. In contrast, the Hill region which ranges in altitude from 610 metres to 4,800 metres above sea level is densely populated. About 45 percent of the total population of Nepal lives in the Hills, which cover an area of 61,345 square kilometres. This region also includes a number of very fertile valleys such as the Kathmandu and Pokhara valleys. Although the terrain is also rugged in this region, because of the higher concentration of people, transportation and communication facilities are much more developed here than in the Mountains. Unlike the Mountains and Hills, the Terai region in the southern part of the country can be regarded as an extension of the relatively fiat Gangetic plains. This area which covers 34,019 square kilometres is the most fertile part of the country. While it constitutes only about 23 percent of the total land area in Nepal, 47 percent of the population live here. Because of its relatively fiat terrain, transportation and communication facilities are more developed in this region than in the other two regions of the country and this has attracted newly emerging industries. In Nepal, climatic conditions vary substantially by altitude. In the Terai temperatures can go up to 44 ° Celsius in the summer and fall to 5 ° Celsius in the winter. The corresponding temperatures for the Hill and Mountain areas are 41 ° Celsius and 30 ° Celsius, respectively, in the summer, and 3 ° centigrade and way below 0 ° centigrade, respectively, in the winter. The annual mean rainfall in the kingdom is around 1,500 millimetres (Central Bureau of Statistics, 1996). For administrative purposes Nepal has been divided into five development regions, 14 zones, and 75 districts. Districts are further divided into Village Development Committees (VDCs) and sometimes into urban municipalities. A VDC consists of nine wards while the number of wards in an urban municipality depends on the size of the population as well as on political decisions made by the municipality itself. Nepal is a multi-ethnic and multi-lingual society. The 1991 Census identified 60 caste or ethnic groups and subgroups of population. The percentage breakdown by size of some of these major groups are as follows: Chhetri and Thakuri (18 percent), Brahmins (14 percent), Magar (7 percent), Tharu and Rajbanshi (7 percent), Newar (6 percent), Tamang (6 percent), Kami--a major occupational group that originated in the Hills (5 percent), Yadav and Abirs (4 percent), Muslims (4 percent), Rai and Kiranti ( 3 percent), and Gurung (2 percent) (Central Bureau of Statistics, 1995). The 1991 Census of Nepal lists 20 different languages or dialects prevalent in Nepal (Central Bureau of Statistics, 1995). These languages originated from two major groups: the lndo-Aryans, who constitute about 80 percent of the population, and the Tibetan-Burmese, who constitute about 17 percent of the population. Nepali is the official language of the country and is the mother tongue of over 50 percent of the population. However, it is used and understood by most of the population and is the national language of Nepal. The other two major languages are Maithili and Bhojpuri, spoken by about 8 percent and 5 percent of the population, respectively. Nepal is a Hindu kingdom with over 86 percent of its population following the Hindu religion. The second largest religious group are the Buddhists (8 percent), and Muslims constitute about 4 percent of the total population (Central Bureau of Statistics, 1995). Economy Forty-eight percent of the GDP comes from the service sector and the agricultural sector accounts for 42 percent of the GDP. The manufacturing sector accounts for 10 percent of the economy (Ministry of Finance, 1996). Because of variations in the climatic and rainfall conditions, agricultural production varies by ecological regions. In the Terai, rice is the main crop, followed by wheat and corn. In the Hills, the major crops are corn and rice, followed by wheat, and in the Mountains, corn, rice and wheat are grown (Central Bureau of Statistics, 1995). 1.2 Population Table 1.1 provides a summary of the basic demographic indicators for Nepal from census data for 1971, 1981, and 1991 (Central Bureau of Statistics, 1995). There was a 59 percent increase in the population over the 20-year period. The population growth rate increased from 2.1 in 1971 to 2.6 in 1981 and then declined again to 2.1 in 1991. Nepal's population is young, with two of five persons below the age of 15. This young age distribution is due to the relatively high fertility in Nepal. In fact, between 1971 and 1981 there was no change in the total fertility rate (TFR) obtained from census estimates. The TFR continues to be high, 5.6 percent in 1991, although it has declined slightly from its 1971/1981 level. The mean age at marriage has risen little over the past two decades, increasing by 0.6 years for males and 1.4 years for females. Nevertheless, data obtained from different demographic surveys indicate that the desired family size in Nepal has decreased over the years from 4 children in 1976 to 3 in 1991 (Ministry of Health, 1993). There has been a corresponding increase in the contraceptive prevalence rate for modem methods from a low of 3 percent in 1976 to 24 percent in 1991. That both fertility and mortality have been declining can be seen from Table 1.1. While the decline in fertility is a more recent phenomenon, mortality has been decreasing slowly over the years. The crude death rate declined from 20 per 1,000 in 1974/75 to 13 per 1,000 in 1991, while the infant mortality rate experienced a 44 percent decline between 1971 and 1991. These trends suggest that the demographic transition is taking place in Nepal with ample scope for both fertility and mortality to decline further. Male and female life expectancy has gone up by about 13 years over the 20-year period. 2 Table l. l Demographic indicators Selected demographic indicators for Nepal, 1971-1991 Indicator 1971 1981 Population (millions) 11.6 15.0 Age 0-14 40.5 41.4 15-64 56.4 55.4 65+ 3.1 3.2 Population density (per square kin) 79 102 Percent urban 4.0 6.4 Crude birth rate 42 44 Crude death rate 19.5a 16. I b Population growth rate (percent) 2.1 2.6 Total fertility rate 6.3 6.3 Infant mortality rate 172 117 Life expectancy Males 42.0 50.9 Females 40.0 48.1 Mean age at marriage Males 20.8 20.7 Females 16.8 17.2 a 1974-75 b 1986-87 Source: Central Bureau of Statistics, 1995 1.3 Population and Reproductive Health Policies and Programmes 1991 Evolution of Population Policy 18.5 Family planning emerged as one of the major components of Nepal's planned development 42.4 activities only in 1968 with the implementation of the 54.1 Third Five-Year Development Plan (1965-70). This 3.5 is when the Nepal Family Planning and Maternal and Child Health Project (FP/MCH) under the Ministry 126 of Health was launched in the government sector. Until then, family planning activities were 9.2 undertaken by the Family Planning Association of 42 Nepal (FPAN), which was established in 1959 to create awareness among the people about the need 13.3 and importance of family planning but not to offer any family planning services. Very little was done to 2.1 directly regulate population growth until 1965 when 5.6 a family planning project was established under the maternal and child health section of the Ministry of 97 Health. Limited family planning services were offered through the existing maternal and child health 55.0 clinics. 53.5 The Fourth Development Plan (1970-1975) 21.4 targeted the provision of family planning services to 18.2 15 percent of married couples by the end of the plan period. From the Fifth Five-year Development Plan (1975-80) onwards, family planning services were greatly expanded through outreach workers and serious attempts were made to reduce the birth rate by direct and indirect means. To coordinate the government's multi-sectorial activities in population and reproductive health, a population policy coordinating board was established in 1975 under the National Planning Commission. In 1978, this board was upgraded to become the National Commission on Population (NCP). It was further reorganized under the chairmanship of the prime minister and maintained its own secretariat to plan, monitor, and coordinate population activities both at the government and private sectorial levels. Subsequent development plans dealt with the population issue from both a policy and programmatic point of view. From the Fifth Plan until the end of the Seventh Plan (1985-1990) population policies and programmes not only emphasized family planning issues in the short run, but also focussed on long-term concerns to encourage the small family norm through education and employment programmes that raised women's status and decreased infant mortality. This included launching population related programmes in reproductive health, agriculture, forestry, urbanization, manpower and employment, education and women's development, as well as community development programmes. In 1990, the NCP was dissolved and its role was given to the population division of the National Planning Commission. In 1996 the government established a National Population Committee comprised of ministers from various ministries and chaired by the Prime Minister, to provide strong political leadership and guidance in formulating population policies and coordinating, implementing, monitoring, and evaluating population activities. The Eighth Development Plan (1992-97) continued with the integrated development approach taken in earlier development plans and set the following demographic targets: • to reduce the total fertility rate from 5.8 to 4.5 by the end of the plan period; • to increase the expectation of life at birth from 54.4 to 61 years; • to reduce the infant mortality rate from 102 per thousand to 80 per thousand; • to decrease under-five mortality to 130 per thousand; • to reduce the maternal mortality ratio from 5.15 to 4.00 per thousand live births; • to manage internal migration. In 1995, the Ministry of Population and Environment (MOPE) was established as a separate ministry for population-related activities and is viewed as the reflection of a strong governmental commitment to population programmes. The ministry is primarily responsible for formulating and implementing population policies, plans, and programmes, and for monitoring and evaluating these programmes. This ministry, along with the Ministry of Health, is also responsible for implementing programmes of action recommended by the 1994 International Conference on Population and Development. The implementation of health-related population programmes in reproductive health such as family planning, safe motherhood, adolescent reproductive health, sexually transmitted diseases, and infertility, nevertheless, falls under the purview of the Ministry of Health. Family Planning Programmes Family planning services in Nepal were started by the FPAN in 1959. Initially, its services were limited to the Kathmandu valley. The pioneering work of the FPAN led to the establishment of a semi-autonomous Nepal Family Planning and Maternal Child Health Project (NFP&MCH Project) in November 1968 at the government level. This project was gradually expanded to cover all 75 districts in Nepal. Currently, government run family planning services have become an integral part of health services. Health services in Nepal are delivered through national, regional, zonal and district hospitals, primary health care centres/health centres, health posts, sub-health posts and peripheral health workers, and volunteers, all of which/ whom provide temporary family planning services (condoms, orals and injectables) on a regular basis. Services such as Norplant implants and IUD insertions are only available at a limited number of hospitals, health centres, and selected health posts where trained manpower is available. Depending on the district, sterilization services are provided at static sites (21 districts) through scheduled "seasonal" or mobile outreach services. At the central level, the Family Health Division in the Department of Health Services is responsible for planning, supervision, and implementation of family planning activities. The National Health Training and Regional Training Centres are responsible for training field workers for reproductive health services. Information, education, and communication (IEC) activities regarding reproductive health are carried out by the National Health Education, Information and Communication Centre in the Department of Health Services. Besides governmental programmes, a number of non-governmental organizations are also currently involved in the delivery of family planning services at the grass root level. These organizations include the FPAN, Contraceptive Retail Sales (CRS) Company, Nepal Red Cross Society, Save the Children Fund (UK and USA), Adventist Development Relief Agency (ADRA), United Mission to Nepal (UMN), Centre for Development and Population Activities (CEDPA), the Asia Foundation (TAF) and CARE. Among these non-governmental organizations (NGOs), FPAN and CRS are the larger ones. FPAN is currently active in providing family planning services in 32 districts in Nepal. FPAN also provides sterilization services at selected clinics and organizes a number of mobile sterilization camps in different districts. Besides the provision of family planning services, FPAN is very much involved in training and IEC activities in reproductive health. The CRS company provides oral contraceptives and vaginal foaming tablets through pharmacies, and condoms through a full range of retail shops (e.g. general stores, paan shops, hotels, etc.) throughout the country. At present, the CRS company supplies contraceptives to more than 12,000 retailers. It is also marketing injectables (DMPA) in the Kathmandu Valley and in eight other districts where these services are available through trained paramedical personnel, and IUDs and Norplants to certified private practitioners. Services of other smaller NGOs are limited to delivery and supply of temporary methods of contraception, mostly pills, condoms and injectables. These organizations have also been involved in educational activities. While the areas served by these NGOs are modest, they do help to complement the Ministry of Health's on-going efforts to expand the availability of family planning methods. 1.4 Objectives and Organization of the 1996 Nepal Family Health Survey The primary objective of the Nepal Family Health Survey (NFHS) is to provide national level estimates of fertility and child mortality. The survey also provides information on nuptiality, contraceptive knowledge and behaviour, the potential demand for contraception, other proximate determinants of fertility, family size preferences, utilization of antenatal services, breastfeeding and food supplementation practices, child nutrition and health, immunizations, and knowledge about Acquired Immune Deficiency Syndrome (AIDS). This information will assist policy-makers, administrators and researchers to assess and evaluate population and health programmes and strategies. The NFHS is comparable to Demographic and Health Surveys (DHS) conducted in other developing countries. Survey Organization The NFHS was conducted under the aegis of the Family Health Division of the Department of Health Services in the Ministry of Health of His Majesty's Government of Nepal. The survey was implemented by New ERA, a local research firm. Macro International provided technical support for the survey through the Demographic and Health Surveys (DHS) project. Funding for the survey came from the United States Agency for International Development (USAID) through its mission in Nepal. Sample Design The NFHS sample was designed to provide estimates of population and health indicators including fertility and mortality rates for the country as a whole and for urban and rural areas separately. In addition, the sample was designed to provide estimates of most key variables, with the exception of fertility and mortality estimates, for the 13 domains (sub-regions) obtained by cross classifying the three ecological zones (Mountains, Hills and Terai) with the five developmental regions (Eastem, Central, Western, Mid-western and Far-western). In total, 253 primary sampling units (PSUs) were selected--34 in the urban areas and 219 in the rural areas. The number of households actually visited was 8,500, and interviews were successfully completed for 8,429 respondents. The sample design is discussed in greater detail in Appendix A. Questionnaires Two types of questionnaires were used in the NFHS: the Household Questionnaire and the Individual Questionnaire. The contents and design of the questionnaires were based on the DHS Model B Questionnaire, which is designed for use in countries with low contraceptive prevalence. The questionnaires were adapted to local conditions and a number of questions pertaining to on-going health and family planning programmes were added in consultation with various ministries and organizations. These questionnaires, which were developed in English, were translated into Nepali, the national language, and two other local languages, Maithali and Bhojpuri. The Household Questionnaire listed all usual residents of each sampled household and all visitors who had slept in the household the night before the interview. For every person listed, some basic information such as their relationship to the head of the household, sex, age, education, and marital status was collected. The main purpose of this section of the Household Questionnaire was to identify women who were eligible for the individual interviews, that is, ever-married women age 15 to 49 years. In addition, the Household Questionnaire also obtained information on the source of water, type of toilet facilities, rooms used for sleeping, main materials of the floor, ownership of various consumer durable goods, and characteristics of household heads such as religion and ethnicity. In addition, the salt used in each household was tested for its iodine content. The Individual Questionnaire was administered to all ever-married women age 15-49 who were usual residents or who were present in the household the night before the survey. It obtained information on the following topics: • Background characteristics including age, education, religion; • Reproductive history; • Knowledge and use of family planning methods; • Fertility preferences and attitudes about family planning; • Marriage; • Antenatal and delivery care; • Breastfeeding and weaning practices; • Vaccinations and health of children; • Husband's background characteristics and women's work; • Knowledge of AIDS; • Maternal mortality; • Height and weight of children and their mothers. Information on vaccinations and health of children, and height and weight measurements were obtained for all children born since Baisakh 2049 of the Nepalese calendar, which roughly corresponds to April 14, 1992 in the Western calendar. ~Due to their small size, the Mountain areas of the Western, Mid-western and Far-western regions were combined. In this report the combined sub-region is referred to as Western Mountain. Both the Household and Individual Questionnaires were pretested in October, 1995 for about two weeks in three areas: the Nepali version in the Kathmandu valley, the Bhojpuri version in Parsa district, and the Maithali version in Dhanusha district. Pretesting was conducted in both rural and urban areas. About 600 interviews were conducted during the pretest. The questionnaires were finalized with input from interviewers involved in the pretest. The English versions of the questionnaires are included in Appendix E. 1.5 Recruitment, Training and Fieldwork Prior to the main survey, 26 household listing teams, each consisting of a lister and a mapper, were recruited and trained for about a week in August 1995 at the New ERA office in Kathmandu. Household listing began soon after and was completed by the end of September 1995. Spot checks were conducted while the listers were in the field to ensure that the work was being done correctly and completely. In some cases, listers were sent back to relist areas where households had been missed or mis-listed. Recruitment for the main survey was also carried out at the New ERA office in Kathmandu. However, keeping in mind the local language requirements, interviewers who spoke Maithili and Bhojpuri were recruited from the Central and Eastern Terai regions in order to administer these local language questionnaires. In general interviewers were recruited for their language skills, academic qualifications and previous work experience. Training for the main survey was conducted in Kathmandu from December 17, 1995 to January 15, 1996. A total of 81 interviewers participated in the training. Because of the large number, interviewers were split up into two groups and were trained simultaneously in two separate classrooms in the same location. The training was conducted by senior project staff of New ERA, the Ministry of Health, and two representatives from Macro International. The four-week training course consisted of instruction in general interviewing techniques and field procedures for the survey, a detailed review of the questionnaires, practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews in the field. In addition, five special lectures were arranged---one each on the health delivery system in Nepal, family planning, maternal health, child health and AIDS. The female trainees whose participation was satisfactory were selected as female interviewers and field editors; male trainees whose participation was satisfactory were selected as male interviewers. Based on the performance of the trainees, field supervisors were also selected. In order to maintain uniform survey procedures, four manuals relating to different aspects of the survey were prepared. The Interviewer's Manual discussed the objectives of the NFHS, interviewing techniques, field procedures, general procedures for completing the questionnaires, and included a detailed discussion of the Household and Individual Questionnaires. The Supervisor's and Editor's Manual contained instructions on organizing and supervising fieldwork, maintaining and monitoring control sheets, and general rules for editing the completed questionnaires. The manual also contained information on height and weight charts, assignment sheets, and the interviewer's progress sheet. Trainers were given the Training Guidelines for DHS Surveys Manual, which described the administrative and logistical aspects of training and data quality checks. The Household Listing Manual described the mapping and household listing procedures used in DHS surveys. The NFHS fieldwork was carried out by 12 teams, each comprised of three female interviewers, one male interviewer, a female field editor, and a field supervisor who was either male or female (see Appendix D for a complete list of the persons involved in the NFHS). The male interviewer administered the Household Questionnaire and the female interviewers administered the Individual Questionnaire. Unlike most DHS surveys in which the Household Questionnaire and the Individual Questionnaire are administered by the same 7 interviewer, in the NFHS, the Household Questionnaire and the Individual Questionnaire were administered by two different interviewers. This procedure was adopted to prevent possible age shifting by interviewers (to lighten their workload) when collecting information in the Individual Questionnaire on children born since the cutoffdate, which is Baisakh 2049 in the Nepalese calendar. The fieldwork started in mid-January and ended in mid-June 1996. Assignment of sample points to the teams and various logistical decisions were made by the NFHS staffofNew ERA in Kathmandu. Each team was allowed a fixed period of time to complete fieldwork in a primary sampling unit (PSU) before moving to the next PSU. In order to maintain close supervision of all the teams during the initial two weeks of field work, all teams started their fieldwork in the Terai region (10 teams in the Eastern and Central Terai regions and two teams in the Western Terai region) and were accessible within a few hours of driving. After two weeks of fieldwork in these regions, the teams went to their assigned district. All teams began their fieldwork from the Terai region and gradually moved to the north. During the initial stage, each interviewer was instructed not to conduct more than two individual interviews of women per day. As interviewers became more familiar with the questionnaire they were conducting up to a maximum of four interviews per day. A minimum of three call-backs were made by the interviewers to ensure that eligible women identified in the sampled households were successfully interviewed. The main duty of the field editor was to examine the completed questionnaires in the field and ensure that they were correctly filled out. An additional duty was to periodically observe ongoing interviews and verify the accuracy of the method of asking questions, recording answers, following skip instructions, and identifying eligible respondents. Throughout the survey, the senior staffofNew ERA maintained close contact with all the teams through direct communication and spot checking. Data collection work was also supervised by staffof the Family Health Division and Macro International. The objective was to provide support and advice to maintain good data quality. Data quality was also ensured by providing feedback to individual teams on the results of the field check tables. These tables were produced by computers at regular intervals from data obtained in the completed questionnaires. These results were discussed with the teams to improve their performance. 1.6 Data Entry and Processing All the completed questionnaires were brought to the New ERA office for data entry and processing. The data entry operation consisted of office editing, coding, data entry, and machine editing. Although all completed questionnaires were throughly edited in the field, codes for ethnicity and occupation were entered in the office. In addition, the line numbers of eligible women and the birth order of all pregnancies were rechecked. Appropriate codes for "other" responses were also assigned. One supervisor and five data entry operators were responsible for the data entry and computer editing operations. The data were entered and edited using five microcomputers and the ISSA (Integrated System for Survey Analysis) software, which was developed for DHS surveys. Data entry was also 100 percent verified in order to minimize errors. The data entry was done directly from the questionnaires and was initiated within two weeks of the first receipt of the completed questionnaires. All data entry and editing operations were completed within two weeks of completion of the fieldwork, that is, by June 1996. Computer based checks were done to rectify inconsistencies. A preliminary report highlighting the key findings of the NFHS was released in September 1996. The purpose of this report was to disseminate the basic findings of the NFHS to policy-makers, programme planners, and administrators. The report contained 19 tables and findings on fertility, awareness and practice of family planning, fertility preferences, utilization of antenatal services, unmet need, immunizations, health of children, infant and child mortality, and knowledge about AIDS. The NFHS followed the DHS tabulation plan in order to maintain data comparability with other countries where DHS has been implemented. Final tables were generated at Macro International. 1.7 Coverage of the Sample Table 1.2 shows the results of the household and individual interviews. A total of 8,500 households were selected for the NFHS, of which 8,111 were located by the field teams. Of the total 8,111 households that were occupied, 8,082 were successfully interviewed, yielding a response rate of 99.6 percent. The household response rate was almost the same in urban and rural areas. A total of 8,580 women were identified as eligible for the individual interview, indicating a ratio of 1.06 eligible women per household. Interviews were completed for 8,429 women, yielding a 98 percent overall individual response rate. The individual response rate was slightly higher in rural areas (98 percent) than in urban areas (97 percent). Table 1.2 Results of household and individual interviews Number of households, number of interviews and response rates, Nepal 1996 Residence Result Urban Rural Total Households interviewed Households sampled 1,025 7,475 8,500 Households found 961 7, ! 50 8,111 Households interviewed 955 7,127 8,082 Household response rate 99.4 99.7 99.6 Individual interviews Eligible women 983 7,597 8,580 Eligible women interviewed 954 7,475 8,429 Eligible women response rate 97.0 98.4 98.2 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS The purpose of this chapter is to provide a descriptive summary of the demographic and socio-economic characteristics of the household population and the individual respondents in the Nepal Family Health Survey (NFHS). This information is useful for interpreting the survey findings and serves as an approximate indicator of the representativeness of the survey. It also provides valuable input for social and economic development planning. In this chapter the NFHS data have, in some instances, been compared with data from the 1991 Census and the 1991 Nepal Fertility, Family Planning and Health Survey (also known as the 1991 NFHS). The NFHS collected information from all usual residents of a selected household (the de jure population) and persons who had slept in the selected household the night before the interview (the de facto population). The difference between these two populations is very small and since past surveys have looked at the de facto population, for comparison purposes, all tables in this report refer to the de facto population, unless otherwise specified. A household was defined as a person or group of persons who live and eat together. 2.1 Age and Sex Composition of the Household Population Information on the age and sex of each household member was obtained from the household head or some other responsible adult member of the household. Table 2.1 shows the age distribution of the population by five-year age groups, according to urban-rural residence and sex. The NFHS enumerated a total of 42,863 persons of whom 52 percent were females. Because of relatively high fertility in the past, a large proportion of Nepal's population (44 percent ) is under 15 years of age. The median age of the population is 17.9 years (Table 2.2). There is a slightly larger proportion of children under age five than age 5 to 9 (Figure 2.1). This is not surprising because of population momentum combined with the fact that fertility has been declining very slowly in Nepal. An examination of the quality of the data in relation to age reporting indicates that there are no serious biases in reporting. For a more detailed examination of data quality refer to Appendix C. Another plausible explanation for the higher proportion of children in the youngest age group could be a marked decline in under- five mortality in the most recent five-year period (see Chapter 7). Further evidence of this is seen in Appendix Table C.4 where the number dead among live births in the 0-4 years before the survey is 40 percent less than in the 5-9 years before the survey. While some of these deaths can be attributed to the longer period of exposure among the older cohort, nevertheless, the marked decline in mortality in the most recent period may contribute to the higher proportion living in the 0-4 age cohort. As seen in Table 2.1, there is a smaller proportion of children under age five in urban areas, suggesting that recent declines in fertility are more evident in urban than rural areas and that the transition to lower fertility began with the urban population. The overall sex ratio, the number of males per 100 females, is 93, which is lower than that obtained in the 1991 Census (100) and the 1991 NFHS (98). The sex ratio differs by residence (Table 2.1). Urban areas have a higher sex ratio (104) than rural areas (92). The sex ratio is markedly lower among the working age population, particularly among those age 15-54 years, where it ranges from 74 to 97. On the other hand, in the younger and older age groups the sex ratio is more balanced. A similar pattern was also documented in the 1991 NFHS. A low sex ratio among the working age population, particularly in rural areas, may be attributed to the high rate of 11 Table 2.1 Household vovulation by age. residence and sex Percent distribution of the de facto household population by five-year age group, according to urban-rural residence and sex, Nepal 1996 Urban Rural Total Sex Sex Sex Age group Male Female Total Ratio Male Female Total Ratio Male Female Total Ratio 0-4 11.8 12.6 12.2 97.7 17.0 15.6 16.3 100.6 16.6 15.3 15.9 100.4 5-9 13.8 11.2 12.5 128.1 16.0 14.7 15.4 100.4 "15.8 14.4 15.1 102.2 10-14 14.4 11.7 13.1 127.9 13.9 12.1 13.0 105.6 14.0 12.1 13.0 107.3 15-19 10.4 I0.0 10.2 107.8 9.2 10.2 9.7 83.3 9.3 10.2 9.8 85.2 20-24 8.6 10.7 9.6 84.1 7.0 8.9 8.0 72.8 7. I 9.0 8.1 73.9 25-29 8.2 10.2 9.2 83.2 6.4 7.6 7.0 77.1 6.5 7.8 7.2 77.7 30-34 7.8 7.7 7.8 104.8 5.3 6.0 5.7 80.8 5.5 6.1 5.8 83.3 35-39 5.6 6.1 5.9 96.3 4.7 5.2 5.0 82.6 4.8 5.3 5. I 83.9 40--44 4.2 3.9 4.0 111.4 4.0 4.3 4.1 85.1 4.0 4.3 4.1 87.1 45-49 3.8 3.8 3.8 105.1 3.8 3.8 3.8 92.0 3.8 3.8 3.8 93.0 50-54 3.0 3.1 3.1 98.8 3.4 3.2 3.3 96.3 3.4 3.2 3.3 96.5 55-59 2.8 2.7 2.7 106.9 2.9 2.6 2.7 101.7 2.9 2.6 2.7 102.2 60-64 2.1 2.2 2.1 97.3 2.4 2.2 2.3 100.5 2.4 2.2 2.3 100.3 65-69 1.5 1.8 1.7 85.9 1.7 1.5 1.6 102.4 1.7 1.6 1.6 lO0.g 70-74 0.8 I.I I.O 71.9 1.3 l.O 1.2 113.9 1.3 1.1 l . l 110.2 75-79 0.7 0.4 0.6 171.1 0.7 0.5 0.6 l l l .O 0.7 0.5 0.6 114.9 80+ 0.6 0.5 0.6 124.4 0.4 0.4 0.4 79.8 0.4 0.4 0.4 84.3 Total 100.0 100.0 100.0 104.2 100.0 100.0 100.0 92.0 100.0 100.0 100.0 93.0 Number 1,889 1,813 3,702 3,702 18,769 20,392 39,161 39,161 20,658 22,205 42,863 42,863 out-migration of males to the urban areas of Nepal, as well as to other countries, including India, in search of short-term and long-term employment. Figure 2.2 presents the distribution of the male and female household population by single year of age (see also Appendix Table C.1). Information on the age of household members is obtained from the head of the household or any responsible adult member of the household. It is clear that there is some heaping in ages ending in zero, two and five and, as expected, age heaping is more severe at older ages. Age heaping is less pronounced among women than men, presumably because women reported their own age and this information was obtained after extensive probing whereas, many of the men's ages were provided by proxy. Table 2.2 compares the broad age structure of the 1996 NFHS population with the population distribution in the 1991 Census and the 1991 NFHS. The age distribu- tion in the 1996 NFHS is almost identical to the age distribution in the 1991 NFHS and similar to the age distribution in the 1991 Census. Table 2.2 Population by a2e from selected sources Percent distribution of the de facto household population by broad age groups, selected sources, Nepal 1991-1996 1991 1991 1996 Age group NFHS Census NFI-[S <15 43.7 42.4 44.0 15-64 52.8 54. I 52.2 65+ 3.5 3.5 3.7 Total 100.0 100.0 100.0 Median age U U 17.9 U = Unknown (not available). Source: Ministry of Health, 1993: Table 3.2; Central Bureau of Statistics, 1991: Vol. 1, Table 5. A~B 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30~34 25-29 20-24 15-19 10-14 5-9 0-4 10 8 Figure 2.1 Population Pyramid, Nepal, 1996 6 4 2 0 2 4 6 Percent 8 10 Nepa l1996 13 Percent 3 Figure 2.2 Distribution of De Facto Household Population by Single Year of Age and Sex 10 15 20 25 30 35 40 45 50 55 60 65 Single Year of Age l ~Male ---FoCal& • 70 + Nepa l1996 2.2 Household Composition Table 2.3 presents the distribution of households by selected background characteristics, which are usually indicative of the socio-economic differences between households. For example, female-headed households are often found to be poorer than male-headed households and the size and composition of a household influences the allocation of limited resources and affects the living conditions of individuals in the household. Households in Nepal are predominantly headed by males regardless of the type of residence (88 percent). Household heads tend to be concentrated in the middle age groups. Thirty-seven percent are in the age group 30-44 and 30 percent in the age group 45-59. The median age of household heads is 43 years; the median age is slightly lower in urban areas (40 years) than in rural areas (43). The average household size is 5.5 persons, which is consistent with the 1991 Census (5.5) but slightly smaller than the 1991 NFHS (5.7). The average household size is slightly larger in rural areas (5.5) than in urban areas (5.2). The majority of household heads are Hindu (87 percent), 7 percent are Buddhist and 5 percent are Muslims. Brahmins and Chhetris are among the most prevalent caste groups in Nepal. Eighteen percent of household heads belong to the Chbetri caste and 15 percent belong to the Brahmin caste. The Occupational caste group, which comprises 14 percent of all household heads, is predominantly found in rural areas. On the other hand, the Newars, who comprise some 7 percent of all household heads, are predominantly found in urban areas. 2.3 Educational Attainment of the Household Population The level of education attained by the population is an important indicator of social development. In 14 Table 2.3 Household comaosition Percent distribution of households by sex, age, religion and caste of househo d head and household size, according to urban-rural residence, Nepal 1996 Residence Background characteristic Urban Rural Total Household headship MaZe 87.5 87.6 87.6 Female 12.5 12.4 12.4 Total 100.0 100.0 100.0 Age of household head <30 17.4 17.5 17.5 30-44 43.2 36.4 37.0 45-59 26.3 29.9 29.6 60+ 13.1 16.1 15.9 Total 100.0 100.0 100.0 Median age 40.4 43.0 42.7 Number of usual members 1 3.3 3.2 3.2 2 7.6 7.8 7.8 3 12.1 10.6 10.7 4 20.4 15.8 16.2 5 19.3 17.9 18.0 6 14.5 15.4 15.3 7 8.6 11.6 11.3 8 5.5 6.7 6.6 9+ 8.9 11.1 10.9 Total 100.0 100.0 100.0 Mean size 5.2 5.5 5.5 Religion of household head Hindu 82.4 87.2 86.8 Buddhist 12.3 6.1 6.7 Muslim 3.7 4.6 4.5 Christian 0.1 0.5 0.4 Other 1.1 1.3 1.3 Don't know/missing 0.4 0.2 0.2 Total 100.0 100.0 100.0 Caste of household head Brahmin 23.8 13.8 14.7 Chhetri 12.9 18.9 18.4 Newar 23.5 5.0 6.6 Gurung 2.7 1.4 1.5 Magar 3.2 7.7 7.3 Tamang/Sherpa 6.0 6.0 6.0 Rai/Limbu 2.5 5.3 5.0 Muslim/Churaute 3.6 4.5 4.4 ThangRajbanshi 2.5 6. I 5.8 Yadav/Ahir 0.2 3.6 3.3 Occupational 8.3 14.7 14.1 Other Hill origin 0.5 3.5 3.2 Other Terai origin 10.1 9.4 9.5 Total 100.0 100.0 100.0 Number of households 716 7,366 8,082 Note: Table is based on de jure members; i.e., usual residents. addition, education has been found to affect reproductive behaviour, the use of contraceptives, and the health of mothers and their children. Tables 2.4.1 and 2.4.2 show the distribution of the male and female household population age 6 years and above by the level of education attained, according to age, residence, ecological region, development region, and sub-region. In this report those who have never been to school are categorized as having no education. Those who have attended primary school or completed it are categorized as "primary." Over one-third of males (36 percent) and two-thirds of females (67 percent) have never been to school. Overall, 39 percent of males and 22 percent of females have attained some primary education, while 18 percent of males and 8 percent of females have attained some secondary education. The median number of years of schooling is 2 for males and less than 1 for females (the median for females is not shown because more than 50 percent of the female household population in most of the categories have no education). An examination of the level of education by age group reveals that there has been an improvement over time in the educational attainment for both sexes. The proportion of males who have never been to school declines from 88 percent among the oldest age group (65 years or more) to 14 percent among those age 10-14. The comparable proportion among females is 99 percent and 38 percent, respectively. Neverthe- less, the gender gap remains large. For example, 24 percent of males in the age group 6-9 have not been to school compared with 41 percent among females in the same age group. Data also indicate that there is a wide gap between urban and rural areas in educational attainment. Thirty-eight percent of males and 70 percent of females in rural areas have never attended school compared with 19 percent of males and 40 percent of females in urban areas. For both sexes, this difference is more pronounced at higher levels of education, presumably because of insufficient numbers of higher educational facilities and inaccessibility in rural areas. 15 Table 2.4.1 Educational level of the male household aooulation Percent distribution of the de facto male household population age six and over by highest Ievel of education attended, and median number of years of schooling, according to selected background characteristics, Nepal 1996 Levelofeduc~ion SLC Don't Number Median Background No Some and know/ of years of characteristic education Primary secondary higher missing Total persons schooling Age 6-9 24.3 74.9 0.1 0.0 0.7 100.0 2.559 0.8 10-14 14.2 67.3 18.5 0.0 0.0 100.0 2,883 3.7 15-19 17.3 26.9 49.6 6.0 0.1 100.0 1,925 6.8 20-24 24.2 25.8 28.5 21.3 0.3 100.0 1,477 6.0 25-29 31.0 24.7 24.2 19.4 0.7 100.0 1,348 4.8 30-34 39.4 25.8 18.0 15.7 I.I 100.0 1,137 3.0 35-39 41.7 30.4 16.1 10.7 1.2 100.0 989 2.3 40-44 47.8 26.5 14.9 9.4 1.4 100.0 824 1.0 45-49 55.8 24.3 11.5 6.8 1.6 100.0 787 0.0 50-54 73.2 14.9 5.2 4.0 2.6 100.0 693 0.0 55-59 79.0 11.6 4.2 3.6 1.6 100.0 590 0.0 60-64 84.1 10.0 2.6 1.9 1.4 100.0 490 0.0 65+ 87.9 6.7 2.1 1.5 1.7 100.0 824 0.0 Residence Urban 18.6 33.4 23.3 23.6 1.0 100.0 1,605 5.7 Rural 37.8 39.1 17.0 5.3 0.8 100.0 14,919 1.6 Ecological region Mountain 43.7 41.2 12.0 2.6 0.5 100.0 1,155 0.9 Hill 31.8 40.5 18.8 7.9 1.1 100.0 7,129 2.6 Terai 38.4 36.5 17.3 7.1 0.6 100.0 8,240 1.5 Development region Eastern 32.9 37.3 21.0 8.0 0.7 100.0 4,166 2.8 Central 39.5 34.7 16.2 9.0 0.5 100.0 5,630 1.3 Western 33.8 41.6 17.5 6.1 1.0 100.0 3,056 2.3 Mid-western 39.1 40.3 14.9 4.5 1.3 100.0 2,261 1.2 Far-western 30.6 48.1 17.0 3.3 1.0 100.0 1,411 2.3 Sub-region Eastern Mountain 36.7 43.8 14.6 4.2 0.7 100.0 314 1.7 Central Mountain 48.0 40.3 10.2 1.3 0.3 100.0 398 0.9 Western Mountain 44.9 40.2 11.7 2.6 0.6 100.0 443 0.9 Eastern Hill 34.6 38.0 20.8 6.0 0.6 100.0 1,313 2.6 Central Hill 30.3 35.7 19.6 13.7 0.7 100.0 2,357 3.2 Western Hill 30.8 43.5 18.5 5.7 1.5 100.0 1,874 2.6 Mid-western Hill 34.1 46.6 14.6 3.3 1.5 100.0 1,081 1.7 Far-western Hill 30.9 45.2 19.6 3.1 1.2 100.0 504 2.4 Eastern Terai 31.6 36.2 22.0 9.6 0.7 100.0 2,540 3.1 Central Terai 45.9 33.2 14.3 6.2 0.4 100.0 2,875 0.9 Western Terai 38.6 38.5 16.0 6.7 0.2 100.0 1,182 1.8 Mid-western Temi 41.5 35.4 15.9 6.1 1.1 100.0 983 1.1 Far-western Teral 27.8 50.4 17.0 3.7 1.1 100.0 660 2.5 Total 36.0 38.6 17.6 7.1 0.8 100.0 16,524 2.0 SLC = School Leaving Certificate 16 Table 2.4.2 Educational level of the female household nooulation Percent distribution of the de facto female household population age six and over by highest level of education attended, according to selected background characteristics, Nepal 1996 Level of education SLC Don't Number Background No Some and know/ of characteristic education Primary secondary higher missing Total persons Age ~ 6-9 41.1 58.2 0.0 0.0 0.6 100.0 2,542 10-14 38.4 49.7 11.8 0.0 0.2 100.0 2,686 15-19 51.5 19.5 25.7 3.1 0.2 100.0 2,259 20-24 64.4 13.7 13.6 8.2 0.2 100.0 1,999 25-29 75.2 11.8 7.4 5.4 0.2 100.0 1,734 30-34 84.7 8.3 4.3 2.8 0.1 100.0 1,365 35-39 88.7 6.9 2.8 1.5 0.0 I00.0 1,179 40-44 91.I 5.0 2.7 1.2 0. I IO0.O 946 45-49 94.0 3.5 1.9 0.6 0.0 lO0.O 846 50-54 96.3 1.5 1.2 0.5 0.6 I00.0 718 55-59 97.6 1.5 0.4 0.5 0.I I00.0 577 60-64 97,5 1.5 0.5 0.2 0.2 I00.0 489 65+ 99.2 0.3 0.2 0.0 0.3 I00.0 794 Residence Urban 40.1 26.9 19.5 13.2 0.3 I00.0 1,547 Rural 69.9 21.8 6.9 1.2 0.2 100.0 16,590 Ecologicalregion Mountain 77.2 17.5 4.2 0.7 0.3 100.0 1,282 Hill 62.0 26.0 9.1 2.7 0.2 100.0 8,285 Terai 71.0 19.3 7.4 2.0 0.2 100.0 8,570 Development region Eastern 62.3 24,6 10.4 2.5 0.2 100.0 4,444 Central 70.5 18.7 7.2 3.2 0.3 100.0 5,839 Western 60.2 27.6 10.1 1.9 0.1 100.0 3,665 Mid-western 75.2 18.6 4.7 1.2 0.3 100.0 2,497 Far-western 73.2 21.9 4.4 0.4 0.2 100.0 1,691 Sub-region Eastern Mountain 60.7 25.9 10.6 2.3 0.5 100.0 326 Central Mountain 78.6 19.1 2.0 0.0 0.3 100.0 446 Western Mountain 86.7 10.8 2.1 0.2 0.2 100.0 509 Eastern Hill 63.8 25.7 8.7 1.5 0.2 100.0 1,511 Central Hill 57.9 24.4 11.5 6.0 0.2 100.0 2,475 Western Hill 54.4 31.9 11.7 1.8 0.2 100.0 2,375 Mid-western Hill 73.8 22.2 3.1 0.7 0.2 100.0 1,235 Far-western Hill 77.4 18.4 3.8 O.l 0.2 100.0 688 Eastern Terai 61.6 23.7 11.3 3.1 0.2 100.0 2,607 Central Terai 80.0 13.9 4.4 1.3 0.3 100.0 2,918 Western Terai 71.0 19.7 7.3 2.0 0.0 100.0 1,291 Mid-western Terai 72.8 17.2 7.4 2.1 0.5 100.0 1,044 Far-western Terai 65.9 28.0 5.3 0.7 0.1 100.0 711 Total 67.3 22.2 8.0 2.2 0.2 100.0 18,136 Note: Median years of schooling is not shown because more than 50 percent of the female household population in most of the categories have no education, The median years of sehooling for females age 6-9 and 10-14 is 0.7 and 2,1, respectively. The median for urban residence is 2.5. SLC ffi School Leaving Certificate Excludes 2 women for whom age was not reported. 17 The pereentage of males and females who have no education is highest in the Mountain region and lowest in the Hill region. Nearly 40 percent of males residing in the Central and Mid-western regions reported having no education. Among females, the highest percentage reporting no education was in the Mid-western region (75 percent), followed closely by the Far-western region (73 percent). The difference in the percentage of males with no education is more pronounced by sub-regions ranging from 28 percent in the Far-western sub-region of the Terai to 48 percent in the Central sub-region of the Mountains. A similar difference is seen among females with no education, ranging from 54 percent in the Western Hill subregion to 87 percent in the Western Mountain sub- region. Tables 2.4.1 and 2.4.2 show the persistence of the gender gap in the level of education even among the sub-regions. While for males the percentage who have never been to school is less than 50 percent in all sub- regions, for females, the percentage who have never been to school exceeds 50 percent in all sub-regions and exceeds 75 percent in four of the thirteen sub-regions. Table 2.5 presents the school enrolment rates of the male and female population age 6-24 years according to age and residence. Slightly more than three of five (65 percent) children age 6-15 are currently enrolled in school. But the enrolment drops substantially after age 15 to less than three often (28 percent) among those age 16-20 and to one of eleven (11 percent) among those age 21-24. This sudden drop may be partly due to lack of financial resources to continue schooling and partly due to the need to work to support the family. Table 2.5 School enrolment Percentage of the de facto household population age 6-24 years enrolled in school, by age, sex, and urban-rural residence, Nepal 1996 Male Female Total Age Urban Rural Total Urban Rural Total Urban Rural Total 6-10 84.9 72,7 73.7 86.9 54.5 56.7 85.8 63.6 65.3 11-15 82.9 75.2 76.0 82.6 48. I 50.8 82.8 61.8 63.6 6-15 83.9 73.9 74.7 84.7 51.6 54.0 84.3 62.8 64.5 16-20 51.0 38,2 39,5 42.2 17.0 19.2 46.6 26.4 28.3 21-24 33,3 13,7 15.8 14.7 3.1 4.2 23.2 7.5 9.1 There continue to be differentials in enrolment by urban-rural residence (see Figure 2.3). The enrolment rate among children age 6-15 is much higher in urban areas (84 percent) than in rural areas (63 percent). This difference persists in all age groups and is much greater among older age groups than among younger age groups. For example, among those age 21-24, urban enrolment is three times that of rural enrolment, whereas among those age 6-1 O, urban enrolment is only 1.3 times as high as rural enrolment. The overall school enrolment rate is also much higher among males than females. However, the gender gap is almost non-existent in urban areas among children age less than 16. This is not the case in rural areas where males continue to be enrolled in larger proportions than females in all age groups. 18 100 80 60 40 20 0 Figure 2.3 School Enrolment among Children Age 6-15 by Age, Sex, and Urban-Rural Residence Percent 83 83 Male Female Male Female 11-15 Years 6-10 Yeara f~Urban ~ Rural I Nepal 1996 2.4 Housing Characteristics Table 2.6 provides information on selected housing characteristics by residence. This information is helpful in assessing the general socio-economic conditions of the population. Overall, only 18 percent of households have electricity. Nevertheless, this is an increase of 5 percentage points over the level obtained in the I991 NFHS. There is a considerable difference between urban and rural households regarding the availability of electricity. While more than three-fourths (78 percent) of households in urban areas have electricity, only 12 percent in rural areas have electricity. Information on the source of drinking water and accessibility to the source was also gathered in the NFHS. Safe drinking water is important for health and sanitation. Table 2.6 shows that only 9 percent of households have water piped into their residence and 23 percent collect water from a public tap. In total, 57 percent of urban households and 29 percent of rural households have access to piped water. Access to piped water has increased when compared with data from the 1991 NFHS. Nearly one-third (32 percent) of households have access to hand pumps, which are more common in rural areas than in urban areas (32 percent versus 27 percent). One-fifth of households interviewed in rural areas reported spring water as their main source of drinking water. The other sources of drinking water include well, river or stream, and stone taps. Those households which did not have access to drinking water within their own premises were also asked about the time required to fetch water. Overall, three of five households have access to water within 15 minutes. As expected there is quicker access to water in urban than in rural areas. The majority of households (77 percent) do not have sanitation facilities. Lack of sanitation facilities is more common in rural areas (82 percent) than in urban areas (26 percent). Thirteen percent of households have a pit toilet or latrine (9 percent in urban areas and 13 percent in rural areas) and 7 percent have pan latrines (45 percent in urban areas and 3 percent in rural areas). Less than 2 percent of the population has access to flush toilets, which are predominantly located in urban households (17 percent). 19 Table 2.6 Housin~ characteristics Percent distribution of households by housing characteristics, according to urban-rural residence, Nepal 1996 Residanee Characteristic Urban Rural Total A large percentage (91 percent) of houses have mud or dung floors. Mud or dung floors are almost universal in rural households, while only two of five urban households have this type of flooring. Five percent of all households have a cement floor, which is more common in urban households (41 percent) than in rural households Electricity Yes 78.4 12.1 17.9 No 21.6 87.9 82.0 Total 100.0 100.0 100.0 Source of drinking water Piped water Piped into residence 46.4 5.2 8.8 Public tap 11.0 23.9 22.7 Well water Well in residence 5.7 1.8 2.1 Public well 3.0 5.2 5.0 Hand Pump Hand pump in residence 20.9 11.0 11.9 Public hand pump 6.4 21.3 20.0 Spring water (Kuwa) 0.0 20.8 18.9 River/stream 3.3 7.6 7.2 Stone tap (Dhara) 1.8 1.6 1.6 Other 0.6 1.4 1.4 Missing 0.9 0.3 0.4 Total 100.0 100.0 100.0 T ime to water source Water within 15 minutes 88.8 58.5 61.1 Sanitation facility Flush toilet 17.1 0.2 1.7 Traditional pit toilet 9.2 13.2 12.9 Ventilated improved toilet 1.8 0.9 1.0 Pan 45.3 3.2 6.9 No facility 26.3 82.3 77.3 Other 0.1 0.0 0.0 Missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Flooring Mud/dung 44.3 95.7 91.2 Wood planks 3.5 2.5 2.6 Cement 41.3 1.6 5.1 Linoleum 3.0 0.0 0.3 Marble chips 1.6 0.0 0.1 Carpet 6.1 0.1 0.6 Other 0.1 0.1 0.1 Total 100.0 100.0 100.0 Persons per sleeping room 1-2 52.0 37.8 39.0 3-4 31.9 37.5 37.0 5-6 12.7 17.4 17.0 7+ 2.8 7.1 6.7 Don't know/missing 0.6 0.2 0.3 Total 100.0 100.0 100.0 Mean persons per room 3.0 3.5 3.5 Number of households 716 7,366 8,082 (2 percent). The extent of crowding is estimated by the number of rooms in a household used for sleeping. Crowding is quite apparent in Nepalese households. Thirty-nine percent of households have 1-2 persons per sleeping room and 37 percent have 3-4 persons. Seventeen percent of households have as many as 5-6 persons per room and 7 percent have 7 or more persons. Overall, there are fewer persons per sleeping room in urban than in rural households, although this difference is not large among smaller-sized families. The overall mean number of persons per sleeping room is 3.5. Information on the possession of various durable goods was also collected at the household level. Table 2.7 shows that overall, 37 percent of households have radios, one-fifth have bicycles, 7 percent have televisions and 1 percent have telephones. There is a vast difference between urban and rural households, with urban households much more likely to own these consumer durable items than rural households. The urban-rural difference is especially pro- nounced for ownership of television and telephones. The percentage owning radios, televisions and bicycles has increased over the last five years, when compared with data from the 1991 NFHS. Lack of a sufficient amount of iodine in the diet can lead to serious nutritional deficiencies such as goiter, nutritional stunting, mental retardation, and cretinism. The Government of Nepal has emphasized the addition of iodine to salt to prevent and control the occurrence of these health problems. The iodine content of salt used in households was tested by the NFHS interviewers. These results are presented in Table 2.8. The test involved 20 Table 2.7 Household durable goods Percentage of households possessing various durable consumer goods, by urban-rural residence, Nepal 1996 Residence Consumer good Urban Rural Total Radio 59.7 34.2 36.5 Television 42.6 3.1 6.6 Telephone 14.1 0.1 1.3 Bicycle 38.9 17.6 19.5 None of the above 25.2 56.0 53.3 Number of households 716 7,366 8,082 Eastern Terai sub-region. Households in than other households to use iodized salt. which the head placing a drop of a special solution onto a small amount of salt supplied by the household respondent, which indicates the presence of iodine in the salt, but not its quality which is subject to degradation. Test kits were supplied by the Nepal Salt Trading Corporation. Results showed that 93 percent of the households use iodized salt. This finding is consistent with an earlier survey which tested salt in local shops at the community level. The findings of that survey indicated that 88 percent of the 288 community shops surveyed sold iodized salt (National Planning Commission Secretariat and UNICEF-Nepal, 1996). NFHS data showed that almost all urban households (99 percent) use iodized salt while the figure for rural households is 93 percent. The proportion of households using iodized salt was highest in the Terai, in the Eastern development region and in the of the household is educated are slightly more likely 2.5 Background Characteristics of Respondents Table 2.9 shows the distribution of respondents to the Individual Questionnaire by selected background characteristics including age, marital status, residence, education, religion, and caste. Respondents are ever- married women age 15-49 who had slept in a selected household the night before the interview. As discussed in Chapter 1, interviews were completed for a total of 8,429 eligible women. The distributions for both ever- married and currently married women are shown but, since the distributions are very similar, only ever-married women will be discussed here. The age distribution of women reveals that one of two women is below 30 years and one of five is 40 years or above. Women are mostly concentrated in the age groups 20-34. This could be because of a trend towards later marriage, and since the survey interviewed ever-married women only there are fewer ever-married women in the youngest age group. This is confirmed by comparison with the 1991 NFHS data. The age distribution of ever-married women in the 1996 NFHS is consistent with the age distribution in the 1991 NFHS except in the 15-19 age group, which is 3 percent higher in 1991. The majority of women are currently married with a very small minority widowed, divorced or separated (5 percent). Ninety-two percent of women are currently residing in rural areas. One of two women live in the Terai, 43 percent live in the Hills and 7 percent live in the Mountains. The distribution of women by development regions shows that one-third are from the Central region, nearly one-quarter (23 percent) from the Eastern region and one-fifth from the Western region. The distribution of women in the Mid-western and Far-western regions is 14 percent and 10 percent, respectively. The sub-regional distribution shows the highest concentration of women in the Central Terai sub-region (19 percent), followed by the Eastern Terai (15 percent) and the Central and Western Hill sub-regions (around 12 percent each). In each of the remaining sub-regions, the distribution of women is less than 10 percent. 21 Table 2.8 Iodized salt Percentage of households using iodized salt, by age of household head and selected background characteristics, Nepal 1996 Number Background of characteristic Percentage households Age of household head < 30 94.0 1,415 30-44 93.8 2,994 45-59 92.5 2,393 60+ 92.0 1,281 Residence Urban 98.6 716 Rural 92.6 7,366 Eeologicalregion Mountain 89.2 608 Hill 92.2 3,695 Terai 94.7 3,779 Development region Eastern 96.2 1,974 Central 93.2 2,703 Western 90.2 1,634 Mid-western 93.5 1,080 Far-western 91.0 690 Sub-region Eastern Mountain 92.3 151 Central Mountain 90.8 228 Western Mountain 85.7 229 Eastern Hill 93.5 640 Central Hill 92.9 1,091 Western Hill 89.8 1,088 Mid-western Hill 94.1 581 Far-western Hill 92.7 294 Eastern Terai 98.2 I, 183 Central Terai 93.8 1,383 Western Terai 90.9 546 Mid-western Terai 95.7 394 Far-western Terai 90.1 272 Educational level of household head No education 91.9 4,806 Primary 94.4 1,654 Some secondary 95.7 951 SLC and above 96.0 560 Don't know/missing 94.6 111 Total 93.2 8,082 Note: Total includes 14 households in which the salt test was not performed. SLC = School Leaving Certificate The vast majority of ever-married women (80 percent) have never been to school; one in nine has attended primary school; 6 percent have some secondary education; and less than 3 percent have passed the School Leaving Certificate (SLC). Four of five women are illiterate. The vast majority of women (87 percent) are Hindu. Six percent are Buddhist and 5 percent are Muslim. The ethnic composition of women shows that Chhetris are the dominant ethnic group (17 percent), followed by the Occupational caste group (15 percent) and Brahmins (14 percent). The Tibetan-Burmese groups such as the Gurung, Magar, Tamang, Sherpa, Rai, and Limbu represent between 1 and 7 percent of the female ever-married population and the Newars 6 percent. The Tharu and Rajbanshi represent 8 percent and the Yadav and Ahir 4 percent. Table 2.10 shows the relationship between women's level of education and other background characteristics. As expected, the level of education decreases with increasing age of the respondents, reflecting an improvement in women's level of education over time. The urban-rural differences in women's level of education is marked. While nearly one half (48 percent) of women in urban areas have no education, the proportion of rural women with no education is 83 percent. The urban advantage is especially pronounced at the higher levels of education. For example, while the urban-rural difference among women who have some primary education is 5 percentage points, the difference among those who have passed the SLC is almost 16 percentage points. Women residing in the Mountain region are least likely to have any education compared with women in the Terai and Hill regions. However, there is very little difference in education between women residing in the Hills and the Terai. Women residing in the Western and Eastern regions are slightly more educated than women residing in the Central region. However, this difference is not marked. Women residing in the Far-western and Mid- western regions are less educated than women in the other regions. Nearly 4 percent of women in the Central region have passed their SLC. The proportion of women who have never attended school ranges from 70 percent in the Central Hill sub-region to a high of 95 percent in the 22 Table 2,9 Background characteristics of resuondants Percent distribution of ever-married and currently married women by selected background characteristics, Nepal 1996 Ever-married women Currently married women Number of women Number of women Background Weighted Un- Weighted Un- characteristic percent Weighted weighted percent Weighted weighted Age 15-19 11.6 982 955 12.1 965 940 20-24 19.3 1,626 1,629 20.1 1,602 1,602 25-29 18.9 1,594 1,591 19.5 1,560 1,556 30-34 16.1 1,361 1,363 16.2 1,292 1,295 35-39 13.3 1,119 1,128 13.0 1,042 1,045 40-44 11.0 923 937 10.4 828 840 45-49 9.8 824 826 8.7 695 700 Marital status Married 94.7 7,982 7,978 100.0 7,982 7,978 Widowed 3.2 272 281 NA NA NA Divorced 0.2 14 15 NA NA NA Not living together 1.9 160 155 NA NA NA Residence Urban 8.4 712 954 8.4 668 900 Rural 91.6 7,717 7,475 91.6 7,314 7,078 Ecological region Mountain 6.8 569 1,061 6.7 538 1,002 Hill 42.7 3,600 3,597 42.1 3,363 3,358 Terai 50.5 4,259 3,771 51.1 4,082 3,618 Development region Eastern 23.0 1,941 1,683 22.9 1,829 1,583 Central 33.5 2,827 2,515 33.5 2,677 2,373 Western 19.5 1,647 1,594 19.6 1,561 1,513 Mid-western 14.2 1,196 1,390 14.4 1,146 1,334 Far-western 9.7 819 1,247 9.6 769 1,175 Sub-region Eastern Mountain 1.5 127 308 1.5 120 290 Central Mountain 2.3 195 349 2.3 183 326 Western Mountain 2.9 247 404 3.0 236 386 Eastern Hill 6.9 578 523 6.7 538 487 Central Hill 12.6 1,065 1,087 12.4 993 1,012 Western Hill 12.1 1,022 923 11.9 952 859 Mid-wastern Hill 7.1 595 616 7.1 567 587 Far-western Hill 4.0 340 448 3.9 3 i 3 413 Eastern Tarai 14.7 1,236 852 14.7 1,171 806 Central Tcrai 18.6 1,566 1,079 18.8 1,502 1,035 Western Terai 7.4 625 671 7.6 609 654 Mid-western Terai 5.8 492 596 6.0 476 577 Far-western Tarai 4.0 341 573 4.1 324 546 Education No education 80.0 6,742 6,736 79.5 6,347 6,337 Primary l 1.0 925 893 I 1.2 896 864 Some secondary 6.3 531 540 6.4 513 522 SLC and above 2.7 231 260 2.8 227 255 Continued 23 Table 2.9 -- Continued Ever-married women Currently married women Number of women Number of women Background Weighted Un- Weighted Un- characteristic percent Weighted weighted percent Weighted weighted Literacy Illiterate 79.1 6,665 6,615 78.8 6,288 6,231 Literate 20.9 1,764 1,814 21.2 1,694 1,747 Religion Hindu 87.3 7,357 7,373 87.2 6,964 6,978 Buddhist 6.0 509 569 6.0 480 535 Muslim 5.0 420 348 5.1 406 337 Christian 0.4 35 31 0.4 30 27 Other 1.1 92 92 1.1 85 85 Missing 0.2 16 16 0.2 16 16 Ethnic group Brahmin 13.6 1,146 1,169 13.5 1,078 1,102 Chhetri 17.4 1,466 1,688 17.3 1,382 1,590 Newar 6.0 509 533 6.0 483 506 Gurung 1.3 107 103 1.3 101 97 Magar 7.1 596 581 7.1 566 551 Tamang/Sherpa 5.6 472 526 5.6 445 496 Rai/Limbu 4.4 370 387 4.3 341 358 Muslim/Charaute 5.0 421 349 5.1 407 337 Thani/Rajbanshi 8.0 670 716 8.1 650 694 Yadav/Ahir 3.8 319 234 3.9 309 227 Occupational 14.6 1,234 1,256 14.4 1,151 1,171 Other Hill origin 3.0 252 218 3.0 238 205 Other Terai origin 10.3 866 669 10.4 832 644 Total 100.0 8,429 8,429 100.0 7,982 7,978 NA = Not applicable SLC = School Leaving Certificate Western Mountain sub-region. In the Central Hill sub-region, 8 percent of women reported having attained at least a SLC level of education. As expected, most (96 percent) illiterate women have no educationJ On the other hand, 20 percent of women with no formal education are literate. This is relatively high when compared with other developing countries, where the percent literate among women with no formal education ranges from less than one percent in Burkina Faso to 22 percent in Colombia (Kishor and Neitzel, 1996). 2 Within Asia, this percentage ranges from less than one percent in Bangladesh to 17 percent in the Philippines. Such a high percentage in Nepal can be attributed to the emphasis on non-formal literacy classes and its success. Nearly one- third (30 percent) of literate women have achieved some secondary education and 13 percent have attained at least a SLC level of education. Women who had never attended school and women who had attended Grade 5 or less were asked if they could read and understand a letter or newspaper. If they said "No", they were given a sentence to read. If they are not able to read, they are categorized as "illiterate." All other women are categorized as "Literate." 2 Any women who stated that she can read, whether easily or with difficulty, is considered literate. Unlike in Nepal, women's literacy was not tested by asking them to actually read a sentence. 24 Percent distribution of ever-married women by the highest level of education attended, according to selected background characteristics, Nepal 1996 Highest level of education Number Background No edu- Some SLC and of characteristic cation Primary secondary above Total women Age 15-19 69.0 19.1 11.2 0.8 100.0 982 20-24 68.1 15.7 10.8 5.4 100.0 1,626 25-29 76.5 12.0 7.1 4.4 100.0 1,594 30-34 85.1 8.1 4.6 2.3 100.0 1,361 35-39 88.0 8,1 2.3 1.6 100.0 1,119 40-44 90.0 5,5 3.4 1.2 100.0 923 45-49 93.0 4.9 1.7 0.5 100.0 824 Residence Urban 48.1 15.4 19.3 17.2 100.0 712 Rural 82.9 10.6 5.1 1.4 100.0 7,717 Ecological region Mountain 89.5 6.9 2.8 0.9 100.0 569 Hill 77.5 12.2 6.8 3.5 100.0 3,600 Tcrai 80.9 10.5 6.3 2.3 100.0 4,259 Development region Eastern 76.3 12.2 8.6 2.9 100.0 1,941 Central 79.4 10.9 5.8 3.9 100.0 2,827 Western 76.1 13.9 7.5 2.5 100.0 1,647 Mid-western 85.6 8.5 4.1 1.7 100.0 1,196 Far-western 90.2 6.2 3.2 0.4 100.0 819 Sub-region Eastern Mountain 76,6 11.4 9.1 2,9 100.0 127 Central Mountain 91.4 7.7 0.9 0.0 100.0 195 Western Mountain 94.6 4.0 1.0 0.5 100.0 247 Eastern Hill 81,6 9.8 6.9 1.7 100.0 578 Central Hill 70.3 12.7 8.8 8.2 100.0 1,065 Western Hill 72.8 16.5 8.4 2.3 100.0 1,022 Mid-western Hill 86.2 10.4 2.6 0.8 100.0 595 Far-western Hill 91.3 4.9 3.6 0.2 100.0 340 Eastern Terai 73.8 13.4 9.4 3.4 100.0 1,236 Central Terai 84.2 10.0 4.4 1.4 100.0 1,566 Western Terai 81.5 9.5 6.1 2.9 100,0 625 Mid-western Terai 82.6 7.4 6.8 3.2 100.0 492 Far-western Terai 87.8 8.1 3.5 0.6 100.0 341 Literacy Literate 19.8 37.0 30.1 13.1 100.0 1,764 Illiterate 95.9 4.1 0.0 0.0 100.0 6,665 Total SLC = School Leaving Certificate 80.0 II.0 6.3 2.7 I00.0 8,429 25 Table 2.11 School Attendance and reasons for leavin~ school Percent distribution of ever-married women 15-24 by whether or not currently attending school and reason for leaving school, according to highest level of education attended, Nepal 1996 Attendance/ Reason for leaving school Educational Attainment Secondary Primary Primary Secondary complete incomplete complete incomplete & higher Total Currently attending 0.0 1.2 9.6 23.1 6.1 Reason for leaving Got pregnant 0.7 Got married 10.8 Care for younger children 8.7 Family needed help 48.6 Could not pay school fees 2.7 Needed to earn money 1.4 Graduated/Had enough schooling 0.0 Did not pass exams 0.0 Did not like school 9.4 School not accessible 3.4 Other 12.5 Don't know/missing 1.9 Total 100.0 Number of women 354 0.0 2.6 6.7 2.0 27.7 54.1 45.3 31.6 8.6 1.8 6.5 6.0 36.5 14.4 2.3 30.1 3.4 1.1 0.0 1.9 0.0 0.3 1.0 0.8 0.0 0.0 1.4 0.2 0.0 5.5 2.1 2.1 3.5 1.4 0.8 5.0 12.9 4.1 2.0 4.5 6.3 4.2 7.8 8.4 0.0 0.9 1.0 1.2 100.0 100.0 100.0 100.0 89 285 96 824 SLC = School Leaving Certificate Reasons for Leaving School Ever-married women who were not currently attending school were asked their reason for leaving school. This information can provide guidance to programs seeking to improve women's educational opportunities. Table 2.11 shows the percent distribution of women age 15-24 according to whether or not they are currently attending school and, if not, their reasons for leaving school, according to the highest level of education attended. Only a small percentage of respondents (6 percent) were attending school at the time of the interview. The two principal reasons women gave for leaving school was to get married or to help in the family (32 percent and 30 percent, respectively). The reasons given for leaving school varied by the level of education. Nearly one out of two women who had not completed primary school said she left because her family needed help (49 percent). This was also the most common reason given by women who had completed primary school, although a smaller proportion stated this reason (37 percent). A sizeable proportion of these women stated that they left school to get married (28 percent) or because the school was not accessible (13 percent). Marriage was the principal reason for leaving school among women who had some secondary education or who had completed secondary education (54 percent and 45 percent, respectively). Twenty-three percent of women who had completed secondary education were attending school at the time of the interview. 2.6 Access to Mass Media The NFHS collected information on women's exposure to both the print and broadcast media. Women were asked if they usually read a newspaper or magazine at least once a week, listen to a radio daily, and watch television at least once a week. This information is important because it provides some indication of the extent to which Nepalese women are exposed to family planning and health messages in the mass media. 26 Table 2.12 Access to mass media Percentage of ever-married women who usually read a newspaper once a week, watch television once a week, or listen to the radio daily by selected background characteristics, Nepal 1996 Reads Listens magazine/ Watches to All Number Background No media newspaper television radio three of characteristic exposure weekly weekly daily media women Age 15-19 61.9 3.6 9.4 33.9 l . l 982 20-24 56.0 8.7 11.7 39.7 3.5 1,626 25-29 57.3 6.9 14.3 37.1 3.8 1,594 30-34 58.2 5.3 13.4 36.4 2.6 1,361 35-39 58.0 4.0 13.3 37.3 2.4 1,119 40-44 60.4 3.3 12.3 35.0 2.4 923 45-49 65.0 1.8 10.2 31.2 1.2 824 Residence Urban 21.1 27.1 63.0 54.3 18.7 712 Rural 62.4 3.3 7.6 34.7 1.1 7,717 Ecological region Mountain 70.4 1.7 2.1 28.8 0.5 569 Hill 52.6 5.9 12.2 43.2 2.8 3,600 Terni 62.7 5.3 13.7 31.6 2.7 4,259 Development region Eastern 46.5 7.1 14.8 50.0 3.3 1,941 Central 61.4 6.3 20.4 29.2 3.8 2,827 Western 60.8 4.7 7.0 36.7 1.9 1,647 Mid-western 64.3 3.5 3.9 34.0 1.3 1,196 Far-western 68.2 1.4 1.4 31.4 0.3 819 Sub-region Eastern Mountain 49.0 5.2 6.8 49.0 1.9 127 Central Mountain 73.9 0.6 1.7 25.5 0.3 195 Western Mountain 78.7 0.7 0.0 21.0 0.0 247 Eastern Hill 43.8 5.4 5.7 55.3 1.0 578 Central Hill 43.0 12.5 34.5 44.5 8.4 1,065 Western Hill 54.1 3.3 3.3 44.8 0.7 1,022 Mid-western Hill 67.6 2.0 0.5 32.2 0.0 595 Far-western Hill 67.2 0.7 0.9 32.8 0.0 340 Eastern Terai 47.6 8.1 19.8 47.6 4.6 1,236 Central Terai 72.3 2.9 13.2 19.3 1.1 1,566 Western Terai 71 .g 7.1 12.9 23.4 3.9 625 Mid-western Terni 57.0 6.2 8.9 39.2 3.2 492 Far-western Terai 65.2 2.3 2.6 34.0 0.6 341 Education No education 66.3 0.4 7.2 30.7 0. I 6,742 Primary 41.1 9.7 20.0 49.3 2.8 925 Some secondary lg.9 32.9 40.1 67.5 16.6 531 SLC and above 6.3 69.9 67.2 76.8 43.5 231 Literacy Literate 28.4 25.4 31.7 60.1 12.6 1,764 Illiterate 67.0 0.0 7.2 30.1 0.0 6,665 Total 58.9 5.3 12.3 36.4 2.6 8,429 SLC = School Leaving Certificate 27 As shown in Table 2.12, overall, only 5 percent of women read a newspaper or magazine at least once a week, 12 percent watch television at least once a week, and 36 percent listen to the radio daily. Only 3 percent of women are exposed to all three media and nearly three of five women (59 percent) have no access to any of the three media. Generally, exposure to television and radio does not vary much by women's age. Exposure to mass media is highest among the age group 20-24 with 9 percent being exposed to the print media, 12 percent to television and 40 percent to radio. Access to television was highest in the age group 25-29. Urban women have greater exposure to all types of media than rural women. In urban areas, 54 percent of women listen to the radio daily, 63 percent of women watch television at least once a week, and 27 percent read a newspaper or magazine at least once a week, while the corresponding data for rural women are 35 percent, 8 percent, and 3 percent, respectively. Rural women have less access to the print media and television than urban women. Women in the Mountain region have less access to all three types of media than women in the Hill or Terai regions. Women residing in the Hill and Terai regions have almost equal access to print media and television, however, Hill women have greater access to the radio. Similarly, women living in the Eastern and Central development regions have greater access to these media than women living in the other development regions. Among all the sub-regions, women from the Central Hill sub-region have greater access to print media (13 percent) and television (35 percent) while, women in the Eastern Hill region have the highest exposure to radio (55 percent). As expected, there is a close relationship between the level of education and exposure to various mass media. Two-thirds of women with no education have had no exposure to mass media in contrast to 6 percent of women who have completed their SLC. Educated women also have greater access to all three media sources. While 44 percent of women who have completed the SLC are exposed to all three media sources, women with no education have almost no exposure to all three media sources. Less educated women are more likely to be exposed to the radio but even then only one in three women with no education listens to the radio daily. The lower level of exposure to the radio among uneducated women, who are also more likely to be poor, may be due to the fact that they cannot afford a radio. 2.7 Employment Status Current Employment In the NFHS, respondents were asked a number of questions about their employment, including whether they were currently working, and, if not, whether they had worked during the year before the survey. Women who were currently working were then asked a number of questions about the kind of work they were doing and whether they were paid in cash or not. Those who earned cash for their work were asked about who made the decision about how their earnings were used. If they had small children they were asked about the arrangements they had for child care when they were working. Information on the employment status of women was also collected in the NFHS. Table 2.13 shows current employment status and continuity of employment by background characteristics of women. Of the 8,429 women, nearly one-fourth (23 percent) were currently unemployed and four in ten women were seasonally employed. Less than one-third (32 percent) of women were employed full-time, that is, were working at least five days a week throughout the year, reflecting the seriousness of the unemployment and underemployment problem among women in Nepal. 28 Percent distribution of ever-married women by employment status and continuity of employment, according to selected background characteristics, Nepal 1996 Employment Currently unemployed Currently employed Did not Worked All year work in in last Background last 12 12 5+ days <5 days Occa- characteristic months months perweek perweek Seasonally sionally Missing Total Number of women Age 15-19 26.3 9.3 24.1 3.5 33.9 2.7 0.2 100.0 20-24 20.3 6.6 28.2 2.3 40.6 1.8 0.2 100.0 25-29 15.9 6.8 33.5 3.0 38.8 1.8 0.2 100.0 30-34 12.5 5.2 35.3 2.5 42.5 1.9 0.1 100.0 35-39 11.3 5.7 35.6 2.1 43.6 1.8 0.0 100.0 40-44 10.4 6.9 34.6 3.7 42.8 1.5 0.2 100.0 45-49 15.1 5.2 32.4 2.8 42.9 1.6 0.0 100.0 Residence Urban 46.0 4.8 25.5 2.4 18.1 2.9 0.3 100.0 Rural 13.3 6.7 32.6 2.8 42.7 1.8 0.1 100.0 Ecological region Mountain 1.0 1.2 47.0 1.7 48.3 0.8 0.0 100.0 Hill 8.1 4.5 34.9 2.5 48.0 2.0 0.0 100.0 Terai 24.9 8.9 27.5 3.1 33.4 1.9 0.2 100.0 982 1,626 1,594 1,361 1,119 923 824 712 7,717 569 3,600 4,259 Development region Eastern 17.9 4.6 28.9 2.7 43.2 2.3 0.3 100.0 1,941 Central 24.6 7.9 40.1 1.7 23.4 2.2 0.1 100.0 2,827 Western 7.4 5.3 24,5 2.0 58.8 2.0 0.0 100.0 1,647 Mid-western 12.5 11.6 27.9 3.1 43.6 1.3 0.1 100.0 1,196 Far-western 5.3 1.2 32.1 7.8 53.2 0.5 0.0 100.0 819 Sub-region Eastern Mountain 3.2 0.6 43.2 2.3 49.0 1.6 0.0 100.0 Central Mountain 0.9 0.6 63.6 1.1 33.2 0.6 0.0 100.0 Western Mountain 0.0 2.0 35.9 1.7 59.9 0.5 0.0 100.0 Eastern Hill 5.2 1.1 30.4 0.8 61.4 1.1 0.0 100.0 Central Hill 17.5 5.0 45.6 1.8 27.7 2.3 0.0 100.0 Western Hill 3.1 2.5 32.2 2.7 56.7 2.9 0.0 100.0 Mid-western Hill 6.6 12.1 27.4 4.1 48.0 1.7 0.0 100.0 Far-western Hill 1.6 1.3 29.9 4.0 62.9 0.2 0.0 100.0 Eastern Terai 25.4 6.6 26.8 3.7 34.1 2.9 0.5 100.0 Central Terai 32.4 10.8 33.4 1.6 19.3 2.2 0.2 100.0 Western Teral 14.4 10.0 12.0 0.8 62.3 0.6 0.0 100.0 Mid-western Terai 22.5 12.4 27.3 2.5 34.3 0.9 0.2 100.0 Far-western Terai 11.2 1.5 31.8 13.6 41.3 0.6 0.0 t00.0 Education No education 12.5 6.9 33.4 2.8 42.7 1.6 0.1 100.0 Primary 23.6 4.9 27.8 3.4 37.5 2.9 0.0 100.0 Some secondary 35.7 4.0 19.6 2.5 34.4 3.7 0.2 100.0 SLC and above 45.7 5.8 36.6 0.0 9.4 2.4 0.0 100.0 Literacy Literate 26.7 4.8 27.7 2.6 35.4 2.7 0.1 100.0 Illiterate 13.3 7.0 33.1 2.8 42.0 1.7 0.1 100.0 127 195 247 578 1,065 1,022 595 340 1,236 1,566 625 492 341 6,742 925 531 231 1,764 6,665 Total 16.1 6.5 32.0 2.8 40.7 1.9 0.1 100.0 8,429 29 One of two women in the urban areas was not employed at the time of the survey, compared with one of five rural women. Nevertheless, rural women are more likely to be seasonally employed (43 percent) than urban women (18 percent). The proportion of women who are currently not working is much higher (34 percent) in the Terai region than in the Hill (13 percent) or Mountain regions (2 percent). Full-time employment was more frequently reported by women from the Mountain region than women in the Hill or Terai regions. Full- time employment was highest among women in the Central development region (40 percent) and lowest in the Western development region (25 percent). Similarly, nearly two-thirds (64 percent) of women in the Central Mountain sub-region reported working all year while only 12 percent of women in the Western Terai sub-region reported working year round. Unemployment was highest in the Central Terai sub-region (43 percent) and lowest in the Central and Western Mountain sub-regions (2 percent each). Surprisingly, the percentage of women currently not employed increases with the level of education. For example, among those with no education, 19 percent are currently not employed, whereas among those who have completed their SLC, 52 percent are currently unemployed. This is perhaps because employment opportunities are limited in the service sector, where most educated persons seek employment, or because more educated women are wealthier and do not have to work. Employer and Type of Earnings Table 2.14 shows that among working women, 7 percent are self-employed, 9 percent work for someone else and an overwhelming majority (84 percent) work for family members. Only 13 percent of employed women receive cash earnings. The proportion of women receiving cash earnings from being self-employed, from non- relatives, and from family members is 2 percent, 3 percent, and 7 percent, respectively. While a slightly higher percentage of older women earn cash for their work, there is no marked difference by age. Regardless of the type of employer, cash employment is higher among women living in urban areas than among women in rural areas. More than one of two women (53 percent) receive cash earnings in urban areas in contrast to one in ten women in rural areas. Cash earnings are highest among women in the Terai. The proportion of women receiving cash earnings is low in the Western sub-region compared with the other regions. There is a significant difference in the proportion of women earning cash by education. The proportion of women earning cash generally increases with increasing level of education and the proportion of employed women receiving cash earnings is highest among those who have passed their SLC, presumably because most of them work in the formal sector. The pattern is generally the same regardless of employer (although it is not as distinct among less educated women employed by non-relatives). Occupation Table 2.15 shows the distribution of employed women by current occupation according to background characteristics. Nine often women are engaged in the agricultural sector, with a majority working on their own land. The proportion of women in agricultural occupations reported in the NFHS is exactly the same as that foundinthe 1991Census(CentralBureau of Statistics, 1991). Nearly 4 percent ofemployed women are in sales or service occupations. The proportion of women working on their own land increases with age while the opposite occurs among women working on family land. 30 Table 2.14 Emolover and form of eam in~,s Percent distribution of ever-married currently employed women by employer and background characteristics, Nepal 1996 form of earnings, according to selected Employed by non- Employed by Self-employed family member family member Does not Does not Does not Number Background Earns earn Earns cam Earns earn of characteristic cash cash cash cash cash cash Total women Ago 15-19 1.1 1.3 3.2 7.6 3.6 83.3 100.0 631 20-24 1.3 3.4 2.3 6.1 5.2 81.8 100.0 1,186 25-29 2.7 4.5 3.2 7.4 9.1 73.1 100.0 1,229 30-34 3.0 5.0 3.5 6.6 8.8 73.0 100.0 1,119 35-39 1.7 5.5 3.6 5.5 8.8 74.7 100.0 929 40-44 2.0 5.1 1.7 7.2 7.8 75.9 100.0 762 45-49 3.1 4.7 3.7 4.2 7.3 77.0 100.0 656 Residence Urban 9.4 0.8 7.5 0.6 36.4 45.3 100.0 348 Rural 1.8 4.5 2.8 6.8 5.8 78.3 100.0 6,165 Ecological region Mountain 0.6 6.2 2.1 1.9 3.5 85.6 100.0 557 Hill 1.5 6.1 2.4 1.3 7.0 81.6 100.0 3,146 Terai 3.2 1.9 3.9 13.1 8.6 69.1 100.0 2,810 Development region Eastern 4.1 3.4 2.7 7.9 9.1 72.5 100.0 1,497 Central 3.1 0.5 2.2 10.8 l l .0 72.4 100.O 1,904 Western 0.4 0.1 5.4 3.1 5.5 85.5 100.O 1,438 Mid-western 1.6 20.2 3.4 4.9 3.5 66.3 100.0 907 Far-western 0.0 4.6 0.9 0.8 3.5 90.3 100.0 766 Sub-region Eastern Mountain 1.7 1.7 1.7 2.4 7.8 84.5 100.0 122 Central Mountain 0.6 0.0 3.2 0.3 1.5 94.5 100.0 193 Western Mountain 0.0 13.4 1.5 3.0 3.0 79.0 100.0 242 Eastern Hill 1.2 4.1 0.0 2.0 3.3 89.0 100.0 541 Central Hill 3.6 0.8 1.3 1.4 15.0 77.9 100.0 825 Western Hill 0.4 0.0 5.1 0.6 7.0 86.9 100.0 966 Mid-western Hill 1.4 33.4 2.6 1.8 1.5 59.2 100.0 484 Far-western Hill 0.0 0.7 0.7 0.9 1.4 96.3 100.0 330 Eastern Terai 6.4 3.1 4.6 12.6 13.0 60.1 100.0 833 Central Terai 3.1 0.3 2.9 21.8 9.3 62.5 100.0 887 Western Terai 0.6 0.4 6.0 8.2 2.3 82.5 100.0 473 Mid-western Terai 2.3 6.9 5.4 9.2 6.9 69.2 100.0 320 Far-western Terai 0.0 0.2 0.4 0.8 5.8 92.8 100.0 298 Education No education 1.5 4.5 2.9 7.6 6.5 77.0 100.0 5,420 Primary 3.5 3.3 2.5 0.9 9.0 80.8 100.0 661 Some secondary 5.4 3.7 2.1 0.5 12.6 75.7 100.0 319 SLC and above 15.3 1.7 17.2 0.7 29.6 35.5 100.0 112 Literacy Literate 4.5 2.7 3.4 0.7 11.7 76.8 100.0 1,206 Illiterate 1.6 4.7 2.9 7.7 6.4 76.5 100.0 5,306 Total 2.2 4.3 3.0 6.4 7.4 76.6 100.0 6,513 Note: Percentages may not add to 100 because table excludes 7 women with missing information on current work status. 31 Table 2.15 Occuoation Percent distribution of ever-married currently employed women by type of agricultural land worked or type of non- agricultural employment, according to selected background characteristics, Nepal 1996 Agricultural Non-agricultural Prof./ Number tech./ of Background Own Family Rented Others manag./ Sales, Skilled Unskilled employed characteristic land land land land clericaP service manual manual Other Total women Age 15-19 35.1 42.1 5.7 11.2 0.2 1.0 3.3 1.3 0.0 100.0 631 20-24 47.2 29.3 6.7 8.9 1.6 2.6 2.3 1.3 0.1 100.0 1,186 25-29 50.5 lg.g 7.1 11.3 3.1 4.2 3.0 2.1 0.0 100.0 1,229 30-34 58.1 12.3 6.2 10.7 1.4 5.7 4.0 1.3 0.3 100.0 1,119 35-39 63.0 8.5 5.9 12.1 1.1 4.2 3.7 1.6 0.0 100.0 929 40-44 65.4 6.3 8.6 11.3 1.4 3.8 1.8 1.5 0.0 100.0 762 45-49 71.8 3.2 4.7 10.3 1.2 3.9 2.6 2.3 0.0 100.0 656 Residence Urban 26.7 7.3 7.8 5.6 12.3 18.9 16.7 4.7 0.0 100.0 348 Rural 57.0 17.9 6.4 11.0 1.0 2.9 2.2 1.4 0.1 100.0 6,165 Ecological region Mountain 68.3 19.1 3.9 4.3 0.8 2.5 0.9 0.0 0.1 100.0 557 Hill 63.7 18.8 3.3 3.8 1.8 3.6 4.0 1.0 0.0 100.0 3,146 Terai 43.5 15.4 10.6 19.9 1.5 4.2 2.3 2.5 0.2 100.0 2,810 Development region Eastern 52.3 12.7 10.3 13.8 0.8 4.4 2.9 2.7 0.1 100.0 1,497 Central 49.0 15.1 4.7 16.3 2.5 6.1 4.9 1.2 0.2 100.0 1,904 Western 60.2 20.9 3.0 6.6 1.8 2.9 3.0 1.7 0.0 lO0.O 1,438 Mid-western 57.2 20.3 9.2 7.8 1.1 2.0 l.l 1.3 0.0 lO0.O 907 Far-western 66.1 21.8 7.0 2.2 0.9 0.7 0.7 0.6 0.0 100.0 766 Sub-region Eastern Mountain 53.0 20.9 10.5 4.1 1.7 9.1 0.7 0.0 0.0 100.0 122 Central Mountain 74.4 19.5 0.6 3.8 0.0 0.9 0.6 0.0 0.3 100.0 193 Western Mountain 71.2 17.9 3.3 4.8 l.O 0.5 1.3 0.0 0.0 100.0 242 Eastern Hin 71.6 13.1 8.2 3.1 1.2 0.6 2.0 0.2 0.0 100.0 541 Central Hill 57.8 15.5 1.9 3.5 3.9 8.3 8.1 1.0 0.0 100.0 825 Western Hill 61.3 20.2 1,7 5.3 1.3 3.6 4.3 2.2 0.0 100.0 966 Mid-western Hill 67.2 24.5 1.3 3.4 0.9 1.6 0.7 0.3 0.0 100.0 484 Far-western Hill 67.4 23.9 6.4 1.6 0.2 0.0 0.5 0.0 0.0 lO0.O 330 Eastern Terai 39.6 I 1.3 I 1.7 22.3 0.4 6.1 3.8 4.7 0.2 100.0 833 Central Terai 35.4 13.8 8.1 30.9 1.7 5.1 2.9 1.7 0.3 100.0 887 Western Terai 57.8 22.2 5.8 9.2 2.8 1.5 0.1 0.6 0.0 100.0 473 Mid-western Terai 35.0 18.1 23.0 14,6 1.6 3.2 1.4 3.2 0.0 100.0 320 Far-western Terai 65.2 17.4 9.5 2.7 1.4 1.5 0.8 1.4 0.0 100.0 298 Education No education 57.5 15.8 7.2 12.4 0.4 2.7 2.2 1.6 0.1 100.0 5,420 Primary 49.9 26.2 4.4 4.0 1.0 6.0 6.3 2.0 0,3 100.0 661 Some secondary 44.7 25.7 1.3 1.1 5.7 12.2 8.6 0.8 0.0 100.0 319 SLC and above 15.2 14.8 0.0 0.0 47.5 18.0 4.5 0.0 0.0 100.0 l l2 Literacy Literate 48.1 24.2 3.1 2.1 6.6 8.5 6.5 0.7 0.1 100.0 1,206 Illiterate 57.0 15.8 7.3 12.7 0.4 2.7 2.2 1.8 0.1 100.0 5,306 Total 55.4 17.3 6.5 10.8 1.6 3.8 3.0 1.6 0.1 100.0 6,513 SLC = School Leaving Certificate t Professional, technical, managerial and clerical occupations. 32 As expected, rural women are more likely than urban women to be employed in the agricultural sector: 92 percent of rnral women compared with 47 percent of urban women. Nearly one-fifth of urban working women are in sales or services and 17 percent are in skilled manual occupations. Women living in the Mountain region are slightly more likely to be working in the agricultural sector than women in the Hill and Terai regions. One of five women living in the Central Hill sub-region is engaged in non-agricultural occupations. This is not surprising since Kathmandu, the capital and largest urban centre, is located there. Table 2.15 also shows that as women become more educated they seek employment in non-agricultural sectors. Among employed women who have passed their SLC, nearly half (48 percent) are in professional, technical, managerial, or clerical occupations and 18 percent are engaged in sales or services. Control Over Earnings Women earning cash for their work were asked who mainly decides how their earnings will be used. Table 2.16 shows that 42 percent of women report that they and their husband jointly decide how the money is to be spent and 39 percent state that it is their sole decision. Generally, younger women are less likely to make sole decisions on spending their earnings. Urban women, women who reside in the Hill region and women from the Central development region are also more likely than other women to make independent decisions on spending their earnings. While there is very little difference by education among women who make joint or independent decisions on how to spend their earnings, decisions by husbands alone decrease markedly as women's education increases. For example, 12 percent of women with no education stated that their husband decides how to spend their earnings, compared with only 3 percent of women who have completed their SLC. Child Care Information on who takes care of working women's young children under age six is presented in Table 2.17. S ixoftenemployedwomenhadat leastonechi ldundersixyearsofage. Itcan be seen from the table that besides respondents themselves, other relatives and older female children of the respondents are important care givers. Thirty-nine percent of working women who had at least one child under six reported that their child is cared for by other relatives, while 22 percent reported that they themselves care for their young child while working; another 22 percent stated that care is provided by other female children and 8 percent stated that other male children provide child care. Other child minders constitute less than 7 percent. Rural children are more likely than urban children to be looked after by other relatives and by older siblings. A sizeable percentage of urban women (10 percent) place their children in schools or institutions. Women living in the Terai region are also more likely than women living in the Mountain or Hill regions, to have other relatives look after their young children. Women with no education are more likely to use their own older children to look after their younger siblings in contrast to educated women who more often resort to institutional child care or care from other relatives. 33 Surprisingly, women engaged in non-agricultural occupations are more likely to look after their young children themselves than women engaged in agricultural occupations. This could presumably be due to the fact that women working in non-agricultural occupations often work in home-based settings, which are more conducive to looking after their own children. Women engaged in agricultural work are more likely to use other relatives or their older children as care givers. As expected, women who are only employed occasionally are more likely to look after their own children than women who work throughout the year on a part-time or full-time basis. Table 2.16 Decisions on use of earnings Percent distribution of ever-married employed women who receive cash earnings by person who decides how earnings will be used, according to selected background characteristics, Nepal 1996 Person who decides how earnings will be used Jointly Jointly with Number Background Self with Someone someone of characteristic only Husband husband else else Missing Total women Age 15-19 23,9 7.6 33.7 24,5 8.5 1.7 100.0 50 20-24 33.8 10.1 37.9 8.2 6.8 3.3 100.0 104 25-29 33.2 9.6 50.4 1.4 4.1 1.2 100,0 185 30-34 45.7 11.1 40.1 3.1 0.0 0.0 100.0 172 35-39 39.7 10.3 44.8 2.1 3.1 0.0 100.0 131 40-44 48,9 7.5 42.0 0.0 1.6 0.0 100.0 89 45-49 44.3 14.6 33,9 0.0 7.3 0.0 100.0 93 Marital status Currently married 33.1 11.6 47,3 4.0 3.1 0.9 100.0 731 Not married 88,0 0.0 0.0 2.4 9.5 0.0 100.0 93 Residence Urban 49.7 7.7 37,3 2.8 2,0 0.6 100.0 185 Rural 36.3 l l . l 43.4 4.1 4,3 0.8 100.0 639 Ecological region Mountain 32.7 4.8 57.2 0,0 5.3 0.0 100.0 35 Hill 44.0 9.0 38.1 4.5 3.1 1.3 100.0 344 Terai 36.2 11.7 43.9 3.6 4.2 0.4 100.0 445 Development region Eastern 37.1 11.3 43.1 3.8 4.3 0.4 100.0 241 Central 45.3 9.3 39.8 1.8 3.4 0.4 100.0 310 Western 41,1 7.1 40.3 7.5 1.9 2.1 100.0 163 Mid-western 22,0 19.4 47,5 5.8 4.3 1.1 100,0 77 Far-western 30.8 6.8 50.7 0.0 11,7 0.0 100.0 33 Education No education 37.2 11.9 43.2 3.4 3,7 0.5 100.0 591 Primary 44.7 9.6 36.5 5.8 1.2 2.3 100.0 99 Some secondary 47.7 4.7 35.1 3.5 7.3 1.6 100.0 64 SLC and above 42.2 2.5 45.8 4.4 5.1 0.0 100.0 69 Literacy Literate 45.8 5.9 39.2 4,8 3.5 0.9 100.0 239 Illiterate 36.7 12,1 43.2 3.4 3.9 0.7 100.0 585 Total 39,3 10.3 42.0 3.8 3.8 0.8 100.0 824 SLC = School Leaving Certificate Note: A breakdown by sub-region is not shown because the number of woman in several sub-regions is less than 25. 34 Table 2.17 Child care while workin~ Percent distribution of currently employed women by whether or not they have a child under six years of age and the percent distribution of employed mothers with a child under six by person who cares for child while mother is at work, according to background characteristics, Nepal 1996 Employed women Child's caretaker, among employed mothers who have children <6 years Child is One or in school/ Not Number No more Other Other Ser- institu- worked of Background child children Respon- female male Other Neighbor/ vant/ tional since employed characteristic < 6 <6 dent Husband child child relative friend help care birth Other Missing Total women t . , tt Residence Urban 47.8 52.2 31.9 2.1 9.7 4.4 34.3 1.4 0.9 10.3 0.0 0.6 4.4 100.0 348 Rural 40.6 59.4 21.9 1.4 22.1 7.7 39.3 1.5 0.1 1.9 1.9 1.3 0.9 100.0 6,165 Ecological region Mountain 36.2 63.8 27.7 2.0 20.9 9.2 32.1 2.8 0.0 1.2 1.1 2.5 0.5 100.0 557 Hill 40.1 59.9 26.4 1.5 20.1 6.4 37.3 1.7 0.1 3.4 1.6 1.2 0.4 100.0 3,146 Terai 42.9 57.1 16.4 1.4 23.4 8.6 42.6 0.9 0.2 1.4 2.1 1.1 1.9 100.0 2,810 Development Region Eastern 44.3 55.7 24.9 1.7 23.5 7.4 34.0 1.1 0.3 0.8 1.9 2.5 1.9 100.0 1,497 Central 42.4 57.6 22.1 1.4 21.6 9.0 39.4 1.4 0.0 2.1 1.7 0.6 0.8 100.0 1,904 Western 41.7 58.3 19.6 0.6 20.0 6.0 44.6 0.9 0.0 3.3 3.2 1.1 0.7 100.0 1,438 Mid-western 32.4 67.6 25.0 1.5 22.6 8.1 35.2 1.8 0.4 3.4 0.5 1.2 0.5 100.0 907 Far-western 40.0 60.0 19.8 2.9 19.4 6.7 42.2 2.8 0.0 2.5 1.2 1.4 1.3 100.0 766 Sub-reginn Eastern Mountain 40.5 59.5 36.9 0.0 19.9 9.1 31.2 1.1 0.0 1.1 0.0 0.6 0.0 100.0 122 Central Mountain 36.3 63.7 37.9 1.4 16.4 7.3 28.3 1.4 0.0 2.3 2.3 2.3 0.5 100.0 193 Western Mountain 33.8 66.2 15.6 3.4 24.8 10.7 35.5 4.6 0.0 0.4 0.8 3.4 0.8 100.0 242 Eastern Hill 38.6 61.4 33.6 1.0 23.9 7.0 29.2 1.7 0.0 0.7 1.0 1.7 0.3 100.0 541 Central Hill 41.8 58.2 23.6 1.6 17.6 7.6 40.6 2.5 0.0 4.0 1.4 0.5 0.5 100.0 825 Western Hill 42.2 57.8 21.7 0.6 17.5 3.7 45.4 1.2 0.0 4.7 3.1 1.6 0.4 100.0 966 Mid-western Hill 32.7 67.3 31.4 1.7 25.6 8.7 24.3 1.5 0.3 3.9 0.6 1.8 0.3 100.0 484 Far-western Hill 43.4 56.6 26.0 4.1 18.3 5.7 41.5 1.2 0.0 1.6 0.8 0.4 0.4 100.0 330 Eastern Terai 48.5 51.5 16.2 2.5 23.8 7.4 38.2 0.7 0.6 0.8 2.9 3.5 3.3 100.0 833 Central Terai 44.3 55.7 16.7 1.1 26.8 10.6 41.0 0.3 0.0 0.2 1.8 0.3 1.2 100.0 887 Western Terai 40.6 59.4 15.4 0.7 24.9 10.4 43.0 0.3 0.0 0.6 3.4 0.0 1.3 100.0 473 Mid-western Terai 31.4 68.6 17.7 0.8 17.3 7.5 49.2 1.6 0.7 3.7 0.4 0.8 0.4 100.0 320 Far-western Terai 39.2 60.8 16.3 l.l lg.0 4.3 48.8 3.1 0.0 4.3 1.4 0.0 2.9 100.0 298 Continued Table 2.17 - - Continued Employed women Child's caretaker, among employed mothers who have children <6 years Child is One or in school/ Not Number No more Other Other Ser- inslitu- worked of Background child children Respon- female male Other Neighbor/ vant/ tional since employed characteristic < 6 <6 dent Husband child child rel~ive friend help care birth Other Missing Total women L~ Education No education 41.2 58.8 22.2 1.6 24.5 8.6 35.8 1.5 0.1 2.0 1.4 1.4 1.0 100.0 5,420 Primary 39.0 61.0 22.3 0.6 8.4 3.6 54.5 2.2 0.4 2.2 3.5 0.9 1.2 100.0 661 Some secondary 41.3 58.7 23.5 0.6 5.3 1.3 57.5 0.0 0.0 6.4 3.8 1.2 0.4 100.0 319 SLC and above 40.3 59.7 25.0 1. I 5.6 0.0 48.9 0.0 2.4 6.3 5.4 0.0 5.3 100.O 112 Literacy Illiterate 40.9 59.1 22.5 1.6 24.5 8.8 35.7 1.3 0.1 1.8 1.4 1.4 0.9 100.0 5,306 Literate 41.4 58.6 21.7 0.9 8.7 2.0 54.0 2.0 0.2 4.6 3.3 1.1 1.4 100.0 1,206 Employer Self-employed 38.6 61.4 33.8 2.9 29.6 10.0 12.4 1.7 1.6 4.1 0.0 2.2 1.7 100.0 421 Family member 41.0 59.0 22.7 1.3 19.8 6.6 41.6 1.5 0.0 2.4 1.9 1.2 1.0 100.0 5,470 Somenne else 42.6 57.4 10.9 1.6 31.4 14.7 35.0 1.0 0.0 0.5 2.4 2.0 0.6 100.0 617 Occupation Agricultural 39.9 60.1 20.6 1.4 22.3 7.7 40.5 1.5 0.1 1.8 1.9 1.4 0.9 100.0 5,861 Non-agricultural 50.7 49.3 42.0 2.8 13.2 6.0 22.7 0.9 0.5 8.0 0.8 0.4 2.7 100.0 646 Employment status All year, full-time 41.6 58.4 23. I 1.4 20.7 7.5 39.3 1.6 0.2 2.2 1.3 1.8 0.9 100.0 2,695 All year, part-time 41.2 58.8 20.6 0.7 27.7 3.7 37.5 2.1 0.0 4.8 0.5 1.2 1.1 100.0 233 Seasonal 40.3 59.7 21.4 1.5 22.0 7.8 39.2 1.4 0.0 2.2 2.2 1.0 1.2 100.0 3,427 Occasional 45.5 54.5 33.8 1.8 16.1 9.1 31.9 0.0 1.8 2.2 2.9 0.0 0.5 100.0 158 Total 41.0 59.0 22.3 1.5 21.6 7.6 39.0 1.5 0.1 2.3 1.8 1.3 1.0 100.0 6,513 Note: Total includes 4 women with employer missing and 5 women with occupation missing. SLC = School Leaving Certificate CHAPTER 3 FERTIL ITY A major objective of the 1996 NFHS is to examine fertility levels, trends, and differentials in Nepal. This is important in view of the Government's policy to reduce the total fertility rate to 4.0 by the year 2000 and bring a balance between population growth and economic development. In order to meet this objective, ever-married women age 15-49 were asked about their pregnancy histories. Each woman was asked to provide information on the number of sons and daughters living with her, the number of sons and daughters living elsewhere, the number of sons and daughters who died, and the number of pregnancies she had had that did not result in a live birth. The woman was then asked to provide a complete pregnancy history including information such as the month and year of all live and non-live births, sex of live births, and survival status. The structure of these questions is designed to improve the completeness and accuracy of the information. This chapter examines current fertility, differ- entials and trends in fertility, and cumulative fertility in Nepal. The chapter also examines the length of birth intervals, age at first birth, and childbearing among adolescents. As is standard practice, the analyses of fertility presented here are based only on live births. The 1996 NFHS obtained reproductive histories only from ever-married women. It is assumed that births outside marriage are negligible in Nepal and, therefore, that the pregnancies experienced by ever-married women are representative of all pregnancies. 3.1 Current Fertility The level of current fertility is one of the most important indicators for health and family planning policy-makers and professionals in Nepal. Table 3.1 presents age-specific fertility rates (ASFR) ~, the total fertility rate (TFR) for women age 15-49 and 15-44, the general fertility rate (GFR), and the crude birth rate (CBR) by residence. All these rates pertain to the three- year period preceding the survey. The TFR is the sum of the ASFRs and can be interpreted as the number of children a woman would have by the end of her Table 3.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-rural residence, Nepal 1996 Residence Age group Urban Rural Total 15-19 101 129 127 20-24 211 271 266 25-29 141 239 229 30-34 59 171 160 35-39 34 100 94 40-44 25 38 37 45-49 0 16 15 TFR women 15-49 2.85 4.83 4.64 TFR women 15-44 2.85 4.75 4.57 General fertility rate 114 172 167 Crude birth rate 27 38 37 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. Total fertility rate (TFR) expressed per woman. General fertility rate (births divided by number of women 15- 44), expressed per 1,000 women. Crude birth rate expressed per 1,000 population. INumemtors of the ASFRs are calculated as the total number of live births that occurred in the period 1-36 months preceding the survey (determined by the date of interview and the date of birth of the child), and classified by the age (in five- year age groups) of the mother at the time of the birth (determined by the mother's date of birth). The denominators of the rates are the number of woman-years lived in each of the five-year age groups during the 1-36 months preceding the survey. Since only ever-married women were interviewed in the NFHS the number of women in the denominators of the rates was inflated by factors calculated from information in the Household Questionnaire on proportions ever-married in order to produce a count of all women. An implicit assumption in this calculation is that never-married women have not given birth. 37 childbearing career if she experienced the prevailing ASFRs. The GFR is defined as the total annual number of births per 1,000 women age 15-44 and the CBR is defined as the total number of live births in a year per 1,000 persons. The TFR for Nepalese women age 15-49 years is 4.6 births per woman. However, the TFR for urban areas (2.9) is about 2 children less than for rural areas (4.8). The age pattern of fertility indicates that Nepalese women have high fertility in the early part of the childbearing period. At the current ASFRs, a woman in Nepal will have given birth to 2 children by age 25 and to 3 children--i.e., two-thirds of her lifetime births--by age 30. The ASFRs in both urban and rural areas peak at ages 20-24. In urban areas, fertility rates decline very rapidly after age 30, whereas in rural areas the fertility decline by age is more gradual. The ASFRs are consistently lower in urban areas compared with rural areas. Table 3.2 Fertility bv background characteristics Total fertility rate for the three years preceding the survey, percentage currently pregnant and mean number of children ever born to woman age 40-49, by selected background characteristics, Nepal 1996 Mean number of children Total ever born Background fertility Currently to women characteristic rate ~ pregnant age 40-49 Residence Urban 2.85 5.7 4.64 Rural 4.83 7.8 5.78 Ecological region Mountain 5.60 8.2 6.17 Hill 4.50 7.0 5.58 Terai 4.64 8.1 5.74 Development region Eastern 4.11 6.7 5.40 Central 4.56 7.8 5.52 Western 4.66 7.3 5.48 Mid-western 5.47 9.2 6.58 Far-western 5.19 8.0 6.15 Education No education 5.08 8.3 5.80 Primary 3.78 7.0 5.30 Secondary+ 2.51 4.6 3.70 Total I Women age 15-49 years 4.64 7.6 5.70 The GFRs for urban areas, rural areas and for all of Nepal were 114, 172 and 167 per 1,000 women age 15-44, respectively. The CBR for the three-year period before the survey was 37 per 1,000 persons. Both these summary rates also indicate higher fertility in rural than in urban areas. Fertility Differentials and Trends Table 3.2 summarizes the current level of fertility by area of residence, ecological region, development region, and education. The TFR in the Terai region (4.6) is similar to that observed in the Hill region (4.5) while the TFR in the Mountain region (5.6) is around one child higher. Within the development regions the Eastern region has the lowest TFR (4.1), while the highest TFR is observed in the Mid-western region (5.5). There is a strong association between fertility and education. Women with at least some secondary education have a TFR of 2.5, which is half the rate among women with no education (5.1). The percentage of women who reported themselves as currently pregnant is also given in Table 3.2. This percentage is known for being underreported, since women in the early stages of pregnancy may not be aware that they are pregnant and because some women may not want to reveal that they are pregnant. However, as can be seen in the table, the percentage of women who are pregnant is generally consistent with current fertility for each major population subgroup in that the group with the highest fertility also tends to have the highest percentage of women currently pregnant. 38 Table 3.3 Trends in fertility Age-specific fertility rates (per 1,000 women) and total fertility rates, Nepal 1976-96 Age NFS NCPS NFFS NFHS NFHS group 1976 j 19812 19863 19914 1996 15-19 145 94 50 98 132 20-24 290 248 216 280 266 25-29 295 253 203 245 237 30-34 269 197 152 187 154 35-39 169 160 124 129 87 40-44 75 67 66 60 31 45-49 23 34 19 19 12 TFR 6.33 5.27 4.14 5.09 4.60 Note: Rates are for the 12 months preceding the survey. These rates are subject to larger sampling errors than rates for the three years preceding the survey. For example, the sampling error for the 1996 NFHS one-year rate is 0.133 yielding a confidence interval of 4.33-4.89, whereas, the sampling error for the three-year rate of 4.64 is 0.095 yielding a confidence interval of 4.45-4.83. A reanalysis of the data for the three years preceding the survey yields a TFR of 5.11 for 1986 and 4.79 for 1991 (Pradhan, 1995:32). i Goldman et al., 1979:21 Ministry of Health and Westinghouse Health Systems, 1983:221 3 Ministry of Health, 1987:186 4 Ministry of Health, 1993:58 Table 3.4 Ace- snecific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age, Nepal 1996 Number of years preceding the survey Mother's age 0-4 5-9 10-14 15-19 15-19 131 156 158 147 20-24 271 294 301 302 25-29 230 262 287 297 30-34 164 193 233 [264] 35-39 102 125 [193] 40-44 39 [59] 45-49 [14] Note: Age-specific fertility rates per 1,000 women. Esti- mates enclosed in brackets are truncated. Table 3.2 also presents the average number of children ever born to women age 40-49, which is a measure of the average lifetime fertility experience of surviving women age 40-49 years (completed fertility). Although this measure is susceptible to omission of children born to older women, comparison of completed fertility among women age 40-49 years with the current TFR indicates fertility decline for all major subgroups of the population. Overall, the results in Table 3.2 suggest that there has been a decline of about 20 percent in fertility levels during the past 20-25 years. Both the current and lifetime fertility indicate that fertility is lower in urban areas and among the more educated. This may suggest that these women are relatively more exposed to media messages about the benefits of smaller families and may also have better knowledge and access to means of fertility regulation. A comparison of direct estimates of the TFR obtained from four earlier surveys in Nepal with the TFR obtained from the 1996 NFHS also indicates a steady decline in fertility from 6.3 births per woman in 1975-76 to 4.6 births per woman for the period 1995-96 (Table 3.3). The TFR estimated for 1985-86 is very low, but this is indicative of data quality problems in the 1986 survey rather than of a true drop in fertility at that time. The pattern of age-specific fertility rates before 1981 indicates that women in Nepal had high fertility at 20-34 years of age with a peak at ages 25-29. From 1986 onwards an earlier peak in fertility at 20-24 years has emerged (Figure 3.1). The decline in fertility atter age 34 is quite marked between 1986 and 1996, which indicates some fertility limiting behaviour among Nepalese women. Fertility trends have to be interpreted within the context of data quality and sample size. A discussion of these issues in relation to earlier surveys is beyond the scope of this report. As such the fertility trend shown in Table 3.3 and Figure 3.1 has to be interpreted with caution. Information from birth histories in the 1996 NFHS allows the calculation of ASFRs for specified periods before the survey, which in turn provide further evidence of recent fertility decline. However, in situations in which the location of births in time may not be reported correctly, trends in fertility could be distorted. Furthermore, ASFRs are progressively truncated as one moves into the past. Nevertheless, the results presented in Table 3.4 indicate a 14 percent decline in fertility among women age 15-29, from 3.7 births per women during the period 15-19 years 39 400 Figure 3.1 Age-specific Fertility Rates Nepal 1976-1996 Births per 1,000 Women 2O0 100 O 15-19 20~24 25~29 30~34 35-39 Age I-s-1976 ~-1981 "~1986 "~1991 ~1996! 40~4 45-49 Nepal 1996 Table 3.5 Fertility rates bv marital duration Fertility rates for ever-married women by number of years since first marriage, for five-year periods preceding the survey, Nepal 1996 Year since Number of years preceding the survey first marriage 0-4 5-9 10-14 15-19 0-4 293 290 268 235 5-9 277 304 320 318 10-14 214 242 282 298 15-19 144 185 229 [282] 20-24 90 117 [199] 25-29 39 [79] Note: Fertility rates per 1,000 women. Estimates enclosed in brackets are truncated. before the survey to 3.2 births per women during the period 0-4 years preceding the survey. The ASFRs suggest that most of the fertility decline among younger women (15- 29) occurred during the five years preceding the survey. An 11 percent decline in fertility among women age 15-29 took place between 5-9 and 0-4 years before the survey versus only a 5 percent decline between 10-14 and 5-9 years before the survey. Fertility rates for ever-married women by duration since first marriage for five-year periods before the survey are presented in Table 3.5. These rates suggest that fertility is decreasing among women at all marriage durations except 0-4 years. In the ten-year period before the survey, the fertility rate among women who had been married for 5-9 years declined by 9 percent, whereas among women who had been married for 20-24 years the corresponding decline was 23 percent. The increase in fertility observed among women who have been married for 0-4 years may be due to an increase in age at marriage, resulting in a smaller proportion of pre-pubertal women being married. 3.2 Pregnancy Outcomes The NFHS collected complete pregnancy histories from women and therefore provides information on pregnancy outcome. It is important to note that collecting pregnancy histories is comparatively more difficult 40 than collecting birth histories retrospectively, particularly regarding information on pregnancies which were wasted spontaneously within the first few months after conception. Therefore, the total number of pregnancies and abortions are likely to be underestimated and caution should be exercised while interpreting these data. Stillbirths are probably more completely reported than abortions. Table 3.6 presents the pregnancy outcomes of ever-married women 0-9 years before the survey by age of the mother and urban-rural residence. Overall, 7 percent of all pregnancies 0-9 years before the survey did Table 3.6 Pre~nancv outcome Among ever-married women, percent distribution of all pregnancies 0-9 years preceding the survey by pregnancy outcome, according to age of the woman and residence, Nepal 1996 Pregnancy outcome Age at pregnancy Spontaneous Induced outcome abortion abortion Number Still Live of birth birth Total pregnancies URBAN' 15-19 4.1 1.3 2.3 92.4 100.0 398 20-24 3.6 2.3 1.4 92.7 100.0 598 25-29 2.4 1.9 4.6 91.1 100.0 317 30-34 5.0 4.3 0.9 89.9 100.0 119 35-39 7.9 1.1 3.3 87.7 100.0 54 Total 3.8 2.0 2.3 91.8 100.0 1,498 RURAL 15-19 5.1 0.4 2.1 92.4 100.0 5,179 20-24 4.2 0.2 1.6 94.1 100.0 7,888 25-29 4.4 0.4 1.7 93.5 100.0 5,164 30-34 5.8 0.3 2.0 91.9 100.0 2,906 35-39 8.6 0.3 2.6 88.5 100.0 1,260 40-44 8.3 0.g 3.7 87.2 100.0 304 45-49 10.1 0.0 4.7 85.2 100.0 26 Total 5.0 0.3 1.9 92.9 100.0 22,726 TOTAL 15-19 5.0 0.5 2.1 92.4 100.0 5,577 20-24 4.1 0.3 1.6 94.0 100.0 8,486 25-29 4.3 0.5 1.9 93.3 100.0 5,481 30-34 5.8 0.4 2.0 91.8 100.0 3,025 35-39 8.6 0.4 2.6 88.4 100.0 1,314 40-44 8.6 0.8 3.5 87.1 100.0 316 45-49 10.1 0.0 4.7 85.2 100.0 26 Total 4.9 0.4 1.9 92.8 100.0 24,224 1 Pregnancy outcomes for age groups 40-44 and 45-49 are not shown because they are based on less than 25 pregnancies. not end in a live birth: 4.9 percent were spontaneous abortions, 0.4 percent were induced abortions, and 1.9 percent were stillbirths. There is little variation in pregnancy outcomes across age groups, although older women (30 and above) are slightly more likely to have a pregnancy resulting in a non-live birth. Similar patterns are observed in urban and rural areas; however, urban women are more likely to report having had an induced abortion than rural women, and rural women are slightly more likely than urban women to report a spontaneous abortion. 3.3 Children Ever Born and Living Table 3.7 presents the distribution of all women and of currently married women by age and number of children ever born (CEB), and the mean number of living children by age. Experience suggests that, even among high fertility and illiterate populations where omission is evident, it is most likely to occur amongst the oldest women for early births (Arnold, 1990). Lifetime fertility reflects the accumulation of births over the past 30 years and, therefore, its relevance to the current situation is limited; nevertheless, information on the mean number of children ever born is useful in examining the variation among different age groups. The mean number of children ever born for all women is 2.9, which means that, on average, Nepalese women age 15- 49 have had just under 3 births, while currently married women in Nepal have on average 3.4 births. Allowing for child 41 mortality, Nepalese women have on average 2.3 living children, while currently married women have an average of 2.8 living children. In contrast, currently married women age 45-49 have given birth to an average of just over 6 children, o f whom 4.5 survived. Therefore, currently married women at the end of their reproductive careers lost 26 percent of their children due to mortality. The distribution of children ever born by age shows that early childbearing is still quite common in Nepal; 43 percent of currently married women and 19 percent of all women age 15-19 have already had at least one birth. Voluntary childlessness is rare in Nepal and currently married women with no live births are likely to be those who are unable to bear children. The level of childlessness among married women at the end of their reproductive careers (age 45-49) can therefore be used as an indicator of the level of primary sterility. In Nepal, primary sterility among currently married women age 45-49 is 3 percent. Less than 2 percent of married women age 35-44 have never given birth, which may indicate some decline in primary sterility. However, this pattern may be due to poorer reporting among women age 45-49. Table 3.7 Children ever born and livin~ Percent distribution of all women and of currently married women by number of children ever born (CEB) and mean number ever born and living, according to five-year age groups, Nepal 1996 Mean Mean number Number of children ever born Number number of Age of of living group 0 1 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN 15-19 81.3 14.9 3.5 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,229 0.23 0.21 20-24 26.9 26.7 27.7 14.3 3.8 0.6 0.0 0.0 0.0 0.0 0.0 100.0 1,909 1.43 1.27 25-29 8.8 9.0 23.1 26.3 19.1 9.9 2.6 0.8 0.3 0.1 0.0 100.0 1,671 2.85 2.48 30-34 5.0 4.3 12.2 19.7 21.9 17.2 11.2 5.2 2.8 0.5 0.1 100.0 1,387 3.92 3.27 35-39 3.2 3.4 8.4 15.8 18.7 15.0 16.1 9.8 4.5 3.0 2.1 100.0 1,136 4.67 3.80 40-44 3.0 2.8 5.9 8.5 13.4 16.1 14.1 13.9 9.5 6.6 6.2 100.0 933 5.57 4.29 45-49 4.3 2.8 4.6 8.7 10.1 13.2 14.9 12.8 12.2 7.6 8.8 100.0 836 5.84 4.30 Total 26.2 11.3 13.4 13.1 11.1 8.4 6.3 4.3 2.8 1.7 1.5 100.0 10,101 2.85 2.32 CURRENTLY MARRIED WOMEN 15-19 57.3 34.1 8.1 0.5 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 965 0.52 0.47 20-24 13.9 31.2 32.7 17.0 4.5 0.7 0.0 0.0 0.0 0.0 0.0 100.0 1,602 1.69 1.51 25-29 4.3 8.9 24.1 27.7 20.3 10.6 2.7 0.9 0.3 0.2 0.0 100.0 1,560 3.01 2.62 30-34 2.7 3.6 12.4 19.8 22.7 18.3 11.7 5.4 3.0 0.5 0.1 100.0 1,292 4.07 3.40 35-39 1.2 2.9 8.1 15.4 19.0 15.7 16.9 10.5 4.9 3.2 2.3 100.0 1,042 4.86 3.97 40-44 1.6 2.0 5.7 8.2 13.0 16.3 14.9 14.1 10.5 7.1 6.8 100.0 828 5.79 4.47 45-49 2.8 2.5 3.4 7.5 10.3 13.4 16.0 13.3 13.3 8.5 9.1 100.0 695 6.09 4.51 Total 11.5 13.5 16.2 15.6 13.3 10.1 7.6 5.0 3.4 2.0 1.8 100.0 7,982 3.41 2.80 42 3.4 Bir th Intervals Short birth intervals are associated with an increased risk of death for mother and child. This is particularly true for babies born less than 24 months since the previous birth. Table 3.8 presents the percent distribution of births in the five years preceding the survey by the number of months since the previous birth according to selected background characteristics. Three of four non-first births occurred at least 2 years after the previous birth and the median birth interval is 32 months. The long period of breastfeeding in Nepal, which is an average of 28 months (see chapter 9), and the corresponding long period of postpartum amenorrhoea, which is an average of 13 months (see chapter 5), are likely to contribute to the relatively low percentage of births occurring after an interval of less than 24 months. The median birth interval increases with the age of the mother from 26 months among births to mothers age 15-19 to 41 months among births to mothers age 40 or more. The relatively high prevalence of short birth intervals among births to younger women may indicate that women generally want to complete their desired family size quickly. The survival status of the previous birth is strongly associated with the length of the preceding birth interval. The median birth interval is more than 6 months shorter for children whose previous sibling died compared with children whose previous sibling survived. Twenty-four percent of children whose preceding sibling died are born after an interval of less than 18 months, compared with only 7 percent among children whose preceding sibling survived. Over 40 percent of children whose preceding sibling died are born within 2 years of the previous birth, compared with 21 percent of those whose preceding sibling survived. The median birth interval decreases with increased education. Births to women with no education have a median preceding birth interval of 33 months, which decreases to 30 months among births to women with some primary education. The median birth interval decreases further to 29 months for births to women with some secondary education. There is relatively little variation in the median duration of birth intervals for other characteristics examined in Table 3.8. 3.5 Age at First Birth Age at onset of childbearing is an important demographic indicator since early childbearing adversely affects the health of mother and child. Furthermore, in many countries, postponement of first births, reflecting an increase in age at marriage, has made a large contribution to overall fertility decline. The proportion of women who become mothers before age 20 is a measure of the magnitude of adolescent fertility, which is a major health and social problem in many countries. However, in Nepal adolescent childbearing takes place mostly within marriage. Table 3.9 presents the distribution of women by age at first birth. The median age at first birth is not presented for the cohort of women born 15-19 years before the survey because fewer than 50 percent had had a birth by the time of the survey. The median age at first birth is around 20 years across all age cohorts, indicating virtually no change in the age at first birth. In every cohort, except the cohort born 35-39 years before the survey, at least 50 percent of women had their first birth before reaching age 20. The highest percentage of women who began childbearing in their teens is observed in the cohort of women who are currently 25-29 years of age (57 percent). 43 Percent distribution of births in the five years preceding the survey by number of months since previous birth, according to demographic and socio-eeonomic characteristics, Nepal 1996 Number of months since previous birth Characteristic 7-17 18-23 24-35 36-47 48+ Total Median Number number of of months since births previous birth Age of mother 15-19 21.0 20.3 47.2 9.8 1.7 100.0 88 25.7 20-29 10.5 17.0 40.4 21.0 11.2 100.0 3,062 30.0 30-39 8.0 12.0 32.5 24.9 22.5 100.0 2,019 34.7 40 + 5.8 9.5 23.7 25.3 35.7 100.0 426 40.9 Birth order 2-3 10.1 16.6 35.9 21.4 16.0 100.0 2,758 31.4 4-6 8.0 12.4 38.4 23.2 18.0 100.0 2,090 32.4 7 + 10.5 13.8 32.6 25.0 18.0 100.0 747 32.9 Sex of prior birth Male 9.0 13.5 35.9 24.2 17.5 I00.0 2,768 33.0 Female 9.8 15.8 36.9 21.0 16.5 100.0 2,827 31.1 Survival of prior birth Living 6.8 14.5 37.6 23.4 17.8 100.0 4,779 32.7 Dead 24.4 15.8 29.5 17.9 12.4 100.0 816 26.4 Residence Urban 8.8 15.7 33.3 19.5 22.6 100.0 316 33.3 Rural 9.4 14.6 36.6 22.7 16.7 100.0 5,279 31.9 Ecological region Mountain 11.4 14.1 34.1 22.5 17.9 100.0 464 31.8 Hill 8.5 14.5 36.4 21.9 18.7 100.0 2,375 32.6 Terai 9.8 14.9 36.8 23.1 15.4 100.0 2,756 31.4 Development region Eastern 11.2 15.3 35.6 22.6 15.2 100.0 1,177 31.3 Central 9.0 13.7 36.7 22.9 17.8 100.0 1,824 32.6 Western 7.6 14.9 35.4 22.7 19.4 100.0 1,075 32.7 Mid-western 10.5 14.2 37.4 21.6 16.3 100.0 925 31.4 Far-western 8.4 16.6 37.3 22.8 14.9 100.0 594 31.3 Education No education 9.1 14.3 35.5 23.2 17.8 100.0 4,753 32.5 Primary 10.5 15.4 42.2 19.0 13.0 100.0 537 30.0 Secondary+ 11.5 18.6 40.1 18.4 11.4 100.0 305 29.3 Total 9.4 14.7 36.4 22.6 17.0 100.0 5,595 32.0 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 44 Table 3.9 A~e at first birth Percent distribution of women 15-49 by age at first birth, according to current age, Nepal 1996 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 Current age 15-19 81.3 0.9 12.4 5.3 NA NA NA 100.0 2,229 a 20-24 26.9 1.9 24.3 25.4 16.3 5.3 NA 100.0 1,909 19.9 25-29 8.8 3.0 27.5 26.7 18.2 13.0 2.8 100.0 1,671 19.4 30-34 5.0 2.3 25.8 24.8 20.3 14.0 7.8 100.0 1,387 19.7 35-39 3.2 2.0 22.4 24.0 20.3 17.3 10.8 100.0 1,136 20.1 40-44 3.0 3.4 25.9 23.8 21.2 13.5 9.1 100.0 933 19.8 45-49 4.3 3.0 25.5 21.5 19.0 13.7 12.9 100.0 836 20.0 NA -- Not applicable a Less than 50 percent of the women in the age group 15-19 have had a birth by age 15. Table 3.10 summarizes the median age at first birth for different cohorts and compares age at entry into motherhood for selected subgroups of the population. Rural and urban women age 25-49 have an identical median age at first birth (19.8 years). But among the younger cohorts (under 30) urban women have a later median age at first birth than rural women. In all cohorts, women in the Mountain and Hill regions have a higher median age at first birth than their Terai counterparts. Overall, there is little difference in the median age at first birth among the development regions. However, younger women (age 25-29) in the Mid-western and Far-westeru development regions have the lowest median age at first birth. Women with some secondary education generally have a higher median age at first birth than women with some primary education or women with no education. 3.6 Adolescent Fertility Adolescent fertility is a major social and health concern. Teenage mothers are more likely to suffer from severe complications during pregnancy and childbirth which can be detrimental to the health and survival of both mother and child. Table 3.11 presents the percentage of women aged 15-19 who are mothers or who are pregnant with their first child by selected background characteristics. Overall, 24 percent of adolescent women age 15-19 are already mothers or are pregnant with their first child. The proportion of teenage women who have started childbearing increases with age from 3 percent among women age 15 to 51 percent among women age 19. The practice of early marriage (almost 44 percent of women age 15-19 are already married (see Chapter 5)) is the major factor accounting for the relatively high proportion of teenagers who have begun childbearing, particularly in their late teens. The low level of early teenage childbearing is largely due to the low proportion of young teenagers who are currently married and partly due to adolescent subfecundity. In Nepal, almost a quarter of rural adolescents have begun childbearing, compared with one-fitth of their urban counterparts. Only 17 percent of adolescents living in the Hills have begun childbearing, compared with 20 percent in the Mountains and 31 percent in the Terai areas. Regionally, the highest level of adolescent childbearing is observed in the Central development region while the lowest is found in the Western development region. The proportion of adolescents who have begun childbearing declines with increasing education from 32 percent among those with no education to 10 percent among those with some secondary education. 45 Table 3.10 Median a~e at first birth Median age at first birth among women 20-49, by current age and selected background characteristics, Nepal 1996 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 21.5 20.1 19.6 19.7 19.9 19.2 20.2 19.8 Rural 19.8 19.3 19.8 20.2 19.7 20.0 19.8 19.8 Ecological Region Mountain a 20.2 20.8 21.3 20.9 22.1 a 20.9 Hill a 20.0 20.4 20.6 20.4 20.5 a 20.4 Terai 19.2 18.7 19.0 19.5 18.9 19.1 19.1 19.0 Development Region Eastern a 20.3 20.2 20.8 19.9 20.6 a 20.3 Central 19.4 19.2 19.5 20.2 19.6 19.4 19.5 19.6 Western 20.0 19.6 19.7 19.9 19.9 20.3 19.9 19.8 Mid-western 19.5 18.7 19.9 19.9 19.6 20.4 19.5 19.5 Far-western 19.0 18.8 19.2 19.4 19.6 20.1 19.3 19.3 Education No education 19.3 19.0 19.6 20.1 19.7 20.1 19.6 19,6 Primary 19.6 19.5 19.9 20.3 19.6 19.4 19.7 19.7 Secondary+ a 21.6 21.8 21.3 21.7 18.5 a 21.5 Total 19.9 19.4 19.7 20.1 19.8 20.0 19.8 19.8 Note: The median for cohorts 15-19 could not be determined because some women may still have a birth before reaching age 20. a Medians were not calculated for these cohorts because less than 50 percent of women in the age group x to x+4 had a birth by age x. Tab le 3 .12 presents the d istr ibut ion o f adolescents by number o f ch i ldren ever born. A lmost one o f f ive teenage women in Nepa l has at least one child: 15 percent have one chi ld and 4 percent have two or more chi ldren. As a l ready noted, teenage motherhood increases wi th age. The proport ion o f teenage women who have two or more ch i ld ren is neg l ig ib le unti l age 18 and then increases substant ia l ly to 12 percent among women age 19. 46 Table 3.11 Adolescent areanancv and motherhood Percentage of women 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Nepal 1996 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of characteristic Mothers child bearing women Age 15 1.1 2.1 3.2 485 16 6.4 5.4 11.8 469 17 15.0 7.8 22.8 428 18 31.2 4.8 36.0 449 19 44.1 6.6 50.7 399 Residence Urban 15.5 4.2 19.7 173 Rural 18.9 5.3 24.3 2,054 Ecological Region Mountain 14.8 5.6 20.4 148 Hill 13.1 3.9 16.9 1,036 Terai 24.6 6.5 31.1 1,052 Development Region Eastern 15.3 4.5 19.8 537 Central 22.2 6.2 28.5 725 Western 15.5 3.3 18.8 457 Mid-western 19.5 7.6 27.0 297 Far-western 20.3 4.7 25.1 217 Education No education 25.0 6.8 31.8 1,123 Primary 17.2 5.1 22.3 497 Secondary+ 7.3 2.3 9.6 672 Total 18.7 5.3 23.9 2,229 Note: Numbers may not add to total due to slight differences in the factors used to inflate the number of ever-married women. Table 3.12 Children born to adolescents Percent distribution of women 15-19 by number of children ever born (CEB), Nepal 1996 Number of Mean children ever born number Number of of 0 1 2+ Total CEB women Age 15 98.9 1.1 0.0 100.0 0.01 485 16 93.6 5.3 1.1 100.0 0.08 469 17 85.0 13.3 1.8 100.0 0.17 428 18 68.8 26.5 4.7 100.0 0.36 449 19 55.9 31.7 12.4 100.0 0.57 399 Total 81.3 14.9 3.7 100.0 0.23 2,229 47 CHAPTER 4 KNOWLEDGE, USE AND ATTITUDES TOWARD FAMILY PLANNING Although information about family planning in Nepal was disseminated as early as 1958 by the Family Planning Association of Nepal (FPAN), family planning services became available only in 1968 with the implementation of the Third Five-Year Plan. Since then, the Nepalese Government has been actively involved in providing family planning services, which have become an integral part of the country's health services. This chapter presents a number of indicators from the 1996 Nepal Family Health Survey (NFHS) pertaining to knowledge and use of family planning, women's attitudes towards family planning, sources of family planning, and exposure to media messages about family planning. This information is of particular interest to policy- makers, programme managers, and researchers in population and family planning. 4.1 Knowledge of Contraception In the NFHS respondents' knowledge of contraception was assessed in two ways. Respondents were first asked to name all the methods of contraception they knew or had heard of. Each method mentioned was recorded as a spontaneous response. The interviewer then read out the name and a short description of each method not mentioned spontaneously but listed in the questionnaire. If the respondent recognized the method it was recorded Table 4.1 Knowledge of contracantive methods Percentage of ever-married women and currently married women who know specific contraceptive methods, Nepal 1996 Ever Currently Contraceptive married married method women women Any method 98.4 98.4 Any modern method 98.3 98.3 Pill 80.0 80.5 1UD 35.6 35.9 lnjectables 84.8 85.0 Diaphragm/Foam/Jelly 28.2 28.3 Condom 74.8 75.3 Female sterilization 96.3 96.3 Male sterilization 89.8 89.7 Norplant 57.0 57.3 Any traditional method 43.9 44.4 Periodic abstinence 36.6 37.0 Withdrawal 28.7 29.1 Other methods 2.7 2.8 Number of women 8.429 7,982 Mean number of methods 6.1 6.2 as a probed response. If she had not heard of the method then she was recorded as having no knowledge of the method. Thus knowledge of a family planning method in the NFHS is defined simply as having heard of a method. Additional questions are not asked to elicit the depth of this knowledge. Information on knowledge of specific methods was collected for eight modern methods--the pill, IUD, injectables, Norplant, vaginal methods (diaphragm, foam or jelly), the condom, female sterilization and male sterilization--and two traditional methods, periodic abstinence and withdrawal. In addition, there was also provision to record any other methods mentioned spontaneously. Knowledge of contraception is nearly universal in Nepal. Table 4.1 shows that 98 percent of both ever-married and currently married women age 15-49 know at least one method of family planning. A greater proportion of currently married women reported knowing a modern method (98 percent) than a traditional method (44 percent). One of the reasons for the low reporting of traditional methods is that these methods are not included in the government family planning programme; therefore, it is possible that there may be some underreporting oftraditional methods. Moreover, women may feel reluctant to mention a traditional method since they are not widely accepted. Most currently married women know about female sterilization (96 percent) and nine often know about male sterilization (90 percent). Eighty- five percent of women know about injectables and 81 percent and 75 percent know about the pill and condom, 49 respectively. Knowledge of Norplant, the IUD, and vaginal methods is much lower. Among the traditional methods, periodic abstinence is more widely known than withdrawal (37 percent compared with 29 percent). Trends in Knowledge of Family Planning Methods Trends in contraceptive knowledge over the past 20 years are presented in Table 4.2 and Figure 4.1. There has been a five-fold increase in the percentage of currently married women who know about modern Table 4.2 Trends in knowledge of familv olannine methods Percentage of currently married women who know specific modem contraceptive methods, Nepal 1976-1996 1976 1981 1986 1991 1996 Method NFS NCPS NFFS NFHS NFHS AI• , I reader n method 21.3 51.9 55.9 92.7 98.3 " 12.0 25.1 27.8 65.8 80.5 IUD 6.0 8.4 6.7 24.1 35.9 Injectables NA 9.0 13.5 64.7 85.0 Diaohragm/Fo am/J elly NA NA NA 19.0 28.3 Condom 4.8 13.6 16.8 51.6 75.3 Female sterilization 13.0 44.4 51.2 88.8 96.3 Male sterilization 15.7 38.1 43. I 85.3 89.7 Norplant NA NA NA 34.6 57.3 NA = not applicable Source: Ministry of Health, 1993:100 methods, over the last two decades, from 21 percent in 1976 to 98 percent in 1996. As shown in Table 4.2, knowledge of specific methods has become more widespread. For example, the proportion of currently married women who have heard of the IUD has increased from 6 percent in 1976 to 36 percent 1996. Knowledge of both female and male sterilization has also increased substantially since 1976 from less than 20 percent to 90 percent or more. Figure 4.1 Trend in Knowledge of Modern Contracept ive Methods Nepal, 1976-1996 Percent lO0 80 60 2O 0 ~ . .~j, NFS 1976 NCPS 1981 i NFFS 1986 NFHS 19191 NFHS 1996 50 Differentials in Knowledge by Background Characterist ics The percentages of currently married women who know any method of contraception and any modem method are presented in Table 4.3 by background characteristics. Because the level of knowledge is so high in Nepal, there is little difference by background characteristics. The high level of knowledge is a result of the successful dissemination of family planning messages through the mass media. 4.2 Ever Use of Family Planning In the NFHS, respondents who said they had heard o f a method of family planning were asked i f they had ever used it. Ever use of family planning methods thus refers to use of a method at any time, with no distinction made between past and current use. These data indicate the proportion of the population using contraceptives at least once. Data on ever use has special significance since it reveals the cumulative success of programmes promoting the use of family planning among eligible couples. Since the proportion and pattern o f ever-use among ever-married and currently married women is very similar, the discussion in this section is limited to currently married women only. While almost all currently married women reported knowing at least one method (usually a modem method), only 38 percent of currently married women report ever having used any method and 35 percent report having used a modem method (Table 4.4). The gap between knowledge and use may in part be due to the fact that knowledge as measured in the NFHS may not imply the detailed familiarity with a method that actually leads to its use. Moreover, women who are either pregnant or trying to get pregnant may not yet have the need for family planning. Ever use varies little between currently married women and ever-married women. Female sterilization is the most popular method among currently married women (12 percent). In contrast, less than 6 percent o f currently married women have used male sterilization. Among the modem temporary methods, injectables are the most widely used, Table 4.3 Knowledge of contraeentive methods bv backnround characteristics Percentage of currently married women who know at least one contraceptive method and at [east one modem method, by selected background characteristics, Nepal 1996 Knows Knows Number Background any modem of characteristic method method women Age 15-19 96.9 96.6 965 20-24 98.7 98.7 1,602 25-29 98.9 98.8 1,560 30-34 98.9 98.9 1,292 35-39 98.6 98.6 1,042 40-45 98.5 98.4 828 45-49 97.7 97.7 695 Residence Urban 99.1 99.1 668 Rural 98.4 98.3 7,314 Ecological region Mountain 96.9 96.9 538 Hill 98.2 98.1 3,363 Terai 98.9 98.8 4,082 Development region Eastern 98.4 98.2 1,829 Central 98.2 98.1 2,677 Western 98.8 98.8 1,561 Mid-western 98.8 98.8 1,146 Far-western 98.0 98.0 769 Sub-region Eastern Mountain 97.9 97.9 120 Central Mountain 95. I 95.1 183 Western Mountain 97.7 97.7 236 Eastern Hill 99.2 99.0 538 Central Hill 97.2 97.1 993 Western Hill 98.6 98.6 952 Mid-western Hill 99.0 98.8 567 Far-western Hill 96.6 96.6 313 Eastern Terai 98.1 97.9 1,171 Central Terai 99.2 99.1 1,502 Western Terai 99.1 99. I 609 Mid-western Terai 99.1 99.1 476 Far.western Terai 99.3 99.3 324 Education No education 98. I 98.0 6,347 Primary 99.7 99.7 896 Some secondary 100.0 100.0 513 SLC and above 100.0 100.0 227 Literacy Literate 99.8 99.8 1,694 Illiterate 98.1 98.0 6,288 Total 98.4 98.3 7,982 SLC = School Leaving Certificate 51 Table 4.4 Ever use of contraception Percentage of ever-married women and of currently married women who have ever used any contraceptive method, by specific method and age, Nepal 1996 Modern method Dia-

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